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Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network Premier Orthopaedic Associates

Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

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Page 1: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Performance Enhancement

Vincent Disabella DO FAOASM

Fellowship Director Inspira Health

Network

Premier Orthopaedic Associates

Page 2: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

What is a PED?

• Any substance used by an athlete to

enhance performance.

• Does not have to be a prescription drug.

• Many different ways to enhance

performance.

• Anything can and will be abused.

Page 3: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think
Page 4: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Strength and Power Naturally

Page 5: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Types of PED’s

• Anabolic Agents

– Anabolic Steroids

– Growth Hormone

• Insulin & IGF-1

• Stimulants

• Pain Killers

• Blood Boosters

• Peripheral Agents

Page 6: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

ANABOLIC STEROIDS

• Androgenic Anabolic Steroids are discovered in 1936.

• AAS find their way into sports in the 1950’s.

• IOC bans AAS in 1964, and begins urine testing in 1968.

• As late as 1990 the medical community denies AAS cause strength gains.

Page 7: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

ANABOLIC STEROIDS

• How do they work?

• Anabolic/Anti catabolic

– Enzyme stimulators- RNA polymerase

produces intracellular protein

– Intracellular oncotic pressure- increased

– Time between work-outs is decreased

Page 8: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

ANABOLIC STEROIDS

• Why have AAS become so popular?

– 10- 25% weight gain in 3- 6 months

– Psychological effects

– Better ones appearance

• Be aware of your patients!!– Various studies of American high school athletes

estimate that 5.9 percent of boys and 4.6 percent of

girls have used anabolic steroids to help them build

muscle.

Page 9: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Popular Anabolic Steroids

• Nandrolone decanoate

(Deca-Durabolin)

• Stanozolol (Winstrol)*

• Methandrostenolone

(Dianabol)*

• Methenolone

(Primobolan)*

• Oxymetholone (Anadrol)*

• Boldenone (Equipoise)

• Testosterone cypionate

• Testosterone propionate

(Virormone)

• Testosterone Blend

(Sustanon 250)

• Testosterone enanthenate

(Testaviron)

• Testosterone undecanoate

(Andriol)

Page 10: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

ANABOLIC STEROIDS• MEDICAL USES

– Refractory anemias

– Hereditary angioedema

– Wasting syndrome in

HIV

– Hormonal replacement

• ADVERSE EFFECTS

– Hepatocellular dysfunction

– Acne and hirsutism

– Mood swings and aggressiveness

– Increased LDL, decreased HDL(c, 2c 3c) and ApoA1

– Raised Apo-B

– Decreased testicular size, gynecomastia

Page 11: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

The Steroid Mindset.

• Many think they need

them to compete.

• Many think everyone

else is doing it so I

have to also.

• Win at All Cost.

• Muscle Dysmorphia.

Page 12: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Most Dangerous Effects of AAS

• Roid Rage.

• Hyper sexuality.

• Over confidence.

• Depression/Suicidal.

• Psychological

Addiction.

• Mood Swings

Page 13: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Calling them out!

• Patient admits to using AAS.

• You see all the signs and ask.

– Often leads to denial.

• Formalized drug testing.

• T4 x HDL- if less than 100 suspect AAS use

• Testosterone/ Epitestosterone > 6:1- AAS use

• HDL > 10 suspect AAS use.

Page 14: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

THGtetrahydrogestrinone

• A chemical manipulation of gestrinone-a

rarely used progestin for treating

endometriosis.

– Was intentionally altered for the sole purpose

of eluding drug testing.

• Slightly altered the progestin and then added a side-

chain similar to Trenbolone(the strongest known

synthetic androgen)

Page 15: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

THG

• Is a potent androgen and progestin

properties but no estrogen properties or sex

steroid antagonism. (Death et al JCEM 5/04)

– More potent than nandrolone and trenbolone.

– Would have to expect all the bad effects of

both.

• Nobolethone is another “supplement” which

was recently discovered.

Page 16: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Growth Hormone

• Growth hormone release increases at the

onset of aerobic activity and decrease at or

close to the cessation of aerobic activity.

• The more intense the aerobic activity the

greater the increase.

– There are many confounding factors.

– Adiposity decreases the GH response.

– Decreases with conditioning.

Page 17: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

In regards to Resistance Training the variables are

much greater in the GH response.

• Length of rest period.

– Shorter rest periods caused greater increases.

• Intensity of workout.

– 1 RM vs 10 RM.

• Volume of work.

Note women during follicular phase have a

higher GH level than men.

Page 18: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Why use HGH

• Increased muscle size

and strength.

• Decrease adipose

stores.

• Increased metabolism?

• Increased bone

density?

• Not easily detected in

testing.

Page 19: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Problems with HGH

• Acromegaly- irreversible bony

enlargement

• Hyperpigmentation

• Glucose intolerance

• Organomegaly- cardiomyopathy

• Carpal Tunnel and other nerve

entrapments.

Page 20: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Muscle Dysmorphia

• AKA: Reverse

Anorexia, Bigorexia.

• Effects Males >

Females.

• DSM IV subclass of

OCD.

• Sports↔MDM

Page 21: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

What to do with MDM?

• What do you look

like?

• What is the ideal

body?

• What do you think

others think you look

like?

• Unlike AN they look

healthy. Identify

• Antidepressants.

• Extensive

Psychotherapy.

Page 22: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Contributing psychobehavioral factors for muscle dysmorphia. (Copyright

2004. From Journal of Strength and Conditioning Research; by Lantz CD,

Rhea DJ, Cornelius AE. Reprinted by permission of Alliance

Communications Group, a division of Allen Press, Inc)

Page 23: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Insulin and IGF-1

• GH anabolic effects are regulated by

Insulin-like Growth Factor-1 (IGF-1)

• Complex interaction of Insulin, GH and

IGF-1 to control the nutrients supplied to

the tissues during fasting and feeding.

• Insulin and GH have been widely available

and now so is IGF-1.

– Let the games begin.

Page 24: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Why IGF-1

• Recently Mecasermin Tercica (Increlex)

and Mecasermin Rinfabate (iPLEX) have

become available to treat growth failure in

children.

– Increlex is rhICF-1.

– iPLEX is rhIGF-I bound to rhIGFBP-3, its

major binding protein.

Page 25: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

IGF-1 now available on the Black

Market.

• Improves endurance.

• Increased muscle

strength.

• Increased tendon

strength.

• Rapid tissue repair.

• Sexual enhancement

and endurance.

• Better BG control.

• Anti-Aging.

• Fat reduction.

• Mood elevation.

• Anti-inflammatory.

• Nerve regeneration.

Page 26: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

IGF-1

• Exogenous IGF-1 has anabolic effects.

– Enhances the uptake of Amino Acids.

– Works at any age, even in sarcopenia.

• Increases glucose uptake by increasing

insulin sensitivity and glycogen production.

– Being used by athletes to rapidly replenish post

extensive exercise.

– Causes symptomatic hypoglycemia.

Page 27: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

IGF-1

• Exogenous administration is shown to increase

lypolysis and lipid oxidation.

– May be indirect by suppression of circulating

insulin.

– Mature adipose cells have receptors for IGF-1

so it may have a direct effect on adipose cells.

• May reduce fat mass.

• Provide abundant fuel source in endurance events

while protecting glycogen and protein.

Page 28: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Insulin

• Many preparations are readily available.

• Insulin mediated glucose uptake enable

glycogen production.

• Causes carbohydrate to be utilized instead

of amino acids and fatty acids.

• Used post exercise to replenish glycogen

and ATP stores.

Page 29: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

GH, Insulin and IGF-1

• There is no proof that insulin or IGF are

performance enhancing.

– Imagine doing that random controlled study.

• Many athletes do their own studies with a

N=1.

• Many use multiple drugs at once.

• Slightest advantage is a Gold vs. not

making the finals.

Page 30: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Potential Problems.

• Hypoglycemia.

• Tonsilar/Adenoid growth—resolves.

• Possible acromegaly like effects due to

similarity of IGF-1 and GH.

• Cardiomyopathy?

• Increased IGF-1 levels in prostate and

colorectal cancers.

Page 31: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Oral Hypoglycemics

• Used for carb loading.

• Metformin is the “safe one”.

– Does not cause hypoglycemia.

– Does cause Rhabdomyolysis.

• Very scary when the athlete only knows

part of the story.

Page 32: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Epogen

• rEPO became available in the late 80’s.

– Blood doping in endurance sports started

almost immediately.

• ↑ Hbg = ↑VO2 max

• Must have adequate iron stores, takes a few weeks

to raise the Hct and Hbg.

Page 33: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Who’s doping?

Page 34: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Problems with blood doping.

• HTN: ↑volume,

↑viscosity & ↑ CO.

• Stroke due to

viscosity.

• MI due to viscosity.

• Seizures

• Antibody Mediated

Aplasia.

Page 35: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Gene Doping

• Introducing a desired gene (transgene) into

an organism via a vector (often a virus).

– Done in agriculture with plants and livestock.

• Genes can also be injected.

• Put in the system with liposomes or

plasmids.

• Beware virus could infect others.

Page 36: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

The Basic Science

• Injection of the gene vector

– Can inject directly into the tissue or

bloodstream

– Can remove cells, alter them then re-introduce

them.

• The gene plasmid is introduced into a virus

and then the patient is infected with the

virus.

Page 37: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

• Can inject the plasmid directly into the

muscle then use E-stim or Ultrasound to

activate the gene.

• Risks are tremendous

– Can’t shut the gene off.

– Over proliferation or mutation causing cancer.

– Immune response to the viruses or vector.

– WADA banned 2003 but not illegal in US.

Page 38: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think
Page 39: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Stimulants

• Who are your abusers?

– Distance athletes.

– MLB, NFL, NHL,

NBA.

– EVERYONE.

• Prescription stimulants.

• OTC stimulants.

• Energy Drinks.

Page 40: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Stimulants

• Ephedra/Psuedophed

– Increased heat stroke.

– Increased

rhabdomyolysis

• Modafinil (Provigil)

– Increase exercise time

17%

– Increased core

temperature at rest.

• Methylphenidate

(Ritalin)

– Same heat issues

• Amphetamines

– All forms

– All the same

• Cocaine

• Don’t forget the heart

issues and strokes!

Page 41: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

How do stimulants work?

• (1) an elevated release of neurotransmitters

(eg, dopamine, noradrenaline, and

serotonin) into the synaptic cleft.

• (2) the direct stimulation of postsynaptic

receptors.

• (3) the inhibition of neurotransmitter

reuptake.

Page 42: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Cocaine

• Used as far back as the Inca’s to enhance

workloads and speed long demanding tasks

in hypoxic environments.

• Used in the 16th century in race walking .

Note

• Use of psuedophedrine has increased

greatly since the lifting of the ban in 2004.

Page 43: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Pain Killers

• NSAID’s

– GI effects well known

– Nephrotoxicity

– Bleeding issues

– Exercise Induced

Hyponatremia

Topical preparations can

decrease some of these

problems.

• Narcotics

– Addiction.

– Injury due to slowed

reactions.

– Injury due to going

through pain.

Page 44: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Peripheral Agents

MASKING AGENTS

• Diuretics to dilute urine.

• Probenecid blocks

excretion.

• Plasma expanders such

as glycerol.

COUNTERACTING

AGENTS

• HCG—prevents

tesicular hypertrophy.

• Selective Estrogen

Receptor Modulators.

• Aromatase inhibitors.

• Anti-Estrogens.

Page 45: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Beta -Blockers

• Used in sports were a steady hand is

important.

– Not used as often in Biathlon.

• Not only decrease Blood Pressure

– Decrease anxiety

– Steady hands and decrease tremors.

Page 46: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Sildenafil and Tadalafil

• Used to treat ED.

• Often used by Sr. Games Athletes.

– Can cause MI, CVA, Hypotension.

– Be aware of interaction with other drugs.

• Many High School and College athletes are

using to become “Superman” off the field

• BE AWARE OF PRIAPISM

Page 47: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

The only benefit of Obamacare

This will end any erection

Page 48: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Inspira Health Network

• AOA Residencies: FP, IM, OB/GYN,

Ortho, ER, Gen Surgery, Podiatry.

Traditional Rotating Internship.

– Fellowships: SM, Uro-Gyn, Nephrology,

Critical Care.

– Sports Medicine Fellowship position 2014-

2015.

Inspirahealthnetwork.org

Page 49: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Interesting websites.

• www.TaylorHooten.org

• www.steroidabuse.com

• www.drugabuse.gov

• www.acsm.org

• www.wada-ama.org

• www.usada.org

Page 50: Performance Enhancement · Performance Enhancement Vincent Disabella DO FAOASM Fellowship Director Inspira Health Network ... size, gynecomastia. The Steroid Mindset. • Many think

Inspira Health Network

• AOA Residencies: FP, IM, OB/GYN, Ortho, ER,

Gen Surgery, Podiatry. Traditional Rotating

Internship.

– Fellowships: SM, Uro-Gyn, Nephrology, Critical Care.

– ACGME FP program.

Inspirahealthnetwork.org