Thoracic Outlet Syndrome: What it is, How to Spot it, a Case Report, and Prevention!

Take Home Points on Thoracic Outlet Syndrome: What it is, How to Spot it, a Case Report, and Prevention!:

1. Thoracic outlet syndrome is a narrowing between your collarbone and first rib, putting pressure on your neurovascular structures.
2. There are many neurovascular impairments at the shoulder.
3. Monitor shoulder pain, symptoms, and alter sensation closely, and adjust prevention programs and biomechanics for greatest improvement.

Though shoulder impingement is the most common form of shoulder injury in swimmers, other cases of shoulder pain exist. These other syndromes impact other tissues, typically the nerual, arterial or vascular. Although these shoulder conditions are not well known, they still occur in overhead athletes. Asymptomatic pitchers even have impaired blood flow on their throwing side, a potential risk factor for Thoracic Outlet Syndrome (TOS). Some of these issues are treated conservatively, while others require surgery.

Types of Thoracic Outlet Syndrome

Knowing what occurs and the symptoms of tissues other than the muscular system is beneficial for a coach and rehabilitation staff. Here are some examples:

1. Nerogenic Thoracic Outlet Syndrome: Compromising the brachial plexus. Symptoms are pain, numbness, tingling, and weakness. 
2. Vascular Thoracic Outlet Syndrome: Compromising the venous or arterial system. The typical presentation includes pain, numbness, tingling, weakness, and/or the presence of vascular compromise. Venous TOS is more common than arterial TOS and is characterized by swelling and cyanosis, pain, and a heavy feeling. 
3. Paget-Schroetter Syndrome: A thrombosis of the subclavian vein.

Clinical Tests for Thoracic Outlet Syndrome in Swimmers

There are manual and diagnostic test for identifying vascular compromise. Sadeghi-Azandaryani (2009) notes:

"Sensitivity of clinical tests was acceptable overall (mean 72%). The EAST test showed the highest sensitivity with 98%, followed by the Adson (sensitivity: 92%) and Eden tests (sensitivity: 92%). In contrast, the sensitivity of the Hoffmann test (47%) was low. Nevertheless, a positive EAST, Eden, Adson, Green-stone or Adson test was not associated with a poorer outcome (p≥0.05).

Systolic blood pressure was measured before and after exercise. Mean systolic blood pressure of the afflicted side in the group of patients with good or fair outcome (85.9% of all patients) showed an average systolic blood pressure of 123.1 ± 12.5 mmHg before exercise and 108.9 ± 12.8 mmHg after exercise (average decrease: 16.2 ± 9.6 mmHg). A decrease in blood pressure of more than 25 mmHg could not be found in this group. In the group of patients with a poor outcome, the systolic blood pressure before exercise was 140.6 ± 24.6 mmHg and 106.7 ± 21.8 mmHg after exercise (average decrease: 35.0 ± 14.1 mmHg). Statistical analyses showed that a distinct decrease in blood pressure after exercises was associated with a poorer outcome (p = 0.0027)."

Here are some of the most common tests:

1. Roo's test: The patient stands and abducts shoulders to 90 degrees, externally rotates the shoulders, and flexes the elbows to 90 degrees. The patient then opens and closes the hand slowly for three minutes. The test is positive if the patient is unable to complete the test or experiences heaviness, numbness, tingling or pain.
2. Adson's test: The examiner locates the radial pulse while arm is held in extension, external rotation and slight abduction. The patient is instructed to take a deep breath and turn head toward the test arm while extending the neck. If there is compression, the radial pulse will be diminished or absent. The goal of this test is to tense the anterior and middle scalenes.
3. Costoclavicular test: The examiner palpates the radial pulse and then draws the patient's shoulder down and back. If the pulse disappears, the test is positive. The goal of this test is to provide compression of the costoclavicular space.
4. Halstead maneuver: The examiner palpates the radial pulse and applies downward traction on the test extremity while the patient's neck is hyperextended and rotated to the opposite side. Absence of the pulse indicates a positive test.6
5.  Wright test (hyperabduction test): The examiner palpates the radial pulse and hyperabducts the arm so the hand is brought overhead with the elbow and arm in the coronal plane. The patient takes a deep breath and may rotate or extend the neck for additional effect.
6. Allen maneuver: The examiner palpates the radial pulse while positioning the shoulder in external rotation and horizontal abduction. The patient then rotates the head away from the test side.

Diagnostic tests also include a Doppler arteriography testing of the vascular system. If the compromise is neurogenic, nerve stimulation is sometimes used for diagnosis.

Example Swimmer with Paget-Schroetter Syndrome

The patient was a 21-year-old male swimmer who noticed swelling and pain in his non-dominant arm. The patient was advised to ice and rest his shoulder. Then, ten days after the initial heaviness, the symptoms returned and the patient was advised to seek emergency care where a Doppler venous ultrasound could be performed. The results were negative. The patient demonstrated a cease of the radial pulse, swelling, and limb cyanosis with the Wright’s hyperabduction test. He also presented with ⅘ strength on the affected side, but 5/5 strength on the non-affected side. Despite a negative Doppler venous ultrasound, the vascular surgeon suggested a venogram, since a Doppler venous ultrasound is best used as a screening tool, not for diagnostics, since it has difficulty specifically measuring the subclavian vein due to the bony structures. The venogram showed a major block of the subclavian vein, venous stenosis, and concomitant thrombosis.

The patient was then administration heparin and a tissue plasminogen activator (tPA) over a three day period in order to achieve thrombolysis.This improved the thrombus by 70%, indicating 30% of the vein had undergone permanent thrombosis. The patient was then prescribed coumadin and Lovenox as a blood thinner. Electromyography (EMG) was also performed to rule-out a neurogenic case of TOS, which demonstrated no muscle membrane instability.

The swimmer returned to the pool with great success (winning the conference in the 100 and 200 breast), then received a resection of the first rib. After the surgery, the patient complained of pain medial to the shoulder blade and demonstrated shoulder-blade winning. Manual muscle tests were performed again and noted 5/5 strength in all muscles. Fine-wire EMG was conducted again and showed normal signs of all muscles except the serratus anterior which demonstrated signs of denervation (likely due to surgical complications to the long thoracic nerve).

Despite the findings of the serratus anterior, the patient started a physical therapy program and home program which resulted in improved EMG readings for the serratus anterior, three months postoperatively.

Thoracic Outlet Syndrome Swimming Prevention Techniques

Steady Streamline:

If the arms move excessively during streamline, the upper arm and neural structures are stressed. Maintain a stable arm position during all streamline, especially dolphin kicking.

Flatter Butterfly:

Some swimmers (like Michael Phelps) press their chest down as they enter their arms in butterfly, delaying their pull. This creates a position with the arm above the chest, stretching and stretching the brachial plexus (all the nerves and vascular areas).  Try starting the pull earlier, not allowing a position of arms higher than the chest. 

Deep catch:

Many swimmers have a "catch-up" style stroke. Unfortunately, this increases stress at the shoulder joint and vascular system. If working on less stress, have the swimmer have a deeper catch as the enter the water.

Neutral Hand Entry:

Entering without hand entry is paramount for all shoulder prevention, as excessive internal rotation increases shoulder stress.

Shallow Backstroke Catch:

Entering with a deep catch in backstroke stresses and strains the neurovascular structures in the front of the shoulder...no good! Instead, have a wider, more shallow catch, similar to Missy Franklin's technique. 

Thoracic Outlet Syndrome Dryland Techniques

Foam Roll Thoracic Spine:

SMR Scalenes:

SMR Pectoralis:

Nerve Mobility:

First Rib Mobilization: 

Anterior Neck Strengthening:

Scapular Strengthening:

Summary on Thoracic Outlet Syndrome for Swimmers

Some cases of TOS require drastic treatment, like surgery (first rib resection). Instead of dealing with potential surgery, keep a close eye on TOS symptoms and begin early with treatment and technique modifications at the first instance of symptoms. 

These are only some technique modifications and treatments, as each person is individual and different stroke biomechanics and rehabilitation/prevention programs are necessary for each person. Moreover, just because some swimmers perform with techniques which increase shoulder stress, doesn't necessarily result in TOS or injury. Therefore, if you are suffering from TOS, see a rehabilitation specialist for guidance and individualization.

If looking for more injury prevention techniques, consider purchasing the COR Swimmer's Shoulder System.

References

1. Nitz AJ, Nitz JA. Vascular thoracic outlet in a competitive swimmer: a case report. Int J Sports Phys Ther. 2013 Feb;8(1):74-9. 
2. M Sadeghi-Azandaryani, D Bürklein, A Ozimek, C Geiger, N Mendl, B Steckmeier, J Heyn Thoracic outlet syndrome: do we have clinical tests as predictors for the outcome after surgery?Eur J Med Res. 2009; 14(10): 443–446. Published online 2009 September 28. doi: 10.1186/2047-783X-14-10-443

By Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University where he swam collegiately. He is the owner of COR, Strength Coach Consultant, Creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

Continue Reading

Kinesiotape for Swimmers: Length, Strength and Timing. Part II

Take Home Points on Kinesiotape and Swimmers:

1. The evidence does not suggest that kinesiotape aids athletic performance
2. Kinesiotape may affect knee mechanics and improve pain in those with patellorfemoral pain syndrome
3. Kinesiotape has been shown to increase acromiohumeral distance, potentially limiting risk for shoulder impingement symptoms. 

This is not a new topic to this blog (See Part I). But like any topic, one snapshot of the evidence is never the final word. So is there anything new to report in the literature on kinesiotape, especially as it may relate to swimming?

Overall, the general consensus is that the performance effects of kinesiotape are negligible to non-existent. Fortunately though, there appear to be no detrimental effects on performance (minus the potential opportunity cost of forgoing other potentially more effective mechanisms). 

In a recent systematic review, Drouin (2013) noted, “There is scant evidence to support kinesiotaping techniques as a successful means of affecting athletic-based performance outcomes such as improved strength, proprioception and range of motion, in healthy persons.” This appears to be definitive statement on the effects of kinesiotaping, but does it end the discussion?

One problem is that in most studies, kinesiotape is applied randomly as opposed to particular subjects for whom kinesiotaping is theorized to work. While the latter approach may sacrifice objectivity for potential bias, the latter may be more reflective of how the intervention is applied in real life. Be careful of labeling any intervention as “good” or “bad” as a blanket statement. Instead, the follow up should be “good or bad for whom?” It is a mistake to justify kinesiotape for performance based of any supporting literature for injury/pain, just as it is mistaken to outright dismiss kinesiotape as a clinical adjunct based on a lack of evidence to support performance improvements. 

Swimmers often focus on taping for the shoulder, but don’t forget the possibilities in the lower extremities, particularly for dryland and breaststroke. Song (2014) recently found that kinesiotaping caused significant shifts in patellar positioning in females with patellofemoral pain syndrome compared to the application of sham tape or a no tape condition during a single leg squat. However, both the sham tape and kinesiotape were successful in pain reduction. 

One especially pertinent study for swimming (Luque-Suarez 2013) published after our previous blog post, examined whether kinesiotape affects acromiohumerdal distance in healthy subjects (a potential measure of shoulder impingement risk). Authors of this randomized controlled trial noted that although the kinesiotape group had significantly greater increases in acromiohumeral distance compared to the sham taping group, direction of taping did not matter.

Conclusion

Overall, little has changed in the evidence on kinesiotape, especially regarding the lack of support for its theorized improvement on performance. However, recent studies have opened relatively new lines of inquiry regarding potential improvements in knee and shoulder biomechanics, both of which may be helpful for swimming health and technique.

References

1. Luque-Suarez A1, Navarro-Ledesma S, Petocz P, Hancock MJ, Hush J. Short term effects of kinesiotaping on acromiohumeral distance in asymptomatic subjects: a randomised controlled trial. Man Ther. 2013 Dec;18(6):573-7. doi: 10.1016/j.math.2013.06.002. Epub 2013 Jul 4.
2. Song CY1, Huang HY1, Chen SC2, Lin JJ3, Chang AH4. Effects of femoral rotational taping on pain, lower extremity kinematics, and muscle activation in female patients with patellofemoral pain. J Sci Med Sport. 2014 Jul 24. pii: S1440-2440(14)00135-2. doi: 10.1016/j.jsams.2014.07.009. [Epub ahead of print]
3. Drouin JL1, McAlpine CT, Primak KA, Kissel J. The effects of kinesiotape on athletic-based performance outcomes in healthy, active individuals: a literature synthesis. J Can Chiropr Assoc. 2013 Dec;57(4):356-65.

Written by Allan Phillips is a certified strength and conditioning specialist (CSCS) and owner of Pike Athletics. He is also an ASCA Level II coach and USA Triathlon coach. Allan is a co-author of the Troubleshooting System and was selected by Dr. Mullen as an assistant editor of the Swimming Science Research Review. He is currently pursuing a Doctorate in Physical Therapy at US Army-Baylor University.

Continue Reading

Weekly Round-up

Each week we aggregate recent swimming journals and blog posts relating to swimming biomechanics, physiology, nutrition, psychology, etc. If you wish to add, please add an article in the comments section.

Journal Round-up

1. Backstroke swimming: exploring gender differences in passive drag and instantaneous net drag force.
2. From early to adult sport success: analysing athletes' progression in national squads.
3. MOTOR IMAGERY-BASED BRAIN ACTIVITY PARALLELS THAT OF MOTOR EXECUTION: EVIDENCE FROM MAGNETIC SOURCE IMAGING OF CORTICAL OSCILLATIONS.
4. Sleep or swim? Early-morning training severely restricts the amount of sleep obtained by elite swimmers.
5. Study of major factors developed among young swimmers during the practice session and competition causing interference of their performances.
6. Factors determining swimming efficiency observed in less skilled swimmers.
7. Inter-arm coordination and intra-cyclic variation of the hip velocity during front crawl resisted swimming.

Blog Round-up

1. Volume 20, Issue 1, "Strength Training 7"
2. Creatine + Sodium Bicarbonate: Two New Studies Show You Can Make the Most-Researched Ergogenic Even Better W/ a Few Grams of Baking Soda - Sign. & Non-Sign. Benefits
3. Dealing with Anticipated Stress
4. 6 Reasons Why Kids Should Play Sports
5. Are the Hamstrings Really Primarily Fast-Twitch?
6. Training Asymmetries with FMS Principles
7. Random Thoughts on Sports Performance Training: Installment 6
8. Creatine for Swimmers
9. Future of Swimming Training
10. Dryland for Swimmers: Don't Fall into the Traps!
11. Swimming for Chronic Pain
12. Friday Interview: Dr Chris Mills and Dr. Mitch Lomax Discusses Breast Influence on Biomechanics

Continue Reading

Friday Interview: Dr Chris Mills and Dr. Mitch Lomax Discusses Breast Influence on Biomechanics

1. Please introduce yourself to the readers (how you started in the profession, education,

credentials, experience, etc.).

Dr Chris Mills

I completed my PhD in 2005 at Loughborough University in the UK, where I was funded by British Gymnastics to investigate force dissipation characteristics of landing mats and gymnasts with the aim of reducing injury. I continued to focus my research on lower and upper body soft tissue motion and for the past 6 years have worked closely with the research group in breast health at the University of Portsmouth. As a part of this group we work closely with garment manufactures to improve their design, as well as conducting fundamental scientific research studies. Most of the research within breast biomechanics to date has been land based however recently a swimwear manufacturer approached our group with an interesting project. We combined our experience of breast biomechanics, swimming mechanics and physiology (via Dr Mitch Lomax, who has contributed to your website in the past) to investigate the effect of breast support on trunk motion during swimming.

Dr Mitch Lomax

I’m a Sport and Exercise Scientist and a Senior Lecturer in Sport and Exercise Physiology at the University of Portsmouth, UK. I gained both my PhD (2007) and MSc (with distinction, 2001) from Brunel University, UK, and my BSc (Hon) from Luton University (1998). I’m an accredited Sport and Exercise Scientist with the British Association of Sport and Exercise Sciences (BASES), Chartered Scientist (Science Council). I have been an advisor to the Amateur Swimming Association of England and was involved in the preparations of the English Pistol Shooting squad for the Commonwealth Games in Glasgow. My main sporting research interest is in swimming and predominantly breathing limitations.

2. You recently published an article on breast displacement in freestyle and breaststroke. Is there any other research on this area in swimming?

At present there is very limited research on breast mechanics, let alone the movement behavior of the breasts in water and the impact breast support has on swimming technique. Clearly more research is needed in this area to ascertain whether swimming costume design modifications could benefit performance.

3. What did your study look at?

We were interested in investigating whether varying levels of breast support influence swimming technique. On land, a lack of sufficient breast support has been shown to decrease performance and increase pain, however we did not know if the same was true in water. We were also particularly interested to understanding whether regular swimsuits afforded any support to the breast during swimming.

4. What were the results of your study?

Key findings suggested that although trunk motion was not altered with varying levels of breast support, a swimsuit was no more effective at reducing the movement of the breasts than not wearing one at all! Despite trunk motion not being effected by breast support conditions, ongoing research hopes to determine whether other aspects of swim stroke mechanics (such as hand path etc.), that may influence swim performance, are effected by the amount of breast support.

5. What were the practical implications for coaches and swimmers from your study?

Female swimmers with larger breasts may wish to consider wearing an additional sports bra under their swimsuit to reduce breast motion and compress the breasts against the chest wall (decreasing the trunk moment of inertia and the possibility of the breasts obstructing the desired hand path during swimming). Our findings revealed that a sports bra (traditionally used for landing based activities) was more effective as reducing breast motion than a swimsuit.

6. Do you think the same results would have occurred with faster women? Hi-tech suits? Women of smaller breast size?

This is difficult to answer however if the women swim faster the drag created would also increase. If the breasts are not ‘restrained’ sufficiently this may increase the ‘bagging’ effect (from our paper) and increase form drag and hence decrease performance. Hi Tech suits usually have a higher level of compression (similar to compression garments on land), however we have not tested this. Unpublished research from the group has found that upper body compression garments do reduce breast motion during land based running. It may be possible that a similar increase in compression may also reduce breast motion (similar to that of the sports bra in this study). Women with smaller breasts do not experience the same magnitudes of breast motion (on land) therefore in the water they are also likely to experience reduced magnitudes of breast motion when compared to women with larger breasts. The ‘bagging’ effect and potential increases in form drag may not be as great for women with smaller breasts.

7. Does male pec size influence swimming? Could this be one reason why "bulkier" male swimmers anecdotally did better with the full body suits?

This is a difficult one to comment on and really outside our area of expertise. The only aspect to consider is that men pecs are mainly muscle and hence are used to generate joint motion; however the female breast does not contain any muscle (just mainly fat and glandular tissue), hence minimizing their form drag may be beneficial to swimming performance.

8. What can swim suit manufactures do to improve swim suits for women?

I would recommend an increase the amount of compression afforded around the breasts to move their center of mass closer to the trunk and help to streamline their shape to decrease form drag. A higher neckline may also help to decrease the ‘bagging’ effect described in our paper. Possibly some structured support, similar to an encapsulation bra. Finally, appropriate sizing, that can cater more for trunk circumference and breast sizes variations, within a, for example, UK size 12 swimsuit.

9. What research or projects are you currently working on or should we look from you in the future?

We currently have two more papers under review associated with breast motion during water based activities. We are also seeking collaborative links with garment manufacturers interested in developing this area of research.

Continue Reading

Future of Swimming Training

Take Home Points on the Future of Swimming Training:

1. Smart technology is on the verge of dramatically enhancing swimming performance, be ready for the revolution.

Swimming is one of the most biomechanically difficult sports. Unlike other sports, swimming works against water while in a horizontal position. The unfamiliar horizontal position makes all stroke corrections more difficult. Water also creates resistance during any motion, making improvements harder! This motion creates drag impeding performance to a greater degree than air resistance.This makes receiving feedback difficult. In fact, Stefan Szczepan beautifully described his work and the role of immediate feedback in swimming.

We reviewed Szczean and Zatoń (2014) research in the latest Swimming Science Research Review. Zatoń (2014) split sixty-four male swimmers into a control and an experimental group. The experiment consisted of 4 freestyle swimming trials of 25 meters. The first two trials were pretest and the third and fourth trials were the experimental trials. In the experimental trials, the swimmers were instructed to "reach out further". 

There was significant improvement in stroke length, stroke rate and swimming velocity.

Future of Swimming Training

Overall, there is a lack of immediate feedback in the sport of swimming despite the shown benefit. As technology decreases prices, these methods must be integrated more in swimming. Whether the feedback is through telemetry systems or visual cues, having immediate feedback will reduce errors. As technology, systems my provide automatic feedback based on performance. 

Biomechanics, Injury Prevention and Coaching

For example, MOOV has created a "smart watch" which provides instantaneous feedback during running. Full disclosure, I consult with MOOV, so I first hand understand the potential of this product. Imagine a device which you wear on your wrist and lets you know when your hand speed is slowing, force production is decreasing, or hand path is altering, then coaches you for improvement! This can improve biomechanics, reduce injuries, increase motivation, and other improve swimming!

Dryland and Recovery

Athos, a smart clothing, is capable of measuring muscular activity when worn! If Athos, or another company, can create waterproof clothing, then huge advancements in muscular training and recovery are possible. Imagine knowing when a muscle is completely fatigued from the resting neuromuscular activity...pretty cool! If this product isn't made waterproof, it still a beneficial product for dryland, knowing exactly which muscles are activity during each exercise. 

Sleep and Recovery

Sleep and recovery have huge potential for swimming improvement. Currently, recovery and sleep and not individualized, although everyone is unique and individual recovery patterns are needed. There are products like BioForce HRV and other smart watch technologies which track sleep and heart rate variability, a potential marker for monitoring recovery. 

Nutrient Levels

One possibility for training and monitoring is blood analysis without skin penetration. As far as I know, this technology doesn't exist. However, if someone can create a device which continuously monitors nutrient levels in the blood or via saliva, exact nutrient levels is possible. This can maximize energy, recovery, and performance!

Summary

If these products are accurate, then the world of swimming and coaching will be transformed. For example, a swimmer is held responsible throughout the main set, not allowing them to "slack" or take an unnoticed break. For the coach, the device will monitor biomechanics more accurately and continuously than the coach. For injuries, knowing when pain starts during a set and seeing the muscular activity or biomechanical deviation at this point in time will influence technique and reduce injuries. Also, knowing when and what to eat for maximal performance, as well as knowing how much sleep is needed for maximal performance has exciting potential! Once again, this will change the sport, so harnessing technology and analyzing data will become even more paramount for success. Make sure you are ready for the next phase of sports enhancement!

Reference

1. Zatoń K, Szczepan S. The impact of immediate verbal feedback on the improvement of swimming technique. J Hum Kinet. 2014 Jul 8;41:143-54. doi: 10.2478/hukin-2014-0042. eCollection 2014 Jun 28.

By Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University where he swam collegiately. He is the owner of COR, Strength Coach Consultant, Creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

Continue Reading

Creatine for Swimmers

Take Home Points on Creatine for Swimmers:

1. Creatine monohydrate is the most effective and most researched form of creatine supplement

2. 20% of athletes do not respond to creatine supplementation

3. May improve competition performances in shorter races (i.e. 50m, 100m, 200m)

4. May aid in training intensity during dry-land training and ultra-short race pace training

5. May hinder competition performances in longer races

You have probably heard of creatine before.  But do you know what it actually is? How it works? Or the possible role it can play for swimmers?

First, it is important to know that creatine is not prohibited by WADA.  It is also widely accepted as an ethical performance-enhancing supplement, and is in no way, shape, or form associated with steroids. It is also important to know how creatine works in the body so that we can start to understand the concepts and uses of a creatine supplement.  The following are the basic facts that you or your athletes need to know about creatine’s role in the human body.

Internal Creatine (In The Body)

Lets start with phosphocreatine, or creatine phosphate (CP).  CP is a naturally occurring energy store in the human body. Creatine is a peptide containing a high-energy phosphate. CP’s role is to donate its phosphate group to form ATP (our body’s primary source of energy).  This occurs as our muscular ATP stores become depleted, typically within the first 10 seconds or so of maximal intensity exercise (e.g. 25m sprint).  This is often known as our ATP-CP energy system. 

External Creatine (Supplements)

Does it actually work?

In short, yes, creatine supplementation works.  Resting CP levels are typically around 125mmol/kg of muscle.  However, the body seems to be able to store around 160mmol/kg before hitting a ceiling where it will not store any more.  About 80% of athletes who supplement creatine will experience an increase in ATP-CP related performance.  This is due to a rise in resting CP stores from around 125mmol/kg to the 160/mmol/kg limit.  (20% are considered “non-responders” wherein they rest closer to their ceiling or their ceiling is below average, or more likely a combination of the two).  For “responders”, the almost 30% increase in muscular CP directly translates to increased duration of the ATP-CP system function.  Simply put, more creatine means more energy for muscles.

CP is the body’s internal form of creatine. Like I said above, CP is creatine bound to phosphate.  Creatine monohydrate is THE basic form of supplemental creatine.  Wherein a creatine molecule is bound to 1 water molecule.  And, with so many variations of creatine on the market, it would take quite a while to find the research and compare each and every type of creatine.  So, instead of getting into all of this, I am going to focus on the supplementation of creatine monohydrate, as it is the most researched and proven to work (You’ll have to take my word for it).

Dosing Protocol

So bottom line, creatine monohydrate does its job of increasing CP stores.  Next lets talk about how to use this supplement.  The following is a typical, well-researched procedure for supplementing with creatine:

·      Loading phase (5 days) – 20g of creatine monohydrate, taken in 4 separate servings throughout the day (4x5g). 

·      Maintenance phase – 5g of creatine monohydrate taken once per day. Realistically, even 3g/day would probably do fine for maintaining saturated CP stores.

Typically creatine monohydrate will come with a 5g scoop.  If yours doesn’t have a scoop, 1 tsp is approximately 5g.  Now the loading phase is not necessary to maximize creatine phosphate (CP) stores, but it will allow you to do so quicker (approximately 5 days).  Without a loading phase, a maintenance dose will eventually maximize creatine phosphate stores, but will take much longer (20-30 days). 

Some research indicates that taking a serving of creatine following a training session may be the most effective way of absorbing it.  However, the reality of it is this: when you take your creatine probably won’t make a difference since you will be maxing out your CP stores regardless. 

The take home message here:

Don’t get too anxious about timing your creatine ingestion.  Just try and get 5g/day.

If you miss a dose one day, carry on as if it never happened, it takes 4-6 weeks for CP stores to return to normal levels. It won’t happen to you in a day!

Uses for Swimmers

Remember which energy system creatine is fuelling.  The ATP-CP system lasts seconds, not minutes!  Creatine supplementation will improve performance in shorter races (i.e. 50m Freestyle) rather than longer ones.  It is interesting to note that when CP donates its phosphate to form ATP, it binds up a H+ ion.  H+ ions are responsible for muscular acidosis, which decreases muscle contraction strength.  You may know this better as that “lactic acid burning”.  So, swimmers competing in races than venture into a few minutes’ duration (e.g. 100m, 200m races) may benefit from increased CP stores as a result of creatine supplementation.

However, even swimmers that don’t compete in 50m, 100m, 200m races may still benefit from creatine supplementation in their high intensity training (e.g. ultra short race pace training USRPT).  Additionally, if these athletes are doing weights in dry-land training with the goal of producing some nervous adaptation, then creatine will help them hit those last few reps with speed. Keep in mind that the harder a swimmer can go in practice or training, the greater their adaptation will be.  This will translate to improved competition performance. 

A typical side-effect is weight gain of several pounds.  It happens quite rapidly.  This is fine, safe, and expected.  With increased CP stores in muscles comes increased water retention as well.  Now, this creates an interesting issue from the propulsion/drag standpoint.  For athletes that compete in 50m, 100m, 200m races, having loaded CP stores probably “outweighs” the weight gain, because of the improved power output in those races.  Athletes who compete in longer events may want to utilize a creating supplement in training to elicit greater adaptation, but cycle off before a competition to lose the additional water weight.  If this is the case, the athlete should cease supplementing creatine for about 4 weeks before the competition.  This should be adequate time for CP stores to return to normal levels, and the body to shed the excess water weight.

By Kevin Iwasa-Madge BASc, CISSN owner of iMadgen Nutrition, and as a former top-5 finisher in the world as a freestyle wrestler, Kevin embodies the lifestyle of an elite athlete. Kevin completed his undergraduate degree at the University of Guelph in the Applied Human Nutrition. This clinically focused program allowed him the opportunity to address a range of diseases from a nutritional approach. After graduation Kevin attained his certification in sports nutrition from the International Society of Sports Nutrition. 

Athletically, Kevin has been an elite wrestler for over 10 years, competing for both the University of Guelph and Team Canada. Kevin is a former First Team All-Canadian, Academic All-Canadian, and Canadian Champion. As a varsity athlete, Kevin was short-listed for the prestigious Student-Athlete of the Year award. He currently trains with and competes for the Guelph Wrestling Club and National Team. Over the years, Kevin has worked with a range of individuals, from those looking to improve their overall health, to rugby player, football players, swimmers, professional fighters, wrestlers, endurance athletes and more.

Continue Reading

Dealing with Anticipated Stress

Take Home Points on Dealing with Anticipated Stress

1. How athletes deal with anticipated is often overlooked in communicating
2. Elite performers show increased activity of the insular cortex to anticipate adverse events
3. Psychology intersects with our understanding of the central governor hypothesis

We all know the feeling of an impending hard set, or on a bigger picture, a hard training block or even a Hell Week.  Anticipation of such an event may even trigger physiological responses: pangs of nervousness, sweating, and perhaps nausea.  Yet we also know that under stress, the best athletes simply cope better than lesser athletes?  What may differentiate the elite from the average?

"Individuals optimize exercise level as it relates to differences between expected and experienced exertion, which can be conceptualized as a body prediction error. The process of computing a body prediction error involves the insular cortex, which is important for interoception, i.e. the sense of the physiological condition of the body." (Paulus 2012)

Elite military operators have been shown to be more adept than control subjects in this realm.  Previous research has shown greater neural processing by Navy SEALs in response to threat stimuli via heightened right insular cortex activation.  (Paulus 2012) One interesting note from studies of elite military selection schools is how many candidates drop out of training in the first day.  Surely, the matter is not physical as training has hardly begun.  Not everyone has the physical and mental capability for elite performance in any genre, but it is enlightening to see the power of the mind in this area

In plain terms, this discussion simply means swimmers may psyche themselves out not from current distress but from anticipated future distress.  Interestingly, the general mechanisms may be similar to the proposed theories behind the central governor, which states that physical output reflects our brain’s perception of physical status.  ("During self-paced exercise, the exercise work rate is regulated by the brain based on the integration of numerous signals from various physiological systems. It has been proposed that the brain regulates the degree of muscle activation and thus exercise intensity specifically to prevent harmful physiological disturbances" (Tucker 2009))

Practical Implication
Now, certainly this information can be used to drive swimmers to push harder through discomfort.  There are many different strategies to cope with the discomfort of a hard effort.  But that’s not our main focus here.  Instead, what about the buildup to a hard effort? 

While functional MRIs to measure insular cortex activity are not readily available poolside, simple strategies may help many swimmers.  Ultimately, the key is for swimmers to have strategies to deal with anticipated stress   Everyone responds to different cues.  Some may respond best to an environment in which the enormity of a hard task is minimized.  Others may respond best to getting pumped up by coaches and teammates. 

Key point is to understand that particular physiological mechanisms underlie psychological strategies.  How we think in this realm will ultimately affect our physiology.  Coaches must create the right environment for athletes to choose the best strategies for themselves to handle future physical stress.

References

1. Tucker R.  The anticipatory regulation of performance: the physiological basis for pacing strategies and the development of a perception-based model for exercise performance.Br J Sports Med. 2009 Jun;43(6):392-400. doi: 10.1136/bjsm.2008.050799. Epub 2009 Feb 17.
2. Paulus MP1, Simmons AN, Fitzpatrick SN, Potterat EG, Van Orden KF, Bauman J, Swain JL.PLoS One. Differential brain activation to angry faces by elite warfighters: neural processing evidence for enhanced threatdetection.2010 Apr 14;5(4):e10096. doi: 10.1371/journal.pone.0010096.
3. Paulus MP1, Flagan T, Simmons AN, Gillis K, Kotturi S, Thom N, Johnson DC, Van Orden KF, Davenport PW, SwainJL. Subjecting elite athletes to inspiratory breathing load reveals behavioral and neural signatures of optimalprformers in extreme environments. PLoS One. 2012;7(1):e29394. doi: 10.1371/journal.pone.0029394. Epub 2012 Jan 19.

Written by Allan Phillips is a certified strength and conditioning specialist (CSCS) and owner of Pike Athletics. He is also an ASCA Level II coach and USA Triathlon coach. Allan is a co-author of the Troubleshooting System and was selected by Dr. Mullen as an assistant editor of the Swimming Science Research Review. He is currently pursuing a Doctorate in Physical Therapy at US Army-Baylor University.

Continue Reading

Weekly Round-up

Each week we aggregate recent swimming journals and blog posts relating to swimming biomechanics, physiology, nutrition, psychology, etc. If you wish to add, please add an article in the comments section.

Journal Round-up

1. Effect of beetroot juice supplementation on aerobic response during swimming.
2. Increased Variability of Lap Speeds Differentiate Medallists and Non-Medallists in Middle Distance Running and Swimming Events.
3. EFFECTS OF MASSAGE ON MUSCULAR STRENGTH AND PROPRIOCEPTION AFTER EXERCISE-INDUCED MUSCLE DAMAGE.
4. Effects of Supplemental Citrulline Malate Ingestion During Repeated Bouts of Lower-body Exercise in Advanced Weight Lifters.
5. Effect on swimming start performance of two types of activation protocols: Lunge and YoYo Squat.
6. Effectiveness of a dry-land resistance training program on strength, power and swimming performance in Paralympic swimmers.
7. The effects of myofascial release with foam rolling on performance.
8. Static stretching can impair explosive performance for at least 24 hours.
9. Hydrodynamic Analysis of Different Finger Positions in Swimming: A Computational Fluid Dynamics Approach.

Blog Round-up

1. Teens, Sleep Deprivation and Morning Swim Practices – Revisited
2. Friday Interview: Stefan Szczepan Ph.D. Discusses Immediate Feedback in Swimmers
3. Do Growth Spurts Increase Injury Risk?
4. Science of Performance: Strength Training and Swimming Performance
5. gu u ,Should Coaches Change Asymmetries in Swimmers: Part III
6. Life-Long Swimming Movement
7. Are Push-Ups Safe for Swimmers?

Continue Reading

Friday Interview: Stefan Szczepan Ph.D. Discusses Immediate Feedback in Swimmers

1. Please introduce yourself to the readers (how you started in the profession, education, credentials, experience, etc.).
Hi, my name is Stefan Szczepan. I'm a scientist at University School of Physical Education in Wroclaw, Poland and I work at the Department of Swimming. This year I received a doctor degree. I'm interested in motor control and learning included motor skill acquisition processes in water environment, especially teaching communication, forms of instruction, augmented feedback, and practice schedules. My mentor is Professor Krystyna Zaton, the head of Institute of Physical Activity in Water Environment in my University. She guides me in the science. I’m very proud with this relationship and I am very thankful for the trust and the knowledge transfer. My most recent research is about the impact of immediate verbal feedback and concurrent visual feedback on the improvement of swimming technique. I am the author or co-author of few articles in research journals. I connect theory with practice while teaching swimming and swimmers trainer.

2. You recently published an article immediate feedback and swimming. What are the different types of feedback?
Feedback is sensory information that results from movement. There are two types of feedback: intrinsic (integral) and extrinsic (augmented feedback). Intrinsic feedback is the sensory information arising as a result of physical activity by the means of sensory mechanisms (exteroreceptors and proprioreceptors). Information that derives from the receptor allows for movement regulation as well as the adjustment of motor task completion to the desired model of physical activity. Extrinsic feedback is formed after the completion of a motor activity and is transmitted by a third. Examples of extrinsic information are verbal communication, gestures, video, timer displays. There are several distinct types of feedback which are categorized according to the time of its transmission: concurrent feedback (provided during motor task concern continuous information), immediate feedback (provided during motor task concern discrete information) and delayed (transmitted after the completion of the motor action). Types of feedback are the most important for me. The most effective information is verbal and immediate. If you are interested in it – follow this link: http://www.ncbi.nlm.nih.gov/pubmed/25114741

3. In your study you worked on improving the swimmers stroke length, can you explain how

you did this?
This study that we conducted together with Professor Zaton concerns the issues related to the importance of the transfer of feedback in an immediate manner to the learner during the learning swimming process. The work shows that the time in which the feedback reaches the learner is important in the motor control and that it improves swimming technique. The feedback communicated to the learner in real time manner regarding a performed motor function allows for the removal of errors in the short-term memory or prevents their formation. I chose a simple kinematic parameter of swimming movement as stroke length to confirm the importance of immediate verbal feedback. In this way the emergence of an error in the time-space structure of swimming motility was eliminated. The objective numerical dimension of the mistakes made allowed for a quantified relationship between the shortening of the swimming stroke length and the constant frequency of the propulsive movements. These factors led to a decrease in the efficiency of swimming, which was noted in the swimming velocity and a decrease in the economization of the swimming techniques, as indicated by the index SI. For these purpose I used special wireless tools including a system, transmitter and receiver for swimmer and teacher. This gave a possibility of a verbally and immediately control of swimming movement. It's an amazing technology that I spent significant money to develop and it works incredibly well.

4. What were the main results of your study?
The use of these tools in an experiment conducted on the experimental group, in which the information regarding the execution of the performed activity was transferred to students in an immediate manner, indicated that the swimming stroke is significantly improved along with an increased swimming speed while maintaining the same frequency of movements. This resulted in an effective movement in the aquatic environment. In the control group, however, where such information was not given, there was no observed swimming stroke elongation while maintaining the same frequency of movements. The transmission of immediate feedback in order to prevent the occurrence of errors or to eliminate them entirely, this also resulted in an improvement in the economization of swimming motor functions. The economization of swimming techniques was assessed using the index of SI [stroke index], which was considered as its measurement. Increase in the index SI values will see a decrease in the physiological cost of effort. In the control group this increase was not observed. It looks like that work tool and the assumptions of study can be used in any other motor swimming motor activity, not only stroke length. An example would be learning and improving movements of the legs and hands, body position in the water or coordination aspects, as well as other swimming motor elements.

5. What were the practical implications for coaches and swimmers from your study?
With the breaking of communication barriers, the following improve:

1. Preventing the occurrence of errors and removing them from the motor memory.
2. Improving motor structures and the cost reduction of physiological effort.
3. Conditions will be created to improve the quality of swimming techniques with various degrees of accomplishment of utilitarian.
4. Recreational values of physical culture, as well as antagonistic values noticeable in the competitive sports oriented towards maximizing achievement. 

The applied value of the method used, in which the verbal feedback was transmitted instantaneously in an immediate manner, in the practice of teaching and coaching is the enrichment of the communication technology regarding the correct structure of swimming motor functions. This is the main principle. The above assumptions are based on the physiological structure of human memory, whose different types are classified depending on how long information is stored in them. At first site, takes include human motor memory and second site augmented immediate verbal feedback. I give a method with used immediate verbal feedback for improves swimming technique and effectively the swimming learning process.
6. Do you think the results would be different if you had older, elite or untrained swimmers?
For sure people perceive information differently, due to age, sex or seniority. Probably we would observe differences between elite and non swimmers. This study showed the impact of immediate feedback on young swimmers. It can be apply for all swimmers, but the results may be a little different. In the future, I will plan other studies that answer on this question clearly.

7. Do you think immediate tactile or visual feedback would have different results?
Teaching and improvement of swimming technique is effective when external information is transmitted in three forms: words, images and practical actions. In case of the tactile I need to appeal to kinesthetic differentiation. It is one of the most important motor abilities. This ability is a precise perception of strength, time, and space. Feeling spatial movements, feeling of movement speed, what it’s called "water feeling” makes precise control of the movements. Tactile feedback can improve kinesthetic differentiation and makes to decrease energy cost and achieving better results. We deal this issue at my University. As regards the visual feedback I use special device. For example, it is the optical fiber giving the swimmer concurrent visual information. The light beam also provides the swimmer with the information on swimming speed. The ability to control the speed of swimming is an important part of preparation during swimming training. This is especially important when the desire is to obtain a pure training stimulus. Swimming with a defined - constant speed impacts on economical labor, and allows for maintaining a low physiological cost. Therefore, the development of a method that allows for acquisition and improvement of that skill is an important methodical goal in the process of swimming training optimization.

8. When working on biomechanics, how do you suggest tapering down feedback when the swimmer is progressing?
The role of the teacher is to provide feedback as long as the swimmer will acquire motor habit. Motor habit in human motor memory are formed after several thousand repetitions, therefore, the time of their acquisition is different. The next step in order to improve the quality of swimming mobility is multiple individual repetitions of the correct structure for motion, which was acquired by the use of immediate, verbal regulation regarding the swimming motor structures. Of course, if there are errors the teacher must again respond. Feedback can be addictive. In order to avoid the negative effects of frequent augmented feedback various techniques have been applied such as faded, bandwidth, summary, average or self-controlled schedules have been used.

9. Should teams utilize immediate auditory feedback?
I have a plan to develop my device and bring it to the swimming team. This allows the delivers of the individual swimmer and for the whole group. It will be easier to conduct training.

10. What makes your research different from others?
An innovative aspect of the subject undertaken is to identify empirically, that the time in which the information reaches the learner is important in the learning process and that it improves swimming technique. My work examines important aspect impeding the process of teaching of swimming and technique improvement. The interference in didactic communication – it is particularly noticeable when an exercise is executed in an atypical environment, for example in water. The aquatic environment hinders the reception of information because a number of disruptive factors such as the distance between the teacher and the learner or ambient noise favors errors in a given exercise. Thus, the environmental factors make it hard to use verbal feedback to its full communicative potential in the process of swimming acquisition or technique improvement. It may also be challenging to immediately eliminate or prevent (within short-term memory) errors as or before they appear, as I said early. I believe that the results of the present research work should contribute to defining the actual significance of immediate verbal feedback in swimming acquisition and improvement.

11. Which teachers have most influenced your research?
The person who influenced the most on my research has been my professor Krystyna Zatoń. For me she is a really big scientist. All the time she teaches me how to be better. It requires a lot of my sacrifices. Since I started working with her at Department of Swimming my life sped up, but I like it. I can learn a lot from a great biomechanic of swimming, a professor Marek Rejman too. We work together. I guess that we are good scientific team. Also I take inspiration from different scientists who are engaged in motor control and learning. There are many in the world, so I need to check of the database brand new publications.

12. What research or projects are you currently working on or should we look from you in the future?
I’m currently working on the evaluation of the achievements of swimmers. This evaluation is performed during motor activity in real time. Ability to take correct feedback to evaluation swimming technique can increase swimming performance. Usually, data are obtained from delay, e.g. with using movement analysis software. In addition, the aquatic environment interferes common available device for the evaluation, e.g. Infrared. Therefore I develop telemetry measuring swimming techniques. It enables in real-time provide feedback on the structure of the swimming movement. Wireless method of assessing swimming techniques can be used for research purposes to create maps of swimming techniques, to quantify. In addition, I’m interested in biofeedback and the implementation of transcranial magnetic stimulation (TMS) in the verification of feedback in swimming learning. Both issues seem to be good for my future. Many questions pertaining to increase the process of swimming acquisition and teaching remain unanswered and further research appears necessary. I hope it finishes successfully. I have one rule in my life, that says never stop.

Thanks Stefan!

Continue Reading