We here at the PT Project are taking a little time to enjoy the last few days of Summer.  While our contributors are relaxing, our web designers are working hard to build a brand-spankin-new PT Project website.  We expect to launch it in a few weeks! 

We wish you a happy end-o-the-summer.

AdamBanks

This is a common question I hear from many patients and clients, asking whether stretching before a run can be beneficial?  A randomized prospective study, conducted by the USA track and field association, found no difference in the risk of injury with 3,000 runners over a 3 month period.  There were two main groups; a pre-run stretch group and a non-stretch group.  Participants in the pre-run stretch group were given a handout with photographs with several static stretches on it to be performed before every run. Researchers found gender, mileage, flexibility, level of competition, and age had weak influence on injury rate. A high BMI and recent/chronic injury prior to the study (greater than 6 weeks) had a strong influence on the risk of injury for each participant. 

In addition to finding correlations between stretching and injury rate, reserachers looked at previous stretching habits of the runners and the effects on injury rate during the study. Runners who had usually performed a pre-run stretch routine, prior to the study, and were grouped into the stretch group, had a low risk of injury.  But, if they were grouped into the non-stretch group; it nearly DOUBLED their risk of injury.

When patients and clients ask about stretching before running, I usually advise a sufficient dynamic warm-up that involves joint mobility exercises and active stretches rather than static stretches alone. Click on the link above for more information.

LeeScantalides

Tags: Stretching

• Extension biased seem to be safest (research by Sinaki et al showed 68% of woman who performed flexion biased exercises developed subsequent fracture vs. 16% who performed extension)
• Avoid flexion stresses during ADLs; even if they haven’t yet experienced fracture
• Perform modified classical yoga poses including: stretching into shoulder flexion, quadruped opposite arm/leg, prone trunk extension and lunges with shoulder flexion.
• Respiratory muscle exercises combined with back extensor strengthening
• Self mobilization by lying supine on a foam roller

For additional manual, bracing and taping suggestions read:

Katzman WB, Wanek L, Shepherd JA, Sellmeyer DE. Age-Related Hyperkyphosis: Its Causes, Consequences and Management. JOSPT. 40 (6); 352-360.

JosephBrence

Tags: back, brence, kyphosis

Sound communication between the orthopedic surgeon and physical therapist is of the utmost importance when managing the care of a patient following surgery. This is particularly the case for patients who have undergone rotator cuff repairs given the delicate nature of the procedure coupled with the fact that there is a relatively high incidence of retears on second look MRIs and ultrasounds. In order to protect the repair from deleterious forces while restoring function, a therapist should obtain as much information about the surgery as possible. This will undoubtedly improve his or her clinical decision making when it comes to advancing a patient through the rehabilitation process. While several protocols exist for rotator cuff repairs, therapists must exercise caution in strictly adhering to them because any experienced PT knows that they serve as a framework rather than a step by step program. After working closely with the orthopedic surgeons at the Nicholas Institute of Sports Medicine and Athletic Trauma (NISMAT) of Lenox Hill Hospital for the past several years, I have learned that there are three important questions to ask an orthopedist when they refer a patient to you following a rotator cuff repair.

1. What was the size of the tear?

2. What was the quality of the tissue?

3. How confident are you in the repair?

Ascertaining this information will not only engender a successful outcome for your patients, but will also convey a sophisticated level of understanding to the referring orthopedist.  Never let your patients be victimized by ill communication.

ChristopherJohnson

In a recent post by Craig Alligham titled, “Posture vs. Strength”, he reported on a study that demonstrated that proficiency in two seemingly different forms of strengthening can yield identical outcomes for the patients undergoing the treatment. This “equality” phenomenon, which exists within as well as outside of our profession, I believe, holds the key to simplifying the complexity of the human body as well as what needs to be involved in successfully treating illness or injury.
Although I have an affinity for a treatment model that emphasizes soft tissue mobilization over joint mobilization for the purposes of restoring an individual’s movement and thus function, I acknowledge that great success can be found in either approach. I also have great respect for the wide array of alternative treatment approaches, such as acupuncture and craniosacral therapy among countless others, that when properly administered, yield comparable success rates for their respective patient populations.
When you look beyond the ego-driven efforts among health care professionals to point out the inherent flaws of the “other approaches”, you begin to see the bigger picture. This being that there must be a system at work within the body that stands above all else. I propose that this SINGLE system, the one that we are all likely working within, is the extracellular matrix (ECM).
The ECM, a liquid chrystalline matrix, is comprised of water molecules aligned in order along the surrounding macromolecules (Ho). The ECM and its liquid chrystalline properties not only allow for instantaneous adaptation to a given stimulus, but also possesses the ability to allow for cellular communication at speeds beyond that of the nervous system. One must ask if the ECM could be behind what is referred to as “being in the zone”? This state, commonly referenced in sports, is a state of which the body seems to work in perfect synchronicity; usually seeming to occur outside of conscious participation from the individual.

The ECM can transform and utilize any form of external energy (mechanical, light, heat etc.) into restorative, or in some cases destructive cellular processes. It is interconnected to the outside and inside of each individual cell and therefore every inch of the human body. No other system in the body has this ability. It come as no surprise that it is also now being looked upon as the only “anatomical structure” that matches the elusive acupuncture meridians; the channels through which energy moves and has been utilized to treat disease for thousands of years in the east.

To discuss how communication occurs within the ECM involves dropping down to the quantum physics world; a subject that I would like to discuss in the next post. For now however, when you or your patient, via active exercise, push, pull, or oscillation of the ECM, ponder the fact that it is actively listening and if given the right input will understand your intent.

GabrielEttenson

While running in central park or training in the gym, I occasionally see people wearing compression garments, which have become popularized by many clothing brands (such as Under Armour).  Do compression garments enhance athletic performance when it comes to strength or endurance?  According to new research, maybe not! One article examined how 3 levels of upper thigh compression shorts effect performance on an explosive lower limb task, measured by a vertical jump test. Results indicate there was no significant difference in max/mean/median jump height in subjects who wore compression garments versus controls. The second article researched what effect lower limb compression sleeves had on highly trained runners in regards to running economy and mechanics. Again, results demonstrate lower limb compression sleeves had no significant effect on running economy (submaximal VO2) and mechanics (various phases of running cycle). If, wearing compression garments DURING endurance/strength tasks have no effect on athletic performance, how about wearing them before or after?  Click the links above for more information.

LeeScantalides

Tags: Compression Garments, Exercise

Last weekend I participated in a ‘Strength In Rehab’ workshop in Brisbane Australia.  This was for physical therapists seeking to update their theory and application of strength development for their clients.  There were three of us leading the workshop – Bruce Rawson and Andrew McGough were my co-teachers, which was a real buzz because they had both been Masters students of mine some years ago.  We share an enthusiasm for resistance training as a critical component of effective, functional rehabilitation believing many programs are discontinued at the first sign of pain relief or return to work or sport.

At these sessions we always have the debate regarding postural training versus functional strength training.  Which is more effective?  From an exercise physiology viewpoint a case can be made for both approaches.  The Postural School advocates awareness (proprioception), alignment, control and low loading programs (think Pilates, Tai Chi, Postural Integration, Feldenkrais or Mensendieck/Cesar).  The Strength School advocates a combination of isolated loading and functional integration using loading or speed as the stimulus and insisting on control into fatigue.  Don’t write telling me this is too simplistic, I know but it is a short blog!

The debate is always dominated by we three leaders because we have the microphone.  Not due to any strong evidence base, but because we have all had great success with clients using a strength based program to build resilience in our rehab clients.   Colleagues who favour a postural training approach (and were contemplating a move toward the dark side) also provided anecdotal ‘evidence’ of its efficacy.

I recall an excellent article in the Harvard Business Review a few years back which looked at the implications for organisations when they introduced new management systems or technology updates.  In a thorough analysis the authors concluded that the type of system or product was not the significant factor in terms of efficiency and productivity gains.  More important than the nature of the change was the manner in which it was introduced.  Those organizations who planned the process, prepared the staff, trained the trainers and embraced all aspects positively and purposefully achieved better outcomes than those who were less professional in their implementation.

I suspect it is the same for our rehab debate.  The nature of the program is perhaps less critical than the enthusiasm, knowledge and professionalism of the therapist in delivering the program to the client.  The words, body language and teaching strategies are always going to be stronger from a therapist who fully embraces the intervention selected.  And we all tend to go with our strengths.  Those skilled in Postural Training will do a great job of Postural Training.  Those skilled in Strength Rehab will do a great job of Strength Rehab.

A report in the Australian Journal of Physiotherapy in 2008 looked at 88 computer workers and the effect on their ‘non-specific work-related upper limb disorders’ of two physiotherapy interventions.  Randomly assigned to either a postural exercise program or a strength and fitness program for ten weeks the workers were assessed for changes in pain levels, disability measures and health related quality of life.  At the 3, 6 and 12 month reviews there was no significant difference between the two groups.  Each showed equal improvements and at 12 months 55% of all the subjects reported being pain free irrespective of the intervention.  There was no control group so we don’t know if doing something is better than doing nothing.

We do know, however, that the type of intervention was not a critical factor for outcome in this group of subjects.  I suggest our clients are just like a business organization and respond well to a program that is delivered professionally, with authority and with an expectation of success.  Providing, of course, that the actual program has a scientific basis on which to expect a therapeutic effect.

Reference:
van Eijsden-Besseling, Staal JB, van Attekum A, van den Heuvel WJ. 2008.  No difference between postural exercises and strength and fitness exercises for early, non-specific, work-related upper limb disorders in visual display unit workers: a randomised trial.  Aust J Physiotherapy 54(2):95-101

CraigAllingham

Ted Corbitt, considered by many to be the “father of American distance running,” was once quoted as saying that “you are only as good as your last injury.” While this is a profound statement, it requires one caveat. I tell people that “you are only as good as your last injury” and the extent to which it was properly rehabilitated. Too often, we witness elite athletes rush back to their respective sports before they are completely rehabbed only to sustain a more catastrophic injury.

Note: I would also like to mention that Ted Corbitt completed 199 marathons and ultramarathons during his lifetime and received the lifetime achievement award from Runner’s World. Of particular relevance to the physical therapy community, Ted was the chief physical therapist at the International Center for the Disabled on East 24th St in Manhattan. I hope you take the time to learn more about this amazing individual in terms of his life and athletic achievements.

ChristopherJohnson

Overuse chronic tendon injuries often result in subsequent structural changes such as tendon thickening, collagen and matrix disruption, and nerve and vessel growth.  When it comes to late stage tendinopathy, we know that the tendon needs to be remodeled through increased cellular activity, increased collagen production, and extracellular matrix re-organization. Eccentric exercise has become the accepted intervention for degenerative tendinopathy.  In the case of patellar tendinopathy, the decline board has come into the spotlight as the preferential mode of treatment.  The literature suggests that squats should be performed on a 25 degree decline board, for 3 sets of 15 repetitions, 2 times a day.  The eccentric phase should be performed on the symptomatic leg, and should be slow and slightly uncomfortable. When pain subsides, weight should be added. Many studies that have examined the effect of the decline board used VAS and VISA as primary outcome measures. Several studies showed an improvement in pain level at the conclusion of treatment and at follow up.  Heavy resistance training has also been suggested to treat this pathology.  Kongsgaard et al. performed a study that compared heavy, slow resistance training, to eccentrics and corticosteroid injections. The heavy resistance training consisted of 4 sets of squats, hack squats, and leg press exercise 3 times a week, for 12 weeks. The researchers found that not only did pain improve at follow-up with heavy resistance training, but that tendon structures and form changed; which did not occur with the other two interventions.  The results of the study showed that tendon fibril mean area decreased and tendon fibril density increased after heavy slow resistance training.  Several explanations have been given by the authors for the success of the heavy resistance training exercise for this pathology.  The increased tendon load throughout the protocol could be one possibility. They suggest that the tendon changes may also be due to the infrequency of training; the tendon has time to repair between workouts. The question remains, what is the best exercise for patellar tendinopathy? Slow, painful eccentric exercise on decline squat, or slow heavy resistance training and how realistic is it for our patients? 

Citations:

Visnes H, Bahr R. The evolution of eccentric training as treatment for patellar tendinopathy (jumper’s knee): a critical review of exercise programmes.  Br J Sports Med. 2007; 41: 217-223.

Kongsgaard M, Kovanen V, Aagaard P. et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009; 19: 790-802.

Kongsgaard M, Qvortrup K, Larsen J, et al.  Fibril morphology and tendon mechanical properties in patellar tendinopathy: effects of heavy slow resistance training.  Am J Sports Med. 2010; 38: 749-756.

KristineGneiss

I just recently took on a young woman in her early 40’s.  She works in a physically demanding retail position.  She is on her feet all day long, reaching for clothes and re-hanging them, as well as stooping and bending during her shift.   She was concerned about not sleeping and gaining weight.  As I interviewed her, I also learned that she had been working two days a week with a personal trainer and she was sure she had strained her low back in some way. 

As part of my client intake process, I ask people to fill out several questionnaires (mostly from Paul Chek, ie Diet and Exercise, Sleep and Food Diary, Health Assessment, and Metabolic Typing Questionnaires) to appropriately determine the problem at hand.  When I looked at her ten-day food and sleep diary, I learned that she never ate breakfast, just drank two cups of black coffee and went to work.  Her lunch was a Weight Watchers muffin; she did not eat a formal meal in the evening; she did consume several ‘snacks’ during the day which were mostly sugar-based such as chocolates from the shop next to where she works, muffins, and cookies from the food court.  She typically woke up two or three times during the night with hunger pains and was in the habit of eating bags of gummy bears during these episodes.   In reviewing her other information on activities and lifestyle, I also learned that there were several major stressors involving her children and spouse.  She also was frequently dizzy upon changing positions from lying/sitting to standing.

Over the past six months she has committed to eating six time a day, three main meals and two nutritious snacks.  She has eliminated processed sugar (including all Weight Watchers products) from her diet and has stopped eating Gummy Bears.  She is in bed by 11 p.m. or earlier, and does not get up until at least 6:30 a.m.  Her fitness routine has expanded to include a wider variety of functional exercises.  Her back pain has disappeared, she has more energy and she’s not waking up in the middle of the night.  While her life stressors have not been eliminated, she is able to cope with them more effectively.  She has lost 7 pounds and improved her muscle tone noticeably.  She no longer experiences frequent dizziness.

By taking a detailed history, it is much easier to effectively help our patients/clients.  The food, exercise, stressor, and sleeping habits all helped to lead to the adrenal fatigue that could have easily been confused as low back pain.

We will continue to meet on a weekly schedule to review her program for effectiveness and to adjust as necessary. 

Eat, Move and Be Healthy!  Paul Chek, CHEK Institute, 2004.

PamScantalides

Tags: Adrenal Fatigue, Diet, Exercise, Fitness, Paul Chek

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