This is a really different topic for me to write about, but since the Winter Olympics were just held in my second favorite country in the entire world, I could not help but think about Turin, the evolution of sports and chiropractic's dedication to helping these fine athletes become even better.
How well I remember that unusual call almost 20 years ago from the ACA Sports Council, asking me to make a presentation at the Xth Pan American Games Congress, whose theme that year was "Sports Medicine Practitioners: Who Do the Athletes Rely on?" For those who know me, this is really funny, because I do not know the difference between a hockey puck and a football (sports just is not one of my strong points), but I always have had a high degree of respect for and interest in how those dedicated DCs who are sports enthusiasts have advanced the profession with the universal language of sports.
I accepted the invitation, but not without trepidation; here I was, about to make a sports presentation to a sophisticated group, and this was one of the first opportunities for chiropractic to participate at this level. Fortunately for me, I had a great support team: Tom Hyde, Stephen Press, John Danchik, Stewart O'Brien, Tom Sawa and L. John Faye all provided excellent commentary and input into my presentation.
As I look back now, I am amazed at what we knew then and how far we have advanced. The following is my 1987 presentation to the Pan Am Congress, followed by an historical update by Tom Hyde, who has truly embodied the enthusiasm and dedication to advance the incorporation of chiropractic participation in the world of sports.
CHIROPRACTIC SPORTS SCIENCES-A NEW PERSPECTIVE
August 6, 1987
THE GREAT DEBATE - WHO DO THE ATHLETES RELY ON? - will certainly bring many differing views from the varied practitioners who are presenting papers during this conference. The most important consideration, however, is not the practitioner, but the athlete who will benefit or suffer from the inclusion or exclusion of any form of therapy which is currently available. As a practitioner of chiropractic, recognizing that the traditional stand of the medical community has been antagonistic (which I am delighted to report is rapidly changing), it is not surprising that sports chiropractic has been ignored to a large degree.
It is interesting to note that George A. Sheehan, MD, the cardiologist/runner, wrote in his book Running and Being, "Physicians who handle emergencies with éclat, who dive fearlessly into abdomens for bleeding aneurysms, who think nothing of managing cardiac arrest and heart failure, who miraculously re-assemble accident victims, are helpless when confronted with an ailing athlete. They are even less able to counsel the athlete and answer his never-ending questions about health." "The athlete," Sheehan concludes, "is medicine's most difficult patient."
Sports Science has been defined as the description and explanation of natural phenomena associated with physical activity and sport. This includes the specialty sciences of exercise physiology, motor learning, sport and exercise biomechanics, sport psychology, sport sociology, and exercise biochemistry.9 The extensive participation by so many professionals in the area of sports has created the need to develop the "Clinical Sports Sciences" aimed at the prevention and treatment of injuries to sports participants. Top athletes are truly a marriage between physiology and biomechanics.
There are good reasons why the athlete should seek the talents of a sports chiropractor for the treatment of a sports injury, because of their special attention of spinal biomechanics and joint manipulation. Active people are physically and emotionally different from sedentary ones -making the athlete a unique organism with special senses and unique needs which must be addressed. Athletes are fine-tuned machines and each working part of their biomechanical system must work in harmony for optimum function. Even a minor breakdown in just one part could mean the difference between participation and being sidelined, or between victory and defeat.
The chiropractic rationale for joint manipulations is based upon the biomechanical and physiological function of joints. Normal joint movement has been shown to be an essential and key factor for all other soft tissue to remain healthy.
The traditional sports medicine practitioners have concerned themselves with two types of joint movement - active and passive. Sports injuries often received the classic strain/sprain diagnosis, along with the standard medical treatment. Many athletes, knowingly or unknowingly, have accepted the limitations imposed by this approach. There are those athletes, however, who have refused to accept the standard orthodox approach and have sought treatment from sports chiropractors. World-class runners, high jumpers, track and field participants, decathlon stars, tennis professionals, Olympic gold medal winners in 400 and 800 meters, professional boxers, and the list goes on.
Their names would read like the "Who's Who" in the various fields of athletics and are unimportant for our discussion today. What is important, however, is to recognize how the approach of sports chiropractors is different. And while the athletes' claim that regular and/or specific manipulation by their chiropractors has led to dramatic performance levels may be subjective, we cannot ignore the fact that these elite athletes are more sensitive to their own human performance levels, and therefore can make statements with some authority and note resultant increased performance using their own past performance as a standard by which to judge the effectiveness of treatment received.
Beyond active and passive joint movement, sports chiropractors recognize another type of joint motion described in detail by Dr. John Mennell11 as specific movements that occur in a joint, not in the normal active or passive range. To illustrate the joint motion we are describing, the joint separation of a few millimeters when the proximal phalange is pulled from the metacarpal bone, provides a classic example. Since there are no muscles to achieve this motion, the pull on the joint provides the long axis extension involved in this joint motion.
The importance of voluntary muscle action depends upon normal joint play.11 If normal specific joint play movements are not present; the range of active motion is lessened. Muscles cannot be trained to their full potential if they cannot fully extend and shorten.
All joints of the body which have restricted joint play will result in a compensatory muscular restriction. For example, hip joints and sacroiliac joints which exhibit a loss of joint play cause the hamstrings and quadriceps to tighten. The emphasis on one or more of the specific joint play movements leads to the diagnosis by the chiropractor of joint dysfunction,11 or fixation,5 or subluxation,13 depending on the era of his terminology.
It is estimated by most experts that as many as 20 percent of all sports injuries affect the area of the body known as the spine.6 These injuries are widely acknowledged to be very incapacitating, complicated, and difficult to manage. Spinal injuries not only can incapacitate the athlete, but to a lesser or greater extent, affect his performance. The use of hands to massage tender to spastic muscles and to mobilize stiff or sore joints, has been widely recognized through the years, as a valid means of keeping athletes from long periods of convalescence after injury.6
Despite the use of stretching exercises and other measures designed to mobilize stiff joints, some athletes find that certain muscles just do not loosen up properly. One reason for this frustrating observation on the part of the athlete is that exercise and stretching alone cannot restore the loss of joint play.3 Rehabilitation requires manipulation in a specific direction or directions, depending on the number of specific joint play movements lost in a particular joint.
Therefore, the expertise of a sports chiropractor becomes increasingly more clear as the focus on joint play is considered.
The dramatic improvement in performance levels claimed by athletes who receive regular manipulation by their chiropractor is now a commonplace phenomenon. Virtually every study conducted on the efficacy of spinal manipulation supports manipulation as being superior to all other forms of conservative care of back pain, acute pain being more conducive to change than chronic pain.4,6,10,12 Thus, the reliability of spinal manipulation conducted by qualified, well-trained practitioners is becoming well-established.
The practitioner of spinal manipulative therapy then will indeed play an integral role in the prevention of injury and the enhancement of athletic performance by the special and specific emphasis placed upon joint play.
One cause of a loss in joint play is a previous inflammation which may have resulted from a sprain or fracture, and resulted in scar formation and fibrosis in and around the joint. The acute condition is commonly treated by physiotherapy, and exercises are employed to ensure that the muscles return to their normal length and strength. Joint play is rarely considered and oftentimes remains abnormal. The athlete with joint dysfunction may experience severe pain only after a certain length of time of performing a certain movement. The runner may find that after 15 minutes of running, his ankle will hurt so badly that he has to stop and rest. Rest will relieve the pain; however, activity produces it again. There will be no swelling, nor can a specific diagnosis be made by an attending physician. The pain has a sudden onset, is sharp and intermittent, and is usually limited to one joint. Eventually, even rest does not relieve the pain and the joint stiffens. Because no specific diagnosis can be made, the possibilities of psychological difficulties are implies. Sports psychologists theorize, and the disillusioned athlete is left to cope with problems on his own. The injury may be a post-traumatic joint dysfunction which can and will prevent the normal functioning of the muscles and the normal range of joint motion. It appears that joint dysfunction increases stress factors to abnormal limits.3
We can state with some degree of authority that with normal joint play movements, joint dysfunction pain syndromes will not develop, nor will the muscles and ligaments tear as often. Additionally, with normal ranges of motion, the joint neurophysiology will give normal proprioception and the range of motion feedback to the central nervous system, which is essential for muscle coordination.
Cibulka, et al., state that "patients with hamstring muscle strains who are treated by correcting a sacroiliac joint dysfunction have a greater increase in peak torque in their injured hamstring muscles than those patients whose sacroiliac joints are not manipulated."1 Sacroiliac joint dysfunction may predispose an athlete to muscle strain; therefore, it is imperative to examine the pelvis for possible dysfunction in athletes who have muscle injuries of the thigh.
The validation of the effects of limited joint motion producing pain and hypertonicity of muscles that move the affected joints is also well documented by Barry D. Wyke, MD, in his text Articular Neurology and Manipulative Therapy. Suffice it to say for this paper that significant attention is now being given to limited joint movement and its effects on joint function.
"The muscle groups and joints of the spine, trunk, and pelvis are the key links in the system responsible for the transmission of force from the trunk and spine to the extremities, thus assuring the stabilization, fixation, and neutralization forces essential for normal mechanics in distal limb segments."2
"In general, it can be stated with considerable assurance that the loss of the contribution of any single component of the neuro-musculo-skeletal apparatus leads to compensatory changes in the remaining functional parts. These changes are directed toward achieving a type of locomotion that minimizes energy expenditure at a given speed. A major loss always causes an increase in energy expenditure at a given speed, and this increase becomes more marked as the speed is increased."7
It is again well-documented that segmental nervous overload can affect the complex integration of the postural and contractile unit neurophysiology, leading to injury states. This is a rational adjunct to the overuse theory of injury and an expanded explanation for the concept of muscle imbalance injury states.
It is obvious that in highly developed, delicate and sensitive individuals with a "kinetic sense" unknown to the average human, the loss of energy can make the difference in this group of elite athletes in which 1/20 of a second is oftentimes the difference between moderate or exceptional performance.
A more detailed explanation of energy loss and physiological fatigue might be appropriate to establish the fact that excessive, long-term motor unit irritation leads to "muscle pain and tenderness to palpation."14 Nerves and nerve roots are subject to "compression, stretching, angulation and torsion."8 The spinal cord is subjected to varying degrees of facilitory and inhibitory modulation. This abnormal activity creates reflexogenic changes at the spinal segmental level that include reduced blood flow, muscle fatigue, mechanical irritation in ligaments, tendons, joint capsules, and muscle bellies. Lewit terms these changes "the functional pathology of the locomotor system."10
All athletes are aware of the potential energy stored in the musculotendinous unit for use in peak performance. Complex processes, known as lagged reciprocal crossed extensor reflexes, come into play in coordination of these flexion and extension reflexes. Physiological fatigue, which produces waste products and inefficient contractile activity due to shortened muscles that will not fully relax, results in what is known as the "delta state" of muscle fatigue. Muscles and tendons undergo the absorption of "load factors" biomechanically in order to produce a measurable output of mechanical force. This overloading causes fatigue and microtearing. Extrinsic overloading causes tendon complex breakdown while intrinsic overloading causes muscle belly breakdown (microtearing). The fatigued contractile units become injured or lead to joint injuries due to their inability to act synergistically and thus protect the joint. The most adequate treatment of joint or spinal segment movement restriction is manipulation.10 This is understandable because structural lesions necessarily produce disturbances of function and vice versa.
On a more practical basis, the sports chiropractor deals on a daily basis with postural imbalances, muscular imbalances, and overuse and misuse syndromes. This approach is unique in that it can therapeutically act to reduce structural pathology using manipulation. Early detection using joint play and motion palpation procedures can correct potential functional pathology. It is very important to understand that when the sports chiropractor is referring to joint flexibility and range of motion, he is taking into consideration two very important factors:
- external joint ROM and making reference to all applicable muscles, tendons, ligaments, etc.
- internal ROM (joint play) including the synovial folds (membranes) cartilage plates, and joint formation, involving itself with the finite movement of the joint.
Both of these factors come into play when the athlete is conditioning himself for peak performance. This applies to all joints in the body whether they are spinal or peripheral, and is necessary to achieve optimum physiological performance.
Research has demonstrated that the maximum power of contraction or the electro motor force (EMF) for a muscle is attained only when a muscle is allowed to expand and contract in its normal anatomical and physiological range. Full joint play thus becomes essential in attaining this goal. Compensation to joint dysfunction increased stress factors to abnormal limits.3
With proper chiropractic diagnosis and care, athletes could reap significant benefits which will include normal muscle function, improved range of motion, improved coordination, and better balance, resulting in fewer performance injuries.
Thus, the evolution of manipulation and the entrance of the sports chiropractor into the arena would lead one to the natural conclusion that every serious athlete should have all joints examined for specific joint play early in the training process. This examination would eliminate lost time, effort, and poor performance caused by undetected joint dysfunction.
Full potential cannot be achieved or attained unless specific attention is paid to this often overlooked factor of human performance. Therefore, "who do athletes rely on?" can be answered by suggesting no one practitioner, but rather a team approach dedicated to areas of expertise unique to each discipline, but collectively imperative to our athletes achieving their peak performance and full human potential in the sports arena.
Cooperation among all health care providers is absolutely essential, and let the competition exist among the athletes.
[References omitted]
I contacted Dr. Hyde and asked if he would put together some thoughts on how far we have come since the Pan Am Congress. He was gracious in putting together his thoughts and in doing so, while taking a trip down memory lane also realized the enormous advancement chiropractic has made.
Dear Lou:
I remember very well your presentation. In discussing who should do that presentation, the ACA Sports Council board thought that despite your "nonathletic" chiropractic background, you could do the presentation and make the best impression possible.
Here are a few things that have occurred since your 1987 presentation. (Almost 20 years ago, it seems like yesterday.) I was at the Pan Am Games in '87 in Indy; you made the presentation to the congress before the games. The excitement among the chiropractors in attendance was palpable. While my recollection may not be 100 percent and I may have overlooked some individuals, the following at least gives you a flavor of what has transpired since those early years, struggling with chiropractic participation in sports. So, I will make an apology in advance to anyone reading this recollection, in the event I have omitted anything of significance. Hopefully, someone will provide the complete historical account of our meteoric rise in sports someday.
More than a decade before the Pan Am Games, a number of chiropractors formed the ACA Sports Council to address how to better train and equip chiropractors to treat athletes. Leonard Schroeder, Sid Birdsley, Bill Womer and others helped to create the council in 1972. Robert Reed and others helped to develop the first CCSP course, and Bob Hazel and others continued to stress further education and helped to create the Diplomate in Sports Chiropractic. Reed was also one of the first to work with a professional football team, the Los Angeles Rams. Leroy Perry worked on many track and field athletes and went to several Olympics, including the 1976 games in Montreal. He did not go as an "official" chiropractor for the United States, but he was able to go to Antigua and treat many of the U.S. Olympians. Because of him and others like him, and their ability to help many of the athletes, the U.S. finally allowed chiropractors to participate in the two-week sports medicine internship program at the U.S. Olympic Training Center in Colorado Springs, Colo. I might have been one of the first to go there in '86, followed by Jan Corwin. From there, I went to the Pan Am Games in '87 and Jan went to the Olympics in '88.
In 1980, George Goodheart went to the Winter Games in Lake Placid at the invitation of Dr. Dardik, who was head of U.S. Olympic Sports Medicine Team. From there, Eileen Haworth was asked to go to the '84 Olympics in Los Angeles. The U.S. decided to "officially" invite a chiropractor; Eileen was asked. As mentioned, Jan Corwin was the first to go through the two-week internship program and then go on to the Olympics. We have had a chiropractor as part of the U.S. Olympic Sports Medicine Team each Summer Games since 1988, and at the Winter Games since 2002, when Robin Hunter broke the ice in Salt Lake City. (As an aside, at each of the past two Olympics, Athens and Turino, two chiropractors were officially assigned to the U.S. team.)
During this period of time, many chiropractors made friends and influenced people around the world, which has led to our being invited to participate in such events as the Olympics (a number of other countries also include DCs now, including Canada, Brazil and New Zealand). We also have worked the Commonwealth Games, World Games, World University Games, Bolivariano Games, Asian Games, Central American and Caribbean Games, Goodwill Games and many, many more. We have worked with national governing bodies for track and field, weightlifting, powerlifting, performing artists, triathletes, swimming, diving, golf, tennis, and really just about every sport you can name worldwide. Years ago, this was only a dream in the hearts and minds of DC who were passionate about sports.
We have established a working relationship with the World Olympians Association (WOA). The WOA consists of approximately 100,000 former Olympians worldwide. They are one of the "pillars" of the International Olympic Committee (IOC). The WOA has now invited chiropractors to work on athletes, IOC dignitaries, National Olympic Committee VIPs, Visa VIPs, and a host of other very influential individuals from business and sports. We have worked the 2002 Winter Games, the 2004 Summer Games, and now just had six DCs from around the world working with the WOA in Torino.
The WOA also has been extremely supportive of our inclusion within the polyclinic at all Olympic Games. To me, this is the one remaining link we have not been able to complete. We continue to struggle with the IOC Medical Commission, but with persistence, we will eventually succeed in becoming included in the polyclinic. Then, I believe we will have achieved a level of "cultural authority" for chiropractic within the sports arena. There have been scholarships established for Olympians who wish to become DCs. There are several Olympians now in chiropractic College, and others under consideration.
So, 20 years ago, things we could only dream about or imagine have now pretty much come to fruition. We are not home completely, but have come a long way. This has been a long road involving many people on both sides of the equation. As of this writing, we are attempting to meet with the head of the IOC Medical Commission. I do not know if this will happen and even if it does, there are no assurances that we will be involved in the polyclinic. But we will not stop until we succeed.
We have men and women involved in sports treatment of athletes. We have actually now served as "medical directors" for many events. Ted Forcum was recently the medical coordinator for the U.S. Figure Skating Championships and Stephen Perle served as medical director for the Mobile Track and Field Championships years ago. We have served the same for international softball tournaments, the Volvo Around the World Race (12-meter sailing yachts) and too many other sports to list. We have created forms to take to the field; we have managed to crack the "travel to treat" issue. This means, for example, having a license in Pennsylvania and requesting permission to travel to treat athletes in N.Y., and have their board approve that treatment. The FCLB has been very helpful in this regard and we are now working with them to make this happen worldwide along with the WFC. Day by day, week by week, agonizing hour by hour, we have made great strides, but in no way can we sit back without continuing to do our homework.
Bob Hazel used to say, "We have so many DCs who wish to treat athletes and not enough events to cover." Now, our biggest problem is just the opposite: too many events requesting our services and not enough chiropractors who are willing to work.
On another note, I believe we now have more than 25 DCs working with NFL teams. We have DCs working in official capacities with professional baseball, basketball and hockey teams, golf pros and many colleges and universities. Where this was once a rare finding, it is now more and more common. We have Ohio State University offering an alternative medicine program (taught by Robin Hunter) that includes sports medicine. Sometimes, I think we have not come very far; then you ask me to reflect and as I write, I see just how much we have accomplished. I also see how far we still have to go.
Tom Hyde
So, there you have it: a brief outline of several decades of chiropractors working like gold medalists to help advance the chiropractic profession. We should truly be proud of these dedicated individuals and their determination to make a difference. They are the chiropractic Olympians.
