KIN 424 Final Exam

Module 7-10

What is doping?

presence of a **prohibited substance** or its metabolites or markers in an athletes sample

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**use or attempted use** by an athlete of a prohibited substance or a prohibited method

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refusing or **failing without compelling justification to submit to sample collection** after notifications as authorized in applicable anti-doping rules, or otherwise evading sample collection

Doping pt 2

* athlete availability for out-of-competition doping
* three missed tests
* tampering
* trafficking
* administration
* assisting, encouraging, aiding, abetting, covering up

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Why do people dope?

* belief that competitors are cheating
* determination to do anything possible to attain success
* direct or indirect pressure from others (Coaches, peers, family)

What are the 3 key prohibited substance categories of doping?

* anabolic agents
* hormones and related substances
* beta agonists

Prohibited Substances: Anabolic Agents

* anabolic agents- typically derivatives of androgens
* anabolic effect
* anticatabolic effect
* enhancement of aggressive behaviour

Prohibited Substances: Hormones and related substances

* erythropoietin (risk of blood clots, stroke, and heart attacks, aids hiv)
* human growth hormone
* anabolic
* insulin
* anabolic
* corticotropin (ACTH)
* causes release of cortisol, (DHEA)
* no ergogenic benefit

Prohibited Substances: Beta-2 Agonists

* bronchodilators used to treat asthma
* most are prohibited but there are exceptions:
* salbutamol, salmeterol, ventolin
* purported benefit for endurance athletes

Prohibited Methods: Enhancement of Oxygen Transfer

* homologous blood doping
* autologous blood doping
* erythropoietin analogues

risk of contracting aids/hiv

What is homologous blood doping?

Using someone else’s blood for doping (not commonly used because dangerous)

What is autologous blood doping?

taking your blood out and putting it back in later (more commonly used and harder to detect)

What are erythropoietin anagloues

synthetic EPO

What is gene doping?

use of genes, genetic elements or cells for non-therapeutic purposes in order to enhance athletic performance

Methods of gene doping?

* modification of our genes used to be considered to be impossible
* however, in gene therapy, new genes can be introduced into various tissues of the human body to correct absence or abnormal expression of natural genes
* the same approach could be used to improve athletic performance (muscle growth, O2 transfer)

How can genes be introduced?

* most common method involves viruses- engineering a virus by replacing its own genes with new therapeutic gene
* the engineered virus becomes a delivery vehicle - so called vector - for expression of new genes
* non-viral methods - DNA alone (“plasmids“) can transfer genetic information

Athletic Biological Passport

* serial measurements of key laboratory variables
* look for changes over time
* particularly useful for blood doping/EPO misuse
* Convictions have occurred
* need many blood tests to achieve a proper biological passport

Athletes whereabouts system

* home address
* training information and locations
* competition schedules
* regular personal activities such as work or school
* for those few athletes included in a RTP, one 60 minute time period a day, where you’ll be available for testing must also be provided

Athletes Whereabouts system: Filing failure

if you dont submit your whereabouts information quarterly and update it as necessary or you provide incomplete information, you may receive a whereabouts strike

Athletes whereabouts system: Missed test

if a doping control office can’t find you at the location indicated during your 60 minute time slot, you may receive a different kind of whereabouts strike

Anti-doping rule violation

any combination of 3 whereabouts strikes in 12 months may result

Risks of Supplements

* substitution
* adulteration
* the intentional debasing of the food quality by admixture and substitution of substances
* economic adulteration: less expensive ingredient used in place of a more expensive ingredient listed on the label
* pharmaceutical adulteration: active drug is included in a purportedly botanical supplement
* unlisted ingredients
* e.g mislabelling
* contamination
* unintentional

Supplements

* 1 study: 15% of non hormonal supplements were **contaminated** with anabolic steroids or androgens
* 59% herbal supplements - **unlisted ingredients**
* 30/44 had **substituted** ingredients
* 32% non of active ingredients were present
* 2007-2016 FDA issues 776 warnings abt unapproved pharmaceuticals in supplements

High risk supplements

* pre-workout
* fat burning supplements
* weight gain supplements

Foodstuffs

* certain food and drink may have prohibited substances
* ex. clenbuterol in meat, narcotics (morphine) in poppy seeds, cannabinoids (food and drinks), N.B hemp-containing foodstuffs

Social Drugs of Abuse

WADA:

* cannabinoids
* narcotics
* amphetamines
* cocaine

**prohibited in competition only**

What is the “no needle policy”?

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What are some exceptions to this rule (3)?

The use of needles for the administration of any substance must not be used during the period of games

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Exceptions & Conditions such as:

* an antibiotic injection for an infection
* an intra-articular of a local anesthetic or glucocorticoid for the treatment of any injury
* athletes who require an injection for a medical injection ex. insulin for insulin dependant diabetes

Case: An athletes blood sample comes to you with a testosterone/epitestosterone ratio greater than 4.1

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Is this normal?

No! Consistent with the administration of a steroid of exogenous origin

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one year ban

Case: You’re a physiotherapist for the Race Walk World Cup in Muscat, Oman. One of your athletes take salbutamol for EIB. Should you be concerned?

No, salbutamol is a treatment for EIB and is not banned by WADA

Case 3: PT going to Race Walk World in Muscat Oman, one of your athletes takes formoterol for EIB. Should you be concerned?

Yes formoterol is a banned substance, take salbutamol instead

You're a physiotherapist for the Race Walk World Cup in Muscat, Oman. \n \n Should you be concerned that one of your athletes wants to take testosterone boosters for the race?

ABSOLUTELY BE CONCERNED. Test boosters have an increased likelihood of being contaminated and don't do anything. \n \n Get the negative side effects, like being popped for gear usage, without the positive side effects, like getting jacked :(

You're volunteering at the Field Hockey Pan Am Cup. It's very hot and humid and an athlete is requesting for IV pre-game. \n \n What should you do?

Deny his request as per the no needle policy. \n \n If they collapse or start experiencing heat illness symptoms, then you can give them an IV.

You're volunteering at the Field Hockey Pan Am Cup. It's very hot and humid and an athlete has developed painful cyst from ingrown hairs on their foot, which interferes with wearing their shoes. \n \n They'd benefit from a cortisone shot. What should you do?

Give them a cortisone shot as per the no needle policy exceptions.

Sport- Related Vascular Conditions in Endurance Athletes

* FLIA
* Adductor Canal Compression / Venous outflow Syndrome
* PAES
* CECS

FLIA - flow limitations in the iliac artery

* Blood flow limitation during exercise
* Functional → structural stenosis
* kinking, compression → endofibrosis
* Progressive months → years
* Ischemia → hypoxia → claudication
* Non-specific symptoms
* pain, burning, powerlessness

FLIA - prevalence

* First described mid 1980’s in elite cyclists
* young, healthy, very fit athletes
* male & female cyclists, skaters, runners…
* estimated 1-in-5 professional cyclists
* occupational hazard in sport

Patient History with FLIA

* pain, burning, powerlessness (claudication)
* quadricep, other working muscles
* Most often left leg (why)? Heart
* Symptoms resolve within 5 mins rest
* ruled out more common MSK diff Dx
* Typically has not responded to previous interventions (physio, training changes)

FLIA- Functional Assessment

* Questionnaire, Diff Dx
* Functional assessment

Ankle-Brachial Pressure Index

* Questionnaire, diff Dx
* functional assessment
* ankle-brachial pressure index (ABI)

Specialists Clinical Evaluation

* Echo-doppler ultrasound imaging
* arterial kink
* excessive length (tortuosity)
* Endofibrosis/stenosis

Peak Systolic Velocity (PSV)

* Ultrasound imaging

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Computed Tomography (CT)

* ultrasound imaging
* PSV
* MR Angiography
* CT Scan

Bike & Body Position

* Goals: open hip angle, reduce impingement of iliac
* upright handlebars, closer to body
* forward saddle
* shorter cranks
* rearward cleat position
* flat shoes, no clips

Biomechanics

* reduce active pulling on upstroke
* decrease PSOAS recruitment
* Increase Glute recruitment
* pedalling in circles is less metabolically efficient
* elite cyclists just push down harder

Training modifications

* decrease intensity, decrease volume, decrease volume of intensity
* decrease symptoms: controllable
* Training zones should account for symptoms
* easy zones = no symptoms
* uncontrolled symptoms indicated above sustainable threshold

Stability and Mobility Exercises

Core, hips, and lumbar stabilizations

* decrease PSOAS recruitment
* increase glute recruitment
* prescription must be individualised

Surgical management

1. arterial kink
2. excessive length (tortuosity)
3. endofibrosis/stenosis (narrowing)

Adductor Canal Compression/ Venous Outflow Syndrome

* Superficial femoral aa. & vv. compression
* hypertrophied quad & adductor mm.
* ischemia → hypoxia → claudication
* symptoms: claudication, swelling, heaviness, paraesthesia
* management: surgical release
* mechanical compression of microvasculature
* local compression from hypertrophied muscle
* ‘up stream’ venous compression?
* back flow of deoxygenated (venous) blood volume on muscle relax

May-Thurner Syndrome

* compression of iliac vein by iliac artery
* symptoms: swelling, discolouration, fullness
* Diagnosis: D-US, MRI, CT Scan
* Management: Angioplasty, bypass

Popliteal Artery Entrapment Syndrome

* compression of artery, vein, nerve
* structural or functional
* subtypes I-VI & F

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Symptoms of Popliteal Artery Entrapment

* claudication : pain in thigh, calf or butt when walking
* swelling, fullness
* paraesthesia: burning or prickling

How is Popliteal Artery Entrapment Syndrome diagnosed?

* provocative testing
* duplex ultrasound imaging
* MR angiography, CT scan

How is Popliteal Artery Entrapment Managed?

* soft tissue treatment
* botox injection
* surgical decompression (fasciotomy, myotomy)
* vascular repair, re-routing, bypass

Return to Play guidelines after an open arterial revascularization procedure

* POD 1-2: gentle active and passive ROM, weight bearing as tolerated
* POD 3-4: supervised walking
* POD 5-6: stairs
* Weeks 2-4: unsupervised walking, lifting,

Chronic Exertional Compartment Syndrome (CECS)

compression of fascial compartments

* muscle, artery, vein, nerve
* mechanical pressure
* ischemia → hypoxia → claudication
* nervous sensory disruption

Symptoms of CECS

* claudication, paraesthesia, fullness, weakness, swelling, hernia
* gradual onset during a training bout
* rapid recovery
* faster onset & slower recovery over time
* commonly bilateral

How is CECS diagnosed?

* Needle manometry pressure testing
* NIRS muscle oxygenation

How is CECS managed?

* manual therapy (not vry effective)
* surgery - fasciotomy
* training modification/ reduction
* Forefoot Running

**Acute** Compartment Syndrome

* surgical emergent
* often direct rauma
* severe tissue ischemia
* pain “out of proportion to injury”
* paresthesia, weakness paralysis
* immediate surgical consult
* fasciotomy

Gastrointestinal Distress effects what percentage of runners?

* 30-90% of runners

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Symptoms of GI Distress

1. heartburn
2. nausea
3. vomiting
4. abdominal cramping
5. bloody diarrhea

An upper GI tract infection could be caused by an infection anywhere in the ______ to _______

Mouth to ileum (small intestine)

A lower GI tract infection could be caused by an infection anywhere in the ______ to _______

Cecum to anus (large intestine)

What are the 3 parts of the GI tract?

1. mouth/salivary glands


1. breaks down food, prepares for ingestion
2. Esophagus


1. transports food to stomach via peristalsis
3. stomach


1. hollow organ that stores food while it is being processed
2. enzymatic and chemical breakdown of food

What are 3 functions of the liver?

\- Processes nutrients absorbed from small intestines \n - Production of bile \n - Major role in detoxification

What are 2 functions of the pancreas?

\- Secretes digestive enzymes into the duodenum (which break down macronutrients \n - Secretes insulin into bloodstream

What are the two functions of the gallblader?

store and concentration of bile

releases it for fat digestion

Small intenstine

* duodenum, jejunum, ilium

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large intestine (colon)

* cecum, ascening, transverse and descending colon, sigmoid colon

Rectum

* connections colon to anus
* holds waste until evacuation

Anus

Final part of the digestive tract

Digestive Tract from start to finish

1. Mouth
2. esophagus
3. stomach
4. liver
5. pancreas
6. gallbladder
7. small intestine
8. large intestine
9. appendix

True or false: during exercise, blood is directed to working muscles and the intestines become ischaemic

true

How does mechanical traction during exercise cause GI distress (3)?

Aggressive diaphragmatic movement, abdominal contractions, and jarring of the intestines, which can also lead to intestinal bleeding

How does exercise affect the gut? (2)

1. Splanchnic hypoperfusion


1. reduced blood flow to the gut - splanchnic vasoconstriction
2. steal of blood flow to exercising muscles
2. Motility


1. reduced esophageal motility and pyloric sphincter tone
2. reduced gastric emptying during severe exercise
3. possible increase intestinal permeability with exercise (leak into abdomen)

How do mechanical factors affect GI stress in runners vs cyclists?

Runners: pounding is likely to cause lower GI stress \n - Leads to flatulence or diarrhea (urgently) \n \n Cyclists: positioning is likely to cause upper GI stress \n - Caused by pressure on the abdomen, and horizontal displacement of esophagus

Nutritional causes of GI stress?

1. fibre
2. fat
3. protein
4. carbs especially fructose (so concentrated)


1. beverages with high osmolatieis
2. delay gastric emptying

Nutritional solutions

mix of glucose/fructose better than single sugar alone

or maltodextrin/fructose

GI Issues - Nutrition

\-individualized

\-athletes should keep track of foods that cause them GI discomfort

\-dont introduce new foods before competition

\-time meals properly

\-fibre should be regular part of diet but avoid immediately before competition or intense training

\-stay hydrated

\-avoid trigger foods

Is there an association with NSAID use and risk of lower GI issues?

No! NSAID use increases risk of UPPER GI issues and can interfere with gastric lining

Your athlete is consuming large amounts of NSAID's and is experiencing reflux and upper GI bleeding. What part of their GI tract is damaged?

Esophagus (common)

Your athlete is consuming large amounts of NSAID's and is experiencing gastritis, perforation and upper GI bleeding. What part of their GI tract is damaged?

Stomach and duodenum (common)

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Your athlete is consuming large amounts of NSAID's and is experiencing increased GI permeability. What part of their GI tract is damaged?

Small intestines (rare)

Your athlete is consuming large amounts of NSAID's and is experiencing increased permeability and lower GI bleeding. What part of their GI tract is damaged

Large intestines (uncommon)

Upper GI Tract Issues

1. heartburn
2. reflux
3. nausea
4. vomiting
5. bloating
6. epigastric pain
7. EILO

Gastroesophageal Reflux

GERD - gastroesophageal reflux disease (heartburn is a symptom)

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Likely causes (at rest):

\-decreases in esophageal peristaltic activity

\-decreased lower esophageal sphincter tone

\-increased transient lower sphincter relaxation

GERD

* Non-exercise causes include:
* smoking, obesity, pregnancy, overeating
* Trigger foods:
* high fat foods, chocolate, coffee, tea, alcohol, tomatoes, cheese, juice, carbonated beverages
* if an athlete starts experiencing GERD (or other GI changes), have them keep a food log to track symptoms

GERD in Athletes

* exercise is common cause
* may mimic symptoms of asthma
* the mechanism by which GERB occurs during exercise is not well understood
* Symptoms of GERD may include chest pain
* always rule out serious conditions that may cause chest pain

How to avoid heartburn, reflux, epigastric pain

* no solid foods before training/competition
* OTC antacid medication (Tums, Rolaids)
* Histamine blocking drugs (Pepcid, Zantac, Tagamet, Famotidine)

Lower GI Tract Issues

* Cramping
* Urge to defecate
* Diarrhea
* Rectal bleeding
* Flatulence

The ‘Stitch’

* sharp pain in UL or UR quadrant during exercise
* mechanism unclear, but likely a spasm of the diaphragm or gas trapped in the colon
* avoiding solid food prior to exercise seems to help

Runners Diarrhea

* “Runners Trots”
* Frequency increases with intensity and duration of exercise
* More prevalent in competition than in practice
* anxiety may be a contributing factor
* caffeine and artificial sweeteners are linked with diarrhea.
* \*\*think sugar free gum, coffee, energy drinks pre competition
* Causes vary and aren’t always clear (ischemia, increase motility)

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Runner's diarrhea is more common during competition as opposed to practice. What are some easy ways to avoid runner's diarrhea before a competition (2)?

\- Reduce fibre consumption 24h prior to race \n - Anti-diarrheals (medication)

Rectal bleeding may occur after an endurance event. What are 2 methods an athlete can use to prevent rectal bleeding?

1\. Assure proper hydration \n 2. Reduce mechanical jarring (change running technique, shoes/surface)

What does FODMAP stand for?

FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols.

What are symptoms of IBS?

* cramping
* abdominal pain
* bloating
* constipation
* diarrhea

Foods containing high FODMAPS (avoid)

* apple, mango, fructose, dried fruit, corn syrup, milk, wheat, baked beans

Foods that are LOW on fodmap GOOD

* banana, celery, zucchini, basil, rice, oats, polenta, milk alternatives, hard cheeses

Pre-event protocol to avoid bowel issues

* Dont experiment during an event
* trial foods during training
* train in a similar environment
* Prior to event, reduce:
* fibre
* caffeine
* specific intolerances: lactose, gluten
* During event, be cautious:
* caffeine and other stimulants
* fibre
* simple sugars, such as fructose alone
* specific intolerances: lactose, gluten
* Dehydration
* NSAIDS

Infectious Diarrhea (AKA Travellers Diarrhea)

* Caused by:
* Bacteria: salmonella, E.Coli
* Virus: Norovirus, Rotavirus
* Parasites
* e.g. Giardia, Cyclospora
* **most common cause: bacteria**
* Associate with:
* frequent bowel movements
* potential fever higher than 38
* potentially blood stool