🔥Upside Chat with Alexi Pianosi (Penguins/NHL) and Dr Marco Nunez (Ex LA Lakers/NBA) on AI Tools to Prevent Injuries, Shockwave Therapy, and More.

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🔥Upside Chat with Alexi Pianosi (Penguins/NHL) and Dr Marco Nunez (Ex LA Lakers/NBA) on AI Tools to Prevent Injuries, Shockwave Therapy, and More.

Julien Blin

Feb 07, 2023

This week we had the honor to interview again a group of sports performance experts.

Alexi Pianosi, Strength and conditioning coach for the Pittsburgh Penguins (NHL).
Dr Marco Nunez, ex Head Athletic Trainer, LA Lakers (NBA)

📝Show Notes: Through this interview, we touched on the various methods they have used to figure out if an athlete is overtraining or undertraining, and what works and does not work. Then we discussed an emerging area called Shockwave therapy. We also talked about the emergence of AI based injury prevention tools and the pros and cons of using such solutions. They also gave us their predictions for the 2023 NBA finals and the NBA champion.

🚀Best Quotes: Here are some of the key discussion points and best quotes from our conversation with Marco and Alexi:

On the various methods they have used to figure out if an athlete is overtraining or undertraining:
- Alexi Pianosi:
  - “ One of our primary metrics that we've played around with a little bit over the past couple of years is heart rate variability or HRV, where we are doing some regular readings. It's becoming a little bit more common practice that athletes are collecting their own HRV now with the Aura rings, the Whoop bands, or Sleep eight”.
  - “It's an interesting field because it has a lot of promise by assessing the underlying state of the autonomic nervous system. But at the same time, anyone who's looked into it, I think would also say that it can be potentially a noisy argument if you're not standardizing your noisy measurement, if you're not standardizing your conditions. If we're recording players after they've come into the arena, and they've woken up, they have increased arousal by driving into the building”.
  - “In professional hockey, professional basketball or baseball, whatever it might be, it's a little bit difficult to try to assess that readiness, I think, on a daily basis. There are no large oscillations or large changes based on travel, or based on an increase in minutes. Last night, the game went to overtime. It was in a more physical game, it was a more running game, or more physical on the ice, so these are key factors to consider”.
  - “So I think there's a lot of context that goes into whether an athlete is over or undertrained and I think HRV is something we use. But again, recognizing that it's only one piece of the puzzle to try to really figure out the state of the athlete is key”.
- Dr Marco Nunez:
  - “Alexi mentioned the need for standardization and setting a baseline for every athlete because every athlete is going to be different. That's one of the key things, and that applies to anything that you do, whether it's injury prevention, any type of analysis, any type of analytics. Any assessments that you're doing is about creating a baseline for the athlete”.
  - “Second, and Alexi touched upon it. As far as either under training or over training or more importantly, like you mentioned, under recovering…Oftentimes an athlete isn't over training. They're more likely under recovered”.
  - “And that's the other trick about this. It's about trying to find out what recovery method is best for each individual because it's not a one size fits all situation. It may not just be a normal ticket, it may just be a cold tub and it may be a fire flight. It can be anything but identifying how this athlete's going to respond the best to this type of recovery method, which is something as simple as a stretch, a massage, whatever it is..is key”.
  - “A lot of NBA players do not like needles. So we did not do blood analysis (at the LA Lakers). We did try the saliva to try to do the cortisol levels, but one of the downsides to that was that we had to send it over to GSSI and by the time we got it back, it would be a couple days later. Then we would just try to create a pattern. And obviously we used to travel with force plates, and we would do the force plate testing on that part for the athletes”.
  - “And that's the other thing to think about. Trying to find what athletes are going to be compliant when you do those types of recovery processes is important. And what are they willing to participate in or are they willing not to participate in? is also important to find out”.
  - “As Alexi mentioned (..) it's rare that once a season begins an athlete is anywhere near a 100% of their full capacity throughout the season. If you get an athlete 90%-91% healthy, that's like an amazing job. Most of these athletes are stuck in the eighties, maybe in the seventies. But it's rare. I would never, ever see during the mid-season, prime season travel an athlete anywhere near a 100% recover”.
  - “And if someone says that this athlete gets to a 100% recovery, that's a bunch of BS because that's not going to happen. It's impossible for somebody with all the traveling, the eating, lack of sleep, and all that stuff, to get to a 100% recovery”.
On the growing number of teams using shockwave therapy:
- Dr Marco Nunez:
  - “I love using shockwave, especially when it comes to a lot of chronic issues, specifically tendonitis, whether it's Achilles tendonitis, patella tendonitis or even muscular strains. That was one of the first things I purchased when I became the head athletic trainer with the Lakers”.
  - “I've used shockwave therapy on a regular basis. You can also use it pre-game, but it just depends on the parameters (..) It's not invasive. It's pretty much pain free, unless it is in certain areas, depending on the parameters, where you may create some discomfort in that area while you're doing the treatment, but it should resolve within a couple of hours. With all our athletes I've worked with, with any type of chronic issues, I've gotten great success with it”.
  - “A shockwave therapy machine bears anywhere between $25,000 to $45,000. They tend to be a little heavy, so they're not very easily to travel with like an ultrasound unit or anything like that. I remember at the LA Lakers we had to get a special case for it because obviously for $45,000, we had to get a special case for it and travel with it”.
- Alexi Pianosi:
  - “One area that I think is interesting with shockwave are for things like bone healing and stimulating osteoblast formations. The NHL does get a lot of broken bones, a lot of shots off the ankles and hands. So if you can find a way to improve the healing of bones or shorten that time for that fracture to heal, you really got something suited for the NHL I think”.
  - “So we have used shockwave therapy a little bit in that case. I feel like we haven't had overly good or bad results at that point. There was some good research on shockwave therapy suggesting that it could be beneficial. Something like 200 orthopedists throughout the United States said they knew about it. They thought it was promising technology, but 11% of them were using it, and so the majority of them were not using it”.
  - “The topic of the article was essentially, we know so much about it, why is no one using it? But if Marco's telling me that he's getting great results on chronic, like tendinopathies that’s great. But I think what works for one person may not work for the other, but if it's shown to be beneficial and has some potential, then I'm certainly open for exploring something like that’.
  - “I think that's why we've used it a little bit with fractures and said, Hey, we can try to apply this, maybe we'll get a couple extra days earlier out of it. Maybe we can load that foot or that wrist or that angle, or whatever it is a little bit earlier and in the context of an NHL seasons and an NBA season, especially as you get close for playoffs or you're in playoffs, one day, two days, three days. That could be the difference in playing in game six or playing in game seven, or not playing at all in the series”.
On the emergence of AI-based injury prevention tools or platforms like Zone 7 or Gemini Sports:
- Dr Marco Nunez:
  - “What Alexi could probably also tell you is that if you're in game seven of the Stanley Cup finals, you get a guy that the AI is telling you he's in a red flag, are you really gonna go to the coach and the GM and say, sorry, this guy can't play, he's a star player, but he's out of game seven, the Stanley Cup, because we got a red flag on him. No. He's going to play anyway”.
  - “I mean, I'm not gonna say this to Kobe Bryant during Game seven against the boss of Celtics or go to the GM or the coach. I mean, if I do that, I might as well just pack my bag and walk out of the building right away”.
  - “But at the end of the day, it's about how are you going to utilize that information from the AI tool that you're getting and apply it to the athlete or to the team setting. Because like I said, everything tells you it is green. Everything tells you it is yellow, everything continues to be red. But the situation is about when, where, and how, and that's how you apply it. So it's just information that you have to help you make a better, more informed decision”.
  - “And like the old saying goes, are you okay with Michael Jordan at 70% healthy on the court versus a non-starter at a 100%? Anybody would take Michael Jordan at 70%-75% healthy, right ?”.
- Alexi Pianosi:
  - “I've sat down with Zone7, and I think Kitman Labs is also doing a similar thing to address the same issue. It's really interesting stuff for sure. I think when it comes to predicting injuries, the two things that came to mind are, one, similar to what we talked about, an athlete being over or under recovered or prepared or trained, I think they're so context driven”.
  - “And one of the great things about an AI or data is that, it strips out the context, so it also strips out the bias, which is great. You get unbiased look at numbers or these patterns or these stats”.
  - “But when it comes to injury prediction, I think the context is so important. Like Marco said, at what point in the season are you at? Is that a tense period? Is that a lighter period? Was the athlete dealing with a personal issue at home? Was the athlete sleeping well? Did their minutes go up because of another injury on the team, or did their minutes go down because they were playing bad and they were arguing with the coach? I think there's a lot more contextual factors in there that, I'm not sure the AI quite comprehends yet”.
  - “So it probably needs a little bit more refinement because once you get that number too, as Marco alluded to, then you have to deliver that message to the coach, to the player. So once we understand that, the AI is a little bit better and Zone7 is a little bit more optimized, then we need to work on how do we take that information and transfer into a sports setting and make it usable on a daily basis”.
  - “I'm optimistic about what AI could do for the injury prevention space in the future. I think we still have a little bit of a ways to go. And I think those AI vendors just need to collect more data. And I'm definitely coming from a sport and a league like the NHL where data is probably the least popular amongst or the least utilized amongst MLB, NBA, or the NFL”.
On their prediction for the NBA finals and champion:
- Dr Marco Nunez:
  - “I think in the finals I'm going to predict the Denver Nuggets against the Boston Celtics. And I'm going to go with the Celtics to win the title just because they have a little more experience”.
- Alexi Pianosi:
  - “I'm a big Steph Curry fan, so it's going to be hard to vote against the Golden State Warriors. If the Warriors keep everybody healthy down the stretch, then you have the best shooter in the game but I think Boston has been playing well too, so maybe there is your final”.