Dustin Nabhan is a health care executive and Doctor of Chiropractic with specialty certifications in sports medicine, strength and conditioning, and musculoskeletal ultrasonography. He currently serves as the Vice President of Health & Performance for Canyon Ranch, where he leads the health, human performance, nutrition, and mental health and spiritual wellness teams.
Freelap USA: You are known for teaching medical professionals the value of sonography. Diagnosis via a combination of orthopedic exam and medical imaging is powerful but adding an assessment of muscle adaptations (architecture) is especially useful. Can you get into the details of assessing adaptations so teams and organizations can raise their game?
Dustin Nabhan: Sonography is a powerful tool when used appropriately; however, most teams and practitioners haven’t tapped into ultrasound’s capabilities. The advantages of ultrasound over traditional imaging include:
- Safety: Ultrasound does not use radiation and is safe to use frequently. We now have a diagnostic imaging modality that can be used for monitoring healing instead of having to save imaging for serious injuries.
- Cost: Current prices are about $30k for a good machine, and no cost per study once the machine is acquired. The new handheld devices are starting to produce amazing images and are already disrupting the market in this area. Low cost means no/low barrier to entry for obtaining images as you monitor an athlete’s recovery from an injury to adaptation to training.
- Portability: I have traveled the world with a musculoskeletal machine in a backpack and set up court/pool/trackside or in locker rooms to evaluate athletes. Ultrasound allows you to obtain images in any setting—the military can take ultrasound in the battlefield to perform abdominal trauma triage, for example.
- Resolution: Ultrasound has a very high resolution (dots per square inch) when compared to traditional imaging modalities such as MRI. An infrapatellar tendon on an MRI may take an inch of your screen; in comparison, you can analyze individual fibers of a tendon on ultrasound. The level of detail that ultrasound provides makes it a better modality for many soft tissue injuries, as you can appreciate more detail in muscle, fascia, or tendon structure, and you can have the patient move while they are being imaged.
- Vascular activity: Vascular activity in a tissue is a clue that an injury has occurred, or healing is taking place. There are patterns of vascular activity that change depending on the healing phase. Dr. Mederic Hall is doing some great work on this at the University of Iowa. Now, instead of guessing based on biological healing times (many of which come from animal studies), we can use the combination of physical examination, functional capacity, tissue structure on ultrasound, and vascular activity to make an educated forecast on how a tissue is healing and what load should be prescribed in the next phase of return to play.
In the U.S., our physicians are paid for productivity, and as a result, most physicians use ultrasound almost exclusively to guide procedures (such as corticosteroid or PRP injections). This has been toxic to the development of ultrasound skills by U.S.-based clinicians. Of the hundreds of highly qualified sports medicine physicians I have worked with, there are only a handful that truly have expertise using ultrasound for diagnostic and return to play decisions.
Freelap USA: While you are a medical professional, you have years of experience using force plates. How important is it for medical professionals to understand real strength and conditioning performance principles beyond return to play?
Dustin Nabhan: I was an S&C coach prior to entering sports medicine, and I worked at a facility that trained Olympic weightlifters. My experience in that setting exposed me to the translated Soviet weightlifting manuals, which opened the door to sport science at a different depth than I was used to in the U.S. In the Cold War era, European sport scientists had load prescription and monitoring dialed in to a level that we probably are still behind here in the U.S.
When I entered sports medicine practice, I challenged myself to push S&C and sport science knowledge into my return to play programs, as it became clear that the industry has done the inverse of this for far too long. Athletes can only benefit if a load is high enough to stimulate adaptation. If your athlete is recovering from a tendon injury, you have to prescribe exercises that are similar to the magnitude and direction of sport for the tendon to adapt accordingly.
There are very few situations in which a TheraBand or Bosu Ball exercise can provide appropriate load—athletes need high load and high-velocity movements to prepare for sport, says @nabhansportsmed. Share on XFor some reason, in the last 20 years the S&C industry has digressed from training with appropriate load and has tried to adopt practices used in physical therapy for general pop patients as part of athlete preparation. There are very few situations in which a TheraBand or Bosu Ball exercise can provide appropriate load—athletes need high load and high-velocity movements in order to prepare for sport.
Choosing appropriate load is done best when technology is used to quantify forces. My clinics were early adopters of dual force plates for athlete screening, monitoring, profiling, and return to play. We are at an exciting time in sport science—previously expensive technology is now available to the masses. The downside to this is that, because few sports science or medicine experts have backgrounds in interpreting force-time curves, we are being bombarded with companies selling black box analysis or making inappropriate claims as to how force plates should be used.
We need more content experts with Ph.D.-level education and clinical experience in this area to guide our practices. Matt Jordan is the perfect example of this—he has extensive experience as an S&C coach and sport scientist and did his Ph.D. on the use of force plates in ACL risk management. Experts like Matt understand how variables like timing of measurement, technical error in measurement, the cues and jump strategies tested, and the number of reps in a testing session affect the interpretation of results. My hope is that the availability of this technology and accessibility to high-quality education help produce more Matt Jordans for our industry.
Freelap USA: You have an extensive network of experts at your disposal beyond domestic experts. How is your international background helping now that you are more focused on U.S. colleges and pro sports? What about international clients?
Dustin Nabhan: The international sports medicine community is strong, and I’m not sure that we use their expertise in the U.S. as well as we could. Also, because the focus of many international sports medicine projects is on soccer, we don’t always pay attention to the amazing work they are doing. The European and Australian model has proven the benefit of integrating graduate students into high-performance teams. This allows them to answer the most pressing questions with high scientific rigor. In the U.S., we don’t always have staff with the appropriate training in scientific methodology to answer the questions that we encounter in practice.
I am in the final stages of finishing my Ph.D. dissertation at the Norwegian School of Sport Sciences. In my opinion, the Norwegians have perfected the integrated research model. If you look at the work coming out of the Oslo Sports Trauma Research Centre (which has led the way in ACL, hamstring, and shoulder prevention research internationally), they almost ALWAYS include a multidisciplinary team in each study. You would be hard-pressed to find a study that does not include both a physician and a physio on the research team, and many also have a physiologist, biomechanist, dietitian, and/or psychologist. The more perspective you have around a complex problem, the easier it will be to find the simple solution.
Freelap USA: When you consult with teams, many of them look for continuing education, but you are more about building medical and monitoring algorithms. Can you go into the importance of installing protocols based on criteria rather than just doing presentations or lectures?
Dustin Nabhan: When I choose a continuing education event, I always look critically at why the event is being put on (what the person is actually selling). Most events are sponsored by the industry and motivated by selling a widget. I’m not a widget guy; I believe in systems. You cannot buy a system. I’m more interested in whether the new knowledge gained from a course will give my team another tool to put in the health and performance ecosystem. This could be a skill, method of analysis or interpretation, communication style, etc.
I am excited that more courses are teaching systems thinking, rather than focusing on technical skill, says @nabhansportsmed. Share on XI am excited that more courses are teaching systems thinking, rather than focusing on technical skill. Ernie Reimer’s decision tree course is a great example. Jurdan Mendiguchia’s approach to hamstring rehab decisions is another one. Hopefully we can collectively work together in sport science and medicine to give providers a higher level of education than simple, technical, competency-based courses.
Freelap USA: Simple blood analysis screens for vitamin D and iron deficiency are not especially exciting, but athletes are often at risk. What is your experience coordinating with nutrition staff and coaches with the aforementioned topics? Lifestyle is much different than treating an acute injury.
Dustin Nabhan: Screening for biomarkers was actually part of my Ph.D. Biomarkers are surrogates of the outcomes—they explain some of the variance of a KPI or disease process, but they are not direct indicators of it. Any time you choose to track a biomarker, you have to consider what factors affect reliability of measurement and physiological variation in response and understand the basic science behind the test.
As an example, serum ferritin is the best marker of iron status. But inflammation due to injury, training, or illness elevates ferritin levels, so you can be misled if you look at the numbers alone. Biomarker monitoring works best when as many health, performance, and lifestyle factors are analyzed in tandem with the biomarker of interest.
For instance, HRV is meaningless on its own because so many factors affect it. But when you look at sleep, hydration, alcohol and caffeine intake, life stress, and training stress together, all of a sudden HRV becomes a useful marker.
My advice for teams looking to monitor a biomarker is to first decide if it is a good enough surrogate of the KPI you are actually interested in. Second, audit the science behind the test you are considering using with original research papers (not the website of the product manufacturer). Then research the factors that are associated with the biomarker and decide if you have a good probability of understanding the variation in the marker with the information at your disposal. Finally, pilot it—make sure the test and results are acceptable to you and the athlete. If you check those boxes, you may have found a good test.
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