Abstract: This article reports an observational study investigating the safety and effectiveness of a high-intensity interval exercise program for patients with peripheral arterial disease. Patients were asked to walk on a treadmill to maximal claudication pain six times in each exercise session, with 3-minute rests in between. Once a patient could walk continuously for 6 minutes without reaching maximal pain, speed and/or grade was increased. To account for the changes in speed and grade, patients’ walking ability was measured as a rehabilitation score, calculated as the product of the two. A total of 47 patients were included in the study. Results showed overall improvement in the rehabilitation score with participation in the program, and specifically showed that participation in more exercise sessions led to greater improvement. Moreover, no adverse events occurred in the study patients, suggesting patients with peripheral arterial disease can safely tolerate high-intensity exercise programs.
Also: “After adjusting for age, gender, and body mass index, the rehabilitation score increased by approximately 0.2 points for each additional exercise session attended. Thus a patent with a rehabilitation score of 3 on entering the program who attended 10 exercise sessions might achieve a score of 5, whereas another patient who attended all 36 sessions might achieve a score of 10.2.”
My comments:
The protocol for this study is listed in the abstract. Improvements were given as a product of both speed and grade of incline, so I can’t compare walking distance very well with the other treatment protocols. While this study was 3 times per week for 3 weeks, a lot of patients didn’t complete every treatment. The authors could compute average improvement per workout ( ~0.2 points per workout), so those who completed more workouts had more improvement in a roughly linear fashion. Patients in this protocol were only given 3 minutes rest between intervals, while the patient I am currently working with reports needing 5 minutes rest for all claudication pain to vacate. Perhaps that is why this program had a lesser number of subjects complete all the workouts.
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.
The aim of this study was to evaluate the effects of supervised treadmill walking training on the calf muscle capillarization in patients with intermittent claudication. The first 12-week period was a non-exercise, within-subject control stage, and the second 12-week period was an exercise training stage. Calf muscle biopsy and functional capacity measurement were performed at baseline, preexercise and postexercise training. In all, 11 subjects completed all procedures. Their average age was (mean +/- standard deviation) 73.9 +/- 5.5 years and resting ankle-to-brachial systolic blood pressure index was 0.57 +/- 0.11. After exercise training, the difference between the pretraining and posttraining capillaries in contact with type IIx and IIa muscle fibers for each subject was significantly correlated with an improved pain-free walking time, r = 0.69 and r = 0.62 (both P < .05), respectively. This finding suggests that the change in calf muscle capillarization might contribute to the improved walking capacity following supervised treadmill walking training in patients with intermittent claudication.
My comments:
The protocol in this paper was as follows;
Start on treadmill at 3.2 kph (2 mph) with incline individualized to get ⅘ (moderate) claudication pain after 5 minutes
Sit and rest after pain reaches ⅘ and begin walking again after pain fully subsides
Increase incline 0.5 % if patient is able to walk 7 minutes continuously
Start increasing speed 0.5 kph after patient works to 5% grade
1 hour per day, 3 times per week for 12 weeks
5 point pain scale slightly different than 4 point scale of other researchers (why everyone can’t just use regular 10 point scale I’ll never know)
no pain
onset of pain
mild pain
moderate pain
max claudication (pain)
This study found capillaries in contact with each muscle fiber increased significantly for type II (fast, anaerobic) muscle fibers but not type 1 (slow, aerobic) fibers to total muscle fibers. Absolute capillary contact number did increase for all fibers, just not significantly, but I expect it would have if there were a greater number of study subjects. Percent increase in capillary contact was 9.7% for type 1 muscle fibers, 9.2% for type IIa fibers, and 15% for type IIx fibers.
Pain free walking distance (PFWD) improved from 130 m to 348 m (168%), while maximal walking distance (MWD) improved from 323 m to 714 m (120%). In an effort to compare apples to apples I’m going to take these percentages per week and percentages per workout. So for this study that works out to:
PFWD/week = 14%
MWD/week = 10%
PFWD/workout (60 minutes) = 4.67%
MWD/workout (60 minutes) = 3.33%
I think the goal should be to find the protocol the most improvement in the least time with the least pain. This protocol is what I started my 1st claudication patient on. He reported it felt pretty good, in that he could stop when it hurt but then he could go at it again when he felt better. At the beginning of his hour he lasted almost exactly 5 minutes but he worked up to 7 minutes by the end of the hour, which he thought was pretty encouraging. The protocol above is also very similar to the TASC II program. The main difference is that intensity is increased after one is able to walk 7 minutes continuously rather than 10 minutes in the TASK II program, but I would be surprised if it made much difference either way. Improvements per week and per workout were not as good as the interval protocol with active rest, however.
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.
Abstract BACKGROUND: Peripheral arterial disease (PAD) is one of the complications of atherosclerosis. Intermittent claudication is the second stage of PAD. In controlled studies on patients with Stage II PAD, intensive rehabilitation training has proved effective for improving the walking distance in this population. The objective of this prospective study was to determine the effects of treadmill interval training followed by active recovery (low-intensity exercise). METHODS AND RESULTS: Eleven patients with Stage II peripheral arterial disease were included in a rehabilitation program (mean age 68.3±10.3years) for five days a week during two weeks including global exercises, exercises below and above the level of injury. The interval training program consisted of treadmill training for 30minutes twice a day (morning and evening) with a progressively increased intensity: the first week speed was increased and the second week slope was increased. Each session included five six-minute cycles. Each cycle was made of three minutes of active workout followed by three minutes of active recovery. RESULTS: All patients improved their walking distance, from a mean of 610 m (120-1930) at the beginning of the program to a mean of 1252 m (320-2870) at the end (P=0.003). All patients were very motivated by the rehabilitation training program. No adverse event was reported. CONCLUSION: This study showed that an interval training program with active recovery was effective and safe for patients with Stage II peripheral arterial disease, the patients’ motivation was high. This study must now be validated by a clinical trial.
My comments:
The protocol used in this study was:
Walk at 70% of max speed for 3 minutes and alternate with walking 40% for 3 minutes 5 times for a total of 30 minutes.
Max speed was determined by walking 1 kph (0.62 mph) and increasing that speed 0.1 (kph) until reaching maximum tolerable pain.
If there was no pain during a walk in the first week, speed was increased 0.1 kph, and if there was no pain in the 2nd week incline was raised half a degree.
Exercise was done 2 times per day 5 days per week.
It says the “training included global gym exercises, exercises below the level of injury (for proximal lesions: sit to stand and tiptoe, for medial lesions standing on tiptoes and for distal lesions: toe flexing exercises) and above the level of injury (including cycloergometer training) and treadmill retraining.”
There are a few things I think are interesting about this study. It’s the first one I have read that used active recovery (slower walking); the prior papers I talked about used passive recovery (sitting or standing). Results were very good, with walking distance at 3 kph (1.86 mph) more than doubling in just two weeks. The prior papers seemed to indicate gains come more slowly.
What’s difficult to tell is if the active rest was better than passive rest, or if the gains were fast because the people trained very frequently 2 times per day 5 days per week. My guess is that it’s the increased frequency that’s most responsible. Also it’s difficult to know if the increase in walking distance from this study is the same as others where subjects are tested walking different or varying speeds. That I’m not so sure about, so I wish everyone would include a universal test like the 6 minute walk test so we can compare apples to apples. Finally, it’s impossible to know what effect the additional “global gym exercises” had as they were neither separated out nor quantified. Thus, it’s difficult to say how much effect was from the treadmill training program. Another thing I don’t like about this protocol is that it comes across as fairly complex and confusing to implement, increasing speed one week and grade the next. I wouldn’t want to try and teach it to patients for home or gym use and as such would prefer simpler protocols described in my last blog. So in future blogs I’ll compare this one to other studies as best as I can to see which parts of it are worthwhile.
I’ll have to remember that this protocol is good for an average of 105% increase in max walking distance (MWD) at 3 kph (1.86 mph) after 2 weeks. Which works out to:
MWD/week is 105%/2 = 52.5%
MWD/workout (30 min 2 per day) 105%/20 = 5.25%
I am curious about the active rest aspect of this study as I have a patient right now who I started using walk/sit intervals with. It takes him about 5 minutes of rest to recover and go again, so I’ll have to let him try reducing the speed by half and see if he feels he recovers better or worse. The more I think about it, I think that would be a good study. I’ll have to see if it’s been done yet.
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.
This was short review paper but I liked it because it gave consensus recommendations from both the TASC II (Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease) as well as the program from the American Heart Association.
The TASC II program is as follows:
Begin treadmill walking at a speed that causes calf pain within 3-5 minutes
Walking should be stopped when claudication pain is moderate (2 on 4 point scale)
Rest until pain has resolved, walk, rest, walk… (progressing from 30-60 minutes)
If the patient can walk 10 minutes without a break (increase either the speed or incline on treadmill)
Train 3 times per week for 3 months
The American Heart Association guidelines are as follows:
Begin walking on treadmill or track with an intensity starts pain (1 on claudication pain scale) in 3-5 minutes
Walk until pain reaches 2 on scale then rest by sitting or standing
Repeat cycle for 35 minutes
Increase the exercise program by 5 minutes to 50 minutes total
Train 3-5 times per week for a minimum of 12 weeks
Pain Scale (used in paper):
Minimal discomfort
Moderate pain (patient can be distracted)
Intense pain
Unbearable pain
Looking at the two programs I see more similarities than differences, so I would expect them to work about the same. They are very similar to the protocol I’m starting my patients with. The paper mentions that supervised exercise still works substantially better than independent exercise, and looking at the program I’m not sure why that is. Possibly it could be that walking with claudication is painful and maybe it helps to have someone tell you when to get up and start walking again. However neither of these programs encouraged the patients to work up to higher levels of pain. It might also be that people who end up with intermittent claudication generally aren’t the kind of people who enjoy cardiovascular exercise for it’s own right (I know I sure don’t), so maybe they need that extra push to get going. I’ll try to learn more about differences found as I read through some of the individual studies, because eventually virtually everyone with PAD is going to need to transition to an independent exercise program.
Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember 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.
Abstract Lower extremity peripheral artery disease (PAD) affects 8 million men and women in the United States and will be increasingly common as the U.S. population lives longer with chronic disease. People with PAD have poorer walking endurance, slower walking velocity, and poorer balance, compared with individuals without PAD. People with PAD may reduce their walking activity to avoid leg symptoms. Thus, clinicians should not equate stabilization or improvement in exertional leg symptoms with stabilization or improvement in walking performance in PAD. In addition, even asymptomatic PAD patients have greater functional impairment and faster functional decline than individuals without PAD. Of the 2 FDA-approved medications for treating claudication symptoms, pentoxifylline may not be more efficacious than placebo, whereas cilostazol confers a modest improvement in treadmill walking performance. Supervised treadmill walking exercise is associated with substantial improvement in walking endurance, but many PAD patients do not have access to supervised exercise programs. Unsupervised walking exercise programs may be beneficial in PAD, but data are mixed.
My comments:
I took a 10 hour continuing education course last year on physical therapy for cardiovascular deficits. Most continuing education courses fall into one of two categories: 1) things you already know and you learned in school, or 2) pseudoscientific nonsense. This course, however, was different. It really got me thinking about use of the 6-minute walk test to determine deficits. I recollected back to the course when referred a patient for low back pain who just so happened to have intermittent claudication (intense calf pain while walking secondary to decreased blood flow to the working muscles). His back pain was relatively easy to treat, leaving intermittent claudication as his primary source of pain. It was preventing him from doing any cardiovascular exercise, and preventing him from playing golf, which was one of his favorite pastimes. I would have had no idea how to treat it if not for the continuing education course. The only problem was the course was written back in 2004, so I figured it best to do a current literature review to come up with what’s new and what I think is the best science-based protocol for intermittent claudication, and the above paper is the first one I read.
The gist is that people with peripheral artery disease (PAD) not only have lower levels of function (measured by walking speed and distance) than normal people of the same age, but they decline in function substantially faster than normal controls. This is thought to be due to the leg pain experienced when walking, such that they walk less and walk slower, to avoid the pain, which results in further downward spiral.
It turns out however that exercise (generally various treadmill programs, but also strengthening and cycle and upper body ergometry) seems to be very effective at improving walking speed, walking distance, and lessening or eliminating pain in the legs when walking. For some reason supervised exercise programs work, but unsupervised exercise programs, not as well, which is odd as you would think there isn’t a lot to walking on a treadmill. Unfortunately there was not a lot of detail with regards to any particular program in this paper, but having obtained a 3” thick pile of studies there seems to be considerable data to go off of. It should make for good blog fodder in the coming weeks, as well as what I hope to be a bang-up treatment protocol that I can alter or not depending on new research findings and as I gather more practical experience treating the condition.
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.
Abstract BACKGROUND: In cluster headache, neuromodulation is offered when patients are refractory to pharmacological prophylaxis. Non-invasive peripheral neuromodulatory approaches are of interest. We will focus on these and particularly on nociception specific, transcutaneous supraorbital nerve stimulation. METHODS: In a study using the nociception specific blink reflex, we made a serendipitous discovery, notably the potential prophylactic effect of bilateral, time contingent, nociception specific, transcutaneous stimulation of the supraorbital nerve. RESULTS: We report on a case series of seven cluster headache patients, in whom attacks seemed to disappear during repeated stimulation of the supraorbital nerves. Three patients stopped experiencing attacks since study participation. CONCLUSIONS: Bilateral, time contingent, nociception specific, transcutaneous supraorbital nerve stimulation may have a prophylactic effect in episodic and chronic cluster headache. Given its limited side effects and its non-invasive nature, further studies to investigate this potential peripheral neuromodulatory approach for both episodic and chronic cluster headache are warranted.
Additional quote:
“The ‘gate-control theory’ of Melzack and Wall deals with the influence of a competition between nociceptive and innocuous signals on second-order neurons (10-11), the latter signals transmitted by A-beta fibers. One may question the applicability of this theory to NSTS of the supraorbital nerve, in which nociception specific stimulation of trigeminal A-delta afferents seem to suppress the transmission of the other nociceptive (i.e. headache) signal on a segmental level.”
My comments:
The parameters used were monophasic 200 Hz train of three 0.5 ms pulses, working up to 2.1 mA given on average 6 times at 2 hour intervals. They were using a type of electrical current they wanted to be painful and testing for a blink response. It was serendipity that they found the cluster headaches went away. Cluster headaches are a particularly painful and problematic variety, so it is good to see potential here from a treatment that is non-invasive and at least in this small sample seems to have worked quite well.
I generally favor alternating current to the monophasic current used in this study, largely because it feels better. However, it certainly is an interesting finding and should perhaps be compared to alternating currents being applied transcutaneously to the supraorbital nerve. I would like to see how it compares to suboccipital stimulation, as well as to the combination of the two for cluster headaches, migraines, tension, and cervicogenic headaches. I have been noticing a very good effect with the latter three. It is also interesting that the headache prevention may not be due to gate-control theory.
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.
AbstractOBJECTIVE:To assess efficacy and safety of trigeminal neurostimulation with a supraorbital transcutaneous stimulator (Cefaly, STX-Med., Herstal, Belgium) in migraine prevention.METHODS:This was a double-blinded, randomized, sham-controlled trial conducted at 5 Belgian tertiary headache clinics. After a 1-month run-in, patients with at least 2 migraine attacks/month were randomized 1:1 to verum or sham stimulation, and applied the stimulator daily for 20 minutes during 3 months. Primary outcome measures were change in monthly migraine days and 50% responder rate.RESULTS:Sixty-seven patients were randomized and included in the intention-to-treat analysis. Between run-in and third month of treatment, the mean number of migraine days decreased significantly in the verum (6.94 vs 4.88; p = 0.023), but not in the sham group (6.54 vs 6.22; p = 0.608). The 50% responder rate was significantly greater (p = 0.023) in the verum (38.1%) than in the sham group (12.1%). Monthly migraine attacks (p = 0.044), monthly headache days (p = 0.041), and monthly acute antimigraine drug intake (p = 0.007) were also significantly reduced in the verum but not in the sham group. There were no adverse events in either group.CONCLUSIONS:Supraorbital transcutaneous stimulation with the device used in this trial is effective and safe as a preventive therapy for migraine. The therapeutic gain (26%) is within the range of those reported for other preventive drug and nondrug antimigraine treatments.CLASSIFICATION OF EVIDENCE:This study provides Class III evidence that treatment with a supraorbital transcutaneous stimulator is effective and safe as a preventive therapy for migraine.
My comments:
This is an interesting paper; this combined with peripheral nerve stimulation studies has changed my current protocol for migraine, cervicogenic and tension headache treatment. These authors were reading and relating their treatment to the same peripheral nerve stimulation studies I was. Like me, they think that research is applicable to transcutaneous stimulation, which avoids the expense and complication of surgery. It’s also interesting where we differ: my initial approach is acute reduction/elimination of headache pain during an attack with 12 minutes of treatment, while they looked at prevention secondary to a daily 20 minute treatment.They use the Cefaly headband device which was shown to be safe in over 2300 patients and was the subject of my last blog. They used parameters of up to 16 mA, at 250 uS, at 60 Hz. While the other paper discussed their findings regarding safety and satisfication, I think this one is more interesting as it gave harder numbers with regards to effectiveness.
How effective was it? At least moderately so for prevention of headaches. Both the TENS and placebo group had a decrease in monthly migraine headaches of about 20% after the first month but in the 2nd and 3rd month of treatment the sham group headaches started increasing more towards baseline while the TENS group continued to improve. At 3 months, total headache days had decreased 32% in the TENS group compared to 3% in the placebo group. Headache severity decreased 8% in the TENS group compared to 3% in the placebo group, and acute drug intake decreased 37% in the TENS group compared to increasing 1% in the placebo group.
Results were not as good as that shown with the surgically- implanted electrode studies. However, surgery was avoided and unlike the surgically-implanted stimulators complications were essentially nil. I still think they are missing something by doing only supraorbital (forehead) stimulation without also hitting the suboccipital (back of the neck) region. It’s still a great paper though, and based on my results with TENS/EMS for headaches the findings are certainly believable. I’ll be doing a follow-up blog comparing acute outcomes of the combined supraorbital and occipital stimulation to what I got with occipital nerve stimulation alone after I collect data on another 15 patients. So far, the results appear favorable.
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.
Abstract BACKGROUND: Transcutaneous supraorbital nerve stimulation (tSNS) with the Cefaly® device was recently found superior to sham stimulation for episodic migraine prevention in a randomized trial. Its safety and efficiency in larger cohorts of headache sufferers in the general population remain to be determined.The objective of this study was to assess the satisfaction with the Cefaly® device in 2,313 headache sufferers who rented the device for a 40-day trial period via Internet. METHODS: Only subjects using specific anti-migraine drugs, and thus most likely suffering from migraine, were included in the survey. Adverse events (AEs) and willingness to continue tSNS were monitored via phone interviews after the trial period. A built-in software allowed monitoring the total duration of use and hence compliance in subjects who returned the device to the manufacturer after the trial period. RESULTS: After a testing period of 58.2 days on average, 46.6% of the 2,313 renters were not satisfied and returned the device, but the compliance check showed that they used it only for 48.6% of the recommended time. The remaining 54.4% of subjects were satisfied with the tSNS treatment and willing to purchase the device. Ninety-nine subjects out of the 2,313 (4.3%) reported one or more AEs, but none of them was serious. The most frequent AEs were local pain/intolerance to paresthesia (47 subjects, i.e. 2.03%), arousal changes (mostly sleepiness/fatigue, sometimes insomnia, 19 subjects, i.e. 0.82%), headache after the stimulation (12 subjects, i.e. 0.52%). A transient local skin allergy was seen in 2 subjects, i.e. 0.09%. CONCLUSIONS: This survey of 2,313 headache sufferers in the general population confirms that tSNS with is a safe and well-tolerated treatment for migraine headaches that provides satisfaction to a majority of patients who tested it for 40 days. Only 4.3% of subjects reported AEs, all of them were minor and fully reversible.
My comments:
What I like was they demonstrated the safety of non-invasive supraorbital (forehead above the eyes) electric stimulation for headaches and found minimal, mild, and no serious side effects on 2313 patients. That is by far the largest population I have seen tested with any form of electric stimulation. They gave reasonably clear parameters with regards to TENS protocol used: a biphasic rectangular waveform, pulse duration of 250 uS, 60 Hz, and maximum intensity of 16 mA to be used 20 minutes per day, daily. Initially I thought those parameters sounded weak, but when programming my own electric stimulation machines (both my Genesy 1100 and EV-906) to the same parameters , 16 mA turns to be pretty strong when electrodes are placed over the forehead. I’m very electric stimulation tolerant and was able to get to 16 mA without much trouble, but it felt intense. My office staff, all of which are female and some of which get headaches, were only able to tolerate 5-7 mA before being limited by pain/discomfort. So, I don’t think weakness of the machine is a problem in the study. I think supraorbital and supratrochlear nerves being very close to the skin surface are relatively easy to reach with TENS and thus don’t need an especially powerful stimulator.
They didn’t give any data with regards to how well the machine worked except that 54.4% said they were happy enough to purchase it at $246 Euros over the rental costs during the study (full price was 295 Euros). However, there was no data given with regards to headache intensity, frequency, or disability over the course of the study. I would think that kind of data would be easy to gather with a survey, and though there was no control group it would be interesting to see if and how much the changes were from pre- to post-treatment for such a large number of people. To be fair, the same group of authors did give such data in another study, on a much smaller number of subjects. I intend to review that next, but it would have been good to see some additional outcome data on this larger group.
Criticisms aside, I like the study. It gives great safety information and got FDA approval on some specific TENS outputs and pad placements that I can incorporate into my own electric stimulation treatments and research. I do suspect that outcomes could be improved by incorporating suboccipital (back of the neck) stimulation with the supraorbital stimulation. That is proving to be the most effective for chronic migraines headaches in the peripheral nerve stimulation studies, which I am currently gathering data on.
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.
“With the publication of their “Gate Control Theory” of pain modulation in 1965, Wall and Melzack provided a conceptual mechanistic foundation for considering direct electrical stimulation of the spinal cord and peripheral nerves as a potential treatment for chronic pain…”
“This is very important, as the clear clinical standard used to define a positive response to a trial stimulator is over 50 % improvement. Thus, of the three largest, double-blinded, prospective studies that have been performed to date on ONS [occipital nerve stimulation] and migraine, two found no significant support for an adequate therapeutic effect, and the other found only a very qualified 39 % success rate.”
“Based on several convergent lines of consideration (see below), in 2006 we hypothesized that using combined ONS and SONS [supraorbital nerve stimulation] may be beneficial in some patients suffering from chronic migraine, where the pain is perceived in hemicephalic or global extent (and therefore involving both the trigeminal and occipital neural systems), and in 2009, we reported on strongly positive responses in a series of seven patients so treated. All were quite debilitated due to daily incapacitating migraine, and all responded, with six describing near complete resolution of the headaches (over 90 % improvement).”
“All five individual “concordant paresthesia” groups of Table 1 reported very high and consistent response rates (88 %, 89 %, 89 %, 98 % and 100 %, respectively) for an overall response rate of 93 %. These results stand in sharp contrast to those found in Table 2, which are those of the groups studying implants that produce non-concordant paresthesias, which overall found less than a 40 % response rate.”
“It is this dramatic difference in the observed success rates that provides such compelling support for the central importance of paresthesia concordancy.”
My comments:
The abstract of this paper didn’t do it any justice so I’m quoting excerpts I thought most interesting. For anyone interested in the treatments of headaches, the entire paper is a must-read. The study is in regard to peripheral nerve stimulation (PNS), which is the surgical implantation of electrodes to stimulate various nerves and decrease pain. I’ve blogged about PNS before and applied it to my transcutaneous electric stimulation for headaches with good result. What researchers found was occipital nerve stimulation (ONS) (at the posterior upper neck/base of the skull region) had about 40% effectiveness on migraine headaches. While reasonably good, this was less effect than they found with PNS of other neuralgias. What they noticed was that migraine pain was more frontal, so they added supraorbital nerve stimulation (SONS) (on the forehead above the eyes) which raised the effectiveness for treating migraines to >90% which was about the same as they were achieving with PNS of other neuralgias.
As I noted in an earlier blog I was acutely decreasing non-specific headache pain 76% with non-invasive transcutaneous stimulation to the occipital region only. I have been happy with that result, and for the most part so have my patients. However, it was still sometimes only marginally effective, perhaps because I was not getting “paresthesia concordancy” (meaning the tingling from the electrodes was not covering the entire region of headache pain). So going forward, my next 20+ patients are going to be getting my electric stimulation protocol with electrodes both on the ONS and SONS region. We will see if there is a greater effect, and if that greater effect relates only to frontal headaches or non-specific headaches.
A word on safety: I have been hesitant to place electrodes directly on the head of patients with headaches. However recently the FDA just approved the use of the Cefaly device, which is a TENS unit on a headband, with electrodes placed directly over the supraorbital region. Safety was established based on a study of 2313 headache sufferers without any serious adverse events, so transcutaneous supraorbital stimulation appears safe if you follow certain parameters. Those parameters were a pulse duration of 250 uS, max intensity of 15 mA, and a rate of 60 Hz, all of which I want to talk more about in my next blog.
Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember 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.
Shooter’s elbow is a bit of a made up term. If it hurts on the outside of your elbow, then it’s the same as tennis elbow (lateral epicondylitis) and if it hurts on the inside of your elbow it’s golfers elbow (medial epicondylitis). I don’t know if any of my friends play tennis, and only a few of them golf; but as a competitive pistol shooter most of my friends shoot, and a lot of them get tendinitis of either their wrist flexors or extensors. So I think the term “shooter’s elbow” works just fine.
Before I go further I want to give Steve Anderson credit for making this blog happen. A while back I was listening to his podcast and he was talking about his elbow pain and all the advice and treatments he was getting. I thought not only is this something I could help him with, but it’s something I could help him with over the phone. So I contacted him, told him I was a shooter myself (12th at Nationals even), a physical therapist, and more importantly Rob Leatham’s physical therapist. So Steve tried out some home exercises I recommended, said they worked great, and he was kind enough to talk about how well they worked in his podcast. He later messaged me saying people had been contacting him about what to do but said he didn’t want to give away my secrets. I told him no worries, I’ll give them away. Hence this blog.
Shooter’s elbow is tendinitis, however even that name is contentious. The “itis” in tendinitis implies inflammation which biopsies reveal is NOT present. This makes tendinitis a misnomer. More modern terms are tendinosis and tendinopathy. I have actually heard people refer to tennis elbow as lateral epicondylopathy, but correct or not “epicondylopathy” is a ridiculous word and I’m not going to use it. As for the rest of those names, I use them interchangeably and I lament having to waste yet another paragraph on semantics trying to avoid sounding either like an elitist or an uneducated fool. Since the vast majority of the people I know who get tendinitis of the elbow are pistol shooters, this blog is for them. However Rob Leatham told me his elbow got sore from breaking the action open on his sporting clays shotgun, so the condition is not only limited to pistol shooters. Tennis players, golfers, and people who get the condition for no apparent reason at all can still learn a lot from this blog as the principles and techniques of treatment are identical as I draw upon tendinitis research from all sports.
Before going further it’s worth noting that shooter’s elbow is a self-limiting condition. That means if you do absolutely nothing at all, it will eventually go away. The problem is it often takes as long as 18 months to just go away, and often goes away for no apparent reason. So, anyone who suffers from shooter’s elbow will swear by whatever they did (or didn’t do) when they got relief, regardless of if it helped or not. The good news is that almost nothing you can do will make it worse except let your doctor give you a cortisone shot. People like cortisone shots because they do make the pain go away in the short-term, and if you are lucky it stays away. However in the mid- and long-term, people who have cortisone shots often relapse, shown by this study wherea group of people who have cortisone are consistently worse off than if they did nothing.So my first bit of advice for shooters elbow is DON’T GET A CORTISONE SHOT, EVER! If it hurts, think of it more as an annoyance rather than a debilitation. If you do your exercises properly it won’t hurt very much, for long anyway.
So what has changed since my 2006 paper? One thing that changed was in 2010 I got medial epicondylitis in both my elbows. I had a motorcycle crash in 2010, straining ligaments in both wrists in the process. The ligament strain took about 8 months to heal but I could still shoot just fine, so long as I taped both wrists. However due to the wrist strain I wasn’t doing any weight training. My elbows were fine at first but after several months of shooting high volumes, the continued gripping and shock absorption gradually got to both arms. I felt it coming on, but at first there was little I could do about it; the wrist curl exercises I liked were too much for my wrists. Finally the wrists healed but by then my tendinitis was severe. I could finally start my standard eccentric exercises but they didn’t work as well as they did back when I was a golfer. I took short times off from shooting and finally a month off, only to have it feel worse when I returned. Finally I just thought screw it, kept shooting, started lifting weights regular, and as my strength increased it felt a lot better. So that’s part of my advice now: just keep shooting and don’t think of it as a big deal because resting it doesn’t help anyway.
My experience of not resting turns out to have been backed up by research as I later came across this study that found taking time off from your sport does nothing to help recovery. So, you may as well continue to train. My personal experience is that every time I took a few days off from shooting and came back to it I would feel some increase in pain (and this happened with my USPSA pistol, my sporting clays shotgun, my air rifle and air pistol). Each one had somewhat different muscle actions or stressed the elbow from a slightly different angle. I took great notes at this time and found that if I missed several days of pistol shooting (live fire or dry fire) and came back to it, it would hurt more. However, after shooting 2-3 days in a row it would be pain free. If I transitioned to another type of firearm, it would hurt again. So while it’s anecdotal, I tell all my shooting friends and patients with tendinitis to continue to handle their gun either in live fire or dry fire at least 10-15 minutes daily just to keep the tendons used to the stress.
In my earlier paper I cited studies saying eccentric exercise worked but concentric did not. However a newer paper found that regular (concentric and eccentric) heavy lifting did more to improve recovery from tendinitis than did eccentric only exercise. This is advantageous for a number of reasons. First concentric/eccentric exercise is more intuitive and simpler to perform than eccentric-only exercise. Regular weight training is more efficient; you can work both arms at once with regular lifting, but for eccentric you can only do one at a time. Last, you never have to decide when to discontinue eccentric exercise and start regular weight training (which is what most people do when they workout) because you are doing it all along. So with research being a bit conflicting, I used both ways for a while. After finding that the combination concentric/ eccentric exercise worked as well or better than eccentric alone, I finally retired my eccentric-only method. If any of that eccentric/concentric talk is confusing, in this video I demo the difference:
In my original paper, I said I would do some ultrasound and soft tissue mobilization after the exercise to help make the patient feel better in the short-term. I don’t do either anymore as I don’t think they add much (if anything) to the healing process. Plus, I notice once a person does their exercises they usually feel better in the short term anyway. Generally they do a set of an exercise that works the injured tendon and it hurts a little. If they have good form I move up the weight and they do another set and it hurts a little, but often less than the first set. If they had good form on the second set I move up the weight again and usually they tell me the heaviest set feels the best. They are generally no worse as a result and often report feeling just as good as when they got the ultrasound and massage. After 2-3 days of this the exercises hardly hurt at all, in spite of the fact that I am increasing their weights every visit until they cannot get 15 good reps. That’s the sweet spot for training: where you are training to failure on the 3rd set. The exercises I recommend now are these:
Dumbbell Curls
Reverse Grip Lying Triceps Extensions
Wrist Curls
Reverse Wrist Curls
Demonstrated below:
The video talks about me doing 3 sets (easy-medium-hard) of 15 reps on each set, which is what I do for patients. If the person gets 15 reps with a full range of motion, pain or not, I ALWAYS increase the weight an increment for the second set. If they get 15 reps with full range of motion then, again, I ALWAYS move the weight up for the third set. If the person gets full range of motion on the 3rd set, then the next day I have them start out with their medium weight before and move up from there. I want to quickly (over a 2-3 days) get them to where they are unable to get all 15 reps on the third set. Only then do I stop increasing the weight until their strength progresses. In my experience 3 times per week works, but 7 days per week works a lot faster. My starting weights are almost never less than 5 lbs. On rare occasions I have worked people up to as much as 50 lb for the dumbbell curls and wrist curls and to 30 lb in the reverse wrist curls and triceps extensions. The idea is you want to make gripping a pistol easy in comparison. I think an adjustable dumbbell set is ideal for home use with the ability to change weights from 5 to at least 30 lb.
Since adopting the above protocol the treatment has always worked. However, I do tell people that I see two kinds of responses, both great but the first obviously better. The first is that the pain goes away completely in a few weeks (maybe 3-6) the person is a lot stronger and able to do everything without pain. The second common response is that the pain gets 90% better in 3-6 weeks. Strength and activity are fully restored, but there is still a little nagging pain (maybe a 1-2/10 with activity) that can last as long as 6 months. While the second is the worst case, if I tell people about it from the start they all agree it’s still a good outcome. As a therapist I have driven myself nuts trying to get rid of that last bit of pain, but now I tell people that it’s normal and to just stick with their exercises. Once strength has been restored and plateaus, I tell my patients they can reduce their training frequency to just 2-3 times a week. Eventually they will notice they haven’t had any pain in a while and their elbow is no longer tender to the touch.
Lastly, I want to give a word about safety. Over the internet I can’t properly diagnose anyone so for all I know a person’s elbow pain could be from bone cancer. However, greater than 90% of people I see with elbow pain have either medial or lateral epicondylitis, so the odds are with you. I find the pain decreasing rapidly with daily exercise to be so consistent that if it does not work I start to question my diagnosis. So if pain increases a bit from one day to the next that’s not a big deal. If it’s getting worse week after week, that’s a red flag you should consider getting checked by a physician. A common method of grading appropriate exercise and activity is to limit the weights you use and the amount of sporting activity (in this case shooting) to that which causes 5/10 pain or less. There is no research that says greater pain is too much, and in fact many of the successful studies told people with Achilles tendinitis to keep running so long as pain was not “debilitating”. A 5/10 on a pain scale might be overly cautious, but I think it’s a reasonable guideline. If I find any other bit of research that changes my advice I’ll be sure to blog about it here.
[5-17-16 UPDATE] So endorsement makes me feel especially good. For most people when you cure their shooter’s elbow, you help them with their hobby. However if you are a professional shooter, you’re helping them with their lively hood. Plus it’s cool to pick up an endorsement by a National Champion. For those who don’t shoot IPSC, this is Shannon Smith, and when Rob texted me saying Shannon was having elbow pain, I knew exactly who he was talking about. Shannon’s case is one that I would describe as a ‘worst case scenario’ as was mine when I had it. As described above, a best case scenario, the person is often 100% healed in 3-6 weeks. Worst case, they are A LOT healed in 3-6 weeks, a LOT stronger but will still have some lingering pain that takes some weeks or months to fully go away. Anyway here’s what Shannon had to say:
Hey Chad,
I have thanked you personally but wanted to leave a comment on your blog for the benefit of others. I am a National Champion pistol shooter, full time competitor and instructor and thought I was going to have to give up shooting last year due to shooters elbow. To the point I didn’t have grip strength to put a tub of sour cream in the fridge. One thing I noticed is everyone has the ‘fix’. Just trying to help I’m sure but everyone had a different remedy and swore by it. I tried compression (as an avid crossfitter I had high hopes for that), motrin, Jamesons (that was pretty decent), ice, heat, deep massage at chiro, some magnet bs thing, nothing worked.
Was talking to Rob Leatham at Nationals in Oct of last year about it and he referred me to you. Of course you said you had ‘the’ fix…just like everyone did. But I was seriously wondering if I would be able to compete at the top levels of the game again and was willing to try anything and everything.
After talking with Chad and viewing all the videos I went to work. Couldn’t even do a 3lb dumbell, started with a can of soup. It was extremely painful. I kept a journal of every days workouts. I hit it every day as heavy as I could. Started at the beginning of Oct. 2015. Within 2 weeks I was up to 15lbs. Journal note Oct 21 “Still painful, may be slightly better, may also be wishful thinking” / Nov 5 “Definitely felt better shot 3 matches in 2 days” / I suck at keeping journals and stopped on Nov 29 with 25lbs on all 4 exercises and the note “Convinced it’s not placebo, shit is definitely working”.
It is now the end of April 2016. The pain isn’t 100% gone if I’m looking for it, but it’s 98% gone and I don’t notice it while shooting. I’ve been pretty consistent staying with the exercises 2-3 days per week. Normally along with my regular workout schedule. Weight training, pull ups, rowing, no pain on any of it! I can say without a doubt doing as Chad said saved my career. All the tricks I was trying and all it took was a few months of pain, sweat, and hard work! Imagine that.
Thanks Chad!!
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.
OBJECTIVE: External muscle stimulation (EMS) of the thighs was previously shown to have beneficial effects in a pilot study on painful diabetic neuropathy. However, differential effects on specific symptoms of neuropathy as well as determinants of treatment response have not been described.
DESIGN: Ninety-two type 2 diabetes patients with different neuropathic symptoms were included in a prospective uncontrolled trial. Patients were treated twice a week for 4 weeks. Symptoms were graded on numeric scales at baseline, before the second and the eighth visit.
RESULTS: Seventy-three percent of the participants reported marked improvement of symptoms. Subjective treatment response was positively and independently associated with symptom intensity but independent of disease extent, metabolic factors, age, or gender. Total symptoms graded by patients on numerical scales decreased significantly after 4 weeks of treatment. Patients in the upper tertile of symptom intensity showed significant improvement of paresthesia, pain, numbness and most pronounced for burning sensations and sleeping disturbances.
CONCLUSIONS: In an uncontrolled setting, EMS seems to be an effective treatment for symptomatic neuropathy in patients with type 2 diabetes, especially in patients with strong symptoms.
Parameters:
Waveform: biphasic sinusoidal
Duty Cycle: 3s ramp, 3 on,
Pulse Duration: ?
Intensity: tolerable but not painful muscle contraction
Rate: 20 Hz frequency scanner of 4096-32768 Hz
Treatment Length: 60 minutes
Training Frequency: 2x/week
Training Length: 4 weeks
Electrodes/Placement: two electrodes per leg placed on the quadriceps
My comments: This study is interesting because it broke down symptom improvement to include paresthesias, pain, burning sensation, sleep disturbance and numbness. However all of these improvements were based on patient reports, which is good, but as of yet nobody that I am aware of has objectively tested sensation to see if it changes. They noted improvement after the 2nd treatment and greater improvement after the 8th. Symptom reduction was consistent, but less than reported in prior studies. I would expect better improvements with daily or every other day stimulation (as the prior study seems to have had greater results with just 3 treatments on consecutive days) so I think portable but strong electric muscle stimulators patients can use at home would have led to a better outcome. Also, treatment duration of 60 minutes does not seem to work any better than 30 minutes. Additionally, anecdotal evidence from my office is that just 12 minutes works pretty well, but I’m using a greater intensity of electric stimulation, with electrode pad placement directly over muscles in the painful/numb regions.
So my take home message from this study is daily stimulation is probably better than 2 times per week, and a really good study would be to objectively test sensation before and after a trail of EMS to see if lost sensation can be restored along with subjective reductions in pain and paresthesias.
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.
Abstract AIMS/HYPOTHESIS: Diabetic distal symmetrical sensory polyneuropathy (DSP) affects 20-30% of diabetic patients. Transcutaneous electrical nerve stimulation (TENS) and electrical spinal cord stimulation have been proposed as physical therapies. We performed a controlled, randomised pilot trial to compare the effects of high-frequency external muscle stimulation (HF) with those of TENS in patients with symptomatic DSP.
METHODS: Patients with type 2 diabetes and DSP (n=41) were randomised to receive treatment with TENS or HF using strata for non-painful (n=20) and painful sensory symptoms (n=21). Both lower extremities were treated for 30 min daily for three consecutive days. The patients’ degree of symptoms and pain were graded daily on a scale of one to ten, before, during and 2 days after treatment termination. Responders were defined by the alleviation of one or more symptoms by at least three points.
RESULTS: The two treatment groups were similar in terms of baseline characteristics, such as age, duration of diabetes, neurological symptoms scores and neurological disability scores. The responder rate was significantly higher (p<0.05) in the HF group (80%, 16 out of 20) than in the TENS group (33%, seven out of 21). Subgroup analysis revealed that HF was more effective than TENS in relieving the symptoms of non-painful neuropathy (HF: 100%, seven out of seven; TENS: 44%, four out of nine; p<0.05) and painful neuropathy (HF: 69%, nine out of 13; TENS: 25%, three out of 12; p<0.05). The responders did not differ in terms of the reduction in mean symptom intensity during the trial.
CONCLUSIONS/INTERPRETATION: This pilot study shows, for the first time, that HF can ameliorate the discomfort and pain associated with DSP, and suggests that HF is more effective than TENS. External muscle stimulation offers a new therapeutic option for DSP.
My comments:
I would have really liked this study had it shown great results with the high frequency (HF) electric stimulation, and compared it to TENS and found the HF worked considerably better. The next study I am going to cite uses the exact same HF machine and calls it EMS (electric muscle stimulation) rather than HF, and that fits with my observations and other research that EMS works better than TENS to control pain.
What I don’t like about this study, however, is that from the description of the parameters I can’t figure out what they used. Plus, other things besides the current are different, including electrode size and placement.
For the TENS group I get:
Waveform: biphasic exponentially decaying
Duty Cycle: continuous (I think)
Pulse Duration: 400 uS
Intensity: 20-30 mA
Rate: 180 Hz
Treatment Length: 30 min
Training Frequency: daily
Training Length: 3 days
Electrodes: two sticky ~2” electrodes per leg, placed on proximal and distal fibula region
For the HS group:
Waveform: biphasic exponentially decaying
Duty Cycle: 3 sec ramp, 3 sec on (3 sec off I think, because that’s what the next study using the same machine reports)
Pulse Duration: does not say but with the high Hz I expect its pretty short
Intensity: adjusted to a pleasant level without pain or uncomfortable paresthesia
Rate: 4096 Hz – 32768
Treatment Length: 30 min
Training Frequency: daily
Training Length: 3 days
Electrodes: two carbon ~3.5” rubber carbon electrodes per leg, placed on the proximal and distal quadriceps.
So in this study the HS group did a lot better, but it is hard to tell if it is due to the difference in current, or the larger electrodes being used in the HS group, or the HS group putting the electrodes over a muscle rather than a bony region. I would expect the larger electrodes to work better because you can turn the machine up higher with greater patient comfort because of lesser current density (coulumbs delivered per square inch of skin). Also I don’t think it’s at all ideal to place the smaller electrodes over the bony region of the fibula, though I find it interesting that the larger electrodes on the quadriceps worked so well since presumably the diabetic neuropathy sufferers were complaining of the most pain and paresthesias in the feet. Another interesting thing is the good results of the HS group was noticed in just 3 days of treatment, which is in accordance with my observation using EMS. My patients report relief immediately after my 12 minute treatment, and those results continue to improve with future treatments. Also interesting from this study is they treated people with both painful and non painful neuropathy, noting it worked on non-painful neuropathy better. My patients tend to report similar improvements painful or not with my protocol, but that could be due to the different parameters where I’m using 4 electrodes per leg instead of two, placing all the electrodes on muscle (including the bottom of the foot), my electrodes are larger still, and I use as long a pulse width as my machines allow (300-450 uS) for as high an intensity as they can tolerate.
So the take home message for me is that all stimulation parameters are not equal, but in this study it is unclear which part of the different stimulation protocols led to the difference in effects. I suspect that greater intensity of stimulation, and on and off period, larger electrodes, placing the electrodes over muscle all contributed to better outcomes in the latter group.
Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.
Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.
OBJECTIVE: To evaluate the efficacy of combining electrotherapy with amitriptyline for the management of chronic painful peripheral neuropathy in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: Patients (n = 26) with peripheral neuropathy were treated with amitriptyline. After 4 weeks, those patients (n = 23) who failed to respond to amitriptyline or who only had partial relief were randomized between a sham treatment group (control) or an electrotherapy group. Transcutaneous electrotherapy was given for 12 weeks by a portable unit (H-wave machine) that generated a biphasic exponentially decaying waveform (pulse width 4 ms, 25-35 V, > or = 2 Hz). The degree of pain and discomfort was graded on a scale of 0-5. An analog scale was used to record the overall change in symptoms. RESULTS: Amitriptyline produced some degree of symptomatic relief in 15 (60%) of the 26 patients by the 4th week; pain scores decreased from 3.8 +/- 0.1 to 2.9 +/- 0.2 (P < 0.1) and the overall reduction in pain was 26 +/- 5% on an analog scale. In the amitriptyline plus sham treatment group (n = 9), pain scores declined from 2.8 +/- 0.3 to 1.9 +/- 0.5 (P < 0.03) and the overall reduction in pain was 55 +/- 12%, suggesting a procedure-related placebo effect. In the group receiving combined electrotherapy and amitriptyline (n = 14), symptomatic improvement occurred in 12 (85%) patients. Five (36%) of the patients in this group became asymptomatic. Pain scores declined from 3.2 +/- 0.2 to 1.4 +/- 0.4 (P < 0.01) and the overall reduction in pain was 66 +/- 10%. The degree of reduction in pain scores and the incremental relief (above the amitriptyline effect) were significantly greater (P < 0.03) with electrotherapy as compared with sham treatment. The outcomes indicate a substantial beneficial effect of electrotherapy over and above any placebo influence. CONCLUSIONS: Our clinical observations suggest that transcutaneous electrotherapy is effective in reducing the pain associated with peripheral neuropathy. This form of therapy may be a useful adjunctive modality when it is combined with a pharmacological agent, such as amitriptyline, to augment symptomatic relief.
My Comments:
This study was conducted by the same authors of the one I reviewed in my prior blog with a focus on decreasing the pain in those with painful neuropathy. Electric stimulation parameters were identical as the prior study… Parameters:
Waveform: biphasic exponentially decaying
Duty Cycle: continuous (I think)
Pulse Duration: 400 uS
Intensity: 35 mA (max)
Rate: user adjustable from 2-70 Hz
Treatment Length: 30 minutes
Training Frequency: Daily
Training Length: 4 weeks
Electrodes: 4 electrodes; 2 placed on the distal quadriceps, 1 on the neck of the fibula and 1 centered gastrocnemius muscle (size not given)
…but what was different was the combination of electric stimulation with the drug amitriptyline. As noted in the abstract above the electric stimulation led to considerably greater pain reduction than the amitriptyline by itself. The drug seems to have helped as well, as there was an average pain reduction in the electric stim/drug group of 66% with 36% of these subjects became completely asymptomatic in 4 weeks. In the prior study average pain reduction of the electric stimulation (only) group was 52% with 17% becoming completely asymptomatic, so the drug and electric stimulation interaction appears to be complimentary. My first question after reading this study is; what would another 4 weeks of electric stimulation do?
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.
Abstract OBJECTIVE: To evaluate the efficacy of transcutaneous electrotherapy for chronic painful peripheral neuropathy in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: Thirty-one patients with symptoms and signs of peripheral neuropathy were randomized to the electrotherapy or sham treatment (control) group. The electrostimulation was given by a portable unit (H-Wave machine) than generated a biphasic, exponentially decaying waveform (pulse width 4 ms, 25-35 V, > or = 2 Hz). Patients treated each of their lower extremities for 30 min daily for 4 weeks at home. Nine patients from the sham-treatment group participated for a second period, during which all of them received the active electrotherapy. Patient’s degree of pain and discomfort was graded on a scale of 0 to 5. RESULTS: In the sham-treated group (n = 13), the neuropathic symptoms improved in five (38%) patients, and the pain score declined from 2.92 +/- 0.13 to 2.38 +/- 0.26 (P < 0.04), suggesting a procedure-related placebo effect. In the electrotherapy group (n = 18), symptomatic improvement was seen in 15 (83%) cases, 3 of which were completely asymptomatic; the pain score declined from 3.17 +/- 0.12 to 1.44 +/- 0.25 (P < 0.01) and the posttreatment pain scores were considerably lower (P < 0.03), indicating a substantial treatment effect over and above any placebo influence. Patients in the electrotherapy group reported greater reduction in symptoms (52 +/- 7% vs. 27 +/- 10% in control subjects, P < 0.05) on an analog scale. Moreover, the electrotherapy decreased pain scores (from 3.0 +/- 0.62 to 1.56 +/- 0.32, P < 0.02) in nine patients who had received sham treatment earlier. CONCLUSIONS: A form of transcutaneous electrotherapy ameliorated the pain and discomfort associated with peripheral neuropathy. This novel modality offers a potential non-pharmacological treatment option.
My comments:
This study didn’t look at function but rather attempted to lessen/eliminate pain in patients with the painful form of neuropathy (some patients don’t hurt but only have numbness). As noted in the abstract, 83% of those treated with electric stimulation improved and 17% became completely asymptomatic.
Parameters used in the study were:
Waveform: biphasic exponentially decaying
Duty Cycle: continuous (I think)
Pulse Duration: 400 uS
Intensity: 35 mA (max)
Rate: user adjustable from 2-70 Hz
Treatment Length: 30 minutes
Training Frequency: Daily
Training Length: 4 weeks
Electrodes: 4 electrodes; 2 placed on the distal quadriceps, 1 on the neck of the fibula and 1 centered gastrocnemius muscle (size not given)
My treatments are shorter in duration using biphasic square waveforms and EMS patterns designed to increase strength, but my patients report pain relief similar to the above researchers. The reason I use the EMS strength protocols is because they have been found to be better than TENS at decreasing pain. For neuropathy, I really want to try to not just decrease pain but also increase muscle mass to help with function, to elicit strong muscle contractions, and to pump blood into the area in an attempt to improve circulation. I think all of these things should help with neuropathic pain. Also I use 4 large electrodes (4” circular) and right now prefer to place 2 on the gastrocnemius, 1 on the tibialis anterior, and 1 on the sole of the foot. One thing I notice with my lower extremity neuropathy patients is they often need an especially strong stimulator to get a good muscle contraction. The 35 mA used in this study I expect will decrease pain, but I think they would get better results if they increased their pulse width to 450 mA, and intensity as tolerated up to around 60-70 mA. Also while I have not tried it yet, I suspect an ideal EMS program would not be just one set of parameters, but rather alternate between 2 or more, with some settings directed at increasing strength, and with others directed more towards improving circulation and cardiovascular benefits.
The study was only 30 days long, and while my patients usually report immediate relief ongoing treatment seems to continually lessen symptoms. My patient who I am following with regards to increased sensation has been doing the electric stimulation at home every other day for 3 months, and we plan to retest going forward. So I do think home use of a stimulator is ideal because they often pay for themselves quickly and ideal use I would expect to be at least 3 times per week if not daily. So while I frequently do the treatment in my office, a lot of what I do is help patients decide what kind of EMS/TENS machine and accessories they need, help them program the machine, and teach them how to set up the electrodes for home use.
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.
This was a pair of studies by the same authors that have some great, real world implications with regards to prevention and physical therapy treatment of low back pain and neck pain.
Abstract The objective of this work was to study the effect of rest periods of various durations applied between six 10-min sessions of static flexion on the development of cumulative low back disorder (CLBD). Three experimental groups of a feline model were used, and the rest duration between sequential static load periods was set to 5, 10, and 20 min, with a corresponding load-to-rest ratio of 2:1, 1:1 and 1:2, respectively. The reflex electromyographic (EMG) activity from the multifidus muscles and supraspinous ligament displacement (creep) were recorded during the flexion periods and over 7 h of rest following the load-rest cycles. It was found that a minor disorder developed in all the groups whereas a severe neuromuscular disorder including a delayed hyperexcitability was observed only in the group subjected to 5 min rest. The two-way ANOVA showed a significant effect of time post loading (p<0.001) and rest duration (p<0.001) on the Normalized Integrated EMG (NIEMG) recovery data; a significant effect of time post loading on the Displacement data (p<0.001) was observed as well. The post hoc Fisher test performed on the NIEMG data during the recovery phase showed a significant difference between the group subjected to 5 min rest and the other two groups (p<0.001). These results suggest that while a short rest period of 2:1 load-to-rest ratio leads to CLBD, longer rest at 1:1 and 1:2 load-to-rest ratio are more favorable for preventing or attenuating the development of CLBD. Short rest periods between sessions of static lumbar flexion, therefore, are a risk factor for the development of CLBD.
Abstract Low back disorders are prominent among the work force engaged in static anterior flexion during the workday. As a continuing part of a long-term research aimed to identify the biomechanical and physiological processes and corresponding risk factors leading to such cumulative trauma disorder (CTD), we ventured to assess the effect of rest and the work-to-rest duration ratios that may prevent CTD. Three groups of the feline model were subjected to three load/rest paradigms: two 30 min loading periods spaced by 10 min rest in Group I, two 30 min loading period spaced by 30 min rest in Group II and one 60 min loading period for Group III. The cumulative loading duration in the three groups was 60 min. Each of the groups were allowed 7h of rest while monitoring EMG and lumbar viscoelastic tissue creep each hour. The results demonstrate that for two 30 min load periods with a 30 min in between rest, an acute neuromuscular disorder was not present whereas for two 30 min loading with a 10 min rest it was. Similarly, for a 60 min loading with long-term rest, the disorder was present. Post hoc Fisher analysis demonstrated significant differences in the delayed hyperexcitability between the first and second group (P<0.0001) and the third and second (P<0.0001) group. Statistical difference in the displacement data of the three groups was not present. ANOVA showed a significant effect of time post-loading (P<0.0001 and different rest durations (P<0.0001) on the EMG data during the 7h recovery. The new data allow us to conclude that a work-to-rest duration ratio of 1:1 can prevent the development of CTD as long as the work periods are not too long (<60 min). Longer static flexion durations do not respond favorably to rest even if it is of equal or longer duration. It is suggested that appropriate durations of rest may be a viable tool to avert CTD in a certain range whereas long static flexion durations should be avoided at all cost.
My comments:
I have a lot of comments on this one because these are really great studies, though perhaps not so much if you are a cat.
The idea is that spine flexion on the job or in some sports leads to low back pain secondary to damage to lumbar discs, overstretching spine ligaments and facet joint capsules. An objective sign of such damage is an increase in hypertonicity (excessive tension) of the spine extensor muscles following pathological durations of end range spine flexion with low to moderate loads. The findings were that a total time of 60 minutes of sustained back flexion would not induce a severe neuromuscular disorder so long as it was broke up in to six 10 minute segments with at least 10 minutes rest in between them or as long as two 30 minutes segments of stretch with at least 30 minutes rest between. Thus the 1:1 ration. However if the stretch was a sustained 60 minutes, there was an increase in hypertonicity regardless of how long the rest was afterwards. So a take home message is that if you are going to partake in a spine flexion posture perhaps during work or sport, you can minimize and hopefully avoid damage if you keep the flexed posture periods 30 minutes or less to be relatively safe, and certainly less than an hour, with necessary rest periods needing to be as long as the stretch time.
Caveats worth knowing is that the cats in this study were apparently without prior injury so someone who already has some degree of spine degeneration might not tolerate as long of flexion periods and might need greater rest periods before they can tolerate flexed postures again. Since I am unaware of any occupations that allow employees a 1-1 ratio of work and rest times, it’s probably best to minimize spine flexion in the first place by having office workers sit in chair with good lumbar support, and make periodic use of standing work stations. More active occupations need a greater emphasis on learning to hinge and bend at the hips and knees while preserving a neutral spine to prevent damage, which is what people learn by using proper technique with multi-joint weightlifting movements. Also while the authors said the resulting hypertonicity was indicative of “severe neuromuscular disorder” all the spines, even with the longer rest periods, displayed hypotonicity (less than normal muscle tone) for hours after all the stretch protocols, which the authors still called a minor disorder. I would expect this minor disorder and hypotonicity would put workers at increased risk of low back injury for as long as this hypotonicity was observed, which in these studies was at least 7 hours. So, only when spine flexion is unavoidable should the above work to rest ratios be endured.
Important to note is regardless of rest period length there was an increase in spine ligament elongation, thus decreasing passive support to the spine. Only when the rest periods were less than the stretch periods (up to 30 minutes) was there a combination of a still greater increase in spine ligament elongation combined with hypertonicity. I think this hypertonicity best explains why many of my back pain patients complain of feelings of stiffness and feel they need to stretch it out. In such cases the stretch that feels good leads to further damage of the spine and in the long run further increases hypertonicity. So I really like these studies as they make the principle considerably more concrete and easier to explain, with some “here’s exactly what happens” examples.
So the counterintuitive answer is to eliminate the flexion stretch in physical therapy and elsewhere, thus allowing the spine to heal and muscle tone to normalize. Patients might still need to increase range of motion around the hips and shoulders so that tasks can still be accomplished without over-stressing the spine. So stretch itself isn’t bad, it just needs to be applied to the right place. The above studies, and a number of others tend to show that the spine itself is the wrong place to stretch. This research likely also explains why massage and soft tissue mobilization generally feels good immediately afterwards, perhaps by normalizing tone, but leads to no long-term relief of prevention of further spine damage because it does not address any of the underlying problems. This is why I much prefer electric muscle stimulation (EMS) as my modality of choice for pain relief, because you not only get pain reduction, but a direct increase in muscle strength and endurance. So it’s a great 2 for 1 that you just don’t get from ASTYM, Graston Technique, Dry Needling or what ever else soft tissues technique of the day.
Increasing core and extremity strength and endurance allows people to better avoid compromising positions thus decrease strain on the spine. Only then will hypertonicity decrease, the spine not feel so stiff, and likely the spine won’t be as stiff. This was objectively found in cervical spine research where rehabilitation programs focusing on strength led to better improvements in range of motion than those that focused on stretching, indicating that the above principles apply to the treatment and prevention of neck pain, much as they do in low back pain.
So it’s an exciting time in spine rehabilitation. These studies are really leading to conservative treatment programs that are very effective at lessening and eliminating back and neck pain. What’s frustrating is that most physical therapists still promote spine stretching treatments that are objectively harmful, and a number of passive modalities that provide only short term relief at best, so that a good number of back and neck pain patients just don’t get better. They then go back to their doctor and say “physical therapy didn’t work”, and eventually they end up with what should have been unnecessary surgery that in the long term does not fix what caused their pain in the first place. Later they end up in pain management, doped up for life, with a diagnosis of spinal stenosis or failed back syndrome. So it’s kind of a big deal.
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.
Abstract BACKGROUND: The Six-minute walk (6 MW) and Timed-Up-and-Go (TUG) are short walk tests commonly used to evaluate functional recovery after total knee arthroplasty (TKA). However, little is known about walking capacity of TKA recipients over extended periods typical of everyday living and whether these short walk tests actually predict longer, more functional distances. Further, short walk tests only correlate moderately with patient-reported outcomes. The overarching aims of this study were to compare the performance of TKA recipients in an extended walk test to healthy age-matched controls and to determine the utility of this extended walk test as a research tool to evaluate longer term functional mobility in TKA recipients. METHODS: The mobility of 32 TKA recipients one year post-surgery and 43 healthy age-matched controls were assessed using the TUG, 6 MW and 30-minute walk (30 MW) tests. The latter test was repeated one week later. Self-reported function was measured using the WOMAC Index and a physical activity questionnaire. RESULTS: 30 MW distance was significantly shorter amongst TKA recipients (mean 2108 m [95% CI 1837 to 2381 m]; Controls 3086 m [2981 to 3191 m], P < 0.001). Test-retest repeatability was high (ICC = 0.97, TKA; 0.96, Controls). Amongst TKA recipients, the 30 MW distance correlated strongly with the shorter tests (6 MW, r = 0.97, P < 0.001; TUG, r = -0.82, P < 0.001). Multiple regression modeling found 6 MW distance to be the only significant predictor (P < 0.001) of 30 MW distance, explaining 96% of the variability. The TUG test models were moderate predictors of WOMAC function (55%) and physical activity (36%) and were stronger predictors than 6 MW and 30 MW tests. CONCLUSIONS: Though TKA recipients are able to walk for 30 minutes one year post-surgery, their performance falls significantly short of age-matched norms. The 30 MW test is strongly predicted by 6 MW test performance, thus providing strong construct validity for the use of the 6 MWtest in the TKA population. Neither a short nor long walk test is a strong predictor of patient-reported function after TKA.
My comments:
The gist of this study was that the 6 minute walk test tells you 97% of what you would need to know about a 30 minute test after total knee replacement, making the latter more arduous test unnecessary. The timed up and go (TUG at 3 meters) test explained 82%. Average TUG was 7.4 seconds for the TKA group and 5.0 for controls.
The 30 minute walk test did yield some interesting data, like average speed being 1.17 meters per second (2.26 mph) in the TKA group and 1.71 meters per second (3.8 mph) in the controls (average age 65). I always like to know the mph so I can give good suggestions regarding treadmill speed goals, and 3.8 mph is moving, indicating a healthy control group. FOr the TKA group, average step length was shorter (.68 vs. .81 meters) and cadence (112 vs 124 steps/min) slower than controls. BMI of the TKA group was 30.8 and controls were 23.6, which researchers said explained some but not all of the difference.
I like this study; I think a good take home message for patients is that if you want normal health after a total knee replacement, you want to walk normal, and normal is upwards of 3.5 to 4 mph. Also, typical physical therapy programs are not getting people there. More emphasis on recovery should be directed at not losing muscle in first place with early electric muscle stimulation, higher intensity exercise, and regular monitoring of progress with functional tests including but not limited to the TUG and 6 minute walk test.
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.
Abstract Much discussion exists about which is the most effective technique to improve spine stability. The purpose of this study was to evaluate the effectiveness of abdominal bracing and abdominal hollowing maneuvers to control spine motion and stability against rapid perturbations. Eleven healthy males were posteriorly loaded in different experimental conditions: resting with no knowledge of the perturbation timing; performing each of the stabilization maneuvers at 10%, 15% and 20% of internal oblique maximum voluntary contraction with no knowledge of the perturbation timing; and naturally coactivating the trunk muscles when perturbation timing was known. An EMG biofeedback system was used to control the pattern and intensity of abdominal coactivation. The muscular preactivation of seven trunk muscles (bilaterally registered), the applied force, and the torso muscular and kinematic responses to loading were measured; and the spine stability and compression were modeled. The hollowing maneuver was not effective for reducing the kinematic response to sudden perturbation. On the contrary, the bracing maneuver fostered torso cocontraction, reduced lumbar displacement, and increased trunk stability, but at the cost of increasing spinal compression. When the timing of the perturbation was known, the participants were able to stabilize the trunk while imposing smaller spine compressive loads.
My comments:
One of the keys to good outcomes with low back pain patients is being able to sort through the research with regards to what is meaningful and what isn’t. When I think of spine stabilization I think of doing exercises in which my core musculature acts to keep my spine in a neutral position whether that exercise is a standing cable press or row, plank, squat, or deadlift. However in a number of (and probably most) research studies, spine or core stabilization exercise has come to mean isolation of the transverse abdominus muscle though abdominal hollowing, with some efforts to isolate the multifidus muscle for good measure. However when I was competing in Olympic weightlifting, none of us, EVER, made any such effort. We just lifted heavy keeping our chest out and our back straight (by straight we meant neutral) and lifted as hard as we could with no conscious effort regarding the contraction of any specific muscles.
What this study found was that efforts directed at abdominal hollowing had a near zero effect on the ability to stabilize the spine during an unexpected load, which was in contrast to simply bracing with all your muscles (as you would tighten them if you were about to be punched in the abdomen). As a former weightlifter, I thought Stuart McGill belabored his point a bit in his book. However as I review older and newer research regarding physical therapy treatments for low back pain, study after study still makes use of abdominal hollowing, calling it “spine stabilization” and “core stabilization,” and wonders why it does not work better than “general exercise.” Often the “general exercise” groups are doing a great amount of genuine stabilization of the spine by holding the core rigid without any attention directed at isolating any particular muscle.
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.
Abstract STUDY DESIGN: Controlled intervention with group randomization. OBJECTIVE: To investigate the effectiveness of a 6-month neuromuscular exercise and counseling program for reducing the incidence of low back pain (LBP) and disability in young conscripts, with a healthy back at the beginning of their compulsory military service. SUMMARY OF BACKGROUND DATA: Basic military training is physically demanding on the back and requires adequate physical fitness. LBP causes significant morbidity and absence from military service. METHODS: Participants were conscripts of 4 successive age cohorts (n = 1409). In the prestudy year, before adoption of the intervention, 2 successive cohorts of conscripts of 4 companies (n = 719) were followed prospectively for 6 months to study the baseline incidence of different categories of LBP. In the intervention year, conscripts (n = 690) of 2 new cohorts of the same companies (intervention group: antitank, engineer;control group: signal, mortar) were followed for 6 months. The intervention program aimed to improve conscripts’ control of their lumbar neutral zoneand specifically to avoid full lumbar flexion in all daily tasks. RESULTS: Total number and incidence of off-duty days due to LBP were significantly decreased in the intervention companies compared with controls (adjusted hazard ratio = 0.42, 95% confidence interval = 0.18-0.94, P = 0.035). The number of LBP cases, number of health clinic visits due to LBP, and number of the most severe cases showed a similar decreasing trend but without statistical significance. CONCLUSION: These findings provide evidence that exercise and education to improve control of the lumbar neutral zone have a prophylactic effect on LPB-related off-duty service days in the military environment when implemented as part of military service among young healthy men.
My comments:
This is a really good paper. Generally when you read a paper regarding spine stabilization and motor control exercises it describes patients performing abdominal hollowing and trying to isolate their transverse abdominus muscles and multifidus, which is a concept that has been disproven but is still pervasive in some physical therapy practices and still persists as a goal even in newer published research. This study, however, gets it right by teaching exercises directed at increasing core and LE endurance while maintaining a neutral spine, combined with counseling on the importance of doing the same during both static and dynamic activities. The exercises were all reasonably light, so I would not expect them to increase strength much in the subject population but would expect them to primarily improve motor control and awareness and ability to maintain a neutral spine during activities. The result was a 58% decrease in off duty days due to low back pain. Full text with a number of photos of slides of the intervention is available here.
Worth talking about is that this study decreased pain by a different mechanism than some other research I have discussed where the researchers focused almost solely on increasing strength, which also worked to some degree. The combination of the two approaches, in addition to using EMS rather than TENS of the core musculature, goes a long way towards explaining the success of my own physical therapy program for low back pain. Over the years I started with the strength approach with reasonably good results. Later, I learned about and integrated more motor learning with education regarding a neutral spine and postural awareness, which improved my outcomes significantly. Later still with the addition of the EMS, the more long-term benefits of exercise and counseling came with substantially shorter-term relief. The best part is that it all works together with each component helping the others. Strength from exercise and EMS makes maintaining a neutral spine easier; maintaining a neutral spine, EMS, and increased strength itself decrease pain making the patient better able to tolerate strengthening exercise. Yin and Yang I guess, and there is always more to learn.
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.
Lessons from this study make up what I think is about a third of the solution to effectively treating low back pain preventing future episodes of back pain. That is, to avoid prolonged damaging posture particularly in spine flexion.
Abstract Prolonged sitting with spine flexion has been linked to low back disorders. A variety of mechanisms account for this based on biomechanical and neurological variables. Airline seats typically cause pronounced lumbar flexion due to their hollowed seat back design. A pneumatic support, placed between the seat back and the lumbar spine, was tested to see if lumbar flexion was reduced. Results showed that when the seats were positioned in the upright position, 15 of 20 participants experienced reduced lumbar flexion (by 15 degrees on average) with the support. The study was repeated on the five non-responders with the seatback set in the reclined position. This resulted in another four experiencing less lumbar flexion. Since seated flexion is associated with disc stress, reducing flexion with the support reduced lumbar stress. Spine flexion that results from prolonged sitting is associated with disc stress and pain. The pneumatic support tested here reduced spine flexion. While it is not known why airline seats are designed with no lumbar support, which causes excessive lumbar flexion while seated, the pneumatic support corrected this deficit. Reclining the seatback enhanced this effect.
My comments:
McGill’s studies on the lumbar spine are always good. Although the above paper is in relation to airline seats (which are particularly bad) sitting with various degrees of spine flexion in automobiles, couches and chairs at home, and computer workstations are often problematic as well. Unfortunately if a person is sitting in prolonged spine flexion causing vertebral ligament strain, muscle spasms, posterior disc bulges, and herniations, no amount of exercise is going to completely fix that. More often than not spine stretches will only make matters worse by further destabilizing already overstretched tissues. The good news is that the solution is often simple. A pillow of various size or other object of that fills the gap between a person’s chair and and the small of their back to maintain a neutral spine just requires some awareness of the problem and a bit of imagination. In this case researchers had subjects use an inflatable support, which can be adjusted to a person’s comfort. However when I fly I find the larger in-flight magazine found in the airline seat pocket in front of me, when folded lengthwise, supports my spine just right and I don’t have to worry about packing it or forgetting it. So far 100% of people sitting next to me have agreed it helps prevent in-flight low back pain, and pain upon landing considerably. Best of all, it’s free.
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.
OBJECTIVE: To evaluate the efficacy of intensive isometric neck strength training and lighter endurance training of neck muscles on pain and disability in women with chronic, nonspecific neck pain. PATIENTS: A total of 180 female office workers between the ages of 25 and 53 years with chronic, nonspecific neck pain. INTERVENTIONS: Patients were randomly assigned to either 2 training groups or to a control group, with 60 patients in each group. The endurance training group performed dynamic neck exercises, which included lifting the head up from the supine and prone positions. The strength training group performed high-intensity isometric neck strengthening and stabilization exercises with an elastic band. Both training groups performed dynamic exercises for the shoulders and upper extremities with dumbbells. All groups were advised to do aerobic and stretching exercises regularly 3 times a week. RESULTS: At the 12-month follow-up visit, both neck pain and disability had decreased in both training groups compared with the control group (P<.001). Maximal isometric neck strength had improved flexion by 110%, rotation by 76%, and extension by 69% in the strength training group. The respective improvements in the endurance training group were 28%, 29%, and 16% and in the control group were 10%, 10%, and 7%. Range of motion had also improved statistically significantly in both training groups compared with the control group in rotation, but only the strength training group had statistically significant improvements in lateral flexion and in flexion and extension. CONCLUSIONS: Both strength and endurance training for 12 months were effective methods for decreasing pain and disability in women with chronic, nonspecific neck pain. Stretching and fitness training are commonly advised for patients with chronic neck pain, but stretching and aerobic exercising alone proved to be a much less effective form of training than strength training.
“Considerable or complete relief from pain was obtained in 73% of participants in the strength training group, and 21% in the control group. Only 3% in all groups felt their pain had become worse from the training.
“In the strength training group, maximal isometric neck strength increased in flexion by 110%, rotation by 76%, and extension by 69%. The results of the endurance training group improved by 28%, 29%, and 16% and the control group by 10%, 10%, and 7% respectively.”
“The conventional stretching group stretching and aerobic exercises the control group were advised to perform had poor effect on the functional parameters of the neck and they had only a weak effect on chronic neck pain and disability.”
Chad’s comments:
This was one of the earlier strength training studies on women with neck pain, and since then a number of additional studies have collaborated the results, which agrees with my findings as well. While the title emphasizes the neck training, the additional strength performed by the experiment groups includes dumbbell shrugs, presses, curls, bent-over rows, flys and pullovers, with the heaviest dumbbell they could use for 1 set of 15 reps, while the endurance group did 3 sets of 20 reps on the same exercises with 2 kg. Both did squats, sit-ups and back extensions with bodyweight, and stretches to the upper body and neck. It’s worth noting that the neck strengthening was not done in isolation, but rather in conjunction with a fairly extensive upper body PRE program, so it is hard to say how much of the pain reduction was secondary to the neck strengthening alone.
The neck strength group performed isometric holds with a Theraband for 15 reps in forward, obliquely right, left and straight back with 80% of their tested max tension. The endurance group did supine neck flexion, only I think they got short-changed in side bending and extension which could contribute to their lesser improvement. They all did some upper body and neck stretches and aerobic training, while the control group did the stretches and aerobic training only.
For me the most interesting part of the study was that the isometric strength group had a considerably greater increase in range of motion (ROM) over the group that did only stretching. The authors did not speculate as to why, however I think it likely that the increased ROM of isometric strength group came from increased muscular stabilization. This, in turn, decreases injurious stress on the intervertebral discs, facet joints and ligaments. Stretching at some point does the opposite: destabilizing the cervical spine in the same way that flexion and rotation stretches have been shown to decrease stability of the lumbar spine. So counter-intuitively, over-stretching vertebral components often increases pain long term and and does not improve ROM as much as intended.
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.
