 Welcome to the wide world of eSports, a show devoted to all things eSports. I'm your host, Catherine Norr. Today we're talking with gamer doc, Dr. Lindsay Migliore, about the treatment and prevention of eSports injuries. Welcome, doctor. Hi, Catherine. Thanks for having me back. All right. Fantastic. We had you in December on talking about diversity in eSports. Now we shift to gamer doc. What is gamer doc? So gamer doc is a company focused on making people and helping people game a little bit healthier. So depending on who you are, that looks a lot different for the casual gamer. That means doing a little bit of an ergonomic setup in order to be able to game into your 40s and 50s and 60s and 70s and 80s. And for the pro gamer, that means performance. It means using scientifically backed principles to improve your performance just like they use principles of sports science. Sure. And so what is your medical specialty? I'm a physical medicine and rehabilitation doctor. The best way to understand that is because we are a very small specialty is I am non-operative sports medicine. Sure. What are the type of injuries that gamers and eSports athletes generally see you for? So it depends. It depends a lot on, you know, what level are they, are they casually, are they professional and what their title is because depending on the title you play, if you're playing a fighting game, you know, on an arcade stick or you're playing a FPS game on mouse and keyboard, you're using different muscles. But a lot of the injuries we see in eSports are what the physical therapists call repetitive strain injuries. So you're using these tiny, tiny muscles of your hands, using these tiny muscles of your fingers and your thumbs to do one movement a thousand times in an hour. And as we know, you know, the hands weren't made to do that. So we get these tiny little baby injuries that I call micro traumas in our hands and our wrists and those tendons. And then it makes them weaker and then they eventually will get injured. So what we're seeing now is a lot of chronic injuries to the hand and wrist. So what kind of treatment do you offer to those who are having those kind of symptoms? So the best treatment and people hate hearing this is prevention. How do you prevent arthritis? Don't get old, so easy. Prevention is the number one treatment for a lot of these injuries. And luckily we are catching a lot of these injuries early because the players are so young. If you're getting a pain in your wrist, it's probably because you have a four inch thick mechanical keyboard that you play at an angle. So something as simple as adjusting the angle of their keyboard, changing to a mouse that fits your hand, adjusting the level of your monitor. That prevention side is huge, you know, teaching them to warm up, teaching them to cool down. The actual treatment aspect is pretty small because a lot of these injuries are musculoskeletal injuries that have a really, you know, quick and simple fix. What are the kind of exercises that someone would do to warm up or to cool down? So if you think about warming up, you know, people get a good exposure to it when they're watching football or when they're watching basketball. The players are doing the movements and the things they're going to be doing during the game. So if you watch LeBron James warm up, he's dribbling, he's passing, he's shooting, he's running, he's stretching. So think about the movements you're going to be doing when gaming. So it's a lot of hand and wrist movements. So what you want to do is warm up your hands and wrists and you want to get the blood flow. And warming up is called warming up because it actually raises the temperature of your tissue, the temperature of your muscles that is not only going to prevent injury, but it's going to increase your reaction time and allow you to play better quicker. And then what would you do to cool down? So this is something my brain is full of random fun party facts because that's what people want to pay attention to. And there's actually a big misconception about the type of stretching that you're supposed to do before and after any sport. Before you do before you do anything, if you're going to be stretching, you want to make sure that it's dynamic, meaning movement based. So you've all seen people running back and forth and doing high knees and butt kicks and high jumps and moving through the whole movement. That's a dynamic stretch. The traditional stretching like standing and touching your toes, reaching forward and touching your toes. That's what's called a static stretch. That's when you hold a stretch and you keep it that way. Static stretching is really good for flexibility, but actually decreases muscle strength in the short term. So you don't want a static stretch before. So the basis of a cool down should be static stretching because it does really help. Now that your muscles are warm and they're ready to, you know, they have that increased elasticity by doing that static stretch after you're going to be greatly benefiting from it. Do you recommend to players that they do exercise, physical exercise in order to be more fit? I recommend everyone does physical exercise. The effects of exercise are wild. If we, if I listed the effects of exercise and then said, by the way, you can get all that with this pill, I would be a quadrillionaire, right? I would be, I would have more money than the people running this GameStop short sell right now. I would be, you know, exercise increases reaction time. It makes you perform better, improves memory, improves learning. And then it helps your heart, it helps your brain, it helps your muscles, it prevents cancer, it makes you sleep better, it makes you lose weight, it makes you happier. Exercise is good for everyone, no matter who you are, no matter what you are, what you're doing as little as 10 minutes a day of getting your heart rate up can have monumental health effects. So yes, I do recommend that everybody, but also this isn't medical advice, but, you know, it's educational to know that exercise is good for everyone. And does diet also factor into how someone's going to handle these injuries or prevent these injuries? Yep. So the three things that I talk about in relationship to performance are sleep, exercise and nutrition. Sleep, exercise and nutrition. If you're not doing those three things, no amount of performance enhancing supplements or special training or coach, nothing else is going to help you because those are the fundamentals of physical health and nutrition is a huge one, nutrition is a huge one. Your brain needs a constant supply of sugar in order to work, can't use any other forms of fuel primarily. Your brain needs to constantly be bombarded with sugar, but if the rest of your body is being bombarded by sugar all the time, that's not good. So, you know, sports nutrition is about making sure you have that right balance of your protein, of your carbohydrates and of your fats. And so you have a sustained energy throughout whatever you're going to be doing, and then it aids recovery after it helps with training during nutrition for these esports athletes is a huge area that also isn't being addressed right now. So yeah, it's huge. And why is sleep so important? Oh, sleep. Sleep is amazing. Sleep is amazing. I tell myself sleep deprived. You, you know, the experts, I think it's like seven to eight hours for adults. A lot of us are hitting the low end of that, but you want to make sure you're getting at least seven hours of sleep a day. So up until like five years ago, we had no idea how the brain cleaned out all of its junk, right? So working muscles produced by products called lactic acid, lactic acid builds up. That's why you feel sore the next day is because you're feeling acid in your muscles. And that's why cooldowns help because it helps clear out that lactic acid. If you are working your brain all the time, those waste products are going to build up. How does your brain get rid of those waste products? Until five years ago, we really didn't know. We had no idea that five years ago, they discovered this system to your waste products in our brain. And guess what? It's more active at night. It's more effective at night. It's more efficient at night. Not only is night when your brain is clearing away those waste products, it's also when it's cementing those memories. It's cementing those skills you learned during the day. Sleep helps you. That's the reason why we dream, right? Or it's ought to be one of the reasons why we dream is because we're rehearsing those things we learned during the day. Practicing them. We're getting, you know, there's no time off. And the other reason that sleep is really good is for performance and reaction time. They did a study of basketball players and they looked at shooting accuracy. And the sleep deprived shooters did terrible. And the ones who are well rested did much better. That's obviously an oversimplification. But sleep is also another fantastic magic pill that you can get for free. And that seems to be really applicable to gaming, right? Totally. A lot of these, a lot of these things, it's, you know, sports medicine, traditional sports medicine is so interesting and so complicated. Like they have cryotherapy tanks. How long do you go in the cryotherapy for like a couple of minutes? If you go too long, you're going to get a freezer burn. If you don't go long enough, you're not going to get the effects. They have these advanced studies on the duration of cryotherapy units. How long you should be in the cold for esports? It's not that hard yet. It's not that hard yet. All you have to do is get sleep. All you have to do is eat vegetables. All you have to do is drink water. And so for a lot of these gamers, especially for these big tournaments, if they're not a team, we're seeing a lot of what's called grinding, right? So they're they're doing 12 to 14 hours of the game. Some players will even play, you know, 10 hours before the tournament starts so they can get warmed up and then they'll, you know, they'll be sleep deprived and exhausted mentally and physically by the time their tournament starts. So we see a lot of people playing late into the night and a lot of people with really poor sleep hygiene. Sure. So at what point would a gamer or a esports athlete come and see you? Like how, you know, if they were having symptoms, you know, I guess if it's in their hands, I can't really walk it off. But but, you know, when when should they seek medical attention? As soon as they decide they want to have esports as their career, as the moment you decide that your gaming hobby is going to become your professional career, you got to start taking it seriously. And that's people love gaming. People love esports, but not a lot of people are taking esports seriously. And that's because the people who are performing the craft don't take it seriously. If you want gaming to be your career, act like it, right? Like it. Treat it like it's like make a schedule of how you're going to train, right? Get a training schedule, get a trainer, get a coach, right? It's all that stuff that we take for granted when we're like 15 years old playing soccer and we have a coach and there's an assistant coach and high school might even have a strength and conditioning coach and maybe even have a dietitian that you can talk to or nutritionist who comes by. Right? Use those resources. Sports medicine and esports medicine is not just about being healthier. It's about being better, right? High performers touch all variables. If you want to be the best at esports, you have to touch all those variables because if you're not going to, someone else will. And so that is what I say is is getting contact with someone who knows something about health and esports and not just any performance coach because those are a dime a dozen these days. You have to go with someone who has been in the industry and who has experience. You don't have to go to me. Go to go to one HP. Dr. Kate McGee knows more than I ever will about esports. And I will. I am 100 percent proud of that fact. There's a lot of people, you know, the Cleveland Clinic has an esports medicine program, NYIT has an esports medicine program. There's lots of these amazing. I feel no no competition about this because there's so much need and there's so little supply. So reach out, get an appointment, have a conversation, start earning, start taking it seriously. When you first see an esports athlete, do you like to look at their ergonomic setup with their computer and their mouse and everything? I do. I mean, that's one of the basics of my evaluation. Usually when I work with a lot of not a lot, but I work with some teams and organizations and, you know, I go and I say I go to their to their venues and to their training centers and look at those ergonomics as well because there's a lot of really simple adjustments that can be made that can be really, really, really helpful by something as simple as the chairs they're using. Ergonomics are an extension of the physical exam these days if you want to be involved in esports, because that's where a lot of the problems arise. If you are evaluating a runner, you're going to watch them run. If you're evaluating a football player, you're going to watch videos. You're going to watch game film, you're going to watch them run. If you're going to evaluate a swimmer, you need to look at what they're doing. So, you know, the same attention that people play to running, paid a running shoes, I like to pay their ergonomics. Sure. And when I was a triathlete, I remember that we would have to be measured to fit our cycle so that your knee is like a certain amount of, you know, distance to your pedal, those kind of things. And, you know, there was a lot of care that was taken into those measurements. Are there measurements that one would use with your chair or your, you know, where the screen is located, where your mouse is located? Yeah, there's a lot of really good guides, a lot of really good resources. I know Ezone, Azone from Europe is working on some really good guides for everybody. But basically your monitor should be one arms distance away. The top of your monitor should be at or just below eye level. And then think 90 degrees. You want a 90 degree angle between your elbow and your hand when you're playing on your keyboard. Your hips need to be above or at the level of your knees, never below. Your feet should be in firm contact with the ground. When you're gaming, you want your, you know, your mouse and when your hands are on your mouse and your keyboard, you want to make sure there's no angle between your wrist and your hand. So no angle like this straight. And, you know, you want to make sure that you have the correct size equipment. Remember that a lot of the gaming peripherals were made for normal sized men, which it's the same thing as like crash test dummies up until like 10 years ago, there weren't female crash test dummies and they were just smaller male dummies. So a lot of things have been tested on men. So if you are a smaller man or you're someone who has smaller features, then you're going to want to find a smaller mouse and a smaller keyboard to fit you because, you know, that's really important. There aren't a lot of really good like how to fit your mouse size. One HP did did one on a while back, but there really aren't at this time because no one's paying attention to that and no one is asking those questions. And, you know, so many of the gamers are children. And, you know, so do you, you know, is there kind of a pediatric pediatric specialty of, you know, game doc? I can count all of the eSports medicine physicians in the United States on one hand. So none of us yet are in pediatric. You know, it becomes kind of a 14 to 25 year old demographic. Anyways, so I, you know, I don't, I don't treat any under 18 just for a lot of reasons right now. But eventually I think that the pediatric population is going to need its own subspecialty, but until eSports medicine is recognized by traditional sports, we will yet to have a pediatric subspecialty. Sure. Well, it seems like that is on its way because of the potential need. Are there a lot of challenges with carpal tunnel syndrome with athletes? So that's that's actually a controversial subject in eSports medicine. Carpal tunnel syndrome is something that that everyone knows about, right? It doesn't matter if you're a brain doctor, a heart doctor, a lung doctor, a general care doctor or any sports medicine physician. Everyone's heard of carpal tunnel syndrome. And so if you go to your physician with wrist pain, with numbness and tingling in your hands and that physician doesn't know what gaming is, doesn't know what eSports is, so they don't bring it up, right? And you don't know it's from gaming because you didn't know you could get injured from gaming. So you're like, yeah, my wrist is tingling a little bit. I have numbness in my fingers. Carpal tunnel syndrome. Everyone's like, oh, yeah, carpal tunnel syndrome because that's the only diagnosis is a lot of people know. But the fact is, is that there's like 50 different diagnoses you can have with the hand and the wrist. And in order to understand those, you have to be involved in the subspecialty or you have to be paying attention to what's going on in eSports right now. So carpal tunnel syndrome is really over diagnosed in the field because it's the only thing that people know when in actuality there are a lot of other conditions going on. And the treatment for carpal tunnel syndrome is sometimes a wrist brace. And if your issue is a muscle that's needs strengthening, a wrist brace can be actually detrimental. So if you get a carpal tunnel syndrome diagnosis and you're under 30 years old, get a second opinion. Well, you know, definitely because, you know, the way I look at it is you have to go more specialized in order to get the best treatment. Otherwise, you like fracture your ankle and you end up with a big cast where if you go to a special orthopedist who only deals with like foot and leg injuries, they'll probably go, oh, you can wear that hard shoe instead of that cast. It seems to me like like if everyone's going to be diagnosing carpal tunnel, you'll end up with a lot of wrists, braces and surgeries that are made, perhaps not even necessary. Is that right? Yeah, I mean, laser surgery for carpal tunnel syndrome is on the rise now. It's it's new, it's sexy. Everyone wants to get their carpal tunnel lasers to fix their carpal tunnel syndrome. So there is definitely, you know, I I think that traditional medicine is fundamentally flawed in the way it works. It's influenced largely by insurance companies. And it's really, you know, it's it's procedure motivated. If you want to keep your doors open, and that's one of the reasons why I love eSports medicine so much is when you make a new field, you get to make your own rules. And right now, the insurance companies don't know what we're doing. So it's it's it's kind of fun to figure out how you can provide the best care to your patient unhindered by bureaucracy and push for procedures. Sounds to me like, you know, when you're looking at these kind of micro injuries and there might be a muscle that needs to be strengthened or something that needs to be stretched, can, you know, if you can identify that, then you probably can provide them the right exercise or right modality to address. Is it is that right? Yeah, definitely. Depending on, you know, what console, what title you're playing at on, there are definitely different things that can affect you. So let's say I'm a console gamer and I'm using my thumbs a lot, right? Using my thumbs to use those analog sticks. And I'm starting to feel numbness and tingling along the base of my forearm. Radial styloid tenacidivitis, also known as gamer's thumb, also known as healthy thumb, also known as new mom's thumb is caused by overuse of your thumb. It's caused by irritation as these two tendons glide through their sheath. So addressing those two tendons is how you fix it. If you get misdiagnosed and you get a different exercise program that doesn't address those two tendons, not probably not going to work. Might make your wrist a little bit stronger, but it's probably not going to work. So and that's why having practitioners who understand what's going on is so important, because if you walk into eSports Medicine with a sports medicine background being like, I can treat these kids and you don't know what Super Smash Brothers is and you don't know what the different varieties of games is you are hindered from treating these patients. So that's another issue with the fields right now. Sure. And we do have a question from a viewer. How do I prevent eye strain from looking at screen? Should I invest in those glasses that filter blue light? And these glasses are not. So blue light is, you know, like the sexy new term everyone's talking about. And blue light is the shortest wavelength of perceivable light by humans. You know, remember Rojibiv? So of the light, we can see blue light has the shortest wavelength, meaning it takes it has the most energy. So there is some hypothetical theories that exposure to blue light because blue light naturally doesn't really occur. It's mostly coming from our computer screens and, you know, lights that are human made. So there's a hypothetical theory that that blue light could damage your eye. We don't know, because honestly, it hasn't been studied long enough. We don't know how it affects kids. We don't know how it's going to affect us in the long run. Do we think it causes eye strain? Probably, but we don't have any data supporting that. Oh, OK. So, you know, I have glasses. They have blue light filters in them. I wear them all the time. Blue light filters cost $30 to add your glasses at Warby Parker. Why not? Right? Why not? The other issue with blue light is how to affect your sleep wake cycle, your circadian rhythm. And that is that is proven. That is known is that it does interfere with that. But the best way to prevent eye strain while you're gaming is every 20 minutes of screen time and exposure. Look at a spot 20 feet away for 20 seconds that isn't your gaming screen because your eyes are muscles just like the rest of your body. Your other eye itself isn't a muscle, but your eye has muscles just like the rest of your body. And so you want to make sure that your muscles aren't tightened and contracted for eight hours and they're looking away and they're flexing and they're stretching. So 2020 rule for and how about posture? How does posture play a role in injury? This is also, interestingly enough, a hotly debated topic. Whenever I post about posture on social media, there's always an athletic trainer with a picture like this who wants to debate me. It's common sense, right? It's common sense. If you sit like this, you're going to get stuck like this. Your muscles are going to adapt to that. When you sit forward in gamer posture with your shoulders rounded forward, these muscles get tight and these muscles get weak. And after a while, that's harder to overcome. So pinch your shoulder blades together down and in like you're trying to hold $20 between your shoulder blades and check in on your posture frequently. I have literally noticed over this pandemic that I've been working from home, I am inflexible in my back because I'm sitting like this all day and I'm noticing it. I'm more paying attention to it than anyone else. But posture is huge, pay attention to it. You don't want to get one of those straps that like holds you in good posture because that also causes weakness. So pay attention to it. Sure, sure. And are you seeing more neck and back complaints or shoulder complaints because of bad posture? I mean, show me a person who sits at a computer for eight hours a day who doesn't have back pain or neck pain. Everyone has back and neck pain because we all have terrible posture and because we all aren't doing core strengthening. You know, one of the most important components of back pain prevention is core strengthening. Your back and your core are supposed to be in a perfect balance, right? Neither pulling either way. But we have tight, tight backs and we have really, really loose cores. So yeah, back and neck pain is also it's huge in the general population, too. So, you know, do a core workout for like five minutes, three times a week. See how much better you feel in two weeks, y'all. And, you know, I think a lot of what we're talking about today is not only applicable to eSports athletes and gamers, but also applicable to those people who sit at their computer for eight hours a day and work. And, you know, so I see this the benefit of this advice to the general population. So I'll let you provide us the last word. We do have to wrap it up. How can people find you and do you have any last bits of advice for us? So if you want to hear more information about how to get a little bit healthier, you can find me on Twitter at gamerdoc underscore. You can also find my website, gamerdoc.net. I will not pay go daddy $5,000 for gamerdoc.com. You and if you want the last word is, you know, pay attention. Prevention starts with acceptance, right, accepting the fact that, yeah, you're going to get injured from playing video games eight hours a day. Yeah, you're going to get injured from sitting in an office desk for 40 years. But it is preventable. It is just do a little bit of prevention, do some core strengthening, drink some water, sleep at night. Those little things can have monumental effects when they when they add up. So, you know, just be aware and prevent it. Well, thank you, doctor. I've learned quite a bit today. So thank you for the viewer who sent in the question. And thank you for joining us today. Next week, I'll be talking with Tom Leonard about prize payments for eSports events. See you then.