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Elite level sports are becoming more popular among younger and younger kids, and often the physical, mental, and emotional demands can take a toll on their developing body. Growing up as a competitive dancer, I had my fair share of injuries and often wondered why my doctors only had the answer: "we can't do anything until you stop dancing." I never understood why there weren't any options to optimize my health to reduce the risk of injuries. And then I learned about naturopathic medicine!
According to the Canadian Physical Activity Guidelines, children between the age of 5 and 17 years old should be getting 60 minutes of moderate to vigorous-intensity activity each day. In comparison, elite athletes might be training in their sport 2-3x more than the daily recommended guidelines. The physical, mental, and emotional demands of training at an elite level requires particular attention to the overall health of the body in order to prevent injuries, sustain training, and improve recovery time.
Elite sports demand for your body to be in excellent condition in order for you to perform your best. For artistic athletes, it's especially important for your body to be in good health; your body is your instrument. Now factor in that your body is still growing, and the puzzle just got more complex. As a former dancer, I understand the level of commitment it takes to master your craft and the passion that pushes you to meet your goals. As a dance instructor, I recognize the demands these athletes undergo on a daily basis and see how common it is for dancers to struggle with injuries, pain, and poor healing. That's why as a naturopathic doctor, I want to help educate athletes on how they can optimize their health and have a sustainable career in their sport.
So, what are the areas that I believe are most important when evaluating an athlete's health?
Nutrition
Adequate nutrition provides the framework for overall health, however, with increased training comes increased requirements in calories, macro- and micronutrients.
Calorie: a unit of energy required by the body for cellular function.
Energy requirement is estimated using a person's activity level and their basal metabolic rate, in other words the amount of energy the body requires to function at rest. The more activity a child does, the more energy the body requires for growth, building muscle, and repairing damaged tissues. An athlete's energy requirements can range anywhere between 2000-5000 calories/day depending on their energy expenditure and their stage of growth. A deficit in calories not only means a lack of fuel for the body, but also can lead to the breakdown of tissues, issues with growth, hormonal imbalance, and increased risk of injuries.
Macronutrients: includes carbohydrates, protein, and fats.
When I talk about energy coming from food, I always reiterate that there is a difference between nutrient-rich and nutrient-deficient foods. Nutrient-rich foods provide more than just quick energy to our body. Macronutrients provide the key building blocks our body needs in order to make energy. Carbohydrates are easily converted to energy in the body and can provide a quick boost, but often are associated with a crash. However, not all carbohydrates are created equal! Carbohydrates are made up of fibre, starch, and sugar; the ratio of these factors determines how quickly the body will use up that energy source. Protein and fat are used as long-term energy sources that keep the body functioning between meal times but aren't a good source of quick energy. When macronutrients are combined in well- balanced ratios, the body can have a sustained energy supply instead of having huge fluctuations in energy.
Micronutrients: includes vitamins and minerals.
Vitamins and minerals also contribute to a food's nutrient-density. Not only are micronutrients used to make cellular energy, they are used to make enzymes, hormones, neurotransmitters, and repair tissues. Specific nutrients that are critical for athletes are calcium, magnesium, iron, and vitamin D. Micronutrient content varies depending on the food, which is why it's important to be eating a variety of whole foods, preferably with a variety in colours.
Stress Management & Sleep Hygiene
While activity itself can relieve stress, the demands of elite training may require additional stress relief strategies. There are many potential areas of stress for elite athletes including the demands of training; performance pressure from coaches, parents, teammates, or self; balancing academic and social priorities with training schedule; and an over-emphasis on 'winning'. Excessive stress increases the risk of injury and susceptibility to infection; and in this state, healing time is hindered. Stress also increases the nutritional demands on the body, which further impacts healing time.
Some of the physical symptoms of stress can present as loss of appetite, headaches, stomach aches, digestive upset, or disturbed sleep. Without strategies in place to cope with the heightened stress, athletes can experience more anxiety, self-doubt, depression, and burn out. Determining effective strategies of stress relief not only improves athletic performance but helps to prevent injuries and illness.
Sleep quality is directly related to "cognitive performance (learning, memory, decision-making, vigilance), physical health (healing, recovery, metabolism, muscle growth, weight control), and mental health (stress/anxiety, mood/depression, emotional control)” (5). This is especially important in young athletes, and studies show that young athletes report 2 fewer hours of sleep each night compared to non-athlete adolescents (3). The hours of sleep aren't the only factor that is important; the quality of sleep and sleep maintenance is important in ensuring you have a healthy circadian rhythm. During deep or non-REM sleep, the brain releases growth hormone, which is crucial in tissue healing and overall growth in adolescents. Establishing healthy sleep hygiene (routine, light exposure, stress reduction, and room temperature) can dramatically effect sleep quantity and quality.
Hormones
Previously, a condition known as the "female athletic triad" was used to describe the syndrome of nutritional deficit (with or without disordered eating), amenorrhea/ oligomenorrhea (the absence of menstruation or irregular menstruation, respectively), and decreased bone mineral density. The name has since been changed to "RED-S", or Relative Energy Deficiency in Sport, because studies have shown similar health implications in male athletes. The condition is most prevalent in running, cycling, gymnastics, figure skating, and dance.
Nutrient deficiency may be the result of unintentionally not matching one's individual energy expenditure or over-training, or intentionally restricting calories to control weight and body composition. Furthermore, puberty puts an excess energy demand on the body, which increases the risks of developing RED-S in young elite athletes. Regardless, the energy deficit leads to disruption of sex hormones (estrogen, progesterone, testosterone) resulting in irregular or absent menstruation, and decreased bone mineralization. Furthermore, studies show that short-term energy deficit impairs athletic performance and can therefore increase the risk of injury, which is further heightened if there is decreased bone density.
RED-S is not just a condition in adolescents, it can occur at any age, however, early detection can prevent the progression of hormone imbalance and loss of bone density. Overall, menstruation (without the use of birth control) gives me a good clinical indication of whether an athlete is at risk of RED-S, as it tells me if hormones are at a healthy level. Other warning signs of an energy deficit include low BMI; recurring stress fractures, bone pain, or injury; delayed puberty; problematic relationship with food; anxiety; or fatigue.
Injury Recovery & Pain Management
RICE vs. METH
Have you ever heard of the acronym "RICE" (rest, ice, compression, elevation)? These suggestions are often recommended following injury as the primary treatment, however, more recent studies show that there is improved recovery time using a new strategy: "METH" (movement, elevation, traction, heat). The updated strategy is rooted in the idea of increasing circulation to the injured area and therefore improve healing time. With increasing circulation, the body is able to bring nutrients and healing factors to the area and carry away inflammatory markers released in tissue injury via the lymphatic system, thus also decreasing swelling and pain.
Movement is important not only to improve circulation of lymph but also repairing the neurological and proprioception pathways to help strengthen muscle stability around the injury. Prolonged immobilization has been correlated to persistent swelling, instability, and a longer recovery time (9). Movement should always be pain-free, most importantly, listen to your body. Similarly, traction improves healing time by providing mechanical stress and the subsequent improvement in collagen deposition. Traction also decreases compression of the tissues and encourages the movement of fluids to help decrease pain.
Heat; isn't this the complete opposite of what you're supposed to do? Well, no. Heat encourages circulation compared to ice that decreases circulation of blood and lymph. Interestingly, there is little evidence the supports using ice for injury recovery or improving healing time. In decreasing circulation, you limit the inflammation that is actually necessary for the tissue to heal. Inflammation is the first phase of healing and it's not the "bad guy".
With all that being said, there is still a time and place for RICE. When swelling needs to be reduced before putting on a cast, ice is a good option. Other good options to reduce swelling include muscle contraction (even small amounts of movement to promote lymphatic drainage) and massage. If you have a high-degree strain/sprain, are unable to weight-bear or move an injury, you should visit your doctor.
Acupuncture
Acupuncture is one of my favourite modalities in naturopathic medicine, and it can be used for musculoskeletal pain and injury recovery. Not only does acupuncture improve circulation, but it decreases the perception of pain by directly effecting the nervous system. Electroacupuncture uses electrical stimulation of the acupuncture needles and has been shown to reduce both neuropathic and inflammatory pain, making it an effective strategy in pain management and injury recovery.
Postural Assessment
Some might assume that dancers have amazing posture just because of the nature of their training. I still think it's important to assess an athlete's full standing posture from "head-to-toe" (but actually we assess posture from the foot- upwards). Artistic athletes are often one-side dominant, which can lead to muscle imbalances that change standing posture. Over time, postural imbalances put excess load on the joints that are compensating, which can lead to increased pain and injury. By determining these muscle imbalances, we can make a plan to help strengthen the weaker muscles and balance standing posture. Additionally, I can use naturopathic adjustments, similar to what a chiropractor does, to help correct any skeletal misalignments.
Furthermore, foot posture is incredibly important. I am lucky enough to work in a clinic with two amazing pedorthists that specialize in the joints from the hip- downwards. Pedorthists make custom orthotics to correct foot posture, which influences the entire chain of joints above. Even better, our pedorthist Noelle is a former ballet dancer!
Stay tuned to learn about a special program we are designing specifically for dancers and young athletes!
Overall, I wish I had known about the available options as a dancer to help prevent recurrent injuries, and improve my performance. Now as a naturopathic doctor, I'm excited to support young athletes through their intense training schedules and help them to be able to continue their sport as long as they want!
References:
Copenhaver, E. A., & Diamond, A. B. (2017). The Value of Sleep on Athletic Performance, Injury, and Recovery in the Young Athlete. Pediatric Annals, 46(3). doi: 10.3928/19382359-20170221-01
Crocker, P. R. E., Tamminen, K. A., & Bennett, E. V. (2017). Stress, emotions, and coping in youth sport. Sport Psychology for Young Athletes, 164–173. doi: 10.4324/9781315545202-15
Fullagar, H. H. K., Skorski, S., Duffield, R., Hammes, D., Coutts, A. J., & Meyer, T. (2014). Sleep and Athletic Performance: The Effects of Sleep Loss on Exercise Performance, and Physiological and Cognitive Responses to Exercise. Sports Medicine, 45(2), 161–186. doi: 10.1007/s40279-014-0260-0
Gibson, S. R. (Ed.). (2014, September). A Guide to Eating for Sports (for Teens) - Nemours KidsHealth. Retrieved from https://kidshealth.org/en/teens/eatnrun.html.
Grandner MA. Healthy sleep for student-athletes: a guide for athletics departments and coaches. http://www.ncaa.org/health-and-safety/sport-science-institute/healthy-sleep-student-athletes-guide-athletics-departments-and-coaches. Accessed January 14, 2020.
Hamlin, M. J., Wilkes, D., Elliot, C. A., Lizamore, C. A., & Kathiravel, Y. (2019). Monitoring Training Loads and Perceived Stress in Young Elite University Athletes. Frontiers in Physiology, 10. doi: 10.3389/fphys.2019.00034
Jeukendrup, A., & Cronin, L. (2010). Nutrition and Elite Young Athletes. The Elite Young Athlete Medicine and Sport Science, 47–58. doi: 10.1159/000320630
Lin, Y., & Hsu, E. S. (2014). Acupuncture for pain management. Heidelberg.
Mattacola, C. G., & Dwyer, M. K. (2002). Rehabilitation of the Ankle After Acute Sprain or Chronic Instability. Journal of Athletic Training, 37(4), 413–427.
Relative Energy Deficiency in Sport (RED-S). (2015). British Journal of Sports Medicine, 49(7), 421–423. doi: 10.1136/bjsports-2014-094559
Sport nutrition for young athletes | Canadian Paediatric ... (n.d.). Retrieved from https://www.cps.ca/en/documents/position/sport-nutrition-for-young-athletes.
Tenforde, A. S., Barrack, M. T., Nattiv, A., & Fredericson, M. (2015). Parallels with the Female Athlete Triad in Male Athletes. Sports Medicine, 46(2), 171–182. doi: 10.1007/s40279-015-0411-y
Urschel, J., Scott, P., & Williams, H. (1988). The effect of mechanical stress on soft and hard tissue repair; a review. British Journal of Plastic Surgery, 41(2), 182–186. doi: 10.1016/0007-1226(88)90049-5
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