Matthew N. Bartels, MD, MPH Professor and Chairman Albert Einstein College of Medicine

1. Aerobic Training and Exercise in Prevention of Injuries and Enhancement of Performance in Athletes (and a Review of Extralegal Enhancement) Matthew N. Bartels, MD, MPH Professor and Chairman Albert Einstein College of Medicine Montefiore Medical Center Bronx, NY

2. Disclosure Matthew N. Bartels, has no relevant financial disclosures. And no interests in the sports described, other than as a fan. (Unfortunately…….)

3. Course Objectives • Learning Objective 1: Course participants will know the basics principles of aerobic training • Learning Objective 2: Course participants will know the application of appropriate exercise testing and training, including interval, high intensity and low intensity training for performance enhancement • Learning Objective 3: Course participants will know the basics of training programs based upon testing to maximize aerobic capacity in performance and casual athletes. • Learning Objective 4: Course participants will have a basic understanding of “extralegal” enhancement techniques seen in sports.

4. 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

5. In the New York Times

6. 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)

7. Basic Exercise for Health

8. 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

9. Cardiopulmonary Exercise Testing • CPET is your ally and friend • Allows risk assessment in individuals with history of potential health issues • Screen for CAD in older athletes • Screen for IHSS or arrhythmia in younger athletes • Most important • Allows for most efficient training program in dedicated athletes • Achieve individual specific target heart rates • Customize exercise program for recovery or improved performance

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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.

17. 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.

18. 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.

19. 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 pre-participation evaluation • Work with trainers and coaches to improve safety - allowing you to be a more valuable member of the athletic support team.

20. 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, 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!)

21. What is Used? • Multiple drugs in multiple classes • Steroids • Epo • Amphetamines • Caffeine • Nitric Oxide • And more……. • Hypoxic training • Blood doping • And, the new frontier => Gene Doping

22. 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/

23. Therapeutic Use Exemption • This is when a treatment will need 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.

24. 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 • Tampering with samples/testing • Gene Doping

25. Effect of Blood Doping • Off the cuff example • Cyclist with baseline VO2 of 80 ml/kg/min\ • This puts you solidly in Peleton – 40-100 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?

26. 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.

27. 1990’s => EPO arrives • Not detectable • Gave marked advantages in aerobic strength • Only could rule high Hct (BjarnRijs – 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

28. So what is used and how? • 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 • Alcohol – not in competition in aeronoautics, driving, archery, karate, power boating, and motorcycling • Diuretics/masking agents – evade testing • Blood transfusions – autologous – as EPO

29. 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

30. New Frontier => Gene Doping • Transfer of polymers of nucleic acids/analogues • Normal or genetically modified cells • Can’t 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.

31. Cutting/Bleeding Edge • 5-aminoimidazole-4-carboxamide-1-β-D-ribofuranoside (peroxisomeproliferator-activated receptor-δ [PPAR-δ]-5' adenosine monophosphate-activated protein kinase [AMPK] agonist) – telmisartan, synergistic with AICAR • GW1516 (PPAR-δ-agonist) - Endurobol • Causes cancers in liver, bladder, stomach, skin, thyroid, tongue, testes, ovaries and uterus • Positive tests in 2013 – Kaykov (Rusvelo) and Ubeto (Lamprey)

32. New/New Frontier • Proteomics • Works at level of proteins to enhance effectiveness of enzyme • Examples include Cytochrome P450 enzymes • Variable activity in various populations – can be altered with pharmacogenetic approaches to enhance the function of the existing gene product. • Altering the effectiveness of existing gene products can alter performance

33. Conclusion • Need to be vigilant to protect our athlete patients • 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!