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Focused Nutrition and the Injured Athlete Accelerated Recovery Through Focused Nutrition Kirt M. Kimball, MD Orthopedic Surgeon Team Physician, Brigham Young University Disclosures/Bio • Orthopedic Surgeon: Revere Health, Provo, Utah • Team Orthopedic Surgeon: Brigham Young University • Fellow AAOS, AOSSM, CAQ Orthopedic Sports Medicine • Medical Director, Intermountain Health Care, Musculoskeletal, South Region • Surgical Consultant/ Advisory Board: ConforMis Total Joints • Chief Medical Officer: Forté Elements • Medical Director, Timpanogas Regional HCA Hospital, Total Joint Division • Consultant: Summit Home Health • Medical Director: I-Works Home Health Today’s focus • Today I will discuss how you, as a Certified Athletic Trainer can, in conjunction with your medical staff, • Support, and in some cases • Augment recovery from many of the acute and chronic injuries/conditions you deal with every day. • You can improve your outcomes by aggressively employing focused nutritional elements you are all familiar with. Patient: D1 Football Player -- FX L3 Treatment: Brace; Time …..healing Conditions of physical stress Recovery impacted by Nutritional elements • Major Trauma or Surgery • Fracture • Elective Surgery • Nerve/Brain Injury • Joint/Cartilage Injury • Chronic Bone injury Fracture Healing Energy Demand and Consumption Increases Energy • Long bone fracture • Normal caloric adult intake 2,500 cal. per day • Fracture can increase daily need to 6,000 cal. per day. Fracture Healing and Protein Protein • By volume 50% of bone is protein • When fracture occurs, protein building blocks needed to synthesize new bone. • 15-20 gram increase in daily amino acids significantly increases rate of fracture healing. • Protein deficiency leads “rubbery” callus and delayed healing. Fracture Healing and Amino Acids Amino Acids • Lysine, Arginine, Proline, Glycine, Cystine and Glutamine • Especially important in fracture healing • Lysine known to: - Enhance calcium absorption - Increase amount of Calcium absorbed in bone matrix - Aids in tissue regeneration Protein and IGF-1 • IGF-1 • Insulin –like growth factor-1 • Polypeptide exerts a positive effect on skeletal integrity, muscle strength, immune response and bone renewal. • Protein supplementation increases endogenous IGF-1 Fracture Healing Anti-inflammatory nutrients • Trauma of fracture creates a burst of pro-oxidants (free radicals) causing oxidative stress that can overwhelm the bodies antioxidant reserves. • Tightly bound collagen strands running through the mineral phase of bone are forcefully broken. • Ruptured collagen strands interact with oxygen-yielding oxygen radical metabolites (Free-radicals) Free Radicals • Create Inflammation • Further breakdown bone collagen • Lead to excessive bone turnover • Free radical production can overwhelm natural anti-oxidant defense mechanisms. • Antioxidants shown to be effective in suppressing destructive effect of free radicals thus improving fracture healing. Anti-oxidants effective in canceling out free radicals • Vitamin E • Vitamin C • Lycopene • Alpha-lipoic acid • Selenium acts as an antioxidant on its own but it is particularly effective when combined with vitamin E. Inflammation Essential to healing • Involves Cyclooxygenase (Cox) enzymes (Cox-1 and Cox-2) enzymes – important part of inflammatory cascade • Many standard non-steroidal anti-inflammatory drugs act by inhibiting COX-1 and COX-2 enzymes – relieves the pain, but also delays healing. NSAID’s NOT Recommended after Fracture aspirin ibuprofen indomethacin etodolac(Lodine) Naproxen ( Anaprox, Naprosyn, Aleve) Nabumetone (Relafen) meloxicam (Mobic) Reduce inflammation naturally • 328 wrist fracture patients – modest 500 mg/day supplementation with vitamin C – reduced by more than 4‐ fold the incidence of post‐fracture complex regional pain syndrome. • Quercitin, - used in doses of 2–3 g per day - has a synergistic effect with vitamin C, amplifying the pain‐relief benefits • Omega‐3 fatty acids - reduce inflammation without inhibiting the COX‐1 and COX‐2 enzymes Reducing Inflammation Naturally soothe the inflammatory process and speed healing. • Vitamin C, • bioflavonoids, • flavonols such as quercitin and proanthrocydins • omega-3 fatty acids • Bromelain and Trypsin Mineral Intake Bone is 70% mineral by weight • Fracture healing requires minerals • Most of us “under-consume” minerals • Stealing “from Peter to pay Paul” to get adequate minerals for fracture healing Fracture Minerals • Zinc - 200 enzymes require zinc for their functioning • Copper - Important in formation of bone collagen. - Demand for copper and zinc increase with severity of trauma. • Calcium: - Important in fracture healing however skeletal sources and diet are adequate. - High calcium intake does NOT speed fracture healing • Phosphorus: - Most have plenty in diet. Supplement not necessary • Silicon: - Important in bone collagen synthesis. - Studies show that bioactive silicon enhances the effects of calcium and vitamin D3 on new bone formation. Enhanced Vitamin needs for Fracture Healing Some vitamins need to be present in “therapeutic” dosage to maximize fracture healing • Vitamin C • Vitamin D • Vitamin K • Vitamin B6 Vitamin C • Essential for proper synthesis of bone collagen protein matrix • Important antioxidant • Important anti-inflammatory • Aggressive Vitamin C support leads to faster and stronger fracture callus and healing Vitamin D • Primary regulator of calcium absorption • Many studies demonstrate low vitamin D leads to suboptimal fracture healing. • Vitamin D in conjunction with Vitamin K stimulates the transformation of fracture site stem cells to bone building osteoblasts. • Vitamin D levels are an independent predictor of recovery after major fracture. Prevalence of Vitamin D Deficiency • Nearly 1/3 of the population and more than 50% of general medicine patients are vitamin D deficient. • We use sun-block, hats, long sleeves leads to less Vit D • Majority of patients undergoing orthopedic surgery are deficient in vitamin D. • Studies show accelerated muscle recovery with Vit D Sources • Holick MF. High prevalence of vitamin D inadequacy and implications for health. Mayo Clin Proce 2006;81:353-373 • Stoker GE, et al. Preoperative vitamin D status of adults undergoing surgical spine fusion. Spine 2013;38(6):507-515. 13. Fisher A, et al. Hip fracture type: important role of parathyroid hormone (PTH) response to hypovitaminosis D. Bone 2010;47(2):400-407. Vitamin K • Essential in binding calcium to bone • Helps preserve calcium by reducing the loss of calcium in the urine • Well established that it is beneficial to fracture healing • Vit. K is noted to be sequestered at the fracture site and circulating vit K levels are influenced by the severity of the fracture. Vitamin B6 • Linked to fracture healing • B6 modulates the effects of vitamin K on bone through complex biochemical pathways. Optimum Fracture healing • Bone is a complex tissue that requires many nutrients • 20 Key bone-building nutrients needed for optimum fracture healing • Several studies have found multi-nutrient therapy to reduce complication rates and accelerate fracture healing. • 2006 Swedish hip fracture study given complex supplementation 15% complication rate vs 70% in non treated group An Example • Male, age 21 • Offensive line • Fractured both-bones forearm 21 months into a 2 year missionary assignment in South America. • Surgical Repair in Chile. • 3 months later completed missionary service and returned to BYU to play football. March 4, 2015 • Patient suffers sub trochanteric femur fracture • Post intra-medullary rod placement August 17, 2015 5 Months Post Fracture September 21, 2015 6 Months Post Injury • Still non-union • Status post secondary surgical correction – rod removed, plate and screws • Salvage attempt with bone graft November 2, 2015 8 Months Post • 2 months post secondary surgical correction • Salvage attempt with bone graft not working • Still non-union January 4, 2016 10 Months Post Fracture • 4 months post secondary surgical correction • 4 months post bone graft • Bone graft failing • Continued non-union Added Intense Focused Nutrition Forté Fracture ® February, 2016 11 Months Post Injury • 5 months post secondary surgical correction, 5 months post bone graft • Continued non-union Patient begins supplementing with Forté Fracture ® intense nutritional supplement April 11, 2016 13 Months Post 2 Months Post Nutritional Intervention • After 2 months of supplementation with Focused Nutritional supplementation • Healing occurs Comprehensive Therapy • Swedish hip fracture study (2006) • 15% complication rate vs 70% rate in group without supplemental therapy. • Swedish meta-analysis of 17 hip fx studies reported oral multinutritional supplements reduced deaths and complications by 50%! Tibia Fracture healing • Multi-nutrient study reduced healing time of tibia fractures by approximately two weeks • 33% healed in 10 weeks compared to 11% in placebo group. Conditions of physical stress Recovery impacted by Nutritional elements • Major Trauma or Surgery • Fracture • Elective Surgery • Nerve/Brain Injury • Joint/Cartilage Injury • Chronic Bone injury Questions? • For copy of Slides or questions: • [email protected]