Gold winning tips and strategies from 2 rowing experts, athletes, and doctors. Dr. Erik Brand is a sports medicine physician and Team USA doc for the London and Rio Games. Dr. Greg Spooner is a high performance physical therapist. Both have won gold medals - Brand a national championship, and Spooner a Guinness World Record winning a rowing race across the Atlantic Ocean from NY to UK.
#1 Video Length: 5min
Title: How To Rehab Smart To Stay In The Game
This video has the following sections:
0:00 Who is Dr. Erik Brand?
1:24 How to stay competitive while injured or in pain
2:21 How to get the athlete back in control when they get injured
3:11 How to take charge of personal recovery process.
Full Video Transcript:
Dr. Spooner:
Hi there, welcome to rowphysio podcast, I’m Greg Spooner, Physical Therapist from San Diego, California (update: We have moved our physical office to Bainbridge Island ,WA so I am seeing patients in Kitsap County). I'm here in Bellevue, Washington at Brand Performance Medicine with Dr. Erik Brand, who himself, just like me, has been rowing for many years, however, this guy has been to the top. A national championship at University of Washington, won the Oxford/Cambridge race, now double board certified, I mean, I've probably hit about 10% of his accolades. I'm really thrilled to be here today to chat briefly with you and with Dr. Brand, so we can share some exciting tips and strategies to help you row faster, feel better and be stronger. Erik, thanks for coming on. Can you give a little bit more appropriate background as to who you are?
Dr. Brand:
As you mentioned, my name is Dr. Brand. I'm a double board-certified sub-specialist in sports medicine with a background in physical medicine rehabilitation. What that means is my goal is to help you get as functional as possible, as quickly as possible, long lasting as possible with as much respect as possible for your time, energy, money, and hope to invest your resources, like I'd want to invest mine as efficiently as possible.
Dr. Spooner:
Dr. Brand, you work with a wide range of athletes from here in Bellevue and around the surrounding area of the weekend warriors and casual athletes all the way up to, you were just in Rio a couple of years ago, working with the national team… What do you feel like is your strategy or your advice that you tend to give that I would anticipate, sort of, spans the generation, spans the skills to create a more healthy, resilient, stronger, happier athlete?
Dr. Brand:
I like to put the athlete in better control of their situation and sort of understand the machine that they're running around in, through education about the anatomy and physiology of our bodies and how to work cooperatively with our bodies to get the most out of it.
“My goal is to help you get as functional as possible, as quickly as possible; long lasting as possible, with as much respect as possible for your time, energy, money, and hope, to invest your resources as efficiently as possible.”
Dr. Spooner:
Can you give an example, for a viewer, where you had somebody come into your office or you happen to see them as they're coming out of their heat, in London, and they say, gosh, I'm feeling this, I'm really concerned. What's your approach to trying to get them dialed back in?
Dr. Brand:
Well, one of the first things I like to do with a patient is to really validate what they're going through, which is typically a pain experience and encompassing the whole person, which may include a process of mourning a mental, emotional injury, really looking at the whole person and context of the injury that they're dealing with to really try to alleviate fear, “unmedicalize” the situation and put the patient back in control as much as possible.
Dr. Spooner:
One of the things that I just thought of as you were describing that was, let's say you're in the middle of a 2K and that you are 1,375 meters into your race, a place that we appreciate to not be in, (Dr. Brand: “hating life”) at that particular point, especially if it's a tight race and the body will zone in and, it’s like you forget what's happening. It isn't until afterward, maybe you get out of the boat, you're getting the boat back up out of the water and your back hurts. Maybe you feel like you strained something or pulled something.
On the physical therapy side of things, they come to me, my approach is going to be, okay, I want to help the athlete understand what's going on with them, and try and take this really difficult convoluted mess of anatomy and help it make as much sense as possible, that way there's a sense of ownership. When I say, okay, here's what needs to happen, here’s what would be really beneficial for you to do, let’s go this route. How does that compare or how do you augment in regard to your recommendations for say, medication or rest or exercise?
Dr. Brand:
The first thing I try to do is recognize that the world's expert in that situation is sitting in front of me as the patient. I'm a doctor and I'm highly qualified, however, the person who's been living this specific situation, 24/7 for sometime an extended period of time is the person in front of me. I try to put them in a position of power, listen very carefully to their whole situation and not just listen long enough that I can give them an answer, but really listen long enough that they feel heard and validated and in control of the situation, which I find oftentimes happens through discussing the anatomy and the physiology of what's going on.
Sometimes normalizing the situation, whether it's some degenerating cartilage or some back pain, talking about how common these things are and how they don't necessarily need someone else such as a doctor or a physical therapist to do health to them, that they are really in control of many things that can be used to get back in action.
“Pain is not the act of injury happening. Pain is a signal between our brain and the nerves in our body that alerts us about what’s going on.”
Length: 6min
Title: Recover Faster By Avoiding These Mistakes
This video has the following sections:
0:00 How to use pain as a healing signal
0:55 Benefits of tissue inflammation during recovery from injury
1:41 Why painkillers and pain meds prolong the healing process
2:16 Why rest is terrible for recovery
2:36 3 rules to follow post injury to speed up recovery
3:08 Why you should trust the natural healing process to heal faster
3:50 How perception of pain, mindset and genetics affect recovery
Full Video Transcript:
Dr. Brand:
But what I do know about pain is that the pain and the emotional centers are wired next to each other in our brains. This is for a good reason, from an evolutionary perspective, if our ancestors almost fell off a cliff, they became afraid of cliffs. Thank goodness we're wired this way. The caveat of that is we cannot have a physical injury without a mental, emotional injury that goes along with it. There may be anxiety, depression, post-traumatic stress, as well as the process of mourning that goes along with losing something.
When I talk about pain, I talk about it as these orange cones on the freeway. It says, don't drive here right now. It doesn't mean forever, but that's a construction zone at the moment. You can drive through there and it might be okay, you might get away with it, but in general, you're kind of asking for trouble. For now, drive around, later on, you go through, it'll be beautiful, the freeway will be fixed and you'll drive right through. But for now, I want you to know it hurts and don't do it. For every dollar we spend on ibuprofen we spend .80 cents on stomach bleeding, kidney failure and heart attacks.
By the way, inflammation is part of the healing process. As I mentioned earlier, rowing doesn't make you stronger, it's the recovery from rowing that makes you stronger and better, and part of that recovery is the inflammatory process of tissues that you've broken down and the reparative process that goes along with that, that's what makes us stronger. Not only do things like ibuprofen turn down your pain biofeedback, but doesn't allow you to do whatever you want. If it hurts, don't do it.
It also stops the healing of inflammation and may interfere with the reparative process. There's also studies that have shown, and I don't have a source for you, but reducing pain by itself decreases healing, which kind of makes sense from a biologic, evolutionary perspective because pain is there for a reason. The body has like a natural cast that's built in when you injure it. What does it do? It swells, it fills with blood, which has things like stem cells and the whole inflammatory cascade goes in where things like macrophages will eat up the loose tissue, and then things will scar down into functional range of motion. So ‘Use it or lose it’ back when we were cave people chasing the lonely mammoth and got injured, we couldn't just sit down and rest. We had to keep going or we would starve or be eaten. We had to keep using it.
Never before did we have this opportunity to rest so much. If you rest too much, I believe that things will scar down in a non-functional range of motion. But if we keep active, just following the three rules:
1st Rule: If it hurts, don't do it (conditional).
2nd Rule: If it hurts more the next day, that was too much.
3rd rule: No more than 10% increase per week...
“Rowing doesn’t make you stronger. It’s the recovery from rowing that makes you stronger and better. And part of that recovery is the inflammatory process. ”
Then things can have a chance to have the healing inflammation - go in, clean up the area, then having scar down the functional range of motion, then when we have pain in an area, the muscles turn off through pain inhibition and it swells up, which is kind of like a natural cast, it's the smartest cast, probably smarter than anything we could design. There has been life on earth for 4 billion years now. What I know about my studies of natural selection is, nature does not waste energy on processes that don't at some point for some person convey a selection advantage.
Whatever our bodies are doing, even if we're not smart enough as doctors to know exactly what it's doing or why, my default is to trust that the body is doing something on purpose, which at some point, sometime, conveyed a selection advantage for somebody and help them survive. To support the body and what it's doing, as opposed to trying to fight it with things like anti-inflammatory drugs or steroids or so many of the interventions we're doing.
“Reducing pain, by itself, decreases healing.”
Dr. Spooner:
I want to come back to what you were talking about "when it hurts, don't do it" because pain is subjective, and depending on somebody's history with pain and their emotional response to pain, how they watched their family respond to pain… That is what crafts their understanding of what they're supposed to do and how they're supposed to respond. When you're saying that, they may come back to you a couple of weeks later when you're checking out on them. I feel like you could see across the board, and I see this in my clinic. You know, you said, if it hurts, don't do it. Well, I put my feet up, I've done nothing, it still hurts. Does it stop there, or do you get a little more into trying to qualify or quantify the "if it hurts don't do it"?
Dr. Brand:
It certainly needs to be individualized, because I believe that there can be intergenerational pain and "pain memory" from experiences that have been had by your parents and grandparents and certain responses to trauma that can be actually passed on and learned by subsequent generations. I believe in intergenerational pain. I believe there are cultural differences in pain. I mean, if you look at the emotional milieu or environment in which pain lives, like the pain of winning a rowing race is much different than the pain of knee degeneration.
The emotional context of what the pain means plays a big role in how it's perceived. Back when I was a surgical intern working on the burn unit, someone would have pain and we'd give them opioids, after more opioids, and more opioids. It wasn't until we treated their anxiety, that we didn't even need all those opioids. The mental, emotional process that was going along with the pain was really a key component.
“The emotional context of what the pain means plays a big role in how it’s perceived or how fast you’ll heal.”
Length: 19 Minutes
Title: How to avoid getting injured
This video has the following sections:
0:00 How to never miss a day of training due to injury
1:13 Let's talk about the benefits of pain
2:49 3 Strategies to follow to avoid getting injured
7:20 Biggest challenge that can put people at risk for injury
8:24 Steps to take to avoid losing sight of your winning goals
12:55 Lessons learned to stay in the game, and win gold!
Full Video Transcript:
Dr. Spooner:
Dr. Brand, one of the things that you had said actually, before we started this up, is that in six years of competitive rowing you were never out of the boat.
Dr. Brand:
I never missed a day due to injury in six years. That's true.
Dr. Spooner:
What was your secret behind that? Or is there such a thing?
Dr. Brand:
Yeah, well, I got to say it's luck. Luck being when preparation meets opportunity. I was one of those people who certainly was very eager before I was a doctor to learn more about my body and how it works and how to work with it. When my body was giving me feedback about what was going on, I would be able to take care of things so that an ounce of prevention would be worth a pound of cure. Listening to my body and listening to that biofeedback, if a certain part of my body is hurting, looking at my technique, my preparation, my training, my recovery, and maybe this is a sign that I'm doing something wrong.
Perhaps with my technique in the boat that I can use to improve, not only row faster but keep myself in the boat more consistently as I'm using pain as biofeedback and making changes.
“An ounce of prevention is worth a pound of cure.”
Dr. Greg Spooner:
Pain in particular is something that all of us have experienced at some point in our lives. Even if you haven't been injured, you've been in pain. Can you speak to what pain is, how you discuss pain, how you describe pain as something that actually may not be something that's bad for you, but something that's actually really good for you?
Dr. Brand:
We talk about pain a lot in sport as like weakness leaving the body or something to be fought. As a doctor, I've learned a different perspective on pain, which is based on pain psychology. It's the idea that pain is a gift that tells the brain when the tissue may be at risk for further injury. Every piece of the body has a corresponding dedicated piece of the brain wired to it. Just like when we lift weights, the biceps get bigger. Well, if we keep on sending pain signals from a certain part of the body to a certain part of the brain, this piece of the brain, physically enlarges to the degree that even when we stopped sending pain signals, this big factory up here may not be able to interpret anything as something other than pain.
With every injury we have at least three jobs:
We have to stop sending pain signals.
We have to stop receiving pain signals.
Then we got to recalibrate the feedback mechanism.
“Pain is a useful tool and a gift that tells the brain when tissue may be at risk for further injury.”
Dr. Spooner:
You've spoken before that you have, I think it was three strategies, and one of these strategies in particular actually has to do with "don't do it if it hurts." What are these three strategies and how do you employ these?
Dr. Brand:
Yeah, so I really believe in active rehabilitation, and this is based on my background in evolutionary biology. I believe that, back when we were cave people chasing the wild animal to hunt it down, if we twisted our knee and injured our knee, for instance, we didn't have the option to just lay still and rest. We had to keep moving or we would starve or be eaten. I think we are evolutionarily designed to engage in active rehabilitation and active recovery, which really goes along well with being an athlete. You don't want to be out of the boat for instance.
I want my athletes to do everything during the recovery process that doesn't violate these three rules: #1. If it hurts, don't do it. #2. If it hurts more the next day, that was too much. We call that the “next day rule”, and #3. No more than 10% increase in the frequency, intensity, time, or type of exercise per week.
Dr. Spooner:
Let's say somebody comes to you, they've been doing some cross training and a person has sprained their knee or ankle and it has swollen up. How can we apply those principles that way?
Dr. Brand:
When you injure your knee, and it swells up this is a system of inflammation and tissue repair that has been evolving over 4 billion years of life on earth. What I've learned is that through natural selection, nature does not waste energy on processes that did not convey a selection advantage to someone at some time and help them survive. Rather than be frustrated and annoyed at what the body is doing, I try to help understand what it's doing and support what it's doing.
Many times, we think, oh, inflammation, quick, take some anti-inflammatory drugs or get rid of the inflammation. There are some problems with this. With ibuprofen, for every dollar we spend on ibuprofen, we spend 80 cents on stomach bleeding, kidney failure, heart attacks, things like this. Steroids go into the cell and stop it from doing transcription, which is one of its main jobs. You can see these things as steroids stopping the cell, the inflaming cells from inflaming, but they also stopped the healing cells from healing.
“I really believe in active rehabilitation and active recovery.”
Dr. Spooner:
Is that what you mean by “transcription”?
Dr. Brand:
Yeah. Transcription where that's one of the main jobs of the cell, in my opinion, where the DNA gets transcribed into chains of amino acids, which then become some of the products that a cell makes. It basically, in some ways stops the cell from doing its job. It stops inflaming cells from inflaming. It also stops healing cells from healing. By the way, inflammation was part of healing. You've kind of stopped things in its tracks.
To me, that's kind of like being really annoyed by a construction site next to your house and sending the entire construction crew home, because you didn't like all the noise. However, now you're left with an incomplete construction site, and you got to hire the crew back at time and a half to come back and resurrect that construction site, which may be harder to resurrect once you've abandoned it.
Dr. Spooner:
Sounds like some sort of a chronic pain syndrome that may have developed. Or a chronic injury, which takes longer to actually address and heal.
Dr. Brand:
What I would do initially is bring the construction crews sandwiches, and water to help them finish the job faster. We're getting away from some of the more recent treatments of steroids and anti-inflammatory drugs. Actually, we're getting back to more traditional practices, such as cupping and coining.
These days, we'll do things like Graston® technique ( a patented form of instrument-assisted soft tissue mobilization used to break down scar tissue. It is a non-surgical technique to benefit the connective tissues present throughout the body, including bones, organs, muscles, nerves, and surrounding blood vessels) or ASTYM® (Augmented Soft Tissue Manipulation - regenerates healthy soft tissues such as muscles, tendons, etc. and removes unwanted scar tissue that may be causing pain or movement restrictions) or injecting sugar water called Prolotherapy ( Also called proliferation therapy is an injection-based treatment used in chronic musculoskeletal conditions), or injecting someone's own blood or certain variations of someone's blood, such as Platelet Rich Plasma (PHP) or bone marrow concentrate, to try to support what the body's doing, to finish the healing job and move forward.
Dr. Spooner:
In your career as a sport’s medical physician, working with everyone from the masters early athlete to your weekend warrior, even maybe your junior rower: Have you ever come across a scenario or an injury where it was particularly challenging in a way that taught you a lesson in your practice and how you can apply better, more effective treatment for that person?
Dr. Brand:
Yeah, I mean, I've run into a number of challenges in treating athletes at every level. I would say one of the biggest challenges we have as people is in communication. Especially communication between athletes and coaches. There can be a lot of dynamics on both sides of that coin that can actually put people at risk for injury in the first place and slower or lack of recovery after someone's been injured.
Dr. Spooner:
Could you then give a piece of advice or illustrate the understanding based off of your experience to a coach who may be watching in terms of how your role as a sports medicine physician, whether you're directly tied with the team or if you happen to be seeing one of their athletes can augment, their training or their work at the training room or with another provider.
“The biggest challenges we have as people is in communication which puts people at risk for injury in the first place and slows down or prevents proper recovery after someone’s been injured.”
Dr. Brand:
Well, I think that the important thing to establish at the beginning is that we're all on the same side and we all want the same thing, which is for that athlete and that boat to win as soon as possible. We have different roles in this thing. I mean, for a coach their job may depend on that athlete performing, that boat winning. These things are just as important to the athlete to have success. However, I know something that I've been guilty of as an athlete myself is not necessarily communicating everything to the coach out of fear.
Fear that they'll think less of me, that I'll be taken out of the boat, they'll think I'm less reliable if I'm prone to injury. I think a lot of these things especially traditionally can create barriers between coaches and athletes. And I think more and more, some of the most successful coaches are taking a very brave step, which is opening up more dialogue with athletes working in partnership. You'll see this at more elite levels. I mean, you'll see very high level athletes that work in partnership with their coaches as opposed to more of a paternalistic relationship that we have in some more traditional environments and maybe even some lower levels of sports.
So really working in partnership, which is a good skill to develop because these skills will be necessarily only in sport, but also in work environments later on. If you're the parent of a junior athlete, these are skills you want your young child to learn how to bring their concerns to the table in a respectful and timely manner. Because sometimes if you wait too long to bring these issues up even though your intentions may have been good, you may put the coach in a very difficult situation.
Learning to express what you're feeling - Well, first of all, recognize what you're feeling in terms of pain, biofeedback, and the potential risk of a developing injury. Communicate these things in a timely manner with the coach who is not your enemy. They are very much interested in your success. As challenging as that may be, developing the skills of bringing yourself to the table and learning to express your concerns in a team oriented, constructive manner.
“Successful coaches take brave steps to open up more dialogue with athletes and to work in partnership preventing injury and winning gold medals.”
Dr. Spooner:
In a real world sense with some of the athletes that I've worked with at the elite level, for example, I have one of my patients who was in a situation where the coach was not as eager to communicate the role of communication in how they're feeling. And was blatantly told “if you are hurting, if you have to go see a physical therapist or go to medicine, don't tell me, do it on your own time. Don't let this get in the way of the work that we have to do.” In talking with some of that athlete's teammates, what we see across the board is, after they've finished their career, they're still nursing a lot of these injuries.
Then, you're looking now... let's juxtapose to today's US rowing team. I had a chance to chat with a few of the coaches at the recent convention and ask their approach on this. It's trending very much in the direction that you're talking about, which is terrific, so what you see are fewer athletes in the training room with longer-term issues. They may roll through to work with PT or massage or nutrition or sports med to iron something out, just iron a wrinkle, as opposed to stitch a tear.
Dr. Brand:
Yeah, exactly. I mean, I think that an ounce of prevention is worth a pound of cure, and sort of once the horse is out of the barn, so to speak, with some of these injuries, we may never be the same after an injury. If we could prevent it in the first place that would be in everyone's best interest of course.
Dr. Spooner:
Based on your own experience in rowing or in your own experience treating rowers who have been at whatever level going for gold and their respective level, do you have any specific or really sound advice that you may have been told at one time that you want to make sure you pass on?
Dr. Brand:
Specific recommendations regarding managing yourself as an athlete?
Dr. Spooner:
The floor is open.
Dr. Brand:
Specific advice that I received... I would say more than advice that I received, there's some things that I sort of figured out through the school of hard knocks that were important for me sort of staying in the game. These were things like focusing on the importance of appropriate levels of exercise, which as an athlete, you're oftentimes not in control of, but really looking at exercise in terms of aerobic, stretching, strengthening, and balancing progressions and not doing too much too fast because there's an exponential spike in the incidence of injury if you do progress your exercise too fast.
The importance of sleep, the importance of diet, and the importance of mindset are some things that I've learned in my own experience as a rower. Then also as a doctor. Something that I figured out pretty early as a freshmen rower at college was rowing is a lot more fun when you've had enough sleep. As a student athlete, there's just not enough time to meet all the demands everyone's placing on you. We need to engage in a process of selective neglect, where we decide, okay, I'm not going to do all the readings for this class, and I'm not going to do all the extra workouts for this coach and all these exercises for my athletic trainer.
I have to engage in a process of figuring out what's most important for me. Sleep definitely is one of those things where I sort of figured out that I needed, probably, about... If I had to push it through finals and whatnot, I could probably perform adequately the next day, athletically on about four hours of sleep, but to perform academically, I needed probably six. But making sure for instance, later on at the master’s level setting a 4:00 AM alarm clock for the 5:00 AM, practice time. Doing the math, going backwards, and resetting everything else to make sure you get enough sleep still. Whether it's a nap during the day or setting your bedtime early enough to get that recovery, because it's not the rowing that makes us stronger. It's the recovery from exercise that makes us stronger.
Dr. Spooner:
That’s where your body is also rebuilding and adapting to that demand, you're imposing on it.
Dr. Brand:
Right. If you're breaking yourself down at practice, when are you going to make yourself stronger and build yourself up? Making sure you're getting enough sleep it's going to be a lot more fun if you do, and you're going to be faster for it. The importance of diet, especially timing of fueling before, during and after practice, especially, the window right after practice and making sure you're getting the right balance of carbohydrates and protein and whatnot. Working with your team nutritionist to not necessarily work harder but work smarter and work with the timing of your fueling in and around practice. That was a big one for me.
“The recovery from exercise is what makes us stronger.”
Then mindset. For me as a college rower during my freshman year, trying to survive in this survival of the fittest natural selection system, it's easy, when you have to miss time with friends because of rowing or go to bed early because of rowing or miss a vacation because of rowing, rowing can quite quickly become something that's the reason for a lot of your unhappiness.
Dr. Spooner:
The mind, the body and the spirit… just crushing the spirit sometimes.
Dr. Brand:
Right and you decided to do this, but depending on how you approach it, it can become not fun. It went to a degree that I actually quit the team for one year, the autumn of my sophomore year. Then, I had a rock in my gut that told me that was just the wrong decision. I went back to it after missing one practice. But I decided that it was no longer going to be the reason I was unhappy that I was choosing to be there. I decided from that point forward that I was going to not let rowing be the reason I was unhappy. That I was there for a purpose. That I was choosing, and I decided to be more flexible and forgiving with myself.
For instance, if my friends were going on a trip to Idaho in the summer, I would go on the trip, and I would get up early and I would train and I would do circuits and whatnot. Then I would enjoy wakeboarding or whatever during the day, but I would stay up and I would go to events with my friends, and I'd make sure I got a nap during the afternoon, or I took a lower difficulty of course load. Basically, allowing myself to have more fun. I called it my own personal program of "Save the Attitude", which meant make it fun, make sure it's enjoyable. Maybe take some pressure off yourself academically or in terms of social events and things like that, so that rowing becomes a more positive, enjoyable thing.
Dr. Spooner:
I can already imagine the Save the Attitude banner that you've made and put it over the door, every time you pass through it's that constant reminder, right?. Fantastic! Dr. Brand, thank you so much for spending your time today with me and with us sharing these immensely valuable tools to success.
“Never underestimate the importance of sleep, diet, exercise and mindset in injury prevention and your success in winning gold or winning in life.”