SpineFITyoga.com

Author: chad reilly

  • Intermittent Fasting Types and Terminology

    Intermittent Fasting and Human Metabolic Health. Patterson RE, Laughlin GA, Sears DD, LaCroix AZ, Marinac C, Gallo LC, Hartman SJ, Natarajan L, Senger CM, Martínez ME, Villaseñor A. Journal of the Academy of Nutrition and Dietetics. 2015 Apr 6.

    My comments:

    I usually read several papers a day and try to find time to blog on one of them and today this one won. My last blog was a mouse study on intermittent fasting types that found it had some benefits over calorie restriction diets, and the benefits of calorie restriction diets appear considerable. This paper was specifically looking at human data so I wanted to give it a read. One benefit of intermittent fasting that I like is you don’t have to count calories, or prepare a number of small sensible meals, which in a million years I’m never going to do.

    The gist of the article is that the various forms of intermittent fasting seem to be at least equally effective as calorie restriction diets and they broke intermittent fasting into several types so they could better compare apples to apples.

    • Complete Alternate Day Fasting: Participants ate every other day, ad libitum (as much as they wanted) on food days and on fasting days they ate nothing. They drank on fasting days, but nothing that contained calories.
    • Modified Fasting: Participants ate what they wanted on food days and did energy restriction, generally 20-25% of normal, with liquid diet. Also these diets often weren’t every other day but were 5 days of food and 2 (non-consecutive days) of relative fasting. It’s the basis of the better known 5:2 diet.
    • Time Restricted Feeding: Participants could eat ad libitum but only during certain hours of the day. It’s the method I thought I was doing with the Warrior diet, but it turns out what I’m doing is more in line with the Fast 5 (5 hour eating window starting at 5 pm, followed by 19 hour fasting in a 24 hour period), which is simpler.  Best of all the the Fast 5 diet book is free.

    As I’m reading more about the various fasting literature and the above 3 pretty much cover it. Some peoples recommendation being a combination or tweak of the above ideas. The Warrior diet being an example, sort of a modified time restriction diet as they allow light snacking during the fast period. The conclusion of this review was that all the methods appear to be effective for a variety of biomarkers described in the calorie restriction diets. As of yet there is not enough data to strongly suggest that one intermittent fasting method is better than others, particularly in humans. However, in general they reported the human study findings were in line with the animal research. They note that unlike the animals, people sometimes cheat on their diets and complain. Noting that on the complete alternate fasting that…

    “self reported hunger on fasting was considerable and did not decrease over time, suggesting that alternate-day fasting may not be a feasible public health intervention.”

    …which changes my plans a bit. I was planning the alternate day fast for 30 days, after 30 days on the Fast 5. However it sounds like in reality, alternate day eating is just as miserable as it sounds and you don’t get used to it. So maybe I’ll just try it for a couple days, just to say I did. On the contrary, I’m 17 days into the Fast 5, and so far it’s a cake walk, figuratively if not literally.

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

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

  • Intermittent Fasting and/vs Calorie Restriction Diets

    Intermittent fasting dissociates beneficial effects of dietary restriction on glucose metabolism and neuronal resistance to injury from calorie intake. Anson RM1, Guo Z, de Cabo R, Iyun T, Rios M, Hagepanos A, Ingram DK, Lane MA, Mattson MP. Proc Natl Acad Sci U S A. 2003 May 13;100(10):6216-20. Epub 2003 Apr 30.

    Abstract
    Dietary restriction has been shown to have several health benefits including increased insulin sensitivity, stress resistance, reduced morbidity, and increased life span. The mechanism remains unknown, but the need for a long-term reduction in caloric intake to achieve these benefits has been assumed. We report that when C57BL6 mice are maintained on an intermittent fasting (alternate-day fasting) dietary-restriction regimen their overall food intake is not decreased and their body weight is maintained. Nevertheless, intermittent fasting resulted in beneficial effects that met or exceeded those of caloric restriction including reduced serum glucose and insulin levels and increased resistance of neurons in the brain to excitotoxic stress. Intermittent fasting therefore has beneficial effects on glucose regulation and neuronal resistance to injury in these mice that are independent of caloric intake.

    My comments:

    I have never been that interested in diet as I never had much of a problem with body weight, nor as a physical therapist did I really think it was my job to talk about it, except maybe to suggest that weight loss or gain might be beneficial for a given patient. However, since reading the paper on dietary restriction preserving muscle mass and preventing sarcopenia I have continued to read more on the subject. I had also read about the Warrior diet on wikipedia, concluded it fit my personality pretty well, not eating during the day then eating as much as you want in the evening. This week I read and finished the warrior diet book, and I thought it had some good insights but I was a bit disappointed to learn that the author did a lot of eating during the day rather than abstaining, which isn’t what I have done or wanted to do. Reading the criticisms of the Warrior Diet on amazon.com a lot of people said they liked the concept but the book was padded out and he did a lot of promoting supplements which I’m not interested in either. Someone said they started off on the Warrior Diet, then moved on the the Fast 5 Diet, which it turns out is what I was already doing, didn’t promote supplements and best of all the pdf of the Fast-5 Diet book is available free. I’m not going so far as to say I’d advocate it yet, but I’m on my 15th day and so far I like it.

    So what’s the point? Calorie restriction has been shown to extend the lifespan and prevent disease, and muscle loss in a wide variety of fauna, with similar metabolic improvements seen in people, though the prolonging of lifespan in humans has yet to be established. Regarding the animals, some of the caloric reductions were done by just limiting available calories 30% (plus or minus depending on the study) while other papers were limiting calories by feeding the animal every other day. This led researchers to wonder how much of the every other day diet (intermittent fasting) benefits were due to the calorie reduction, and how much of it was due to the spacing out of the food source (fasting irrespective of calorie reduction). Most of the mice on the every other day diet decreased overall calories but the strain used in this paper ate almost double on the feeding days such that overall calorie intake was about the same (~90% as the mice allowed to eat as much as they want everyday).

    Both the fasting and the calorie restriction mice had reductions in blood glucose and insulin to a similar degree with a slight edge given to the fasting mice. IGF-1 and B-hydroxybutyrate however increased in the fasting mice, but went down in the calorie restricted mice with the researcher concluding these increases might be neuroprotective, as was the shift towards ketosis, found in the fasting but not calorie restrictive diets. The mice were then injected with kanic acid to their hippocampus to assess if there was an effect with either diet on neuron survival. Both the caloric restriction and intermittent fasting rats had better survival of neurons compared to the mice that ate their fill daily, with the intermittent fasting mice being significantly better.

    So based on this study intermittent fasting has some health benefits in addition to and separate from what you get from calorie restriction alone (EVEN IF YOU EAT DOUBLE ON THE NON-FAST DAYS). The question then becomes, what’s the best/easiest/most tolerable form of intermittent fasting. The mice did an every other day fasting diet, which to me sounds miserable. Though, skipping breakfast and lunch per the Warrior and Fast 5 diets sounded fairly miserable to me too, until I tried it, and so far I like, and I definitely feel like I have more energy during the day. It’s still unknown, at least to me, if the once a day diet has similar protective benefits to the every other day diet. I should point out that it likely doesn’t have to be either/or proposition as these researchers had to search for a strain of mice that ate double on the feeding days because most didn’t and calorie reduction went hand in hand with intermittent fasting. Thus far I notice it does seem to reduce my overall calories too, so with the best of both worlds maybe I’ll live to 150 before I have my consciousness uploaded into a robot;) To be continued…

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

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

  • Exercise Won’t Selectively Activate the VMO but Electric Stimulation Will

    Effects of electrical stimulation of vastus medialis obliquus muscle in patients with patellofemoral pain syndrome: an electromyographic analysis. Garcia FR1, Azevedo FM, Alves N, Carvalho AC, Padovani CR, Negrão Filho RF. Rev Bras Fisioter. 2010 Nov-Dec;14(6):477-82.

    Abstract
    BACKGROUND:
    The use of surface electromyography (SEMG) has been considered a tool for quantitative assessment of patellofemoral pain syndrome (PFPS). Conservative treatments aim to improve patellar alignment, and electrical stimulation of the vastus medialis obliquus (VMO) muscle has been considered effective because it is selective and does not cause joint irritation.

    OBJECTIVE:
    This study aims to investigate the efficiency of a muscle strengthening program with electrical stimulation of the VMO muscle in PFPS by SEMG.

    METHODS:
    A group of ten young women (age: 23.1 ± 4.9 years; body mass: 66.8 ± 14.0 kg; height: 1.63 ± 6.9 cm; BMI: 25.1 ± 5.6 kg/m²) with unilateral PFPS participated in the study. They performed the functional test of stair stepping to capture the electromyographic (EMG) activity of the VMO and vastus lateralis (VL) muscles, before and after a program of electrical stimulation of the VMO muscle. The electrical stimulation was performed three times per week for six weeks. For an analysis between the VMO and VL muscles, we considered the variables: ratio of time of onset to peak of activation, ratio of the integrals of the signals (t-test for dependent samples), and any difference between onsets of activation (Wilcoxon test), with a significance level of p < 0.05.

    RESULTS:
    The results only showed  change in behavior in the EMG signal for the ratio of the integrals of the signals, indicating that changes occurred in the force-generating capacity of the muscle after the training.

    CONCLUSION:
    The use of electrical stimulation should be considered to complement the conservative therapeutic approach in patients with PFPS, and the analysis of the ratio of the integrals of the SEMG signals should be considered as an instrument of evaluation.

    My comments:
    I’m not a fan of attempting to selectively strengthen the VMO (oblique fibers of the vastus medialis) for patellofemoral pain. The idea is that by doing so, it will help the patella track more medially and thus decreasing stress on lateral structures. The reason I’m not a fan is due to reading study after study, there is an indication that it’s pretty much impossible to preferentially recruit the VMO with exercise. As a physical therapist I hear about it all the time, and though the VMO might help pull the knee medial, when you do exercise the brain activates all aspects of the quads, lateral as well as medial. Exercises attempting to tweak the balance towards the medial by turning the toes out, coactivating the hip adductors, etc. just don’t pull it off. If any exercise does make a percent of difference between VM or VMO vs. vastus lateralis (VL) activation ratios, they generally do so by making the entire quadriceps EMG decrease. That said, electrical muscle stimulation (EMS) is different. You put EMS electrodes on a portion of a large muscle like the quadriceps and that portion of the muscle will contract to the exclusion of the rest. It’s plainly evident if you try it on yourself, which is what I think every physical therapist should do.

    This study tested the EMS theory out to see if doing so would get the VMO to activate earlier, which it did not. However, it did make the VMO activate stronger after training with EMS 3 times per week for 6 weeks. Such that the electromyographic signal ratio of the VMO/VL increased from 0.89 to 1.82, which is pretty substantial. Whether this helps to decrease patellofemoral pain is another matter that was not tested, as it appears that the primary muscle weakness seen with patellofemoral pain isn’t quadriceps, but rather at the hip. Still it makes me think that if I’m going to put some number of EMS electrodes on the quadriceps, at least one of them is going to be on the vastus medialis. I was doing that most of the time already, but until I have a better idea, I figure I’ll do it all the time now.
    EMS parameters used in this study were as follows:

    • Waveform: asymmetric bipolar
    • Frequency: 50 Hz
    • Pulse duration: 500 US
    • Treatment duration: 7 minutes
    • Duty Cycle and treatment duration: 6 sec on 12 sec off for 7 minutes, progressing to 10 sec on 20 sec off for 30 minutes.
    • mA: “maximum intensity the participant could bear, without pain during contraction”

    Those are not  the parameters I would use but they seemed pretty effective anyway. One of the downsides of EMS research is that parameters used are all over the place, with certain guidelines emerging as good, but still lots of exceptions. The bright side is that more often than not, the exceptions from the norm still work.

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

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

  • Decreasing Calories 30% Increases Testosterone 21-27%

    Impact of moderate calorie restriction on testicular morphology and endocrine function in adult rhesus macaques (Macaca mulatta). Sitzmann BD, Brown DI, Garyfallou VT, Kohama SG, Mattison JA, Ingram DK, Roth GS, Ottinger MA, Urbanski HF. Age (Dordr). 2014 Feb;36(1):183-97.

    Abstract:
    We previously reported that moderate calorie restriction (CR) has minimal impact on testicular gene expression in young adult rhesus macaques, and no obvious negative impact on semen quality or plasma testosterone levels. We now extend these findings by examining the influence of CR on various aspects of the reproductive axis of older males, including 24-h circulating testosterone levels, testicular gene expression, and testicular morphology. Young adult and old adult male rhesus macaques were subjected to either 30 % CR for 5-7 years, or were fed a standard control diet. Analysis of the 24-h plasma testosterone profiles revealed a significant age-associated decline, but no evidence for CR-induced suppression in either the young or old males. Similarly, expression profiling of key genes associated with testosterone biosynthesis and Leydig cell maintenance showed no significant CR-induced changes in either the young or old animals. The only evidence for CR-associated negative effects on the testis was detected in the old animals at the histological level; when old CR animals were compared with their age-matched controls, there was a modest decrease in seminiferous tubule diameter and epithelium height, with a concomitant increase in the number of depleted germ cell lines. Reassuringly, data from this study and our previous study suggest that moderate CR does not negatively impact 24-h plasma testosterone profiles or testicular gene expression. Although there appear to be some minor CR-induced effects on testicular morphology in old animals, it is unclear if these would significantly compromise fertility.

    Select quotes from the study:

    “Testosterone decline, especially during aging, can result in weakening muscle function, bone density and alteration of other physiological parameters related to overall aging (Bremner et al. 1983; Feldman et al. 2002; Harman et al. 2001; Moffat et al. 2002; Sitzmann et al.2008). Also of importance is the neurological impact of T loss. Some studies have reported that men with Alzheimer’s disease (AD) have significantly lower T levels than aged men without AD (Moffat et al. 2002; Rosario et al. 2006). Significantly, T depletion appears to occur well before clinical and pathological diagnosis of AD, suggesting that low T levels may contribute to AD pathogenesis rather than results from it (Rosario et al. 2006).”

    “Surprisingly, maximum circulating T levels were significantly higher in old CR males than in their age-matched controls. Whether this apparent increase is physiologically significant is unclear, but when considered together with our previous finding that CR enhanced the daily minimum T levels in young males, it may be indicative of a subtle improvement of physiological efficiency elicited by moderate CR.”

    “Moreover, findings in the old adults may be an indication that CR can contribute to the maintenance of elevated T levels during old age, which would be of great physiological benefit.”

    “The most important finding, however, is that moderate CR does not suppress T production or disrupt the 24-h pattern of T in the circulation; if anything, it may even enhance circulating T levels. Consequently, CR is unlikely to negatively impact androgen-mediated nonreproductive functions, and may exert additional beneficial effects.”

    My comments:

    I was in my office talking about my recent blog topic of calorie restriction reducing muscle loss and sarcopenia with aging and how it was the opposite of what I would have expected. One of my patients asked why. I was unsure, saying most of the papers I looked showed an overall reduction in cell death, and muscle cells are among those cells, and this appears to explain at least part of it, though the mechanisms are still not understood. Then someone said something about calories and testosterone, and I said given the results on muscle mass, calorie restriction might also increase/preserve testosterone levels with age. Within minutes I was on pubmed combining key words of calorie restriction and testosterone and this was the first paper I got printed.

    The researchers found that calorie restriction (30%) for 5-7 years did not negatively affect testosterone levels but actually increased mean plasma testosterone levels 20.7% in young adult male monkeys (beginning at the peripubertal period of 4 years 11 months) and 26.7% in older ones (age not given). Also interesting to me is that the terminal body weight at death of the older calorie restricted monkeys was slightly more in the control group (6.69 vs 6.27 kg), but the calorie restricted monkeys were lighter in the younger group (9.19 vs 10.72 kg) perhaps reflecting some combination of increased muscle/decreased fat that one might expect with increased testosterone levels as found in the other study.

    As a physical therapist, findings like this sound like they could have considerable positive impact on my patients’ lives. I’m still not sure how to ideally implement it in the lives of people. For example 30% reduction compared to what? I’ll keep reading the research and see what I find, but in the meantime it makes for interesting conversation in the gym.

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

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

  • Caloric Restriction Decreases Muscle Cell Death with Age

    Sarcopenia: the role of apoptosis and modulation by caloric restriction. Dirks Naylor AJ, Leeuwenburgh C. Exerc Sport Sci Rev. 2008 Jan;36(1):19-24.

    Abstract
    The mechanisms of sarcopenia have been slowly unraveled and likely involve activation of apoptosis. It is hypothesized that caloric restriction may, in part, attenuate sarcopenia by affecting apoptotic signaling. The signaling pathways responsible for the execution of apoptosis in aging muscle and the modulation of these pathways by caloric restriction are discussed.

    My Comments:
    This was a review paper I found when following up on my recent blog describing the monkey study where they found a 30% reduction in calories resulted in less muscle fiber atrophy and loss due to age. This paper, though earlier, is a review attempting to explain why, describing caloric restriction as:

    “the only nongenetic intervention known to slow the intrinsic rate of aging in mammals. Caloric restricting rodents 40% of ad libitum diet, while maintaining adequate nutrition, increases maximum lifespan 30-40%. Caloric restriction slows the progressive decline in widespread organ function and attenuates the onset of age-related diseases, such as cancer, diabetes, and Alzheimer disease. Caloric restriction also attenuates the decline in skeletal muscle function with age.”

    They cited studies on rats, which were recently confirmed on primates and it seems that at least some of the benefit is the prevention/slowing of apoptosis also known as programmed cell death. Muscles cells, being cells, seem be among the many tissues that just survive better when you eat less. The gist of the paper is that apoptosis of muscle cells is documented to occur, there is a lot of research being done attempting to describe the exact mechanism, which as of yet is unknown. It was interesting to see that the earlier primate study I cited wasn’t a novel finding but rather confirming what had already been shown in other mammalian species. In other papers I have ordered and started to read on, calorie restriction and intermittent fasting for slowing nearly all aspects of aging are fascinating and something I expect I’ll be continuing to blog on, as though diet related, seems pretty relevant to physical therapy and just health in general.

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

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

  • Short Term Effects of the Epley Maneuver for BPPV

    Short-term efficacy of Epley’s manoeuvre: a double-blind randomised trial. von Brevern M, Seelig T, Radtke A, Tiel-Wilck K, Neuhauser H, Lempert T. J Neurol Neurosurg Psychiatry. 2006 Aug;77(8):980-2.

    Abstract
    BACKGROUND:
    Benign paroxysmal positional vertigo of the posterior canal (PC-BPPV) is a common vestibular disorder and can be easily treated with Epley’s manoeuvre. Thus far, the short-term efficacy of Epley’s manoeuvre for treatment of PC-BPPV is unknown.

    OBJECTIVES:
    To evaluate the efficacy of Epley’s manoeuvre for treatment of PC-BPPV 24 h after applying the manoeuvre.

    METHODS:
    The short-term efficacy of Epley’s manoeuvre was compared with a sham procedure in 66 patients with PC-BPPV by using a double-blind randomised study design.

    RESULTS:
    24 h after treatment, 28 of 35 (80%) patients in the Epley’s manoeuvre group had neither vertigo nor nystagmus on positional testing compared with 3 of 31 (10%) patients in the sham group (p<0.001).

    CONCLUSION:
    Epley’s manoeuvre is shown to resolve PC-BPPV both effectively and rapidly.

    My Comments:

    This is not exactly breaking news or controversial anymore but I have been getting increasing referrals vestibular rehabilitation and often times it works but sometimes it doesn’t. I figured I could help my patients better if I looked into some of the newer maneuvers for treating BPPV (the most common cause of vertigo) and to compare new to old it would be worth looking at some of the earlier studies. This one seemed particularly well done, being a double blind controlled trial, with the sham treatment being the identical but opposite maneuver (for the wrong ear). Thus I expect the blinding was maintained pretty well and placebo effect well controlled for.  As the abstract says 80% were cured when tested 24 hours later with the Epley Maneuver as compared to 10% in the control group.

    What was interesting to me, and not described in the abstract, was that the Epley maneuver was successful at eliminating symptoms 43% of the time with the first attempt, thus 57% required a 2nd or 3rd attempt to eliminate symptoms when retested with the Dix-Hallpike test. Somehow I missed that when reading Herdman, so if it didn’t work the first time I was on to my roll over maneuver. So going forward I’ll give Epley’s maneuver a couple extra tries. You learn something new every day.

    Even in the newer papers the Epley maneuver is holding up really well as THE (or at least A) treatment of choice for BPPV with involvement of the posterior semicircular canal. The posterior canal is implicated by noting mixed torsional or upbeating nystagmus with the torsional component to the undermost/affected ear. Unfortunately BPPV descriptions aren’t exactly laymen friendly, nor necessarily physical therapist friendly, with diagnosis and treatment complicated when different, or more than one semicircular canal is affected. The great thing about BPPV is when hit it with the right canal with the right maneuver you are often an immediate hero. So I’m looking up my hero average a bit. I also learned “maneuver” is the American spelling, while the rest of the english speaking world uses “manoeuvre” but they mean and are pronounced the same. That’s two things for today.

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

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

  • McKenzie Method as Lackluster as Back School for Back Pain

    Effectiveness of back school versus McKenzie exercises in patients with chronic nonspecific low back pain: a randomized controlled trial. Garcia AN, Costa Lda C, da Silva TM, Gondo FL, Cyrillo FN, Costa RA, Costa LO. Physical Therapy. 2013 Jun;93(6):729-47.

    Abstract
    BACKGROUND:
    Back School and McKenzie methods are popular active treatment approaches that include both exercises and information for patients with chronic nonspecific low back pain.

    OBJECTIVE:
    The purpose of this study was to compare the effectiveness of Back School and McKenzie methods in patients with chronic nonspecific low back pain.

    DESIGN:
    The study was a prospectively registered, 2-arm randomized controlled trial with a blinded assessor.

    SETTING:
    The study was conducted in the outpatient physical therapy clinic in São Paulo, Brazil.

    PATIENTS:
    The study participants were 148 patients with chronic nonspecific low back pain.

    INTERVENTIONS:
    The 4-week treatment program (one session/week) was based on the Back School (delivered to the group) or McKenzie (delivered individually) principles. The participants also were instructed to perform a daily set of home exercises.

    MEASUREMENTS:
    Clinical outcomes were assessed at follow-up appointments at 1, 3, and 6 months after randomization. Primary outcome measures were pain intensity (measured by the 0-10 pain numerical rating scale) and disability (measured by the 24-item Roland-Morris Disability Questionnaire) 1 month after randomization. Secondary outcome measures were pain intensity and disability at 3 and 6 months after randomization, quality of life (measured by the World Health Organization Quality of Life-BREF instrument) at 1, 3, and 6 months after randomization, and trunk flexion range of motion measured by an inclinometer at 1 month after randomization. The data were collected by a blinded assessor.

    RESULTS:
    Participants allocated to the McKenzie group had greater improvements in disability at 1 month (mean effect=2.37 points, 95% confidence interval=0.76 to 3.99) but not for pain (mean effect=0.66 points, 95% confidence interval=-0.29 to 1.62). No between-group differences were observed for all secondary outcome measures.

    LIMITATIONS:
    It was not possible to monitor the home exercise program. Therapists and participants were not blinded.

    CONCLUSIONS:
    The McKenzie method (a more resource-intensive intervention) was slightly more effective than the Back School method for disability, but not for pain intensity immediately after treatment in participants with chronic low back pain.

    My comments:
    This was a pretty good study and I think the researchers findings and conclusions are reasonable. They reported McKenzie Method was slightly more effective at reducing disability (2.37 points better on a 24 point scale) but not pain in comparison to Back School. The authors noted that McKenzie Method required one on one training while the back school didn’t, such that if a cost benefit analysis were done they suspected the back school would win out.

    Both programs consisted of patient education emphasizing maintaining good postures while sitting and at work, which while details were not given I do agree that good postures when sitting and moving are a good thing for back pain. However looking over the exercise programs in each group, I’m of the impression that the postural advice might be what resulted in the bulk of the pain reductions (which were minimal at that). I would expect neither programs exercises to have much benefit with regards to decreasing back pain. This would stand to reason, given a meta-analysis of McKenzie Method concluded it had an “absence of clinically worthwhile effects” and was less effective than advice to just stay active.

    When I read McKenzie’s books I thought general postural advice was quite good so maybe it’s the exercises themselves that got in the way as in this study they were just spine stretching exercises and a lateral shift that don’t result in any increased fitness. The Back School exercises were just diaphragmatic breathing, spine and hip stretches, pelvic tilts, crunches and single leg lifts, which I would expect to have minimal, at best, effects on fitness levels or back pain. Pain in both the McKenzie Method and Back School programs decreased from ~6/10 to 4/10 in a month but at 3 and 6 months had returned back up to 5/10. Low back pain being reduced from a 6/10 to a 5/10 is hardly worth leaving home for. Thus I think physical therapists, AND PHYSICAL THERAPY SCHOOLS should be embracing newer research findings rather than clinging to and teaching the past so their students can pass worn out board exams. Speaking of worn out material, where’s my file on PNF?

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

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

  • Sprints Better than Plyometrics in Every Way

    Effects of sprint and plyometric training on muscle function and athletic performance. Markovic G, Jukic I, Milanovic D, Metikos J Strength Cond Res. 2007 May;21(2):543-9.

    Abstract
    The purpose of this study was to evaluate the effects of sprint training on muscle function and dynamic athletic performance and to compare them with the training effects induced by standard plyometric training. Male physical education students were assigned randomly to 1 of 3 groups: sprint group (SG; n = 30), plyometric group (PG; n = 30), or control group (CG; n = 33). Maximal isometric squat strength, squat- and countermovement jump (SJ and CMJ) height and power, drop jump performance from 30-cm height, and 3 athletic performance tests (standing long jump, 20-m sprint, and 20-yard shuttle run) were measured prior to and after 10 weeks of training. Both experimental groups trained 3 days a week; SG performed maximal sprints over distances of 10-50 m, whereas PG performed bounce-type hurdle jumps and drop jumps. Participants in the CG group maintained their daily physical activities for the duration of the study. Both SG and PG significantly improved drop jump performance (15.6 and 14.2%), SJ and CMJ height ( approximately 10 and 6%), and standing long jump distance (3.2 and 2.8%), whereas the respective effect sizes (ES) were moderate to high and ranged between 0.4 and 1.1. In addition, SG also improved isometric squat strength (10%; ES = 0.4) and SJ and CMJ power (4%; ES = 0.4, and 7%; ES = 0.4), as well as sprint (3.1%; ES = 0.9) and agility (4.3%; ES = 1.1) performance. We conclude that short-term sprint training produces similar or even greater training effects in muscle function and athletic performance than does conventional plyometric training. This study provides support for the use of sprint training as an applicable training method of improving explosive performance of athletes in general.

    My comments:

    I have to admit that I’m not a fan of plyometrics. When I was on the weightlifting team at NAU doing my undergraduate course work on exercise science I read the book Jumping into Plyometrics by Donald Chu and got the idea that adding drop jumps to my weightlifting program was a good idea. I remember my weightlifting coach at the time saying that was dumb, but I didn’t listen. My experience was that it didn’t help my weightlifting ability a single percent, but within a couple weeks I had a nasty case of patellar tendinitis that plagued me the rest of my weightlifting career. It did get me VERY interested in the treatment of tendinitis when in physical therapy school and my resultant tendinitis treatment protocol is stellar. So perhaps my reading Dr. Chu’s book was for the greater good. Unfortunately I didn’t figure out my protocol until well after I graduated so my knees pretty much just hurt, all the time, until I quit competitive weightlifting. I was still able clean and jerk 347 lb, which was pretty good, but I always felt that if my training wasn’t limited by the patellar tendinitis. I would have cleaned and jerked over 400 lb. Thanks plyometrics!

    It was of interest to me when I read the above paper comparing plyometric hurdle jumps and drop jumps at 40 to 60 cm height to that of roughly equal time doing short sprints of 10-50 meters. The subjects were then tested on speed, jump ability and strength. One might expect a degree of specificity to come about with the sprint group being better at running type drills and the plyometric group being better at jumping drills. This, sort of, happened with the sprint group running away (haha) from the plyometric group with significant improvements in 20 meter sprint times by 3.1% and 20 yard shuttle runs of 4.3%, while the plyometric group was shy of significance with less than half the improvement of the sprinters. The sprint group improved in strength (squats) by 10%, while the plyometric group didn’t improve at all. When testing got to where the plyometrics should have the advantage, the plyometric group did improve, but the sprint group always edged them out.  Sprint training improving performance over the plyometric group on squat jumps (10% vs 6.5%), countermovement jumps (7.4% vs 6.3%), drop jumps (15.6% vs 14.2%) and standing long jump (3.2% vs 2.8%) for the sprint vs. plyometric groups respectively.

    So to sum it up, sprinting made you faster and more agile in running related activities while the plyometric group didn’t. Sprinting increased squat strength while the plyometrics didn’t, and while both groups improved vertical and horizontal jumping ability the sprint group managed to do even that ever so slightly better. Plyometrics have become commonplace in sports and fitness training programs and while I think they are a higher risk with regards to overuse injuries I don’t think they deliver enough performance improvements to make that risk worth it. So if you ask me where plyometrics can best be implemented into a training program, I say nowhere, leave them out. Yes plyometrics “work” but I think I can always think of something that works better. As this study demonstrated, sprint training always works better.

    The sprint group protocol was 3 sessions per week thusly: 

    week 1 10-m sprint x 3 x 3
    week 2 10-m sprint x 4 x 3
    week 3 20-m sprint x 3 x 3
    week 4 20-m sprint x 4 x 3
    week 5 30-m sprint x 3 x 3
    week 6 (rest)
    week 7 30-m sprint x 4 x 3
    week 8 40-m sprint x 3 x 3
    week 9 40-m sprint x 4 x 3
    week 10 50-m sprint x 3 x 3
    week 11 50-m sprint x 4 x 3

    The plyometric protocol was, eh who cares. 

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

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

  • Eat Less for More Muscle?

    Always looking for something for nothing, this might be the ultimate. When I was a competitive bodybuilder and weightlifter I was always force feeding myself to gain weight and compete in higher weight classes, and as fun as that sounds it gets old. In the last few years I had been vaguely following the results of various starvation diets (now referred to as “calorie restriction” diets) but had never gone further than reading the Wiki and a few news articles on them. I knew they were associated with increased longevity in many species of animals now up to and including primates, but not yet tested in humans. While I expect the calorie restriction diets have a number of health benefits I would have figured those animals to be both thinner and frailer, so I was surprised by this study, making it a most fascinating read (full text at the link):

    Cellular adaptation contributes to calorie restriction-induced preservation of skeletal muscle in aged rhesus monkeys. McKiernan SH, Colman RJ, Aiken E, Evans TD, Beasley TM, Aiken JM, Weindruch R, Anderson RM. Exp Gerontol. 2012 Mar;47(3):229-36. [FREE FULL TEXT]

    Abstract
    We have previously shown that a 30% reduced calorie intake diet delayed the onset of muscle mass loss in adult monkeys between ~16 and ~22 years of age and prevented multiple cellular phenotypes of aging. In the present study we show the impact of long term (~17 years) calorie restriction (CR) on muscle aging in very old monkeys (27-33 yrs) compared to age-matched Control monkeys fed ad libitum, and describe these data in the context of the whole longitudinal study. Muscle mass was preserved in very old calorie restricted (CR) monkeys compared to age-matched Controls. Immunohistochemical analysis revealed an age-associated increase in the proportion of Type I fibers in the VL from Control animals that was prevented with CR. The cross sectional area (CSA) of Type II fibers was reduced in old CR animals compared to earlier time points (16-22 years of age); however, the total loss in CSA was only 15% in CR animals compared to 36% in old Controls at ~27 years of age. Atrophy was not detected in Type I fibers from either group. Notably, Type I fiber CSA was ~1.6 fold greater in VL from CR animals compared to Control animals at ~27 years of age. The frequency of VL muscle fibers with defects in mitochondrial electron transport system enzymes (ETS(ab)), the absence of cytochrome c oxidase and hyper-reactive succinate dehydrogenase, were identical between Control and CR. We describe changes in ETS(ab) fiber CSA and determined that CR fibers respond differently to the challenge of mitochondrial deficiency. Fiber counts of intact rectus femoris muscles revealed that muscle fiber density was preserved in old CR animals. We suggest that muscle fibers from CR animals are better poised to endure and adapt to changes in muscle mass than those of Control animals.

    My Comments

    So I learned a rhesus monkey hits middle age when 16 years old and has an average life expectancy of 27 years with age related declines in function similar but 2.5-3 times faster than in humans. Calorie restriction (CR) monkeys reached their peak in leg muscle mass at 18 years, 2 years after the control monkeys, and they held onto their muscle longer. Body weight of CR monkeys was 20% lower than controls with body fat 35% lower. At 27 years of age upper leg muscle mass of the CR monkeys was 1347 grams compared to 1218 grams for controls (10.6% more in the CR monkeys). 27 year old CR monkeys maintained 73.03% of their peak muscle mass at age 18 compared to control monkeys maintaining only 56.80% of their peaks at age 16. CR monkeys had less fibrotic material in their muscle tissue 6.44% compared to controls with 13.98%. CR monkeys maintained more fast twitch (type II) muscle fibers (typically lost with age), had larger type II muscle fibers, and they had greater number and larger slow twitch (type I) muscle fibers compared to controls. CR monkeys still lost type II muscle fibers over time, but it was delayed ~10 years in comparison to controls. Basically the CR monkeys were better off, A LOT BETTER OFF, on every measure. It’s probably worth mentioning that the researchers noted the CR monkeys had a more youthful appearance and 5/15 of the control monkeys died, while only 2/15 CR monkeys did.

    With a number of the physical therapy patients I treat being seen for balance and fall risk which is primarily due to sarcopenia (age related muscle loss) dietary restrictions that maintain muscle mass and health while positively affecting a number of other disease processes might be very beneficial. It’s always worth noting that these results are in monkeys and may not apply to humans, though generally they do. The amount of calorie restriction was 30%, which is less than a monkey wants to eat but not enough to make them malnourished. From what I have read a 30% reduction in calories (compared to what the average organism wants to eat) seems to be the sweet spot with regards to slowing the aging process and in this case maintaining muscle mass. I expect in a few decades they will have human research that collaborates this one on the monkeys, but in the meantime I think I’m skipping breakfast, and maybe lunch. And as much as I advocate for exercise, eating less is a lot easier, cheaper, certainly more convenient than working out more.

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

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

  • Electric Stim to Prevent DVTs After Total Hip Replacement

    Haemodynamic performance of neuromuscular electrical stimulation (NMES) during recovery from total hip arthroplasty. Broderick BJ, Breathnach O, Condon F, Masterson E, Ólaighin G. J Orthop Surg Res. 2013 Mar 5;8:3.

    Abstract
    BACKGROUND:
    Patients post total hip arthroplasty (THA) remain at high risk of developing Deep Vein Thrombosis (DVT) during the recovery period following surgery despite the availability of effective pharmacological and mechanical prophylactic methods. The use of calf muscle neuromuscular electrical stimulation (NMES) during the hospitalised recovery period on this patient group may be effective at preventing DVT. However, the haemodynamic effectiveness and comfort characteristics of NMES in post-THA patients immediately following surgery have yet to be established.

    METHODS:
    The popliteal veins of 11 patients, who had undergone unilateral total hip replacement surgery on the day previous to the study, were measured using Doppler ultrasound during a 4 hour neuromuscular electrical stimulation (NMES) session of the calf muscles. The effect of calf muscle NMES on peak venous velocity, mean venous velocity and volume flow were compared to resting values. Comfort was assessed using a 100mm non-hatched visual analogue scale taken before application of NMES, once NMES was initiated and before NMES was withdrawn.

    RESULTS:
    In the operated limb NMES produced increases in peak venous velocity of 99% compared to resting. Mean velocity increased by 178% compared to resting and volume flow increased by 159% compared to resting. In the un-operated limb, peak venous velocity increased by 288%, mean velocity increased by 354% and volume flow increased by 614% compared to basal flow (p<0.05 in all cases). There were no significant differences observed between the VAS scores taken before the application of NMES, once NMES was initiated and before NMES was withdrawn (p=.211).

    CONCLUSIONS:
    NMES produces a beneficial hemodynamic response in patients in the early post-operative period following orthopaedic surgery. This patient group found extended periods of calf-muscle NMES tolerable.

    My comments:
    I get a lot of total hip arthroplasty (THA) and total knee arthroplasty (TKA) and blood clots/deep vein thrombosis (DVT) are a real problem, usually soon after the procedure and before I get them for physical therapy. Often they are treated with anti-coagulants and if high enough risk with intermittent pneumatic compression (IPC). I don’t at all consider myself an expert regarding DVT or the various prophylactic drugs or compression devices, but my electrical stimulation knowledge is right up there and I’m always interested in new applications.  So it was interesting to read what they found in this study, how they found it, and I had some ideas that I thought would make EMS both more effective and easier to apply. According to the paper DVT are caused by 3 factors, 1) altered blood constitution or hypercoagulability, 2) alterations blood flow, or venous stasis, and 3) vascular endothelial damage. They reported 1 and 2 were closely linked, saying that when venous stasis is present hypercoagulability follows.

    They used 2 channel bi-phasic square wave stimulator with a 350 uS pulse width, which is pretty stout, going at 36 hz that sounds like it alternated between 30 second contraction between the right and left leg, thus 30 seconds on and 30 seconds off for 4 hours. Volume of venous blood flow increased 159% in the operated limb and 614% in the unoperated limb. So it obviously worked but I will have to read up on the IPC devices to see how they compare. While it more than doubled blood flow to the operated limb, the unoperated limb increased blood flow over 6 times so there were apparently some restrictions on the side due to the surgery. According the the paper DVT also in the unoperated limb due to similar inactivity after surgery.

    The researchers reported they had some difficulty properly locating the motor points to put the electrodes in the right position and it was hard on the patients, due to post-op pain to position themselves to get the electrodes right. However I think a problem was they were using 5 cm square electrodes, which are usually the cheapest, smallest, sticky electrodes that come with the machines. If however they used 10 cm circular rubber carbon electrodes, which are more comfortable and last longer, make it so you don’t have to be so particular about locating motor points.  The larger electrodes you can just stick them over the muscle and you are good to go. With the larger surface area, but big electrodes generally cover several motor points, if you are into that.  Also I wouldn’t expect the 30 second on, 30 second off duty cycle to be ideal for increasing blood flow. Most of the research coming out on cardiovascular conditioning are using constant 4-6 Hz frequency to mimic shivering and I expect similar parameters would improve lower extremity blood flow more effective than the parameters given here, such that the 4 hour treatment time could be shortened. Also in my own subjective experience with EMS to increase a pumping action of the calves, having one large electrode of the gastrocnemius and another over the tibialis anterior sure feels like it is not only inducing muscle contractions but feels like it is mechanically squeezing the muscles against the tibia and fibula bones so it would be interesting to see if that has any additional improvement on blood flow and venous return. Having one electrode over the tibialis anterior should also at least partially offset the forceful plantar flexion contractions experienced by a minority of subjects in the study. I would think larger pads and a 4 channel device, so that you could add a pad to the quadriceps and hamstrings, as well as the calves would significantly improve blood flow as compared to just doing so on the calf musculature in this study. All in all it has me thinking about getting my own ultrasound doppler device to test these variables out on my own.

    Also if the machines are programmable they would be able to change the settings to prevent post-op muscle atrophy and decrease pain as well, which is not bad for a machines that only cost a couple hundred dollars. I imagine that compares favorably in the cost benefit ratio over the IPC machines. Though this paper was done on total hip replacements, my assumption would be that the EMS would also work for other procedures where DVT are a problem to include total knee replacements.

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

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

  • Hamstring Activity During Sprints

    Hamstring musculotendon dynamics during stance and swing phases of high-speed running. Chumanov ES, Heiderscheit BC, Thelen DG. Med Sci Sports Exerc. Med Sci Sports Exerc. 2011 Mar;43(3):525-32.

    Abstract

    INTRODUCTION:
    Hamstring strain injuries are common in sports that involve high-speed running. It remains uncertain whether the hamstrings are susceptible to injury during late swing phase, when the hamstrings are active and lengthening, or during stance, when contact loads are present. In this study, we used forward dynamic simulations to compare hamstring musculotendon stretch, loading, and work done during stance and swing phases of high-speed running.

    METHODS:
    Whole-body kinematics, EMG activities, and ground reactions were collected as 12 subjects ran on an instrumented treadmill at speeds ranging from 80% to 100% of maximum (avg max speed = 7.8 m·s(-1)). Subject-specific simulations were then created using a whole-body musculoskeletal model that included 52 Hill-type musculotendon units acting about the hip and the knee. A computed muscle control algorithm was used to determine muscle excitation patterns that drove the limb to track measured hip and knee sagittal plane kinematics, with measured ground reactions applied to the limb.

    RESULTS:
    The hamstrings lengthened under load from 50% to 90% of the gait cycle (swing) and then shortened under load from late swing through stance. Although peak hamstring stretch was invariant with speed, lateral hamstring (biceps femoris) loading increased significantly with speed and was greater during swing than stance at the fastest speed. The biarticular hamstrings performed negative work on the system only during swing phase, with the amount of negative work increased significantly with speed.

    CONCLUSION:
    We concluded that the large inertial loads during high-speed running appear to make the hamstrings most susceptible to injury during swing phase. This information is relevant for scientifically establishing muscle injury prevention and rehabilitation programs.

    My Comments:

    This is a pretty interesting study. Most of the reports I have read of hamstring muscle injuries have been at the end of the swing phase, but there is some controversy with arguing that there is also risk at foot strike. This paper sought to settle that with regards to where forces through the hamstring muscle and tendon are greatest, but also found/reported other interesting findings which they and I agree, should have bearing on physical therapy exercise protocols for preventing and rehabilitating hamstring muscle and tendon injuries.

    So what they did was have subjects sprint on a treadmill at speeds of 80%, 85%, 90%, 95% and 100% of their maximum. Hamstring forces at foot impact didn’t change significantly at higher speeds. Hamstring muscle length didn’t change either, because increased hip flexion at higher speeds was combined with increased knee flexion, keeping hamstring length at different speeds about the same. Hamstring forces however, particularly in the biceps femoris long head (the most frequently injured) did increase during the swing phase as sprint speed increased, particularly so up and above 90% with 95% and 100% being greater still. So this would lend credence to the idea that it’s at or near the terminal aspect of the swing phase, with the leg out in front that the injuries are most likely. Hamstrings were only eccentrically contracting at the very late swing phase, corresponding to where the forces are highest.

    They referenced that hamstring moment arms are greater at the hip than at the knee, which I think is why Romanian Deadlifts (RDLs) feel like they work better than leg curls, and a newer exercise I have been working with, the Nordic Hamstring Curl (NHC). Based on the results of the study the authors suggested that resistance training be done with the knee fixed in extension and flexing the hip to end range (exactly what an RDL does). They also agreed that training the muscle eccentrically to be important. The RDL with a sufficiently loaded barbell trains the hamstrings (and glutes) hard both eccentric and concentrically, but does not quite overwhelm the hamstrings eccentrically like the NHC does. Unfortunately NHC acts more at the knee than the hip, and doesn’t stretch the hamstrings much at all like the RDL. So as of now I think the combination of the RDL and NHC are state of the art for the prevention and treatment of hamstring strains. If I had to pick one I’d go with the RDL, and I’m not sure that the NHC adds much to a program with the RDL already there. To play it safe I include the NHC since multiple large studies in professional soccer players have demonstrated it reduces the risk of hamstring injury and re-injury. The RDL, while I expect is better, hasn’t been specifically tested for prevention or rehabilitation of hamstring injuries. I think both are worth having in a program along with other good exercises like squats, lunges, and Olympic lifts/variants. Everything else, especially the various posterior bridging exercises, with or without a swiss ball, I think are trash.

    Cheers.

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

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

  • Fast Weight Lifting, Better Than Slow, for Osteopenia

    J Appl Physiol (1985). 2005 Jul;99(1):181-8. Power training is more effective than strength training for maintaining bone mineral density in postmenopausal women. Stengel SV, Kemmler W, Pintag R, Beeskow C, Weineck J, Lauber D, Kalender WA, Engelke K. J Appl Physiol (1985). 2005 Jul;99(1):181-8.

    Abstract
    Physical exercise has a favorable impact on bones, but optimum training strategies are still under discussion. In this study, we compared the effect of slow and fast resistance exercises on various osteodensitometric parameters. Fifty-three postmenopausal women were randomly assigned to a strength training (ST) or a power training group (PT). Both groups carried out a progressive resistance training, a gymnastics session, and a home training over a period of 12 mo. During the resistance training, the ST group used slow and the PT group fast movements; otherwise there were no training differences. All subjects were supplemented with Ca and vitamin D. At baseline and after 12 mo, bone mineral density (BMD) was measured at the lumbar spine, proximal femur, and distal forearm by dual-energy X-ray absorptiometry. We also measured anthropometric data and maximum static strength. Frequency and grade of pain were assessed by questionnaire. After 12 mo, significant between-group differences were observed for BMD at the lumbar spine (P < 0.05) and the total hip (P < 0.05). Whereas the PT group maintained BMD at the spine (+0.7 +/- 2.1%, not significant) and the total hip (0.0 +/- 1.7%, not significant), the ST group lost significantly at both sites (spine: -0.9 +/- 1.9%; P < 0.05; total hip: -1.2 +/- 1.5%; P < 0.01). No significant between-group differences were observed for anthropometric data, maximum strength, BMD of the forearm, or frequency and grade of pain. These findings suggest that power training is more effective than strength training in reducing bone loss in postmenopausal women.

    My comments:

    This was an interesting study because it directly separated out concentric speed (the lifting part) of weight lifting (as fast as possible in the power training group) vs lifting the weight over 4 seconds in the strength training group. The power group maintained BMD over a year, while the regular strength training group lost some bone mineral density. Set and repetition range was not given (which would have been nice of them to mention) but training intensity was said to be 70-90% of their 1 repetition max (1 RM) for 12 weeks, interspersed with a 4-5 week recovery period training at 50% of their 1 RM. The exercises were machine based; leg presses, leg curls, bench press, rowing, leg adduction and abduction, abdominal flexion, back extension, lat pulldown, hyperextension, leg extensions, shoulder raises and hip extensions. Given that the weight training sessions were only 6 minutes long, including a 20 minute warm up, followed by some jump training before starting the weights;  the large number of machines used and the Arthur Jones’esc use of 4 seconds up and 4 seconds down, I’m going to guess they did only one, and maybe just 2 sets per exercise.

    Another variable that might have affected overall outcomes is that these women were not untrained having just preceding 3 year study in which they were weight training. I’ll have to read the prior study to be sure but they likely had already gained a fair degree of bone mineral density, after which point additional gains would be more difficult. Also I think the 4 second eccentric period, in even the power training group, would lessen their overall training load. If my physical therapy patients and personal training clients take longer than half a second to lower the weights I tell them to go faster. 4 seconds down is REAL SLOW and you can’t lift as heavy a weight that slow, so overall training intensity is lessened. Known to just about every weightlifter, powerlifter, bodybuilder, or strength and conditioning coach (but apparently not every researcher) is that nobody strong trains like that. Strong people generally lower their weights (eccentric contraction) in a smooth but swift manner, and if they really know what they are doing, they lift those weights (concentric contraction) as fast as they can, the latter as done in the power training group here. So I don’t really like the power training vs strength training terms used in this study. Rather I would have called them slow vs fast strength training, for which prior research has shown that faster strength training is better for both strength and power, while slower training is lame for both, though probably not as lame as yoga;)

    So all my criticisms aside, even with the slow 4 second eccentric phase the power training group was able to maintain bone mineral density in pre-trained postmenopausal women, while the slow strength training group was not. Being as this was a 2005 study, it likely helped researchers towards the more recent program performed on osteoporotic women using “Maximal Strength Training” which led to substantial increases in bone mineral density in just 12 weeks. It’s also why I am skeptical of use of yoga, particularly given the potential for injury in women with osteopenia and osteoporosis.

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

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

  • Yoga Only Delays Bone Loss in Osteopenic Women

    The Effect of Yoga on Markers of Bone Turnover in Osteopenic Women: a Pilot Study. Balk, Judith; Gluck, Melissa; Bernardo, Lisa; Catov, Janet, International Journal of Yoga Therapy;2009, Vol. 19, 63-68

    ABSTRACT

    Weight-bearing exercise is recommended to improve bone density. Hatha Yoga is a popular form of weight-bearing exercise that includes physical postures, stretching, breathing, and relaxation. We hypothesized that Hatha Yoga would have beneficial effects on bone turnover markers. We conducted a small feasibility pilot study with a prospective, pre-post design comparing markers of bone turnover before and after Yoga training in sedentary osteopenic postmenopausal women. Markers of bone formation were measured with serum bone-specific alkaline phosphatase (BAP). Measures of bone resorption were measured with urinary type I collagen cross-linked N-telopeptide (uNTX). Seven participants completed a 12-week series of one hour per week Yoga classes, in addition to home Yoga practice. We analyzed the correlation between time spent on Yoga and time spent on other weight-bearing exercise and change in bone turnover markers. The amount of Yoga practice was significantly correlated with BAP levels (r = 0.68, p = 0.09). A weaker, non-significant correlation was found between the amount of Yoga practice and uNTX levels (r = -.54, p = .21). Compared to Yoga, other physical activities were less correlated with BAP and uNTX levels. Yoga may have beneficial effects on bone turnover in osteopenic postmenopausal women.

    My comments

    This is a continuation on my research as to the effectiveness of yoga for osteoporosis after having received that continuing education flyer for yoga based physical therapy treatment that was osteoporosis specific. “Meeks Method” if you want to google it.

    As opposed to my last blog which suggested yoga flexion poses could cause vertebral compression fractures, this one looked at the positive aspects of yoga and it’s effects on bones. They reported taking care to avoid end range flexion and extension, which I think is a good idea, and they tried to focus on more weight bearing exercises. The problem was that those weight bearing exercises, as described, were at most balancing on one leg. While I think single leg balance is a good exercise and I have my patients work on it from time to time, I don’t think of it as optimally effective for increasing bone mineral density.

    Out of the 13 subjects who entered the study, 5 (38%) dropped out because it was too time consuming (one 60 minute class per week, and 30 minute home exercises on most other days for 12 weeks). Of the remaining 8 subjects they got post test on bone markers showing positive trends but not statistical significance. They did report a trend towards an increase in bone formation, but only 3/7 showed a decrease in bone resorption. Such that they concluded yoga would have a positive benefit those with with osteopenia because it would “slow the expected trajectory” of bone resorption, thus delaying the onset of osteoporosis. I think that is all well and good when compared to nothing, which is what this study did. However, when compared to just doing squats with weights 3 times per week, which has been shown to build back bone in those with osteoporosis, just slowing the inevitable with yoga, seems like an inefficient use of one’s time at best.

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

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

  • Vertebral Fractures after Yoga in Women with Osteopenia

    Yoga spinal flexion positions and vertebral compression fracture in osteopenia or osteoporosis of spine: case series. Sinaki M. Pain Pract. 2013 Jan;13(1):68-75. [FREE FULL TEXT with good pics]

    Abstract
    OBJECTIVE:
    The objective of this report is to raise awareness of the effect of strenuous yoga flexion exercises on osteopenic or osteoporotic spines. We previously described subjects with known osteoporosis in whom vertebral compression fractures (VCFs) developed after spinal flexion exercise (SFE) and recommended that SFEs not be prescribed in patients with spinal osteoporosis.
    METHODS:
    This report describes 3 healthy persons with low bone mass and yoga-induced pain or fracture.
    RESULTS:
    All 3 patients had osteopenia, were in good health and pain-free, and had started yoga exercises to improve their musculoskeletal health. New pain and fracture areas occurred after participation in yoga flexion exercises.
    CONCLUSIONS:
    The development of pain and complications with some flexion yoga positions in the patients with osteopenia leads to concern that fracture risk would increase even further in osteoporosis. Although exercise has been shown to be effective for improving bone mineral density and decreasing fracture risk, our subjects had development of VCFs and neck and back pain with yoga exercises. This finding suggests that factors other than bone mass should be considered for exercise counseling in patients with bone loss. The increased torque pressure applied to vertebral bodies during SFEs may be a risk. Exercise is effective and important for treatment of osteopenia and osteoporosis and should be prescribed for patients with vertebral bone loss. Some yoga positions can contribute to extreme strain on spines with bone loss. Assessment of fracture risk in older persons performing SFEs and other high-impact exercises is an important clinical consideration.

    My comments:

    I had just received a solicitation for a yoga based exercise course for physical therapists for treating osteoporosis. I was curious about this as I think science based physical therapy for restoring bone mineral density and reducing fall risk should include a fair amount of progressive resistance exercise, and I don’t think yoga quite cuts it. I was curious if there was any science behind the method and found a few papers I intend to review. What immediately caught my eye was this paper citing 3 people with osteopenia (defined bone mineral density of 1.0 to 2.5 standard deviations less than an average 30 year old) who developed vertebral compression fractures and severe back or neck pain after beginning yoga classes. The first was an 87 year old woman who developed a compression fracture at L2, the second a 61 year old woman with a new compression fracture at T4, the third a 70 year old woman compression fractures at T8-9. Osteopenia is bone loss that is less severe than osteoporosis, which is when bone mineral density drops to >2.5 standard deviations below normal. So I think one might reasonably conclude that if these stretches are causing compression fractures with osteopenia, they are even higher risk for those with osteoporosis.

    The author noted he had seen but not reported other compression fractures in women with yoga flexion stretches before and said they were considered incidental until other yoga related vertebral fractures were reported at which point he decided to do this paper. With a lot of vertebral compression fractures going unreported I expect the incidence is greater than this paper suggests. The author did a good job of defining which yoga stretches are the problematic ones, which are those in which the person flexes their back or neck as they bend forward to touch the floor/their feet, or flexes their neck as they bring their chin forward towards their chest. These flexion stretches mimic the direction that causes lumbar discs to herniate. However in this case osteopenia/osteoporosis the vertebral bones are weaker than the discs, or the discs are already degenerated, so the next thing to break is the the vertebral bones themselves

    Also worth noting is that extension strengthening, contrary to flexion stretching, has been shown to be protective against vertebral compression fractures and squats with accelerating progressive resistance has been shown to increase both hip and lumbar bone mineral density. The right exercises are good, the wrong exercises are bad and physical therapists need to differentiate what exercises are going into their programs to maximize rewards and minimize risks. Yoga instructors as well might want to bone up (haha) on the risks of spine flexion. I’ll read through the rest of the papers to see if research demonstrates any particular yoga specific benefits, but depending on the exercises it appears there are significant risks. In the meantime, I think I’ll have my patients do squats.

    Setu Bandha Sarvangasana
    Pachimottanasana
    Inverted Asana, this pose had our tech’s neck hurting for a week

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

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

  • Just Squats for Osteoporosis Increases Bone Mineral Content

    Maximal strength training in postmenopausal women with osteoporosis or osteopenia. Mosti MP1, Kaehler N, Stunes AK, Hoff J, Syversen U. J Strength Cond Res. 2013 Oct;27(10):2879-86.

    Abstract
    Current guidelines recommend weight-bearing activities, preferably strength training for improving skeletal health in patients with osteoporosis. What type of strength training that is most beneficial for these patients is not established. Maximal strength training (MST) is known to improve 1-repetition maximum (1RM) and rate of force development (RFD), which are considered as important co-variables for skeletal health. Squat exercise MST might serve as an effective intervention for patients with low bone mass. We hypothesized that 12 weeks of squat exercise MST would improve 1RM and RFD in postmenopausal women with osteoporosis or osteopenia and that these changes would coincide with improved bone mineral density (BMD) and bone mineral content (BMC), and serum markers of bone metabolism. The participants were randomized to a training group (TG, n = 10) or control group (CG, n = 11). The TG underwent 12 weeks of supervised squat exercise MST, 3 times a week, with emphasis on rapid initiation of the concentric part of the movement. The CG was encouraged to follow current exercise guidelines. Measurements included 1RM, RFD, BMD, BMC, and serum bone metabolism markers; type 1 collagen amino-terminal propeptide (P1NP) and type 1 collagen C breakdown products (CTX). At posttest, 8 participants remained in each group for statistical analyses. The TG improved the 1RM and RFD by 154 and 52%, respectively. Lumbar spine and femoral neck BMC increased by 2.9 and 4.9%. The ratio of serum P1NP/CTX tended to increase (p = 0.09), indicating stimulation of bone formation. In conclusion, squat exercise MST improved 1RM, RFD, and skeletal properties in postmenopausal women with osteopenia or osteoporosis. The MST can be implemented as a simple and effective training method for patients with reduced bone mass.

    My comments:

    This is a great study! It has a pretty good review of strength training for reversing osteoporosis and then had the patients perform only one exercise; a squat machine for 2 warm-up sets of 8-12 reps (at ~50% of the persons max) then 4 sets of 3-5 reps at 85-90% of their max. The exercises were done 3 times per week for 12 weeks and the result was an increase in hip (femoral neck) bone mineral content of 4.9% (that’s a lot in osteoporosis studies), and an increase in lumbar spine bone mineral content of 2.9%. The strength had improved 154%.

    It’s worth talking more about how they did the reps which was explosively with the subjects exploding upwards with the weights as fast as they could. They called this “Maximal Strength Training” (MST) which is a new term for me but sounds identical to Compensatory Acceleration Training (CAT) coined by Fred Hatfield back in the 80’s. Some say tomato and some say potato but either way I expect the exploding with the weights throughout the concentric (upward) motion is a better way to train. As I recall studies from the 90’s showing it increased strength better than conventional weight lifting exercises with college students being the subjects. When I was doing Olympic Weightlifting at NAU, pretty much all our reps were explosive. So it’s cool to see explosive training with weights being applied to and helping elderly women with osteoporosis. It goes to show, yet again, that the best techniques for physical therapy come out of the weight room rather than the classroom.

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

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

  • Atrophy and Hypertrophy After Hamstring Strain in Athletes

    MR observations of long-term musculotendon remodeling following a hamstring strain injury. Silder A, Heiderscheit BC, Thelen DG, Enright T, Tuite MJ. Skeletal Radiol. 2008 Dec;37(12):1101-9.

    Abstract
    OBJECTIVE:
    The objective of this study was to use magnetic resonance (MR) imaging to investigate long-term changes in muscle and tendon morphology following a hamstring strain injury.
    MATERIALS AND METHODS:
    MR images were obtained from 14 athletes who sustained a clinically diagnosed grade I-II hamstring strain injury between 5 and 23 months prior as well as five healthy controls. Qualitative bilateral comparisons were used to assess the presence of fatty infiltration and changes in morphology that may have arisen as a result of the previous injury. Hamstring muscle and tendon-scar volumes were quantified in both limbs for the biceps femoris long head (BFLH), biceps femoris short head (BFSH), the proximal semimembranosus tendon, and the proximal conjoint biceps femoris and semitendinosus tendon. Differences in muscle and tendon volume between limbs were statistically compared between the previously injured and healthy control subjects.
    RESULTS:
    Increased low-intensity signal was present along the musculotendon junction adjacent to the site of presumed prior injury for 11 of the 14 subjects, suggestive of persistent scar tissue. The 13 subjects with biceps femoris injuries displayed a significant decrease in BFLH volume (p < 0.01), often accompanied by an increase in BFSH volume. Two of these subjects also presented with fatty infiltration within the previously injured BFLH.
    CONCLUSION:
    The results of this study provide evidence of long-term musculotendon remodeling following a hamstring strain injury. Additionally, many athletes are likely returning to sport with residual atrophy of the BFLH and/or hypertrophy of the BFSH. It is possible that long-term changes in musculotendon structure following injury alters contraction mechanics during functional movement, such as running and may contribute to reinjury risk.

    My comments:

    So on to this study. The abstract didn’t mean a lot to me before I took an in depth look at the anatomy. They found the LONG HEAD of the biceps femoris (the larger of 2 heads of the 3 muscles that make up the hamstrings) was generally what was strained in 13 out of the 14 injured, and was 10% smaller when measured between 5 and 23 months post injury. The biceps femoris SHORT HEAD was 13% larger. And the proximal conjoined tendon of the LONG HEAD biceps femoris and semitendinosus (another of the 3 hamstring muscles) was 85% larger. This was AFTER the athlete had completed their physical therapy and had returned to sport.

    So what I learned from this is that the long head tendons being 85% larger is indicative of increased scar tissue that is still there as long as 23 months post injury. The LONG HEAD of the biceps does not recover full strength in spite of typical rehabilitation, but the SHORT HEAD becomes larger apparently to compensate for the injury of the LONG HEAD. Unfortunately the physical therapy rehabilitation exercises were not standardized so it’s unknown what exercise were performed. This meant something to me, but still not a lot until I looked up the particular attachments of the LONG HEAD and SHORT HEAD of the biceps femoris and saw that only the SHORT HEAD only crossed the knee joint and didn’t act at all to extend the hip, but only flexed the knee. The LONG HEAD in contrast crossed both the knee and the hip acting as both a hip extensor and a knee flexor.

    So my thought is that these athletes were likely rehabilitated with hamstring strengthening exercises that act only on the knee, like leg curls, (both seated and prone) and to a lesser extent the Nordic Hamstring Curl, (which acts a lot at the knee and only a little at the hip). In contrast a Romanian Deadlift (RDL) acts primarily at the hip and I would expect would better target the LONG HEAD of the biceps femoris, and this might be what was missing from these athletes physical therapy protocols. SHORT HEAD atrophy of the biceps femoris, resulting from RDLs being a missing part of rehabilitation might also be why so many athletes, soccer players in particular injure and strain their hamstrings. It might also be why you test an injured athlete’s hamstring strength with knee flexion (a leg curl) and it might seem strong but they go right out and reinjure when running at high speeds, which requires strong hip extension.

    So continuing to think out loud the Nordic Hamstring Curl has the advantage of particularly targeting eccentric strength of the hamstring, but the RDL being both eccentric and concentric does a better job at increasing strength in hip extension, plus better stretching the LONG HEAD, so the combination of the two exercises might be ideal. What I still don’t know is how strong an RDL an athlete should have in relation to their other exercises for safe return to sport, but based on my experience in therapy and at the NAU Weight room it should be AT LEAST as high as the persons back squat. But then you still get into problems of what kind of squat, high bar or low bar, how deep, etc. I also think this brings in need for isokinetic testing of hip extension both concentric and eccentric in normal players and players with hamstring strains much like it is done for the same muscle at the knee.

    Further thinking out loud, it also gave me an idea for a new exercise I just made up called the “3 bounce RDL” where the person goes down to the bottom stretch position and bounces 3 times before returning upward. It might increase the eccentric strength component of the exercise and I think it most certainly will work to increase hamstring flexibility combined with strength. The problem I foresee however is that though you might stretch more, I don’t know if it would really cause any additional increase in eccentric strength as the athlete would almost certainly train with a lighter weight. So maybe it’s worthwhile only if the athlete has tighter hamstrings. Anyway makes me want to start looking for my own isokinetic muscle tester to one day gather dust and take up space in my office.

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

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

  • Imbalance/Weak Hamstrings Predict Strains in Pro Soccer

    Strength imbalances and prevention of hamstring injury in professional soccer players: a prospective study. Croisier JL, Ganteaume S, Binet J, Genty M, Ferret JM. Am J Sports Med. 2008 Aug;36(8):1469-75.

    Abstract
    BACKGROUND:
    The relationship between muscle injury and strength disorders remains a matter of controversy.

    PURPOSE:
    Professional soccer players performed a preseason isokinetic testing aimed at determining whether (1) strength variables could be predictors of subsequent hamstring strain and (2) normalization of strength imbalances could reduce the incidence of hamstring injury.

    STUDY DESIGN:
    Cohort study (prognosis); Level of evidence, 1.

    METHODS:
    A standardized concentric and eccentric isokinetic assessment was used to identify soccer players with strength imbalances. Subjects were classified among 4 subsets according to the imbalance management content. Recording subsequent hamstring injuries allowed us to define injury frequencies and relative risks between groups.

    RESULTS:
    Of 687 players isokinetically tested in preseason, a complete follow-up was obtained in 462 players, for whom 35 hamstring injuries were recorded. The rate of muscle injury was significantly increased in subjects with untreated strength imbalances in comparison with players showing no imbalance in preseason (relative risk = 4.66; 95% confidence interval: 2.01-10.8). The risk of injury remained significantly higher in players with strength imbalances who had subsequent compensating training but no final isokinetic control test than in players without imbalances (relative risk = 2.89; 95% confidence interval: 1.00-8.32). Conversely, normalizing the isokinetic parameters reduced the risk factor for injury to that observed in players without imbalances (relative risk = 1.43; 95% confidence interval: 0.44-4.71).

    CONCLUSION:
    The outcomes showed that isokinetic intervention gives rise to the preseason detection of strength imbalances, a factor that increases the risk of hamstring injury. Restoring a normal strength profile decreases the muscle injury incidence.

    My comments:

    This study is a follow up to the last one I had blogged on by the same authors. It’s largely the same design with largely the same results but rather than following 26 athletes with prior hamstring injuries, they followed 687 soccer players and completed information on 462 of them. That’s good research! In my file there is a lot of good research on hamstring strains apparently because soccer is such big business world wide. With the larger number of subjects, small factors that originally showed inconsistent results are now turning out to be both practically and statistically significant.

    So what they found was that a professional soccer players without muscle imbalance had a 4.1% hamstring injury frequency, those with imbalances had a 4 fold increase hamstring injury frequency of 16.5%. They found that if strengthening exercises were done to normalize muscle imbalances that hamstring injury frequency dropped to 11%. If soccer players not only did their exercises but did so to the point that the imbalances were normalized, the injury frequency dropped to 5.7% which is almost as low as those with balanced strength levels to begin with.

    Also interesting from the paper is that they judged an imbalance to be that in which a hamstring deficit of just 5% was seen in a side to side comparison. Concentric H/Q ratio of <0.57 or 0.55 on Cybex or Biodex testing equipment respectively, and a mixed H/Q ratio of <.98 or 1.04 on Cybex or Biodex respectively.  As with the prior study, the mixed ratio (eccentric hamstring strength at 30 degrees a second/concentric quadriceps strength at 240 degrees a second) proved most predictive of future hamstring injury. No player with a mixed ratio of 1.40 sustained a hamstring injury, which indicates stronger hamstrings than the norm, and that strong hamstrings (particularly in eccentric strength) was predictive of minimal risk of future injury.

    The downside of this study, like the author’s other paper, was that it relied on isokinetic testing and training, which isn’t practical for most players. The author’s admitted that for recreational players, isokinetic testing would be too expensive and too time consuming. It would be recommended but due to the high prevalence of hamstring injuries, all players should perform manual or weight training exercises to their hamstrings.  For future research I would love to see how much players with a 1.40 mixed ratio are able to lift on leg curls (prone or seated) compared to leg extensions, and what they can lift on RDLs vs front or back squats (high bar or low). That would then give strength coaches, athletic trainers, and physical therapists more practical information to go on with regards to returning soccer players, sprinters and other athletes with hamstring strains/muscle injuries to sport as opposed to arbitrary recommendations of some number of weeks rest.

    The take home message seems to be that stronger hamstrings are better, with a 1.4 mixed ratio being particularly protective, the problem being that very few places have the testing equipment to tell you what your mixed ratio is. Also worth noting is that common goals of strength recovery of 80-90% in comparison with the uninjured leg likely isn’t sufficient and goals of 95% strength recovery being more protective against injury recurrence.

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

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

  • Sports, Soccer and Recurrent Hamstring Strains

    One thing fun about my job is that I never know what’s going to come through my door that I’m going to have to figure out how to treat. Recently I had an former professional soccer player who was super fit but had strained his hamstrings several times and wanted to get back to playing in his league games. Muscle strains are something I generally consider easy to treat. You just rest them for some time, then start working on increasing muscle circulation, strength, and in my opinion the last would be range of motion. But the problem was when my player started asking questions like: How long will I be out? How do I know when I am ready to return to play? How strong should my hamstrings be? How come my hamstring strength is equal to the other side, my range of motion is equal to the other side, I feel completely normal, but when I play a game I start to feel the pain return just a little? Should I stop play as soon as I feel that pain? What’s the best warmup? What’s a good warmup when I don’t have much time? Should I stretch before I play? Those were a lot of good questions and some of which I had less than definitive answers. So when asked questions I do what I normally do, which is go to pubmed.com, start typing in keywords, reading reviews, commentary and randomized controlled trials. Often musculoskeletal injuries are obscure enough that there is little data, but I was amazed at how much there was on hamstring injuries, particularly with football (soccer for us Americans) which is their number one injury with recurrent strains being a considerable problem, costing team outcomes, affecting player’s careers, and costing millions of dollars at the pro level. So where the money is, so the research goes. There was a lot to learn here that I figured I could apply to muscle strain injuries with my other patients. Also in collecting and reading the papers that I have I had a fair amount of comments and ideas for where there are still holes in the research that need answering to optimise recovery and ideally prevent injuries from happening in the first place.

    So now I have stack of papers 2-3 inches thick. I have read a number of them that I think would make for good blogs, so where to start? I guess here:

    Hamstring muscle strain recurrence and strength performance disorders. Am J Sports Med. 2002 Mar-Apr;30(2):199-203. Croisier JL, Forthomme B, Namurois MH, Vanderthommen M, Crielaard JM.

    Abstract
    We determined the frequency of strength disorders in 26 athletes with a history of hamstring muscle injury and recurrent strains and discomfort. We also assessed the effectiveness of rehabilitation to correct muscle performance. After concentric and eccentric isokinetic assessment, 18 athletes were found to have strength deficits, as determined by statistically selected cutoffs of peak torque, bilateral differences, and the flexors/quadriceps ratio. The discriminating character of the eccentric trial was demonstrated, combining a preferential eccentric peak torque deficit and a significant reduction of the mixed eccentric flexors/concentric quadriceps ratio. The athletes with muscle imbalances followed a rehabilitation program individually adapted from their strength profile. Treatment length was from 10 to 30 sessions and resulted in isokinetic parameter normalization in 17 of 18 subjects. Isokinetically corrected subjects were observed for 12 months after return to athletics. None sustained a clinically diagnosed hamstring muscle reinjury. Subjective intensity of pain and discomfort were significantly reduced, and they all returned to their prior level of competition. These results demonstrate that persistent muscle strength abnormalities may give rise to recurrent hamstring injuries and discomfort. An individualized rehabilitation program emphasizing eccentric training based on specific deficits contributes to a decrease in symptoms on return to sports.

    My comments:
    This wasn’t the first paper I read but I thought it was well written, it was cited by a lot of reviews and I was familiar with the authors as they had done isokinetic research on the treatment of tendinitis which I had blogged on before.

    So, what they found was that in 26 male athletes with a history of hamstring injury and recurrent strains (18 soccer players, 7 track and field & 5 martial artists) 18 of them had strength deficits that when given a custom exercise program directed at correcting those deficits. Those deficits were some combination of either right vs left leg strength, hamstring strength vs quadriceps strength, or eccentric strength vs concentric strength, with the most striking finding being mixture of low slower eccentric hamstring strength as compared with faster concentric quadriceps strength. The imbalances were corrected with custom isokinetic exercises that normalized the imbalances in the 18 athletes with the deficits and they were followed for a year, none of whom had any additional hamstring injury.  So it interesting that they spent their efforts on strengthening, as opposed to stretch and/or trendy passive modalities and none of the athletes were re-injured.

    The downside of this study is that the testing and exercise programs were done on isokinetic exercise equipment, which is expensive (I think in the range of $30,000) and generally used today only for research such that very few teams, physical therapists, gym goers, and even universities have it available. So it worked in concept but it’s not very practical for even testing let alone training.

    Though this is an older 2002 study that’s perhaps not ultimately practical, it is still very relevant. What I would like to see done now (to the point I started pricing used isokinetic testing equipment, tempered only by the fact isokinetic equipment was all the rage in the 80s, in spite of the price I never saw it do anything but gather dust in physical therapy clinics in the 90s, and disappeared in the 2000s) is see performance on knee and hip. Specifically with isokinetic equipment correlated with strength on more common and likely more effective exercises such as leg extensions and leg curls (for purer isolation of quads, hamstrings and right vs left legs). Also more efficient and functional exercises such as squats, lunges, pulls and RDLs, or the new hotshot exercise for hamstring strains and soccer players which is the Nordic Hamstring Curl.

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

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

  • Osteoarthritis and Obesity

    This blog is a request of my Aunt who asked if I could post anything relating to obesity and extra wear and tear on the the joints (aka osteoarthritis). It’s considered common knowledge in medicine that obesity increases the risk for arthritis, and I hear my physical therapy patients frequently say that their knees or hips would feel better if they lost weight. So I thought it would be interesting to see exactly how much weight actually effects arthritis. Two relatively recent studies appeared to best answer the question being as follows:

    Obesity and osteoarthritis in knee, hip and/or hand: an epidemiological study in the general population with 10 years follow-up. Grotle M, Hagen KB, Natvig B, Dahl FA, Kvien TK. BMC Musculoskelet Disord. 2008 Oct 2;9:132.

    Abstract
    BACKGROUND:
    Obesity is one of the most important risk factors for osteoarthritis (OA) in knee(s). However, the relationship between obesity and OA in hand(s) and hip(s) remains controversial and needs further investigation. The purpose of this study was to investigate the impact of obesity on incident osteoarthritis (OA) in hip, knee, and hand in a general population followed in 10 years.

    METHODS:
    A total of 1854 people aged 24-76 years in 1994 participated in a Norwegian study on musculoskeletal pain in both 1994 and 2004. Participants with OA or rheumatoid arthritis in 1994 and those above 74 years in 1994 were excluded, leaving n = 1675 for the analysis. The main outcome measure was OA diagnosis at follow-up based on self-report. Obesity was defined by a body mass index (BMI) of 30 and above.

    RESULTS:
    At 10-years follow-up the incidence rates were 5.8% (CI 4.3-7.3) for hip OA, 7.3% (CI 5.7-9.0) for knee OA, and 5.6% (CI 4.2-7.1) for hand OA. When adjusting for age, gender, work status and leisure time activities, a high BMI (> 30) was significantly associated with knee OA (OR 2.81; 95%CI 1.32-5.96), and a dose-response relationship was found for this association. Obesity was also significantly associated with hand OA (OR 2.59; 1.08-6.19), but not with hip OA (OR 1.11; 0.41-2.97). There was no statistically significant interaction effect between BMI and gender, age or any of the other confounding variables.

    CONCLUSION:
    A high BMI was significantly associated with knee OA and hand OA, but not with hip OA.

    Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis.Silverwood V, Blagojevic-Bucknall M, Jinks C, Jordan JL, Protheroe J, Jordan KP. Osteoarthritis Cartilage. 2014 Nov 29.

    Abstract
    Osteoarthritis (OA) is a leading cause of pain and disability and leads to a reduced quality of life. The aim was to determine the current evidence on risk factors for onset of knee pain/OA in those aged 50 and over. A systematic review and meta-analysis was conducted of cohort studies for risk factors for the onset of knee pain. Two authors screened abstracts and papers and completed data extraction. Where possible, pooled odds ratios (OR) were calculated via random effects meta-analysis and population attributable fractions (PAFs) derived. 6554 papers were identified and after screening 46 studies were included. The main factors associated with onset of knee pain were being overweight (pooled OR 1.98, 95% confidence intervals (CI) 1.57-2.20), obesity (pooled OR 2.66 95% CI 2.15-3.28), female gender (pooled OR 1.68, 95% CI 1.37-2.07), previous knee injury (pooled OR 2.83, 95% CI 1.91-4.19). Hand OA (pooled OR 1.30, 95% CI 0.90-1.87) was found to be non-significant. Smoking was found not to be a statistically significant risk or protective factor (pooled OR 0.92, 95% CI 0.83-1.01). PAFs indicated that in patients with new onset of knee pain 5.1% of cases were due to previous knee injury and 24.6% related to being overweight or obese. Clinicians can use the identified risk factors to identify and manage patients at risk of developing or increasing knee pain. Obesity in particular needs to be a major target for prevention of development of knee pain. More research is needed into a number of potential risk factors.

    My comments:

    The two papers look at the issue of osteoarthritis, obesity and other risk factors and come to similar but somewhat different conclusions, which is the norm for medical research. The first paper found that obesity defined as a BMI of >30 increased the risk of developing knee arthritis 2.81 times. The risk of hand arthritis was increased almost the same at 2.59 times, while the risk of hip arthritis was increased only 1.11 times (which surprised me) and was not statistically significant. So it’s interesting to note that obesity over the 10 year study period had little to no effect on the hips, but considerable effect on both the knee and hands. In this paper the researchers did note that other studies did associate obesity with hip arthritis and with an odd ratio of ~2.0 which indices double the risk.

    The second paper pooled the results from a number of other studies looking directly at the knee, and found being overweight (defined as a BMI between 25-30) increased the risk of developing knee arthritis 1.98 times, obesity (BMI >30) 2.66 times. Female gender increased the risk 1.68 times and a previous knee injury increased the risk 2.83 times, with hand arthritis increasing the risk of having knee arthritis 1.3 times, the latter of which was not significant.

    So there is still some question regarding quantifying effects of obesity on the development of osteoarthritis and with researchers generally measuring inputs, outcomes and time frames a little different. The take home seems to be that obesity increases the risk of  knee arthritis 2-3 times, hand arthritis ~2.5 times and hip arthritis somewhere between no effect and maybe 2 times.  The results were given with in the form of odds ratios, which implies association but not causation. Obesity might cause knee arthritis first making you move less, lessening the effects on the hips, but making getting up and out of chairs more difficult stressing the hands as you push off. While that explanation is logical sounding, and potentially correct, it’s something I just made up off the top of my head as I write this but according to the CDC knee replacements outnumber hip replacements by more than 2 to 1 so maybe I guessed right.  Still from your joints perspective, it seems good to eat less and exercise more.

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

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

  • NSAIDs vs Corticosteroid Injections for Frozen Shoulder

    Comparison between NSAID and intra-articular corticosteroid injection in frozen shoulder of diabetic patients; a randomized clinical trial. Dehghan A, Pishgooei N, Salami MA, Zarch SM, Nafisi-Moghadam R, Rahimpour S, Soleimani H, Owlia MB. Exp Clin Endocrinol Diabetes. 2013 Feb;121(2):75-9.

    Abstract
    INTRODUCTION:
    Frozen shoulder or adhesive capsulitis is a relatively common encountered musculo-skeletal disease in which arouses following soft tissue involvement of glenohumeral joint and presents with pain and limitation of shoulder’ active and passive motions. The incidence of frozen shoulder among diabetic patients is about 10-20%, stiffness in such patients is more severe and should be managed actively. Local Glucocorticoid injection, NSAIDs and physiotherapy each can relief the symptoms. The aim of this study was to compare the efficacy of glenohumeral injection of Glucocorticoid with NSAIDs in frozen shoulder of diabetic patients.

    METHOD:
    The randomized clinical trial study conducted during Feb 2009-Aug 2010 on diabetic patients with frozen shoulder that were referred to rheumatology and endocrinology clinics, Yazd, Iran. Diagnostic criteria of capsulitis were pain of shoulder and range of motion limitation in all directions. The patients were divided into 2 groups, patients of first group received NSAID while the latter group were undergone intra-articular corticosteroid injection. After 1 week, home exercise was done for both group and evaluation of the patients after first visit was done likewise 2nd, 6th, 12th and 24th weeks. All registered data were transformed into SPSS-15 software and analyzed.

    RESULTS:
    Totally 57 patients (19 males (33.3%) and 38 females (66.7%) were included in the analysis. There was no significant difference between sex (P=0.4) and age (P=0.19) of patients. No significant relation was detected between 2 groups after 24 weeks according to range of motion in flexion (P=0.51), abduction (P=0.76), external rotation (0.12) and internal rotation (P=0.91). Also any significant difference in pain score was not detected (P=0.91).

    CONCLUSION:
    Based on our study, both intra-articular corticosteroid and NSAID are effective in treatment of adhesive capsulitis and there is no significant difference between efficacies of these 2 treatment modalities in diabetic patients.

    My comments:

    I’ve been seeing an increase in physical therapy referrals for patients with frozen shoulder/ adhesive capsulitis patients as of late so I figured I’d review the literature and see f there is anything worth knowing. A few of the papers I have read thus far look good enough to blog on but at least per the research there appears to be more questions than answers, to a large degree because a lot of the prior research is of poor quality. This paper seemed pretty good though and related particularly to patients with diabetes.

    They compared 500 mg of the NSAID Naproxin (AKA Aleve) twice daily for which the duration of treatment was unspecified vs a single intra-articular injection of the corticosteroid (40 mg of triamcinolone). The results were roughly similar with no significant difference between groups however the injection group at 2 weeks had a reasonably substantial lead in ROM increases at 2 weeks with shoulder flexion increasing 53.1 degrees in the injection group compared to 37.7 degrees in the NSAID group, abduction was 50.9 vs 42.5 degrees, and external rotation 10.4 vs 9.3 degrees. Later at the 6, 12 and 24 week follow ups the NSAID group mostly caught up but absolute improvements were still a few degrees behind the injection group. I would have thought the researchers were going to recommend the NSAIDs but they advocated the steroid injection saying the one time injection had less side effects than the prolonged NSAID use, which sounds reasonable. I am a big critic of corticosteroid injections for tendinitis/plantar fasciitis per the the general finding that that the result in short term pain loss but 6-8 weeks later those who had injections being worse off than those who had no treatment at all, and with a substantial increased risk for tendinous tissue rupture. However with frozen shoulder and an intra-articular injection the risk reward profile is significantly different with those getting corticosteroid injections appearing to be ahead of controls early on and maintaining these improvements over time though with controls in other studies generally catching up, or almost catching up at 6 months to a year out.

    In my clinical experience patients with frozen shoulder, if in the inflammatory stage often, but not always, don’t do well with aggressive stretch and strengthening, and sometimes not that well with milder exercises. If this is the case I have seen a cortisone injection make an immediate night and day difference improving exercise tolerance so that ROM and strength can be restored in a matter of weeks rather 1-3 years which seems to be the normal course of the condition.

    One downside noted in the research (including this one) is that there is little if any differentiation between patients in the inflammatory stage of frozen shoulder (when the shoulder is very painful even at rest and sometimes intolerant to any exercise) and the frozen/thawing stages where the shoulder generally does not hurt at rest and tolerates/benefits from strength and stretch just fine. In the later stages I would not expect either the injections nor the NSAIDs to make much difference, but I think that the drugs do, and the injection does particularly quickly is knock out the inflammation quickly so that the exercises can sooner be effective.

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

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