SpineFITyoga.com

Author: chad reilly

  • Hip Pain, Trochanteric “Bursitis”/Tendinopathy, Exercise Best, Cortisone Worst

    This study was more interesting in its entirety than its abstract. I thought the home exercises given were beyond banal, but they still turned out best in the long term. Cortisone injected into tendons was yet again shown to be fool’s gold, and shock wave therapy? I don’t know but I’m still skeptical. More comments below…

    Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. Rompe JD, Segal NA, Cacchio A, Furia JP, Morral A, Maffulli N. Am J Sports Medicine. 2009 Oct;37(10):1981-90

    Abstract

    BACKGROUND:
    There are no controlled studies testing the efficacy of various nonoperative strategies for treatment of greater trochanter pain syndrome. Hypothesis The null hypothesis was that local corticosteroid injection, home training, and repetitive low-energy shock wave therapy produce equivalent outcomes 4 months from baseline.

    STUDY DESIGN:
    Randomized controlled clinical trial; Level of evidence, 2.

    METHODS:
    Two hundred twenty-nine patients with refractory unilateral greater trochanter pain syndrome were assigned sequentially to a home training program, a single local corticosteroid injection (25 mg prednisolone), or a repetitive low-energy radial shock wave treatment. Subjects underwent outcome assessments at baseline and at 1, 4, and 15 months. Primary outcome measures were degree of recovery, measured on a 6-point Likert scale (subjects with rating completely recovered or much improved were rated as treatment success), and severity of pain over the past week (0-10 points) at 4-month follow-up.

    RESULTS:
    One month from baseline, results after corticosteroid injection (success rate, 75%; pain rating, 2.2 points) were significantly better than those after home training (7%; 5.9 points) or shock wave therapy (13%; 5.6 points). Regarding treatment success at 4 months, radial shock wave therapy led to significantly better results (68%; 3.1 points) than did home training (41%; 5.2 points) and corticosteroid injection (51%; 4.5 points). The null hypothesis was rejected. Fifteen months from baseline, radial shock wave therapy (74%; 2.4 points) and home training (80%; 2.7 points) were significantly more successful than was corticosteroid injection (48%; 5.3 points).

    CONCLUSION:
    The role of corticosteroid injection for greater trochanter pain syndrome needs to be reconsidered. Subjects should be properly informed about the advantages and disadvantages of the treatment options, including the economic burden. The significant short-term superiority of a single corticosteroid injection over home training and shock wave therapy declined after 1 month. Both corticosteroid injection and home training were significantly less successful than was shock wave therapy at 4-month follow-up. Corticosteroid injection was significantly less successful than was home training or shock wave therapy at 15-month follow-up.

    My comments:

    I found it interesting that the authors recognized that lateral hip pain, frequently diagnosed as trochanteric bursitis, rarely finds bursitis (inflamed bursa) when MRI is performed. They correctly noted that what is usually found is gluteus medius and minimus tendinopathy or tearing. The gluteus medius and minimus are hip abductors, which are the muscle you work when you lay on your side and lift your leg out Jane Fonda style. Strangely, however, in their home exercise program they didn’t do any hip abduction exercises. Rather, they did two stretches (piriformis stretch and IT band) and three quasi strength/endurance exercises, all without added resistance (straight leg raise, wall squat with ball between knees, and prone hip extension).

    When I’m trying to strengthen a muscle, like almost every great athlete in the world, I prefer to lift weights. However, I understand that home exercises are used because not everyone has gym access or weights at home. The side-lying hip out (aka hip abduction exercise if you speak latin) is actually a really good exercise that can be easily performed at home. The problem with this study is that they didn’t do the side-lying hip out, or any exercise to strengthen the weakened gluteus medius/minimus that actually has the tendinopathy. So to me, the home program makes as much sense as trying to treat Achilles tendinopathy without doing a calf raise or tennis/golfer’s elbow without doing wrist or reverse wrist curls. In other words, it makes almost no sense at all. Nevertheless, the exercise group had the best long term improvement, likely because even though they didn’t target the affected muscles, and even though I think the wall squat is the worst type of squat, squats in general are great. A better program would have used free squats, progressed with weights, RDLS, hip-out AND hip-in machine, and FOR SURE side-lying hip-outs! All of which is what my upcoming paper is about.

    Feeling an average pain of 2.7/10 after a year isn’t ideal in my experience. With real strengthening exercises (lifting weights) combined with direct strengthening of the hip abductors (side hip outs, hip out machine, etc.) I believe patients can expect their pain to be eliminated. An aside is that in 100% of patients that I treat with greater trochanteric pain syndrome, I find their hip adductor muscles (the muscles that pull the leg back in) are also weak, making use of the hip-in machine (aka hip adduction if you speak latin) important. In general, for all tendinopathies I often find gross weakness in the general area, such that you really want a generalized strength program performed 2-3 days per week, with focused strengthening to the affected muscle performed daily. In this case I would give the side hip outs as a home exercise program. The author’s told the subjects not to expect short term improvements in pain with the exercises, but I find with targeted and more intense exercises that the pain is reduced immediately. EMS following exercise helps speed both pain reduction and strength gains along.

    As has been seen with other types of tendinopathy cortisone injections start out looking great, but in the long run people who have them are worse off.

    Radial shock wave therapy? I have read a few papers that say it works, but nothing yet that convinces me it works better than theatrical placebo. I’m open to hearing more about it, but the other problem is that the machines are very expensive (if I recall correctly about $150,000) and insurance won’t reimburse for treatment. I have spoken with a podiatrist that had one in his office to treat plantar fasciitis (and I have a lot to say about plantar fasciitis) for which he said he thought it worked, but said he never used it because insurance wouldn’t cover it and it was too expensive to pay out of pocket, so what good is that?

    One final point of interest from this paper was that the resistance test used to diagnose GTPS was supine resisted external rotation rather than resisted abduction. I might start adding that to my evaluations when I expect GTPS as I find hip abduction is very often weak, but not that painful. I’m curious if hip external rotation more reliably reproduces symptoms of pain. If so, it would make me think my hip out machine more ideal, as I have often thought that hip abduction performed in sitting really hits the hip external rotators.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Intermittent Fasting Improves Heart Attack Survival, A LOT!

    Anyone familiar with my blog, or me, will know that I have a pretty fair obsession with intermittent fasting for what are becoming more reasons than I can easily count. So what is particularly interesting about this paper, contrary to other papers where they have animals or people start fasting to prevent problems, this one found it helped after the fact. Intermittent fasting (alternate day fasting) was started 2 weeks AFTER an experimental heart attack was induced and was continued for 6 weeks. The beneficial effects were what I would call HUGE. Reference & abstract below, followed by my comments:

    Chronic intermittent fasting improves the survival following large myocardial ischemia by activation of BDNF/VEGF/PI3K signaling pathway. Katare RG, Kakinuma Y, Arikawa M, Yamasaki F, Sato T. J Mol Cell Cardiol. 2009 Mar;46(3):405-12.

    Abstract
    Chronic heart failure (CHF) is the major cause of death in the developed countries. Calorie restriction is known to improve the recovery in these patients; however, the exact mechanism behind this protective effect is unknown. Here we demonstrate the activation of cell survival PI3kinase/Akt and VEGF pathway as the mechanism behind the protection induced by intermittent fasting in a rat model of established chronic myocardial ischemia (MI). Chronic MI was induced in rats by occlusion of the left coronary artery. Two weeks later, the rats were randomly assigned to a normal feeding group (MI-NF) and an alternate-day feeding group (MI-IF). After 6 weeks of observation, we evaluated the effect of intermittent fasting on cellular and ventricular remodeling and long-term survival after CHF. Compared with the normally fed group, intermittent fasting markedly improved the survival of rats with CHF (88.5% versus 23% survival, P<0.05). The heart weight body weight ratio was significantly less in the MI-IF group compared to the MI-NF group (3.4+/-0.17 versus 3.9+/-0.18, P<0.05). Isolated heart perfusion studies exhibited well preserved cardiac functions in the MI-IF group compared to the MI-NF group (P<0.05). Molecular studies revealed the upregulation of angiogenic factors such asHIF-1-alpha (3010+/-350% versus 650+/-151%), BDNF (523+/-32% versus 110+/-12%), and VEGF (450+/-21% versus 170+/-30%) in the fasted hearts. Immunohistochemical studies confirmed increased capillary density (P<0.001) in the border area of the ischemic myocardium and synthesis VEGF by cardiomyocytes. Moreover fasting also upregulated the expression of other anti-apoptotic factors such as Akt and Bcl-2 and reduced the TUNEL positive apoptotic nuclei in the border zone. Chronic intermittent fasting markedly improves the long-term survival after CHF by activation through its pro-angiogenic, anti-apoptotic and anti-remodeling effects.

    My comments:

    This was a rat study. Apparently people won’t submit to having one of their coronary arteries pinched off to see what happens with various eating plans. A number of things are interesting about this paper, not the least of which was 88.5% of the fasting rats survived compared to only 23% of the control group. That’s not exactly a subtle difference. Also I have read a number of papers and linked a Ted Talk by Mark Mattson, head of the National Institute on Aging, in which he talks about the positive effects of brain derived neurotrophic factor (BDNF) on the brain from both exercise and fasting. This paper suggests that the BDNF acts on the heart by increasing vascular endothelial growth factor (VEGF) thus stimulating the growth of new blood vessels in the heart (aka angiogenesis) improving circulation improves. They also noted lessened scar tissue formation and cardiac tissue hypertrophy, the combination of all factors greatly increased survivability. There was more to it than that, with the whole paper being a fascinating read.

    I’m more a fan of the “time restricted feeding” variety of intermittent fasting, as I think alternate day fasting sounds particularly arduous. In spite of the health benefits, papers I have read describing people following alternate day fasting reported they never really got used to it, and continued to complain of hunger. I think for most people alternate day fasting is not a workable long term solution. However, I’m almost 9 months into what is currently a 20/4 (20 hour daily fast and 4 hour eating window) and it’s a piece of cake (but only after 5 pm). Fortunately, time restricted feeding with a 16/8 seems showing similar health improvements as alternate day diets. Personally I hadn’t heard about the 16/8 window until after I had read the Warrior Diet and Fast-5 (which is FREE) books. At that point, going back to 16/8 seemed like a reversal and not that different from what I was already doing since college by skipping breakfast. Once switching to the Fast-5 eating plan I reduced my total cholesterol 41 points in 43 days.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Dry Needling Collapses Lung, on Video

    I had a physical therapist stop by my office last week and try and sell me on dry needling. I said heard all about dry needling and that I thought that like the force, it can have a strong influence on the weak minded. I said I thought dry needling sounded a lot like acupuncture and said I agreed with Colquhoun and Novella’s position that acupuncture is theatrical placebo.

    She said dry needling was better because it had Western rather than Eastern justifications. I said the Western justifications I had heard thus far were different, but to me, no more convincing. She said lots of physical therapists do it, and I said critical thinking isn’t most therapists strong suit. She said she had a lot of great testimonials, I said so do I and I don’t have to stab my patients.  That was the gist of the conversation, but before she left I printed off a copy of Colquhoun and Novella’s paper to take with her.

    So anyway that got me thinking I ought to do some more investigating of this whole dry needling thing to see if I’m missing out on anything, and this was the first newer paper I found, which was fascinating and almost comedic with full text AND VIDEO available.

    Pneumothorax complication of deep dry needling demonstration [FREE FULL TEXT]

    The paper was considerably more juicy than I anticipated. I expected it to be a complication of some inexperienced dry needling practitioner performing a risky technique, or a patient rolling over their needle. However, what it was was one doctor performing a demonstration on another doctor, while teaching ‘safe’ and ‘correct’ technique. Right after the instructor “emphasized the danger of pneumothorax” and explained, at length, how to perform the movement safely to avoid such he then pushed the needle 4 centimeters into the man’s chest cavity. As promised [update this promise expired; link to video no longer available, sorry]

    All’s well that ends well, the victim later complained of chest pain and had difficulty breathing and a chest x-ray confirmed the pneumothorax with his left lung collapsed 20%. He was treated conservatively, after 2 weeks breathlessness lessened, and at 6-8 weeks he was back to normal. That’s more than you can say for another patient for which another dry needling mishap resulted in a epidural hematoma and emergency spine surgery. The authors later went on to emphasis safety techniques when performing dry needling over the thorax. Strangely abstinence of dry needling, particularly over the rib cage, was not one of their ideas. I would imagine Traditional Chinese Medicine practitioners might say acupuncture is better but they have similar horror stories, almost as if dry needling and acupuncture were in effect the same thing.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Neutral Spine Protects Against Axial Compression

    Lumbar spine endplate fractures: Biomechanical evaluation and clinical considerations through experimental induction of injury. Curry WH, Pintar FA, Doan NB, Nguyen HS, Eckardt G, Baisden JL, Maiman DJ Paskoff GR, Shender BS, Stemper BD, J Orthop Res. 2015 Nov 26.

    Abstract
    Lumbar endplate fractures were investigated in different experimental scenarios, however the biomechanical effect of segmental alignment was not outlined. The objectives of this study were to quantify effects of spinal orientation on lumbar spine injuries during single-cycle compressive loads and understand lumbar spine endplate injury tolerance. Twenty lumbar motion segments were compressed to failure. Two methods were used in the preparation of the lumbar motion segments. Group 1 (n = 7) preparation maintained pre-test sagittal lordosis, whereas Group 2 (n = 13) specimens had a free-rotational end condition for the cranial vertebra, allowing sagittal rotation of the cranial vertebra to create parallel endplates. Five Group 1 specimens experienced posterior vertebral body fracture prior to endplate fracture, whereas two sustained endplate fracture only. Group 2 specimens sustained isolated endplate fractures. Group 2 fractures occurred at approximately 41% of the axial force required for Group 1 fracture (p < 0.05). Imaging and specimen dissection indicate endplate injury consistently took place within the confines of the endplate boundaries, away from the vertebral periphery. These findings indicate that spinal alignment during compressive loading influences the resulting injury pattern. This investigation identified the specific mechanical conditions under which an endplate breach will take place. Development of endplate injuries has significant clinical implication as previous research identified internal disc disruption (IDD) and degenerative disc disease (DDD) as long-term consequences of the axial load-shift that occurs following a breach of the endplate.

    My comments:

    This a great paper looking at one of the hypothesised causes of low back pain and DDD (Degenerative Disc Disease). The discussed cause is endplate fractures, the interface between the disc and the vertebral body (the bone) where the disc does not herniate posteriorly, but rather vertically, with ruptures through the vertebral endplate, either up or down into the bone marrow above or below the disc, forming what is called a Schmorl’s node in the process. The disc then becomes shorter, hence degenerated, the first D in DDD.

    The gist of this paper is that discs can be herniated vertically entirely by compression. They note that this generally isn’t thought to be due to lifting technique, but more so trauma (like falls or accidents.) To test this, they took human lumbar cadaver spine segments and applied increasing axial force to lumbar discs until they broke. They did one group of discs aligned neutral (preserving the normal lordotic arch, which is in fact some extension) thus preserving the normal wedge shape of the lumbar disc. The other group did so with the discs fixed in flexion (representing a rounded, slouched, non-neutral posture) in which the same axial (compressive) force was then applied. The interesting finding was that the neutral spine position was largely protective such that only 2 of the 7 spine segments had endplate failures, while 5 out of the 7 vertebral bodies themselves failed first. In the flexed spine group, all the endplates failed first and failure was at 3703 Newtons, which was less than half of the force absorbed by the neutral spine vertebral segments, which didn’t fail until force reached 8442 Newtons. That’s a 128% increase in compression strength just by keeping the spine neutral.

    It is pretty clear per a number of other studies that posterior disc herniations are caused by repeated spine flexion, which is accelerated with lumbar twisting, and worsened when alternating spine flexion with extension stretches. As such, maintaining neutral spine during the bulk of daily activities and exercise appears ultimately protective. What this paper adds is that the same neutral spine position that protective against posterior disc herniations also lessens risk of endplate fractures and vertical disc herniations. That’s what one might call a pretty cool coincidence.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Retired Weightlifters, Wrestlers, DDD, and Back Pain

    Low back pain among retired wrestlers and heavyweight lifters. Granhed H, Morelli B. Am J Sports Med. 1988 Sep-Oct;16(5):530-3. [FREE FULL TEXT]

    Abstract
    The lifetime incidence and prevalence of low back pain among 32 retired wrestlers (ages 39 to 62 years) and 13 retired heavyweight lifters (ages 40 to 61 years) were evaluated and compared to the corresponding results in a cross-sectional study of 716 men (ages 40 to 47 years). The radiologic findings and the findings upon physical examination in the athletes were compared to the findings in another study of normal, active, similarly aged men who were sampled at random. The lifetime incidence and prevalence of low back pain was higher among the wrestlers (59%) compared with both the lifters (23%) and the control group (31%). The tolerance for backache seemed to be higher among the athletes than the controls. A higher frequency of old fractures was found among the wrestlers. The athletes with fractures had a higher frequency of low back pain. A significant decrease in disk height was found among the lifters.

    My comments:
     
    This blog is a partial answer to the question I got about axial loading of the spine from weight lifting (particularly squats and deadlifts) and if there was any evidence it would cause/accelerate any degenerative disc disease (DDD).
     
    While answering the question (which you can find on my Dec 12-15 entry of this blog), I recalled the above study, which looked at retired competitive weightlifters and wrestlers 20 years after they stopped competing. Per their survey, wrestlers had increased incidence of low back pain in comparison to age matched control subjects, while weightlifters had a lesser incidence (but not significantly) of pain. It looks like wrestlers get wrenched in such a way that leaves them worse off, while the weightlifters (which isn’t clearly stated but I’m assuming are Olympic weightlifters) aren’t. The good thing about Olympic weightlifting is that almost all the lifts are done with the spine neutral.  Though given the time period, these guys probably did the Olympic press, which used to be a competitive lift but was eliminated from competition in 1972.  Depending on the technique employed, the Olympic press sometimes put the lifter in the extremes of spine extension with considerable weights.  Still, the weightlifters didn’t have an increased incidence of back pain.
     
    The weightlifters did in fact have decreased disc height (at least 50%) in at least one level in 62% of their lumbar spines, while the same was found in 32% of the wrestlers, and the same for control subjects. So  there is evidence increased DDD in retired weightlifters, but it does not seem to be associated with any increase in pain or disability.  Also it is impossible to say if the DDD is because axial loading, because there was a lot of spine extension with the Olympic press. Though the Olympic lifts generally don’t have any spine flexion, (which is inordinately risky and causal for herniated discs and subsequent DDD), a lot of abdominal training that weightlifters often did was. Even so, functionally and pain wise, retired lifters’ low backs seem to do pretty well. Research has also shown squats which do cause axial compression and a neutral spine is particularly good for increasing bone mineral density for women with osteoporosis, and periodized weight training is beneficial for those with chronic low back pain. There is also evidence that free weight programs, which generally include squats and deadlifts, result in a lesser incidence of low back pain than those consisting of machine based training and stretching. In my practice, the vast majority of the physical therapy patients I see referred for low back pain progress to doing both squats and Romanian deadlifts (RDLs) and they do great. However, I am very strict to limit range of motion, insisting the spine stays neutral throughout, and having my patients stop the exercise immediately if there is any increase in pain, even if the spine is neutral. I also keep reps relatively high (15s) in my patients with pre-existing back pain.
     
    Unfortunately, wrestlers didn’t hold up as well and, as such, I would expect them to do better increasing core strength and avoiding extreme spine range of motion, which is probably not the easiest task in competition.
     
    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • High Resistance / Weights Needed for Tendon Adaptation

    Adaptational responses of the human Achilles tendon by modulation of the applied cyclic strain magnitude. Arampatzis A1, Karamanidis K, Albracht K. J Exp Biol. 2007 Aug;210(Pt 15):2743-53. [FREE FULL TEXT]

    Abstract
    Tendons are able to remodel their mechanical and morphological properties in response to mechanical loading. However, there is little information about the effects of controlled modulation in cyclic strain magnitude applied to the tendon on the adaptation of tendon’s properties in vivo. The present study investigated whether the magnitude of the mechanical load induced as cyclic strain applied to the Achilles tendon may have a threshold in order to trigger adaptation effects on tendon mechanical and morphological properties. Twenty-one adults (experimental group, N=11; control group, N=10) participated in the study. The participants of the experimental group exercised one leg at low-magnitude tendon strain (2.85+/-0.99%) and the other leg at high-magnitude tendon strain (4.55+/-1.38%) of similar frequency and volume. After 14 weeks of exercise intervention we found a decrease in strain at a given tendon force, an increase in tendon-aponeurosis stiffness and tendon elastic modulus and a region-specific hypertrophy of the Achilles tendon only in the leg exercised at high strain magnitude. These findings provide evidence of the existence of a threshold or set-point at the applied strain magnitude at which the transduction of the mechanical stimulus may influence the tensional homeostasis of the tendons. The results further show that the mechanical load exerted on the Achilles tendon during the low-strain-magnitude exercise is not a sufficient stimulus for triggering further adaptation effects on the Achilles tendon than the stimulus provided by the mechanical load applied during daily activities.

    My comments

    I like this article. The researchers had subjects train isometrically, four times per week, doing 5 sets of 3 second holds at either 55% of max voluntary contraction (MVC) strength on one leg, while the other leg (on the same subject) did the same with 90% MVC. They set it up so that volume was the same, however they calculated volume as an “integral of the plantar flexion movement over time” which had the high intensity (90% side) do only 4 reps per side, while the low intensity (55%) side did 7 reps. I would have thought to keep volume the same by having them keep the reps the same, but they did so by keeping the area under the curve (load/time) the same, which sounds fair enough, and even with the repetitions and time under tension reduced in the high intensity group, only the high intensity group showed positive adaptations of tendon stiffness. Both sides got stronger, but the high intensity group more so. A cross-section area of the tendons, only in the high intensity side, with this increase being significant only in the central part of the tendon (near 20%), less than significantly in the proximal tendon (~10%), and not much at all in the distal tendon (~5%). The increase in tendon stiffness in the high intensity group (26.5%), however, was greater than the overall increase in cross section area. As such, the researchers thought that with the higher intensity contractions, there was fair amount or remodeling and reorganization of the tendon-collagen matrix leading to improved tensile properties without a lot of tendon hypertrophy, which I think is particularly interesting in people with tendinopathy who often have thickened tendons, which are often shown to reduce (become more normal) with higher intensity resistance exercise. So likely the tendons thicken up a bit with adequate training, but get thicker still when tendinopathy results in irregular collagen formation, at which point normalization of the tendon structure results in a lesser tendon diameter.

    Also in the tendinopathy research, there have been a fair number of papers coming out which are starting to hone in on the ideal combination of exercise intensity (weight or percent tension) frequency (days per week) and volume being (sets, reps, or time under tension), and exercise type (eccentric, concentric, or isometric). I think it’s much analogous to weight training to increase muscle strength where there are a great deal of variables in sets, reps, weights which all work, some better than others, but no know ideal for everyone in every situation. Also much like strength training for muscle gains, if the resistance level isn’t sufficiently higher than what the tendon receives during daily activities, it isn’t going to get any stronger. For tendinitis/tendinopathy, my go-to program is still 3-5 sets (usually just 3) of 15 reps of increasing intensity (working to as heavy as possible), fairly regular repetition speed, and with normal concentric/eccentric type contractions much as illustrated in my shooter’s elbow blog. Rather than 4 days per week in this study I prefer daily exercise, which is noticeably more effective in my office but also backed up by research. Still this paper shows 4 days per week is still pretty good.

    Still this paper was cool in that it demonstrated 90% MVC for a total of 60 seconds contraction time (5 sets, 3 seconds, 4 reps) was able to positively increase muscle and tendon properties better than the 55% MVC for 105 seconds (5 sets, 3 seconds, 7 reps). It also explains why one of my more recent tennis elbow patients failed to improve after several months of treatment at some other hand physical therapy clinic, where he said the heaviest weight he handled on wrist curls and reverse wrist curls was 2 lb (which was probably only 15% MVC, so they weren’t even in the ballpark). He said they had him do only 1 lb for several weeks prior. Such low intensities are sure not to hurt anything, but sure not to help either as this study attests. So if you are a certified hand therapist, I suggest you put down the splint material for a day and read up on strength and conditioning, your patients will thank you. Anyway, day 1, I think I started him with 5, 8, and 10 lb (he felt immediately better) and worked up from there to 20 something and within 3 weeks he was 90% better. So yeah, my experience agrees with the study findings, light weights for tendons generally equals no improvement. On the contrary heavy weights (within reason of course) helps a lot. It’s science.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Massive Herniated Discs and Low Back Pain, the Good News

    Conservatively treated massive prolapsed discs: a 7-year follow-up. Benson RT, Tavares SP, Robertson SC, Sharp R, Marshall RW. Ann R Coll Surg Engl. 2010 Mar;92(2):147-53.

    Abstract
    INTRODUCTION:
    The natural history of a lumbar hernia of the nucleus pulposus (HNP) is not fully known and clear indications for operative intervention cannot be established from the literature. Several studies have shown that the largest discs appear to have the greatest tendency to resolve. The aim of this study was to investigate whether massive prolapsed discs can be safely managed conservatively once clinical improvement has occurred.

    PATIENTS AND METHODS:
    Thirty-seven patients were studied by clinical assessments and serial magnetic resonance imaging (MRI) over 2 years. Patients had severe sciatica at first, but began to show clinical improvement despite the large disc herniations. Clinical assessment included the Lasegue test and neurological appraisal. The Oswestry Disability Index was used to measure function and changes in function. Serial MRI studies allowed measurement of volume changes of the herniated disc material over a period of time.

    RESULTS:
    Initial follow-up at an average of 23.2 months revealed that 83% had a complete and sustained recovery at the initial follow-up. Only four patients required a discectomy. The average Oswestry disability index improved from 58% to 15%. Volumetric analysis of serial MRI scans found an average reduction of 64% in disc size. There was a poor correlation between clinical improvement and the extent of disc resolution.

    CONCLUSIONS:
    A massive disc herniation can pursue a favourable clinical course. If early progress is shown, the long-term prognosis is very good and even massive disc herniations can be treated conservatively.

    My comments:

    The entire article above is worth reading, and fortunately a free full text is available. I have a read a lot of case reports and observations of both cervical and lumbar disc herniations (prolapsed discs) healing or reabsorbing on their own and thought it would be good to know both how often and to what extent this was occurring. This paper with its 7 year follow up was the best one I found and it fits with my experience pretty well with low back pain patients showing or reporting poor looking MRIs but still progressing very well with their exercise program, often with a full resolution of symptoms with strength, endurance and function returning to better than they were pre-injury.

    Interesting factoids and comments from the paper were as follows:

    • Massive herniated discs were defined as those for which the extruded disc material occupied 50% or more of the anteroposterior diameter of the spinal canal. I’d agree that’s big.
    • 83% of the 37 patients reported complete and sustained recovery 7 years after the injury.
    • The average reduction in the size of the disc prolapse was 64% most of which occurred in the first 6 months after the initial scan at which point they were only one third of their original size. They slightly better at 6-12 months after which point reduction volume was relatively unchanged.
    • They cited another paper that found that with herniated disc larger than 6 mm, that that on average they improved 36% in 6 weeks, and 60% at 6 months, which closely agrees with the 6 month outcome of this study.
    • Four of the 37 patients went on to have surgery and their average volume reduction was less at 47%.
    • Seven years later 90% of the conservatively treated patients were satisfied with their outcome, while with only 50% of those having surgery being satisfied, though the difference was not statistically significant.
    • In the discussion they cited other research that surprisingly found the worst discs had greatest ability to improve (on a percent of initial injury) over time, speculating that it was due to increased immune/inflammatory response with macrophages and neovascularization playing a role.
    • They cited two additional studies indicating similar outcomes with herniated discs in the cervical spine, aka, neck.
    • The noted the degree of disc resorption was not always correlated with symptoms as they cited several papers where patients showed considerable improvement in symptoms even when MRI changes were minimal.
    • They thought, and I agree, that patients with sciatica should be initially treated with conservative treatment and that early access to surgeons and diagnostic can result in unnecessary surgery.

    The authors said that only four of the patients had surgery. However there was no mention regarding what types of therapy, exercises, postural advice, etc, was or wasn’t utilized as part of the conservative course of treatment. Also there was no mention as to what caused the herniated discs, which seem often the case from the point of view from a lot of practitioners. Often a person will complain of severe back or neck pain, go to their doctor, get an MRI, see a herniated disc, and there’s the cause. However physical therapists who want to more effectively treat spine pain, need to look further back than that.

    I’ve read a fair number of philosophy books and it seems there are very few uncaused events, and vertebral discs don’t herniate by magic. While there often isn’t a specific injury, it is known that most disc bulges and herniations are caused by repeated spine flexion, which is exacerbated by sustained flexion loads, with rotational stresses not doing the discs a lot of good either. So sufferers of back pain (and neck too) should keep this in mind, and should probably avoid a lot of spine stretching, and sustained poor postures, or else what happened to the disc in question will likely happen to neighboring discs either above or below. As many pain sufferers can tell you, a good number of spine injuries result in recurrent and chronic pain, then is only eliminated when bad habits are eliminated and strength increased. Still the good news from this study is that even with the worst of herniated discs generally respond very well to treatment without the need of surgery.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Intermittent Fasting Educational Videos

    For those of you who don’t like to read, this blog about intermittent fasting educational videos is for you.

    I have been doing intermittent fasting for 6 months now, and I have a number of comments to add since making my observations after my first 40 plus days. Since the initial 40 days, I basically think the same stuff, but I plan on doing an update soon on new things I noticed and the results I’ve had. Since starting, I have done a ton of research regarding intermittent fasting for a number of medical conditions that often have nothing to do with weight loss, and in my situation, I’m using it to GAIN muscle and just be healthier. At this point I’m thinking it’s nearly a universally healthy thing to do; for adults at least. Even so, I would still definitely ask your doctor first, but if he’s against it, maybe ask another doctor.

    Because I’m starting to get a little tired of sounding like a broken record talking about generalities, and I usually tell people not to take my word for it but to research it themselves before trying the diet; I wanted to write a blog on my favorite video’s of people who are either medical/academic experts (as well as some regular people) and their experiences. The video’s I cite periodically through this blog, show those people’s experiences, which seems legit, and are in line with (and sometimes ahead) of the curve in regards to the research. In my case, I learned a little, just started it, and learned a lot more as I went. I think it’s one of those things where you really have to try it to understand it. There are some books I have bought and read that I don’t regret, but most of the information is available for free, so I’m only citing free sources. I did a blog on the different types of intermittent fasting protocols, which might be worth looking at if any of the differences listed below are confusing. Some of the resources below will describe alternate day fasting, modified alternate day fasting, or my favorite; time restricted feeding, which to me sounded the easiest to follow both physically and psychologically, and is what I do and recommend. So now, on with the videos.

    Why Fasting Bolsters Brain Power, by Mark Mattson, is fascinating the entire 16 minutes! Dr. Mattson is Chief of the Laboratory of Neurosciences at the National Institute on Aging, and it turns out, an author of a number of the fasting and caloric restriction studies I have read. He was quoted in the book “The 8 Hour Diet” (which was fair at best) as saying “The fast I’m doing: Skip breakfast and lunch and exercise instead, then eat a nice meal over dinner.” It sounds a lot like the Fast-5 plan, which is a 19/5 (19 hours fasting/5 hours eating daily), my go-to recommendation for people because it’s simple, easy to follow, and I think psychologically ideal. The book is free, and only takes about 30 minutes to read, which is another plus. However, I thought the author and MD, Burt Herring’s TedTalk, though good, wasn’t exactly exhilarating.

    The BBC documentary Eat, Fast and Live Longer by Michael Mosley put the 5:2 diet on the map is great. The 5:2 diet is done by eating normally 5 days per week and doing a “modified fast” eating one 500-600 calorie meal 2 days per week. It’s not the kind of intermittent fasting I do but the research supports it as good, though perhaps not best, and the show is certainly interesting.

    “Scott the truck driver” video blog (VLOG) showed up one day on my youtube recommended watch list. He has a number of fasting video’s, all of which are good, but I think the one where he talks about losing 41 pounds in 18 weeks is my favorite. WARNING, he swears a LOT, so if you are offended by such things, you have been warned. What I like about his channel is that he’s a regular guy who doesn’t have time to exercise much, doesn’t eat very healthy, and is using intermittent fasting to lose weight anyway. Whereas I have stuck entirely with time restricted feeding, first the 19/5 plan and now 20/4 while he tries a bunch of methods, with the primary goal being weight loss and comments on what he likes and doesn’t. As red neck as he comes across his information, though ‘colorful’ is really accurate.

    The HodgeTwins

    It was through Scott’s channel that I heard about the HodgeTwins. It turns out they have been making intermittent fasting videos for years. If you like older Eddie Murphy comedy, you’ll like the HodgeTwins; if you don’t, you’ll likely be deeply offended. If sensitive, I would, however, recommend you suspend your disgust and watch them anyway because it really is some of the best fasting information out there, especially in relation to working out and looking better. They really do a great job of comparing it to other diets because they have tried and ‘vlogged’ about having tried a lot of those other diets before they learned about IF (intermittent fasting). When did they learn about IF you might ask? Apparently 3 days prior to June 18 2012, or at least that’s the date they uploaded their first video on intermittent fasting, having heard about Martin Berkan’s Leangain.com 16/8 approach. The HodgeTwins are a couple of bodybuilders who are using intermittent fasting to gain muscle and get ‘ripped.’ They, and I, agree that intermittent fasting is an easier way than the typical fitness mantra of eating six small meals a day. They also generally do time restricted feeding, eating 3-9 hours a day ,and fasting the rest of the time. They vary their eating window depending on whether they are cutting or bulking. Per their videos, it’s obviously working. They probably have thousands of short videos out, and a few of my favorites are:

    24 Hour Fast And We Feel Great: This is my favorite HodgeTwins video of how they felt after their first 24 hour fast. It’s just a good overall talk about intermittent fasting, how it makes you feel, how they noticed their appetite was decreased, how they were stronger, how they had increased energy, and how they were burning fat at the same time. They talk about how much the supplement industry would lose if the word got out that if you want to lose weight, you just have to stop eating. It’s back from July 2012 within a couple months of when they first started fasting. “If you want to get bigger and stronger and leaner, STOP EATING…!”

    More on the increased energy you get with intermittent fasting, which if you ask me, is the best part.

    Intermittent Fasting Kills Food Cravings. That’s another one of the big things I noticed and didn’t expect. You just don’t crave the bad foods anymore, certainly not as much.

    Conspiracy by the food industry, bogus research, and doctors don’t know. Sounds right.

    Just to reiterate, intermittent fasting does not slow your metabolism. Nope, if anything it likely revs it, where do you think all that energy comes from?

    Six small meals a scam? Pretty much.

    Eating Crap and Still Losing Weight

    Is caloric restriction necessary with intermittent fasting? They say it is, though probably less so than with regular diets; which fits with my experience because I am actually gaining weight with intermittent fasting, though it’s an effort. One of my patient’s weight was static on a 19/5 fast the first month decided to reduce her calories to 1250 per day to start weight loss, and she was adamant that fasting is easier and more satisfying than regular dieting. She commented that eating 1250 calories in a 4-5 hour window did fill you up, while when spread out over an entire day she was always hungry.

    INTERMITTENT FASTING TO GAIN MUSCLE for which if I didn’t agree, I wouldn’t have linked the video. Generally they recommend a longer eating window, around 8 hours eating, 16 hour fasting for bulking, but so far I’m gaining muscle eating just 4 hours and fasting 20 largely because it fits my schedule better, and I wanted to see if I could do it. When I get home from work though I have to really get on it, and basically binge for 4 hours. It’s still better than when I was bodybuilding and on the weightlifting team at NAU, where I would had to binge all day to gain weight.

    Here they talk about the 8 Hour Diet, which is the book I mentioned above. I have a lukewarm opinion on it, for pretty much the same reasons as the HodgeTwins. Just to show that the HodgeTwins are not fad diet followers, here is them giving what I think is some pretty good advice regarding Paleo diets, the Atkins and low carb diet; which all predate their discovery of fasting. Also what I think makes it particularly interesting, is how their faces are fatter and muscles are smaller in the older pre-intermittent fasting videos. The fasting, which they quickly became sold on (I shouldn’t say sold because it is free) has obviously and visually worked for both muscle gains and fat loss. When it comes to gaining muscle and losing fat, bodybuilders generally have more experience than anyone.

    Herschel Walker, says he’s been eating one meal a day since he was 18 years old, that he has around 8 or 9 at night. That predates even the Warrior Diet by a couple decades making Herschel one of the true founding fathers of intermittent fasting.

    Hugh Jackman says he used intermittent fasting 16/8 to get in shape for Wolverine (1:50 in) and he learned it from none other than Dwaine “the Rock Johnson.

    I plan to do a number of additional blogs on intermittent fasting in relation to specific disease and metabolic conditions that I treat but the above gets through the basics with a bit of flavor as to why people like it. With the above video’s you should know know more about intermittent fasting than most anyone, but you won’t know how good it feel and how easy it is till you try it.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Creatine and Weight Training for Older Adults

    Creatine supplementation during resistance training in older adults-a meta-analysis. Devries MC, Phillips SM. Med Sci Sports Exerc. 2014 Jun;46(6):1194-203.

    Abstract
    INTRODUCTION:
    Age-related sarcopenia and dynapenia have negative effects on strength and the ability to perform activities of daily living. Resistance training (RT) increases muscle mass and strength in older adults and is an established countermeasure for sarcopenia and dynapenia, and creatine may enhance this effect. We aimed to determine whether the addition of Cr to RT increased gains in muscle mass, strength, and function in older adults over RT alone by conducting a systematic review and meta-analysis.

    METHODS:
    PubMed and Healthstar databases were searched. Randomized, placebo-controlled trials that involved older adults supplemented with Cr and included RT regimens (>6 wk) were included. Data was analyzed using fixed or random (if data were heterogeneous) effects meta-analysis using RevMan 5.

    RESULTS:
    The meta-analysis comprised 357 older adults (average ± SD Cr: 63.6 ± 5.9 yr, Pl: 64.2 ± 5.4 yr) with 12.6 ± 4.9 wk of RT. Cr + RT increased total body mass (P = 0.004) and fat-free mass (P < 0.0001) with no effect on fat mass as compared with RT alone. Cr + RT increased chest press (P = 0.004) and leg press (P = 0.02) one-repetition maximum to a greater extent than RT alone, with no difference in the effect on knee extension or biceps curl one-repetition maximum, isokinetic or isometric knee extension peak torque. Cr + RT had a greater effect than RT alone on the 30-s chair stand test (P = 0.03).

    CONCLUSION:
    Retention of muscle mass and strength is integral to healthy aging. The results from this meta-analysis are encouraging towards supporting a role for Cr supplementation during RT in healthful aging by enhancing muscle mass gain, strength, and functional performance over RT alone; however the limited number of studies indicates further work is needed.

    My comments:
    I do a lot of work with older adults, and just about every study that looks at performance measures after surgery, risk factors leading to surgery, back pain, risk factors for falls, and risk factors for developing arthritis all seem to center on lack of muscle mass and muscle strength as being one of, if not the most, important factors. As such, my patients pretty much all lift a lot of weights. There’s not a lot of massage, stretch bands, or swiss ball action going on in my gym. Even my pain management modalities increase muscle mass.

    Ever since writing one of my favorite blogs showing how caloric restriction preserves muscle mass with aging, which is the opposite of what I would have expected, I have been increasingly interested in dietary changes to help with recovery. One might respond, “What’s the deal Chad? You’re not a registered dietitian, why are you giving dietary advice?” Well, mainly because in the 16 years I have been a physical therapist I can count on one hand the number of patients of mine for whom insurance covered a visit to a registered dietitian. If they actually got a visit, it was usually only one, of which they got a diet that was too complicated to follow anyway; nor did a single one of them came back with information about creatine monohydrate, protein supplementation, or intermittent fasting. So now I figure that’s up to me, and that’s what the research seems to be supporting as the cutting edge for a number of conditions, and for general health as well. Mixing the best of nutrition/supplements without being referred to a number of different specialists, who all disagree with one another, is an example of what “integrative medicine” ought to be; as opposed to what integrative medicine generally is, which is a rebranding of ineffective alternative medicine treatments blended with real medicine, so you can’t tell the difference.

    This meta-analysis pooled the results of 10 other studies, some of which found creatine combined with resistance training helped, while some didn’t. Overall, the results were in favor of creatine supplementation significantly  increasing total body weight 1.00 kg, significantly increasing lean tissue 1.33 kg, and there was a trend towards losing fat of 0.36 kg, all in an average of 12.6 weeks.  Leg press strength increased 3.25 kg, chest press 1.74 kg,  and function per a 30-s chair stand test of 1.93 stands, all in comparison to subjects on the same exercise program but taking a placebo supplement. Average dose was 5.0 grams of creatine per day, and six of the 10 studies had them load for 18.9 grams per day for the first week. Nine of the 10 studies had them train three days per week, and 8/10 were whole body programs. Two of the 10 studies were women only, four were men only, and four were men and women combined.

    They did talk about factors that they thought might contribute to some studies finding a significant effect, while some didn’t.  From the data, they could not tell that differences in exercise intensity as a factor, but they did note that in five trials where carbohydrates were not administered with the creatine, that four did not show positive effects. These notes, to me, show that taking carbohydrates with your creatine might be an important factor. This is interesting to me because I never take my five grams per day with carbs, and they did cite a paper where co-ingestion of carbohydrates increased muscle uptake and decreased excretion. If I recall correctly, the idea is that taking carbs with your creatine spike your insulin levels which then help transport creatine into the muscle cells where it does it’s good. This is a bit of a dilemma for me because I workout at noon and don’t eat any calories till 5-6 pm per my current intermittent fasting protocol, and taking your creatine, which is calorie free, right after a workout is also supposed to help muscle uptake of creatine. What I am most likely going to do is take a jug home so I can take my creatine with my evening meals on rest days, and keep a jug at work to take after training on workout days. As much as I like the creatine, I like intermittent fasting more, so I don’t intend to change my eating schedule.

    Overall, the dose of five grams per day sounds right, the results are well in line with the many studies looking at the use of creatine in younger weight trainers and athletes, in line with another paper I reviewed that found creatine helped Parkinson’s patients, and are in line with what I used to do on the weightlifting team at NAU when I first discovered creatine. Back then I loaded on just nine grams a then maintained on three grams and still gained 11 lb, so I kind of feel like loading with 25 grams is overkill. If you ask me, 15 grams loading for a week is probably plenty. That said, creatine is cheap, with my favorite brand Creaform now with a kilo costing just $30-40 a kg. That’s not bad for a >six month supply, even if you waste some.

    Also interesting from the introduction, was the mention that protein supplementation was also likely helpful to aid strength and muscle gains. They cited a study, however, that said maximal muscle synthesis in older adults required a dose of 40 grams of protein as opposed to 20 grams in younger people, so I’ll be having to look up and read that paper. I swear every paper read leads to an average of five more to look up. Just found it, just printed it…

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Coffee & Tea: How Much is Healthy?  

    Coffee and tea: perks for health and longevity? Bhatti SK1, O’Keefe JH, Lavie CJ. Curr Opin Clin Nutr Metab Care. 2013 Nov;16(6):688-97. [FREE FULL TEXT]

    From the Abstract:
    RECENT FINDINGS:
    Tea consumption, especially green tea, is associated with significantly reduced risks for stroke, diabetes, depression, and improved levels of glucose, cholesterol, abdominal obesity and blood pressure. Habitual coffee consumption in large epidemiological studies is associated with reduced mortality, both for all-cause and cardiovascular deaths. In addition, coffee intake is associated with risks of heart failure, stroke, diabetes mellitus, and some cancers in an inverse dose-dependent fashion. Surprisingly, coffee is associated with neutral to reduced risks for both atrial and ventricular arrhythmias. However, caffeine at high doses can increase anxiety, insomnia, calcium loss, and possibly the risk of fractures.

    SUMMARY:
    Coffee and tea can generally be recommended as health-promoting additions to an adult diet. Adequate dietary calcium intake may be particularly important for tea and coffee drinkers.

    Quotes from the Article about Tea:

    “The authors concluded that people who drink at least four cups of tea per day may have a 16% lower risk of developing type 2 diabetes than nontea drinkers.”

    “The results were replicated in another meta-analysis [17] that included 22 trials and showed that green tea consumption was associated with significant reduction in total and LDL cholesterol levels with no significant effect on HDL and triglyceride levels.”

    “In NHANES study, hot tea consumption was inversely associated with obesity, mean waist circumference, and inflammatory markers, but interestingly enough, the association was reversed for cold tea… …plausible that the increased antioxidant content, lower sugar content, and more favourable metabolic effects of hot tea make it more effective at burning off abdominal fat and reducing inflammation than cold tea…”

    “…individuals consuming at least four cups green tea per day had a 51% significantly lower likelihood of having depressive symptoms than participants consuming one cup/day or less of green tea…”

    Quotes about Coffee:

    “both all-cause and heart-related, with the lowest risks noted among those individuals chronically consuming about two to four cups/day”

    “A very recent observational study suggested that high coffee consumption (>28 cups/week) was associated with increased all-cause mortality”

    “On the basis of this study [52], it seems appropriate to suggest that people avoid heavy coffee consumption (more than four cups/day).”

    My comments:

    Historically, I haven’t been a big tea person, but I’ve been drinking coffee for years. I actually thought the coffee might be a problem, so a few years back I gave it up for a couple weeks before reading that coffee is generally considered healthy these days; however I was wondering if I might be getting too much of a good thing, so I figured I’d do some more research. I was especially interested in researching this since I developed my new interest in intermittent fasting, for which just about everyone asks, “What about coffee?” Nobody has yet asked me, “What about tea?” with regards to fasting, apparently because we’re in ‘Merica.’ Even so, I thought the comparisons were interesting.

    There was an interesting finding in the paper stating that people who consume hot tea had lesser abdominal fat and inflammatory markers, while the opposite was found in cold tea drinkers. The authors thought the temperature/type of tea may or may not be the reason for these opposing findings, but instead thought that it may be because cold tea drinkers were more likely to add sugar to their drinks. In conclusion, sugar is likely bad enough to offset tea’s goodness, which was also noted in the paper regarding coffee and diabetes, so it’s probably a good idea that I gave up the Coffee-mate.

    I think the tricky part in adequately dosing your beverage for health, is determining how much a cup is. It’s not like they accurately dosed out coffee and tea and held people in a biosphere to see how long they lived, rather in the papers reviewed often went on people’s reports. One thing that came to my attention when trying to accurately measure out a cup of coffee, is that all mugs are different.  My coffee mug holds 413 ml, which is about 1.75 8 oz cups.

    That part I suspected, but what I didn’t expect was that cup indicator marks on my Mr. Coffee machine weren’t even close. My coffee pot measured four cups of liquid, reading as six cups! To my surprise, when my office staff told me I was regularly drinking 11 cups per day (which is probably bad) I was in fact only drinking seven cups (which is probably bad, but not as bad). The revelation made me think that the amounts of both coffee and tea studies are likely all somewhat suspect, as I have my doubts that anyone surveyed actually pulled out a graduated cylinder and measured what they were actually consuming.

    Still, the general recommendation of four plus cups of tea per day being ideal was confirmed by several studies, with no data given regarding an upper limit of health going much beyond that as found with coffee when you went beyond four cups. According to wikipedia, Health Canada recommends no more than 2.5 mg/kg body weight of caffeine for adults which could be used as a guide, but even then you run into questions which vary; “how much caffeine is in a given type of coffee or tea, and how it is prepared?”

    So the best take home message for proper dosage now appears to be four plus ‘cups’ of tea per day, with green tea perhaps being best, while coffee being two to four cups, but not more being somewhere close to ideal. There was no data given regarding a combination, but the mechanisms of action cited were not identical, so I plan to switch it up.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Tennis Elbow, Strong Evidence AGAINST Platelet-Rich Plasma

    Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. de Vos RJ, Windt J, Weir A. Br J Sports Med. 2014 Jun;48(12):952-6.

    Abstract
    BACKGROUND:
    Chronic lateral epicondylar tendinopathy is frequent in athletes, and platelet-rich plasma (PRP) is being used increasingly in its treatment.

    OBJECTIVE:
    To systematically review the literature on the efficacy of PRP injections for chronic lateral epicondylar tendinopathy.

    METHODS:
    The databases of PubMed, EMBASE, CINAHL, Medline OvidSP, Scopus, Google Scholar, Web of Science and Cochrane Library were searched in October 2013. Inclusion criteria were a clinical diagnosis of chronic lateral epicondylar tendinopathy, a randomised controlled trial, an intervention with a PRP injection and the outcome measures described in terms of pain and/or function. One author screened the search results and two authors independently assessed the study quality using the Physiotherapy Evidence Database (PEDro) score. A study was considered to be of high quality if its PEDro score was ≥6. A best evidence synthesis was used to identify the level of evidence.

    RESULTS:
    Six studies were included, of which four were considered to be of high quality. Three high-quality studies (75%) and two low-quality studies showed no significant benefit at the final follow-up measurement or predefined primary outcome score when compared with a control group. One high-quality study (25%) showed a beneficial effect of a PRP injection when compared with a corticosteroid injection (corticosteroid injections are harmful in tendinopathy). Based on the best evidence synthesis, there is strong evidence that PRP injections are not efficacious in chronic lateral epicondylar tendinopathy.

    CONCLUSIONS:
    There is strong evidence that PRP injections are not efficacious in the management of chronic lateral elbow tendinopathy.

    My comments:

    I don’t have a lot to add to this one. The researchers did a great job,  they knew their material and knew that in the one out of four high-quality studies where platelet-rich plasma did show a benefit, it was because it was compared to corticosteroids that are outright harmful for tennis elbow, and pretty much harmful for tendons in general. I’m not sure I care for the term “chronic lateral epicondylar tendinopathy,” as it’s right up there with “lateral epicondylopathy” in awkwardness, and has even more syllables. So, I’m find with the term, “tennis elbow.”

    I would expect the results of this study to generalize to other forms of tendinitis/tendinopathy, because every other treatment I have read about that is or isn’t effective, generalizes to other forms of tendinopathy. Because the authors cited another review which stated that if research showed platelet-rich plasma was supposed to work for anything, “refractory lateral epicondylosis” (yet another new term for tennis elbow) was their strongest case. Plus, new treatments that don’t likely work at all tend to generalize their ineffectiveness to other body parts, and the juggernaut of medical review articles Cochrane seems pretty down on platelet-rich plasma for all musculoskeletal soft tissue injuries.

    The idea of withdrawing one’s blood, concentrating the platelets and injecting them back into the tendon just sounds sketchy to me. First of all, the concentration isn’t that much, just 2.2 to 5.5 times in the studies reviewed, so platelets are already there to some extent. Secondly, once you shot the tendon up with platelets I would expect them to float away fairly quick in general circulation, well before they had a chance to attract the various growth factors for which the are purported to do. Yeah, sayer’s will say that tendons have poor circulation so the platelets might not wash away, and they might be right. So again, how are those platelets supposed to attract those growth factors?  My guess, is that those growth factors are all in the blood.

    However, there are a few positive sides. Platelet-rich plasma is generally marketed to physicians and shows that medical doctors fall for the same type of over-hyped bogus treatments that physical therapists do, so that makes me feel better. Platelet-rich plasma doesn’t generally leave you worse off than you started, other than your wallet being lighter, which you can’t say for cortisone. Actually, I take that back. Having your tendon peppered by a needle is not pleasant at all, but I expect the theatrics induce a fair placebo effect.

    OK, so here is a genuine bright side. The right exercises do a GREAT JOB at relieving tennis elbow, which is easily treated at your gym or at home FOR FREE, if you have dumbbells. The basics, and in depth details, of my program are fully illustrated in my blog on “shooter’s elbow.” Shooter’s elbow is just another colloquial name for tennis elbow in people that shoot rather than play tennis. The principles and rehabilitation are exactly the same.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Intermittent Fasting Maintains Muscle when Dieting

    Intermittent versus daily calorie restriction: which diet regimen is more effective for weight loss? Varady KA. Obes Rev. 2011 Jul;12(7):e593-601. [FREE FULL TEXT]

    Abstract
    Dietary restriction is an effective strategy for weight loss in obese individuals. The most common form of dietary restriction implemented is daily calorie restriction (CR), which involves reducing energy by 15-60% of usual caloric intake every day. Another form of dietary restriction employed is intermittent CR, which involves 24 h of ad libitum food consumption alternated with 24 h of complete or partial food restriction. Although both diets are effective for weight loss, it remains unknown whether one of these interventions produces superior changes in body weight and body composition when compared to the other. Accordingly, this review examines the effects of daily CR versus intermittent CR on weight loss, fat mass loss and lean mass retention in overweight and obese adults. Results reveal similar weight loss and fat mass loss with 3 to 12 weeks’ intermittent CR (4-8%, 11-16%, respectively) and daily CR (5-8%, 10-20%, respectively). In contrast, less fat free mass was lost in response to intermittent CR versus daily CR. These findings suggest that these diets are equally as effective in decreasing body weight and fat mass, although intermittent CR may be more effective for the retention of lean mass.

    My Comments:

    I thought this was an interesting review paper looking at a number of papers about human intermittent fasting in people (for which there are relatively few) vs. standard caloric restriction diets (for which there are many) to see which was more effective for weight loss. In the paper, what they describe as “intermittent CR” was another name for intermittent fasting (IF). The types studied were mostly alternate day-type fasting with either full or ~75% caloric restriction on fast days, rather than the time restricted feeding versions that I prefer.

    What they described, but didn’t quantify in the summary above, was that dieters on more or less standard caloric restriction diets, 25% of their weight loss was lean tissue (i.e muscle), while in the IF groups the lean tissue loss was only  about 10%. I wouldn’t hold those numbers as gospel truth at this point because the diets and fasting protocols were all a little different, as were the time periods over which the subjects were tested. I would expect combining both CR and IF with weight training would lessen, and I expect IF might completely eliminate muscle loss when dieting. It’s still unknown why IF appears better, but today makes 137 day on Fast-5 IF protocol and I’m now combining it with both heavy weight lifting and EMS, while still actively gaining muscle. It sure feels better than regular dieting, which I suspect has something to do with the adrenaline rush you get with it. I don’t know, there is a quite a bit of animal research on IF with human studies only recently being finished, so there is still a lot of uncertainty about what it can do in the long run and how it does it. However, as I’m on it longer and longer, it has gone from feeling “not that bad” and “not that hard,” to “this feels awesome!” I have taken some additional notes over the last few months on my thoughts with IF and weight training, compared to my initial 40 days. However, I don’t want to write them up until I surpass Gandhi’s record who fasted a total of 140 days over his lifetime. So just four more days to go on that, and it’s all too easy. Gandhi never did more than 21 days in a row, and apparently he did complete fasts rather than IF, but that’s neither healthy nor sustainable, nor do I think he could squat very much. In fact in the move the movie I saw, he had trouble walking afterwards.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Low Level Laser Doesn’t Work for Tendinitis Either

    Clinical effectiveness of low-level laser therapy as an adjunct to eccentric exercise for the treatment of Achilles’ tendinopathy: a randomized controlled trial. Tumilty S, McDonough S, Hurley DA, Baxter GD.

    From the Abstract
    OBJECTIVE:
    To investigate the effectiveness of low-level laser therapy (LLLT) as an adjunct to a program of eccentric exercises for the treatment of Achilles’ tendinopathy.

    DESIGN:
    Randomized controlled trial with evaluations at baseline and 4, 12, and 52 weeks.

    INTERVENTION:
    Both groups of participants performed eccentric exercises over a 3-month period. In addition, they received either an active or placebo application of LLLT 3 times per week for the first 4 weeks; the dose was 3J per point.

    RESULTS:
    Baseline characteristics exhibited no differences between groups. At the primary outcome point, there was no statistically significant difference in VISA-A scores between groups (P>.05). The difference in VISA-A scores at the 4-week point significantly favored the placebo group (F(1)=6.411, sum of squares 783.839; P=.016); all other outcome scores showed no significant difference between the groups at any time point. Observers were blinded to groupings.

    CONCLUSIONS:
    The clinical effectiveness of adding LLLT to eccentric exercises for the treatment of Achilles’ tendinopathy has not been demonstrated using the parameters in this study.

    My comments:

    This study was interesting for a lot of reasons, and it turned out to be a lot more of an investigation, work, and writing compared to what I expected before reading. The first thing that I found interesting about this study, is because it found low level laser therapy (LLLT) ineffective for tendinitis. This result tends to back up the comments from quackwatch.org author Stephen Barrett, who thinks that LLLT doesn’t help treat any condition.

    Secondly, at 4 weeks out, the placebo/sham treatment group improved MORE than the laser group, which was the same thing researchers commented on in the Anodyne study for neuropathy. I expect worse healing rates for both studies are likely just bad luck/chance/coincidence, but had chance gone the other way, I would bet dollars to donuts that the pro laser folks would be trumpeting the “positive trends” that didn’t quite reach statistical significance. In the case of this study, the worse outcome at four weeks did reach significance, which makes you go hmmm.

    The third thing that caught my attention, is that the LLLT treatment and research seems really contentious. I expect the yeah sayers to blow off negative findings like this study, by likely saying the researchers are biased, however, the primary author in this paper, Steve Tumilty, really looks like he was a true believer. Tumilty did a pilot study in 2008 that also found no significant differences, and in 2010 he was the primary author on an extensive review and meta-analysis on LLLT for tendinopathy, which I thought was fairly biased in favor or laser therapy being effective in spite of clearly conflicting research. In his review he noted that 25 trials of laser therapy and tendinopathy, that 12 trials showed positive effects, while 13 didn’t. Apparently, they hadn’t seen Ben Goldacre’s Ted Talk about publication bias in medical research in which Ben shows when there is an apparent even split in the research, the truth is often much worse, as both researchers and journals only like to publish positive findings, while negative findings often just get trashed. Subsequently taking only the positive trials and averaging the improvements, like Tumilty did in his review, is something I would give the stinkeye to. And doing so,  it only came to an average pain reduction of 13.6 mm on a 100 mm pain scale, which on a 1-10 point pain scale corresponds to decreasing pain just 1.36 points, which sounds like much ado about nothing. Anything that over several weeks of treatment that drops my pain only about 1 point, that’s likely psychological anyway, isn’t something I’d want to pay for, which is probably why a number of insurance companies also refuse to pay for it.

    Fourth, in Tumilty’s review he went on and on about the correct parameters being necessary for the LLLT to be effective, and noted in this paper that his pilot study (which also failed to show a treatment benefit from LLLT) might have used too intense a light, and that his pilot study had been criticized for that, for their laser parameters being too intense. Because of these criticisms,  he decreased the laser intensity for this study to be right in the middle of the “World Association of Laser Therapy” guidelines. What happened, you may ask? Turns out that other LLLT practitioners criticized their laser for being too light. I guess sometimes you can’t win for trying.

    Fifth, the eccentric exercise program (Alfredson’s protocol), 6 sets of 15 reps every day morning and night, showed immediate benefit that appeared to be steady and linear improvements up until 12 weeks when the exercises were discontinued. Once discontinued, the gains were good, but they mostly stopped with there still being some residual treatment. Tendinitis/tendinopathy is one of my pet areas, so I have reviewed Alfredson’s papers and even did his protocol in my office for a while before deciding that I thought 6 sets of 15 twice per day is overkill (not that it doesn’t work), but realizing that I think 3 sets of 15 works just as well. Later, I discarded the eccentric only exercise, not that it didn’t work, but  because concentric exercise was found to benefit tendons too, and more conventional exercises (heavy eccentric and concentric exercise) are superior. Eccentric only exercise is just so 1990s. Anyway, what I thought was interesting and relevant to all exercise programs, which all seem to work to greater or lesser degrees, is that if you stop doing them and still have symptoms, even if lesser, you are likely going to stop improving. For instance, if you have tendinitis and after 12 weeks you are 80% better, you might want to keep up your exercise program until your are 100% better,  or else that nagging 20% might still be there a year later.

    Regardless, I remain pretty skeptical of the whole laser thing. I mentioned in my last blog that when laser therapy was performed on me, I couldn’t feel a thing, good or bad, such that if I was blindfolded, I wouldn’t even know the machine was on. This leads me to believe that maybe it’s like TENS/EMS, where early on there were a lot of studies going back and forth as researchers, physical therapists, and sports/strength coaches learned how to set up the machines so they will work. It also makes me think that perhaps it’s more like ultrasound or spinal manipulation/mobilization, where no matter how they slice it, the benefits just aren’t there to be found or so minimal as to just not matter.

    I also want to say hat’s off to Steve Tumilty and his fellow authors. I thought they had a fair amount of bias going in, but they designed a great study with a placebo/sham device that had both subjects and researches agnostic as to the which was the real device until the end. They also published their paper with findings that went, seemingly at least, against their interests. Of course, at the end they called for more research to be done, so hope springs eternal. I just hope it’s not funded by government (meaning our) dollars.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Cold Laser, Low Level Laser, Anodyne… Bogus for Neuropathy

    Does anodyne light therapy improve peripheral neuropathy in diabetes? A double-blind, sham-controlled, randomized trial to evaluate monochromatic infrared photoenergy. Lavery LA, Murdoch DP, Williams J, Lavery DC. Diabetes Care. 2008 Feb;31(2):316-21.

    Abstract
    OBJECTIVE:
    The purpose of this study was to determine the efficacy of anodyne monochromatic infrared photo energy (MIRE) in-home treatments over a 90-day period to improve peripheral sensation and self-reported quality of life in individuals with diabetes.

    RESEARCH DESIGN AND METHODS:
    This was a double-blind, randomized, sham-controlled clinical trial. We randomly assigned 69 individuals with diabetes and a vibration perception threshold (VPT) between 20 and 45 V to two treatment groups: active or sham treatment. Sixty patients (120 limbs) completed the study. Anodyne units were used at home every day for 40 min for 90 days. We evaluated nerve conduction velocities, VPT, Semmes-Weinstein monofilaments (SWM) (4-, 10-, 26-, and 60-g monofilaments), the Michigan Neuropathy Screening Instrument (MNSI), a 10-cm visual analog pain scale, and a neuropathy-specific quality of life instrument. We used a nested repeated-measures multiple ANOVA design. Two sites (great toe and fifth metatarsal) were tested on both the left and right feet of each patient, so two feet were nested within each patient and two sites were nested within each foot. To analyze the ordinal SWM scores, we used a nonparametric factorial analysis for longitudinal data.

    RESULTS:
    There were no significant differences in measures for quality of life, MNSI, VPT, SWM, or nerve conduction velocities in active or sham treatment groups (P > 0.05).

    CONCLUSIONS:
    Anodyne MIRE therapy was no more effective than sham therapy in the treatment of sensory neuropathy in individuals with diabetes.

    My comments:
     
    Anodyne is a brand name for cold laser, low level laser, monochromatic infrared photo energy (MIRE, I would have called it MIPE), red beam, near infrared, far infrared, and probably a lot of new names to come out in the future to refresh an old idea.

    What I thought was particularly interesting about this study, was that the manufacturers came up with a sham/placebo device that was so convincing, that neither the patients, nor the investigators could tell which device was which. At the end of the study, it  turned out that unlike in prior poorly controlled, or even fully uncontrolled studies, they found no treatment effect whatsoever that was greater than the sham treatment. In fact, the authors commented:

    “If these studies had failed to include a sham therapy arm, MIRE would appear to provide significant improvement in peripheral sensation because of the placebo effect. This effect may help explain the observations in uncontrolled studies showing that MIRE was effective.”

    “Not only was there no clear benefit from the treatment, but there was also a large placebo effect in which the sham therapy showed double the number of improvements in the effect size compared with the anodyne treatment.”

    These results make me feel bad for Anodyne, in that they went out of their way to construct a bomber sham device, and in doing so they scientifically sawed off the branch which they were sitting. Doing so makes me think they honestly thought they were on to something. Stephen Barrett of quackwatch.com did write up on low level laser therapy, which is really bad news for your treatment.

    Interestingly enough, I decided to give the infrared photoenergy treatment a try. This all came about because I was at a gym talking about something exercise and EMS related in front of a durable medical goods provider, who suggested I try a low level laser treatment, and really thought he would convince me of its effectiveness. I didn’t have much in the way of placebo effect because I had already read Dr. Barrett’s critique. Even so, I was still curious as to what low level laser felt like, especially since it was supposed to have a good placebo effect, it should feel like something. However, I was fully underwhelmed with the process. Honestly, it felt like nothing; no warmth, no tingling. In fact, if I didn’t see the purple lights, I wouldn’t have been able to tell that it was on. You know how it feels when you shine an old D-cell flashlight against your hand when you are a kid and your fingers glow red from the other side? I suspect that’s the source of the placebo effect. It looks kind of cool, but you can’t feel anything? Well, turns out it was exactly like that. This study would tend to suggest that low level laser therapy works about as well as shining a flashlight against you, which is no real effect at all, unless of course you are really open to the power of suggestion. How much was the DME asking for his fancy flashlight with the purple color filter you ask? Only $4700. Sorry, no sale, but I felt all good about myself for being open minded enough to try it and the salesman sincerely thought I was going to like it.

    It would be really neat if ineffective treatment modalities were discontinued, but I guess if you are a chiropractor or physical therapist who paid several thousand dollars for a device only to find it didn’t work, you still want to use it. On top of that, it sucks to admit you made a mistake and just toss it in your backroom. I say this because this situation actually happened to me with my ultrasound machine that I haven’t used in 10 years. From experience, I say suck it up, be a professional, and stop fooling your patients. Practicing science or evidence based medicine means that you may have to stop doing things you used to do when you find out, in fact, that they don’t really work. If you continue with the same practices because “it seems like it’s working,” well, you got placeboed too right along with your patient, and having that graduate degree means you should be beyond all that. If you do it just because it pays the bills, well, you’re selfish. In either case, STOP.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Alcohol Dose and Mortality (Remedy or Poison?)

    Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies. Arch Intern Med. 2006 Dec 11-25;166(22):2437-45. Di Castelnuovo A, Costanzo S, Bagnardi V, Donati MB, Iacoviello L, de Gaetano G. [FREE FULL TEXT]

    Abstract
    BACKGROUND:
    Moderate consumption of alcohol is inversely related with coronary disease, but its association with mortality is controversial. We performed a meta-analysis of prospective studies on alcohol dosing and total mortality.

    METHODS:
    We searched PubMed for articles available until December 2005, supplemented by references from the selected articles. Thirty-four studies on men and women, for a total of 1 015 835 subjects and 94 533 deaths, were selected. Data were pooled with a weighed regression analysis of fractional polynomials.

    RESULTS:
    A J-shaped relationship between alcohol and total mortality was confirmed in adjusted studies, in both men and women. Consumption of alcohol, up to 4 drinks per day in men and 2 drinks per day in women, was inversely associated with total mortality, maximum protection being 18% in women (99% confidence interval, 13%-22%) and 17% in men (99% confidence interval, 15%-19%). Higher doses of alcohol were associated with increased mortality. The inverse association in women disappeared at doses lower than in men. When adjusted and unadjusted data were compared, the maximum protection was only reduced from 19% to 16%. The degree of association in men was lower in the United States than in Europe.

    CONCLUSIONS:
    Low levels of alcohol intake (1-2 drinks per day for women and 2-4 drinks per day for men) are inversely associated with total mortality in both men and women. Our findings, while confirming the hazards of excess drinking, indicate potential windows of alcohol intake that may confer a net beneficial effect of moderate drinking, at least in terms of survival.

    My last blog on the effects of drinking alcohol and the prevention of obesity results, in women, were were highest in the 15-30 (~1-2 drinks) grams per day and  >30 grams (>2 drinks) per day group. This amount was higher than what I recall as the general recommendations of one drink a day for a woman and two per day for a man being the ideal amount for overall health benefits and longevity, from when I researched it for my own health back in college. At the time, I was exploiting the French paradox to counteract the high calorie diet was I using to gain weight for weightlifting. In my recent blog I also mentioned that I had read recommendations that were higher than the 1-2 drink recommendations.  I think such recommendations come from the abstract of the above paper, which I don’t feel is the best interpretation of the findings.

    Reading the paper, it looks like women are indeed healthier with up to two drinks per day, and men are so with up to four drinks per day. Even so, when you get into the details at the upper limits of two and four drinks respectively, people aren’t much healthier. When you read the details in the paper itself, it seems that ‘healthier’ and ‘healthiest’ are not quite the same thing. The big thing with alcohol and health is what’s being called a “J-curve.” The J-curve being a meaningful curve downward slope in mortality with moderate drinking, and then follows an onward and upwards turn in health risks when drinking becomes heavy. With moderate drinking, the cited benefits include increased HDL cholesterol, increased fibrinolysis, decreased platelet aggregation and coagulation factors, improved endothelial function, and reduced inflammation. With heavy or binge drinking, the problems become severe including increases in cardiovascular disease, cirrhosis, various cancers, violence, and accidents which the World Health Organization says kills ~2.5 million people per year.

    The reversion point (the upper limit for which the protection of alcohol was no longer statistically significant)  for women was 18 grams of alcohol per day, which is towards the lower end on what was found reasonably effective in preventing obesity, while in men it was found to be 38 grams. However, at the bottom of the J, the healthiest point was right at about 5 grams per day, which is less than half of a standard 14 gram USA drink per day. The health benefits were still pretty good at 10-15 grams which gives you your 5 oz glass of wine, and by 20-30 grams the reduced risk of mortality was used up. Anything beyond that amount, the health risks started to increase relative to not drinking at all. The numbers are all a bit fuzzy because they were based on a number of studies with varying numbers of additional factors included or adjusted for, but the overall gist was consistent. For men, the bottom of the J-curve was in the range of 5-15 grams (one drink region), which was still better than not drinking at two drinks per day, but above 30-60 grams per day the health consequences started to increase. The range for men was also pretty wide and varied by country, which might have to do with differences in drinking habits, genetics, or lifestyle.

    So all that reading and it just brings me back to what my research on the topic found years ago, probably a small to a full drink per day is best for women, ans 1-2 per day for men. Pushing the drinks up to two per day for women and four per day for men isn’t bad, but is moving into the point where the remedy starts to become a poison, which is a bit of a buzzkill, haha.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Alcohol Fights Fat (in moderation)

    Alcohol consumption, weight gain, and risk of becoming overweight in middle-aged and older women. Wang L, Lee IM, Manson JE, Buring JE, Sesso HD. Arch Intern Med. 2010 Mar 8;170(5):453-61. [FREE FULL TEXT]

    Abstract
    BACKGROUND:
    The obesity epidemic is a major health problem in the United States. Alcohol consumption is a source of energy intake that may contribute to body weight gain and development of obesity. However, previous studies of this relationship have been limited, with inconsistent results.

    METHODS:
    We conducted a prospective cohort study among 19 220 US women aged 38.9 years or older who were free of cardiovascular disease, cancer, and diabetes mellitus and had a baseline body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) within the normal range of 18.5 to less than 25. Alcoholic beverage consumption was reported on a baseline questionnaire. Body weight was self-reported on baseline and 8 annual follow-up questionnaires.

    RESULTS:
    There was an inverse association between amount of alcohol consumed at baseline and weight gained during 12.9 years of follow-up. A total of 7942 (41.3%) initially normal-weight women became overweight or obese (BMI > or =25) and 732 (3.8%) became obese (BMI > or =30). After adjusting for age, baseline BMI, smoking status, nonalcohol energy intake, physical activity level, and other lifestyle and dietary factors, the relative risks of becoming overweight or obese across total alcohol intake of 0, more than 0 to less than 5, 5 to less than 15, 15 to less than 30, and 30 g/d or more were 1.00, 0.96, 0.86, 0.70, and 0.73, respectively (P( )for trend( )<.001). The corresponding relative risks of becoming obese were 1.00, 0.75, 0.43, 0.39, and 0.29 (P( )for trend( )<.001). The associations were similar by subgroups of age, smoking status, physical activity level, and baseline BMI.

    CONCLUSION:
    Compared with nondrinkers, initially normal-weight women who consumed a light to moderate amount of alcohol gained less weight and had a lower risk of becoming overweight and/or obese during 12.9 years of follow-up.

    My comments:

    I’ve been aware of the health benefits of moderate daily alcohol consumption since college when I first read about the French paradox. At the time, I was eating 5000 calories a day to gain weight for weightlifting and wanted to make sure I didn’t have a coronary. During that time, they thought the tannins,or anti-oxidents, in the red wine was responsible for the cardio-protective effects and I went from being a teetotaler to a wine drinker. Over the years it was found that it’s the alcohol itself that improved lipid profiles, and  because of this I added a greater variety of drinks to my dinner.

    I was having a conversation with someone about the health effects of alcohol and she said what about weight loss? I told them that moderate drinking was about health, not weight loss.  Still it made me wonder, so I did a pubmed search, and while I wasn’t able to find anything regarding short term weight loss, I did find a number of studies describing the prevention of weight gain over the years. So because of these findings, one might consider that ‘relative’ weight loss.

    What I thought was most interesting about the above study was they not only found alcohol helped lessen weight gain and lower the risk of obesity, but they also quantified it by amount and to a lesser extent type of alcohol. Looking at all the graphs and tables in the study it was a bit of a toss up as to what amount was better, 15-30 grams per day or >30 grams per day, but those amounts were considerably better than lesser amounts and none. If it were me, I would split the difference and aim right at 30 grams per day, as less is maybe not as good, as my recollection was that research found the health consequences (like cirrhosis) start to increase as drinking becomes more than moderate. Still the general recommendation has always been 1 drink per day for women and 2 per day for men as being most healthful, but I do see the amounts creeping higher in more recent papers. So, if the standard drink in the US is 14 grams of alcohol, and that’s a standard 12 oz beer, 5 oz of wine or a 1.5 oz shot, it looks like the sweet spot for women is closer to 2 drinks per day than just one. [8-21-15 edit, that for health 1 drink per day for women, and 1-2 for men still looks ideal]

    Also, the red wine seems slightly better per the human studies.  In this review, I saw it cited that rats gain less weight on red wine, however when I looked up the cited study, on the contrary to how it was cited the rats that drank regular ethanol gained slightly less weight than the ones that drank the red wine and the ethanol drinking rats had greater fat cell aromatase expression than the red wine rats, which was thought to be the primary mechanism of action, and kind of sinking the superiority of the red wine concept. It’s a good lesson to see that you can’t always trust what’s written in a review, and you can’t always trust abstracts either.

    It seems to me that red wine growers have a more powerful political lobby than white wine, beer, and spirits, and it’s my suspicion that as things might play out much the same regarding the effects of alcohol on fat cells. This paper tended to show red wine was maybe ever so slightly better, but not by much, and the differences weren’t significant. A lot of people ‘seem’ to think that red wine works better, even if it doesn’t. Whenever I talk about the health effects of moderate alcohol consumption, even with evidence now being pretty overwhelming, people still look at me funny. If I say “red wine” and they are all like, “of course red wine is good for you.”  I think the meme that red wine is healthy is well established, while alcohol being healthy isn’t yet, such that if there are any real differences in health or weight gain by type of alcohol, it might be that those drinking red wine are generally more health conscious, in comparison to beer or whisky drinkers. However, wine has less calories than most beers and mixed drinks, but straight shots still have less. I suspect you don’t have to drink, as per the French paradox, with your pinky sticking out. Still, ~30 grams of alcohol, or ~2 drinks per day looks best for the prevention of obesity, at least per this paper.

    As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

    Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

  • Anorexia: Light Weightlifting is all but Worthless

    Does resistance training improve the functional capacity and well being of very young anorexic patients? A randomized controlled trial. del Valle MF, Pérez M, Santana-Sosa E, Fiuza-Luces C, Bustamante-Ara N, Gallardo C, Villaseñor A, Graell M, Morandé G, Romo GR, López-Mojares LM,Ruiz JR, Lucía A. J Adolesc Health. 2010 Apr;46(4):352-8.

    Abstract
    PURPOSE:
    We determined the effects of a 3-month low-moderate-intensity strength training program (2 sessions/week) on functional capacity, muscular strength, body composition, and quality of life (QOL) in 22 young (12-16 yrs) anorexic outpatients.

    METHODS:
    Patients were randomly assigned to a training or control group (n=11 [10 females] each). Training sessions were of low intensity (loads for large muscle groups ranging between 20%-30% and 50%-60% of six repetitions maximum [6RM] at the end of the program). We measured functional capacity by the time up and go and the timed up and down stairs tests. Muscular strength was assessed by 6RM measures for seated bench and leg presses. We estimated percent body fat and muscle mass. We assessed patients’ QOL with the Short Form-36 items.

    RESULTS:
    The intervention was well tolerated and did not have any deleterious effect on patients’ health, and did not induce significant losses in their body mass. The only studied variable for which a significant interaction (group x time) effect was found (p=.009) was the 6RM seated lateral row test.

    CONCLUSIONS:
    Low-moderate-intensity strength training does not seem to add major benefits to conventional psychotherapy and refeeding treatments in young anorexic patients.

    My comments

    This is one of those studies and subsequent findings, where any strength coach would look at it and say, “duh.” However, it’s interesting to see the outcomes quantified and compared to the same authors more recent paper, where intense/heavy weight training had very beneficial performance outcomes in patients with anorexia.

    The researchers chose reasonably good exercises; bench press, shoulder press, leg extension, leg press, leg curl, abdominal crunch, low back extension, arm curl, elbow extension, seated row, and lat pulldowns, which were essentially the same exercises as the newer paper. The main difference was that in the study that worked, they did 3 sets of 8-10 reps (very similar to what a lot of strength would do) while this study did only one set of 15 reps with 20-60% of the 6 RM (a 6 RM being only ~85% of a 1 RM to begin with) nothing anyone who knows how to lift would recommend.

    The big caution, apparently, being girls with anorexia have weakened bones and muscles and thus can’t handle heavy weights. However, what I think should have been apparent is that when you are basing intensities off of a RM (repetition maximum, 1 rep, 6 or whatever) a weakened person is going to have a lower max, and thus percents of it are already going to be lower, such that the safety is already built in. Working 20-60% of a 6 RM (which is already only 85% of a 1 RM) is just too light to do anybody any good, which is exactly what they found.

    I still like this paper in context with the other. This paper shows that higher intensity weights not only work as per the primary authors later study, but they are necessary, because lighter weights just don’t cut it. There were similar results with intense lifting recently being found in elderly women with osteoporosis, or pretty much anybody training for fitness. Weights are supposed to be heavy, that’s why they call them weights.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Vegans vs Vegetarians vs Pescatarians

    Mortality in vegetarians and nonvegetarians: detailed findings from a collaborative analysis of 5 prospective studies. Key TJ, Fraser GE, Thorogood M, Appleby PN, Beral V, Reeves G, Burr ML, Chang-Claude J, Frentzel-Beyme R, Kuzma JW, Mann J, McPherson K. Am J Clin Nutr. 1999 Sep;70(3 Suppl):516S-524S.

    Abstract
    We combined data from 5 prospective studies to compare the death rates from common diseases of vegetarians with those of nonvegetarians with similar lifestyles. A summary of these results was reported previously; we report here more details of the findings. Data for 76172 men and women were available. Vegetarians were those who did not eat any meat or fish (n = 27808). Death rate ratios at ages 16-89 y were calculated by Poisson regression and all results were adjusted for age, sex, and smoking status. A random-effects model was used to calculate pooled estimates of effect for all studies combined. There were 8330 deaths after a mean of 10.6 y of follow-up. Mortality from ischemic heart disease was 24% lower in vegetarians than in nonvegetarians (death rate ratio: 0.76; 95% CI: 0.62, 0.94; P<0.01). The lower mortality from ischemic heart disease among vegetarians was greater at younger ages and was restricted to those who had followed their current diet for >5 y. Further categorization of diets showed that, in comparison with regular meat eaters, mortality from ischemic heart disease was 20% lower in occasional meat eaters, 34% lower in people who ate fish but not meat, 34% lower in lactoovovegetarians, and 26% lower in vegans. There were no significant differences between vegetarians and nonvegetarians in mortality from cerebrovascular disease, stomach cancer, colorectal cancer, lung cancer, breast cancer, prostate cancer, or all other causes combined.

    My comments:

    Either my social circle has been expanding to include more vegetarians as of late or since I’m interested in intermittent fasting, the health attributes of different diets comes up more in conversation. Though, this is an older study it does seem to be the most comprehensive paper on longevity with vegetarian diets and it went so far as to sort out the different types. It does seem really hard to tell what works best with all the factors involved, but it does seem that eating a lot of red meat isn’t the greatest, reducing the eating of meat to less than once a week seems better. Being a lacto-ovo vegetarian (eats dairy and eggs) and or being a pescatarian (dairy, eggs, plus fish) seem to be the sweet spot for health.

    Excluding all animal products might be great for moral reasons, and though it reduces mortality due to heart disease; all cause mortality, it was not reduced compared to regular meat eaters. Interestingly, and not clear from the abstract, all cause mortality was rated at 1.00 for regular meat eaters, 0.84 for occasional meat eaters, 0.82 for pescatarians, 0.84 for lacto-ovo vegetarians, and back up to 1.00 for vegans, per table 7 of the study.

    Perhaps meaningful caveats to this study are that there were fewer vegans (753) in the study vs 2375 fish eaters and 23,265 lacto-ovo vegetarians, and per the vegan website where I found this study, a lot of the data was taken before the importance of B12 supplementation for vegans was known. Still, per the data thus far, it seems there is some benefit to including dairy, eggs and fish in your diet. As for veganism, one remaining benefit is you should still get the subtle nods of approval from every passing animal. So far I’m still appreciating the benefits of my intermittent fasting where I can eat as much as I want, of anything I want, just not always whenever I want. It does make me wonder what would happen if you combined intermittent fasting with a lacto-ovo or pescatarian diet, would you become immortal or would it be too much of a good thing?

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Low Back Pain & Reverse Ergonomics: Fit the Person to the Job?

    Evolving ergonomics? McGill SM. Ergonomics. 2009 Jan;52(1):80-6.

    Abstract

    The theme developed in this position paper follows the current evolution of injury prevention in the backs of workers. Job change or ‘fitting the task to the person’ has come far, but will probably not result in zero injury rates. This is because the cause of injury is heavily influenced by the way that a worker moves. A review of injury mechanisms reveals the need for the biomechanist/ergonomist to incorporate features in biomechanical models that recognise these injury mechanisms. The implication of one such model is that the next leap toward a zero injury rate may be approached with ‘fitting the person to the task’ or at least retraining the way that workers move. A few examples of movement-based back injury prevention strategies are provided. Finally, some thoughts on implementing such an approach are expressed. This is a review and position paper written in honour of Professor Don Chaffin’s career.

    My comments:

    The entire paper is great, concise, poignant, and full of useful advice for avoiding lumbar injuries in the work place. While prevention is ideal, as a physical therapist I rarely see people pre-injury, however the same techniques described in this paper make up a full third or more of my rehab programs for low back pain, as it is really difficult, or rather impossible, to get the patient’s pain to go away and stay away, if they are continuing to injure it on the job. So retraining movement patterns is every bit, if not more important, than restoring strength and endurance. The good news is that if you choose your exercises properly you can do both at the same time. Exercises that do such are things like standing cable rows & presses, squats, lunges and RDLs, all performed with a neutral spine. What’s great about these exercises is that they build a lot of strength and a lot of core stability that you just don’t get with yoga, bridges, pelvic tilts, trunk twists and knee to the chest stretches, much don’t build much fitness and are bad for your back and will likely cause you to go back to your doctor saying physical therapy didn’t work. As which point you are on to “pain management” meaning narcotics and spine surgery, which often doesn’t work either and does nothing to prevent the worsening of spine degeneration, and frequent recurrence of pain.

    Comments from the paper that I both like and endorse are:

    “Job change or ‘fitting the task to the person’ has come far but will probably not result in zero injury rates. This is because the cause of injury is heavily influenced by the way that a worker moves…”

    “…the next leap toward zero injury may be approached with reversing the axiom ‘fitting the task to the person’ to ‘fit the person to the task’. More specifically, this means training the way that workers move.”

    “…reasonably robust measures of both psychosocial and biomechanical factors have shown that both are important but that mechanical loading, at least for low back injury, dominates…”

    “…there simply is not a safe or justifiable way for workers to repeatedly pick heavy objects from the floor. So starting height is governed by job design. But if the weight is raised to the height such that a worker can move about the hips without flexing the spine, substantial loads can be lifted.”

    “Those with healthy backs tend to utilise very low spine power – in other words, if they have high spine loads they have virtually no spine motion…”

    “Olympic lifters provide a wonderful example of maximising hip power and minimising spine power to lift without back troubles. They violate popular ergonomic guidelines for load limits, yet rarely experience back injury.”

    “Specifically, maintaining the spine in a neutral posture ensures the most resilient spine possible…”

    “Surprisingly, the chronic backs had higher strength measures. While this was initially puzzling, analysis of the mechanisms revealed they used their backs more than their healthy colleagues! They chose to move with more spine motion and activate muscle in a way that caused higher back loads.”

    “This evidence suggests that an approach to address the cause rather than the symptoms must include ergonomics, but also to look farther and consider changing the individual.”

    “In the case of disc herniation, repeated joint flexion appears to be a necessary condition (McGill 2007). If the motion is transferred to the hip, the mechanism is eliminated.”

    “This is an essential component in removing the cause of the painful condition so that any subsequent therapy has a chance for success.”

    “Specifically, a fully flexed disc will sustain damage at a 23–43% lower load than when in a neutral posture (Gunning et al. 2001).”

    “Use skill to transfer momentum and reduce loading – even though it is popular in various work manuals, instructing workers to ‘lift slowly and smoothly’ reduces their joint-sparing skill.

    “In many cases, ergonomic approaches involving job design are impractical or do not address the injury mechanisms that form the root cause of disabled backs. Entire sectors of the workforce cannot use job design (in jobs such as in law enforcement, forestry, farming, fishing, to name a few). The argument made here is that optimisation of the ergonomic effort for successful reduction of back injury rates in the future will have to consider ‘changing the person to fit the task’ or training the way an individual moves.”

    I don’t have a lot to add. It’s all right. A lot of my recent blogs on low back pain have been about avoiding treatments that don’t appear to work (traction, vertebral manipulation/manual therapy, Kinesiotape, William’s flexion stretches or McKenzie method) but it’s definitely good to have something positive to talk about. Improving the way a person with back pain moves is definitely a good thing. For more good things; lumbar supports work, strength training works, electric muscle stimulation works.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Traction, Low Back Pain, Research Suggests it Doesn’t Work

    Traction for low-back pain with or without sciatica. Wegner I, Widyahening IS, van Tulder MW, Blomberg SE, de Vet HC, Brønfort G, Bouter LM, van der Heijden GJ. Cochrane Database Syst Rev. 2013 Aug 19;8

    Quotes from abstract (but I read the whole thing)

    We included 32 RCTs involving 2762 participants in this review. We considered 16 trials, representing 57% of all participants, to have a low risk of bias based on the Cochrane Back Review Group’s Risk of bias’ tool.

    For people with mixed symptom patterns (acute, subacute and chronic LBP with and without sciatica), there was low- to moderate quality evidence that traction may make little or no difference in pain intensity, functional status, global improvement or return to work when compared to placebo, sham traction or no treatment. Similarly, when comparing the combination of physiotherapy plus traction with physiotherapy alone or when comparing traction with other treatments, there was very-low- to moderate-quality evidence that traction may make little or no difference in pain intensity, functional status or global improvement.

    For people with LBP with sciatica and acute, subacute or chronic pain, there was low- to moderate-quality evidence that traction probably has no impact on pain intensity, functional status or global improvement.

    For chronic LBP without sciatica, there was moderate-quality evidence that traction probably makes little or no difference in pain intensity when compared with sham treatment.

    Adverse effects were reported in seven of the 32 studies.

    These findings indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP. There is only limited-quality evidence from studies with small sample sizes and moderate to high risk of bias. The effects shown by these studies are small and are not clinically relevant.

    To date, the use of traction as treatment for non-specific LBP cannot be motivated by the best available evidence. These conclusions are applicable to both manual and mechanical traction.

    Only new, large, high-quality studies may change the point estimate and its accuracy, but it should be noted that such change may not necessarily favour traction. Therefore, little priority should be given to new studies on the effect of traction treatment alone or as part of a package.

    My comments:

    The authors comments pretty much say it all. Lots of studies done, little to no effect was found and that’s even including studies that are of high risk for bias. I have been following the traction (aka spinal decompression therapy) research for years and this is the strongest wording, as to ineffectiveness, to date coming from Cochrane. Cochrane reviews are usually pretty conservative and lenient with medical claims. Usually they will suggest that more research needs to be done, while these authors seem content to basically say, “save it.”

    I had an inversion table in my office for a couple years that was given to me by a patient who no longer used it. I honestly can’t say it did anyone any real good, so my experience is in line with the findings of this review. Plus I thought someone was going to break a leg climbing on and off of it. So I guess you could say I was open to the idea that traction might work, and gave it a shot because it did make a certain amount of intuitive sense. I even have a pair of gravity boots from the 80s, that you can still buy on Amazon collecting dust somewhere.

    Reports like this really makes me feel bad for all the physical therapists and chiropractors who went out and purchased Vax D machines, which were not at all cheap. Still I feel more sorry for their patients, so I figured this blog was worth writing. The word was pretty much out on the ineffectiveness of lumbar traction/Vax-D, (on Chirobase, and Wikipedia) but this most recent Cochrane review added some additional studies strengthening the case against. Given I still see traction promoted around town by some physical therapists and chiropractors for the treatment of low back pain I figured it was worth a blog.

    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 Yoga Teacher Training at Sampoorna Yoga in Goa, India.