SpineFITyoga.com

Author: chad reilly

  • Optimism, Physical Therapy and Everything Else

    Optimism. Clin Psychol Rev. 2010 Nov;30(7):879-89. Carver CS, Scheier MF, Segerstrom SC.

    Abstract
    Optimism is an individual difference variable that reflects the extent to which people hold generalized favorable expectancies for their future. Higher levels of optimism have been related prospectively to better subjective well-being in times of adversity or difficulty (i.e., controlling for previous well-being). Consistent with such findings, optimism has been linked to higher levels of engagement coping and lower levels of avoidance, or disengagement, coping. There is evidence that optimism is associated with taking proactive steps to protect one’s health, whereas pessimism is associated with health-damaging behaviors. Consistent with such findings, optimism is also related to indicators of better physical health. The energetic, task-focused approach that optimists take to goals also relates to benefits in the socioeconomic world. Some evidence suggests that optimism relates to more persistence in educational efforts and to higher later income. Optimists also appear to fare better than pessimists in relationships. Although there are instances in which optimism fails to convey an advantage, and instances in which it may convey a disadvantage, those instances are relatively rare. In sum, the behavioral patterns of optimists appear to provide models of living for others to learn from.

    Full text and PDF available HERE

    My comments:
    This was a fascinating review paper, for which I link the full text, as I think everyone ought to read it for themselves. I got thinking about it after reading a few sports psychology books, some papers on positive psychology in general and noting that one of my new physical therapy techs had probably the best disposition of anyone I know (genuinely happy and positive without being annoying). It had a noticeable beneficial effect on my patients when she was taking them through their exercise programs. I asked her if she had always been that way, and she said a couple years ago her parents were going to send her to psychologist for depression and she said she just decided to change her outlook and look at the bright side of things regardless of how bad they seemed at the time. I said that sounded just like Polyanna’s “glad game” and found a youtube clip of it, and she said, yeah that’s pretty much it. She thought that if you start off pessimistic you have to fake it till you make it, but eventually it becomes how you look at things. She reports the positive impact on her life has been immeasurable. I asked if she read any books on it, and she said she hadn’t. Emily Porter apparently hadn’t either and the above paper appears to show that her 1913 ideas are holding up better than her contemporary Sigmund Freud’s psychoanalysis.

    The paper discusses a good number of health related effects secondary to taking a positive view on things. Taking a positive rather than negative view on things leads to better outcomes, less depression and greater feelings in well-being even when dealing with serious health issues ranging from heart surgery to breast cancer. None of the studies specifically addressed diagnoses frequently treated in physical therapy such as low back, neck, or arthritic pain, however the benefits did seem largely general such that I would expect the positive benefits to be widespread. I have been a critic of the biopsychosocial model of back pain for an example, but I do think that much of the newer research on positive psychology likely has considerable application to physical therapy as well as life in general.

    Part of the paper I thought pertinent was that optimism heritability was estimated to be about 25%. Optimists were more likely to take a proactive approach to problems rather than avoidance/denial, and in my physical therapy practice, which is largely exercise based, a being proactive is a big part of recovery. Interestingly all the studies indicated that optimists did a better job of dealing with disappointments and if a goal became truly hopeless optimists were more likely to adopt a new goal and do better at it. Optimists also tended to have less heart disease, less mortality, earned more lifetime income, had better personal relationships, and greater social network.

    Interestingly the paper reported there was still uncertainty as to whether and to what extent a pessimist can become an optimist. They suggested cognitive behavioral approach, which it seems the cognitive aspect is what my tech did intuitively, basically changing her inner dialog to more positive thoughts.  The finding was that optimism is 25% genetic, that leaves 75% to be affected by controllable factors, so the glass is three quarters full right from the start.

    Being a long-time fan of philosophers Schopenhauer and Voltaire (though Voltaire reads like the worlds happiest and best humored pessimist) I think pessimism is often more realistic and perhaps more intellectually satisfying, however if you just want a better recovery from your injuries and illnesses, more friends, better relationships, more income, greater happiness and what appears to be a better life overall, research seems to indicate that you you are better off looking at the bright side of things.

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

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

  • EMS Effects the Brain as well as Muscles

    Functional MRI determination of a dose-response relationship to lower extremity neuromuscular electrical stimulation in healthy subjects. Exp Brain Res. 2003 May;150(1):33-9. Epub 2003 Mar 27. Smith GV1, Alon G, Roys SR, Gullapalli RP.

    Abstract
    Although empirical evidence supports the use of neuromuscular electrical stimulation (NMES) to treat physical impairments associated with stroke, the mechanisms underlying the efficacy of this modality are poorly understood. Recent studies have employed functional imaging to investigations of brain responses to median nerve stimulation. These studies suggest a dose-response relationship may exist between selected stimulation parameters and hemodynamic responses in sensorimotor regions. However, substantial gaps exist in this literature. The present study was designed to address these deficiencies. Ten healthy subjects participated. In phase one, four stimulus intensity levels were established: (1). sensory threshold [Th], (2). (MM-Th)x0.333+Th [low-intermediate level, LI], (3). (MM-Th)x0.666+Th [high-intermediate level, HI], and (4). maximal motor (MM). In phase two, subjects were scanned using a spiral-echoplanar imaging technique at each stimulus level. Image sets were analyzed to determine hemodynamic responses at the highest Pearson correlation level ( r) ascertained for each of five areas of interest (AOI): (1). primary sensory, (2). primary motor, (3). cingulate gyrus, (4). thalamus, and (5). cerebellum. ANOVA demonstrated significant main effects for BOLD signal amplitude ( p<0.05) changes in all AOI. Similarly, ANOVA showed significant differences in the volume of activation ( p<0.05) with increasing stimulus intensity in four AOI. Secondary analyses of pooled data showed increasing probabilities of activation at higher stimulus intensities within each AOI. Collectively, these data indicate a dose-response relationship exists between lower extremity NMES and brain activation in specific neural regions. The current results, while limited in their generalizability, are foundational for future studies of interventions using NMES.

    My comments:
    I think this is a very interesting study that I read about a year ago.  I find myself talking about it frequently with my patients when I find EMS (semantically the same as NMES) working better than I expect. EMS is used primarily for muscle strengthening but has been found to be more effective than TENS for pain reduction, works exceptionally well for neuropathy/neuropathic pain, and I have seen it immediately eliminate arm tremors in a patient. The patient had gone through a bastion of tests at Barrow Neurological, been diagnosed with conversion disorder, then after a 12 minute EMS treatment the tremors were gone.  I thought of this again yesterday when I was treating a 74 year old patient for poor balance, neuropathy, back and neck pain all with a combination of exercise and EMS. She reported all of her other pain had resolved but she had elbow pain which I diagnosed as lateral epicondylitis/tennis elbow. I didn’t want to spend much time treating the elbow as I thought  it was the least of her worries. I wanted to continue to work on fall prevention with general strengthening, balance and agility training. She also had a history of dropping light objects, she calls it her “dropsies”, but over the course of her treatment said it been reduced ~50%. Her muscle strength was much improved so weakness was not a reason for her dropping objects. Long story shorter, I decided to add reverse wrist curls to her exercise program and did EMS to her biceps, triceps, and forearm muscles with a hope to further increase UE strength and lessen pain.  After one treatment and following a weekend she reported her dropsies had decreased another 30-40%, which is pretty big improvement over one intervention. So the next day I applied EMS to her arm again but also added in my hand grip electrode to provide EMS through the palm of the hand.  So, on her next visit I will see what she has to say. Even though I treated the arm reluctantly, I maybe came up with a new understanding and breakthrough with her, which I can hopefully apply to other patients.

    When you are using multiple interventions (which is generally the case in physical therapy) to treat a problem it is sometimes impossible to say what does what and how much. Also there is a lot of overlap between each intervention (strength exercise, balance exercise, coordination exercise, EMS) and what you are hoping to achieve. However, this patients rapid response was much faster than one would expect from a single day of exercise and I think most likely due to the EMS working on the muscles in the arm and hand and also increasing activation and blood flow in the brain as found in the above quoted study. It’s also interesting that brain activity was seen in a dose response manner, in that more intense EMS causes more of a brain response. This perhaps strengthens neural connections and improves nerve conduction velocity resulting in improved coordination. I am starting to see this in other studies as well. What’s also interesting is all the areas of the brain that are affected. Electric muscle stimulation applied to the study participants’ quadriceps increased blood flow to the primary sensory cortex, primary motor cortex, cingulate gyrus, thalamus, and cerebellum with blood flow always increasing more so in the brain as intensity levels of electrical stimulation was applied to the study subjects leg muscles.

    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.

  • Emetophobia and the Biopsychosocial Model of Low Back, Neck Pain

    Exposure therapy for emetophobia: a case study with three-year follow-up. J Anxiety Disord. 2013 Jun;27(5):527-34. Maack DJ, Deacon BJ, Zhao M.

    Abstract
    Emetophobia, also referred to as a specific phobia of vomiting, is a largely under-researched and poorly understood disorder with prevalence estimates of ranging between 1.7 and 3.1% for men and 6 and 7% for women (Hunter & Antony, 2009; Philips, 1985). The current case study, therefore, sought to methodically apply exposure-based behavioral treatment to the treatment of a 26 year-old, Hispanic, female suffering from emetophobia. Although not as powerful as a randomized design, this description may still add to the existing emetophobia literature through the illustration of adaptation of published behavioral treatments for other specific phobias. The case presented was successful in terms of outcome, and includes a three-year follow up wherein treatment gains were measurably maintained.

    My comments:

    So what does an case study from the Journal of Anxiety regarding emetophobia (fear of vomiting, either doing it or witnessing it) have to do with physical therapy, back and neck pain? Well let me summarize the treatment, how it worked and I’ll get to that.

    First some background: In community college I took General Psychology and Developmental Psychology and that’s the extent of my professional training in psychology. Since then I have done a fair amount of reading psychology books and individual studies such as to make me a better than average dabbler. However what I think I excel at is searching pubmed (the world’s largest medical database) for papers and studies regarding any number ailments/treatments, reading and evaluating the quality of the findings, and linking those findings to one another and integrate them with my own ideas and experiences. The use of case studies, clinical trials, randomized controlled trials, meta-analysis and review papers is a universal practice in good medicine and is largely similar between medical professions for which the subject matter is different.

    I recently learned the considerable stress that emetophobia has on a friend of mine, with research showing other emetophobics will go so far as to avoid social gathering for fear that someone there will become intoxicated and vomit and that 44% of all female emetophobics will avoid pregnancy out of the fear of morning sickness. I looked up and read several peer-reviewed papers (of which only a few exist) so since yesterday I have probably become one of the world’s experts on emetophobia. The condition is understudied, and as such there are no randomized controlled trials on emetophobia so treatment effects are still speculative. There are a few case studies (reports on a single patient describing treatment and effect), and the most frequent method of treatment I came across with beneficial effect included some kind of “exposure therapy” for which randomized controlled trials have found effective in the treatment of a number of related psychological conditions including anxiety and phobias. All of this makes sense to me as I will often get a patient I have to treat for an ailment for which the effects of exercise or electric stimulation has not been well studied, so you do your best following proven principles on as similar conditions as possible and more often than not it works.

    The above cited case report was the newest and most descriptive and the treatment appeared to work very well. In order for the patient to get over her fear required 5 treatments (1-3 hours in length) spaced 1-2 weeks apart, in which the patient was started off giving her history and taking a few standardized anxiety tests to objectify her level of impairment and a treatment plan was developed for which the patient agreed to. Treatment than began immediately by watching relatively benign videos of people vomiting on the computer and the patient was given a home program to watch 30 minutes of such videos daily gradually increasing graphic nature of sounds and images in youtube videos over time. As she did so anxiety was shown to quickly decrease and over the course of her 5 visits she was given increasingly difficult tasks including pretending to vomit, watching two of her treating psychologists actually vomit (which is more than I do for my patients) and culminating in her making herself throw up, at which point she didn’t like it (who does) but no longer thought it was such a big deal that it negatively impacted her life. Three years later her improvements remained. The results of this paper sound very reasonable to me and as such I have no reason to doubt the positive treatment effect.

    So what does this have to do with physical therapy, back and neck pain? One of the “schools of thought” in the treatment of back and neck pain is the “biopsychosocial model”. Followers of that model want to treat these painful conditions by emphasising the psychological aspects and all but ignoring the biological and environmental aspects. They will suggest patients continue to work and ignore their pain, consider their pain a normal part of life, and even do exercises that cause pain, apparently such that they become habituated to their “exposure” and used to it. This habituation is apparently in theory similar to the exposure therapy in the above psychological case. However, the problem is that activities that expose you to neck and back pain very often do cause further injury such that patients don’t get used to the pain, they just get worse. Neck and back pain generally have a large, large environmental component and are usually not an irrational phobia but a real injury. Sustained awkward postures, particularly in lumbar and cervical flexion and or repeated flexion and extension, does in fact damage spinal discs, causing disc bulging and herniation and over stretches stabilizing ligaments and muscles of the spine. Painful habituation exercises to the spine generally rely on various painful stretches to the spine, and by any rationality further damage painful tissues of the spine. Telling a patient with back and neck pain that it is normal and to return to work as usual, especially if that work includes excessive prolonged and repeated spine flexion, extension and twisting will only further damage the spine, increase pain, and cause more disability. Telling a patient that exercise is beneficial “but is all the same” will only lead to further spine damage and pain if that exercise consists of repeated and prolonged spine flexion/extension and twisting. Come to think of that, trusting this model might be why a spine surgeon performed not one, but two spine fusions on a road cyclist who later became my patient, and the surgeon said he should have no problem returning to cycling. I guess he figured all exercise is the same even if the spine is kept in full flexion, and he didn’t do the math and figure if two segments were fused, the remaining 3 would then be further stressed as the patient leaned forward to tuck into the bars. Incidentally my patient still wanted to ride and worked hard on core, LE strength, and neutral spine awareness. He continues to perform a lot of hamstring stretches while maintaining a neutral spine and is now able to ride his bike safely keeping spine neutral, though isn’t able crouch fully into his triathlon aero bars. He gave up some aerodynamics but is still on the road and won’t be a cripple so I think was a good compromise.

    So does psychology have anything to add to physical therapy treatment for neck, back and other disorders. The research thus far would indicate no for both low back and neck pain, but I think the research thus far has been based on utilization of poor psychological methods that don’t understand the causes of spine injury. With neck pain in particular I often notice that anxiety has a significant effect on correlation with pain. It also tends to make patients very apprehensive with regards to beneficial strength-based exercise programs, which research shows are very effective. I notice this tendency much less so with back pain but I don’t doubt some effect. Active exercise programs that increase strength, ability and confidence as the patients sees themselves get stronger is psychologically empowering. Proper lifting techniques (using a neutral spine) teaches the neck or back pain sufferer that they can complete difficult tasks without pain and injury, resulting in lessening anxiety with such activities. Lessening anxiety also helps to reduce pain, the improved fitness of the exercise program contributes to improved feelings of well being. Such that a negative spiral of damage, pain, and disability is turned around. Psychological principles of adopting optimistic as opposed to pessimistic attitudes also increases hope, decreases discomfort, and all that is a lot easier to achieve when you teach the patient how they can lessen or eliminate pain, rather than tell them that pain is normal. So I don’t think the biopsychosocial model of low back and neck pain in physical therapy needs to be thrown out but it certainly needs a complete overhaul, needs to take into account environmental factors contributing to low back pain, it needs to understand that some activities and exercises are more damaging than others, and needs to stay up to date with new psychological techniques including much coming out in the new field of positive psychology.

    So that’s my talk on emetophobia and physical therapy. The psychology paper helped me to better understand how psychologists treat some of mental disorders and thus where those methods might fall short, and where they might still be of benefit to physical injuries I treat as a physical therapist. It’s all very interesting and a bit of a new frontier for me so I expect this won’t be my last foray into the world of psychology and how it relates to physical therapy. I particularly think there is a lot to be learned and applied to my patients’ benefit, which off the top of my head I think will most help those with histories of chronic neck pain and headaches.

    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.

  • Return to NBA after ACL Reconstruction

    Return-to-Sport and Performance After Anterior Cruciate Ligament Reconstruction in National Basketball Association Players. Harris JD, Erickson BJ, Bach BR Jr, Abrams GD, Cvetanovich GL, Forsythe B, McCormick FM, Gupta AK, Cole BJ. Sports Health. 2013 Nov;5(6):562-8.

    Abstract
    BACKGROUND:
    Anterior cruciate ligament (ACL) rupture is a significant injury in National Basketball Association (NBA) players.

    HYPOTHESES:
    NBA players undergoing ACL reconstruction (ACLR) have high rates of return to sport (RTS), with RTS the season following surgery, no difference in performance between pre- and postsurgery, and no difference in RTS rate or performance between cases (ACLR) and controls (no ACL tear).

    STUDY DESIGN:
    Case-control.

    METHODS:
    NBA players undergoing ACLR were evaluated. Matched controls for age, body mass index (BMI), position, and NBA experience were selected during the same years as those undergoing ACLR. RTS and performance were compared between cases and controls. Paired-sample Student t tests, chi-square, and linear regression analyses were performed for comparison of within- and between-group variables.

    RESULTS:
    Fifty-eight NBA players underwent ACLR while in the NBA. Mean player age was 25.7 ± 3.5 years. Forty percent of ACL tears occurred in the fourth quarter. Fifty players (86%) RTS in the NBA, and 7 players (12%) RTS in the International Basketball Federation (FIBA) or D-league. Ninety-eight percent of players RTS in the NBA the season following ACLR (11.6 ± 4.1 months from injury). Two players (3.1%) required revision ACLR. Career length following ACLR was 4.3 ± 3.4 years. Performance upon RTS following surgery declined significantly (P < 0.05) regarding games per season; minutes, points, and rebounds per game; and field goal percentage. However, following the index year, controls’ performances declined significantly in games per season; points, rebounds, assists, blocks, and steals per game; and field goal and free throw percentage. Other than games per season, there was no significant difference between cases and controls.

    CONCLUSION:
    There is a high RTS rate in the NBA following ACLR. Nearly all players RTS the season following surgery. Performance significantly declined from preinjury level; however, this was not significantly different from controls. ACL re-tear rate was low.

    CLINICAL RELEVANCE:
    There is a high RTS rate in the NBA after ACLR, with no difference in performance upon RTS compared with controls.

    My comments:
    I thought what was most interesting about this study was the NBA players generally had a near complete recovery following ACL reconstruction with 86% able to return to play in the NBA the following season with little performance decrement. This was generally not different from non injured control players, which declined slightly as well apparently due to age. However, research on average populations shows considerable residual muscle weakness in which they sometimes have difficulty getting even normal walking patterns back to normal.  Certainly pre-injury fitness is a factor but likely more important is post injury rehabilitation.  NBA players don’t have to worry about physical therapy being limited by insurance companies looking to cut costs, and when therapy is finished NBA players are returning to strength and conditioning programs which further restore performance levels. The general population often doesn’t have this opportunity.  It does indicate that with optimal physical therapy programs and continued strength and conditioning, knee function following ACL reconstruction if often at or near 100% in athletes at the highest level of performance.

    While they reported no significant differences in time of injury during game play they did note that 40% of ACL injuries were in the 4th quarter and 62% in the second half of the game. This might indicate fatigue as a factor predisposing players to increased risk of injury, making the removal of starting players at the end of the game if there is a comfortable lead a prudent move.

    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.

  • Vitamin E Ointment Does Not Improve Scar Healing

    The effects of topical vitamin E on the cosmetic appearance of scars. Baumann LS, Spencer J. Dermatol Surg. 1999 Apr;25(4):311-5.

    Abstract
    BACKGROUND:
    Vitamin E is a generic term for a group of tocol and tocotrienol derivatives. Since the discovery that vitamin E is the major lipid soluble antioxidant in skin, this substance has been tried for the treatment of almost every type of skin lesion imaginable. Anecdotal reports claim that vitamin E speeds wound healing and improves the cosmetic outcome of burns and other wounds. Many lay people use vitamin E on a regular basis to improve the outcome of scars and several physicians recommend topical vitamin E after skin surgery or resurfacing.
    OBJECTIVE:
    We attempted to determine whether topically applied vitamin E has any effect on the cosmetic appearance of scars as suggested by multiple anecdotal reports.
    METHODS:
    Fifteen patients who had undergone skin cancer removal surgery were enrolled in the study. All wounds were primarily closed in 2 layers. After the surgery, the patients were given two ointments each labeled A or B. A was Aquaphor, a regular emollient, and the B was Aquaphor mixed with vitamin E. The scars were randomly divided into parts A and B. Patients were asked to put the A ointment on part A and the B ointment on part B twice daily for 4 weeks. The study was double blinded. The physicians and the patients independently evaluated the scars for cosmetic appearance on Weeks 1, 4, and 12. The criteria was simply to recognize which side of the scar looked better if there was any difference. The patients’ and the physicians’ opinions were recorded. A third blinded investigator was shown photographs of the outcomes and their opinion was also noted.
    RESULTS:
    The results of this study show that topically applied vitamin E does not help in improving the cosmetic appearance of scars and leads to a high incidence of contact dermatitis.
    CONCLUSIONS:
    This study shows that there is no benefit to the cosmetic outcome of scars by applying vitamin E after skin surgery and that the application of topical vitamin E may actually be detrimental to the cosmetic appearance of a scar. In 90% of the cases in this study, topical vitamin E either had no effect on, or actually worsened, the cosmetic appearance of scars. Of the patients studied, 33% developed a contact dermatitis to the vitamin E. Therefore we conclude that use of topical vitamin E on surgical wounds should be discouraged.

    My comments:

    I just looked this up because I had a total knee patient doing leg presses and I commented that her incision looked like it was healing well. She said she had been putting vitamin E on it, and I said I have heard a lot about patients doing that to assist healing and final appearance of their scars. I said, “I wonder if it works,” as I had heard it recommended by physicians, other therapists, and patients over the years. I had always meant to look it up to see if it was true or not. This was the reminder I needed.

    The above study found that not only did the vitamin E solution not work, it led to increased complications with 5 of the 15 patients developing an erythematous rash resulting from the vitamin E and none did so with the control solution. At 12 weeks there was no difference in scar appearance judged in 60% of the patients, the control was judged superior in 30%, and the vitamin E superior in only 10% of the patients.

    So I think the use of topical vitamin E for scar healing has developed into an urban legend, for which one can look at as a glass half empty or a glass half full. The glass half full conclusion is that most patients are pleased with the healing of their incisions and anecdotal reports of good outcomes with the use of topically applied vitamin E would likely have been at least as good without it. In the future patients can save money by not purchasing vitamin E oil or ointment. What’s interesting is that this study is 15 years old and it’s the first I heard of in only after I looked specifically for it. Medical myths die slow.

    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.

  • Low Hip Strength Associated with Increased Spine Motion

    Relationship between hip strength and trunk motion in college cross-country runners. Med Sci Sports Exerc. 2013 Jun;45(6):1125-30. Ford KR, Taylor-Haas JA, Genthe K, Hugentobler J.

    Abstract
    PURPOSE:
    Hip strength may directly relate to abnormal running mechanics and contribute to the high incidence of overuse injuries in distance runners. The purpose of this study was to determine the relationship between hip isokinetic strength and thorax and pelvic motion during treadmill running.

    METHODS:
    Isokinetic hip strength and treadmill running kinematics were collected on 24 collegiate cross-country runners (14 males and 10 females). Each subject completed a running protocol on a treadmill at a self-selected speed (3.58 ± 0.26 m·s) and prescribed speed (3.58 ± 0.0 m·s). Kinematic data were collected with retroreflective markers attached to the thorax, pelvis, and each lower extremity segment (thigh, shank, and foot). Thorax and pelvis range of motion (ROM) were calculated from initial ground contact to toe-off. Pearson correlation coefficients were used to determine the relationship between strength and ROM (P < 0.05). Differences between male and female athletes were tested with mixed-design ANOVAs (P < 0.05).

    RESULTS:
    Isokinetic hip extension and abduction torque had significant inverse correlations to thorax axial rotation ROM during stance phase of running (r = -0.60 and r = -0.53) at self-selected speed. Frontal plane pelvic obliquity ROM was also significantly correlated to hip strength (extension r = -0.49; abduction r = -0.44). Similar correlations were found during the prescribed speed condition. Female runners had significantly decreased normalized strength (hip extension 1.8 ± 0.4 N·m·kg, P < 0.05; hip abduction 1.0 ± 0.2 N·m·kg, P < 0.05), increased pelvic obliquity (13.1° ± 2.6°, P < 0.05), and thorax axial rotation (34.5° ± 7.0°, P < 0.05) ROM compared to males (hip extension 2.5 ± 0.5 N·m·kg; hip abduction 1.3 ± 0.2 N·m·kg; pelvic obliquity 8.9° ± 1.9°; thorax axial rotation 22.6° ± 3.5°).

    CONCLUSIONS:
    Moderate correlations were found in hip extensor and hip abductor strength and pelvic and thorax motion during running in collegiate runners.

    My comments:
    This is a good recent paper that I think relates to both back pain sufferers who run and those that don’t.  I’ve done a number of recent blogs on running injuries that show hip strength relates to knee, shin, foot and ankle pain.  This study didn’t look at low back pain per se, but increased spine motion with every step in a run I expect is some kind of risk factor.

    Also for non-runners with low back pain, where the hip muscles are weaker still, I would expect increased spine motion with normal walking.  I often see  that clinically in my physical therapy office when patients with hip and back pain walk on a treadmill.  As such I think it very prudent to include all around hip extensor strengthening for runners to include hip abduction exercises and my favorites for hip extensors being Romanian Deadlifts (RDLs).

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

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

  • Muscle Strength Protective Against Arthritis

    The role of muscles in joint degeneration and osteoarthritis. J Biomech. 2007;40 Suppl 1:S54-63. Epub 2007 Apr 16. Herzog W1, Longino D.

    Abstract
    The purpose of this work was to establish a controlled and reversible muscle weakness model for studying the effects of weakness on joint degeneration leading to osteoarthritis (OA). The knee extensor muscles of rabbits were injected with single or repeat doses of Botulinum type-A toxin (BTX-A) to partially inhibit acetylcholine (ACh) release at the neuromuscular junction. BTX-A-injected muscles atrophied, they became weaker and push-off forces during hopping were reduced compared to control. BTX-A injections had the greatest effect at short-muscle length and low-stimulation frequencies. Superimposing BTX-A injections on anterior cruciate ligament transection did not cause greater muscle atrophy or weakness than BTX-A injections alone. Monthly repeat injections could be used to keep muscles weak for half a year without any obvious adverse effects to the animals. Gross morphology of the knees and histology of articular cartilage suggested that, in some animals, 4 weeks of muscle weakness resulted in initial signs of joint degeneration, indicating that weakness may be an independent risk factor for joint degeneration leading to OA.

    My comments
    This study was very interesting because it is part of a few papers taken together which are starting to indicate that muscle weakness leads to arthritic changes in the joints. Hitherto, the primary assumption has been that arthritis caused pain, which then caused less activity, which was followed by muscle atrophy.  This one shows that the effect can go the other way as well. The paper showed this by injecting small amounts of botox into the muscles in one limb of rabbits, enough to cause weakness but not paralysis. The rabbits were tested 4 weeks later and researchers found the start of arthritic changes in that limb.

    The findings I think are of particular importance in treatment of knee or hip injuries, after joint arthroscopies, and ACL reconstructions for which studies show that leg range of motion returns but strength levels often are not fully restored.  This and a few other studies would indicate that the increased number of joint replacements could be avoided with adequate strengthening either in physical therapy or continuing with an independent exercise program. The problem with the latter is that if fitness isn’t a lifestyle for the patient, then most likely they will stop exercising when they are done with physical therapy.  The other problem is insurance companies using self-evaluated surveys of function to their advantage to force the discharge of patients before they have fully recovered, because they don’t have any remaining “functional limitations”. Apparently muscle weakness isn’t a “functional limitation.”

    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.

  • Physical Therapy After Vertebroplasty and Kyphoplasty

    Significantly fewer refractures after vertebroplasty in patients who engage in back-extensor-strengthening exercises. Huntoon EA, Schmidt CK, Sinaki M. Mayo Clin Proc. 2008 Jan;83(1):54-7.

    Abstract
    OBJECTIVE:
    To determine whether patients with osteoporotic compression fractures would have decreased fracture recurrence or a longer time before refracture after percutaneous vertebroplasty (PVP) if they also participated in the Rehabilitation of Osteoporosis Program-Exercise (ROPE) instruction, which includes back-strengthening exercises.

    PATIENTS AND METHODS:
    We reviewed and collected data from the medical records of 507 patients with osteoporosis who were treated at Mayo Clinic’s site in Rochester, MN, from July 1, 1998, through August 31, 2005. Patients older than 55 years with at least 1 radiographically confirmed nontraumatic vertebral compression fracture (VCF) were identified, and those with evidence of secondary osteoporosis, traumatically induced VCF, long-term oral corticosteroid use, or bone malignancy were excluded. The remaining 57 patients were categorized into 3 groups: those receiving treatment with ROPE only (n=20), PVP only (n=20), or both PVP and ROPE (n=17). The end point was the refracture date or date of the last recorded follow-up if no refracture occurred. Statistical analysis of time-to-recurrence data was performed using the Kaplan-Meier method and the log-rank test (P less than .05).

    RESULTS:
    The median time before refracture for patients treated with PVP was 4.5 months (95% confidence interval [CI]), 1.4-9.3 months; for patients treated with ROPE only, 60.4 months (95% CI, 27.6 months-upper limit undefined); and for patients treated with PVP-ROPE, 20.4 months (95% CI, 2.8 months-upper limit undefined) (P <001).

    CONCLUSION:
    This retrospective study showed that a targeted exercise program after PVP significantly decreased fracture recurrence. Refracture rates also were lower in the ROPE-only group vs the PVP-only group.

    My comments:

    Vertebroplasty is a relatively non-invasive procedure.  A person with a painful vertebral compression fracture, most often resulting from osteoporosis, has that vertebra stabilized and if lucky decompressed to some degree with the injection of bone cement.  Kyphoplasty is largely the same procedure with a small differences. Rather than decompressing the vertebra with bone cement, the vertebra is decompressed with a balloon first, the balloon is removed and the cement is injected into the cavity. Outcomes thus far appear similar as  both procedures have been shown to be effective in rapidly reducing back pain in those with painful vertebral compression fractures. There is still debate among physicians as to whether one procedure is safer or better at restoring vertebral height.

    One complication, however, is a high incidence of additional compression fractures above and below the one being stabilized. There is some debate remaining as to whether this additional fracture rate is secondary to the stiffness of the treated vertebra after being stabilized or if it is resultant from the ongoing osteoporotic changes in the spine.

    This study found that by adding back extensor muscle training they were able to significantly reduce the refracture rate. They used exercises begun in sitting and progressing to back extensions and bird dog type exercises in prone or quadruped.  Unfortunately they did not give much in the way of details as to when the exercises were started after the procedure, frequency, sets or repetitions performed. However, so far it’s the only study that addresses exercise after vertebroplasty so sometimes you just have to take what you get and develop your physical therapy programs with less than perfect data.  Did I say sometimes?  Actually rehabilitation being an infant science it’s pretty much all the time, which is what keeps the job interesting, and also illustrates the importance of continued research, reading and implementing said research.

    The good news was that the back extensor exercises had significant beneficial effects at reducing additional fractures. The incidence of additional compression fractures within 12 months was reduced from 75% in the control group to 35% in the exercise group. This makes sense. If patients’ spine extensors are strong enough to hold their spines neutral during daily activities, that would take pressure of the anterior vertebral bodies, which is increased primarily due to spine flexion. Based on this, and a lot of other spine research, I would think it prudent as well to add abdominal exercises (performed with the spine neutral and perhaps with a bias into extension) as well as hip and lower extremity strength exercises. These make it easier for those with osteoporosis to lift with their legs as opposed to their backs.  Not to mention that those with osteoporosis need the weight bearing through their hips to increase bone mineral density there and lessen the risk of hip fractures. If it were me I would stay away from “conventional” yoga.

    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.

  • Creatine Increases Strength with Parkinson’s Disease

    Resistance training with creatine monohydrate improves upper-body strength in patients with Parkinson disease: a randomized trial. Neurorehabil Neural Repair. 2007 Mar-Apr;21(2):107-15. Hass CJ, Collins MA, Juncos JL.

    Abstract
    BACKGROUND:
    Persons with Parkinson disease (PD) exhibit decreased muscular fitness including decreased muscle mass, muscle strength, bioenergetic capabilities and increased fatigability.
    OBJECTIVE:
    This purpose of this investigation was to evaluate the therapeutic effects of resistance training with and without creatine supplementation in patients with mild to moderate PD.
    METHODS:
    Twenty patients with idiopathic PD were randomized to receive creatine monohydrate supplementation plus resistance training (CRE) or placebo (lactose monohydrate) plus resistance training (PLA), using a double-blind procedure. Creatine and placebo supplementation consisted of 20 g/d for the first 5 days and 5 g/d thereafter. Both groups participated in progressive resistance training (24 sessions, 2 times per week, 1 set of 8-12 repetiions, 9 exercises). Participants performed 1-repetition maximum (1-RM) for chest press, leg extension, and biceps curl. Muscular endurance was evaluated for chest press and leg extension as the number of repetitions to failure using 60% of baseline 1-RM. Functional performance was evaluated as the time to perform 3 consecutive chair rises.
    RESULTS:
    Statistical analyses (ANOVA) revealed significant Group x Time interactions for chest press strength and biceps curl strength, and post hoc testing revealed that the improvement was significantly greater for CRE. Chair rise performance significantly improved only for CRE (12%, P=.03). Both PLA and CRE significantly improved 1-RM for leg extension (PLA: 16%; CRE: 18%). Muscular endurance improved significantly for both groups.
    CONCLUSIONS:
    These findings demonstrate that creatine supplementation can enhance the benefits of resistance training in patients with PD.

    My comments:

    Recommending dietary supplements is outside my scope of practice, however I thought this study was interesting. Creatine monohydrate was something all the we all took when I was on the weightlifting team at NAU, as did the entire football team. I did papers on it regarding performance enhancement when I was working towards my exercise science degree. The creatine worked noticeably well for us weightlifters and football players, and creatine monohydrate has since become a very well studied and demonstrated safe ergogenic aid for sports. So I think it’s interesting that it’s now being studied to see how it helps in patients who could benefit as much, if not more, than athletes.

    Athletes generally “load” creatine by taking 10-20 grams per day for a week, then maintain on 3-5 grams per day. This study did the same with Parkinson’s patients taking 20 grams for the first week and 5 grams afterwards, in addition to a basic total body weightlifting program. Their results were compared to other Parkinson’s patients who did the exercise program without the creatine monohydrate. Both groups improved in strength but the creatine group improved more with chest press strength increasing 21% compared to 9% in the control group, leg extensions increased 18% compared to 16% in the control (little difference) and biceps increased 23% in the creatine group compared to 8% in the control group. So it seemed to work better for upper body than lower body, but in a squat test the creatine group increased 11% compared to 6% in the control group. All the research on athletes I have seen showed it worked just as well for the lower body as the upper, so I expect the lesser improvement in the legs of the Parkinson’s patients is a spurious finding. Not bad for a supplement for which the brand I use costs $29 for a 6 month supply. I found a few other studies looking at creatine improving outcomes with fibromyalgia, and increasing longevity in mice. I’ve found enough newer/general health applications that I think I will blog more on some of it, and it got me to start taking it again.

    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.

  • So Called “Trunk Stabilization” Exercises are Anything but…

    Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Physical Therapy. 2005 Mar;85(3):209-25. Koumantakis GA1, Watson PJ, Oldham JA.

    Abstract
    BACKGROUND AND PURPOSE:
    The purpose of this randomized controlled trial was to examine the usefulness of the addition of specific stabilization exercises to a general back and abdominal muscle exercise approach for patients with subacute or chronic nonspecific back pain by comparing a specific muscle stabilization-enhanced general exercise approach with a general exercise-only approach.

    SUBJECTS:
    Fifty-five patients with recurrent, nonspecific back pain (stabilization-enhanced exercise group: n=29, general exercise-only group: n=26) and no clinical signs suggesting spinal instability were recruited.

    METHODS:
    Both groups received an 8-week exercise intervention and written advice (The Back Book). Outcome was based on self-reported pain (Short-Form McGill Pain Questionnaire), disability (Roland-Morris Disability Questionnaire), and cognitive status (Pain Self-Efficacy Questionnaire, Tampa Scale of Kinesiophobia, Pain Locus of Control Scale) measured immediately before and after intervention and 3 months after the end of the intervention period.

    RESULTS:
    Outcome measures for both groups improved. Furthermore, self-reported disability improved more in the general exercise-only group immediately after intervention but not at the 3-month follow-up. There were generally no differences between the 2 exercise approaches for any of the other outcomes.

    DISCUSSION AND CONCLUSION:
    A general exercise program reduced disability in the short term to a greater extent than a stabilization-enhanced exercise approach in patients with recurrent nonspecific low back pain. Stabilization exercises do not appear to provide additional benefit to patients with subacute or chronic low back pain who have no clinical signs suggesting the presence of spinal instability.

    My comments:

    This is a great study on low back pain and exercise, all but killed by a bad title.  I have often seen it misquoted by researchers, physical therapists and physicians who are fans of the “biopsychosocial model” of treatment for low back pain.  The conclusion of the abstract doesn’t help either; both give the impression that exercises intended to strengthen or stabilize the spine are no more effective for reducing low back pain than general exercise. When I think of general exercise I think of treadmill, or recumbent cycling, or step aerobics, you know, general exercise.  I guess there is a lesson to be had here for people who read a study title, then skip to the abstract conclusion to draw their own conclusion.  That’s almost exactly what I do; I read the title, skip to the conclusion, to see if a study is interesting. I am glad in this case that I decided to send off for and read the entire paper, or else I would have missed what really happened.  In fact I read onward because I thought this study was going to refute one of the core tenants of my physical therapy treatment programs for low back pain, only to find that it supported it.  I think another lesson there is that you should always read opposing views to find out what you are missing, and I have learned a lot by doing so.

    So what was this study really all about?  They compared two exercise programs performed twice weekly over 8 weeks.  The “general exercise” program wasn’t really general at all but was filled with a plethora of core (abdominal, low back, and hip) muscle strength and endurance exercises to include curl ups, planks, bridges, bird dogs, etc., all of which I would expect would do a great deal to “stabilize” the trunk.  The “trunk-stabilizing” group however included some of the above exercises but didn’t get to them until the last 3 weeks of the program. They first began with “abdominal hollowing” exercises intended to isolate the transverse abdominus. However, spine researcher Stuart McGill has shown it actually destabilizes the spine in comparison to abdominal bracing, which recruits all the core muscles at once.  Additional exercises (their exercise duration was twice as long) in the “trunk-stabilization” group were exercises attempting to isolate the multifidus, and then spine flexion/extension in sitting with an effort to literally aggravate low back pain.  This was so the patients could lose their fear of such aggravation.  The latter seems especially boneheaded to me, but apparently that’s the kind of treatment approaches one is left with once they have internalized the biopsychosocial model, ignore environmental factors, and treat low back pain as a psychological disorder rather than an anatomical one.

    The results were that the “general exercise” group (which consisted of many exercises that in fact do stabilize the trunk/core) reduced low back disability faster than the “trunk-stabilization” group (which in fact contained very few exercises that increase true stabilization strength and endurance of the “trunk”).  The “trunk stabilization” group also had 2 subjects drop out due to increased pain with the exercise program, which I would speculate had a lot to do with the biopsychosocial model contribution to the program in which patients were instructed to work into painful motions such that they might be less fearful of them.

    So I think a better title for this study is “So Called Trunk Stabilization Exercises are Anything But”. The terminology “trunk/core stabilization” in the low back therapy research really has been co-opted to mean transverse and multifidus muscle isolation, neither of which I think are very good ways to rehabilitate or stabilize the spine. In fact, this study showed they did nothing but delay functional improvements in those with low back pain in comparison to trunk strength/endurance exercise.

    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 Foot Exercise for Flat Feet

    Effect of foot orthoses and short-foot exercise on the cross-sectional area of the abductor hallucis muscle in subjects with pes planus: a randomized controlled trial. Jung DY1, Koh EK, Kwon OY. J Back Musculoskelet Rehabil. 2011;24(4):225-31.

     Abstract

    OBJECTIVE:
    To prevent overuse injuries related to excessively pronated feet, the strengthening of the foot intrinsic muscles has been recommended. The purpose of this study was to examine the effects of foot orthoses and a short-foot exercise intervention on the cross-sectional area (CSA) of the abductor hallucis (AbdH) muscle and strength of the flexor hallucis (FH) in subjects with pes planus.

    METHODS:
    Twenty-eight subjects with pes planus were randomly assigned to the foot orthosis (FO) group or the combined foot orthosis and short-foot exercise (FOSF) group for an 8-week intervention. The CSA of the AbdH muscle and the strength of FH were assessed before and after intervention. Data were analyzed using a mixed-model ANOVA.

    RESULTS:
    Significant group by intervention interaction effects were observed in CSA of the AbdH (p=0.009) and strength of the FH (p=0.015). The results of the post hoc paired t-test showed that that the CSA of the AbdH muscle and the strength of the FH significantly increased after the intervention in both groups (p=0.000). The mean CSA of the AbdH muscle and the strength of FH were significantly greater in subjects in the FOSF group compared with subjects in the FO group (mean difference of FO vs. FOSF=13.61 mm(2) in CSA of AbdH muscle; 0.90 kgf in strength of FH; p=0.008).

    CONCLUSIONS:
    Results from this study demonstrate that foot orthoses combined with short-foot exercise is more effective in increasing the CSA of the AbdH muscle and the strength of FH compared with foot orthoses alone. Therefore, foot orthoses combined with short-foot exercise are recommended for improving strength of AbdH muscle in subjects with pes planus.

    My comments:

    There have been a number of recent studies on the “short foot exercise”. Standing on one leg, you try to shorten your foot by pulling the ball of your foot towards your heel while keeping your toes relaxed. This attempts to isolate the foot intrinsic muscles rather than extrinsic toe flexors which work more with towel bunch type exercises.  In this case for 3 sets of 5 repetitions holding each rep for 5 seconds and working up to holding each rep for 10 seconds, 2 times per day for 8 weeks.  I should make a video and insert it here.

    In this case the exercise was effective at increasing muscle hypertrophy of the foot intrinsics, which are known to be weak and atrophied in conditions such as plantar fasciitis and posterior tibial tendinopathy. This likely contributes to a number of other lower extremity problems including medial tibial stress syndrome, patellofemoral pain, etc.  Having tried the exercise myself it did feel like my foot muscles were working, but I also noticed I was was using my tibialis anterior and and posterior tibialis to raise the arch of my foot, so I don’t think it’s entirely isolating the foot intrinsic muscles.  Also the intensity of intrinsic muscle contraction feels well inferior to what I get with electric muscle stimulation (EMS) of those muscles. Plus, with EMS isolation of the foot intrinsic muscles is easy.   Still it feels effective and might be a good alternative or addition to EMS.

    This study was done on those with pes planus (flat feet) that did not have pain so it is still not established that it will help with plantar fasciitis and related conditions. However, I expect it would help as PART of a more comprehensive exercise program including strengthening of the calf musculature (which has recently been shown to help with plantar fasciitis) in addition to strengthening of other LE and hip muscles also shown to be weaker with foot and LE pain. Also there has yet to be a study that has shown exercise might decrease pes planus, which would be interesting to see in future research.  I think what isolation studies like this do is demonstrate how each component might fit into a comprehensive physical therapy program, and it would be a mistake to use just this exercise in isolation.

    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.

  • Plantar Fasciitis Stretches? Why My Patients Skip Them

    Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am. 2003 Jul;85-A(7):1270-7. DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, Baumhauer JF.

    Abstract
    BACKGROUND:
    Approximately 10% of patients with plantar fasciitis have development of persistent and often disabling symptoms. A poor response to treatment may be due, in part, to inappropriate and nonspecific stretching techniques. We hypothesized that patients with chronic plantar fasciitis who are managed with the structure-specific plantar fascia-stretching program for eight weeks have a better functional outcome than do patients managed with a standard Achilles tendon-stretching protocol.

    METHODS:
    One hundred and one patients who had chronic proximal plantar fasciitis for a duration of at least ten months were randomized into one of two treatment groups. The mean age was forty-six years. All patients received prefabricated soft insoles and a three-week course of celecoxib, and they also viewed an educational video on plantar fasciitis. The patients received instructions for either a plantar fascia tissue-stretching program (Group A) or an Achilles tendon-stretching program (Group B). All patients completed the pain subscale of the Foot Function Index and a subject-relevant outcome survey that incorporated generic and condition-specific outcome measures related to pain, function, and satisfaction with treatment outcome. The patients were reevaluated after eight weeks.

    RESULTS:
    Eighty-two patients returned for follow-up evaluation. With the exception of the duration of symptoms (p < 0.01), covariates for baseline measures revealed no significant differences between the groups. The pain subscale scores of the Foot Function Index showed significantly better results for the patients managed with the plantar fascia-stretching program with respect to item 1 (worst pain; p = 0.02) and item 2 (first steps in the morning; p = 0.006). Analysis of the response rates to the outcome measures also revealed significant differences with respect to pain, activity limitations, and patient satisfaction, with greater improvement seen in the group managed with the plantar fascia-stretching program.

    CONCLUSIONS:
    A program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fasciitis. These findings provide an alternative option to the present standard of care in the nonoperative treatment of patients with chronic, disabling plantar heel pain.

    My comments:

    This paper is relatively famous among physical therapists with relation to the treatment of plantar fasciitis.  They found plantar fascia specific stretches (crossing your leg and bending your toes backwards with your hand 10 times 10 seconds 3 times per day) to be more effective at decreasing pain than equal time on calf stretches. However, I have several problems with the conclusions in spite of the positive outcomes with plantar fascia specific stretches.

    First: other research has found that the plantar fascia isn’t particularly tight in patients with plantar fasciitis, while the calf muscles are. So, even if the results of this study are correct with regards to pain reduction you are maybe overstretching a tissue that isn’t tight (plantar fascia), while leaving the one that is tight (calf muscles) abnormally short.

    Second: the results of plantar fascia specific stretches, even if better than calf stretches, aren’t particularly impressive. This study only showed a combined pain reduction of 19% after 8 weeks of treatment, compared to 13% for the calf stretches.  So to me it seems like a lot of bother for not a lot of effect with either.  Pain at worst decreased more at 26% with the plantar fascia stretches compared to 14.7% with the calf stretches but that still just bringing an 8/10 pain down to a 6/10 pain after 8 weeks of stretching 3 times per day.

    Third: a recent study found relatively simple strengthening exercises were significantly more effective at treating plantar fasciitis when performed once every other day. They were more effective than these plantar fascia specific stretches performed 3 times per day every day.  Even that study did not address strengthening of foot intrinsic muscles, and hip abductors and extensors known to be weaker in those with plantar fasciitis and other similar conditions.

    Fourth: I think the researchers, perhaps inadvertently, stacked the deck in favor of the plantar fascia stretch group and against the calf stretch group. They placed particular importance on pain reduction during the first steps getting out of bed. The plantar fascia stretching group did their first stretches before they got out of bed, while the calf stretch group did their first stretches of the day after getting out of bed.  The plantar fascia group was warmed up already for their first steps of the day, which is when plantar fasciitis pain is known to be most painful.  This is why I think they found pain at worst was reduced with plantar fascia stretches.

    Last: the plantar fascia is a passive structure that supports the arch of the foot, and if it is stretched out, other structures (muscles, tendons and ligaments) logically must either take up that load or the foot will flatten. This likely leads to other problems, including posterior tibial tendinopathy potentially resulting down the road in acquired flat foot deformity.  So while plantar fascia stretches may be the current conventional wisdom, conventional wisdom is often long on convention and short on wisdom.  When developing my physical therapy protocols, I’ll chose more current research, applied logic and sound reasoning over conventional wisdom 10 times out of 10.

    So what do we do instead?  If the calf muscles are tight we do stretch them, but more importantly we strengthen the all the muscles (intrinsic and extrinsic, including the hips) that support the foot arch with a combination of exercise and EMS. Thus, improving overall fitness while we take the stress off the plantar fascia.  Besides strengthening, EMS has the great side effect of immediately reducing pain.

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

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

  • Electric Stimulation and Plantar Fasciitis

    Use of low-frequency electrical stimulation for the treatment of plantar fasciitis. J Am Podiatr Med Assoc. 2009 Nov-Dec;99(6):481-8. Stratton M1, McPoil TG, Cornwall MW, Patrick K.

    Abstract
    BACKGROUND:
    Recent research has discussed the use of low-frequency electrical stimulation to increase blood flow by eliciting muscular contraction in soft tissues. This randomized clinical trial examined the efficacy of low-frequency electrical stimulation combined with stretching exercises and foot orthoses in individuals diagnosed as having plantar fasciitis for less than 6 months.

    METHODS:
    Twenty-six participants aged 18 to 65 years diagnosed as having plantar fasciitis were randomly assigned to two treatment groups: a control group receiving only stretching and orthoses and a treatment group receiving low-frequency electrical stimulation in addition to stretching and orthoses. To assess treatment response, a visual analog scale was used to determine first-step morning pain, and changes in daily activity levels were monitored by using a validated outcome measure. All of the participants were assessed before starting treatment, after 4 weeks of treatment, and 3 months after the conclusion of treatment.

    RESULTS:
    Participants in the control and experimental groups demonstrated pain reduction and improvements in functional activity levels after 4 weeks and 3 months.

    CONCLUSIONS:
    Regardless of whether low-frequency electrical stimulation was used as an intervention, the use of plantar fascia-specific stretching and prefabricated foot orthoses provided short-term (3-month) pain relief and improvement in functional activity levels.

    My comments:

    McPoil and Cornwall were two of my favorite professors at NAU and most of what I know about foot anatomy and mechanics I learned from them.  Both treatment groups wore the same foot orthotics, both did the same plantar fascia stretching protocol described by DiGiovanni, but one group also did low rate TENS to the bottom of the foot at a rate of 10 pulses per second and at an intensity such that they felt a “moderate contraction or pulsing action that was comfortable.”  The TENS was performed once daily before they did their evening stretches.  No additional data was given with regard to pulse width, or amplitude used.

    The conclusion of the paper was that both groups improved, such that the effectiveness of the TENS treatment was questionable and there was no significant difference between the groups.  However when I calculated the pain score improvement myself I found the TENS group decreased pain 35% at 4 weeks, compared to 23.9% in the control group, and at the 3 month follow up the TENS group pain was 68% improved while the control group was 54.1% improved.  The P-value for the difference between groups was not given but knowing what I know about TENS, a greater number of subjects likely would have shown a statistically significant treatment difference, and maybe the same would have happened if the TENS intensity was increased. In the TENS research low or uncontrolled intensity TENS is often questionable with regards to pain reduction, but if the machines are turned up to the strongest comfortable current consistent pain reductions are often found.

    Still I am not a biggest fan of TENS because good quality electric stimulation machines can also be programed to do electric muscle stimulation (EMS) parameters that increase muscle strength. I would be very interested in seeing this study repeated using to target the foot intrinsic muscles, known to be weak in those with plantar fasciitis.  I currently prefer 10 seconds on, 50 seconds off for 12 minutes (10-50-12) with maximal pulse width and max tolerable amplitude using an electrode placement identical to that in this paper.  Besides improved muscle strengthening, EMS parameters have been shown to be superior to TENS for pain reduction as well.  The 10-50-12 EMS parameters would be almost identical to what world renowned sprint coach Charlie Francis favorite duty cycle (10-50-10) used for foot injuries in his sprint coaching book.  I just like to add 2 extra minutes to my treatment to get the intensity of the machine where I want it.  Also I would like to see the study repeated replacing DiGiovani’s stretches with comprehensive muscle strengthening program of the entire lower extremity.  A recent study just found basic calf strengthening, which was far from comprehensive, superior to Digiovani’s stretches.  In my physical therapy clinic the combination of EMS and strength exercises I am noticing  acceleration in the rate of recovery in my plantar fasciitis patients, most of whom have tried various foot stretches, and orthotics for months with little or no relief.

    Updated 1/25/2016

    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.

  • Post-Concussion Syndrome Treated With Aerobic Exercise

    A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. 2010 Jan;20(1):21-7.  Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B.

    Abstract
    OBJECTIVE:
    To evaluate the safety and effectiveness of subsymptom threshold exercise training for the treatment of post-concussion syndrome (PCS).

    DESIGN:
    Prospective case series.

    SETTING:
    University Sports Medicine Concussion Clinic.

    PARTICIPANTS:
    Twelve refractory patients with PCS (6 athletes and 6 nonathletes).

    INTERVENTION:
    Treadmill test to symptom exacerbation threshold (ST) before and after 2 to 3 weeks of baseline. Subjects then exercised 5 to 6 days per week at 80% ST heart rate (HR) until voluntary peak exertion without symptom exacerbation. Treadmill testing was repeated every 3 weeks.

    MAIN OUTCOME MEASURES:
    Adverse reactions to exercise, PCS symptoms, HR, systolic blood pressure (SBP), achievement of maximal exertion, and return to work/sport.

    RESULTS:
    Pretreatment, ST occurred at low exercise HR (147 + or – 27 bpm) and SBP (142 + or – 6 mm Hg). After treatment, subjects exercised longer (9.75 + or – 6.38 minutes to 18.67 + or – 2.53 minutes, P = .001) and achieved peak HR (179 + or – 17 bpm) and SBP (156 + or – 13 mm Hg), both P < .001 versus pretreatment, without symptom exacerbation. Time series analysis showed significant change in rate of symptom reduction for all subjects and reduced mean symptom number in 8/11. Rate of PCS symptom improvement was related to peak exercise HR (r = -0.55, P = .04). Athletes recovered faster than nonathletes (25 + or – 8.7 vs 74.8 + or – 27.2 days, P = .01). No adverse events were reported. Athletes returned to sport and nonathletes to work.

    CONCLUSIONS:
    Treatment with controlled exercise is a safe program that appears to improve PCS symptoms when compared with a no-treatment baseline. A randomized controlled study is warranted.

    QUOTE FROM THE STUDY WORTH REMEMBERING:
    Experimental animal data show that premature voluntary exercise within the first week after concussion impairs, whereas exercise performed 14-21 days after concussion improves, cognitive performance.

    My comments:

    I think this study is very promising and seems to be the most effective treatment program I have been able to find when researching post-concussive syndrome for a new physical therapy patient I have with the condition.  This is especially important because I was seeing him for balance/vestibular troubles but I really had my doubts that vestibular rehabilitation, which works great for BPPV, was going to work for him.  So I did a literature review on the subject and blogged on a study that found vestibular rehabilitation exercises had no effect on dizziness in adults with post-concussive syndrome.  Based in part on having read the book Spark, which was about the effects of exercise, particularly cardiovascular exercise and the brain, I thought the use of aerobic exercise for post-concussive syndrome made a lot of sense.

    The treatment protocol in this study was to first test patients with what is called the Balke Protocol. They walked on a level treadmill at 3.3 mph for 1 minute, then added 2% incline, then increased the incline another 1% each minute until post-concussive symptoms were increased. The patients’ heart rate was then recorded and the test was stopped.  The initial test was done to see what heart rate increased symptoms, so that the patients could exercise just below that level going forward.

    The following exercise program was done on a treadmill with a target heart rate of 80% of the threshold heart rate, 5-6 days per week.  Subjects were told to terminate the exercise at the first point of symptom exacerbation or if they reached their goal duration, which was same duration reached during the prior treadmill test.  Balke Protocol treadmill tests were performed every 3 weeks until symptoms were no longer exacerbated by the test.

    There were only 12 subjects in the study so results can’t be said to be universal. Treatment duration ranged from 11 to 112 days, with an average of 31.8.  Exercise times on the treadmill increased from 9.75 minutes to 18.67 minutes.  At follow up 3 months after the end of exercise 10 of the 12 subjects reported being symptom free, one still had cognitive and visual symptoms and one still had migraine headaches, but had a history of migraines prior to his injury.

    Though still preliminary, overall these are very promising results for a problem that causes significant disabilities; for 15% of sufferers the symptoms can last for years or be permanent.  And based on it, I’ll be putting aerobic exercise in my post-concussion physical therapy protocols going forward and will evaluate how well it works in real time.

    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.

  • Vestibular Rehabilitation & Post-Concussion Syndrome

    Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurologic Physical Therapy. 2010 Jun;34(2):87-93. Alsalaheen BA, Mucha A, Morris LO, Whitney SL, Furman JM, Camiolo-Reddy CE, Collins MW, Lovell MR, Sparto PJ.

    Abstract
    BACKGROUND AND PURPOSE:
    Management of dizziness and balance dysfunction is a major challenge after concussion. The purpose of this study was to examine the effect of vestibular rehabilitation in reducing dizziness and to improve gait and balance function in people after concussion.

    METHODS:
    A retrospective chart review of 114 patients (67 children aged 18 years and younger [mean, 16 years; range, 8-18 years]; 47 adults older than 18 years [mean, 41 years; range, 19-73 years]) referred for vestibular rehabilitation after concussion was performed. At the time of initial evaluation and discharge, recordings were made of outcome measures of self-report (eg, dizziness severity, Activities-specific Balance Confidence Scale, and Dizziness Handicap Inventory) and gait and balance performance (eg, Dynamic Gait Index, gait speed, and the Sensory Organization Test). A mixed-factor repeated-measures analysis of variance was used to test whether there was an effect of vestibular rehabilitation therapy and age on the outcome measures.

    RESULTS:
    The median length of time between concussion and initial evaluation was 61 days. Of the 114 patients who were referred, 84 returned for at least 1 visit. In these patients, improvements were observed in all self-report, gait, and balance performance measures at the time of discharge (P < .05). Children improved by a greater amount in dizziness severity (P = .005) and conditions 1 (eyes open, fixed support) and 2 (eyes closed, fixed support) of the Sensory Organization Test (P < .025).

    DISCUSSION:
    Vestibular rehabilitation may reduce dizziness and improve gait and balance function after concussion. For most measures, the improvement did not depend on age, indicating that vestibular rehabilitation may equally benefit both children and adults.

    CONCLUSIONS:
    Vestibular rehabilitation should be considered in the management of individuals post-concussion who have dizziness and gait and balance dysfunction that do not resolve with rest.

    My comments:

    The problem with this study is in the abstract it says vestibular rehabilitation is equally effective for both children and adults.  However, if you read the actual paper, the findings showed anything but. Adults showed no significant improvements in self reported dizziness, improving from a 21/100 pretreatment to only 20/100 post treatment, while children improved from 26/100 to a 7/100.  In testing for Dynamic Computerized Posturography children improved pretreatment to post treatment, while adults had zero improvement.  The text of the paper even says:

    “…there was no significant difference in dizziness for the adult group between pre- and post-treatment”

    The exercises described in the study were gaze stabilization in which the person maintained focus on a fixed object while they turned their head, standing balance on a foam roll with eyes open and closed, and walking with balance challenges to include head turning, tandem walking, and obstacle avoidance.  They did canalith repositioning in only a few cases and it was interesting that out of 114 patients with post-concussive syndrome dizziness only 5 were diagnosed with benign paroxysimal positional vertigo (BPPV). I think this helps to explain the lack of effect with vestibular rehabilitation in the adults.  In my physical therapy practice I have noticed canalith repositioning to be near miraculous for eliminating vertigo, and it’s well supported by research for that, but for other balance disorders I can’t say that I have noticed much of an effect from the other vestibular exercises, gaze stabilization etc.

    So while this paper is a bit of downer with regards to vestibular exercise for post-concussive syndrome, it’s valuable in that helps to indicate some exercises patients and therapists probably shouldn’t waste their time on for adults with post concussive syndrome.  The good news is that in researching potential physical therapy programs for post concussion syndrome, I came across a number of papers finding very positive effects with the use of aerobic exercises, which I plan to do a few blogs on coming up. [edit to add research showing effectiveness of aerobic exercise on post-concussion syndrome]

    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.

  • Resistance Training Improves Running Biomechanics

    Resistance training is accompanied by increases in hip strength and changes in lower extremity biomechanics during running. Clin Biomech (Bristol, Avon). 2009 Jan;24(1):26-34. Snyder KR, Earl JE, O’Connor KM, Ebersole KT.

    Abstract
    BACKGROUND:
    Movement and muscle activity of the hip have been shown to affect movement of the lower extremity, and been related to injury. The purpose of this study was to determine if increased hip strength affects lower extremity mechanics during running.

    METHODS:
    Within subject, repeated measures design. Fifteen healthy women volunteered. Hip abduction and external rotation strength were measured using a hand-held dynamometer. Three-dimensional biomechanical data of the lower extremity were collected during running using a high-speed motion capture system. Measurements were made before, at the mid-point, and after a 6-week strengthening program using closed-chain hip rotation exercises. Joint range of motion (rearfoot eversion, knee abduction, hip adduction, and internal rotation), eversion velocity, eversion angle at heel strike, and peak joint moments (rearfoot inversion, knee abduction, hip abduction, and external rotation) were analyzed using repeated measures analysis of variance (P <or= 0.05). The independent variable was time (pre-, week 3, and week 6). A separate analysis of variance was conducted with the dependent variables of peak hip abduction and external rotation strength.

    FINDINGS:
    Hip abduction (P=0.009) and external rotation strength (P<0.0005) increased by 13% and 23%, respectively. Eversion range of motion decreased (P=0.05), hip adduction range of motion increased (P=0.05), and a trend of decreased hip internal rotation range of motion (P=0.08) were found. Rearfoot inversion moment (P=0.02) and knee abduction moment (P=0.05) decreased by 57% and 10%, respectively.

    INTERPRETATION:
    The hip abductors and external rotators were strengthened, leading to an alteration of lower extremity joint loading which may reduce injury risk. These exercises could be used in the rehabilitation, or prevention, of lower extremity injuries.

    My comments:

    I have been blogging on running related injuries and how much research is showing they are secondary to hip muscle weakness causing increased stress on the knee and ankle by allowing the thigh to adduct (bend inward), internally rotate (thigh twists to midline) causing  abduction to the knee (shin bending outward in relation to the thigh) and the shin externally rotating (twisting outwards in relation to the thigh).  This puts excess force on the knee, the tibia (primary shin bone) and drives the foot flat, stressing the posterior tibial tendon and plantar fascia among other things.  In other words it is a cornucopia of stress throughout the entire leg and foot to run, particularly for women, if their hip muscles are not strong enough to stabilize the leg in relation to the torso.

    So these researchers came up with an progressive resistance exercise program (3 exercises) working on hip abduction, internal and external rotation all performed while standing with a cable machine, attaching the cable to the side of the hip with a belt. And as stated in the abstract the exercise program worked well, increased hip strength which then decreased hip internal rotation, knee abduction, and rearfoot eversion all decreasing while running.  Hip adduction for some reason increased slightly, which the researchers were unable to account for, but 3 out of 4 biomechanical measures being positive is pretty good for a 6 week intervention.

    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.

  • Posterior Tibial Tendon Dysfunction & Muscle Weakness

    Women with posterior tibial tendon dysfunction have diminished ankle and hip muscle performance. J Orthop Sports Physical Therapy. 2011 Sep;41(9):687-94. Kulig K, Popovich JM Jr, Noceti-Dewit LM, Reischl SF, Kim D.

    Abstract
    STUDY DESIGN:
    Controlled laboratory study using a cross-sectional design.

    OBJECTIVES:
    To characterize ankle and hip muscle performance in women with posterior tibial tendon dysfunction (PTTD) and compare them to matched controls. We hypothesized that ankle plantar flexor strength, and hip extensor and abductor strength and endurance, would be diminished in women with PTTD and this impairment would be on the side of dysfunction.

    BACKGROUND:
    Individuals with PTTD demonstrate impaired walking abilities. Walking gait is strongly dependent on the performance of calf and hip musculature.

    METHODS:
    Thirty-four middle-aged women (17 with PTTD) participated. Ankle plantar flexor strength was assessed with the single-leg heel raise test. Hip muscle performance, including strength and endurance, were dynamometrically measured. Differences between groups and sides were assessed with a mixed-model analysis of variance.

    RESULTS:
    Females with PTTD performed significantly fewer single-leg heel raises and repeated sagittal and frontal plane non-weight-bearing leg lifts, and also had lower hip extensor and abductor torques than age-matched controls. There were no differences between sides for hip strength and endurance measures for either group, but differences between sides in ankle strength measures were noted in both groups.

    CONCLUSION:
    Women with PTTD demonstrated decreased ankle and hip muscle performance bilaterally.

    My comments:

    In the study the authors reported ankle plantar flexion (calf muscle) strength in those with posterior tibial tendinitis reduced 63% of normal, hip extension reduced 33.8%, and hip abduction 28.4%.  These results of calf and hip muscle weakness being associated with foot and ankle pain are in near complete agreement the other studies on hip, knee, ankle, and foot injuries, and would explain why they are so resistant to healing. Many physician, podiatrist, and physical therapy programs focusing on the site of injury, or treating with passive modalities do little to affect either the underlying cause or symptom of the condition, or worse with a cortisone injection which makes the involved tissue weaker and much more likely to tear.  While not measured in this study I would be surprised if the injured subjects didn’t have intrinsic foot muscle weakness as well.

    My way of thinking is that it is much better to start patients off on a good progressive resistance exercise program that restores strength at the same time it reduces pain.  I generally start with lighter exercises, and electric muscle stimulation, at the site of injury to prevent exacerbation of symptoms but more aggressive exercise elsewhere else to get foot, hip and thigh strength back up to normal ASAP, which in turns help to normalize forces when walking and running, in this case at the ankle.

    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.

  • Orthotics Cause Shin Splints in Runners?

    Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis. Open Access J Sports Med. 2013 Nov 13;4:229-41. Newman P, Witchalls J, Waddington G, Adams R.

    Abstract
    BACKGROUND:
    Medial tibial stress syndrome (MTSS) affects 5%-35% of runners. Research over the last 40 years investigating a range of interventions has not established any clearly effective management for MTSS that is better than prolonged rest. At the present time, understanding of the risk factors and potential causative factors for MTSS is inconclusive. The purpose of this review is to evaluate studies that have investigated various risk factors and their association with the development of MTSS in runners.

    METHODS:
    Medical research databases were searched for relevant literature, using the terms “MTSS AND prevention OR risk OR prediction OR incidence”.

    RESULTS:
    A systematic review of the literature identified ten papers suitable for inclusion in a meta-analysis. Measures with sufficient data for meta-analysis included dichotomous and continuous variables of body mass index (BMI), ankle dorsiflexion range of motion, navicular drop, orthotic use, foot type, previous history of MTSS, female gender, hip range of motion, and years of running experience. The following factors were found to have a statistically significant association with MTSS: increased hip external rotation in males (standard mean difference [SMD] 0.67, 95% confidence interval [CI] 0.29-1.04, P<0.001); prior use of orthotics (risk ratio [RR] 2.31, 95% CI 1.56-3.43, P<0.001); fewer years of running experience (SMD -0.74, 95% CI -1.26 to -0.23, P=0.005); female gender (RR 1.71, 95% CI 1.15-2.54, P=0.008); previous history of MTSS (RR 3.74, 95% CI 1.17-11.91, P=0.03); increased body mass index (SMD 0.24, 95% CI 0.08-0.41, P=0.003); navicular drop (SMD 0.26, 95% CI 0.02-0.50, P=0.03); and navicular drop >10 mm (RR 1.99, 95% CI 1.00-3.96, P=0.05).

    CONCLUSION:
    Female gender, previous history of MTSS, fewer years of running experience, orthotic use, increased body mass index, increased navicular drop, and increased external rotation hip range of motion in males are all significantly associated with an increased risk of developing MTSS. Future studies should analyze males and females separately because risk factors vary by gender. A continuum model of the development of MTSS that links the identified risk factors and known processes is proposed. These data can inform both screening and countermeasures for the prevention of MTSS in runners.

    My comments

    Medial tibial stress syndrome (MTSS) is the new term for shin splints. This review paper was the first to perform a meta-analysis of risk factors related to the condition.  Based on the paper the exact cause of the shin pain is unknown, but they noted that recent interpretations from imaging studies seem to be implicating the tibia bone itself as the most likely source of pain.

    Navicular drop (an indicator for foot pronation) increased BMI, female gender, fewer years running experience and prior history of MTSS were all associated with increased risk, none of which was particularly surprising.  They noted ankle dorsiflexion range of motion was most certainly not a risk factor so time spent stretching the ankle should have no protective effects.  However, what was surprising to me were these findings:

    “Prior use of orthotics was found to be a highly significant risk factor for developing MTSS. The effect size was large.”

    “Orthotics are commonly prescribed to correct or support a foot that has been deemed to be in less than optimal alignment, but their role in prevention and intervention is unclear according to a recent systematic review. [56] Our analysis suggests their use is a causative risk factor and therefore they are not useful for prevention.”

    “At least 25% of the participants included in this meta-analysis had been prescribed orthotics prior to developing MTSS.”

    The authors weren’t sure why the orthotics might cause MTSS. They thought that the orthotics might cause deconditioning of the foot musculature, that they might decrease shock attenuation too much (preventing the tibial bone from positively adapting by increasing bone mineral density), or it was perhaps due to altered foot and ankle positions when running.  Given that foot Orthotics have little effect on plantar fasciitis, moderate effects on patellofemoral pain, and apparently increase risk of MTSS, they should probably not be used as a matter of course. The overall risk-reward profile might not be worth it.  The foot arch is better supported naturally through exercising the muscles of the foot, leg, hip and core.

    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.

  • Patellofemoral Pain & Orthotics, Predicting Who Will Benefit

    A clinical prediction rule for identifying patients with patellofemoral pain who are likely to benefit from foot orthoses: a preliminary determination. Br J Sports Med. 2010 Sep;44(12):862-6. 26. Vicenzino B1, Collins N, Cleland J, McPoil T.

    Abstract
    OBJECTIVE:
    To develop a clinical prediction rule to identify patients with patellofemoral pain (PFP) who are more likely to benefit from foot orthoses.

    DESIGN:
    Posthoc analysis of one treatment arm of a randomised clinical trial.

    SETTING:
    Single-centre trial in a community setting in Brisbane, Australia.

    PARTICIPANTS:
    42 participants (mean age 27.9 years) with a clinical diagnosis of PFP (median duration 36 months).

    INTERVENTIONS:
    Foot orthoses fitted by a physiotherapist.

    MAIN OUTCOME MEASURES:
    Five-point global improvement scale at 12-week follow-up, dichotomised with marked improvement equalling success.

    RESULTS:
    Potential predictor variables identified by univariate analyses were age, height, pain severity, anterior knee pain scale score, functional index questionnaire score, foot morphometry (arch height ratio, mid-foot width difference from non-weight bearing to weight bearing) and overall orthoses comfort. Parsimonious fitting of these variables to a model that explained success with orthoses identified the following: age (>25 years), height (<165 cm), worst pain visual analogue scale (<53.25 mm) and a difference in mid-foot width from non-weight bearing to weight bearing (>10.96 mm). The pretest success rate of 40% increased to 86% if the patient exhibited three of these variables (positive likelihood ratio 8.8; 95% CI 1.2 to 66.9).

    CONCLUSION:
    Post-hoc analysis identified age, height, pain severity and mid-foot morphometry as possible predictors of successful treatment of PFP with foot orthoses, thereby providing practitioners with information for prescribing foot orthoses in PFP and stimulating further research.

    My comments:

    This study was a follow up on an earlier study by the same authors that I also blogged. That study found foot orthotics with arch supports only had a modest beneficial effect in treating patellofemoral pain, with success (defined as those patients experiencing a marked improvement) in only 40% with the use of orthotics in those with patellofemoral pain.

    What they did in this study was go back and look at the 40% who had success and see what factors they had in common, so that physical therapists can better predict who is likely to benefit from orthotic use.  They found four variables that increased the odds orthotics would help.

    1. being over 25 years old
    2. being shorter than 165 cm (shorter than 5’5”)
    3. worst pain less than 53.3 mm on a VAS (pain at worst less than 5.33 out of 10)
    4. midfoot width difference greater than 10.96 mm (a more mobile foot that flattens more when you put weight on it)

    What they found was if the patient had 3 out of 4 of those variables, the chance of success more than doubled from 40% up to 86%.  2 out of 4 and you still had a 61% of success.

    So the take home is that if you are over 25, not too tall (less than 5’5”), your pain isn’t too bad (less than ~5/10 at worst), and your foot flattens more than usual (probably you will need someone to measure that), there is a pretty good chance that orthotics with arch supports will help lessen patellofemoral pain.  With newer research showing patellofemoral pain is multifactorial, principally involving hip and thigh muscle weakness, orthotics should probably be considered only part of the solution in some people and study helps us decide who those people are.

    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.

  • Tibial Stress Fractures in Runners: It’s All the Same Problem

    Distinct hip and rearfoot kinematics in female runners with a history of tibial stress fracture. Journal of Orthopaedic & Sports Physical Therapy. 2010 Feb;40(2):59-66. Milner CE1, Hamill J, Davis IS.

    STUDY DESIGN:
    Cross-sectional controlled laboratory study.

    OBJECTIVES:
    To investigate the kinematics of the hip, knee, and rearfoot in the frontal and transverse planes in female distance runners with a history of tibial stress fracture.

    BACKGROUND:
    Tibial stress fractures are a common overuse injury in runners, accounting for up to half of all stress fractures. Abnormal kinematics of the lower extremity may contribute to abnormal musculoskeletal load distributions, leading to an increased risk of stress fractures.

    METHODS:
    Thirty female runners with a history of tibial stress fracture were compared to 30 age-matched and weekly-running-distance-matched control subjects with no previous lower extremity bony injuries. Kinematic and kinetic data were collected using a motion capture system and a force platform, respectively, as subjects ran in the laboratory. Selected variables of interest were compared between the groups using a multivariate analysis of variance (MANOVA).

    RESULTS:
    Peak hip adduction and peak rearfoot eversion angles were greater in the stress fracture group compared to the control group. Peak knee adduction and knee internal rotation angles and all joint angles at impact peak were similar between the groups.

    CONCLUSION:
    Runners with a previous tibial stress fracture exhibited greater peak hip adduction and rearfoot eversion angles during the stance phase of running compared to healthy controls. A consequence of these mechanics may be altered load distribution within the lower extremity, predisposing individuals to stress fracture.

    My comments:

    I thought this study was interesting because I have been reading studies and blogging on patellofemoral pain and plantar fasciitis. I’ve been finding there are likely similar causes/results from each condition, being hip adduction (the thigh moving more towards midline of the body) and or internal rotation and flat feet (AKA fallen arches, over pronation).  This study found largely the same thing with tibial stress fractures in female runners.  They did not find increased hip internal rotation but they did find increased hip adduction, and when they talk about “rearfoot eversion,” that is another measure of fallen arches or flat feet.

    The researchers concluded that hip abduction strengthening and arch supports might be good for treatment and/prevention. Both of those sound reasonable, but I would suggest a general lower extremity and core strength training program. Though it is true the hip abductors do tend to be particularly weak, runners with patellofemoral pain and plantar fasciites have been found to have more global muscle weakness as well.  Strengthening the foot intrinsic muscles might also help to support the arches and lessen tibial stress.

    The researches also said:

    “The greater hip adduction in the stress fracture group may be the result of the greater rearfoot eversion, or, conversely the greater hip adduction may be the cause of greater rear foot eversion.”

    I was thinking this very thing with relation to plantar fasciitis and fallen arches. If the hips are weak and the thigh adducts and internally rotates, it puts increased stress on the arch of the foot, and might be causing a flattening effect on the feet. This may potentially result in foot conditions such as plantar fasciitis, posterior tibial tendinitis, acquired flat foot deformity, patellofemoral pain, and as this study indicates tibial stress fractures.  And let’s not forget greater trochanteric pain syndrome/trochanteric bursitis.  Even low back pain is associated with LE weakness.  The picture coming together from all this research is that all of these problems stem from the same cause (generalized LE, and likely core, weakness) which perhaps isn’t so much overuse in running but rather underuse of  strength training.  The result is muscles aren’t strong enough to properly support bones and joints, causing breakdown of tissue wherever the weak link in the chain is (be it the hip, knee, tibia, ankle or foot).  Worse is that injury of the weak link alters running and walking mechanics, and often due to disuse leaves the rest of the chain in a weakened condition, more prone to further injury.

    Knowing all this I’m going to go out on a limb and suggest that passive modalities (stretching, soft tissue mobilization, foam rolls, ultrasound, dry needling, kinesio tape, or whatever the current fad is) in physical therapy probably isn’t the best use of anyone’s limited resources.  Probably it’s better to add some balanced and well prescribed strength training to your running program.  The good news is that while one should take time off from running to let a stress fracture heal, there is a lot of strengthening that can be done both above and below the fracture site that won’t place any stress on it.

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

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