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In a perfect world, you would be able to train year round as hard as you possibly could and never get hurt but training at the ragged edges of your ability can come at a price. As a result, surgery may be necessary to get you back to baseline or give you another shot at achieving your athletic goals. Here are five strategies you can implement to help you optimize your recovery after surgery.
1. FISH OIL SUPPLEMENTATION
What is fish oil? The primary ingredients in fish oil are the omega-3 fatty acids EPA and DHA. omega-3s are essential fatty acids, meaning that they are required for human health and development, but interesting enough our bodies are only able to make a very small amount.
Omega-3 fatty acids have properties that reduce the risks of blood clots, regulate fat levels in the blood and have vasodilatory effects to promote adequate blood flow to tissue throughout the body. Additionally, omega-3 fatty acids reduce inflammation, while some omega-6 fatty acids, it’s counterpart, promote inflammation which at times can be advantageous after injury.
Experts have suggested that an optimal diet should consist of a balance between omega-6 and omega-3 fatty acids at a ratio of anywhere from 1:1 to 5:1. The typical American or Western diet consists of a ratio of roughly 15:1 omega-6 to omega-3 fatty acids. Diets that heavily favor omega-6’s have been linked to increased incidences of cardiovascular diseases and cancer as well as inflammatory and autoimmune disease development and progression.
The omega-3s EPA and DHA in fish oils are considered useful anti-inflammatory agents. Inflammation is our body’s normal response to stress, that’s why at time omega-6 fats are necessary. However, a large or chronic inflammatory response can lead to long-term chronic health issues, which includes delayed tissue healing. Multiple studies have demonstrated that increasing your intake of omega-3’s while reducing your intake of omega-6’s can improve your body’s inflammatory response.
Omega-6 fatty acids (which include the polyunsaturated fat found in vegetable oils and processed foods) work like antagonists to omega-3’s, competing for the same fatty acid receptors and promoting inflammation in the body. This is especially important for athletes to consider because trauma induced from high intensity exercise leads to an elevated inflammatory state. This elevated inflammatory state can be made even greater through the intake of omega-6 fatty acids in your diet. The good news is that you can counteract these effects, if you consume adequate amounts of omega-3’s (particularly DHA and EPA) and reduce your omega-6 intake.
REGULATE BODY COMPOSITION
EPA and DHA can produce the following effects on the body: increase fatty acid oxidation for regulation of body composition, increase production of antioxidant enzymes, increase insulin sensitivity helping to better regulate blood glucose levels, and increase oxygen delivery to cardiac muscle, allowing the heart to reduce its work-load for adequate oxygenation.
In addition to being important anti-inflammatory agents, EPA and DHA have also been shown to positively impact strength outcomes and counteract muscle loss. A study by Rodacki et al. showed that 12 weeks of strength training in combination with omega-3 fatty acid supplementation elicited higher measures on all strength outcomes when compared to strength training alone.
Additionally, studies have demonstrated the ability of fish oil to stimulate the rate of muscle protein synthesis through multiple pathways. One specific pathway involves the stimulation of satellite cell activity. Satellite cells are stem cells specific to muscle with their main function being to repair injured muscle tissue via myogenesis. Additionally, research has shown that fish oil supplementation is linked to an increased response to insulin and amino acids, leading to increases in muscle protein concentrations and individual muscle cell sizes, ultimately stimulating muscle accumulation.
HOW MUCH SHOULD YOU TAKE?
As you begin your road to recovery following surgery, fish oils are essential to include in your daily diet once your doctor approves the use of these supplements. With benefits that include inflammation management, muscle loss prevention and promotion of healthy body composition; Fish Oil is essential for optimizing recovery.
For athletes, EPA + DHA supplementation of 1 - 2g daily at a ratio of 2:1 EPA:DHA has been recommended to counteract exercise-induced inflammation. However, the research supports a much higher dose of up to 6-8 grams/day of EPA+ DHA to improve athletic performance. Most health organizations recommend, at minimum, 250-500mg of EPA + DHA to maintain general health.
It is critical for your recovery after surgery to begin exercise as soon as you receive clearance by your doctor. Exercise is extremely beneficial after surgery for multiple reasons. First, exercise can increase the production of endogenous growth hormone (hGH). Growth hormone works as an anabolic hormone, playing a key role in muscle, bone and collagen growth, as well as regulation of fat metabolism and overall body composition. hGH secretion is stimulated through a number of various mechanisms, including sleep and exercise.
During exercise, skeletal muscle takes in hGH and, through various pathways, stimulates muscle protein synthesis in humans. Studies have repeatedly demonstrated a significant increase in exercise-induced growth hormone response to resistance training. The key with hGH and exercise is that exercise promotes hGH release into general circulation, thus affecting growth factors in tissues throughout the body.
STIMULATING TISSUE GROWTH & REPAIR
hGH secretion also leads to an increase in production of insulin-like growth factor (IGF), which is another major player in anabolic tissue responses. IGF-1 has been shown to act in both synergy with, and independently of hGH, to stimulate tissue growth throughout the lifespan. Exercise becomes important because when IGF-1 is released from the liver in response to hGH, it typically stimulates a reduction in additional hGH release.
However, studies have shown that with exercise, these negative feedback loops can be inhibited to allow for continued hGH secretion. Through exercise an individual can elevate their growth hormone levels to stimulate tissue growth and repair.
DOES IT MATTER WHAT TYPE OF EXERCISE I’M DOING?
Resistance training leads to significant increases in hGH response. In one study, hGH response to resistance training was shown to be dependent on program design. In this study, two resistance exercise protocols were utilized (P1 and P2). The P1 exercise protocol utilized a 5RM load (80-95% of 1RM) and 3 minute rest intervals, whereas the P2 protocol used a 10RM load (70-85% of 1RM) and 1 minute rest intervals. The results showed differences in hGH concentrations between the two groups, with the P2 group exhibiting significantly higher levels of the hormone. From these results, the researchers concluded that higher volume, shorter rest breaks and moderate loading can elicit dramatic increases in hGH levels.
Endurance training has also been shown to increase hGH levels, with increases being dependent on intensity, frequency and duration of the exercise. Research has demonstrated that exercise above “lactate threshold” for at least 10 minutes elicits a significant increase in hGH levels during and after exercise, for up to 24 hours.
Determining “lactate threshold” is difficult because there is not a single accepted definition, value or point in which blood lactate levels rise that researchers agree upon as the actual point where the lactate threshold has been reached.
In general terms though, the lactate threshold is the maximal effort that an individual can maintain with little to no increase in blood lactate, and is commonly described as a speed/pace (meters/second) or power output (in watts).
A TALE OF TWO STUDIES
In one study by Weltman et al., the lactate threshold was determined by taking blood samples while subjects underwent VO2 max testing following an incline treadmill protocol. The point at which the highest velocity was reached that was NOT associated with an increase in blood lactate concentrations was determined to be the velocity associated with lactate threshold. This value was then used to determine training speed for each of the groups.
Felsing, on the other hand, used noninvasive methods to determine lactate threshold.20 The lactate threshold, measured while performing VO2 max testing on a cycle ergometer, was determined to be the VO2 at which the ventilatory equivalent and the end tidal O2 increased WITHOUT an increase in the ventilatory equivalent for CO2 and the end tidal CO2.
Felsing et al. demonstrated that prior to the 10 minute mark of high intensity exercise, there was only nonsignificant elevation in hGH, and with low intensity exercise, statistical significance was never reached. Exercise above “lactate threshold” (high intensity) for at least 10 minutes elicited a significant increase in hGH levels during and after exercise. Furthermore, Weltman et al. showed that exercise above the lactate threshold increased the release of hGH at rest for the 24 hours following exercise. Whereas training at or below lactate threshold did not elicit significant hGH increases.
Studies have shown that frequency of endurance exercise has an effect on hGH levels. In one study, researchers demonstrated that repeated bouts of aerobic training on a single day significantly increased hGH levels with each subsequent exercise session. The researchers concluded that to optimize hGH release, an individual should train multiple times per day, while following the endurance parameters above, regarding lactate threshold and duration.
Sleep plays an important role in tissue healing and repair, which is why it should be high on your list of priorities following surgery. While asleep, your brain stimulates the secretion of hormones for tissue repair, including those for wounds and damaged muscle. Your immune system also benefits from sleep, as your body creates white blood cells (WBC) during this time in order to fight infections that may otherwise impair healing. Importantly, for post-op patients, sleep disturbances have been associated with longer hospital stays, increased functional limitations and worse emotional states and reduced quality of life.
HOW SLEEP IMPROVES YOUR MUSCLE RECOVERY
Individuals suffering from “sleep debt” have been shown to have increased levels of cortisol (a catabolic hormone), and reduced levels of testosterone and IGF-1 (anabolic hormones), favoring proteolytic and degradation pathways that ultimately result in impaired muscle recovery.
A study by Nedeltcheva et al. demonstrated that in calorie restricted subjects, individuals who were allowed 5.5 hours of sleep experienced 60% more muscle mass loss and had 55% less fat loss than those in the control group who were allotted 8.5 hours of sleep/night. After surgery, energy expenditure is typically reduced, so sleep becomes important not only for muscle maintenance, but also for augmentation of fat acquisition, and overall regulation of body composition.
4. Mental Imagery
For many years, mental imagery has been used by athletes to improve performance both in training and in competition. Mental imagery studies have demonstrated improvements in strength performance, reduction in muscle fatigue, and even enhancement of muscle recovery in individuals with injuries.
In a systematic review of mental imagery effects on strength in both healthy and patient populations, Slimani et al. concluded that imagery interventions have a significant effect on prevention of strength loss in the affected limb in athletes who are inactive or immobilized following injury.
Additionally, the use of mental imagery during the rehab process after injury and subsequent surgery of ACL reconstruction has been shown to reduce pain and lessen re-injury anxiety, as well as increase knee strength.
INTERNAL VS. EXTERNAL IMAGERY
Broadly speaking, there are two perspectives for mental imagery training: internal and external. Internal practice requires one to picture themselves experiencing the movement as if they are really performing the act, whereas the external perspective takes on an out-of-body visual, as if you’re watching through a camera.
Across studies, internal imagery is supported as the superior technique for muscle excitation and strength performance. Additionally, Ranganathan et al. demonstrated greater outcomes on strength with high mental effort imagery (20.5%) vs. low mental effort visualization (2%). Furthermore, greater EMG activity is produced when mental imagery is focused on heavier force production “heavy weight” vs. imagining lifting lighter weight.
With internal perspective imagery, it is theorized that greater neural adaptations, stronger brain activation, higher muscle excitation and higher physiological responses all contribute to greater strength performances when compared to external perspective imagery. When considering mental imagery training, neural adaptations are the major contributor for muscle gain and strength increases, versus changes at the muscular level.
In addition to strength gains, mental imagery practice can also improve muscle coordination, for example- improved coordination of agonist/antagonist muscles during maximal voluntary contraction.
Creatine is a naturally occurring non-protein amino acid. In our diet, creatine can be found in meat and fish. Within our bodies, 95% of creatine is located in skeletal muscle. The purpose of creatine is to help with energy production, especially during high intensity, anaerobic exercise, such as heavy lifting and short-duration interval training. Supplementation with creatine has been shown to increase muscle mass and strength, as well as enhance recovery.
Creatine is one of the most researched and evidence-backed legal supplements available to athletes. Numerous studies have demonstrated the safety of long-term use, with trials running for 5 years with intakes of up to 30g per day with well-tolerated outcomes in both healthy and patient populations across the lifespan.
The International Society of Sports Nutrition (ISSN) position stance on the safety and efficacy of creatine supplementation states that “In addition to athletic and exercise improvement, research has shown that creatine supplementation may enhance post-exercise recovery, injury prevention, thermoregulation, rehabilitation, and concussion and/or spinal cord neuroprotection. These studies provide a large body of evidence that creatine can not only improve exercise performance, but can play a role in preventing and/or reducing the severity of injury, enhancing rehabilitation from injuries, and helping athletes tolerate heavy training loads.”
REDUCTION IN RISK OF OVER-TRAINING INJURIES
Research has demonstrated significant effects regarding creatine supplementation and muscle recovery. In multiple studies, ingestion of creatine with glucose led to enhanced storage and retention of creatine and carbohydrates in skeletal muscle. When compared to carbohydrate loading alone, creatine loading coupled with carbohydrate loading prior to high intensity exercise produced better glycogen restoration. These results are important because glycogen restoration promotes recovery and reduces risk of over-training injuries for high intensity athletes.
Additional evidence supports that supplementation with creatine can reduce muscle damage. One study demonstrated greater muscle strength during recovery following exercise-induced muscle damage in participants who were given creatine. Enhanced recovery after heavy training allows athletes to continue to train under intense loading with reduced risk of injury and overuse injury, allowing for greater training adaptations.
PREVENTING MUSCLE ATROPHY
Further research has been done regarding creatine supplementation effects on muscle atrophy during periods of limb immobilization due to injury and subsequent rehabilitation phase. A study by Hespel et al. looked at the effects of creatine use and muscle atrophy in subjects who had their legs immobilized in a cast for two weeks. The results of the two weeks of immobilization and 10 week rehabilitation period showed that subjects in the creatine group (20g/day down to 5g/day) had a faster recovery rate of quad strength and muscle mass than the control group (who did not receive creatine) during the rehabilitation phase.
POST SURGERY BENEFIT
In a similar study, Op’t Eijnde et al. found that creatine use reduced the amount of muscle GLUT4 protein loss during immobilization. GLUT4 protein plays an important role in glucose uptake into skeletal muscle, thus controlling energy production, muscle maintenance and glucose homeostasis. Based on the role of GLUT4 protein and creatine’s effects on GLUT4’s levels, researchers concluded that creatine supplementation can reduce the degree of muscle atrophy during periods of immobilization. Their results also supported what Hespel concluded in that creatine use can stimulate muscle hypertrophy after immobilization, during the rehabilitation phase.