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 ID: 776398
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Exercise enhancement in athletes: legaland illegal, with specific examples and case presentations
Matthew N. Bartels, MD, MPH Professor and ChairmanAlbert Einstein College of MedicineMontefiore Medical CenterBronx, NY
Slide2Disclosure
- 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…..
Slide3Course 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.
Slide4Basics of Exercise Training
Divided into two main categories, dependent upon type of sportAerobic conditioningEndurance sports, e.g. long distance running, triathlon, cycling, football (soccer)Strength trainingShort burst activity and poser sports, e.g. sprinting, American football, weight liftingMost sports require a balance of the two
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Slide5In the New York Times
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Slide6Remember Basic Physiology!
Endurance activity requires more aerobic fibersThis is predominantly Type 1 fibersSustain activity for hours, but slow twitch speed and small fiber sizeShort burst activity requires more anaerobic fibersThese 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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Slide7Basic Terminology
Measurement of exercise capacityAerobic TrainingVO2 – defined as Liters of O2/minute or mlO2/kg/minMET – one metabolic equivalent - 3.5 mlO2/kg/minWattage – Resistance on an ergometer – this is power outputHeart rate – Used to determine the level of intensity once power at a given heart rate establishedRPE – can guide exercise once power rates determinedResistance TrainingMaximum Voluntary contraction – one rep max
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Slide8Cardiopulmonary Exercise Testing
CPET is used regularly in athletesScreen for IHSS or arrhythmia in younger athletesAllows for most efficient training program in dedicated athletesDone in sports specific testingAchieve individual specific target heart ratesCustomize exercise program for recovery or improved performance
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Slide9Exercise Guidelines for Athletes
Use established guidelines – but best with exercise testing to determine true levels of intensityAlways have appropriate warm up and cool downSome controversy exists on benefits, but nothing that states it is harmfulRole of CPETFor high level athletes, can help to refine exercise programs and prevent overtraining. Has a role in defining work efficiency/economyCan allow for maximal performance
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Slide10CPET – What Are You Looking For?
Peak capacity in resistance/intensity and VO2Anaerobic/ventilatory thresholdRespiratory compensation point above AT – for peak strength/interval trainingCan give youHR targetsWith task specific testingWattage/cadence for cyclistsSpeeds/inclines for runnersProfessionals use this all the time
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Slide11Aerobic Training – Injury Avoidance
Principles to avoid injuryAvoid overtrainingIncorporate multiaxial activityUtilize neumuscular and proprioceptive trainingE.g. running on reular surfaces better than on a treadmill, or road cycling better than on a stationary bikeEmphasize agilityUse well maintained equipment
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Slide12Aerobic Training – Injury Avoidance
Consume appropriate nutrientsDuring and in the first hour after exertion- need to have glucose and some protein, fats less criticalConsume appropriate liquidsAvoid overhydration – can use thirst as a guideHyponatremia is the highest risk – can lead to mortalityMaintain ElectroytesUse of appropriate protective equipment
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Slide13Aerobic Exercise Capacity
For endurance only trainingWork at or lightly above Anaerobic thresholdUse as base intensity, build up training sessions Perform dailyFor power combined with enduranceGoal is to build burst power in addition to building enduranceInterval training is a good way to achieve thisAlternate long endurance sessions with interval sessions
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Slide14Sample Exercise Program
Endurance athlete – 30 y/o male runnerCPET Max VO2 is 60 ml/kg/minAT is at 51 ml/kg/minHR at peak 188, HR at AT is 165Exercise 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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Slide15Sample Exercise Program
Elite Competitive Cyclist– 27 y/o female cyclistCPET Max VO2 is 56 ml/kg/minAT is at 48 ml/kg/minHR at peak 198, HR at AT is 170Exercise 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 BPMInclude strengthening with weight training focused on thigh muscles, and core along with agility/balance.
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Slide16Strength Training Exercise
Weight lifter 35 y/o man, recreational/semi-competitiveEstablish one rep maximum trainingDO a program of low repetition and high weight training – using reps in the >85% on rep max levelInclude several bouts of lower intensity free weights for agility and endurance – helps with injury preventionUse spotting, appropriate equipment/protective gearAdvise that some aerobic exercise also is important for general fitness – at moderate intensity level 70% peak HR.
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Slide17Strength Training Exercise
Football player 20 y/o man, competitiveThe balance between aerobic and strength will depend on the position – must be tailored to position.Establish maximum training program for strengthInclude low repetition and high weight training – using reps in the >85% on rep max levelInclude several bouts of lower intensity free weights for agility and endurance – helps with injury prevention as well as core exercisesUse spotting, appropriate equipment/protective gearInclude aerobic exercise at moderate intensity level 70% peak HR, with sprints as appropriate.
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Slide18Conclusion
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 pre-participation 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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Slide19Enhancement
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
Slide20Now 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 recentlyLance 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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Slide21What is Used?
Multiple drugs in multiple classesSteroidsEpoAmphetaminesCaffeineNitric OxideAnd more…….Blood dopingProteomics/gene regulationAnd, the new frontier => Gene Doping
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Slide22How is it regulated?
Up to individual sportsProfessional and Olympic sports are under WADAAmateur and school based are under a hodgepodge of regulationsWADA has available downloads Of particular use are: The list of banned substanceBiological Passport (ABP) guidelinesTherapeutic 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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Slide23Therapeutic Use Exemption
You need to know the rules to allow necessary treatment with a banned substance or methodAll TUE need to be filed to protect the athleteSubmitted to the relevant anti-doping agencyVia paper or the ADAMS systemShould be 30 days prior to competition, or as soon as the condition is diagnosed if < 30 daysAnswers go to the athlete => then treatment can startIf they start before approval – technically in violation. Can get retroactive TUE emergencies or TUE cannot be reviewed in time.
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Slide24How does doping work?
Depends on the substance/sport/athleteThis is an entire world of its ownCan be harmful for athletes long termBUT benefits are very high – so risk is secondaryCan include METHODS as well as substancesBlood doping with transfusionEnhancing recovery, limiting pain Tampering with samples/testingGene Doping
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Slide25Some Sample Doping
Cycling is easy to discuss – covers all issuesAllegations since the first TDF (No dope, no Hope!)NTG, Strychnine, cocaine, alcohol, amphetamines, pain killersDeaths in 1960’s1960 Knud Jensen died in Olympic time trial with amphetamines and vasodilators in his system => Olympic ban1st high profile issue in TDF 1967 death of Tom Simpson (amphetamines, alcohol, dehydration)1970’s – Amphetamines and steroids foundEddy Merkx among those positive for PemolineSteroids for recovery, not strength (cortisone)First cases of trying to fool testing (methods) Pollentier and the condom.
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Slide261990’s => EPO arrives
Not detectableGave marked advantages in aerobic strengthOnly could rule high Hct (Bjarn Rijs – Mr. 60%)This was era when Lance started doping1998 – Festina Scandal Van with soigneur Willy Voet stopped at Spanish border with narcotics, EPO, hGH, testosterone, amphetaminesLance allegations swirl from 1998-20062006 – 1) Operation Puerto – The method of dopingBlood bags in a fridge – most famous riders caught2) Landis tests (+) for testosterone:epitestosterone at 11:12010 => Contador stripped for clenbuterol => Transfused?2012-13 – Armstrong stripped of titles after admissions
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Slide27Effect 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?
Slide28So what is used and how?
Clenbuterol – increased lean body mass (LBM)Anabolic Steroids – increase LBM, speed recoveryGlucocorticoids – speed recovery, ease painhGH, IGF-1, PDGF, VEGF, etc – increase LBMHormone and metabolic modulators – increase performanceSERMs, myostatin inhibitors, insulins, aromatase inhibitorsEPO – Increase blood volume/hemoglobinAmphetamines – increase performanceBeta agonists – Enhance breathing/performanceBeta blockers – in selected sports – calm shakingNarcotics – ease pain, speed recoveryAlcohol – not in competition in aeronoautics, driving, archery, karate, power boating, and motorcycling = > historically to ease pain in competitionDiuretics/masking agents – evade testingBlood transfusions – autologous – as EPO
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Slide29What is therapeutically allowed?
Beta agonists: Salbutamol (1600 mg/24hr)Inhaled formoterol (54microgram/24hrs)Inhaled Salmeterol used as per manufacturer’s regimenAlcohol – out of competition allowedBeta blockade – only out of competition, except never for archery, shootingAdrenaline in anesthetic injectionPseudophedrine <150 micrograms/mlEphedine/methylephedrine <10 micrograms/mlCathine <5 micrograms/ml
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Slide30New/New Frontier
ProteomicsWorks at level of proteins to enhance effectiveness of enzyme => myostatin inhibition leads to hypertrophyCytochrome P450 enzymesVariable 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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Slide31Cutting/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 AICARGW1516 (Endurobol): (PPAR-δ-agonist) Causes cancers in liver, bladder, stomach, skin, thyroid, tongue, testes, ovaries and uterusPositive tests in 2013 – Kaykov (Rusvelo) and Ubeto (Lamprey)
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Slide32New Frontier => Gene Doping
Transfer of polymers of nucleic acids/analoguesNormal or genetically modified cellsCan’t currently be testedUnclear if used Significant potential risks and benefitsIntroduced 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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Slide33Conclusion
You can legally help athletes perform at their bestNeed to protect our athlete patients form extralegalProtection:1) from using drugs and enhancers – can be dangerous and it is bad sportsmanship2) from testing false positive due to treatments we giveKnow the reporting process and be openCheck on WADA site for any questions you haveBe an advocate for clean competition => especially in amateurs!
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