"Don't get out of breath...some helpful tips to control exercise-induced asthma."

Exercise-induced asthma (EIA) can affect any individual from beginner to Olympic athletes. This disorder is more commonly associated with endurance athletes. During the 1988 Olympics, of the 597 U.S. Team members, 67 athletes with symptoms of EIA were responsible for winning 41 Olympic medals, including 15 gold and 21 silvers. This demonstrates that with proper medication and management, athletes can participate at the highest level without their performance suffering.

Exercise-induced asthma is a respiratory disorder characterized by recurring episodes of shortness of breath, wheezing on expiration/inspiration, coughing, chest tightness, fatigue during exercise, or productive mucous secretions. Symptoms can vary in degree and can become more severe with rapid, shallow breathing, difficulty breathing, wheezing, chest tightness, and coughing.

Most people with asthma have symptoms when exercising, especially if the air is cold and dry. Severe reactions are called exercise-induced bronchospasms (EIB), which is an actual reduction in pulmonary (lung) function as it relates to flow rate.

Exercise-induced asthma can be controlled with prophylactic use of aerosol or oral bronchodialators, beta-adrenergic drugs, or short-term use of corticosteroids. It is important that a physician is consulted before using any form of drug or inhalant. Other preventative methods include appropriate warm-up; the use of a mask or muffler to warm inspired air in cold, dry climates; and the avoidance of exercise when environmental pollutants are present at elevated levels.

Scott Miller, M.S.P.T., SCS., C.S.C.S.
Board Certified Sports Clinical Specialist/Certified Strength and Conditioning Specialist
Agility Physical Therapy and Sports Performance

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Tackle Heat Illness

There have been 19 heat related deaths among high school and college football players since 1995. This includes Minnesota Vikings tackle Korey Stringer, a well-conditioned professional athlete, who is used to playing in high heat and wearing full gear.

What are athletes subject to?

Heat cramps – Painful cramps involving abdominal muscles and extremities caused by intense prolonged exercise in the heat and depletion of salt and water due to sweating.

Heat Syncope – Weakness, fatigue and fainting due to loss of salt and water in sweating and exercise in the heat. Predisposed to heatstroke.

Heat Exhaustion – Excessive weight loss, reduced sweating, weakness, headaches, vomiting, dizziness and sometimes unconsciousness.

Heat Stroke – An acute medical EMERGENCY related to thermoregulatory failure. Associated with nausea, seizures, disorientation, and possible unconsciousness or coma.

Temperature Precautions (WBGT index)
65-72 degrees- moderate risks
74-82 degrees - high risk
82 plus degrees- very high risk

What to do incase of emergency.

Immediately cool the body (bring to cooler location)
Remove clothes.
Submerge athlete in cold water, or apply ice bags on the neck, in the armpits and groin areas.
Can apply alcohol or cold water to skin and fan vigorously (causes evaporation and cooling)

Water Intake

Consume 17 to 20 oz of water 2 to 3 hours before exercise
Consume 7 to 10 oz 10 minutes before exertion, same every 10 to 20 minutes during exercise.
Consume 20oz of water per pound loss within 2 hours after exercise.

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The role of a clinical sport psychologist as part of the sports medicine team is becoming increasingly endorsed. Research tells us that sport psychology skills such as positive self-talk, goal-setting and imagery are associated with rapid recovery from injury (1).

Although many physiotherapists also feel the psychological components of injury recovery are important (2), the majority feel limited in their ability to deal with these concepts and desired additional training (3). Psychological interventions may be especially important when difficulties with adjustment arise. For example, physiotherapists have endorsed noncompliance with the rehabilitation programme as a significant problem preventing effective recovery and rehabilitation (4). This behavior often may not be a lack of motivation by the athlete, but a symptom of emotional distress. Adherence tends to decrease as mood disturbance increases (5).

Five to thirteen percent of patients with sport injuries experience clinically significant levels of emotional distress (6). Symptoms of depression and anxiety that do not meet diagnostic criteria are likely to be present in a larger percentage (7) and can still significantly compromise rehabilitation. Sport physiotherapists from Australia, New Zealand and Canada perceive anxiety, frustration, and fear as the most frequently experienced emotional responses by injured athletes (4). Recognition and treatment of depression and anxiety is necessary to maximize rehabilitation outcome.

Stress, Anxiety and Depression
Stress and anxiety are among the most frequently cited psychological conditions observed by sports medicine physicians (8). Such distress will affect the injured athlete physically as will as emotionally.

For example

• Stress inhibits the production of proinflammatory cytokines, delaying wound recovery.
  
• Muscle tension is commonly associated with stress and it increases pain.
  
• Anxiety can restrict blood flow to the injured area and impede healing. The resulting pain, fear and discomfort prevent the athlete from fully participating in therapy, hindering improvement.

The physical symptoms of anxiety may be recognized as muscle tension and bracing, poor coordination, rapid breaths and speech, recurrent physical complaint of secondary injuries. Cognitively, the anxious patient will be overly self-critical and negative, have low confidence in rehabilitation and express a fear of the future. The anxious athlete with often verbalize extreme thinking or unrealistic expectations. Former National Football League player, Keith Millard, illustrated this thinking style following an injury when he exclaimed, “My knee’s shot. My knee’s shot. There goes my whole career. It’s over, I’m through” (10). Emotionally the athlete may be angry, irritable, or impatient.

Socially he or she is less communicative and socially withdrawn. The anxious patient’s performance suffers and the athlete may demonstrate less motivation or enjoyment in rehabilitation, less interest in sport and other activities and give up easily in response to setbacks. At the other extreme, he or she may “try too hard” in therapy.

Physiotherapist can reduce an athlete’s anxiety by educating the patient about his or her injury and recovery timeline. Daily, specific, behavioral goals foster a sense of accomplishment. And further reduce worry. Modeling positive self-talk and redirecting negative thinking toward the injured athlete’s progress will also help. Relaxation training and biofeedback reduces the physiological arousal associated with stress and minimizes its negative impact. These interventions can also benefit the athlete with mild depressive symptoms.

Depression increases sensitivity to pain and decreases motivation. Both reduce the effectiveness of rehabilitation. Depression is characterized by feeling down, discouraged or sad. Poor adherence, poor effort or intensity in physical therapy and a loss of confidence could be symptomatic of depression. Negative self-talk, catastrophising or expressions of doubt and uncertainty may be obvious. The depressed athlete may demonstrate low energy, loss of interest and pleasure from previously enjoyed activities and become socially withdrawn. Physically, he or she may complain of persistent fatigue, sleep or appetite disturbance or emotional distress expressed via pain and discomfort. If an athlete feels excessively hopeless, worthless or helpless, particularly if suicidal ‘ideation’ is discovered, a referral to a clinical or counseling psychologist is warranted.

Referral
Common referral issues include: depression, stress and anxiety, substance abuse, and eating disorders. Less common but equally important are compliance issues, persistent pain and conflicts with coaches, treatment providers and others. When and how vigorously referral should be recommended will be influenced by the severity and urgency of the problem and how significantly it is interfering with rehabilitation or the patient/athlete’s sporting and personal life.

Professionals qualified to treat injured athletes with psychological disorders (eg. major depression, post-traumatic anxiety, eating disorder, or substance abuse) will have a doctorate in clinical or counseling psychology. Ideally the psychologist will specialize in the treatment of athletes. In America, certification by the Association for the Advancement of Applied Sport Psychology (AAASP) identifies professionals trained in performance enhancement techniques. A significant percentage of these professionals are licensed psychologist. A list of certified consultants may be found on their website (www.aaasponline.org).

Physiotherapists rate communication and motivation as the most important psychological skills/characteristics both therapists and athletes can possess (2,4). This is particularly true for a successful referral as the athlete must understand the need and perceive it as acceptable and credible. When explaining to the athlete the reason for the referral, normalize the stressful mature of injury and emphasize the performance-enhancement focus of sport psychology. The purpose of treatment can be described as applying the mental skills of sport performance to rehabilitation in order to speed recovery. Simply stating that psychological treatment will help with problems of pain (or feeling ‘on edge’) is often sufficient.

It should also be noted that this is an opportunity for the athlete to speak with someone confidentially about worries and concerns associated with sport injury or other life situations. This helps mentally prepare the athlete by letting him/her know what to expect and it also expresses understanding and support of psychological treatment.

Be clear about your enthusiastic support of psychology. The more comfortable and excited you are, the more relaxed but eager the athlete will be. Reinforce you continued care and concern. Let the athlete know she or he is not crazy and that the injury is real. Describing previous referral and success associated with them is reassuring and encourages follow-through by the athlete.

The simplest way to assure follow-through is to immediately, in the athlete’s presence, schedule an appointment with the psychologist. By also scheduling a follow-up with the athlete soon after she or he meets with the psychologist, the sports medicine team member will limit the athlete’s fear of being ‘dumped’ or ignored. This also provides an opportunity to review the athlete’s experience with the psychologist, facilitating coordination of care and reinforcing the psychologist treatment plan.

References
1. Ievleva L and Orlick T. Mental links to enhanced healing: An exploratory study. The Sport Psychologist 1991; 5(1):25-40
2. Francis SR, Andersen MB and Maley P. Physiotherapists’ and male professional athletes’ views on psychological skills for rehabilitation. Journal of Science and Medicine in Sport 2000;3(1):17-29
3. Gordan S, Milios, D. and Grove JR. Psychological aspects of the recovery process from sport injury: The perspective of sport physiotherapists. The Australian Journal of Science and Medicine in Sport 1991;23(2):53-60
4. Ford IW and Gordon S. Perspectives of sport physiotherapists on the frequency and significance of psychological factors in professional practice: Implications for curriculum design in professional training. The Australian Journal of Science and Medicine in Sport 1997;29(2):34-40
5. Daly JM, Brewer BW, VanRaalte JL, Petitpas AJ, & Sklar JH. Cognitive appraisal, emotional adjustment, and adherence to rehabilitation following knee surgery. Journal of Sport Rehabilitation 1995; 4:23-30
6. Brewer BW. Psychological application in clinical sports medicine: Current status and future directions. Journal of Clinical Psychology in Medical Settings 1998;5(1):91-102
7. Heil J. Sport psychology, the athlete at risk, and the sports medicine team. In J. Heil (Ed.), Psychology of the Sport Injury pp. 1-13, Champaign, IL: Human Kinetics. 1993
8. Brewer BW, VanRaalte JL, and Linder DE. Role of the sport psychologist in treating injured athletes: A survey of sports medicine providers. Journal of Applied Sport Psychology 1991;3:183-190
9. Glaser R, et al. Stress-related changes in proinflammatory cytokine production in wounds. Archives of General Psychiatry 1999;56,450-456
10. Haber J. Deeps scars. Sports Illustrated, 1990;75(5):36-44

Dr. Edmund O’Conner, PhD is chief psychologist of the PEAK, Pain and Headache Programs at Rehabilitation Professionals in Grand Rapids, Michigan, USA. He is a certified consultant through the Association for the Advancement of Applied Sport Psychology and a member of the United States Olympic Committee

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Stop Slumps Before They Begin

Poor performances are a normal, but frustrating, part of sports. Occasionally these performances turn into full-blown slumps that can last throughout the game -- or longer. Your body has stopped responding and you can't explain why. You've lost your jump shot and can't buy a bucket. Your bases-loaded, game winning opportunity ends with your third strikeout of the afternoon. Your mind and body are out of sync. The harder you try, the worse you play. Doubt creeps in. You feel out of control. Your confidence is gone.

Slumps do not mean your athletes are "mentally weak" or "head cases." Slumps usually follow a predictable cycle that start with a bad performance. Negativity, self-doubt, and worry enter the mind. This takes the athletes= concentration off the tasks at hand. They try too hard to do well and increase tension. Slumping athletes do not pay attention to the cues that would enable them to play their best. Failure follows again, further decreasing their confidence and distracting them from what's important. The slump spiral has begun. Fortunately, there are several things you can do as a coach to put your players back on track.

1) Communicate clearly, directly, and often. Let the athletes know where they stand, how you feel about their struggle, and what they can do to get through it. If you bench them, help them understand why. Describe what they need to do to get back in the game. Be specific in your feedback and give behavioral examples. For example, "You need to give more effort by making a quick transition to defense after you miss a shot," not "You need to try harder." Don't focus on everything they are doing wrong. Instead focus on what they need to do right to improve.

2) Reinforce. Compliment athletes on both their effort and good physical plays. This will increase their focus on what they are doing right and increase the likelihood of breaking out of their slump. Be liberal with reinforcement of specific behaviors and praise the little things. You will see increased effort and performance.

3) Encourage immediately after mistakes. Feed the athletes a positive sandwich: two positive comments wrapped around instruction. Start with a compliment ("Way to hustle!"). Give future-oriented instruction ("If you follow through by fully flexing your wrist, you'll sink those baskets."). End with another positive statement ("You're close. Keep practicing and you'll shoot like Michael Jordan.").

4) Be empathetic. Let the athlete know you understand how it feels to struggle. Don't tease athletes about their performance or call them "stupid" or "choker." Avoid comparing great performances in the past with their present poor ones (unless you use the good ones for positive instruction).

5) Show confidence in them. Help them believe this is temporary.

6) Don't remind the athlete how long they have been performing badly-- they know.

7) Don't penalize athletes for poor performances, and don't give them the silent treatment or ignore them. They need your support and encouragement now more than ever.

These interventions build athletes confidence. Encourage them to focus on what they are doing right. Athletes will often beat themselves up during a slump and become their own worst critic. This attitude produces poor performances. Instead, athletes should encourage themselves with positive self-talk. When this is done consistently, they develop a mental toughness that prevents slumps from occurring in the future.

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The Marathon Mental Game: What You Think Matters

Marathon training is a long and challenging task for even the most experienced runner. During competition, participants are left alone with their thoughts for two to six hours as they push their bodies to physical limits. Your thinking can greatly affect your performance. As a result, marathon runners choose from various cognitive strategies to perform their best. Rarely is only one strategy used. Rather a combination of strategies best addresses the demands of competition.

Monitoring of race relevant information is most often used by experienced runners during competition. This strategy should be used when increased effort and awareness is desired. Inward monitoring is most common during a race and involves being aware of muscle soreness, fatigue, breathing and pace. External monitoring consists of awareness of race conditions such as route, strategy, drink stations and split times. Monitoring allows modifications in pace and race strategy to be made and is associated with faster running times.

Distraction is used most during training and may help increase your endurance on long runs. Examples of external distraction include the scenery, spectators and chatting with other runners. External distraction can be particularly useful for novice runners, who may be disturbed by fatigue and pain. The flip side of distraction is that it is also associated with a reduced running pace and slower times. Internal distraction is highly associated with "hitting the wall." Daydreams, fantasies and imagining music are the least useful strategies and can hurt your performance.

Distraction reduces the metal monotony of long runs and focuses attention away from fatigue and discomfort. However, its usefulness for pain is limited. As pain intensity increases, it may become increasingly difficult to distract yourself from it. At that point, switching to an associative strategy and redefining the sensation may be more beneficial. For example, extreme fatigue around Mile 20 is often associated with an increased focus on pain. Try redefining these sensations and encouraging yourself with statements such as, "The feeling in my legs is a good sign that I am working hard and maintaining my pace. I can do this!"

Redefining negative perceptions and sensations is an excellent way to maintain your motivation and confidence. Another common and useful example is to redefine pre-competition anxiety. Instead of thinking, "I am so nervous," tell yourself "I am excited to get started!" The physical sensations of anxiety and excitement are identical. It is how we interpret them that determine how they will affect our performance.

When racing, use distraction when you are struggling to keep going and monitoring when you want to pick up the pace. Avoid internal distractions such as singing to yourself. Keep your thinking positive, short and specific, encouraging and motivating. Base your positive thinking on reality; evidence of your training experience, the mileage you have put in and all your race preparations. Let your confidence flow from the fact that you have prepared for this race and you are ready to achieve your goals.

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Sports Nutrition

Good nutrition will not replace a good training program, effort, genetics, and personal drive. However, it is essential, without question, when your goal is peak performance. As an athlete you burn more energy, lose more fluids, and put greater stress on the body's muscles, joints, and bones. Healthy eating will help you improve your endurance, increase your strength, and prevent dehydration.

The key to healthy eating is whole nutrient dense foods!

• The principal purposes of the nutrients in the food we eat are to provide energy, build and repair body tissues, and regulate metabolic processes in the body.
  
• More than forty specific nutrients are essential to life processes. They may be obtained in the diet through consumption of the six major nutrient classes: carbohydrates, fats, proteins, vitamins, minerals, & water.
• The Recommended Dietary Allowances (RDA) should not be construed to be an ideal diet plan, but they provide us with a set of standards for our nutritional needs. New RDA are being developed with the goal of promoting optimal health.
  
• If most healthy individuals in a given population consume wholesome, natural foods in amounts adequate to meet their individual needs there will be little likelihood of nutritional inadequacy or impairment of health.
  
• The Food Guide Pyramid and the related Food Exchange System-meat, milk, starch, fruit, vegetable, and fat-should be viewed as an educational approach to help individuals obtain proper nutrition. Foods of similar nutrient value are found in each of the six exchanges.
  
• There are eight key nutrients (protein, vitamin A, thiamin, riboflavin, niacin, vitamin C, calcium, and iron) that, if adequate in the diet and obtained from wholesome foods, should provide an ample supply of all nutrients essential to human nutrition.
  
• Some foods contain a greater proportion of these key nutrients than other foods and thus have a greater nutrient density or nutritional value.
  
• Twelve general recommendations for healthier nutrition include: (1) maintain or improve your body composition, (2) consume a wide variety of foods, (3) choose a diet low in total fat, saturated fats, and cholesterol, (4) choose a diet with plenty of whole-grain products, legumes, fruits, and vegetables, (5) choose a diet moderate in sugars, (6) choose a diet moderate in salt and sodium, (7) drink alcoholic beverages in moderation, if at all, (8) eat protein adequate to LBM and activity, (9) choose a diet adequate in calcium and iron, (10) obtain fluoride, (11) avoid excess dietary supplements, and (12) eat fewer foods containing questionable additives.
  
• Vegetarians must be careful in selecting foods in order to obtain a balanced mixture of amino acids and adequate amounts of B12, calcium, iron, and zinc.
  
• Vegetarian diets are based on healthful nutritional concepts, but non-vegetarian diets may confer the same health and performance benefits if animal foods are chosen carefully.
  
• Fad diets such as high protein and low-fat low fiber diets will not provide long term health benefits.

To give you an understanding of how exercise increases your calorie needs the following represents approximate energy expenditure in Calories per minute for increasing levels of exercise intensity for an average adult male.

The majority of energy for sports and everyday life should come from carbohydrates. They should supply 55 to 65 percent of your total energy needs. Protein should supply 15 to 20 percent of total energy needs. Fat should supply 20 to 25 percent of calories. The following is a very general way of determining calorie needs.

How much fluid do I need?

Know the signs of dehydration. Some of the early signs are flushed skin, fatigue, increased body temperature, and increased breathing and pulse rate, followed by dizziness, increased weakness, and labored breathing with exercise. Replace fluids before symptoms get too serious.

Sample Menu

Here is an example of a balanced menu for one day.

Breakfast - Orange juice ž cup, oatmeal 1 cup, whole wheat toast 2 slices, peanut butter 2 teaspoons, skim milk 1 cup.

Snack - Whole grain crackers 2, peanut butter 2 teaspoons, banana

Lunch - Albacore Tuna salad ½ cup, Kaiser roll 1, Lettuce 2 leaves, tomato 1 slice, three bean salad 1 cup, Italian dressing 1 tablespoon, Fresh peach 1, Skim milk 1 cup.

Snack - Yogurt 1 cup, whole grain cereal mix with almonds and raisins 1 cup

Dinner - Vegetable soup 1 cup, baked chicken breast 4 ounces, brown rice 1 cup, steamed broccoli 1 cup, tossed green salad 1 cup, Lemon and olive oil dressing 2 tablespoons, whole grain dinner roll 1, mixed fruit salad 1 cup, skim milk 1 cup.

Snack - Apple 1, fig bars 3

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