The Evolving Role of Chiropractic Treatment in Sports Medicine
A Q&A with Dr. Steven Bernabeu. DC:
Non-surgical treatments for running and other sports injuries--as well as lifelong injury prevention strategies--are becoming ever more central to the ways in which we think of our training, our recovery, and our healing process.
Dr. Steven Bernabeu has been a Doctor of Chiropractic (DC) since 1989. As such, he has seen enormous developments in chiropractic over the years, including not just within its scope of treatments but also in its dramatically increased role in training and treating competitive athletes of every sport.
Among the elite athletes Dr. Bernabeu has successfully treated are Marion Jones and other sprinters under Trevor Graham, three-time national champion figure skater Michael Weiss, Olympic medalist Tim Goebel, three-time World Championship medalist Sasha Cohen, Olympic swimmer Matt McLean, American mile record holder Alan Webb, and world champion shot putter C.J. Hunter in 1999, the year of his victory. He was treating Julius Achon at the time he broke the 800m American Collegiate Record (1:44.55) in 1996 as a student at George Mason University--a record that still stands.
The American Running Association had the pleasure of speaking with the energetic and candid Dr. Steve about the history, present state, and future of chiropractic technique, Division 1 athletics, and other sports medicine related issues affecting us today.
Where are you currently practicing?
I currently practice at Patriot Chiropractic Center in Fairfax, Virginia with my wife and partner Dr. Gina Simonetti. We are both 1989 graduates of New York Chiropractic College and have been practicing in Fairfax since 1991.
Can you discuss your early background a bit, and how it's led you to this particular career focus?
In my third year of practice in Virginia, I was approached by George Mason University’s Track Coach John Cook to work with their track athletes. I was placed on staff as part of their medical team in 1994, so that is when my relationship with university teams really began. In 1996, GMU won the NCAA Indoor National Championships. I was with the athletes for the entire week administering chiropractic and muscular therapy, treating injuries, and tuning them up in preparation to compete. I performed in the same capacity in 1996 in Eugene, Oregon, when we took second place outdoors.
Before earning my chiropractic degree and moving to Virginia, I earned my bachelor's degree from Long Island University in Respiratory Therapy and Critical Care Medicine. I worked for four years at a major trauma center and teaching hospital in New York and then went on to chiropractic school. Throughout the years, I've taken many post-graduate courses in nutrition, functional medicine, and biochemistry to understand how to optimize the health of patients. This knowledge has become incredibly useful with respect to the treatment of athletes. I have found that most athletes, in particular younger kids, don't know how to eat properly and understand less about proper supplementation and vitamin therapy.
Your role in treating athletes includes nutritional advice as well?
By spending extended time with the athletes like this, you start to spot overall habit patterns. For example, at Penn Relays, I saw an athlete going in to eat at a fast food restaurant. I ran over to them and explained to them that “you're not going to perform well eating this way; put that stuff down and I'm going to show you how to eat!”
So from the get-go it's been about all aspects of bodily health. Is that how you define--or begin to define--chiropractic?
What I do with chiropractic techniques regarding the athletes is specifically biomechanical balancing and sports performance enhancement. In that sense I see myself as a body mechanic. In chiropractic, you're looking at the balance of the kinetic chain of the body--right to left, front to back. For example, one of the main reasons that an athlete gets a hamstring injury is because his hip extensors aren't firing properly or because they are firing out of sequence. But if athletes are intact in their lower kinetic chain, they are less likely to have injuries. In chiropractic college at NYCC, I studied neurology and muscluloskeletal medicine. Back in 1989, a lot of chiropractors were primarily focused on spinal adjustments and were not doing a lot of massage therapy and work with trigger points in the muscles. By implementing the muscular work with chiropractic, I was able to have great success in treating patients with these methods early on in my practice.
Is it safe to say the meaning of the word has changed significantly over the last twenty-five or so years?
It's really evolved over the last fifteen to twenty years into a whole different subset of treatment protocols.
It seems the field is concerned mainly with total body movement now versus what may have once been more spine-centric?
Yes, the least of what I do is spinal manipulation. I'm looking at ways to turn the whole kinetic chain from a musculoskeletal and neurological position. I use a lot of acupuncture, myofascial release therapy, and a lot of nutritional supplementation to heal the system. With regard to nutrition, for example, if a person’s electrolyte balance is off, or particularly in the case of girls, if they're anemic and their iron is off, they're just not going to have the oxygen-carrying capacity to run fast and their performance is affected. It is essential for an athlete to have their nutritional cellular physiology to be functioning at peak capacity as well.
All of this certainly makes chiropractic a natural fit for sports medicine.
When approaching the treatment of an athlete, I try to look at every single factor that will get them to run faster and train at a higher level. This will also allow them to recuperate quicker.
How does chiropractic differ from osteopathy?
Osteopathic medicine and chiropractic were relatively the same early on. The American Medical Association basically told both groups that they could join them through residencies. The osteopaths did that and the chiropractors decided against it. The techniques back then were very similar. Most current osteopathic schools teach one semester of manipulation; in chiropractic school you get manipulation throughout your entire four years of training. With regard to the musculoskeletal system, it's all about how you assess and reset the system. Most osteopaths today function primarily as most medical doctors do and rarely perform manipulations. There are osteopathic practitioners out there that do function in a similar capacity to chiropractors regarding manipulation, but do not typically additionally treat the muscular system.
Osteopathy and chiropractic can both be categorized as "holistic." This is a term that sometimes scares people, but should it?
All holistic means is that you are taking a natural non-pharmacological, non-surgical approach to healing the tissue. It facilitates and potentiates one’s own ability to heal naturally. In my office, it translates to mean that you have to work the four major components: the joints, the muscles, the energetics (meaning the acupuncture points), and the nutrition.
What do you use acupuncture to treat?
What I figured out around the time I was working with Marion Jones was that there are certain sequences to turning muscles on and off and make them fire faster. I used my knowledge of acupuncture to help in this sequencing. In addition to traditional needles, I also use electronic acupuncture and even stimulate acupuncture points with my hands. A lot of acupuncture points will overlap with traditional massage therapy trigger points so there is an added benefit to treating both. What I will do with an athlete prior to their performance is to balance them out using joint manipulation front to back, left to right and then, using this acupuncture sequence, turn the system on at the very end right before they run.
In balancing them out, I'll always adjust up the kinetic chain by treating the joints of the lower extremities (feet, ankles, knees, hips), release the hip flexors, the back extensors, and even go up into the cervical spine. You can relieve someone's low back pain either by adjusting the cervical spine, or by just going into that region and releasing the muscles. The system is integrally connected so it’s ultimately a variety of techniques and treatment to various regions in order to resolve an issue.
You mentioned myofascial release, a kind of deep-tissue massage. What is the main role of this method in the treatment process?
You have to keep the muscles warm and moving. This is why I also emphasize stretching with my patients--to get rid of the lactic acid and drain the lymphatic system. All the by-products of muscular metabolism end up stagnating in the muscular tissue. Stretching forces the contraction and relaxation of the tissues so that the tissue gets rid of its own debris and sends it through the lymphatic system for removal. That's why people who are sedentary tend to have more physical issues than ones who are not sedentary-the tissues aren't moving and draining waste products into the lymphatic system. We take waste products away by muscular contraction. Massage therapy is a method that aids in that drainage.
What issues do you see most in the elite class of athlete?
The main components in every single sport--whether it's hockey, basketball, figure skating, track, baseball--are running or throwing maneuvers. So it's about fixing the lower kinetic chain, and doing the same thing for the upper kinetic chain. Sprinters get the most hamstring injuries because the gluteal muscles do most of the work of extension of the lower extremity when powering out of the blocks. So what frequently occurs is that they “pop” a hamstring. When the quad-to-hamstring ratio is abnormal and they're not properly pulling from their gluteal muscles, they will engage other secondary muscles to perform the actions that were not designed to do.
In long distance runners, low back pain is common. This occurs because the quadratus lumborum [a muscle in the lower back used for stabilization] is inadvertently doing most of the pulling because their gluteal muscles are fatigued and shut off. It's important to turn them back on and re-establish their normal firing patterns so that they're strong and functioning.
But please understand that this is in addition to great coaching. A big mistake that a lot of coaches make here in the United States is that the coaches over train these kids and do not have a supportive therapeutic care apparatus in place. What I would see on the collegiate level that would annoy me is that as soon as the athlete improved, the first thing the coach would do is increase their mileage. And then the kid would get re-injured.
As you see it, is this tendency toward athlete burnout at all indicative of a broader problem in American competition?
Well, one major issue is, in European countries, they might have one or two coaches while in America they may have twenty coaches that remain with an athlete doing different things. In order to take American middle distance to the top, we need a couple of coaches to coalesce and figure out. Currently, the coaches are all scattered and they're all doing their own thing in different places.
To sum it up, it sounds like chiropractic treatments have evolved tremendously, and now have a vital place alongside more traditional forms of sports medicine. Is the medical culture late to see that?
In chiropractic school we studied the same diagnosis protocols and underwent the same academic curriculum as they do in medical school: extensive classes in cardiovascular, neurological, orthopedic, respiratory diagnosis, et cetera, and then, additionally, there were nutrition and biochemistry classes that were much more in-depth than most people realize. But a lot of medical school students aren’t really aware of what we know and a lot of medical physicians don't exactly know what we are able to do. They just think we just treat the spine. They do not realize the extensive differential diagnosis process we use, have no idea how sophisticated some of the techniques we use are, and also how effective the techniques we use can be. But the athlete knows the value of the treatment and, that they also understand that, if you loosen someone up and increase their stride by two inches in the 800 meters, it can be the difference between first and fourth place.
Jeff Venables is the editor of Running & FitNews®, the publication of the American Running Association.