Transcript Slide 1

Rehabilitation Medicine
Exercise enhancement in athletes: legal
and illegal, with specific examples and
case presentations
Matthew N. Bartels, MD, MPH
Professor and Chairman
Albert Einstein College of Medicine
Montefiore Medical Center
Bronx, NY
Disclosure
- I have no relevant financial disclosures.
- I have no financial interests in the sports described,
other than as a fan.
(Unfortunately…….)
- Off Label Usage: None advocated, but I will discuss
what is done so you know what to watch for…..
Course Objectives
 Learning Objective 1: Course participants will know the
basics principles of aerobic and strength training as they
apply to performance enhancement
 Learning Objective 2: Course participants will know the
basics of training programs based upon cardiopulmonary
and other testing to maximize aerobic capacity in
performance and casual athletes.
 Learning Objective 3: Course participants will have a
basic understanding of “extralegal” enhancement
techniques seen in sports.
Basics of Exercise Training
 Divided into two main categories, dependent upon type
of sport
– Aerobic conditioning
 Endurance sports, e.g. long distance running,
triathlon, cycling, football (soccer)
– Strength training
 Short burst activity and poser sports, e.g. sprinting,
American football, weight lifting
– Most sports require a balance of the two
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In the New York Times
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Remember Basic Physiology!
 Endurance activity requires more aerobic fibers
– This is predominantly Type 1 fibers
 Sustain activity for hours, but slow twitch speed and small fiber
size
 Short burst activity requires more anaerobic fibers
– These are predominantly Type 2 fibers subdivided into:
 2a moderately fast – long term anaerobic (<30 min)
 2x fast – intermediate short term aerobic(<5 min)
 2b very fast – short term aerobic (<1 min)
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Basic Terminology
 Measurement of exercise capacity
– Aerobic Training
 VO2 – defined as Liters of O2/minute or mlO2/kg/min
 MET – one metabolic equivalent - 3.5 mlO2/kg/min
 Wattage – Resistance on an ergometer – this is power output
 Heart rate – Used to determine the level of intensity once power
at a given heart rate established
 RPE – can guide exercise once power rates determined
– Resistance Training
 Maximum Voluntary contraction – one rep max
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Cardiopulmonary Exercise Testing
 CPET is used regularly in athletes
– Screen for IHSS or arrhythmia in younger athletes
 Allows for most efficient training program in dedicated
athletes
– Done in sports specific testing
– Achieve individual specific target heart rates
– Customize exercise program for recovery or
improved performance
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Exercise Guidelines for Athletes
 Use established guidelines – but best with exercise
testing to determine true levels of intensity
 Always have appropriate warm up and cool down
– Some controversy exists on benefits, but nothing that
states it is harmful
 Role of CPET
– For high level athletes, can help to refine exercise
programs and prevent overtraining.
– Has a role in defining work efficiency/economy
– Can allow for maximal performance
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CPET – What Are You Looking For?
 Peak capacity in resistance/intensity and VO2
 Anaerobic/ventilatory threshold
 Respiratory compensation point above AT – for peak
strength/interval training
 Can give you
– HR targets
– With task specific testing
 Wattage/cadence for cyclists
 Speeds/inclines for runners
 Professionals use this all the time
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Aerobic Training – Injury Avoidance
 Principles to avoid injury
– Avoid overtraining
– Incorporate multiaxial activity
– Utilize neumuscular and proprioceptive training
 E.g. running on reular surfaces better than on a
treadmill, or road cycling better than on a stationary
bike
– Emphasize agility
– Use well maintained equipment
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Aerobic Training – Injury Avoidance
 Consume appropriate nutrients
– During and in the first hour after exertion
– - need to have glucose and some protein, fats less
critical
 Consume appropriate liquids
– Avoid overhydration – can use thirst as a guide
– Hyponatremia is the highest risk – can lead to
mortality
 Maintain Electroytes
 Use of appropriate protective equipment
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Aerobic Exercise Capacity
 For endurance only training
– Work at or lightly above Anaerobic threshold
– Use as base intensity, build up training sessions
– Perform daily
 For power combined with endurance
– Goal is to build burst power in addition to building
endurance
– Interval training is a good way to achieve this
– Alternate long endurance sessions with interval
sessions
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Sample Exercise Program
 Endurance athlete – 30 y/o male runner
– CPET Max VO2 is 60 ml/kg/min
– AT is at 51 ml/kg/min
– HR at peak 188, HR at AT is 165
– Exercise program should be to maintain HR for long
endurance at 165 BPM – with program to include
some gently strengthening, agility, and core exercises
to avoid injury.
– Footwear maintenance and appropriate hydration and
nutrition with exercise sessions is essential
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Sample Exercise Program
 Elite Competitive Cyclist– 27 y/o female cyclist
– CPET Max VO2 is 56 ml/kg/min
– AT is at 48 ml/kg/min
– HR at peak 198, HR at AT is 170
– Exercise program should be to maintain HR for long endurance
at 170 BPM several days a week for 30-60 mile road rides
– Intervals alternate with endurance workouts with shorter
30minute to 60 minute sessions – hill repeats or long ride with
multiple sprints for strength building HR to 190 BPM with
intervals, base activity at 165 to 170 BPM
– Include strengthening with weight training focused on thigh
muscles, and core along with agility/balance.
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Strength Training Exercise
 Weight lifter 35 y/o man, recreational/semi-competitive
– Establish one rep maximum training
– DO a program of low repetition and high weight training –
using reps in the >85% on rep max level
– Include several bouts of lower intensity free weights for
agility and endurance – helps with injury prevention
– Use spotting, appropriate equipment/protective gear
– Advise that some aerobic exercise also is important for
general fitness – at moderate intensity level 70% peak HR.
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Strength Training Exercise
 Football player 20 y/o man, competitive
– The balance between aerobic and strength will depend on
the position – must be tailored to position.
– Establish maximum training program for strength
– Include low repetition and high weight training – using
reps in the >85% on rep max level
– Include several bouts of lower intensity free weights for
agility and endurance – helps with injury prevention as
well as core exercises
– Use spotting, appropriate equipment/protective gear
– Include aerobic exercise at moderate intensity level 70%
peak HR, with sprints as appropriate.
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Conclusion
 Gain familiarity with exercise physiology and the specific
requirements of sports
 Remember that application of exercise training can help
with both injury prevention and enhancement of exercise
performance for athletes in all sports.
 The physiatrist has an important role to play in both athletes
after an injury (teachable moment) as well as with preparticipation evaluation
 Work with trainers and coaches to improve safety allowing you to be a more valuable member of the athletic
support team.
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Enhancement
 Not all enhancement is “illegal”
– High altitude training
– Interval training
– Dietary modification (high protein diets, carbo loading)
– Modalities
 cooling after exercise, icing, massage, heat
 Problem comes with use of pharmacologic and newer
methods of artificial enhancement
Now to the “Extralegal”
 This is all over the press – and is seen in all types of sports
at all levels of competition.
 Many high profile cases recently
– Lance Armstrong (and most cyclists from the last 30 years)
– Olympic athletes (Marion Jones, et al.)
– Baseball (Mark McGuire, Sammy Sosa, et al.)
– American Football (Just who do they think they are kidding)
– Professional Soccer (Has not caught up yet – but it is there)
 Just not tested (but they look awfully fresh after a match)
 AC Milan and FC Barcelona season prep plans found in “Operation Puerto”
which broke cycling wide open.
– Power lifting and body building (never covered up – Arnie!)
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What is Used?
 Multiple drugs in multiple classes
– Steroids
– Epo
– Amphetamines
– Caffeine
– Nitric Oxide
– And more…….
 Blood doping
 Proteomics/gene regulation
 And, the new frontier => Gene Doping
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How is it regulated?
 Up to individual sports
 Professional and Olympic sports are under WADA
 Amateur and school based are under a hodgepodge of
regulations
 WADA has available downloads
– Of particular use are:
 The list of banned substance
 Biological Passport (ABP) guidelines
 Therapeutic use exemption guidelines (TUE)
 Need to know the rules to help prevent patients from
consequences!
 Go to: http://www.wada-ama.org/en/
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Therapeutic Use Exemption
 You need to know the rules to allow necessary treatment
with a banned substance or method
 All TUE need to be filed to protect the athlete
– Submitted to the relevant anti-doping agency
– Via paper or the ADAMS system
– Should be 30 days prior to competition, or as soon as the
condition is diagnosed if < 30 days
– Answers go to the athlete => then treatment can start
 If they start before approval – technically in violation.
– Can get retroactive TUE
 emergencies or TUE cannot be reviewed in time.
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How does doping work?
 Depends on the substance/sport/athlete
 This is an entire world of its own
 Can be harmful for athletes long term
 BUT benefits are very high – so risk is secondary
 Can include METHODS as well as substances
– Blood doping with transfusion
– Enhancing recovery, limiting pain
– Tampering with samples/testing
– Gene Doping
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Some Sample Doping
 Cycling is easy to discuss – covers all issues
– Allegations since the first TDF (No dope, no Hope!)
 NTG, Strychnine, cocaine, alcohol, amphetamines, pain killers
– Deaths in 1960’s
 1960 Knud Jensen died in Olympic time trial with amphetamines and
vasodilators in his system => Olympic ban
 1st high profile issue in TDF 1967 death of Tom Simpson (amphetamines,
alcohol, dehydration)
– 1970’s – Amphetamines and steroids found
 Eddy Merkx among those positive for Pemoline
 Steroids for recovery, not strength (cortisone)
 First cases of trying to fool testing (methods) Pollentier and the condom.
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1990’s => EPO arrives
 Not detectable
 Gave marked advantages in aerobic strength
– Only could rule high Hct (Bjarn Rijs – Mr. 60%)
– This was era when Lance started doping
 1998 – Festina Scandal
– Van with soigneur Willy Voet stopped at Spanish border with
narcotics, EPO, hGH, testosterone, amphetamines
 Lance allegations swirl from 1998-2006
 2006 – 1) Operation Puerto – The method of doping
– Blood bags in a fridge – most famous riders caught
– 2) Landis tests (+) for testosterone:epitestosterone at 11:1
 2010 => Contador stripped for clenbuterol => Transfused?
 2012-13 – Armstrong stripped of titles after admissions
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Effect of Blood Doping
 Off the cuff example
– Cyclist with baseline VO2 of 80 ml/kg/min\
 This puts you solidly in Peleton – 40-100k Euro/year
 Has 2 units PRBC infused
 Baseline blood volume (5 liters) now with additional
500 cc blood – 10% increase
 New VO2 is about 88 ml/kg/min (10% increase)
– This is in the level of top cyclists – salary >100k
Euro, 8k/stage, 450k for win, and Endorsements.
– So I wonder why they cheat?
So what is used and how?
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Clenbuterol – increased lean body mass (LBM)
Anabolic Steroids – increase LBM, speed recovery
Glucocorticoids – speed recovery, ease pain
hGH, IGF-1, PDGF, VEGF, etc – increase LBM
Hormone and metabolic modulators – increase performance
– SERMs, myostatin inhibitors, insulins, aromatase inhibitors
EPO – Increase blood volume/hemoglobin
Amphetamines – increase performance
Beta agonists – Enhance breathing/performance
Beta blockers – in selected sports – calm shaking
Narcotics – ease pain, speed recovery
Alcohol – not in competition in aeronoautics, driving, archery, karate, power
boating, and motorcycling = > historically to ease pain in competition
Diuretics/masking agents – evade testing
Blood transfusions – autologous – as EPO
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What is therapeutically allowed?
 Beta agonists:
– Salbutamol (1600 mg/24hr)
– Inhaled formoterol (54microgram/24hrs)
– Inhaled Salmeterol used as per manufacturer’s regimen
 Alcohol – out of competition allowed
 Beta blockade – only out of competition, except never
for archery, shooting
 Adrenaline in anesthetic injection
 Pseudophedrine <150 micrograms/ml
 Ephedine/methylephedrine <10 micrograms/ml
 Cathine <5 micrograms/ml
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New/New Frontier
 Proteomics
– Works at level of proteins to enhance effectiveness of
enzyme => myostatin inhibition leads to hypertrophy
– Cytochrome P450 enzymes
 Variable activity in various populations – can be
altered with pharmacogenetic approaches to
enhance/hinder the function of the existing gene
product.
– Caffeine/Adrenaline are metabolized via p450 so
changing the activity…….
 Altering the effectiveness of existing gene products can
alter performance
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Cutting/Bleeding Edge
 AICAR: 5-aminoimidazole-4-carboxamide-1-β-D-ribofuranoside
(peroxisome proliferator-activated receptor-δ [PPAR-δ]-5' adenosine
monophosphate-activated protein kinase [AMPK] agonist) =>
upregulates mitochondria, less type 1 fiber fatigue, altered insulin
sensitivity, angiogenesis
 Telmisartan (Micardis): angotensin II receptor blocker
– synergistic with AICAR
 GW1516 (Endurobol): (PPAR-δ-agonist)
– Causes cancers in liver, bladder, stomach, skin, thyroid,
tongue, testes, ovaries and uterus
– Positive tests in 2013 – Kaykov (Rusvelo) and Ubeto (Lamprey)
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New Frontier => Gene Doping
 Transfer of polymers of nucleic acids/analogues
 Normal or genetically modified cells
 Can’t currently be tested
 Unclear if used
– Significant potential risks and benefits
 Introduced via a vector (Viral or non viral)
 Can enhance gene expression – EPO, Muscle proteins,
mitochondrial genes, hGH, angiogenic factors, etc –
your imagination is the limit.
 Add genetic screening to the biologic passport?
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Conclusion
 You can legally help athletes perform at their best
 Need to protect our athlete patients form extralegal
 Protection:
– 1) from using drugs and enhancers – can be dangerous
and it is bad sportsmanship
– 2) from testing false positive due to treatments we give
 Know the reporting process and be open
 Check on WADA site for any questions you have
 Be an advocate for clean competition => especially in
amateurs!
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