CHAPTER 16

Complementary and Integrative Health and Sports Injuries

Nancy Ann Cotter, MD, CNS

Complementary and integrative health (CIH) is the term used to refer to approaches that bring together conventional (or mainstream) and complementary (nonmainstream, or not taught in U.S. medical schools) approaches in a coordinated way. The National Center for Complementary and Integrative Health, or NCCIH, is the U.S. federal government’s lead agency for scientific research on and dissemination of CIH health approaches.

The use of integrative approaches for health and wellness has grown within care settings across the United States (Nahin 2016). Researchers explore the potential benefits of integrative health in a variety of situations, including pain management for military personnel and veterans, relief of symptoms in cancer patients and survivors, and programs to promote healthy behaviors. The latter is a relatively new direction in the approach to disease management and health maintenance that fuses alternative and conventional medical practices. Complementary and integrative health differs from conventional medicine in its use of nonmainstream approaches to care as well as its whole-person philosophy and acknowledgment of the contributions of lifestyle, environment, and community to overall health. It emphasizes the therapeutic partnership between health care providers and patients and lends itself to a team approach.

Sports medicine is the branch of medicine concerned with physical fitness; the underlying science of function and performance in sport and exercise; and the prevention, diagnosis, and treatment of injuries or illnesses affecting the athlete. Complementary and integrative health and sports medicine philosophies are based on common foundational principles such as enhancement of health through lifestyle, optimization of performance through manual therapies, and the importance of therapeutic and team relationships. As CIH approaches gain a greater evidence base and more mainstream recognition, they may offer valuable insights for athletes and those who work with them.

The National Center for Complementary and Integrative Health (NCCIH) divides CIH modalities into three broad categories:

1. Natural products. These include nutritional supplements, herbal medicines, and botanicals.
   
2. Mind and body practices. These comprise manual therapies such as osteopathy and chiropractic, and movement therapies such as yoga and tai chi.
   
3. Other. Included here are therapies that do not fit into one of the other two categories, such as acupuncture, East Asian medicine, or Ayurveda, the system of medicine that is native to India. Both East Asian medicine and Ayurveda are complete systems of healing that include sophisticated systems of herbal medicine, mind–body therapies, and movement therapies (i.e., tai chi and yoga).

Natural Products

Sports nutrition is a large field of practice in which there are specific training courses and certifications, such as the one offered by the International Olympic Committee (IOC). It is well recognized that the increased nutritional needs relating to physical exertion in athletes create a demand for increased caloric consumption. This increased demand should be addressed by thoughtful food choices that meet the requirements of muscular restructuring and tissue repair.

There is no replacement for the advice of a nutrition professional for the individual athlete. This professional guidance should take into account the athlete’s body composition, medical and training history, and training requirements. The U.S. Olympic Committee (USOC) offers general recommendations on nutrition, including guidelines for preventing colds, travel nutrition, adjusting food intake to training intensity, hydration, and dietary composition and timing. Although this chapter does not cover the details of sports diets, some excellent resources for athletes on nutrition can be found in Nancy Clark’s Sports Nutrition Guidebook and the USOC and IOC publications. A newer aspect of nutrition that overlaps with integrative medicine is the area of nutritional supplements and botanicals. The IOC has created a consensus statement on the use of dietary supplements in sport, which can be found on the IOC’s website.

Dietary and Botanical Supplements

The global sports nutrition market accounted for $28.37 billion in 2016. In the United States, supplements and botanicals are regulated as foods rather than drugs, so the quality of these products should be evaluated and monitored via consulting with knowledgeable professionals or verifying the product quality through other means (such as text references and independent testing labs). The regulation of products through the Dietary Supplement Health and Education Act (DSHEA) has created a situation in which product quality is variable—mainly because quality control over the product is primarily at the discretion of the manufacturer.

Nevertheless, reputable botanical and supplement companies exist, and a growing body of research suggests that selected supplements might have medicinal value, particularly for treating sports injuries. Compared with conventional medications, botanical alternatives contain lower doses of pharmacologically active ingredients found in natural substances. These lower doses require more time to reach a therapeutic range. Additionally, as with all oral preparations, potential allergic reactions and interactions with conventional medications must be considered. All too often people erroneously assume that because many supplements are “natural” they pose no risk. But there have been reports of dramatic interactions and misuse of supplements that has caused great harm through misinformation and poor judgment in dosing. Although supplements are not regulated, collegiate and elite athletes are subject to drug testing by their national governing body. It is up to each athlete to know what substances are banned and to use only supplements that have been declared safe to use.

The IOC consensus statement defines a supplement as “a food, food component, nutrient, or non-food compound that is purposefully ingested in addition to the habitually consumed diet with the aim of achieving a specific health and/or performance benefit” (Maughm 2018). While a complete review of supplements with evidence of the effect on performance is beyond the scope of this chapter, some highlights stand out. For repletion, it is not unusual for athletes to need supplementation with vitamin D (800-1,200 IU per day), calcium (1,500 milligrams per day), and iron (18 and 8 milligrams or more for women and men, respectively). For performance enhancement, supplements with reasonable evidence to support use include caffeine, creatine, nitrate, and beta-alanine (with and without sodium bicarbonate):

• Caffeine has been shown to be helpful for endurance in distance runners (French et al. 1991), cyclists (Paton, Costa, and Guglielmo 2015), rugby players (Wellington, Leveritt, and Kelly 2017), and rowers (Bruce et al. 2000) in doses varying from 3 to 6 milligrams per kilogram.
  
• Creatine is a nitrogenous organic acid that plays a role in energy recycling in the cell. It is found primarily in skeletal muscle and to a lesser degree in the heart, brain, testes, and other tissues. The body synthesizes 1 to 2 grams per day in the liver, kidneys, and pancreas from food sources of creatine, primarily meat and fish. The intestinal absorption of creatine makes it extremely bioavailable, because nearly 100 percent is absorbed in the intestine as food. A position statement of the International Society of Sports Nutrition (ISSN) states that creatine monohydrate is the most effective ergogenic nutritional supplement currently available to athletes for increasing high-intensity exercise capacity and for increasing lean body mass during training (Buford et al. 2007). Recommended dosing is 0.3 grams per kilogram per day for at least three days followed by 3 to 5 grams per day in order to maintain elevated stores.
  
• Beta alanine (β-alanine) supplementation can increase muscle carnosine concentration and improve exercise capacity and performance. Carnosine (β-alanyl-L-histidine) is a compound composed of the amino acids β-alanine and histidine and is abundant in skeletal muscle, which suggests that it plays an important role during exercise. One key role for carnosine is intracellular pH regulation. Cosupplementation of β-alanine and sodium bicarbonate, to increase both intracellular and extracellular buffering capacity, was shown to result in additional improvements above those with β-alanine alone.
  
• Nitrate is abundant in green leafy vegetables and in beets. Nitrate supplementation has been shown to exert physiological effects that promote exercise performance. Most research has been done on beet juice, not in the form of a pill or capsule.

Other supplements such as glutamine, ornithine alpha ketoglutarate, boron, chromium, selenium, zinc, ginseng (Panax ginseng), Siberian ginseng (Eleutherococcus senticosus), carnitine, choline, coenzyme Q10 (ubiquinone), pyridoxal-alpha ketoglutarate, and pyruvate have been used by athletes based on the belief that they can enhance endurance or strength. The research for many of these supplements, although somewhat promising, is too limited to warrant recommendation for use in sports medicine at this time.

Anti-Inflammatory Botanicals

Many anti-inflammatory botanical preparations are useful for sports injuries. Because botanicals can take up to two months to achieve maximal therapeutic benefit, one strategy is to implement a botanical supplement in the subacute phase of injury, introducing its use after beginning anti-inflammatory control with a faster-acting nonsteroidal anti-inflammatory drug (NSAID). For more information on many of the botanicals discussed in the following sections, see the resources list for this chapter on page 337.

Turmeric

One of the five spices found in curry is turmeric (Curcuma longa), a root whose active ingredients have significant anti-inflammatory properties. The active constituents in this spice, known as curcumoids and turmerones, influence prostaglandins, leukotrienes, and cyclooxygenase enzymes in the same way that conventional NSAIDs do. The customary oral dose of turmeric is 500 milligrams four times daily. Adding this spice to the diet will have positive anti-inflammatory influence, but to maximize the medicinal effects of this natural aspirin-like spice, a concentrated turmeric supplement should be taken. No equivalent dose in cooking is recommended, although the average Asian consumption of turmeric is approximately 2 grams a day, a dose thought to have some degree of anti-inflammatory influence.

Ginger

Another rhizome with anti-inflammatory abilities is ginger (Zingiber officinale). Multiple trials have suggested that ginger is effective in reducing pain in those with osteoarthritis, cancer, and gastrointestinal distress. Given the results of these studies, we can extrapolate that ginger taken as a dietary supplement would be useful for any sports injury in which inflammation plays a part or in which one would normally suggest the use of NSAIDs. Ginger’s active ingredients are gingerdione and shogoals, which are concentrated in the root. Ginger is generally well tolerated, but if consumed in doses over 5 grams per day, heartburn is likely. The recommended dose as an anti-inflammatory botanical is 250 milligrams twice a day as a dietary supplement. Another dietary source of ginger that may have an anti-inflammatory influence is candied ginger, which is full of the shogoals that reduce inflammation.

Devil’s Claw

A native plant of Africa, devil’s claw (Harpagophytum procumbens) is another promising botanical for treatment for anti-inflammatory conditions. It has been investigated for use either alone or in conjunction with NSAIDs, and preliminary results suggest modest reduction in pain symptoms from osteoarthritis. In addition, a study combining devil’s claw with NSAIDs lowered the need for a high-dosing schedule of the NSAID (Chantre et al. 2000). Recently, the 2012 Cochrane review of lower-back pain found strong evidence that daily doses standardized to 50 to 100 milligrams of harpagosides were better than placebo for short-term improvements for pain and rescue medication (Gagnier et al. 2016). Devil’s claw is also known to mildly reduce glucose, increase stomach acid, lower blood pressure, and increase bile production. For those with borderline hypertension or acid reflux, using devil’s claw might be doubly beneficial. Usual dosing for the treatment of osteoarthritis is 2.6 grams daily, providing 57 milligrams of the harpagoside equivalent and 87 milligrams of the iridoid glycosides daily as a dietary supplement.

Mind and Body Practices

The category of CIH practices known as mind and body practices comprises a large and diverse group of techniques that are administered or taught to others by a trained practitioner or teacher. Examples include acupuncture, massage therapy, meditation, relaxation techniques, spinal manipulation, and yoga. Although these techniques are taught, each can be practiced on one’s own after sufficient training. For example, acupressure (or manual stimulation of acupuncture points) and self-massage may be taught to the acupuncture and massage recipient, and meditation and yoga students are encouraged to have their own home practices. Each is intrinsically different, but all may be used for healing injuries and to improve performance and recovery or overall well-being.

Musculoskeletal Manipulation and Movement Therapies

Musculoskeletal manipulation involves passive manual maneuvers by skilled practitioners that “extend the patient’s range of motion beyond the elastic barrier but do[es] not exceed the anatomic barrier” (Greenman 1996). Two of the most well-known practices of this nature are osteopathic medicine and chiropractic, both founded in the 1890s. Massage is also considered in this category. Each has distinct medical models as the basis of its manipulative treatments, and each is used as an important component of sports medicine.

Osteopathic Manipulation

A variety of techniques are used in osteopathic medicine and are described by the American Academy of Osteopathy. They include soft tissue technique, or pressure, traction, and stretching in proximity to the spine and joints. The aim is to redistribute excess tissue fluid from the swollen area and reduce tension in the muscles and fibrous tissue at sites where injury or physical stress has been sustained.

• Myofascial release refers to the manual massage technique for stretching and releasing bonds between fascia and muscles and bones with the aim of balancing the body, eliminating pain, and increasing range of motion. After the release is achieved, the dysfunctional tissue is guided or “reeducated” through passive movement to achieve flexibility.
  
• Cranial osteopathy is aimed at balancing the inherent rhythm of the craniosacral fluid. When the natural rhythm is restored, the nervous system and muscular tissues are more optimally supported.
  
• Lymphatic technique is a manual procedure of stimulating lymphatic fluid movement. It involves the use of pressure by physicians using their hands over the lymphatic system. Hand movement is directed toward the upper chest while the athlete is lying prone. When the athlete inhales, hand pressure is increased; when the athlete exhales, pressure from the hands is removed. This activity generates a negative pressure and reinforces the natural movement of the lymphatic fluid to drain back into the right atrium via the thoracic duct.
  
• High-velocity, low-amplitude (HVLA) technique is a high-velocity maneuver in which the objective is the restoration of natural joint movement. Neural reflexes are “reset” by this manipulation. This therapy restores joint movement and reduces pain, stiffness, and tenderness.
  
• Muscle energy technique is a manual intervention in which the athlete assumes a precise muscle position. The physician then applies a counterforce that changes or resets the neuromuscular asymmetry of the injured area to restore joint mobility and range of motion.
  
• Counterstrain is used with acute injuries in which more aggressive manipulation cannot be undertaken because of pain or severe restriction of movement. The practitioner moves the athlete from the restricted position generated by the injury to a position of comfort. The athlete is without pain, and in this painless state the practitioner resets restricted range of motion and increases flexibility.

A review of osteopathic manipulative therapy (OMT) or the single osteopathic manipulative techniques administered in 1,441 recreational and professional athletes including those involved in golf, football, soccer, and baseball showed that OMT improved the glenohumeral internal rotation, the hamstring extensibility, the outcomes of chronic ankle instability and chronic epicondylitis and by inference improved athletic performance (Civitillo 2018).

Chiropractic

Chiropractic is a health care profession founded by Daniel Palmer, a self-taught naturalist healer who observed that spinal manipulation seemed to help a variety of ailments. Therapeutic chiropractic interventions involve spinal manipulation but also include lifestyle counseling, nutritional management, and the use of many physiotherapeutic treatments, such as ultrasound, electrical muscle stimulation, traction, heat, and manual therapy. Reports on conditions in the literature indicate improvement through chiropractic manipulation of acute or subacute lower-back and neck strain and other areas of muscle tension and soreness caused by overuse during sports participation.

Review of the medical literature suggests that in relation to sports injuries, osteopathic and chiropractic manipulation would be appropriate for acute nonsurgical back strain and neck strain and other areas with acutely derived sports-related muscle tension or plantar fasciitis (Grimshaw 2002). The risk of either osteopathic or chiropractic manipulation is vertebral artery syndrome, an injury to the intimal lining of the vertebral artery caused by sudden thrusts that combine rotation and extension of the cervical spine. The injury results in formation of a thrombus that extends upward, moving into the posterior inferior cerebellar artery. There are no tests available to help predict who is at risk from this injury. The frequency of the injury is estimated to be 1 in 1 million manipulations that use HVLA maneuvers in OMT and 3 to 6 in 10 million for major impairment in chiropractic.

Osteopathic or chiropractic high-velocity manipulation should not be used to treat people with certain conditions such as unusual hypermobility or ligamentous laxity. In these instances, soft tissue technique is used, avoiding any vulnerable areas. Another group in which to avoid manipulations or adjustments is athletes with joints that show obvious signs of sepsis (an illness caused by overwhelming bacterial infection) or active bleeding. These individuals should not receive osteopathic or chiropractic manipulative or adjustment treatment until they have been conventionally evaluated and stabilized.

Massage

Like osteopathic and chiropractic manual therapies, massage has long been a part of maintenance and recovery for athletes. In North America, the term massage usually refers to the group of techniques known as Swedish massage. This is in contrast to the manual massage-type therapies that are associated with the Ayurvedic and East Asian medicine traditions, which are philosophically linked to their respective healing traditions. Swedish massage in athletes is focused mainly on relieving muscle soreness, releasing tight tissue, and assisting in muscle recovery. Although routines vary with athlete need and preference and medical staff guidance, athletes at the elite or Olympic level are encouraged to use massage as part of a maintenance or recovery routine (or both).

Yoga and Tai Chi

Yoga, a discipline that began evolving over 4,000 years ago in the Indus River Valley, is an essential practice of Ayurveda, the medical system that is native to India. Yoga is more than the practice of physical postures for fitness. In its highest form of practice, yoga embodies the conscious discipline of spiritual reflection in conjunction with physical well-being.

There are many types of yoga. Some are more physically demanding (Ashtanga, Bikram, Iyengar), and others are more contemplative (Integral and Kripalu). Hatha yoga, the most popular form in the United States, focuses primarily on a gentle mixture of postures, breath work, and meditation. Yoga applies to sports medicine first and foremost in its promotion of flexibility. Yoga that is slower and more contemplative speaks to the mental aspect of athletics by promoting calmness and serenity during physical activity. Carefully chosen postures with supportive props such as chairs and pillows can be incorporated to enable athletes with mobility limitations to perform appropriate postures and engage in a form of conditioning without causing injury or discomfort. The more vigorous and physically demanding types of yoga can be used in sports to build up physical endurance. The benefits reported from yoga in sport include increased balance and flexibility.

Tai chi, developed by the Chan family in 1820, has many styles. Although its movements are derived from martial arts, its purpose is to enhance longevity and health. The postures of a tai chi practitioner encourage softness, which is far different from the objective of postures in martial arts practiced primarily for self-defense; defensive martial arts postures emphasize a substantial amount of muscle tension in each pose.

Like yoga, tai chi reinforces calmness, agility, and balance. Tai chi requires the ability to hold postures as in yoga, but tai chi postures are executed only in a standing position. For athletes who have difficulty sitting still but need to develop calmness, balance, and concentration during sports activities, tai chi might prove rewarding.

East Asian Medicine and Acupuncture

East Asian medicine, which includes the traditional medical practices of China, Japan, Vietnam, and Korea, represents an ancient form of medicine that is nearly 2,000 years old. Even today these systems serve as primary health care practices in many developing countries. The practices are founded on principles that focus more on maintaining health than on reacting to or modifying a disease. The fundamental approaches to health maintenance include the implementation of changes in diet and attitude. Acupuncture (insertion of needles), a form of massage called tui-na, energy work called qi-gong, and other East Asian treatments are used to treat injury or disease. Although this section highlights acupuncture, East Asian medicine is actually a mixture of practices encompassing a variety of treatments that include botanical medicines and therapeutic lifestyle interventions. Refer to the additional resources section for more information.

Acupuncture has been increasingly incorporated into Western medicine since the 1970s and is becoming more and more accepted as an effective treatment for many conditions and ailments. In 1997, a scientific panel sponsored by the National Institutes of Health (NIH) convened to provide consensus on the merits of acupuncture. Their conclusion notes that in addition to other uses, “needle acupuncture is efficacious for adult postoperative nausea and vomiting” and that “there are reasonable studies (although sometimes only single studies) showing relief of pain with acupuncture on diverse pain conditions”(NIH 1998). In an integrated sports medicine regimen, acupuncture might be helpful for the following conditions:

• Nausea
  
• Pain from fractures, bruises, blunt trauma, or contusions
  
• Myalgia from muscle strain
  
• Acute inflammation of the joints from overuse
  
• Joint inflammation caused by degenerative or inflammatory joint disease

The practice of acupuncture involves the insertion of fine solid 32- to 36-gauge needles in a variety of precise spots located on channels of energy flow known as meridians. There are 365 points described in classic acupuncture texts. The primary principles governing treatment include the idea that wellness and illness result from the balance and imbalance of yin and yang. Yin represents the feminine aspect of life: nourishing, cool, inside, receptive, protective, soft, and yielding. Yang represents the masculine aspects: hard, dominant, energetic, upper, hot, excessive, outside, and creative. The movement between each seemingly opposite force is identified as Qi, which is the essential element in the healing process. The needles “unblock” Qi’s vital force, which in a healthy state flows ceaselessly through the meridians.

The mechanisms of action of acupuncture remain incompletely understood. Skeptics have asserted that acupuncture’s effectiveness is derived from the placebo effect, citing that needle insertion sites do not correlate with any anatomical or physiological phenomenon that provides a clear explanation for the asserted effects. However, it has been observed that the acupoints are located at sites that have a high density of neurovascular structures that are on the edges of muscle groups. In this way, proponents say:

1. Acupuncture needles stimulate nerve fibers in muscles that block the signaling of pain to the spine and brain.
   
2. Acupuncture signals areas within the brain that release neurohormones into the spine to inhibit the pain signals where pain might have been perceived.
   
3. Acupuncture stimulates pituitary release of endorphins, neurohormones that create feelings of well-being.

Acupuncture during pregnancy is a relative contraindication, because some acupoints can precipitate contraction. Additionally, acupuncture should be avoided in people with needle phobia, to avoid exacerbation of distress, or those who cannot sit still, to avoid self-harm. People who have known metal allergies, who are taking anticoagulants, and who have bleeding disorders should be considered for acupuncture on a case-by-case basis.

Based on a review of studies published on acupuncture and its effectiveness in sport-related conditions, Bell and Falconi (2016) review its use in osteoarthritis, traumatic brain injury, and low back pain.

Reported adverse effects include pneumothorax, cardiac tamponade, damage to neurovascular structures, infection, hematoma formation, and broken needles with remnant migration. These reports are extremely rare and generally occur with inexperienced practitioners. The overall combined data from prospective and retrospective publications indicates that acupuncture is safe when administered by competent practitioners.

It is useful to think of integrative therapies as interventions that can be administered in a layered fashion. For example, if an athlete has a mild ankle sprain, in addition to implementing medications such as an NSAID and proper mechanical support (e.g., splints and braces), acupuncture can also be initiated. Acupuncture may provide shorter recovery time, reduced pain, and more rapid symptom resolution. Taking this example one step further, if the athlete with this injury has poor gastrointestinal tolerance to NSAIDs, botanical preparations such as turmeric (Curcuma longa) or ginger (Zingiber officinale) can be used as alternative options for healing and reducing inflammation. Furthermore, if the injury is related to repetitive motion, work with an osteopathic physician for gait assessment and subtle limb-length discrepancies could be added.

There are many treatments and indigenous medical systems that are not discussed in this chapter. Rather than being a comprehensive review of CIH, this chapter is designed to give a general sense of an integrative approach with regard to traditional and alternative medicine’s applications in sports medicine. Ultimately, the preferences of the athlete, existing available expertise, and medical conditions will dictate the best course of action. However, the inclusion of CIH treatments in an integrative medicine approach, with its increased emphasis on nutrition, flexibility, and musculoskeletal support, can greatly enhance physical well-being and reduce vulnerability to injury. The judicious inclusion of many alternative treatments and anti-inflammatory alternatives might also enhance pain management in acute and chronic sport-related injuries.

Related posts:

Neck and Cervical Spine Injuries Concussions and Head Injuries Lower-Leg and Ankle Injuries Hip Injuries Foot and Toe Injuries Wrist and Hand Injuries

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