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Author: chad reilly

  • Alfredson’s exercise program in Achilles tendinopathy 5 years later

    A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. van der Plas A, de Jonge S, de Vos RJ, van der Heide HJ, Verhaar JA, Weir A, Tol JL. Br J Sports Med. 2011 Nov 10. [Epub ahead of print]

    Abstract
    BACKGROUND: Eccentric exercises have the most evidence in conservative treatment of midportion Achilles tendinopathy. Although short-term studies show significant improvement, little is known of the long-term (>3 years) results.
    AIM: To evaluate the 5-year outcome of patients with chronic midportion Achilles tendinopathy treated with the classical Alfredson’s heel-drop exercise programme.
    STUDY DESIGN: Part of a 5-year follow-up of a previously conducted randomised controlled trial. Methods 58 patients (70 tendons) were approached 5 years after the start of the heel-drop exercise programme according to Alfredson. At baseline and at 5-year follow-up, the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire score, pain status, alternative treatments received and ultrasonographic neovascularisation score were recorded.
    RESULTS: In 46 patients (58 tendons), the VISA-A score significantly increased from 49.2 at baseline to 83.6 after 5 years (p<0.001) and from the 1-year to 5-year follow-up from 75.0 to 83.4 (p<0.01). 39.7% of the patients were completely pain-free at follow-up and 48.3% had received one or more alternative treatments. The sagittal tendon thickness decreased from 8.05 mm (SD 2.1) at baseline to 7.50 mm (SD 1.6) at the 5-year follow-up (p=0.051).
    CONCLUSION: At 5-year follow-up, a significant increase of VISA-A score can be expected. After the 3-month Alfredson’s heel-drop exercise programme, almost half of the patients had received other therapies. Although improvement of symptoms can be expected at long term, mild pain may remain.

    Diagnosis: Mid portion Achilles tendinitis (2-6 cm above insertion)

    Outcome: VISA-A at 1 year and 5 year. Average score improved from 49.2 to 65 following 12 week trial, increased to 75 at one year and 83.4 at 5 years. 39.7% were completely pain free at 5 years, rest has some degree of residual symptoms.

    When Assessed: 1 year and 5 years

    Subjects: 46 subjects at follow up, ave age 51, 35 of which were recreational athletes.

    Protocol: After completing Alfredson’s 12 week protocol, 67% never performed eccentric exercise again, but no correlation in pain status was found between patients who continued the exercises and those who did not.

    Other Activity: No mention of other activity during or after protocol. Perhaps in their earlier short term study with same subjects this is mentioned, older study on order.

    Chad’s Comments:  Interesting to me was that most did not continue with the exercise after the 12 week trail, and that there was no correlation towards further improvement in those that did and didn’t. I suspect this might be a limitation of Alfredson’s protocol as there is no work to increase concentric strength at any point, perhaps holding them back with regards to further functional gains. Also eccentric exercises do become unwieldy and perhaps needlessly complex and that might decrease compliance compared to continuing with more conventional progressive resistance exercise program.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Tennis Elbow: Improved with Isometric Exercise

    Prospective evaluation of the effectiveness of a home-based program of isometric strengthening exercises: 12-month follow-up. Park JY, Park HK, Choi JH, Moon ES, Kim BS, Kim WS, Oh KS. Clin Orthop Surg. 2010 Sep;2(3):173-8. Epub 2010 Aug 3.

    Abstract
    BACKGROUND: The aim of this prospective randomized clinical trial was to investigate the efficacy of a home-based program of isometric strengthening exercises for the treatment of the lateral epicondylitis (LE) of the distal humerus. We hypothesized that 1) use of isometric strengthening exercises would result in clinical benefits similar to those provided by medication and pain relief and 2) functional improvements after exercise would be time-dependent.
    METHODS: Patients were assigned to one of two groups: 1) an immediate physical therapy group (group I), or 2) a delayed physical therapy group (group D). Group I patients (n = 16) were instructed how to do the exercises at their first clinic visit and immediately carried out the exercise program. Group D patients (n = 15) learned and did the exercises after being on medications for 4 weeks.
    RESULTS: Outcomes at the 1-month clinic visit indicated that pain (measured using a visual analogue scale [VAS]) had been significantly reduced in group I compared to group D (p < 0.01). However, significant differences between groups were not found at 3-, 6-, and 12-month follow-up for either VAS scores or Mayo elbow performance scores. For modified Nirschl/Pettrone scores, a significant difference between groups was found only at the 1-month follow-up visit. By then, the number of participants who returned to all activities with no pain or occasional mild pain was six (37%) in Group I and two (13%) in Group D (p = 0.031). At the final follow-up visit, 88% of all participants performed physical activities without pain.
    CONCLUSIONS: Isometric strengthening exercises done early in the course of LE (within 4 weeks) provides a clinically significant improvement.

    Diagnosis: Lateral Epicondylitis

    Outcome: VAS dropped from 53.1 at start to 29.7 at 1 month, 10.6 at 3 months, 8.5 at 6 months, 7.8 at 12 months for the immediate group, the delayed group was similar but with delayed results ~4 weeks, catching up with immediate group by 6 months. By 12 months 88% of participants were performing all daily activities without pain.

    When Assessed: 1, 3, 6 and 12 months

    Subjects: 31 subjects, 15 in the immediate therapy group, 16 delayed exercise 4 week. No control group. Average age 50 years. 13 men and 19 women.

    Protocol: Isometric holds, 4 sets of 50 repetitions performed daily, with each rep held 10 seconds. Participants were instructed to perform the exercises gently, without pain. Elbow held in full extension in demo photo. Does not say if the 4 sets were done all at once or divided throughout the day. Not told to stop the exercises but compliance ~80% after 1 month, and dropped steadily to ~40% as 12 months.

    Other Activity: No mention of other activities.

    Chad’s Comments:  This one is interesting because it showed isometric exercise to be effective, rather than the more frequent use of eccentric exercise. Also no equipment was required and they trained without pain. I would expect, over time the isometric contractions without pain would become stronger, but there was no mention of this. No control group, the the 4 week delay in treatment group served as a kind of control, with no meaningful improvement in that group until after they started the exercises, while the immediate group was well ahead by this time. The authors theorized isometric exercise might be better for epicondylitis because forearm contractions during ADLs were more isometric in nature than calf or quadriceps contractions, but it would be interesting to see if results are generalizable.  While the exercise program did not require any equipment (4 sets of 50 reps, with each rep being 10 seconds long) the program does sounds a bit arduous. 10 seconds each, times 50 reps means each set is 8.33 minutes, not counting any rests. It 10 minutes per set if you rest 2 seconds between reps.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Cortisone, Eccentric vs Heavy Slow Resistance for Patellar Tendinopathy

    Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, Magnusson SP. Scand J Med Sci Sports. 2009 Dec;19(6):790-802. Epub 2009 May 28.

    Abstract

    A randomized-controlled single-blind trial was conducted to investigate the clinical, structural and functional effects of peritendinous corticosteroid injections (CORT), eccentric decline squat training (ECC) and heavy slow resistance training (HSR) in patellar tendinopathy. Thirty-nine male patients were randomized to CORT, ECC or HSR for 12 weeks. We assessed function and symptoms (VISA-p questionnaire), tendon pain during activity (VAS), treatment satisfaction, tendon swelling, tendon vascularization, tendon mechanical properties and collagen crosslink properties. Assessments were made at 0 weeks, 12 weeks and at follow-up (half-year). All groups improved in VISA-p and VAS from 0 to 12 weeks (P<0.05). VISA-p and VAS improvements were maintained at follow-up in ECC and HSR but deteriorated in CORT (P<0.05). In CORT and HSR, tendon swelling decreased (-13+/-9% and -12+/-13%, P<0.05) and so did vascularization (-52+/-49% and -45+/-23%, P<0.01) at 12 weeks. Tendon mechanical properties were similar in healthy and injured tendons and were unaffected by treatment. HSR yielded an elevated collagen network turnover. At the half-year follow-up, treatment satisfaction differed between groups, with HSR being most satisfied. Conclusively, CORT has good short-term but poor long-term clinical effects, in patellar tendinopathy. HSR has good short- and long-term clinical effects accompanied by pathology improvement and increased collagen turnover.

    Diagnosis: Patellar Tendinitis

    Outcome: VAS during sports and VISA-P Cortisone group VISA-P increased from 64 to 82 at 12 weeks but returned to 64 at 6 months, VAS during preferred sporting activity decreased from 58 to 18 at 12 weeks, but back up to 31 at 6 months. The eccentric group VISA-P increased from 53 to 75 at 12 weeks and 76 at 6 months, VAS during preferred sporting activity decreased from 59 to 31 at 12 weeks, and 22 at 6 months. The concentric group VISA-P increased from 56 to 78 at 12 weeks and 86 at 6 months, VAS during preferred sporting activity decreased from 61 to 19 at 12 weeks, and 13 at 6 months.

    When Assessed: 12 weeks and 6 months

    Subjects: 52 male recreational athletes, age 18-50, average 31-34 years, 12 in CORT group, 12 in ECC group, 13 in HSR group.

    Protocol: Cortisone group had 2 shots in patellar tendon, one at week zero and one at 4 weeks. The Eccentric group did eccentric decline squats 3×15 twice per day 7 days per week for 12 weeks. The concentric group did 15 RM worked down to 6 RM by week 12, 4 sets per exercise on squats, leg press and hack squats 3 times per week. 3 second concentric and 3 second eccentric phases on each. Pain was OK during both eccentric and concentric exercises so long as pain was not increased following the exercise.

    Other Activity: Sporting activities were allowed in all groups so long as pain did not rise above 30 on VAS. They noted other studies had gone as high as 50 on VAS in recreational activities and still been successful.

    Chad’s Comments:  Most interesting new study to me, found combined concentric/eccentric training better than eccentric training, with benefits being greater as time went on. “HSR proved to be more effective than ECC with regard to tendon tissue normalization and collagen turnover/production, and tended to improve clinical outcomes more than ECC.” The cortisone group started off best in the short term (12 weeks) but finished up worst in the long term (26 weeks) as usual.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Cluster Headaches and Migraines, What I Am Learning from the Surgically Implanted Electrical Stimulation Studies.

    Greater occipital nerve stimulation via the Bion microstimulator: implantation technique and stimulation parameters. Clinical trial: NCT00205894. Pain Physician. 2009 May-Jun;12(3):621-8.

    Abstract

    BACKGROUND:
    Millions of patients suffer from medically refractory and disabling primary headache disorders. This problem has led to a search for new and innovative treatment modalities, including neuromodulation of the occipital nerves.

    OBJECTIVES:
    The primary aim of this study is to describe an implantation technique for the Bion microstimulator and document stimulation parameters and stimulation maps after Bion placement adjacent to the greater occipital nerve. The secondary aim is to document outcome measures one year post-implant.

    DESIGN:
    Prospective, observational feasibility study.

    METHODS:
    Nine patients with medically refractory primary headache disorders participated in this study. Approximately 6 months after Bion insertion, stimulation parameters and maps were documented for all patients. At one year, outcome measures were collected including the Migraine Disability Assessment Score.

    RESULTS:
    At 6 months, the mean perception threshold was 0.47 mA, while the mean discomfort threshold was 6.8 mA (stimulation range 0.47-6.8 mA). The mean paresthesia threshold was 1.64 mA and the mean usage range was 16.0. There were no major complications reported such as device migration, infection, or erosion. One patient stopped using her Bion before the 12-month follow-up visit. At one year, 7 of the 8 patients were judged as having obtained fair or better results in terms of reduction of disability; 5 patients had greater than a 90% reduction in disability.

    LIMITATIONS:
    Small, heterogeneous patient population without control group. Not blinded or randomized.

    CONCLUSION:
    The Bion can be successfully inserted adjacent to the greater occipital nerve in an effort to treat refractory primary headache disorders. This microstimulator may provide effective occipital stimulation and headache control while minimizing the risks associated with percutaneous or paddle leads implanted subcutaneously in the occipital region.

    Chad’s comments:

    I read this study to get greater details of the parameters researchers were using when using their implanted electrodes to see what I can learn when I do my electric stimulation parameters externally targeting the same nerve.

    First I was happy to see that 5 of the 9 patients had a better than 90% reduction in headache disability via the MIDAS form and only 1/9 failed to make any improvement. Also 4/9 headache sufferers had cluster headaches which are particularly difficult to treat and all but one had better than 90% improvement.

    So about those parameters. Pulse duration used varied from 200-350 uS, rate was 45-60 Hz, and intensity was up to 10 mA. They noted the average perception threshold was 0.4 mA, paresthesias felt at 1.6 mA, and discomfort felt on average of 6.2 mA, but a number of subjects did 10 mA, which I think is the max output of the machine. I don’t see that they standardized pulse duration with regards to mA reached. The electrodes were implanted next to the greater occipital nerve just under the skin, which makes me think the results should be easy to match with my transcutaneous electrodes but mA used with my patients is considerably greater to overcome the resistance of the skin. It gave me some ideas for my research including the use of the MIDAS test, and testing perception, paresthesias and discomfort thresholds with my transcutaneous electrodes and see how it relates to subcutaneous use.

    Not explicitly stated, but what I assume from the study is that the stimulation is continuous rather than with an on and off duty cycle which I am currently using with my patients. The amount of time the stimulation was on with the Bion stimulator was highly variable between patients, ranging from as low as 30 minutes every 2 weeks to 24 hours per day (both with “excellent” outcomes) with no clear pattern with regards to which dosage works best. All are longer than what seems to work well in my data collection, which is 12 minutes. I have limited data showing an additional 12 minutes does not further affect relief of pain.

    Overall I think the study provides considerable useful data. However, I still think for most headache sufferers surgical implantation of electric stimulation devices is overkill. This is especially true if common hand-held electric muscle stimulators can provide comparable relief at a fraction of the cost without the side effects (pain of surgery, infection, lead migration, additional surgery to replace defective devices, etc.). Thus far my preliminary data collection indicates that they can.

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    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Eccentric vs Eccentric Plus Shock-Wave Treatment for Achilles Tendinopathy

    Eccentric loading versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy: a randomized controlled trial. Rompe JD, Furia J, Maffulli N. Am J Sports Med. 2009 Mar;37(3):463-70. Epub 2008 Dec 15.

    Abstract
    BACKGROUND: Results of a previous randomized controlled trial have shown comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) in patients suffering from chronic midportion Achilles tendinopathy. No randomized controlled trials have tested whether a combined approach might lead to even better results.
    PURPOSE: To compare the effectiveness of 2 management strategies–group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy.
    STUDY DESIGN: Randomized controlled trial; Level of evidence, 1.
    METHODS: Sixty-eight patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on an intention-to-treat basis.
    RESULTS: At 4 months from baseline, the VISA-A score increased in both groups, from 50 to 73 points in group 1 (eccentric loading) and from 51 to 87 points in group 2 (eccentric loading plus shock-wave treatment). Pain rating decreased in both groups, from 7 to 4 points in group 1 and from 7 to 2 points in group 2. Nineteen of 34 patients in group 1 (56%) and 28 of 34 patients in group 2 (82%) reported a Likert scale of 1 or 2 points (“completely recovered” or “much improved”). For all outcome measures, groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up. At 1 year from baseline, there was no difference any longer, with 15 failed patients of group 1 opting for having the combined therapy as cross-over and with 6 failed patients of group 2 having undergone surgery.
    CONCLUSION: At 4-month follow-up, eccentric loading alone was less effective when compared with a combination of eccentric loading and repetitive low-energy shock-wave treatment.

    Diagnosis: Mid portion Achilles tendinitis (2-6 cm above insertion)

    Outcome: VISA-A score improved from 50 to 73 in eccentric group, while combined eccentric exercise and shock-wave treatment group improved from 50 to 86.5. Combined group had slightly less women in it 53% vs. 59% but were on average older 53 years vs. 46 years. Only 26% in group eccentric and 35% in combined groups performed some sort of sporting activity at least once per week.

    When Assessed: 4 months, treatment was 12 weeks.

    Subjects:  34 patients per group, average age 46 in eccentric, and 53 in combined. 59% women in eccentric and 53% in combined.

    Protocol: Eccentric group: 2 exercises (one with knee straight and one with knee bent) 3×15 each, 2 x per day, 7 days per week for 12 weeks, starting with full body weight on one leg, train with pain unless “disabling”, no indication of varied speed. Combination group also had SWT 3 times, at weekly intervals. Exercises were demonstrated once by author and subjects were instructed to add 5kg of books at a time to their backpacks.

    Other Activity: “After 6 weeks, the patients were told to slowly return to their previous sports/recreational activity.”

    Chad’s Comments:  Subjects were told to increase resistance by putting books in a backpack at home, which I think might have decreased compliance regarding increasing resistance levels as eventually it will be difficult to keep adding books to a backpack, thus patients might max out before optimal strength levels are reached. Also no recording of BMI, such that less fit individuals might be starting off with higher resistance levels and less strength than more fit counterparts. Only 9/34 in group 1 and 12/34 performed some sort of sporting activity at least once per week. Appears to less athletic than the Scandinavian studies. I think that though differences between groups were statistically significant, but relatively minor and may be due to the increased females and lesser number of athletes of eccentric group, so it is hard to say how much effect the SWT had on outcomes.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Eccentric Exercise and Heel Brace for Achilles Tendinopathy

    Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation. Knobloch K, Schreibmueller L, Longo UG, Vogt PM. Disabil Rehabil. 2008;30(20-22):1685-91.

    Abstract
    PURPOSE: To compare eccentric training and the combination of eccentric training with the AirHeel Brace for the management of tendinopathy of the main body of the Achilles tendon.
    METHODS: We recruited 116 subjects with unilateral tendinopathy of the main body of the Achilles tendon, who were randomized in two groups. Group A performed a regimen of daily eccentric training associated with the AirHeel Brace (Donjoy Orthopedics, Vista, CA, USA). Group B performed the same eccentric training without the AirHeel Brace. Tendon microcirculatory mapping was performed using combined Laser-Doppler and spectrophotometry. Pre- and post-operative FAOS score and VAS score were used to evaluate the patients.
    RESULTS: The FAOS score and the VAS score showed significant improvements from pre-operative to post-operative values in both groups (A 5.1 +/- 2 vs. 2.9 +/- 2.4, 43% reduction and B: 5.4 +/- 2.1 vs. 3.6 +/- 2.4, 33% reduction, both p = 0.0001). There were no statistically significant differences in FAOS score and VAS score when comparing the two groups after the end of the intervention. In Group A, tendon oxygen saturation in the main body of the Achilles tendon showed significant increase from pre- to post-management values (68 +/- 12 vs.74 +/- 8%, p = 0.003). Post-capillary venous filling pressures showed significant reduction from pre- to post-intervention values.
    CONCLUSION: Eccentric training, associated or not with the AirHeel Brace, produces the same effect in patients with tendinopathy of the main body of the Achilles tendon. The combination of eccentric training with the AirHeel Brace can optimize tendon microcirculation, but these micro-circulator advantages do not translate into superior clinical performance when compared with eccentric training alone.

    Diagnosis: Achilles Tendinitis

    Outcome: FAOS improved significantly in both groups that did eccentric exercise but did not differ with use of the brace. VAS decreased from 5.1 to 2.9 in one group and 5.4 to 3.6 both eccentric groups (a 43.1% and 34.6% improvement respectively) while use of heel brace did not have a significant effect on pain or function.

    When Assessed: 12 weeks

    Subjects: 63 males and 34 females average age 47

    Protocol: Eccentric training 3 sets of 15 reps twice daily.

    Other Activity: “All groups performed their regular sport activity throughout the study period for at least 12 weeks.”

    Chad’s Comments:  Physical therapy study showing beneficial changes in pain, function, and quality of life with eccentric exercise WHILE ALLOWING SUBJECTS TO CONTINUE WITH REGULAR SPORTS ACTIVITY.  The ankle brace had no effect on outcomes and I expect much the same to be true with the use of elbow straps with medial or lateral epicondylitis.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Electric Stimulation for Headaches, Migraines (My Results)

    This treatment is serendipitous, so I’ll add some background information on how I came to it.  As shown by my other blogs, in the last year I’ve been especially interested in electric muscle stimulation (EMS) to help recovery by accelerating strength gains better than exercise alone.  A number of my knee and back pain patients commented that the EMS helped with pain better than my earlier use of transcutaneous electrical nerve stimulation (TENS), which is basically the same thing as EMS but with shorter pulses and/or lesser intensity.  The intention of TENS being to control pain rather than restore muscle.  I had a patient with low back pain that had a near full recovery of strength, but had a persistent 1/10 pain  which was reduced but not eliminated when using TENS. I mentioned he might want an electric stim machine for home;  I had just started using it for core strength and thought it might help him strengthen since his pain level plateaued.  After using EMS for 12 minutes to his abdominal muscles as well as low back, he said he was pain free for the first time.  Soon after I read a study using EMS for low back pain that used similar pad placement and parameters for patients with low back pain. I have been successfully using that method as part of my treatment for my low back pain patients ever since. Around the same time, I had a patient come in who had just suffered a stroke, and had severe neuralgia in one of her legs, confining her to a wheelchair. She wasn’t able to tolerate any exercise with that leg because it was hypersensitive to pressure, so I figured I would try EMS on it and she would either like it or hate it. Turns out she loved it; it immediately and substantially decreased her pain, she was walking later that hour, and had full recovery of leg strength, endurance, and gait in about a month. She asked me if it would work for headaches. I said I would do some research and this is the first paper I came up with:

    Peripheral nerve stimulation for the treatment of primary headache.  Curr Pain Headache Rep. 2013 Mar;17(3):319.

    Abstract

    A headache is a common neurological disorder, and large numbers of patients suffer from intractable headaches including migraine, tension headache and cluster headache, etc., with no clear therapeutic options. Despite the advances made in the treatment of headaches over the last few decades, subsets of patients either do not achieve adequate pain relief or cannot tolerate the side effects of typical migraine medications. An electrical stimulation of the peripheral nerves via an implantable pulse generator appears to be good alternative option for patients with treatment-refractory headaches. A number of clinical trials show considerable evidence supporting the use of peripheral nerve stimulator (PNS) for headaches not responding to conservative therapies. However, the mechanism by which PNS improves headaches or predicts who will benefit from PNS remains uncertain. The decision to use PNS should be individualized based on patient suffering and disability. Hence, further work is imperative. Here, we discuss the mechanism, indication, efficacy, implant technique, and complications of PNS.

    The data from the paper sounded good, with the following taken from the outcomes:

    “Since 1999 a number of studies have shown the efficacy of effective treatment of intractable headaches using PNS.  Weinert and Reed showed 80% success in a group of 62 patients with intractable occipital headache [55].  For occipital neuralgia Slavin et all., determined that 70% of patients experienced pain relief [42] while Melvin et al., reported that 91% of patients experienced a reduction of medication need [43].”

    “Propency and Alo reported significant improvement in headache frequency, severity, and disability (migraine disability assessment score [MIDAS]) in 25 patients with chronic disabling transforming migraine with ONS [54].  The average improvement in the MIDAS score at the 18 month follow up was 88.7%.”

    “Magis et al., presented a prospective pilot study on occipital nerve stimulation for drug-resistant cluster headaches.  In their study two patients (n=8) were pain free after a follow up at 16 and 22 months, and three patients experienced a 90% reduction in attack frequency.  The intensity of attacks improved by 50%, and all but one patient was able to substantially reduce their preventative drug treatment [57].”

    With results that good, it makes you wonder why everyone suffering with severe headaches wasn’t having PNS.  The problem is that the PNS electric stimulators were surgically implanted with wire leads placed alongside the occipital nerve at the base of the skull.  There were a number of serious complications including infection and lead migration (when the wire planted alongside the nerve shifts). Plus, the surgically implanted battery pack only has a 3-5 year life span, and the rechargeable version has a 10 year span.  So while the PNS treatment seems very effective, I can’t imagine many headache sufferers would be willing to go that route.

    PatientPain
    Before    		Pain After
    (12 min)    		Pain
    Decrease    		Pain %
    Change    		max mA
    110/100/1010100%? mA
    28/102/10675%35 mA
    34/10 0/104100%30 mA
    43/101/10266.7%41 mA
    54/100/104100%31 mA
    63/100/103100%30 mA
    74/101.5/102.562.5%30 mA
    83/100/103100%33 mA
    98/102/10675%34 mA
    106/100/106100%40 mA
    118/100/108100%50 mA
    124/100/104100%36 mA
    136/106/1000%49 mA
    144/103.5/100.512.5%25 mA
    154/100.5/103.587.5%38 mA
    165/102/10360%40 mA
    174/100/104.5100%42 mA
    183/102/10133.3%33 mA
    196.5/100/106.533.3%38 mA
    203/100/103100%38.mA
    Averages5.1/101/104.0/1079%36 mA

    I figured the occipital nerve is very superficial and should be easy to stimulate with my EMS unit by placing the electrodes high on the posterior aspect of the cervical spine.  I was already using large rubber carbon electrodes rather than sticky gel electrodes so there was no interference with the patients’ hair, and they are effectively held in place by a snug but not tight 4” wide elastic strap around the neck.  I used my favorite EMS settings that worked for me better than TENS with the low back pain and neuropathic hypersensitivity. At worst I figured I would increase the strength of the suboccipital muscles and posterior cervical extensors, which would be better than nothing.  I had a knee patient come in complaining of a 10/10 headache saying she didn’t think she would be able to do her exercises.  I suggested we try EMS and 12 minutes later her pain was gone and did not return.  A few days later another patient being treated for low back pain had an 8/10 headache, I stimmed her suboccipital region and 12 minutes later it was a 2/10 and later resolved.  So I started offering a free EMS treatment to anyone with a current headache. I have been keeping and recording the results in a spreadsheet. This is my result thus far:

    So far, nobody has reported increased pain and only one patient had no immediate improvement (we later found via MRI that this patient’s headaches were due to severe multi-level cervical stenosis). Twelve of the 21 had complete relief of headaches immediately following the treatment.  Most patients comment that the EMS is comfortable and removes the aura associated with migraines as well as the headache. Some have said when they stim while first experiencing an aura it stops the migraine from coming on.  Some have tried the EMS with lower intensity stimulation with modest effect and tried it again later with increased intensity to have their pain fully resolved. Pain reduction or elimination has ranged from relief lasting several hours, to several days, to headache pain not returning at all.

    Since then I have modified my treatment parameters to see if they improve results. I have been reading more papers, including some from back in the 80s when they were doing traditional TENS for headaches and were finding positive results as well, though that research seems to have been forgotten.  I’ll do some blogs on them to talk about what can be learned, good or bad, from prior and upcoming research as well as updates from my data collection.  So far I’ve been collecting data with reference to immediate reductions in pain once the headache is there, but going forward I’ll also be looking at more at specific parameters in the older TENS and current PNS studies and combining that with my surface EMS to see if that affects frequency and intensity of future headaches.

    In the meantime if anyone local to my office has a current headache and wants to be part of my study and see if EMS works for them please call the office and we’ll try to get you in for an immediate and free appointment to try it out.  In the future I’ll likely be adding a placebo/control group to control for the power of suggestion, but at this point I’m collecting preliminary data you’re sure to get what I think works best.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFITyoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Eccentric Exercise vs. Ultrasound for Achilles Tendo Pain

    Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain–a pilot study. Chester R, Costa ML, Shepstone L, Cooper A, Donell ST. Man Ther. 2008 Dec;13(6):484-91. Epub 2007 Jul 26.

    Abstract

    A number of studies have indicated that eccentric calf muscle training has beneficial effects in the management of Achilles tendon pain for recreational athletes. The purpose of this prospective randomised single blind pilot study was to investigate their potential effectiveness compared with therapeutic ultrasound in subjects with relatively sedentary lifestyles in an NHS hospital setting. Eleven men and five women (mean age 53+/-21 years) with Achilles tendon pain of minimum duration 4 months were randomised to one of two treatment groups; either eccentric loading or ultrasound. Administration of ultrasound and regular supervision of exercises occurred over a period of 6 weeks, with unsupervised exercises continuing for another 6 weeks. Outcome measurements were taken prior to and after 2, 4, 6 and 12 weeks after commencing treatment. They included: pain on a visual analogue scale, functional index of the leg and lower limb, and the five question EuroQol generalised health questionnaire. The difference in mean score was calculated together with 95% confidence intervals assuming a normal distribution. There were no statistically significant differences between groups or clear trends over time. In addition there was considerable overlap between the confidence intervals. This is not unexpected given the small sample size. Both interventions proved acceptable to the patients with no adverse effects. On this basis we intend conducting a full multi-centred study.

    Diagnosis: Achilles Tendinitis

    Outcome: FILLA and VAS “during rest, walking, and if appropriate during recreational sport” Graphs of VAS not significantly different between exercise or ultrasound and not different from what I would expect from natural course without treatment.

    When Assessed: 2, 4, 6 and 12 weeks, TREATMENT WAS ONLY 6 WEEKS

    Subjects: 4 male and 4 female in exercise group with average age of 59, while ultrasound group had 7 male and 1 female average age of 48.

    Protocol: Exercise was eccentric, slow of UP TO 3 x 15 reps with a TEN SECOND REST at bottom of each rep, with both straight knee and bent knee, once per day 7 days per week for 6 WEEKS. Instructed to continue unless pain is disabling. “only one subject progressed to using a backpack with weights and a number of subjects were unable to progress to performing the exercise with a bent knee.”

    Other Activity: Group was largely sedentary. “It is reasonable to suggest that the sedentary or relatively sedentary lifestyle in our study in comparison with the majority of the subjects in the studies above is a likely contributing factor to our results.”

    Chad’s Comments:  I think this study is difficult to assess in relation to others. The subjects did not progress on exercises very well, the treatment weeks was only 6 weeks compared to 12 in others, the exercise protocol included a 10 second stretch on every rep while no others did so, and the randomization procedure led to non-random and unequal treatment groups for which they admit “the subjects in the eccentric loading group were older, had a greater proportion of women to men, had a longer duration of symptoms and had a greater number of additional pathologies than the subjects allocated to the ultrasound group.”

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Electric Muscle Stimulation BEFORE Total Knee Replacement Improves Outcomes

    “Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty. A pilot study. BMC Musculoskelet Disord. 2010 Jun 14;11:119. ”
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    BACKGROUND:
    Supervised preoperative muscle strengthening programmes (prehabilitation) can improve recovery after total joint arthroplasty but are considered resource intensive. Neuromuscular electrical stimulation (NMES) has been shown to improve quadriceps femoris muscle (QFM)strength and clinical function in subjects with knee osteoarthritis (OA) however it has not been previously investigated as a prehabilitation modality.

    METHODS:
    This pilot study assessed the compliance of a home-based, NMES prehabilitation programme in patients undergoing total knee arthroplasty (TKA). We evaluated its effect on preoperative and postoperative isometric quadriceps femoris muscle (QFM) strength, QFM cross-sectional area (CSA) and clinical function (subjective and objective). Seventeen subjects were recruited with 14 completing the study (NMES group n = 9; Control group n = 5).

    RESULTS:
    Overall compliance with the programme was excellent (99%). Preoperative QFM strength increased by 28% (p > 0.05) with associated gains in walk, stair-climb and chair-rise times (p < 0.05). Early postoperative strength loss (approximately 50%) was similar in both groups. Only the NMES group demonstrated significant strength (53.3%, p = 0.011) and functional recovery (p < 0.05) from 6 to 12 weeks post-TKA. QFM CSA decreased by 4% in the NMES group compared to a reduction of 12% in the control group (P > 0.05) at 12 weeks postoperatively compared to baseline. There were only limited associations found between objective and subjective functional outcome instruments.

    CONCLUSIONS:
    This pilot study has shown that preoperative NMES may improve recovery of quadriceps muscle strength and expedite a return to normal activities in patients undergoing TKA for OA. Recommendations for appropriate outcome instruments in future studies of prehabilitation in TKA have been provided.

    My comments:

    My conclusions agree with the researchers. Often patients have insurance imposed limitations in the number of therapy visits they are allowed in a year, or large copayments make prolonged therapy unaffordable. However quality EMS units are becoming more and more affordable (~$200), are simple to use with minimal training, and allow arthritic patients to aggressively work muscles surrounding their most irritated joints in a without additional weight bearing, so it’s ideal for home use

    Stimulation parameters used had a max intensity of 70 mA, 50 Hz, a changing pulse width between 100-400 uS, 5 seconds on and 10 seconds off, 20 minutes per day for 6 weeks. “Based on the the majority of strength training research with EMS” this isn’t exactly the parameters I would have chosen (I don’t see any use for a changing pulse width I would have used 300-400 uS and I generally use a longer rest period) but the strength and hypertrophy gains were still significant. Another case study I am aware of showed max strength gains after EMS were measured 4 weeks after cessation of use, so prehab is probably an ideal way to get a heads up on preventing atrophy following total knee replacement, and probably any other orthopedic surgery. Having the EMS unit at home already would give patients a head up to start immediate post-op EMS which would further prevent atrophy, restore strength, control pain, and likely decrease risk of blood clots.

    I think an ideal situation to maximize post-op recovery while minimizing costs would be a single visit referral to physical therapy where the patient can learn to use, and obtain that day, a quality, programmable, 4 channel, battery operated, EMS unit, ASAP after the decision is made to go forward with the replacement. They could then use it as little as 12 minutes per day up to the time of their surgery and then immediately thereafter, and start outpatient rehabilitation when ordered by their surgeon at which point they would already have a substantial head start towards recovery.

    [contact-form to=’chadmreilly@gmail.com’ subject=’New Blog Comment(s)’][contact-field label=’Name’ type=’name’ required=’1’/][contact-field label=’Email’ type=’email’ required=’1’/][contact-field label=’Website’ type=’url’/][contact-field label=’Comment’ type=’textarea’ required=’1’/][/contact-form]

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Eccentric calf muscle training in athletic patients with Achilles tendinopathy

    Eccentric calf muscle training in athletic patients with Achilles tendinopathy. Maffulli N, Walley G, Sayana MK, Longo UG, Denaro V. Disabil Rehabil. 2008;30(20-22):1677-84. 

    Abstract
    PURPOSE: To evaluate the effects of eccentric strengthening exercises (ESE) in athletic patients with Achilles tendinopathy.
    METHODS: Forty-five athletic patients (29 men, average age 26 years +/- 12.8, range 18 – 42; 16 women, average age 28 years +/- 13.1, range 20 – 46; average height: 173 +/- 16.8, range 158 – 191; average weight 70.8 kg +/- 15.3, range 51.4 – 100.5) with a clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks.
    RESULTS: The mean pre-management VISA-A scores of 36 (SD 23.8; 95% CI: 29 – 46) improved to 52 (SD 27.5; 95% CI: 41.3 – 59.8) at the latest follow up (p = 0.001). Twenty seven of the 45 patients responded to the eccentric exercises. Of the 18 patients who did not improve with eccentric exercises, 5 (mean age: 33 years) improved with two peritendinous aprotinin and local anaesthetic injections. 10 of the 18 patients (9 men, mean age 35 years; 1 woman aged 40 years) who did not improve with eccentric exercises and aprotinin injections proceeded to have surgery. The remaining three patients (3 women, mean age 59.6 years) of the 18 non-responders to eccentric exercises and aprotinin injections declined surgical intervention.
    CONCLUSIONS: ESE in athletic patients provide comparable clinical outcome compared to our previous results in non-athletic patients. ESE are a viable option for the management of AT in athletes, but, in our hands, only around 60% of our athletic patients benefited from an intensive, heavy load eccentric heel drop exercise regimen alone. If ESE fail to improve the symptoms, aprotinin and local anaesthetic injections should be considered. Surgery is indicated in recalcitrant cases after 3 to 6 months of non operative management.

    Diagnosis: Mid portion Achilles tendinitis (2-6 cm above insertion)

    Outcome: VISA-A. Average score increased from 36 to 52. 60% were considered successful, unsuccessful was judged if pain still interfered with normal activities and if VISA-A score did not improved less than 10 points.

    When Assessed: 12 weeks

    Subjects: 45 athletic patients, 29 men average age 26, and 16 women average age 26

    Protocol: Subjects worked up 3 sets of 15 reps with knee bent and with knee straight, twice per day, 7 days a week. Allowed to work through mild to moderate pain, starting with body weight (1 set of 10 reps) and adding 5 kg at a time if 3rd set painless. They did work from a slow to fast pace then increased weights, working a slow to fast pace again in later weeks of the study.

    Other Activity: No mention of other activity during or after protocol.

    Chad’s Comments:  This is an interesting study in that they did not find the same results as did Alfredson (60% effective vs better than 80% effective as reported by Alfredson). Differences I see, is that these patients worked to increase rep speed rather than just resistance levels while keeping speed constant like Alfredson. Could be the increased rep speed lessens time of tension on eccentric exercise and thus lessens adaptation? Also there is no mention about return to running, or sports during the course of treatment. It has been my experience that patients do better with relative rest (less duration), but not complete rest from the offending activity, and that with complete rest the pain just returns as they start the activity again, regardless exercise intervention. Another difference is the use of ice massage after treatment, but other studies have found ice to have no effect on outcomes rather than deleterious effect.  All data that’s worth knowing when designing physical therapy programs for tendinopathy.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Electric Muscle Stimulation for Strength, How to Make It Work.

    ”Electromyostimulation–a systematic review of the influence of training regimens and stimulation parameters on effectiveness in electromyostimulation training of selected strength parameters. J Strength Cond Res. 2011 Nov;25(11):3218-38. ”

    Since I plan to discuss a number of studies on electric stimulation, I figured I should get this one out there. It gives some background as to which electric stimulation parameters work for increasing muscular performance so that people can judge if what they are doing (or plan to do) is anywhere close to the ballpark of what works. There are countless electric stim machines out there that range from less than $100 to many thousands of dollars, and this is a case where it’s not as simple as “you get what you pay for”. Rather, you have to know what works and if a given machine can do that or not. In that sense this review is incredibly useful. The abstract, which is a bit daunting, is as follows:

    “Our first review from our 2-part series investigated the effects of percutaneous electromyostimulation (EMS) on maximal strength, speed strength, jumping and sprinting ability, and power, revealing the effectiveness of different EMS methods for the enhancement of strength parameters. On the basis of these results, this second study systematically reviews training regimens and stimulation parameters to determine their influence on the effectiveness of strength training with EMS. Out of about 200 studies, 89 trials were selected according to predefined criteria: subject age (7 days). To evaluate these trials, we first defined appropriate categories according to the type of EMS (local or whole-body) and type of muscle contraction (isometric, dynamic, isokinetic). Unlike former reviews, this study differentiates between 3 categories of subjects based on their level of fitness (untrained subjects, trained subjects, and elite athletes) and on the types of EMS methods used (local, whole-body, combination). Special focus was on trained and elite athletes. Untrained subjects were investigated for comparison purposes. The primary purpose of this study was to point out the preconditions for producing a stimulus above the training threshold with EMS that activates strength adaptations to give guidelines for implementing EMS effectively in strength training especially in high-performance sports. As a result, the analysis reveals a significant relationship (p < 0.05) between a stimulation intensity of ≥50% maximum voluntary contraction (MVC; 63.2 ± 19.8%) and significant strength gains. To generate this level of MVC, it was possible to identify guidelines for effectively combining training regimens (4.4 ± 1.5 weeks, 3.2 ± 0.9 sessions per week, 17.7 ± 10.9 minutes per session, 6.0 ± 2.4 seconds per contraction with 20.3 ± 9.0% duty cycle) with relevant stimulation parameters (impulse width 306.9 ± 105.1 microseconds, impulse frequency 76.4 ± 20.9 Hz, impulse intensity 63.7 ± 15.9 mA) to optimize training for systematically developing strength abilities (maximal strength, speed strength, jumping and sprinting ability, power).”

    My comments:

    In the text they look at all aspects of electric stimulation: the type of wave, the intensity, duration, rate, etc. The authors discuss how it performed with an emphasis on athletics, give a summary of the results with regards to what seemed most effective, and give some ballpark figures to work with. Though the paper attempts to focus more on the training of healthy athletes, I find that information invaluable in rehabilitation situations as well.  Unless I have reason not to, I tend to use similar (but not always the same) parameters with my patient population. Reading each section, what the authors note/recommend is as follows:

    • Impulse type/form: biphasic square wave is emerging as the current favorite
    • Training Frequency: 3 days per week
    • Contraction time: 3-10 seconds
    • Duty Cycle: 20-25% (i.e. a ratio of 1 on 3-4 off)
    • Impulse Frequency: >60 Hz
    • Impulse Width: 200-400 uS
    • Impulse intensity: >50 mA

    The guidelines are all a little rough, but this paper describes parameters that current research is pointing towards. It’s more current and usable than any electric stimulation book I have read. Unfortunately, while it is pretty well established that electric muscle stimulation works, there are still a lot of unknowns with regards to what works best.

    Training 3 times per week sounds like a good place to start, however I think if a person’s muscles are particularly atrophied and difficult to activate, more frequent stimulation might be better. Some studies on post-op knee replacement have stimmed 2 times per day with beneficial effects. On the other hand if muscle is developed and the stimulation intensity is high, I think 3 times per week might be too much for adequate recovery between workouts. In my own training where I have worked up to a high intensity of stimulation, training each bodypart every 3rd day feels about right.

    In terms of contraction time, 3-10 seconds sounds right. I usually use 10 seconds on and 50 off, but I do so largely by appealing to the authority of Kots (Russian stim) and Charlie Francis’ work with his sprinters. Duty cycle of 20-25% sounds good, but the famed “Russian stim” parameters is a 10 second on 50 second off, which equates to about 16% duty cycle. I liken this to lifting weights when people ask what number of reps is best. The answer is “it depends.” The idea of the long rest period of 10 on 50 off is that your muscles are able to recover more fully and thus contract harder during each upcoming contraction. I do notice however that if I shorten the rest period, upcoming contractions are not as hard, but I am then able to turn up the intensity of the machine and reach new muscle fibers. This makes me wonder which contraction time pattern is more effective in the long term.

    Impulse frequency >60 Hz sounds right according to most research I have seen and is enough to give a tetanic contraction. I use 120 Hz because I first became interested in electric stimulation after reading sprint coach Charlie Francis’ book, and that’s what he used. I have yet to find any reason to change it. 120 Hz feels more smooth than 60 Hz for what that is worth.

    In my experience impulse width is underappreciated and is as important as intensity. 200 uS seems a bit short to me. It will probably work fine for arms but won’t be enough for core or leg musculature. 300 uS is pretty stout, will adequately train most anyone, and can be found in inexpensive but quality stim machines (i.e. the EV-906). 300 uS is also strong enough that most people will not be able to max out. I do notice my patients with neuropathy in the calves and feet, 300 uS at 100 mA often isn’t enough to get a strong muscle contraction. However, in that case the Globus unit with the availability of 450 uS is enough to get good muscle activation out of all but those with full denervation.

    Impulse intensity over 50 mA sounds reasonable. If the pulse width of the machine is just 50 uS,  then 50 mA isn’t going to feel very strong, but bring the pulse width up to 300+ and it’s another matter altogether. For optimal strength the research seems to suggest that more intensity is better. Work up to as much as you can take!

    Not addressed in this paper but worth knowing: I find you can comfortably get more current into a large muscle by adding electrodes rather than just turning up the electrodes. Two electrodes (1 channel) for large muscles like the quadriceps and hamstrings does not feel like it works the muscle as completely as 4 electrodes (2 channels) on each. However, this depends on the size of the person, how many channels you have available, and how many muscles you want to work at once. Large electrodes are more comfortable than small ones because they lessen the current density going through your skin. Rubber carbon electrodes last a lot longer than sticky gel electrodes, but you do need straps to hold them in place. In my opinion stick on gel electrodes are more trouble than they are worth. Rubber carbon electrodes wet with water and held with good straps feel better, work better, and last a lot longer. I’ve tested all sizes and 4” round rubber carbon electrodes are my favorite type and size.  A 4” wide elastic-velcro strap is best to hold them in place.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFitYoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Physical Therapy and EMS: Restores Activation, Strength 1 Year Post TKA

    ”The use of neuromuscular electrical stimulation to improve activation deficits in a patient with chronic quadriceps strength impairments following total knee arthroplasty. Journal of Orthopaedic & Sports Physical Therapy. 2006 Sep;36(9):678-85.”

    This was a single-patient case study of a patient who had high level function but persistent quadriceps weakness and activation deficits 13.5 months post op.

    Treatment consisted of reasonably aggressive unilateral leg strengthening with an emphasis on quadriceps for 6 weeks. On the weaker of his quadriceps they also did electric muscle stimulation with 2 electrodes, 2500 Hz, sinusoidal alternating waveform current at a burst rate of 75 bursts with intensity to the patients maximum tolerance, 10 seconds on and 80 seconds off, 3 times per week prior to doing his resistance training.

    The addition of the electric stimulation was pretty effective, as the authors put it:

    “The patient was a 62-year-old male cyclist 12 months following simultaneous, bilateral TKA with impairments in left quadriceps strength and volitional muscle activation. His left quadriceps strength was 26% weaker than his right and central activation ratio (CAR) of his left quadriceps was 13% lower than his right quadriceps CAR. NMES to the left quadriceps was implemented for 6 weeks, in addition to an intense volitional weight-training program with emphasis on unilateral lower extremity exercises.”

    “The patient demonstrated a 25% improvement in left quadriceps femoris maximal volitional force output following 16 treatments of combined NMES and volitional strength training over a 6-week period. The patient’s volitional muscle activation improved from a CAR of 0.83 before treatment to 0.97 after treatment. At discharge from physical therapy and at his 18-month postoperative follow-up, the patient’s left quadriceps strength was only 4% lower than his right quadriceps strength. At the 24-month follow-up, the patient’s left quadriceps strength was 6% stronger than his right quadriceps strength.”

    “The patient was able to achieve symmetrical quadriceps strength and complete muscle activation following 6 weeks of NMES and volitional strength training. An intense strengthening program may have the potential to reverse persistent strength-related impairments following TKA.”

    “Aggressive strength training at 75% of 1-repetition maximum can increase force-generating capacity and induce muscle hypertrophy. However weakness combined with activation deficits presents even greater challenges. If a muscle can not be activated to its full potential it can be argued that strengthening solely through volitional exercise will not be sufficient to overload the muscle and enhance strength”

    Chad’s comments:

    The latter paragraph says a lot. In addition to the primary findings of the report, the introduction discussed other studies that noted failure to restore lower extremity strength may lead to an emergence or progression of symptomatic osteoarthritis in other joints. The next most likely joint replacement being the other knee, the other hip, and finally the same hip as the original knee replacement. One might conclude that such progression on the contralateral (other) leg was because it was taking on an increased burden during activities of daily living, picking up the slack from the replaced knee that remained weak. Only after the contralateral leg was weakened from its joint replacement would the ipsilateral (same side) hip require replacement. All of this may be prevented by fully restoring strength to the originally replaced side from the start.

    While it would have been ideal to get the patient started with more aggressive strengthening and EMS as early as possible, this study was able to show substantial progress over a year post op which has not been researched in any of the other EMS/TKA studies.

    The researches used only one channel/2 electrodes on the subjects quadriceps.   They used large electrodes making the electric stimulation more comfortable. However, in my experience they would have had even greater recovery if they had placed 4 electrodes on the quadricep to recruit a greater number of nerves and subsequent muscle fibers. The additional channel on the same quadriceps doubles the muscle fiber recruitment without the increase in discomfort you would get from further increases in current intensity. Also, if the EMS machine has additional channels you might as well put 4 electrodes on the hamstrings as well, or any other muscle that tests as relatively weak.  On most good EMS units those additional channels are there, so it seems a shame not to use them.

    [contact-form to=’chadmreilly@gmail.com’ subject=’New Blog Comment(s)’][contact-field label=’Name’ type=’name’ required=’1’/][contact-field label=’Email’ type=’email’ required=’1’/][contact-field label=’Website’ type=’url’/][contact-field label=’Comment’ type=’textarea’ required=’1’/][/contact-form]

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • No Rest Necessary for Achilles Tendinopathy

    Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Am J Sports Med. 2007 Jun;35(6):897-906.

    Abstract
    BACKGROUND: Achilles tendinopathy is a common overuse injury, especially among athletes involved in activities that include running and jumping. Often an initial period of rest from the pain-provoking activity is recommended.
     
    PURPOSE: To prospectively evaluate if continued running and jumping during treatment with an Achilles tendon-loading strengthening program has an effect on the outcome.
     
    STUDY DESIGN: Randomized clinical control trial; Level of evidence, 1.
     
    METHODS: Thirty-eight patients with Achilles tendinopathy were randomly allocated to 2 different treatment groups. The exercise training group (n = 19) was allowed, with the use of a pain-monitoring model, to continue Achilles tendon-loading activity, such as running and jumping, whereas the active rest group (n = 19) had to stop such activities during the first 6 weeks. All patients were rehabilitated according to an identical rehabilitation program. The primary outcome measures were the Swedish version of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A-S) and the pain level during tendon-loading activity.
     
    RESULTS: No significant differences in the rate of improvements were found between the groups. Both groups showed, however, significant (P < .01) improvements, compared with baseline, on the primary outcome measure at all the evaluations. The exercise training group had a mean (standard deviation) VISA-A-S score of 57 (15.8) at baseline and 85 (12.7) at the 12-month follow-up (P < .01). The active rest group had a mean (standard deviation) VISA-A-S score of 57 (15.7) at baseline and 91 (8.2) at the 12-month follow-up (P < .01).
     
    CONCLUSIONS: No negative effects could be demonstrated from continuing Achilles tendon-loading activity, such as running and jumping, with the use of a pain-monitoring model, during treatment. Our treatment protocol for patients with Achilles tendinopathy, which gradually increases the load on the Achilles tendon and calf muscle, demonstrated significant improvements. A training regimen of continued, pain-monitored, tendon-loading physical activity might therefore represent a valuable option for patients with Achilles tendinopathy.

    Diagnosis: Achilles Tendinopathy

    Outcome: VISA-A, VAS, and a variety of functional tests.

    When Assessed: 6 weeks, 3 months, 6 months, and 1 year

    Subjects: 19 subjects per group, ~half men and women, average age 46

    Protocol: Both groups did same rehab exercise protocol including concentric, eccentric, and plyometric calf muscle exercises 12 to 15 total sets of 10-15 reps increasing intensity over 12 weeks, then at 12 weeks reducing exercise frequency to 2-3x per week. The “exercise group” was instructed to continue normal running and jumping activities keeping pain <5/10, while the “active rest group” was instructed to stop all running and jumping type exercises for 6 weeks.

    Other Activity: Active rest group only did exercise program as per protocol for the first 6 week, while the exercise group was instructed to continue running and jumping activities over the course of treatment so long as pain did not rise above 5/10 on VAS and pain did not rise from week to week.

    Chad’s Comments:  There is a lot to be learned from this study. Both groups had an rapid increase in function in first 6 weeks and more steady improvements thereafter. Both groups improved statistically equal in regard to both pain and function, but absolute gains in the resting group were a little higher with VISA-A score increasing from 57 to 75 at 6 weeks and 91 at 1 year. The exercise group improved from 57 to 70 at 6 weeks and 85 at 1 year. One could ague the rest helped a little but the continued exercise group improved nearly as much in spite of continued exercise and would otherwise be better able to maintain and or further improve fitness/sports performance rather than a decline in health/function from lesser activity. Downside of this study is it did not state how active either group was before or after the 6 week differential period, so it is hard to say how this adapts to various activity levels. In light of the in season elite level volleyball players it does seem improvements can be seen in pain and function even with intense and prolonged additional exercise. Also this study used both concentric, eccentric, and plyometric types of exercises in their program indicating that the combination of contractions types is effective in treating Achilles tendinopathy.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Anatomic factors related to the cause of tennis elbow

    Anatomic factors related to the cause of tennis elbow. Bunata RE, Brown DS, Capelo R. J Bone Joint Surg Am. 2007 Sep;89(9):1955-63.

    Abstract
    BACKGROUND: The pathogenesis of lateral epicondylitis remains unclear. Our purpose was to study the anatomy of the lateral aspect of the elbow under static and dynamic conditions in order to identify bone-to-tendon and tendon-to-tendon contact or rubbing that might cause abrasion of the tissues.
    METHODS: Eighty-five cadaveric elbows were examined to determine details related to the bone structure and musculotendinous origins. We identified the relative positions of the musculotendinous units and the underlying bone when the elbow was in different degrees of flexion. We also recorded the contact between the extensor carpi radialis brevis and the lateral edge of the capitellum as elbow motion occurred, and we sought to identify the areas of the capitellum and extensor carpi radialis brevis where contact occurs.
    RESULTS: The average site of origin of the extensor carpi radialis brevis on the humerus lay slightly medial and superior to the outer edge of the capitellum. As the elbow was extended, the undersurface of the extensor carpi radialis brevis rubbed against the lateral edge of the capitellum while the extensor carpi radialis longus compressed the brevis against the underlying bone.
    CONCLUSIONS: The extensor carpi radialis brevis tendon has a unique anatomic location that makes its undersurface vulnerable to contact and abrasion against the lateral edge of the capitellum during elbow motion.

    Diagnosis: Lateral epicondyle

    Outcome: “As the elbow is extended, the undersurface of the extensor carpi radialis brevis rubbed against the lateral edge of the capitellum while the extensor carpi radialis longus compressed the brevis against the underlying bone.” “Dramatic bowing and stretching of the tendons over the epicondyle and the capitellum occur with the elbow in full extension.” “…we believe this wear leads to tendon abrasion and is the initial step in the cause of tennis elbow.”

    Subjects: 85 cadaver elbows.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Muscle Deficits Usually Persist Long after Total Knee Replacement

    “Muscle deficits persist after unilateral knee replacement and have implications for rehabilitation. Physical Therapy. 2009 Oct;89(10):1072-9.”

    From the study:

    “Participants were 29 women and 19 men who were 55 to 75 years old and had undergone unilateral knee replacement surgery an average of 10 months earlier. The maximal torque and power of the knee extensor and flexor muscles were measured with an isokinetic dynamometer. The knee extensor muscle CSA was measured with computed tomography. The symmetry deficit between the knee that underwent replacement surgery (“operated knee”) and the knee that did not undergo replacement surgery (“nonoperated knee”) was calculated. Maximal walking speed and stair-ascending and stair-descending times were assessed.”

    “The mean deficits in knee extensor and flexor muscle torque and power were between 13% and 27%, and the mean deficit in the extensor muscle CSA was 14%. A larger deficit in knee extension power predicted slower stair-ascending and stair-descending times. This relationship remained unchanged when the power of the nonoperated side and the potential confounding factors were taken into account.”

    “Mizner et al reported that performance in stair-climbing and “stand-up-and-go” tests returned to the preoperative level at 2 months after surgery. Therefore, although functional ability may improve to the preoperative level, which already is severely impaired because of pain and long-term disuse, it rarely reaches the level in age-matched control subjects. For example, Walsh et al and Yoshida et al reported that people with knee replacement had a lower maximal walking speed and negotiated stairs more slowly than control subjects even beyond 1 year after surgery.”

    “In particular, the ability to recover from a stumble is highly dependent on the power and coordination of the leg muscles. In addition, Portegijs et al found that, even in people who were healthy, a knee extension power deficit was associated with falls.”

    Chad’s comments:

    Results and conclusions of this study largely speak for themselves. I think the problem is several fold.

    Expectations: Generally, after a TKA, patients are very pleased with the reduction in pain and their function quickly returns to better than they are used to. However, since they are used to considerable disability they stop treatment well before strength and power levels return to normal. Unfortunately, everyday living does not cause people to catch up to age-matched peers. As the patients continue to age, the weakness leads to lesser activity, accelerating them towards cardiovascular disease, osteoporosis, sarcopenia, frailty, etc.

    Physical Therapy Techniques: Treatment techniques that include passive modalities:  light exercises such as heels slides, straight leg raises, bridging, rubber bands and mini-squats are not as up to the task with regards to strength gains as is progressive resistance exercise with real weights through a full range of motion. Properly applied electric muscle stimulation has been shown to be very helpful. In a number of recent studies, EMS is shown to prevent post-op muscle atrophy in the first place, leading to early and more complete recovery of both strength and muscle mass post-op. If however, treatment time is squandered on more faddish and less proven modalities, which right now seems to include foam rolls and ASTM, one might expect a less than optimal recovery when it comes to regaining lost muscle mass.

    Insurance Policies: More than before, insurance companies like Medicare are cutting reimbursement, and worse, Medicare “replacement policies” are paying minimal flat rates while saddling patients with both high deductibles and copayments. This encourages therapists to cut treatment time per day to maximize profit, while at the same time makes patients unable to afford continued care. I know of one clinic in town that is scheduling patients with just 30 minutes of treatment per day, which I can’t imagine helps outcomes. Plus, if I were a patient I don’t think I would feel very inclined to pay a $40 or $50 copayment for that.

    Like the problems, I think the solution is several fold. Alongside knee range of motion, use simple but objective functional tests like timed single leg balance, timed up and go, walking speed, stair climbing and 6 minute walk tests. These allow patients to make progress and compare themselves to where they should be with regards to function. Emphasize strength training early post-op which is better tolerated than most people (including me) would have thought. Utilize a number of single leg strength exercises performed concurrently with training of the non-surgical side. This lets both the patient and therapist gain a good understanding of where one leg is in relation to the other. Include hip and core strength and endurance exercise. Utilize aggressive stretch methods that emphasize total end range time and intensity, putting the patient in charge of both. This lessens both anxiety and muscle guarding because they know exactly what to expect and know they can stop at any time. Start aggressive electric muscle stimulation to both quadriceps and hamstrings immediately post-op and preferably at home pre-op. Lastly, progress the patient to gym type exercises and teach them to be independent with exercise programming. Encourage them to join their local fitness center and make full use of insurance covered fitness programs, encouraging senior fitness such as SilverSneakers. Home exercise programs are certainly better than nothing, but gym programs give the patients more options to work both muscle strength and cardiovascular endurance harder, through a fuller range of motion, with less impact.

    [contact-form to=’chadmreilly@gmail.com’ subject=’New Blog Comment(s)’][contact-field label=’Name’ type=’name’ required=’1’/][contact-field label=’Email’ type=’email’ required=’1’/][contact-field label=’Website’ type=’url’/][contact-field label=’Comment’ type=’textarea’ required=’1’/][/contact-form]

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Eccentric exercise in treatment of Achilles tendinopathy

    Eccentric exercise in treatment of Achilles tendinopathy. Nørregaard J, Larsen CC, Bieler T, Langberg H. Scand J Med Sci Sports. 2007 Apr;17(2):133-8.

    Abstract
    AIM: Prognosis and treatment of Achilles tendon pain (achillodynia) has been insufficiently studied. The purpose of the present study was to examine the long-term effect of eccentric exercises compared with stretching exercises on patients with achillodynia.
    METHODS: Patients with achillodynia for at least 3 months were randomly allocated to one of two exercise regimens. Exercise was performed daily for a 3-month period. Symptom severity was evaluated by tendon tenderness, ultrasonography, a questionnaire on pain and other symptoms, and a global assessment of improvement. Follow-up was performed at time points 3, 6, 9, 12 weeks and 1 year.
    RESULTS: Of 53 patients with achillodynia 45 patients were randomized to either eccentric exercises or stretching exercises. Symptoms gradually improved during the 1-year follow-up period and were significantly better assessed by pain and symptoms after 3 weeks and all later visits. However, no significant differences could be observed between the two groups. Women and patients with symptoms from the distal part of the tendon had significantly less improvement.
    CONCLUSIONS: Marked improvement in symptoms and findings could be gradually observed in both groups during the 1-year follow-up period. To that extent this is due to effect of both regimens or the spontaneous improvement is unsettled.

    Diagnosis: Achilles tendinitis, both mid portion and insertional.

    Outcome: Reported minimal improvement at 12 weeks in both groups, however at 1 year 21/23 tendons in eccentric group had “very significant improvement” or “completely cured” while only 12/19 were as improved in the stretching group.

    When Assessed: 3, 6, 9, and 12 weeks and 1 year

    Subjects: 45 patients, ~half men and women, average age ~42.

    Protocol: Eccentric Protocol: 1 increasing to 2 & 3 sets of 15 reps of body weight eccentric calf raises with knees straight and with knee bent. 5kg added at a time to backpack pain decreased. Performed twice daily for 12 weeks. Stretching group did 5x 30 seconds with straight knee and bent knee performed twice per day. No other details as to how stretches were performed.

    Other Activity: “They were allowed to continue ongoing pain free sporting activities, but were told not to take up new activities or increase the amount of training.”

    Chad’s Comments:  The authors noted their results were not as good or as fast as Alfredson 1998 and Fahlstom 2003, but used the same training protocol, however they noted their groups activity may be lower, they included insertional tendinitis. They also reported supervision of subjects was not as good and subjects were not encouraged to work through pain as with Alfredson and Fahlstom. They also suspect their subjects less athletic to start. They also noted women had a poorer prognosis then men.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • How Soon is Too Soon to Lift Weights after Total Knee Arthroplasty?

    Progressive strength training (10 RM) commenced immediately after fast-track total knee arthroplasty: is it feasible? Disabil Rehabil. 2012;34(12):1034-40.

    From the study:

    “Fourteen patients with unilateral TKA were included from a fast-track orthopedic arthroplasty unit. They received rehabilitation including progressive strength training of the operated leg (leg press and knee-extension), using relative loads of 10 repetition maximum with three training sessions per week for 2 weeks. Rehabilitation was commenced 1 or 2 days after TKA. At each training session, knee pain, knee joint effusion and training load were recorded. Isometric knee-extension strength and maximal walking speed were measured before the first and last session.”

    “The training load increased progressively (p < 0.0001). Patients experienced only moderate knee pain during the strength training exercises, but knee pain at rest and knee joint effusion (p < 0.0001) were unchanged or decreased over the six training sessions. Isometric knee-extension strength and maximal walking speed increased by 147 and 112%, respectively.”

    “Progressive strength training initiated immediately after TKA seems feasible, and increases knee-extension strength and functional performance without increasing knee joint effusion or knee pain.”

    Chad’s comments:
    This study will probably change my practice, at least a little. With my background in weightlifting I have always considered myself more aggressive than average with my rehabilitation programs, but even I always started my patients off with the standard post-op exercises: heel slides, quad sets, straight leg raises and ankle pumps, along with PRE hip strengthening exercises that don’t directly affect the knee. I always waited until their follow-up appointment to add in leg presses and resistive leg extensions, etc, which if this study proves correct is still being overly cautious.

    [contact-form to=’chadmreilly@gmail.com’ subject=’New Blog Comment(s)’][contact-field label=’Name’ type=’name’ required=’1’/][contact-field label=’Email’ type=’email’ required=’1’/][contact-field label=’Website’ type=’url’/][contact-field label=’Comment’ type=’textarea’ required=’1’/][/contact-form]

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy

    Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achilles: a randomized controlled trial. Rompe JD, Nafe B, Furia JP, Maffulli N. Am J Sports Med. 2007 Mar;35(3):374-83. Epub 2007 Jan 23.

    Abstract
    BACKGROUND: Few randomized controlled trials compare different methods of management in chronic tendinopathy of the main body of tendo Achillis.
    PURPOSE: To compare the effectiveness of 3 management strategies-group 1, eccentric loading; group 2, repetitive low-energy shock-wave therapy (SWT); and group 3, wait and see-in patients with chronic tendinopathy of the main body of tendo Achillis.
    STUDY DESIGN: Randomized controlled trial; Level of evidence, 1.
    METHODS: Seventy-five patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on intention-to-treat basis.
    RESULTS: At 4 months from baseline, the Victorian Institute of Sport Assessment (VISA)-A score increased in all groups, from 51 to 76 points in group 1 (eccentric loading), from 50 to 70 points in group 2 (repetitive low-energy SWT), and from 48 to 55 points in group 3 (wait and see). Pain rating decreased in all groups, from 7 to 4 points in group 1, from 7 to 4 points in group 2, and from 8 to 6 points in group 3. Fifteen of 25 patients in group 1 (60%), 13 of 25 patients in group 2 (52%), and 6 of 25 patients in Group 3 (24%) reported a Likert scale of 1 or 2 points (“completely recovered” or “much improved”). For all outcome measures, groups 1 and 2 did not differ significantly. For all outcome measures, groups 1 and 2 showed significantly better results than group 3.
    CONCLUSION: At 4-month follow-up, eccentric loading and low-energy SWT showed comparable results. The wait-and-see strategy was ineffective for the management of chronic recalcitrant tendinopathy of the main body of the Achilles tendon.

    Diagnosis: Mid portion Achilles tendinitis (2-6 cm above insertion)

    Outcome: VISA-A etc. Eccentric group improved from 50.6 to 75.6, shock-wave treatment from 50.3 to 70.4 and wait and see from 48.2 to 55. Eccentric and shock wave treatment were not significantly different but both were significantly better than the wait and see group.

    When Assessed: 16 week after start of treatment, intervention was for only 12 weeks.

    Subjects: 75 patients, 25 per group, average age 48 in eccentric group, 51 in SWT group, and 46 in wait and see. Most ~2/3 were not athletic.

    Protocol: Subjects worked up 3 sets of 15 reps with knee bent and with knee straight, twice per day, 7 days a week for 12 weeks. Allowed to work through mild to moderate pain, starting with body weight (1 set of 10 reps) and adding 5 kg at a time if 3rd set painless. Speed was not varied.

    Other Activity: “Patients were asked to avoid pain-provoking activities throughout the 12-week treatment period. Walking and bicycling was allowed if it could be performed with only mild discomfort or pain. Light jogging on flat ground and at a slow pace was allowed after 4 to 6 weeks, but only if it could be undertaken without pain. Thereafter, activities could be gradually increased if no severe tendon pain occurred.”

    Chad’s Comments:  Interesting in that it compares eccentric exercise to wait and see and found significantly better improvements, which is good as previous research looking at traditional physical therapy exercises were not noticeably better than wait and see. Still the results were not as good as the Scandinavian studies. This study had the fewer number of athletes stop running for first 6 weeks but Scandinavians had done that too in some studies, however the proportion who were runners was less in this study.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Achilles Tendinopathy, Symptom Recovery Does Not Ensure Functional Recovery

    Full symptomatic recovery does not ensure full recovery of muscle-tendon function in patients with Achilles tendinopathy. Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Br J Sports Med. 2007 Apr;41(4):276-80; discussion 280. Epub 2007 Jan 29.

    Abstract
    OBJECTIVE: To assess the relationship between muscle-tendon function and symptoms in patients with Achilles tendinopathy using a validated test battery.
    DESIGN: A prospective non-randomised trial.
    SETTING: Orthopaedic Department, Sahlgrenska University Hospital, Sweden.
    PATIENTS: 37 patients with a clinical diagnosis of Achilles tendinopathy in the midportion of the tendon, with symptoms for >2 months, were evaluated at the initiation of the study and after 1 year.
    INTERVENTION: The patients were treated using a rehabilitation programme, under the supervision of a physical therapist, for 6 months.
    MAIN OUTCOME MEASUREMENTS: The patients were evaluated using the Swedish version of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A-S) for symptoms, and a test battery for evaluation of the lower leg muscle-tendon function.
    RESULTS: There were significant improvements in the VISA-A-S score (p<0.00, n = 37) and the test battery (p<0.02, n = 19) at the 1-year follow-up. The VISA-A-S questionnaire had an effect size of 2.1 and the test battery had an effect size of 0.73. A low correlation (r = 0.178, p>0.05) was found between the VISA-A-S score and the test battery. A high correlation (r = 0.611, p<0.05) was found between the drop counter movement jump and the VISA-A-S score. All other tests in the test battery had low correlations (r = -0.305 to 0.155, p>0.05) with the VISA-A-S score. Only 25% (4/16) of the patients who had full symptomatic recovery had achieved full recovery of muscle-tendon function as measured by the test battery.
    CONCLUSION: Full symptomatic recovery in patients with Achilles tendinopathy does not ensure full recovery of muscle-tendon function. The VISA-A-S questionnaire and the test battery are sensitive to clinically relevant changes with treatment and can be recommended for use in both the clinic and research.

    Diagnosis: Achilles Tendinitis

    Outcome: VISA-A and various functional tests. At one year follow up 67% were classified as fully recovered, average VISA-A increased from 56 to 89. Of those fully recovered (VISA-A at or above 90) only 25% had functional tests 90% or greater than their contralateral side.

    When Assessed: 12 months

    Subjects: 37 people, 17 women & 20 men, 30-58 years, ave age 46

    Protocol: Progressive battery of exercises including both eccentric and concentric calf raises slow and fast, progressed over 6 months.

    Other Activity: unclear, but these researches in other studies advocated continuing with recreational activities so long as pain (VAS) does not rise over 5/10. “In a recent study, we found that continued physical activity with use of a pain-monitorying model des not seem to hinder recovery (unpublished data).

    Chad’s Comments:  Study used both concentric and eccentric exercises successfully, but found functional status often continues to lag even if patients are asymptomatic.  As such performance tests should be done to ensure full functional status has been restored.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • EMS Decreases Back Pain, Increases Core Strength, Endurance

    “Effects of electrical stimulation program on trunk muscle strength, functional capacity, quality of life, and depression in the patients with low back pain: a randomized controlled trial. Rheumatol Int. 2009 Jun;29(8):947-54.”

    Right now this is my favorite electric muscle stimulation (EMS) study with regards to low back pain as I read it soon after I came up with my own protocol, which was fairly similar.

    Abstract
    The aim of this clinical trial was to evaluate the effects of electrical stimulation (ES) program on trunk muscle strength, functional performance, quality of life (QOL) in the patients with chronic low back pain (CLBP). A total of 41 patients with definite CLBP were included in this study. These patients were randomized into two groups. Group 1 (n = 21) was given an ES program and exercises. Group 2 (n = 20) was accepted as the control group and given only exercises. Both the programs were performed 3 days a week, for 8 weeks in the out-patient department. The patients were evaluated according to pain, disability, functional performance, endurance, quality of life, depression. The muscle strengths were measured with a hand-held dynamometer. There were significant improvements for all the parameters in two groups after the treatment. Except depression and social function, the improvements for all the parameters were better in the ES group than in the control group. We observed that ES program was very effective in improving QOL, functional performance and isometric strength. In conclusion, we can say that ES therapy provides comfortable life functions by improving muscle strength, functional performance and QOL. Durmus et al. Low Back Pain set up.

    They did 4 electrodes on the rectus abdominus region and partial on the obliques for 15 minutes using 50 Hz, 50 ms phase time, and 70-120 mA until “apparent muscle contraction was established”. They used a 10 second on 10 second off pattern, then flipped the patient over and did the same on the lumbar erector spinae muscles. This group of patients was compared to a control group 3 times a week for 8 weeks. The EMS group did exercises as well as electric muscle stimulation, while the       control group did only exercise. Researchers conclusions were as follows:

    “Both the programs were performed 3 days a week, for 8 weeks in the out-patient department. The patients were evaluated according to pain, disability, functional performance, endurance, quality of life, depression. The muscle strengths were measured with a hand-held dynamometer. There were significant improvements for all the parameters in two groups after the treatment. Except depression and social function, the improvements for all the parameters were better in the ES group than in the control group. We observed that ES program was very effective in improving QOL, functional performance and isometric strength. In conclusion, we can say that ES therapy provides comfortable life functions by improving muscle strength, functional performance and QOL.”

     Exercise & EMS startExercise & EMS at 8 weeksExercise only startExercise only at 8 weeks
    Pain VAS (out of 10)817.74
    Oswestry Disability Index(sec)36.666.5737.2219.22
    Extensor Endurance Test(sec)3515059.983.5
    Abdominal Endurance Test(sec)98236104.5144.88
    50 meter walking time(sec)40.7123.4239.2232.16
    Pain Disability Index194229.5
    Back extensor strength(kg)716711
    Back flexor strength(kg)6166.510.5

    My comments:

    As you can see from the above table, adding EMS to the core muscles of those with low back pain led to reductions in pain and the increases in strength, endurance, and function were substantial.  The electrode placement I do is nearly the same. I put 4 electrodes on the rectus abdominus (usually in a diagonal pattern), 2 electrodes more lateral than they do to better target obliques and transversus abdominis, and just 2 on the lumbar region, which feels plenty sufficient at high intensity (as much as is tolerable rather than just what is comfortable). I also use a 4 channel machine so I can stim all the muscles at once rather than having to do the front first and later the back. I do a 10 second on and 50 second off period, 120 Hz and 300 uS pulse width for 12 minutes. [Update to add on a Globus machine I set the pulse width to 450 uS] My combination of parameters closely approximates the “Russian Stim” duty cycle used on olympic athletes and recommended by Charlie Francis as what he used with his sprinters. While perhaps coming across a white noise to patients with low back pain, a therapist understanding the specific EMS parameters is critical to getting an adequate treatment response. EMS performed this way is in fact exercising the muscles very intensely, and the parameters need to be adjusted as you would adjust exercise sets, reps and resistance level when weight training.

    My patients report this immediately decreases pain better than classic TENS patterns I used prior and does more to increase abdominal strength than any conventional exercise I have ever tried, all while the spine is kept in a neutral posture with no external load. I think combining the treatment with exercise for extremity strength and spine awareness is certainly ideal, but I find the EMS to significantly boost both pain reduction and strengthening. The best part is that high quality machines are very affordable, so the treatment can be done at home while watching TV. As such, therapy time in the clinic can be maximized with whole body strength, endurance and spine awareness/motor control exercises.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.