Spring 2005.qxp

The Magazine of The Sport Medicine Council of Alberta

Spr ing 2005

pulse

IInnssiiddee::Managing Heat Stroke on the Field

Drug Education: The Most Commonly Asked QuestionsHow to Change your Body Composition

2 SMCA Pulse Spring 2005

The SMCA has recently revised our Athletic First Aid Manual—last updated in 1992 —to provide very specific information, resources and up -to-date techniques regarding the treatment and prevention of various athletic injuries. This new manual was written by a diverse committee of sport medicine professionals from Alberta, some of the best in their area of expertise. Our previous manual was composed by the Inter -Provincial Sport Medicine Network of Canada, which disbanded in 1995 and has yet t o reunite. The Sport Medicine Council of Alberta intends for this manual to be used during an individual’s formal training in athletic first aid and injury prevention, especially since the writings and illustrations in the manual accentuate the proper teaching of an Athletic First Aid course.

Prices SMCA Members will save an

additional $5/manual (on top of the

already low membership price !) when

purchasing a class set of 20 manuals. Member Prices: $30/manual

Non-Member Prices: $35/manual

To place an order, please fill out the

www.sportmedab.ca/shopping.html

Save $5/manual When Purchasing a Class Set of 20

Manuals! Athletic First Aid Topics Covered in the New Manual:

Introduction to Athletic First Aid

Planning & Preparation

Preparing for an Emergency

Understanding Athletic I njuries

Game Time

Sport Related Injuries

Managing Specific Athletic Injuries

Special Topics

Taping & Wrapping

Medical & Event Forms

References & Resources

“Making Alberta a Safer Place to Play!”

Sport Medicine Council of Alberta 11759 Groat Road Ph: (780) 415 -0812 Edmonton, AB Fax: (780) 422 -3093 T5M 3K6 Email: [email protected]


Spring 2005 Vol. 18 No. 1

SMCA SMCA Board of DirectorsBoard of Directors

President . . . . . .Koralee Samaroden, BPE, PFLC

Past -President . .Dr. Joel Weaver, MD, CCFP, CASM

Vice-President . .Dr. Gordon Bell, Ph.D.

Treasurer . . . . . . .Darren Turchansky, CA

Secretary . . . . . . .Jennifer Hanon

ASSM Rep . . . . . . .Dr. Joel Weaver, MD, CCFP, CASM

SPC Rep . . . . . . . . .Gabrielle Cave, BSc., P.T., MCPA

AATA Rep . . . . . . .Dwayne Laing, BPE, CAT (c)

SSAA Rep . . . . . .Dr. Gordon Bell, Ph.D.

SNS Rep . . . . . . . .Jane Dawson-Edwards, R.D.

Member at Large .Ray Kardas

SMCA SMCA E m p l o y e e sE m p l o y e e s

Executive Director . . . . . Ryan Petersen, BPE

Account Manager . . . . . . Janice Peters, BCom

Director of Programs

Services & Fundraising . Michael Pugh, BPE

Special Projects

Coordinator . . . . . . . . . . . . . Jennifer Johnson, BPE

Pulse Magazine Published by:Sport Medicine Council of Alberta

11759 - Groat RoadEdmonton, Alberta, Canada

T5M 3K6Phone: (780) 415 - 0812

Fax (780) 422 - 3093Website: www.sportmedab.ca

Email: [email protected]

Contents copyright 2005 by SMCA. Articles may not be reprintedwithout permission. The opinions are those of the respective

authors are not necessarily those of the SMCA.ISSN: 1181-9812

Publication agreement no. 40038086Subscriptions: 1 year $14.99 plus GST

Send subscription request and changes via email to:[email protected]

We gratefully acknowledge the financial support of AlbertaCommunity Development and the Alberta Sport, Recreation, Parks

and Wildlilfe Foundation, towards our editorial costs.

ppuullssee

The Sport Medicine Council of Alberta Would Like to Thank our Partners

for their Ongoing Support:

LL aa tt ee ss tt NN ee ww ssf r o m t h e SSMMCCAA

~The SMCA has decided to further pursue theDevelopment of our Website into the springand summer. We began redesigning the siteback in November of 2004, and we’re notfinished yet! In the coming months, visitors tothe site can expect our shopping and courseregistration forms to be submitted electron-ically, and members will also have theopportunity to advertise with us online! Keepchecking our website for details.

~ The partnership between the SMCA andWillis/Aviva Traders has resulted in an out-standing benefits package available only tomembers of the SMCA!! Enjoy savingsthrough preferred group rates and auto orhome insurance with competitive premiums.For more information, turn to page 5 of themagazine, or contact one of the WillisInsurance Specialists today!

~ With much success, the 2005 ResourceDirectory has been up and running sinceFebruary from its new online location, foundat:

http://www.sportmedab.ca/directory.php.

The directory contains the names and contactinformation of various sport medicine profes-sionals affiliated with the SMCA located allthroughout Alberta. Visitors to our onlineresource directory can now convenientlysearch and find information to contact a sportphysician, sport nutritionist, chiropractor,athletic therapist or other sport medicineprofessional in their area. If you are apracticing professional in any of thesedisciplines and would like to have yourcontact information published, please fill out amembership application form online at: http://www.sportmedab.ca/membership.html.

~ Last month, the SMCA Athletic First AidCourse Conductors Forum took place inCalgary. Attendees gathered to review thenew Athletic First Aid manual and discuss itsvital role in the SMCA Athletic First AidCourses and the Athletic First Aid EquivalencyProgram. The SMCA would like to thank allthose conductors who attended, includingSMCA Master Course Conductors Dave Katoand Gerry Poole who lead the discussion.We would also like to welcome DeniseBrochu-O’Neill, the newest SMCA AFA CourseConductor.

~ This past year, Sport Nutritionists of theSMCA have been busy revamping thecurriculum for the Level 1 Sport NutritionSpecialist Course. New content will includeproper nutrition for competition and everydayactivities, hydration, vitamin and mineral use,and much more. Anyone over the age of 16can take the Level 1 SNS course: look forupcoming dates to be posted on the coursespage of our website at:

http://www.sportmedab.ca/courses.php.

~ The SMCA is pleased to announce ourparticipation in the 2005 HPEC Conference,taking place in Fort McMurray May 12-14.Conference attendees will have the chanceto view a variety of SMCA products, as wellas inquire about school specific programs andservices.

~ The SMCA is also excited to announce thereactivation of our Speaker & Writers Bureau!Now anyone can book a sport medicineprofessional to speak their class, club or teamon a variety of sport related topics. For moreinformation, visit:

http://www.sportmedab.ca/speaker.html.

I am pleased to be a part of the SMCA, an organization that is dedicated to providing excellent programs and services in the fields of sport medicine, sport safety promotion and injury prevention to the residents of Alberta.

The SMCA in partnership with its provider groups, the Alberta Society of Sports Medicine, the Sport Science Association of Alberta, Sport Physiotherapy Alberta and the Sport Nutrition Specialists of Alberta continue to ensure safe and healthy environments for sport and recreational activities in Alberta. We look forward to continuing these partnerships and building new ones in the future.

Highlights of this past year include the bi-annual sport exchange with Hokkaido Japan, and the redevelopment of the SMCA website, resulting in a fresh new look and increased functionality.

I would like to send a special thank you to all those involved with the production of the new Athletic First Aid Manual. Your efforts have created an excellent guide and resource which will serve the needs of Albertans for years to come.

I would also like to thank the SMCA staff whose dedication to excellence has made my time as President a wonderful experience. I have enjoyed my year as president and look forward to serving as past president.

Finally, I would like to wish all SMCA members a safe and enjoyable summer and encourage you to contact the office or visit the website for all your sportmedicine questions or concerns.

~Koralee


M e s s a g e f r o m SMCA P r e s i d e n t

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On-tthe-FF ield Management of Heat Stroke

By: GGrreeggoorryy GG.. DDaammmmaannnn,, MMDD && BBaarrrryy PP .. BBooddeenn,, MMDD

Keeping Cool . . .

Heat stroke is defined as a life-threatening illness characterized by elevated core body temperature above 104 degreesF (40 degrees C) and central nervous system dysfunction. Heat stroke carries a high mortality rate if diagnosis and

treatment are delayed. The recent deaths of athletes from heat-related illness have generated great interest from themedia. Despite ever-expanding medical technology, the incidence of heat-related illness and death is on the rise.

According to the National Center for Catastrophic Sports Injury Research, there have been 37 heat-related deaths infootball from 1980-2001, with over half occurring since 1995. It is critical that sports medicine physicians be prepared to

promptly treat athletes with heat illness. Proper management of heat stroke requires a thorough understanding of thepathophysiology, risk factors, treatment, and prevention of this condition.


PathophysiologyThe basic mechanism of heat stroke is a heat load on the body greaterthan the body's ability to dissipate the heat. The source of heat can beexogenous, endogenous, or, most often, a combination of the two. Duringexercise, blood flow is shunted to active muscles. As muscle temperatureelevates with activity, warmed blood can lead to an increase in core bodytemperature. In an attempt to dissipate this heat, blood is delivered to theskin where sweat is evaporated and heat is lost. During exercise,excessive sweating and inadequate fluid intake can lead to volumedepletion. The body attempts to maintain a normotensive state bydelivering less blood to the skin, which results in less dissipation of heat.

Classification Heat stroke may be classified as either classic or exertional. Classic heatstroke typically affects elderly patients with co-morbid medical conditionswho present with hyperpyrexia, mental status changes, and anhidrosis(lack of sweating). Exertional heat stroke occurs in younger patientswithout chronic medical conditions, most notably athletes and laborers.The primary differentiating sign is that, unlike victims with classic heatstroke, patients with exertional heat stroke continue to sweat.

Risk FactorsThe major risk factors for heat stroke are:

1. Environmental conditions such as temperature, humidity, clothing, and activity level;

2. Prescription medications and over-the-counter supplements such as Ephedra;

3. Medical conditions such as sickle cell trait, dehydration, recent febrile illness, sleep deprivation, sunburn, and obesity.

Ephedra belongs to the class of sympathomimetic alkaloids that maycause hypertension and tachycardia thereby lowering the susceptibility toheat illness. These risk factors all have the potential to affect the heatload on the body or the body's ability to dissipate heat (Table 1).Knowledge of risk factors may help in identifying athletes predisposed toheat stroke and assist in counseling both coaches and players on actionsthat can be implemented to diminish the risk of heat stroke.

DiagnosisAn elevated core body temperature greater than 104 degrees F is alwaysassociated with heat stroke, but necessitates rectal temperature. Axillary,tympanic, and oral sites are not accurate measures of core bodytemperature. Since the brain is extremely sensitive to temperatureelevation, confusion is usually the first sign of heat stroke. Mental statuschanges range from confusion and dizziness to delirium and coma. Inaddition to the central nervous system malfunction, other organ systemsmay be affected and require prompt medical attention. Tachycardia isusually present, with hypotension and cardiovascular collapse occurringlate. Coagulopathy may occur with purpura, hemoptysis, and hematuria.Acute renal failure secondary to acute tubular necrosis may also develop.Rhabdomyolysis is common as a result of muscle contraction and rigidity.Liver involvement usually is associated with central lobular necrosis andcholestasis (4). Progression of symptoms may lead to seizure, coma, ordeath.

Differential DiagnosisThe differential diagnosis of heat stroke includes heat exhaustion, cardiacabnormalities, exertional hyponatremia, epilepsy, and hypoglycemia.Cardiac arrhythmias can be detected or excluded by careful auscultation.Exertional hyponatremia is most often caused by the inappropriate,excessive use of hypotonic rehydration solutions such as water duringendurance events. Decreased plasma sodium concentration can resultfrom replacement of large amounts of sweat loss with plain water. Thetypical hyponatremic athlete is competing in an endurance event in theheat and develops subtle mental status changes. Most hyponatremicathletes can tolerate their electrolyte changes, but more severehyponatremic patients may present with athletic collapse. Nausea,vomiting, headache, and dizziness are other associated symptoms. Thebest means to differentiate between exertional heat stroke and exertionalhyponatremia is by measuring the core body temperature. Heat stroke isexcluded as the diagnosis if the core body temperature is normal. Thedefinitive diagnosis of exertional hyponatremia is made by measurementof serum sodium. Since most athletic events are not equipped to measuresodium, transportation to the Emergency Room is required for definitivediagnosis. As with heat stroke, the best treatment for exertional hypona-

tremia is prevention. Coaches, trainers, athletes, and parents need to be educated on the dangers of drinking excessive amounts of regular waterduring endurance events in the heat. Due to the concern of exertionalhyponatremia, the American College of Sports Medicine recommends theinclusion of sodium in the rehydration solution ingested during exerciselasting longer than one hour (7).

TreatmentTreatment of heat stroke begins with prompt recognition of the signs andsymptoms (5, 6-9). Early diagnosis is based on a high index of suspicionin any athlete who exhibits an altered level of consciousness whileexercising in the heat. Initial management of a heat stroke victim beginswith an assessment of the patient's airway, breathing, and circulation (2).A secure airway and intravenous access are necessary because of therisk of seizure. Rapid cooling is the most important step in treatment andshould be started as soon as the diagnosis is suspected. Mortalitysignificantly increases when cooling is delayed (3). On the field, coolingshould consist of moving the athlete out of the hot environment, fanning,and removing clothing and equipment. Immersion in an ice water bath isan effective method to rapidly lower core body temperature. Evaporativecooling, which involves spraying the athlete with cool water while warmedair is passed over the body, is another effective means to lower bodytemperature. There is conflicting evidence as to which of these methodsis superior (4). An adjunctive method of cooling involves the application ofice packs to the neck, groin, and axilla. Cooling efforts should bediscontinued when the rectal temperature reaches 101 degrees F (38degrees Celcius) to prevent overcorrection with resultant hypothermia (1).Patients should be transported to an emergency department as soon aspossible for identification and treatment of potential medical problems thataccompany heat stroke.

PreventionThe most effective treatment of heat stroke is prevention. As such, itiscritical to remain cognizant of the latest developments in this issue. Forexample, in early 2004 the Food and Drug Administration banned the useof Ephedra because of safety concerns.

Article Continued on the Next Page...

Table 1. Risk Factors for Heat Stroke

Dehydration

Febrile illness

History of prior heat injury

Poor acclimatization

Cardiac disorders (hypertension)

Metabolic disorders (hyperthyroidism, diabetes mellitus)

Sickle cell trait

Obesity

Medications:

Anticholinergics

Antihistamines

Benzodiazepines

Beta blockers

Calcium channel blockers

Neuroleptics

Ephedra/ ma huang

Environmental factors such as high humidity

Sunburn

Sleep Deprivation


Sports medicine physicians need to educate athletes, parents, and coach-es about the potential hazards of high-intensity exercise in hot, humid cli-mates as well as the importance of acclimatization and proper hydration. The Guidelines from the American Academy of Pediatrics Committee onSports Medicine recommend the following for prevention of heat illness(10):1. At the beginning of a strenuous exercise program or after traveling toa warmer climate, the intensity and duration of exercise should be limitedinitially and then gradually increased during a period of 10-14 days toallow time for acclimatization. When this period of time is not available,the length of practice sessions and competition should be shortened. 2. The use of the Wet Bulb Globe Temperature, which is an index ofclimatic heat stress, should be used as a guide for exercising in the heat.3. Hydration should begin before the exercise period. Five hundred ml offluid should be consumed 2 hours before exercise to ensure hydration,and allow time for excretion of excess ingested fluid. Another 200-300 mlshould be consumed 30 minutes prior to exercise. The recommendedfluid intake during exercise is 200-300 ml of cold tap water or a flavoredsalted beverage every 20 minutes. An effective method of monitoring fluidstatus is to weigh athletes before and after practice. An athlete who losesmore than 3% of body weight during exercise is not receiving adequatehydration.4. The type of fluid replacement is dependent on the duration of theevent. Plain water is adequate for events lasting less than 1 hour.However, for events longer than 1 hour, the replacement fluid shouldcontain carbohydrates, sodium, and potassium, which are standardcomponents of commercial sports drinks.5. Clothing should be light-colored and limited to one layer of absorbentmaterial to facilitate evaporation of sweat. Sweat-saturated garmentsshould be replaced by dry garments if possible during competition.

ConclusionWith the increasing incidence of heat stroke, sports medicine physicians

need to be prepared to evaluate and treat heat stroke victims. Effectivemanagement requires prompt diagnosis, which is aided by recognizingrisk factors. Once the diagnosis is made, rapid treatment is needed tostabilize the patient while cooling measures are initiated to lower corebody temperature. Prompt, effective treatment can significantly lower themortality from heat stroke.

References:1.Sandor RP. Heat illness. The Physician and Sportsmedicine. 1997.

25:6.2.Wexler RK. Evaluation and treatment of heat-related illnesses.

American Family Physician. 2002. 65:11.

3.Sparling PB, Stafford MN. Keeping participants safe in hot weather. The Physician and Sportsmedicine. 1999. 27:7.

4.Hinton MA in DeLee JC, Drez D, Orthopaedic Sports Medicine, Second Edition. Philadelphia, PA: Saunders. 2003.

This article originally appeared in the May-June, 2004 issue ofSports Medicine Update,

the official newsletter of the AmericanOrthopaedic Society of Sports Medicine.

For more information, visit:www.sportsmed.org

KKeeeeppiinngg CCooooll......From page 7

Q: It seems like so many items are on thebanned list. What can I take for commonailments?A: There are many examples of permitted Canadian brand namemedications for treating common ailments:

Antibiotics: Amoxil, Cipro, Erythromycin, Noroxin, Penicillin, TetracyclineAnti-Inflammatories: Advil, Celebrex, Motrin, Vioxx, VoltarenDecongestants: Advil Cold & Sinus, Decongestant Nasal Mist/Spray, Drixoral Decongestant Spray, Rhinaris Saline Solution, Sudafed DecongestantAntidiarrheals: Immodium, Kaopectate, Pepto-BismolAntinauseants: Bonamine, Dimenhydrinate, Gravol, StemetilMuscle Relaxants:Glexeril, Robaxacet,Robaxin, RobaxisalAntihistaminics:Allegra, Chlor-Tripolon, Claritin, ReactineCough: Benylin DM-E, Robitussin, Robitussin DM

This list is subject to change by WADA (worldanti-doping agency) at any time. It is theathlete’s responsibility to stay informedconcerneing such changes. This list isintended for use as a guileline for treatment ofcertain medical conditions. It is not acomplete list, nor should it be considered anendorsement or recommendation of thesedrugs. It is the athlete’s responsibility tocheck the status of all medications.

Q: Is it true that caffeine is a ProhibitedSubstance?A: It was until January 1, 2004. At that time, WADA took it off of theprohibited list. However, it is still something that should not be takenlightly as it affects the central nervous system. Large doses can causeadverse health effects, ranging from headaches to convulsions. Someso-call energy replacement drinks now contain “guarana”, which is muchthe same as coffee (both originate from a bean) in that they both producecaffeine.

Q: What if I need to take a medication, formedical reasons, that contains a prohibitedsubstance?A: This question gets asked at every workshop. Medical ApprovalApplication Forms for the approval of a prohibited substance are providedby the the CCES (Canadian Centre for Ethics in Sport.) The athlete’sprescribing physician must complete this form. The application form isthen reviewed by the Doping Control Review Board, which consists of apanel of medical experts. If a medically justified reason exists, approvalfor the use of this substance will be granted on a domestic basis for aperiod of two years. For interanational approval, the athlete shouldcontact his/her International Federation (IF.)

Q: You have mentioned that there is no guar-antee of the purity of herbal and nutritionalsupplements and they in fact could containprohibited substances. How can this be pos-sible?A: Supplements can, and often do, contain prohibited substances. TheCCES has indicated that research has demonstrated that as many as onein six products are tainted with prohibited substances that could result inan athlete’s suspension from competition. The main reasons for this arethe availability of numerous products from unregulated countries, andlimited regulation of supplements in Canada. Because the content andlabeling of many supplements is uncertain, it is very difficult for athletes todistinguish clean, safe and reliable products. Until this environmentchanges, there is no guarantee that all the ingredients in a supplementhave been listed on the packaging, or that the composition is the samefrom batch to batch. Athletes are ultimately responsible for what theyconsume. If you are unsure of what you’re consuming, then simply don’t

take it! Recently, there have been a number of media announcements regarding guaranteesby nutritionalsupplement companies. CVTechnologies, a Canadian developer of naturalhealth products, has publicly announced that itsanti-cold/anti-flu product is proven effective,safe and free of prohibited substances.USANA, a Utah-based manufacturer ofpharmaceutical-grade nutritional supplements,has recently begun offering individualguarantees to select Canadian athletes. Anathlete who qualifies for the program enters intoa contractual agreement with USANA, who payup to one million dollars if the athlete tests

positive for a banned substance in competition as a result of usingUSANA nutritional products. Be careful - as there is always a concernregarding teh use of supplement products by athletes given what wementioned previously, as well as sponsorship agreements between sportorganizations and supplement companies. Money talks!

Q: What types of testing are there?A: The CCES conducts two types of testing: announced andunannounced. Announced testing regers to pre-scheduled doping controltests that are conducted at designated training camps, competitions orother sporting events with competitive elements. Unannounced testingrefers to doping control tests that are conducted at any time on ashort-notice or no-notice basis. These tests may be conducted incompetition or out of competition, on a random testing or target-testingbasis. Target tests, usually unannounced, and pre-games testing(announced or unannounced) are different means of delivering CCEStesting.


TThhee MMoosstt CCoommmmoonnllyy AAsskkeedd QQuueessttiioonnssaatt DDooppiinngg CCoonnttrrooll WWoorrkksshhooppss

Drug Education:

By: Scott Jule


Q: What if I’m so nervous that I cannotprovide a urine sample? How long do I haveto provide the sample?A: You have as long as you need to provide the required volume ofurine. It can take minutes or it can take hours. It is not unusual for anathlete to be unable to provide his/her urine sample all at once becauseof dehydration or nervousness. Sometimes it may take 2 or 3 attempts.

Q: What happens if I don’t want to provide asample (participate in the doping controlprocess?)

A: Effective doping control requires the cooperation and participation ofall athletes. Under the current sport and government policies, a refusal orfailure to comply with doping control procedures, without sufficient cause,constitutes a doping-related infraction. Therefore, you are considered tohave something in your system and will face the same sanctions as if youactually did test positive to a banned substance.

Q: Are urine samples always analyzed for allsubstances, like cannaboids?

A: Not always. In competition situations, samples are analyzed for allsubstances and methods banned by the IOC (International OlympicCommittee.) This includes stimulants, narcotics, cannaboids (whichincludes marijuana), anabolic agents (androgenic steroids), peptidehormones, beta-2 agonists (asthma medications), agents withanti-estrogenic activity (prohibited in males only), masking agents, andglucocoricosteroids. For out-of-competition situations, the samples aretypically analyzed for the following categories: anabolic agents (steroids),peptide hormones, beta-2 agonists, agents with anti-estogenic activity(prohibited in males only), masking agents, and beta-blockers in archeryand shooting. However, some sports have additional substances thatthey also test during out of competition testing.

Q: Where can I get advice about takingnutritional supplements?

A: Team physicians and sport nutritionists are excellent resources andcan be contacted through your sport organization or Canadian SportCentre. If these professionals are not available to you, you should seekadvice from a pharmacist. Always make sure the professional knows ofthe doping risks associated with supplement use and reviews the WorldAnti-Doping Agency (WADA) Prohibited List before providing advice. TheCCES' Substance Classification Handbook applies the WADA list to theCanadian market, and can be downloaded at:www.cces.ca/pdfs/CCES-PUB-SubstanceClassification-E.pdf.

If the professionals advise you to take supplements, they should besuitable for your nutrient needs and safe for your health. If you decide totake supplements you should take them with full knowledge andacceptance of the strict liability

Q: What is the safest source of supplements?

A: There is always an increased risk of doping when supplements arepurchased through non-traditional means such as: over the internet,through magazines or directly from a non-licensed supplier. Productspurchased from a trusted retailer or directly from a reputablemanufacturer are likely to be associated with lower risk of inadvertentdoping. If possible, determine if the manufacturer produces any productscontaining substances from the WADA Prohibited List - if so, there will bea higher risk of cross-contamination between products. If you decide to use supplements, you should purchase your productsfrom companies which have a good reputation and use goodmanufacturing practices, such as major multinational pharmaceuticalcompanies. Before making your purchase, you or preferably your physician shouldcontact the manufacturer to determine if it is prepared to stand behind itsproducts should they cause an anti-doping rule violation. Does themanufacturer offer any form of guarantee or compensation? What proofdoes the manufacturer require to qualify for that compensation? If themanufacturer does offer a guarantee, always obtain a letter ofconfirmation signed by a senior official from the company.

Q: If I choose to use a supplement, whatother steps can I take to minimize the risk ofinadvertent doping?

A: Always follow the recommended dosage and route of administrationas indicated on the product label. Be especially cautious of potentialnegative interactions if consuming more than one supplement product ata time. Use supplement products like you would any over-the-countermedication - for example, if the recommended dose is one tablet, two ormore may be unhelpful, counter-productive or even dangerous.

DDrruugg EEdduuccaattiioonn......From page 9

Find a complete listing of permitted and prohibitedsubstances in the SubstanceClassification Bookletpublished by the CanadianCentre for Ethics in Sport(CCES).

To Download your To Download your Free Copy Today, Visit: Free Copy Today, Visit:

http://www.sportmedab.ca/publications.html

Still unsure of WhichSubstances May be Banned?


This article originally appeared in the Spring/Summer 2004 issue of the

official newsletter of the Sport Medicine and Science Council of

SaskatchewanFor more information, visit: www.smscs.ca


Athletic First Aid Injury Rehabilitation Taping & Strapping Sport Specific Low Back or Back Injuries

Athletic First Aid Injury Rehabilitation Low Back or Back Injuries

Substance Abuse in Sport Anti-Doping Program Doping Control Procedures Drugs, Pressures & Solutions

Sport Specific Skill Analysis

Different Techniques Philosophy

AIDS Other Infectious Diseases

SPEAKERS & WRITERS BUREAU

Medical, paramedical, and scientific professionals are available to speak or write on a wide variety of sport medicine topics. The Speakers Bureau may be accessed for, but

not restricted to, the following topic areas:

SPORTS NUTRITION ATHLETIC INJURIES

Eating Disorders Meal Planning Diabetic Athletes Myths vs. Facts How to Gain/Lose Weight Traveling Tips: Restaurant Eating &

Eating on the Go RISK MANAGEMENT

SPORT PSYCHOLOGY Motivation Concentration Preparation for Competition DRUGS IN SPORTS Stress Management Stress in Youth Sports Psychological Aspect s of Injury and

Rehabilitation Psychological Aspects of Drugs in

Sport SPORT BIOMECHANICS Goal Setting

PHYSIOLOGY SPORTS MASSAGE

Sport Specific Lab and Field Testing Athletic Training and Condi tioning Weight Training: Advantages/ BIOHAZARDS

Disadvantages Weight Training Techniques Strength and Flexibility Fitness Programs

Fees or honoraria vary with the topic requested, the target group, the length of the

presentation, the level of technicality, and other factors.

Verbal or written requests should be made at least one month prior to the confirmation

date for a speaker or writer.

TO BOOK A SPEAKER OR WRITER, VISIT: http://www.sportmedab.ca/speaker.html


Ifind that many athletes struggle when it comes to achiev-

ing a healthy weight. Some need to gain weight, while oth-

ers want to lose weight (or body fat). Whether you main-

tain, lose, or gain is primarily a matter of energy balance.

You'll maintain your weight if you consume roughly the

same amount of energy, or calories, that you expend. To gain

weight, you'll need to consume more calories than you burn

off. To lose weight, you must expend more calories than you

take in. In other words, you'll need to eat less and exercise

more, or ideally, do both. It sounds simple, but in reality the

process can be quite complex. You're dealing with the human

body after all, not a machine.

Strategies for Losing Weight Before embarking on a plan to lose weight, be sure that you really needto. Don't assume that your performance will automatically improve if youlose weight or assume that every time you weigh more on the scaleyou've gained fat. Determining your body-fat percentage or taking skinfoldmeasurements can be particularly useful before you attempt to loseweight, especially if you're an athlete sporting a stocky, muscular build ora female who tends to look heavier because you carry weight on your

hips and thighs. In any case, if your body fat is at a reasonable level, youwon't gain anything from dieting or starving yourself to reach a new lowon the scale.You may instead need to concentrate on accepting your inherited bodytype or, if you're a coach or trainer, on accepting the body types of theathletes you work with. One of my collegiate teammates, the best femalecross-country runner in her state as a high school senior, is a perfectexample. Tall with a lean upper body, she carried all her weight on thelower half of her body. Despite completing a successful high schoolcareer at a certain weight, our coach decided she would perform better incollege if she lost five pounds. Living on salad, air-popped popcorn, and asmall dinner (accompanied by a scoop of ice cream as a reward formaking it through the day), she did lose the five pounds. But she wasconstantly battling an upper-respiratory infection and even pulled someintercostal muscles (between the ribs) from coughing so hard! She neverfully recuperated and ran poorly all year.

Second, I always remind people trying to lose weight not to excessivelyrestrict calories or attempt to follow a very low-calorie diet. These meth-ods of losing weight are not an option, especially for a serious athlete. Ifyou lose more than a pound a week (two pounds for males), you're notlosing fat-you're losing water, muscle glycogen, and lean muscle mass.Your competitors are the only ones who benefit from this type of weightloss. Athletes who are chronically dehydrated and operating with lowglycogen stores find it difficult to maintain their usual training pace, fatigueearlier in workouts and competitions, and suffer more injuries. It's alsodifficult to be in peak mental shape if you're depressed, anxious, weak, orpreoccupied with food.

Whhaatt yyoouu nneeeedd ttoo kknnooww....

To Change Your Body CompositionB y : S u s a n G i r a r d E b e r l e


The long-term consequences of losing weight rapidly can be costly: lossof muscular strength and power, electrolyte disturbances due todehydration, increased susceptibility to colds and other illnesses, irondeficiency anemia, amenorrhea (loss of menstrual periods), low bonedensity (due to hormonal imbalances and the lack of calcium), ketosis (anundesirable state the body enters when it must use its fat to fuel thebrain), and potential kidney problems. You may ultimately end up losingtraining time or even missing competitions, so don't try to lose weightduring your competitive season or when you need to deliver a peakperformance. Repeated attempts to manipulate body weight or body fat below a levelthat is normal for you are counterproductive. Significant metabolicchanges result from chronic dieting or the loss of critical fat stores. Forexample, if you restrict your caloricintake too drastically, your body resistsyour attempts to lose weight byimmediately dropping its restingmetabolic rate-that is, your body willrequire fewer calories to carry onessential vital functions and will storeexcess calories as fat. Because yourbody has no way of knowing how longthis "starvation" will last, it attempts toprotect itself by adapting to fewercalories.

Although this reduction in restingmetabolic rate probably isn't permanentin most people, it may play a role if you lose and gain weight repeatedly.It appears that the body receives messages via brain signals andhormones that help it become more efficient at extracting energy fromfood and storing it as body fat. Consequently, perpetual dieters often findit progressively harder to lose weight and must eat even fewer calories inthe future to induce further weight loss. Muscles burn calories (fatdoesn't) and lean muscle tissue is lost every time you diet, especiallywhen you drop pounds quickly. So, as your muscle mass decreases, yourbody requires fewer calories to remain at the same weight.

Set a realistic weight-loss goal. You can't lose body fat over night. Focuson achieving a weight you can maintain at this point in your life throughexercise and healthy eating habits. Perhaps you've added children to yourfamily or picked up additional hours at the office that cut into your trainingtime. If this is the case, don't assume you can weigh what you did incollege or even what you weighed last year!

Forget about diets and short-term fixes too. As long as you believe aquick, easy way to lose weight is waiting for you right around thecorner-the next miracle diet, a promising new supplement-you'll neverfully commit to changing your eating habits. Keeping that in mind, read onfor some guidelines on how to lose weight sensibly.

Strategy #1. Keep a food diary A food diary serves the same purpose as a training log. It can help you orsomeone with a trained eye (like a registered dietitian) decipher yourcurrent eating habits-what works for you and what doesn't. As in theexercise in chapter 1, simply write down everything you eat or drink fromthe time you get up in the morning until you go to bed. It also helps torecord the reason you are eating. For example, are you eating becauseyou are hungry? Bored? Nervous about an upcoming race? Writing down everything you eat can help you stay committed to yourlong-range goal of losing weight sensibly. One study followed 38 dieters

who had been on a weight-loss programfor a year through the "danger zone"; forexample, two weeks before Thanksgivinguntil two weeks after New Year's Day.The 25 percent of participants whoconsistently recorded all the foods theyate during this period managed to loseseven more pounds! The other 75percent who weren't so vigilant gainedback an average of three pounds.

The very act of writing down your dailychoices, not exactly what you record, iswhat counts. Self-monitoring forces usto be accountable for our daily actions.

For example, you can't as easily ignore thefact that you nibbled through a jar of peanuts while meeting a deadline atwork if you write it down. You can also glance at a food diary to see ifyou're eating enough of the healthy foods you need. Leave your fooddiary in a visible place as a visual reminder (for example, on your desk orin your kitchen) or record what you eat in your day planner or training log.

Strategy #2. Reduce your current intake by nomore than 500 calories a day Losing one pound a week requires you to create a deficit of 3,500calories, or 500 calories a day, by exercising more and eating less.Drastically reducing the amount you eat isn't realistic for most athletes.Dieting all day by skimping on breakfast and lunch and then beating apath to the refrigerator from dinner until bedtime doesn't work. Starvingyourself while working out as hard as you can isn't something you cankeep up for long either. Trimming the amount of calories you currently consume by smallincrements (such as 200 to 300 calories for an athlete consuming 3,000calories) shouldn't suppress your metabolism and it helps protect againstthe loss of too much lean muscle tissue. You'll also still have plenty ofenergy to train at a high level, which is essential if you want to keep theweight off permanently. Your family, officemates, and training buddies willappreciate this approach, too, as you won't feel deprived and become acomplete bear to live with. Once you've met your nutrient needs (keeping the Food Guide Pyramid inmind) look for ways to trim extra calories. You may be suffering fromportion distortion. Due to the "super-sizing" of America, an averagebakery bagel now provides 320 calories-the equivalent of eating three tofour slices of bread! Paying attention to serving sizes can be an easy wayto reel in your calorie intake. Mega-sized cookies, muffins, and sodasmay appear to be a good buy, but can you afford the 500 to 800 caloriesthey provide?

If you eat out frequently, watch your intake of high-fat foods. Inquire abouthow foods are prepared before ordering them to detect hidden fats, suchas cream sauces, olive oil, and cheese. And then ask yourself how manytimes you begin meals by eating a whole basket of bread! If therestaurant won't honor special requests, such as serving the saladdressing on the side and having the skin taken off chicken, find a newrestaurant. Getting a handle on how many calories you drink throughoutthe day can be helpful too. Cutting back on soda, alcohol, sports shakes,and even juice, may be all you need to do.

Keep in mind that losing weight is best done in stages. Once you lose afew pounds, let your body get used to your new weight, then decidewhether you're feeling weaker or stronger before trying to lose more.Incorporating even small changes into new habits takes time and effort.


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Stop and assess how you are doing at maintaining the healthy changesthat got you to a lower weight. Can you realistically continue them? Willyou be able to do more? You may find that you'd be better off directingyour efforts elsewhere, into your training or accepting your body type,rather than continuing to try to lose more weight.

Strategy #3. Eat enough real food Don't throw the Canada Food Guide out the window because you'retrying to lose weight. You still need to consume foods from all four foodgroups, just like everyone else. Many female athletes I know wouldn'tdream of sitting down and eating a real lunch, a sandwich and a glass ofmilk, for example. Instead, they nibble their way though the day rackingup calories from mini chocolate bars, candy, energy bars, nonfat frozenyogurt, oversize bagels and muffins, and soda or juice drinks. If you find yourself constantly eating out of a box, in your car, or whilestanding up, consider that these unfulfilling actions may be sabotagingyour efforts to lose weight. You're more likely to feel full and experienceless guilt or denial if you simply plan to eat meals (of at least three foodgroups) and snacks (aim for one to two food groups). You'll likely eatfewer calories too.

You may lack skills in the cooking and domestic department. I met onecollege athlete who lived off campus and was responsible for his ownmeals. He routinely boiled four hotdogs for lunch, followed by four morefor dinner!If you're like me and can't afford to hire a personal chef, investsome time and energy into learning basic cooking and meal-planningskills. Keep a variety of nutritious, easy-to-prepare foods on hand so youwon't have to rely on takeout and fast foods. Watch how much soda andalcohol you drink. These beverages contribute calories and little in theway of nutrients. You don't want them to crowd out low-fat milk and fruitjuices, which are more nutritious.

Strategy #4. Concentrate on eating your calorieswhen you need them most during the dayHave you worked out today? Have you eaten today? Because most ofus perform the bulk of our training, our work, and our family obligationsbetween nine and six (even earlier if you train first thing in the morning),why do most of us insist on eating the majority of our calories after sixo'clock? Our muscles and our brain cells thrive on having a steady,constant supply of fuel available. To avoid becoming too hungry anddevouring everything in sight, divide your calories up throughout the day.Plan to eat a meal or healthy snack every three to four hours so yourblood sugar doesn't dip too low. Otherwise, you'll be racing for thenearest vending machine or fast food outlet.

Be creative with your eating schedule. Even if you're trying to loseweight, you still need to be well fueled before you head out the door,and you still need to replenish your glycogen stores following exercise.For instance, if you train after work, eat less at lunchtime and save somecalories for an afternoon snack closer to your workout time. A sportsdrink or energy bar after you finish can take the place of that secondhelping or extra dessert at dinner. You can diet by eating reasonablesize portions (a good reality check is the serving size listed on the label),selecting lower-fat items, and by eating fewer calories at night when youdon't really need them.

Strategy #5. Keep some fat in your diet The fat you eat in foods doesn't inevitably reappear as body fat. You canstill obtain a desirable level of body fat if you snack on half a bagelspread with peanut butter or drizzle salad dressing over your greens.Besides supplying energy and essential fatty acids, fat allows your bodyto absorb and use fat-soluble vitamins.

Fat also heightens the flavors of food, curbs cravings, and helps you feelfull. Without some fat in your diet, it's easy to overeat in thecarbohydrate department. How many times have you passed on eating ahamburger because it's too fattening only to find yourself plowingthrough a box of fat-free cookies a few hours later? The fact remainsthat excess calories will be converted into body fat, whether thosecalories come from fat, carbohydrates, or protein.

Eating a diet that contains an appropriate amount of fat, at least 20percent of total calories or 1/2 gram per pound of body weight, is not

overdoing it. The key is to concentrate on eating the right kind of fat. Nutsand "natural" nut butters (those not processed with partially hydrogenatedfats), seeds, avocados, and oils such as olive, canola, and flaxseed, arerich in heart-healthy monounsaturated fat. Of course, even theseheart-healthy fats supply calories, so watch the amounts you consume.

Fats that you don't need in your diet are saturated fats and partiallyhydrogenated, or trans, fats. To reduce the saturated fat in your diet,choose low-fat dairy products and lean cuts of meat. Limiting traditional"fatties" such as fried food, fast food, and processed foods containingpartially hydrogenated vegetable oils such as stick margarine, snack foods,and bakery goods will help keep the amount of trans fat you consumeunder control.

Strategy #6. Complement your aerobic trainingwith anaerobic or strength training. Don't fall into the trap of believing that you must train at a slow pace to burnfat and lose weight. Although it's true that exercising at lower intensities(aerobic exercise) uses a higher percentage of fat than high-intensityexercise (anaerobic exercise, such as interval or speed work), it's not thatsimple. Exercise does more than just help you burn fat. It helps create acalorie deficit in the body; in other words, it helps you expend more caloriesthan you consume. Remember that to lose a pound, you need to create adeficit of 3,500 calories, either by eating less, exercising more, or somecombination of the two. No matter what fuel you burn during exercise, thebody can pull from its fat stores at a later time to make up for the caloriesexpended during exercise.

The amount of calories you burn during exercise depends on manyfactors-your body weight, the type of exercise you do, the intensity, theduration, and whether you are a novice or a trained athlete. As anendurance athlete, you're most likely focusing on putting in the miles. Butstrength or resistance training and higher intensity exercise, such asintervals, tempo workouts, and fartlek training (breaking your normal paceup with fast bursts), can help you lose weight, as well as boost yourperformance. Don't forget that during exercise you burn both fats andcarbohydrates for energy.

Given the same time period, lower-intensity exercise uses a greaterpercentage of fat, but it also burns fewer total calories than higher-intensityexercise. During faster paced activities, a greater percentage of caloriescome from carbohydrate than from fat, but the overall amount of caloriesyou use is higher. What matters most is the total number of calories used,not the percentage of fat-to-carbohydrates. Higher-intensity exercise helpsyou lose weight because it uses more calories per minute.


BBooddyy CCoommppoossiittiioonn......From page 13

LIKE THE ARTICLE YOU ARE READING? Interested in learning more about proper nutrition

for peak sporting performance?Pick up Susan Girard Eberle’s latest book

“Endurance Sports Nutrition” if you compete inany of these sports:

• Running • Triathlon• Swimming• Rowing• Cycling • Mountain biking • Cross-country skiing • Adventure racing • Mountaineering/trekking


Think about it this way: a large percentage of a small number can besmaller than a small percentage of a large number. For example, a150-pound cyclist averaging a leisurely 12 miles per hour may burn 380calories an hour, with about 70 percent of the energy derived from fat.The same cyclist may burn approximately 780 calories per hour riding at18 miles per hour, with fat providing about 50 percent of the necessaryfuel. However, 70 percent of 380 is 266, and 50 percent of 780 is 390, sothe more intense ride burns over 100 more fat calories. More important,because few people have unlimited time to exercise, riding more intenselyburns 400 more calories in the same period (780 versus 380).

Trained athletes burn more fat for two reasons. They use fat sooner dur-ing exercise (training helps you store more fat within muscles for easyaccess), and they have the ability to work at higher intensities (thanks inpart to an elevated lactate threshold) than recreational athletes, thusburning more calories and proportionally higher amounts of fat. Of course,you can't just go flying out the door and start training frantically every dayin an attempt to lose weight. You'll burn very few calories from the couchif you come down with an injury.

Working at lower intensities until you can handle more intense workoutshelps you avoid injuries and prepares the body for future stress. As youwork up to handling higher-intensity workouts, duration becomes agreater factor in losing weight not to burn more fat, but to burn morecalories. In other words, you need to exercise longer to make up for thelower number of calories used per minute. Consider increasing yourtraining volume by adding more miles to your weekly training program. Orsimply become more active during the day, such as taking the stairsinstead of the elevator and walking instead of driving to complete errands.

Visiting the weight room while trying to lose weight is especiallybeneficial. Strength training builds muscle mass, which boosts yourresting metabolic rate. This means you'll be burning more caloriesthroughout the day, even when you're not exercising. Weight training alsohelps ensure that the weight you lose is from body fat, not muscle.

Strategies for Gaining Weight Gaining weight can be an advantage if speed, power, leverage, or masscome into play in your sport or activity. Of course you most likely want togain lean muscle tissue, not fat. Adding muscle mass can increase yourstrength-to-weight ratio, which ultimately increases your strength andpower, enabling you to perform at a higher level. Depositing extra bodyfat does little to enhance power or strength. On the other hand, someendurance athletes find that carrying a little extra padding may help themfend off illness and better weather the rigors of hard training. Like those athletes trying to lose weight, you need to be realistic aboutthe amount of weight or lean body mass you can gain. Adding a fewpounds before you head off to an ultrarun or adventure race is one thing,but expecting to transform your physique is a whole different ball game.Your genes, gender, diet, training program (including the amount ofstrength training you're willing to do), and motivation all count. Look at theother members of your family, especially your parents, to get a clearpicture of your potential. If you're a well-trained athlete or simply a "hardgainer," you may find it difficult, if not impossible, to gain weight withoutsubstantially increasing the amount of calories you eat or cutting back onyour exercise.

The bottom line, of course, is that to gain weight you must consume morecalories than you expend. In general, you'll need to eat an extra 500calories a day to gain about one pound of lean muscle in a week. Don'tlook to supplements as a substitute for hard work and good nutrition. Nomagic nutrients exist that promote substantial gains in strength andmuscle mass. (See chapter 4 for a complete review of creatine and othersupplements that are touted for their potential to enhance lean musclemass in athletes.) Keep the following guidelines in mind as you attempt togain lean muscle mass.

Strategy #1. Calories and strength training count Contrary to popular opinion, your calorie intake, not the amount of proteinyou consume, has the most impact when it comes to gaining muscle.Bulking up, or building muscle, requires you to have enough calories onboard to meet your energy demands, as well as support the growth ofnew tissue. If you don't take in enough calories, the protein you consume

will be used to satisfy your energy needs instead of building new muscletissue. You must also commit to a well-designed strength orweight-training program. Just eating extra calories or protein, or ingestingvitamins or other supplements, won't magically do the trick. Strengthtraining helps muscle cells become more efficient at using availableprotein to synthesize new cells.

If you're training and eating appropriately, most of the weight you put onwill be muscle. Of course, if you simply overeat (literally consume morecalories than you burn off), then the extra calories from anysource-carbohydrates, protein, or fat-will help you gain weight byincreasing your body fat.

You may need to make eating a higher priority to ensure that you'regetting enough calories. Eat frequently throughout the day and eat mealseven if you don't feel hungry. Plan ahead by buying and keeping healthysnacks on hand at home, at the office, and in your car. You can alsoboost your calories by choosing heartier versions of foods, such asgranola over cornflakes and split-pea soup instead of vegetable broth.Eating larger-than-normal portions of healthy foods, such as anotherhelping of baked beans or an extra sandwich, will also add calories. Ifyou're crunched for time or planning to exercise shortly, drink yourcalories. Liquid meal products, homemade liquid meals such as milkshakes and fruit smoothies, and even juice, can be easy ways to downadditional calories.

Strategy #2. Choose foods rich in carbs andprotein to meet your higher calorie needs.Special protein powders or weight-gainer supplements aren't necessarywhen you're trying to put on muscle or gain weight. Simply eating moreprotein, such as meat or eggs, won't necessarily translate into moremuscle either. Most athletes have trouble gaining weight because theylack calories or enough carbohydrates in their day-to-day diet, notbecause they lack protein. Besides, although it's true that you need extraprotein when you're involved in a strength-training program, most athleteswill consume enough extra protein from the additional food they eat toboost their calories. Carbohydrate-rich foods should still supply themajority (60 percent) of your calories. Your body relies on carbohydratesto fuel your weight-training sessions, as well as the endurance activitiesyou participate in. Consuming adequate carbohydrate also replenishesyour muscle glycogen stores so you can continue to train daily.

To meet your protein and carbohydrate needs simultaneously, follow thefood pyramid's recommendation to eat a variety of foods. Meat, poultry,fish, eggs, cheese, and tofu all supply quality protein (as well as fat,obviously) but virtually no carbohydrates. Few foods, though, arecomposed of one nutrient: milk (regular and soy), yogurt, cottage cheese,dried beans, and lentils are good sources of both protein andcarbohydrates. Vegetables and other carbohydrate-rich foods like pasta,rice, bread, and cereal contain relatively small amounts of protein, but itreally adds up if you are having large portions.

To remind yourself of the importance of eating enough carbohydrate andprotein, include a protein-rich food (from the milk group or the meat andbeans group) with your carbohydrate-rich meals and snacks. Forexample, melt cheese on a bagel, add tuna, chicken, or a hard-boiled eggto a salad, top pasta with a meat sauce, and eat baked beans over rice oron top of a baked potato. Adding a strength-training program to analready ambitious training schedule will increase your body's need forprotein initially, so pay particular attention to your food choices when youfirst hit the weight room.

If you're still concerned that you're not eating enough protein, considersports shakes or complete meal replacement powders. These productsoffer a more complete nutritional package than straight protein powders orsupplements. They're relatively expensive, so you might consider savingthem for travel or for days when a busy schedule would otherwise resultin missed meals. If you don't have a milk sensitivity, you can add nonfatdried milk powder to homemade shakes or smoothies, or stir it intooatmeal, soup, cooked rice, and other dishes. It's a high-quality,inexpensive protein supplement (a quarter cup provides about 11 gramsof protein) without the unproven additives that many other supplementsprovide.

BBooddyy CCoommppoossiittiioonn......From page 14

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Sport Medicine Council of Alberta

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(25) Knuckle Bandaids (5 rolls) Athletic Tape (1.5” x 5 yds.) (1) Tuf-Skin (4 oz. can) (25) Regular Bandaids (2 rolls) Pro-Wrap (Underwrap Foam) (1) Skin Lube (2.75 oz. tube) (2pk.) Coverstrips (Steri -Strips) (2 rolls) Heavyweight Tape (3” x 5 yds.) (1) Savlon Germicide (100 ml) (10) Alcohol Prep Pads (2) 4” width Tensor Bandages (1) Tiger Balm (3 oz. jar) (10) Sterilized Tongue Depressors (3) Triangular Bandages (Slings) (1) Nailclippers (10) Plastic Ice B ags (2 rolls) 3” width Rolled Kling Guaze (10) Safety Pins (assorted sizes) (1 pr.) Black-Handled Utility Scissors (10) Sterilized 3x3” Gauze Pads (1) Disposable Razor (1 pr.) 5.5” Bandage Scissors (20) Foam 3x3” Heel & Lace Pads (1) Pad of Paper and Pen (1 pr.) Shark Tape Cutters (1 sheet) Moleskin (3”x16”) (1) Instant Cold Pack (1) Disposable Penlight (2 sheets) Adhesive Felt (4”x5.5”x1/8”) (1) Royal Blue Nylon Bag (2 prs.) Powdered Latex Gloves (M) (2 sheets) Adhesive Foam (4”x6”x1/8”)

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