SpineFITyoga.com

Author: chad reilly

  • Periodized Resistance Training Works Better than Aerobic Training for Chronic Low Back Pain

    A comparison of two forms of periodized exercise rehabilitation programs in the management of chronic nonspecific low-back pain. J Strength Cond Res. 2009 Mar;23(2):513-23. Kell RT, Asmundson GJ.

    From the study:

    Abstract
    The purpose of this study was to determine the influence of 2 different periodized exercise rehabilitation programs (resistance training [RT] and aerobic training [AT]) on musculoskeletal health, body composition, pain, disability, and quality of life (QOL) in chronic (>or=3 months; >or=3 d.wk) nonspecific low-back pain (CLBP) persons. Twenty-seven CLBP subjects were randomly assigned to 1 of 3 groups, 1) RT (n = 9), 2) AT (n = 9), or 3) control (C; n = 9). Subjects were tested at baseline and at weeks 8 and 16 of training. Intensity and volume were periodized in the training groups. Significance was set at p <or= 0.05. No significant differences were noted among the groups at baseline. The RT group significantly decreased body fat percent from baseline to week 8 and from baseline to week 16, whereas the AT group significantly decreased body fat percent and body mass from baseline to week 16. The RT group significantly improved most musculoskeletal fitness, pain, disability, and QOL outcomes from baseline to week 8, baseline to week 16, and weeks 8 to 16. However, the AT group showed significant improvements in flexibility from baseline to week 8 and in cardiorespiratory and peak leg power from baseline to week 8 and baseline to week 16. The AT groups showed no significant improvements in pain, disability, or QOL. The primary finding was that periodized RT was successful at improving many fitness, pain, disability, and QOL outcome measures, whereas AT was not. This study indicates that whole-body periodized RT can be used by training and conditioning personnel in the rehabilitation of those clients suffering with CLBP.

    Chad’s comments:

    This is another great study by the same authors as my prior blog, but was published two years earler using largely the same exercise program, focusing on total body strength rather than just core stabilization. Subjects also had chronic low back pain but were a little younger, averaging 35-40 years. Rather than compare to a control group that just stayed active, the other experimental group did periodized aerobic training. As the abstract states, group that lifted weights improved their low back disability scores and decreased pain considerably more than the aerobic and control group. Reading the entire did a good job in explaining their exercise selection and helps to dispel some of the errors you continue to hear from the biopsychosocial proponents, many of whom seem to think that all activity/exercise is of equal benefit or consequence to the spine. Rather, movements matter, postures matter, fitness matters, exercise selection matters, and so does your physical therapist if they are not keeping up with the latest in rehabilitation science.

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

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

  • Strength Training, Function and Low Back Pain.

    The influence of periodized resistance training on recreationally active males with chronic nonspecific low back pain. J Strength Cond Res. 2011 Jan;25(1):242-51.
    Jackson JK, Shepherd TR, Kell RT.

    From the study:

    Abstract
    The most common musculoskeletal health issue is chronic nonspecific low back pain (CLBP). CLBP increases pain and disability, which reduces quality of life (QoL). Generally, pain, disability, and QoL are improved with a moderate volume and intensity of physical activity. Recently, periodized resistance training (PRT) was shown to be effective at improving CLBP in sedentary young, middle-age, and older adults. The purpose of this study was to determine if PRT would increase strength, reduce pain and disability, and improve QoL in recreationally active, moderately trained middle- and older-age males. Forty-five male subjects were divided according to age into 1 of 3 groups: (a) middle-age exercise (ME), (b) old-age exercise (OE), or (c) control (C). All subjects suffered from CLBP and were considered to be moderately trained, participating in recreational ice hockey for 60 minutes, 2 times per wk(-1) for ∼5 months/year along with other recreational activities. The study ran for 16 weeks (3-week familiarization and 13 weeks of testing and PRT) with 5 repetition maximum testing at baseline and weeks 8 and 12. The PRT program systematically and progressively overloaded all major muscle groups (whole-body workout). The results indicate that middle- and old-age recreationally active males with CLBP respond similarly in magnitude to PRT, with improvements in all outcome measures (strength, pain, disability, QoL) across all time points of the study. Clinical significance (≥ 25%) in outcome measures was reached on most variables for the ME and OE groups. The results suggest that PRT may be effectively applied as rehabilitation for moderately trained recreational athletes with CLBP.

    Chad’s comments:

    This is a great study regarding strengthening and low back pain, as most people are taught that they need to stretch. In it the middle aged men averaged 52 years and the older group average age was 63. Age did not have much effect on the outcomes. The percent changes were great on all variables including strength on all exercises. Decrease in disability as per the Oswestry questionnaire was considerable 46-52%. Initially I was least impressed with the pain reduction which while it was a significant 26-27% decrease, means pain only decreased from 4.3-4.5/10 to a 3.2-3.3/10, which I feel could be better. Looking at their exercise program I was initially critical as I think there are some exercise selections that would have improved outcomes further. What they used were:

    1. Leg press
    2. Leg extensions
    3. Leg curl
    4. Bench Press
    5. Incline Bench Press
    6. Lat Pulldown
    7. Low cable row
    8. DB shoulder press
    9. Arm curl
    10. Triceps pushdown
    11. Ab Crunches
    12. Swiss ball crunch
    13. Prone superman

    However when I read the preceding study by the same authors using the same exercise program they specifically stated they wanted  as few confounding variables as possible and wanted to know what periodized strengthening alone did, not strengthening in combination with some other factor.  I would prefer more exercises like standing cable presses, standing cable rows, squats, Romanian deadlifts (RDLs), and lunges. The latter I think would better challenge the ability to maintain a neutral spine, and teach motor control of the spine while doing so, but would introduce additional variables into the study. That said the researchers appear to have all major muscle groups covered, including the core. This was explained in the prior paper as well, as they wanted to know what total body strengthening did as opposed to core strength alone. I agree that the total body approach is best because a strong core does the back little good if the arms and legs are not strong as well. It’s not easy to bend over and pick up something heavy with a neutral spine if your legs and arms are not strong also.  A strong core that does most of the lifting with by flexing and extending the spine, rather than flexing and extending the hips, still often hurts.

    Overall it’s a great study to see what the effects increases in strength have on pain and disability. I still I think a complete lumbar rehabilitation program should also include postural awareness/spine/hip motor control teaching the ability to maintain a neutral spine during work, rest and play, this study showed what total body strength by itself contributes. The results were still substantial and considerably better than just staying active (as the control group did), which is more than you can say for the McKenzie method, flexion stretches, etc. so physical therapists should take note.  I expect I’ll be citing this study on the reg.

    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.

  • Hard Times for McKenzie Method, Low Back Pain

    The McKenzie method for low back pain: a systematic review of the literature with a meta-analysis approach. Spine. 2006 Apr 20;31(9) Machado LA, de Souza Mv, Ferreira PH, Ferreira ML.

    From the study:

    “Eleven trials of mostly high quality were included. McKenzie reduced pain (weighted mean difference [WMD] on a 0- to 100-point scale, -4.16 points; 95% confidence interval, -7.12 to -1.20) and disability (WMD on a 0- to 100-point scale, -5.22 points; 95% confidence interval, -8.28 to -2.16) at 1 week follow-up when compared with passive therapy for acute LBP. When McKenzie was compared with advice to stay active, a reduction in disability favored advice (WMD on a 0- to 100-point scale, 3.85 points; 95% confidence interval, 0.30 to 7.39) at 12 weeks of follow-up.”

    “When analyzing the results of individual trials, McKenzie was as effective as flexion exercise at 2 weeks for chronic pain.. … and marginally better than flexion exercise for acute pain at 8 weeks…”

    “Delitto et al reported a large effect on acute disability… …favoring McKenzie when compared with flexion exercises after 5 days.”

    “Two high-quality studies reporting on acute LBP compared McKenzie with advice to stay active… The pooled results in Figure 5 indicate a significant decrease in disability… … favoring advice to stay active at 12 weeks follow up.”

    “There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP; however, the magnitude of the difference suggests the absence of clinically worthwhile effects.”

    My comments:

    This is not exactly breaking news but McKenzie method of diagnosis and treatment of low back pain is still being taught to physical therapists and physical therapy patients still have to endure end range, and sometimes end range plus overpressure, spine extension, and to a lesser degree flexion stretches. Googling “Mckenzie method” will bring up a plethora of physical therapists touting Mckenzie method benefits and anecdotal reports of it being great. But what does the actual research say? Ehh, the reality seems a little less remarkable. The results of the above study (which was a meta-analysis that pooled the results of relevant research that went before it) are about what I would expect. Overall the researchers found the McKenzie method is perhaps slightly better than passive modalities (but not enough to matter), better than Williams’ lumbar flexion exercises, but slightly less effective than the simple advice to keep active. I’ve read McKenzie’s books so I have a pretty good grasp on his techniques and why I think they don’t work so well for the average low back pain sufferer.

    I do agree with much of McKenzie’s observations that spine flexion happens too often and for too long for most people in activities of daily living, and I do agree that people should take steps to lessen spine flexion. I think this is why this study found McKenzie worked better than Williams flexion exercises but not much better than nothing at all. Williams flexion exercises were the standard McKenzie was reacting to when he came out with his method favoring spine extension in 1981. This is because once you remove any placebo and gate control effects of flexion stretches on pain, you are left with a motion that causes posterior displacement of nucleus material in the lumbar disc and stretch/creep to passive ligaments that are supposed to control spine motion. Thus flexion stretches over time decrease spine stability, increasing long term pain and disability. So I would say McKenzie is not as harmful as Williams spine flexion exercise.

    In his books McKenzie likes to use the example of having a person hold their finger backwards at end range until it starts to hurt as analogous to what goes on in the discs during spine flexion, and that if you remove the stress on the finger and bend it the other way the pain goes away. The problem I think is that McKenzie goes too far the other way. The solution to pain injury in flexion is not hyperextension but just eliminating the flexion and returning the joint to a more neutral position. This works with both the finger and low back. I would not cure the finger joint pain from prolonged extension by bending it the other way as far as possible and holding it there, rather I would just remove the stress.

    As this paper correctly asserts, McKenzie method should not be thought of as just extension exercise because McKenzie also teaches spine flexion stretches if the patient has an increase in symptoms with extension during his evaluation. I disagree with this as well, because posterior disc herniation caused by too much flexion during ADLs can be irritated with extension and still worsened in the long run with more flexion. Different spinal structures can also play a role in these symptoms’ presentation as well. For example, if one already has a collapsed disk at L5-S1 causing facet joint approximation and arthritis at that level, we would expect to see worsened symptoms with back extension. Flexion stretching in this case might unload the irritated facet joint and provide short term relief, but would be putting the discs above (T12 and L1-L4) at risk for flexion-related injury. A better method in this example (and in most cases of low back pain) would be teaching the patient to avoid both extremes in flexion and extension. This would serve two roles: lessening stress and pain on the posterior facet joints, while preventing further degeneration of the remaining vertebral discs.

    Worth mentioning is that even with McKenzie’s more common extension-related treatment, he still teaches flexion exercises after pain is resolved, “to restore normal range of motion.” I disagree with this as well, since (as McKenzie rightfully surmises) daily activities still generally give people too much spine flexion. As such I think most don’t need any stretches in spine flexion but rather total body fitness, mobility around the peripheral joints, and motor control/postural awareness to maintain a neutral and pain free spine position during work, play and, rest.

    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.

    Update: 12-1-15

    This is currently my second most popular blog, and while I think it’s good stuff, I think my best material is written below in answer to comments and questions. Also this blog is a bit negative, being mostly about what doesn’t work, or at least what the above meta-analysis suggest doesn’t work very well. However, in answering questions below I wrote a great deal below about what I think does work. Much of which has been summarized in my low back pain info page. Also, I made an example low back pain workout video of what I would say is my stereotypical low back pain workout. I don’t start people off on all these exercises, but generally start with the standing rows, standing presses, and maybe add the hip in/out machine on day one. All performed 3 sets or 15 reps (easy, medium and hard weights) stopping immediately if there is any pain. If the person does well with those exercises on day one, I’ll add 1-2 exercises per day, until I get to what I think is a complete program. Some patients can’t do all the exercises, some do alternatives and some do extra, but the video program is my basic. The exercises themselves only make up about ⅓ of what it often takes to recover from low back pain. The other parts are improving static postures and motor control during active motions, the latter of which the exercises help teach. To help it all, unless a patient has an abdominal hernia, or a pacemaker, I almost ALWAYS perform electric muscle stimulation (EMS) to the abdominal and low back region to both decrease pain and improve core strength. This works especially well when patients can’t perform regular exercises intense enough to increase strength, and the lucky side effect is the harder you do EMS, generally the less pain you have after. 

  • ACL Repair: Abnormal Gait, Future Arthritis Due to Low Strength

    The effect of insufficient quadriceps strength on gait after anterior cruciate ligament reconstruction. Clin Biomech (Bristol, Avon). 2002 Jan;17(1):56-63. Lewek M1, Rudolph K, Axe M, Snyder-Mackler L.

    From the study:

    BACKGROUND:
    Individuals following anterior cruciate ligament rupture often demonstrate reduced knee angles and moments during the early stance phase of gait. Alterations in gait can neither be ascribed to instability nor to quadriceps weakness alone when both are present.
    METHODS:
    Twenty-eight individuals with complete anterior cruciate ligament rupture (10 patients with acute rupture, 8 patients following reconstruction with quadriceps strength >90% of the uninvolved side [strong-anterior cruciate ligament reconstructed group], and 10 patients after reconstruction with quadriceps strength <80% of the uninvolved side [weak-anterior cruciate ligament reconstructed group]), and 10 uninjured subjects underwent an examination of their lower extremity to collect kinematics, kinetics, and electromyography during walking and jogging. Anterior cruciate ligament reconstruction was arthroscopically assisted and a double loop semitendinosis-gracilis autograft or allograft was used as a graft source. All reconstructed subjects had stable knees, full range of motion, and no effusion or pain at the time of testing (more than three months after surgery).
    RESULTS:
    Knee angles and moments of the strong group were indistinguishable from the uninjured group during early stance of both walking and jogging. The weak subjects had reduced knee angles and moments during walking, and jogged similarly to the deficient subjects. Regression analysis revealed a significant effect between early stance phase knee angles and moments and quadriceps strength during both walking and jogging.
    CONCLUSION:
    Inadequate quadriceps strength contributes to altered gait patterns following anterior cruciate ligament reconstruction.

    Chad’s comments:

    Muscle inhibition was ruled out as a factor because percent of muscle recruitment was similar between groups.  Pain was ruled out as a factor because all subjects were painless.  Weaker subjects were a few weeks further out post-op (20.8 weeks vs 14.3 for the stronger group), so recovery time was not a factor.  Weak subjects were considered anyone with the repaired side quadriceps <80% of their non-repaired side (averaging 67.6%) while strong subjects was anyone with quadriceps >90% of their non-surgical side (average 95.3%) which gives us good information with regards to what strength levels are necessary to normalize gait (how you walk).  The entire paper was a fascinating read with much pertinent background information given in the introduction and discussion. The researchers found the abnormal gait of weaker ACL reconstruction patients to be very similar to ACL deficient patients (not repaired) and suspect this would likely lead to similar early joint degeneration/arthritis, and thus negate much of the the point of the reconstruction in the first place.

    The take home message for physical therapists and patients alike after ACL reconstruction is that you really want to restore a normal walking pattern. To do so the best strategy is to restore quadriceps strength to >90% of the contralateral side, but this must be done safely, respecting the healing process of the graft so as to not damage the repair. It probably isn’t a bad idea to get hamstrings, calves, hip abductors and adductors >90% while you are at it.  After surgery, strength is best increased with progressive resistance exercise, and when active muscle contractions are inhibited, electric muscle stimulation. As is usually the case, time in physical therapy is limited, so time spent on passive modalities de jour (soft tissue mobilizations, arthrokinematic joint mobilizations, ASTYM, Graston Technique, dry needling, magnets, psychic surgery, whatever) is likely time wasted.

    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.

  • After ACL Repair: Lunges Appear Particularly Safe

    Rehabilitation after ACL Injury: A Fluoroscopic Study on the Effects of Type of Exercise on the Knee Sagittal Plane Arthrokinematics. Biomed Res Int. 2013;2013 Norouzi S1, Esfandiarpour F, Shakourirad A, Salehi R, Akbar M, Farahmand F.

    From the study:

    Abstract
    A safe rehabilitation exercise for anterior cruciate ligament (ACL) injuries needs to be compatible with the normal knee arthrokinematics to avoid abnormal loading on the joint structures. The objective of this study was to measure the amount of the anterior tibial translation (ATT) of the ACL-deficient knees during selective open and closed kinetic chain exercises. The intact and injured knees of fourteen male subjects with unilateral ACL injury were imaged using uniplanar fluoroscopy, while the subjects performed forward lunge and unloaded/loaded open kinetic knee extension exercises. The ATTs were measured from fluoroscopic images, as the distance between the tibial and femoral reference points, at seven knee flexion angles, from 0° to 90°. No significant differences were found between the ATTs of the ACL-deficient and intact knees at all flexion angles during forward lunge and unloaded open kinetic knee extension (P < 0.05). During loaded open kinetic knee extension, however, the ATTs of the ACL deficient knees were significantly larger than those of the intact knees at 0° (P = 0.002) and 15° (P = 0.012). It was suggested that the forward lunge, as a weight-bearing closed kinetic chain exercise, provides a safer approach for developing muscle strength and functional stability in rehabilitation program of ACL-deficient knees, in comparison with open kinetic knee extension exercise.

    Chad’s comments:

    This one is interesting for a few reasons. First they did real time fluoroscopy on ACL deficient and normal knees so they could see exactly what’s happening during the exercise. Lunges came out looking particularly good, making them a good choice for post-op ACL reconstruction, as opposed to other research on wall squats. In my opinion, and the opinion of most weightlifters and strength and conditioning specialists, lunges are more functional. It makes you wonder why so many physical therapist like wall squats so much. It’s probably because most physical therapists, in spite of their schooling, do not have good backgrounds in strength and conditioning.

    What was also interesting was they found no anterior tibial translation with leg extensions without resistance, but they did when the added a load, and in the study that load was 2 kg. It would be interesting to see the study repeated with greater than 10 kg, as other research found that increased training loads on leg extensions were associated with decreased anterior tibial translation.  However, that was measured after 6 weeks of training, rather than real time as in this study.

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

  • Rehabilitation after ACL Reconstruction: Leg Extensions, Knee Laxity, and Training Load (Not What You Would Expect)


    Is knee laxity change after ACL injury and surgery related to open kinetic chain knee extensor training load? Am J Phys Med Rehabil. 2009 May;88(5):369-75. Morrissey MC, Perry MC, King JB.
    From the study:

    OBJECTIVE:
    The purpose of this study was to evaluate whether knee anterior laxity changes after anterior cruciate ligament injury and surgery are related to aspects of thigh muscle resistance training during rehabilitation.
    DESIGN:
    Forty-nine subjects (13 females) diagnosed with an anterior cruciate ligament-deficient knee or who had undergone anterior cruciate ligament reconstructive surgery participated in this study. The subjects trained their knee extensors in the open kinetic chain during a 6-wk program, and the relationship of aspects of training (for example, absolute resistance load) and other factors to anterior laxity change during this period were analyzed using linear regression analysis.
    RESULTS:
    The only factor found to be significantly related (r = -0.347) to anterior knee laxity change was average absolute load used in training the knee extensors.
    CONCLUSIONS:
    These results offer some early clinical support for increasing the strain on the anterior cruciate ligament graft (in patients treated with reconstruction) or other passive restraints to anterior tibial displacement, during rehabilitation after anterior cruciate ligament injury and reconstruction surgery to promote decreased knee anterior laxity.

    Chad’s comments:

    This one is very interesting in that the researchers found the opposite of what they would have expected and the opposite of what I would have expected. Resistive leg extensions have been considered taboo after ACL reconstruction for decades because they were thought to stretch out the graft resulting in a loose knee joint, prone to arthritis and reinjury. However, subsequent research found that adding leg extensions to a rehabilitative program does improve functional outcomes. Also timing is important with regards to when you should add them into a program, with earlier than 12 weeks post-op perhaps being too soon, particularly with hamstring graft reconstructions.

    Researchers of this study expected that increased weights used in rehabilitation of both ACL deficient and ACL reconstructed knees would be the important factor in whether the graft stretched or not. They found that it was, but in the opposite direction of what they thought. Those that trained at a higher intensity (>10 kg seeming to be particularly protective) had less knee joint laxity than those who trained at a lower intensity. Subjects worked to relative high intensity 6RM loads.

    These results still leave a number of questions. Is it the weight itself used that resists changes in laxity?  Or are those with stronger muscles better able to protect their ACL, which then leads one to believe higher resistance levels are good because they build stronger muscles? The patients did prone leg curls as well. I would assume use of heavier weights in extensions would be strongly associated with use of heavier weights in flexion. Hamstrings (worked by knee flexion) do act to resist strain on the ACL, so perhaps the difference is related to hamstring strengthening. However, this study found correlation of knee laxity for leg curl load was less so than for quadriceps load. Or perhaps the heavier weights used are the important thing, and using them causes greater compressive stress on the knee during exercise and this fights strain on the ACL.

    Also worth noting is 6 of the 24 reconstructions were hamstring graft reconstructions and the rest were patellar grafts, and differences in laxity between these types of reconstructions was not reported. ACL deficient knees however also had lesser laxity after heavier training loads. Leg extension exercises training 90 to 0 degrees were not added until 8 weeks post-op. Other researchers have found that leg extensions added as early as 6 weeks post op did cause increased knee laxity in hamstring graft repairs, but they did not address training load. Perhaps starting the exercise later allows one to train at heavier resistance levels, which are then protective. And of course it could be all those things and more, which keeps physical therapy interesting.

    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.

  • Wall Squats Not so Good after ACL Reconstruction


    Tibial displacement and rotation during seated knee extension and wall squatting: a comparative study of tibiofemoral kinematics between chronic unilateral anterior cruciate ligament deficient and healthy knees. Knee. 2013 Oct;20(5):346-53. Keays SL1, Sayers M, Mellifont DB, Richardson C.

    From the study:

    “Following anterior cruciate ligament (ACL) rupture, the knee becomes unstable with alterations in joint kinematics including anterior tibial displacement (ATD), and internal tibial rotation. Therapeutic exercises that promote faulty kinematics should be discouraged, especially early post-reconstruction, to avoid graft stretching and possibly longer-term osteoarthritis. Our study aimed to compare ATD and tibial rotation during two commonly prescribed exercises, namely: open kinetic chain (OKC) seated extension and closed kinetic chain (CKC) single leg wall squatting in ACL-deficient and healthy knees.”

    “We found increased ATD in the wall squat compared to the seated extension (p=0.049). There was no difference in ATD between the healthy and ACL-deficient knees but overall the tibia was significantly more internally rotated (p=0.003) in ACL-deficient knees, irrespective of the exercise, possibly interfering with the screw-home mechanism.”

    “CKC exercises, in particular wall squats, are not necessarily safer for patients with ACL-deficiency and possibly ACL-reconstruction; although generalization should only be made with appropriate caution. Clinicians require a detailed knowledge of the effect of exercise on knee joint kinematics.”

    Chad’s comments:

    I’ve never been a fan of wall squats. What I like about regular squats compared to exercise machines is that you train balance and coordination at the same time you train for strength. By leaning back against a wall when doing squats you take that balance aspect away and you might as well just be doing leg presses. The problem with wall squats as compared to leg presses, however, is that you are stuck with body weight as resistance, but with a leg press I can make the exercise considerably lighter, making it much easier for patients to get started strengthening after injury or surgery. So wall squats have always been the worst of both worlds. Now to top it off these researchers find they put potentially harmful stress on the post surgical ACL.

    One potential problem in the above study is that the wall squats were performed with body weight, while the leg extensions used only 3 kg. The different intensity of quadriceps contraction might be a confounding variable, however that goes back to the weakness of the wall squat as an exercise: being you can’t easily and consistently grade and progress the exercise early after rehabilitation. Plus, later on when the ACL graft is strong there are a lot better and more dynamic body weight and body weight plus exercises to choose from than the wall squat. Like regular squats, lunges and RDLs.

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

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

  • ACL Reconstruction, Leg Extensions Safe but Timing is Everything

    Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study. Knee Surg Sports Traumatol Arthrosc. 2007 Apr;15(4):402-14. Epub 2007 Jan 12. Heijne A, Werner S.

    From the study:

    Abstract
    The purpose of the present investigation was to evaluate physical outcome after anterior cruciate ligament (ACL) reconstruction with early versus late initiation of open kinetic chain (OKC) exercises for the quadriceps in patients operated on either patellar tendon or hamstring grafts. Sixty-eight patients, 36 males and 32 females, with either patellar tendon graft (34 patients) or hamstring graft (34 patients) were enrolled in this study. All patients were randomly allocated to either early (the 4th postoperative week) or late (the 12th postoperative week) start of OKC exercises for the quadriceps, resulting in four subgroups: patellar tendon reconstruction, early start (P4) or late start (P12) of OKC quadriceps exercises, hamstring tendon reconstruction, early start (H4) or late start (H12) of quadriceps OKC exercises. Prior to surgery and 3, 5 and 7 months later, assessments of range of motion (goniometer), anterior knee laxity (KT-1000), postural sway (KAT 2000), thigh muscle torques (Kin-Com dynamometer) and anterior knee pain (anterior knee pain score) were evaluated. No significant group differences were found in terms of range of motion 3, 5 and 7 months postoperatively. The H4 group showed a significantly higher mean difference of laxity over time of 1.0 mm (CI: 0.18-1.86) than the P4 group (P=0.04). Within the same type of surgery, the H4 against the H12, the mean difference over time was 1.2 mm (0.37-2.1) higher in the H4 group than in the H12 group (P=0.01). There were no significant group differences in terms of postural sway or anterior knee pain at the different test occasions. Significant differences in trends (changes over time) were found when comparing the four groups, for both quadriceps muscle torques (P<0.001) and hamstring muscle torques (P<0.001). All groups, except the P4 group, reached preoperative values of quadriceps muscle torques at the 7 months follow-up. In the H4 and the H12 groups, significantly lower hamstring muscle torques at the 7 months follow-up compared with preoperative values were found. In conclusion, early start of OKC quadriceps exercises after hamstring ACL reconstruction resulted in significantly increased anterior knee laxity in comparison with both late start and with early and late start after bone-patellar tendon-bone ACL reconstruction. Furthermore, the early introduction of OKC exercises for quadriceps did not influence quadriceps muscle torques neither in patients operated on patellar tendon nor hamstring tendon grafts. On the contrary, it appears as if the choice of graft affected the strength of the specific muscle more than the type of exercises performed. Our results could not determine the appropriate time for starting OKC quadriceps exercises for patients who have undergoneACL reconstruction with hamstring tendon graft. Future studies of long-term results of anterior knee laxity and functional outcome are needed.

    Chad’s comments:

    This is another great ACL/exercise study that did change how I treat my ACL patients. As noted in another blog, open kinetic chain exercises like resistive leg extensions do help isolate quadriceps and thus strengthen them. That strength does allow better return to sports when added to a program consisting of closed kinetic chain exercises like squats, lunges, etc.

    What this study found was that patellar tendon graft ACL repairs benefit from leg extensions as early as 4 weeks post-op without overstretching the graft. Hamstring tendon graft ACL repairs had increased laxity when leg extensions were started at 4 weeks, but remained tight if the leg extensions were started 12 weeks out. The study also found that delaying the start of OKC exercises to 12 weeks did not significantly impair quadriceps strength when measured 7 months post-op. The 4 week groups started knee extensions with range of motion limited 90-40 degrees, not progressing to 0 degrees extension until 6 weeks post-op. The 12 week group started 90-0 degrees knee extensions immediately at 12 weeks. So, 12 weeks seems safe enough to start resistive leg extensions 90-0 degrees with hamstring graft ACL reconstructions.  Starting any earlier than that, you are risking a lax knee joint, reinjury and perhaps early arthritic changes. The 4 week start knee extensions are apparently safe with the patellar graft, with the caveat of early limited range of motion.

    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.

  • After ACL Repair, Closed Kinetic Chain Exercises Not Enough to Restore Quadriceps Strength


    Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg Sports Traumatol Arthrosc. 2000;8(6):337-42.  Mikkelsen C1, Werner S, Eriksson E.

    From the study:

    Abstract
    Rehabilitation after anterior cruciate ligament (ACL) reconstruction has focused over the past decade on closed kinetic chain (CKC) exercises due to presumably less strain on the graft than with isokinetic open kinetic chain exercises (OKC); however, recent reports suggest that there are only minor differences in ACL strain values between some CKC and OKC exercises. We studied anterior knee laxity, thigh muscle torque, and return to preinjury sports level in 44 patients with unilateral ACL; group 1 carried out quadriceps strengthening only with CKC while group 2 trained with CKC plus OKC exercises starting from week 6 after surgery. Anterior knee laxity was determined with a KT-1000 arthrometer; isokinetic concentric and eccentric quadriceps and hamstring muscle torque were studied with a Kin-Com dynamometer before and 6 months after surgery. At an average of 31 months after surgery the patients answered a questionnaire regarding their current knee function and physical activity/sports to determine the extent and timing of their recovery. No significant differences in anterior knee laxity were noted between the groups 6 months postsurgery. Patients in group 2 increased their quadriceps torque significantly more than those in group 1, but no differences were found in hamstring torque between the groups. A significantly higher number of patients in group 2 (n = 12) than in group 1 (n = 5) returned to sports at the same level as before the injury (P < 0.05). Patients from group 2 who returned to sports at the same level did so 2 months earlier than those in group 1. Thus the addition of OKC quadriceps training after ACL reconstruction results in a significantly better improvement in quadriceps torque without reducing knee joint stability at 6 months and also leads to a significantly higher number of athletes returning to their previous activity earlier and at the same level as before injury.

    Chad’s comments:

    The key to physical therapy after ACL reconstruction is to restore strength and function as fast as possible with minimal risk to the graft. Another key is to avoid dogmatism. When I was in PT school in the 90s all the talk was about closed kinetic chain (CKC) exercises (exercises done with the foot fixed to the floor or a plate) being safe for the repaired ACL while open kinetic chain (OKC) exercises (with the foot free to move) putting the repair at risk. The reason was stated that the quadriceps acting alone without cocontraction of the hamstrings would stretch the ACL graft and made the knee too loose, perhaps leading to graft failure and early arthritic changes. Since then considerable additional research has been completed providing sound answers as to what exercises are safe, what exercises are most beneficial, and what is good timing with regards to recovery.  What this and a few other studies found was that a mixture of exercises including CKC and OKC are needed to improve the odds of full recovery. So while some of my favorite CKC exercises like squats, RDLs and lunges are great for restoring overall leg strength, physical therapy after ACL repair should include some resistive leg extensions as well to restore full active range of motion and strong knee extension.

    This additional knee extension strength did in fact have a significant effect with regards to both strength and return to sporting activities.  Adding resistive leg extensions to the rehabilitation program increased quad strength to ~80% of contralateral side at 6 months compared to ~70% in the group that did only CKC exercises, with no increase in ACL laxity. It should be noted that the ACL grafts used were bone tendon bone grafts from the patellar tendon which seems to tolerate earlier strain without stretch than does the hamstring tendon grafts.  Also though the OKC group started leg extensions at 6 weeks, they performed the exercise through only 90 to 40 degrees of knee flexion at first and did not progress to 90-10 degrees until 12 weeks out. Per other research 12 weeks post-op seems to be where hamstring tendon graft ACL repairs can safely tolerate resistive OKC exercise.

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

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

  • Hip Pain: Trochanteric Bursitis Isn’t Bursitis


    Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001 Sep;44(9):2138-45. Bird PA1, Oakley SP, Shnier R, Kirkham BW.

    From the Study

    “All subjects were women (median age 58 years, range 36-75 years). The median duration of symptoms was 12 months (range 12-60 months). MRI findings were as follows: 11 patients (45.8%) had a gluteus medius tear, 15 patients (62.5%) had gluteus medius tendinitis (pure tendinitis in 9 patients and tendinitis with a tear in 6 patients), 2 patients had trochanteric bursal distension, and 1 patient had avascular necrosis of the femoral head. Trendelenburg’s sign was the most accurate of the 3 physical signs in predicting a tendon tear, with a sensitivity of 72.7% and a specificity of 76.9%. Moreover, Trendelenburg’s sign was the most reliable measure, with a calculated intraobserver kappa of 0.676 (95% confidence interval 0.270-1.08).”

     “The results support the hypothesis that gluteus medius tendon pathology is important in defining GTPS. In this series, trochanteric bursal distension was uncommon and did not occur in the absence of gluteus medius pathology. The physical findings suggest that Trendelenburg’s sign is the most sensitive and specific physical sign for the detection of gluteus medius tears, with an acceptable intraobserver reliability. Further delineation with MRI, especially in patients with a positive Trendelenburg’s sign, is recommended prior to any consideration of surgery in this group of patients. Finally, with the pathology of this condition defined, the challenge will be to devise and assess, by randomized controlled trial, an appropriate treatment strategy for this group of patients.”
    “Bursal distension in isolation was not identified in any of the cases reviewed.”

    “Physical therapy may also provide symptom relief, but it is likely that physiotherapy would need to be tailored to strengthen the abductors of the hip and would be preferable to the current techniques of treatment , which includes stretching of the iliotibial band.”[emphasis mine]

    Chad’s comments:

    This is a study that I wish I had read in 2001! Trochanteric bursitis was one of those diagnoses that was easy to make, hip abductor weakness, opposite hip dropping when walking, sharp tenderness with palpation over the side of the hip/greater trochanter, which was and is still frequently referred to physical therapy. The problem was and still is that there were no studies guiding physical therapists with regards to how to treat trochanteric bursitis, or bursitis of any kind, rather just few descriptions of what therapists did. With this a few other similar studies showing that the condition is primarily tendinopathy, I started applying tendinopathy treatment programs which included an emphasis on hip abductor strengthening, just as authors of this study suggested, with remarkably better results than I got from iliotibial band stretches, again, just as the authors suggested.

    Unfortunately I still get regular referrals to treat “trochanteric bursitis” and none for “greater trochanteric pain syndrome” so it takes a while to get the word out. The problem for patients is that improper diagnosis leads to improper treatment and as this study found 45% of patients progressed to the point of having tears of the hip abductor muscles, which are not so easy to treat and can lead to long term disability. The take home message for patients is that if you have been diagnosed with trochanteric bursitis you have probably been diagnosed incorrectly which then becomes a problem if you are treated incorrectly. There is fairly extensive amount of research for tendinopathy/tendinitis on other body parts and that research suggests that RICE (rest, ice, compression, and elevation) various stretches and painful massage does not help much to heal the tendon and restore muscle strength, rather strengthening exercises heals tendons and restores muscle strength.

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

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

  • Low Back Pain: Use of Biopsychosocial Model Does Not Improve Outcomes

    Twenty-five years with the biopsychosocial model of low back pain-is it time to celebrate? A report from the twelfth international forum for primary care research on low back pain. Spine (Phila Pa 1976). 2013 Nov 15;38(24):2118-23.

    From the review:

    “The biopsychosocial model of back pain has become a dominant model in the conceptualization of the etiology and prognosis of back pain, and has led to the development and testing of many interventions. Despite this, back pain remains a leading source of disability worldwide.”

    “Although there is good evidence for the role of biological, psychological, and social factors in the etiology and prognosis of back pain, synthesis of the 3 in research and clinical practice has been suboptimal.”

    “Nevertheless results from trials testing interventions aimed at changing psychological factors have been disappointing, and findings from systematic review of psychological interventions for chronic pain groups show the effects are modest at best.”

    “In taking stock of the current state of knowledge, it seems evident that vast gaps remain in our understanding about the etiology, prognosis, and effective interventions in back pain despite the biopsychological model. In our view, the biopsychosocial model has not failed to explain back pain, what has failed is the mostly restrictive way it has been understood and applied.” [emphasis added]

    Chad’s comments:

    Or maybe the model has failed to explain back pain, and practitioners continued defense of interventions is just post hoc rationalization for psychological techniques that don’t matter.

    This paper was my first introduction to the “biopsychosocial” model of low back pain that was started with Gordon Waddell’s, 1987 paper. I actually thought Gordon’s paper was great for the time and when I read it, and I recall few initial objections. However it seems to me that his concept has been taken too far– with followers who want to overemphasize psychological components of pain having to ignore a great deal of subsequent physiological findings with regards to the causes of spinal degeneration, how those causes can be avoided and what exercises do in fact stabilize the spine. Subsequently a large number of practitioners,  are treating low back pain as primarily a psychological issue, and telling them to continue to work with little in the way of tools to help them avoid further pain. Now after 25 years of doing so, they are having to deal with the fact that their hypothesis (though containing degrees of truth) is not helping  patients lessen low back pain and disability.

    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.

  • Rotation Stretch Increases Low Back Pain and Decreases Spine Stability

    Low back pain development response to sustained trunk axial twisting. Eur Spine J. 2013 Sep;22(9):1972-8.

    From the study:
    METHODS:
    Sixteen male pain-free university students volunteered for this study. The trunk axial twisting was created by a torsion moment of 50 Nm for 10-min duration. The axial rotational creep was estimated by the transverse camera view directly on the top of the head. The visual analog scale in low back area was examined both in the initial and at the end of twisting. Each performed three trials of lumbar flexion-extension with the cycle of 5 s flexion and 5 s extension in standing before and after twisting. Surface electromyography from bilateral erector spinae muscles as well as trunk flexion performance was recorded synchronously in video camera. A one-way ANOVA with repeated measures was used to evaluate the effect of twist.
    RESULTS:
    The results showed that there was a significant (p < 0.001) twist creep with rotational angle 10.5° as well as VAS increase with a mean value 45 mm. The erector spinae was active in a larger angle during flexion as well as extension after trunk axial twisting.
    CONCLUSIONS:
    Sustained trunk axial twisting elicits significant trunk rotational creep. It causes the visual analog scale to have a significant increase, and causes erector spinae muscles to become active longer during anterior flexion as well as extension, which may be linked to the decrease of the tension ability of passive tissues in low back area, indicating a higher risk in developing low back pain.

    Chad’s comments:
    This is a timely study for me as I just evaluated a new patient for low back pain with classic facet syndrome, (pain with extension, pain with side bending left, pain with rotation right, most pain with extension into the left quadrant, no pain whatsoever with flexion or slump tests). I see A LOT of people with low back pain and this is the first patient I had diagnosed with facet joint syndrome in years. Mostly facet joint irritation is secondary to a to degenerative disk disease, resultant from to too much spine flexion causing posterior disc prolapse and loss of disc height. This then brings the facet joints into close approximation with resultant arthritic changes. Only after the degenerative disc disease becomes advanced is spine extension solely provocative. This patient had none of that, and it only made sense when he later noted in passing that spends a fair amount of his work day sitting with his trunk rotated to the right, bingo.

    This study relates in that researchers found trunk rotation sustained at end range just 10 minutes was enough to cause back pain in healthy subjects reaching 45 mm on a 100 mm scale (4.5/10). Trunk rotation afterwards increased a significant 10.5 degrees, which if sustained one would expect to only further increase pain. The study also noted they thought the rotation of the spinal discs increased compression and likely decreased hydration like wringing water from a wash cloth.

    Also interesting from the study was they found erector spinae muscles to be active longer both during flexion and extension after the stretch than before. The researcher thought this was likely due to the rotation stretch decreasing passive structural support and putting them at a higher risk for the onset of developing low back pain. So the take home message is you really should not spend much, if any, time stretching your spine in rotation. Rather if your job or sport requires axial rotation, it’s a lot better if you pivot through your hips and your feet while you exercise to keep your spine strong and stable.

    For the treatment of my patient if I were a follower of Williams I would have him stretch his knees to his chest and suggest he sit with his spine in a flexed posture regardless, unwittingly helping him herniate his lumbar discs. If I were a McKenzie practitioner I would also have him stretch away from the direction that causes pain, so in his case that would still be flexion, along with side bending right and rotation left stretches. I expect this would be entirely unnecessary as a spine does not need to be stretched in extremes of one direction to lessen stress from extremes of the other. Rather you just need to avoid the extremes. So most importantly I’m going to teach him to maintain a neutral spine during his workouts and to eliminate the prolonged spine rotation during his job through ergonomic changes. I’ll apply EMS to his abdominal and lumbar regions to eliminate pain in the short term, but also because there are no active exercises that work the abdominal muscles as well or intensely as EMS. Just as important is what I am not going to do, and that to have him lay on his back and rotate his hips from side to side and tell him it has to feel worse before it gets better.

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

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

  • Low Back Pain: Cyclic and Static Spine Flexion Both Bad for the Back

    Human lumbar spine creep during cyclic and static flexion: creep rate, biomechanics, and facet joint capsule strain. Ann Biomed Eng. 2005 Mar;33(3):391-401.

    From the study:
    Abstract
    There is a high incidence of low back pain (LBP) associated with occupations requiring sustained and/or repetitive lumbar flexion (SLF and RLF, respectively), which cause creep of the viscoelastic tissues. The purpose of this study was to determine the effect of creep on lumbar biomechanics and facet joint capsule (FJC) strain. Specimens were flexed for 10 cycles, to a maximum 10 Nm moment at L5-S1, before, immediately after, and 20 min after a 20-min sustained flexion at the same moment magnitude. The creep rates of SLF and RLF were also measured during each phase and compared to the creep rate predicted by the moment relaxation rate function of the lumbar spine. Both SLF and RLF resulted in significantly increased intervertebral motion, as well as significantly increased FJC strains at the L3-4 to L5-S1 joint levels. These parameters remained increased after the 20-min recovery. Creep during SLF occurred significantly faster than creep during RLF. The moment relaxation rate function was able to accurately predict the creep rate of the lumbar spine at the single moment tested. The data suggest that SLF and RLF result in immediate and residual laxity of the joint and stretch of the FJC, which could increase the potential for LBP.

    Chad’s comments:

    This study is largely confirmation that both sustained and repeated spine flexion decreases passive integrity of the spine. The take home message is that people with low back pain, and people that don’t want low back pain, should not sit prolonged in chairs with no lumbar support, should avoid stooped postures with a flexed spine (rounded back), should not exercise with movements into spine flexion (like situps, crunches, and stiff legged dead lifts) and should avoid stretches into spine flexion (like toe touches, posterior pelvic tilts, and knee to chest stretches). What they should do, and what I generally teach in physical therapy is the maintenance of a neutral spine while sitting with good support from chairs, proper adjustments of seating position while driving, and exercises to increase core and extremity strength all performed with the spine neutral and movement taking place at the hips and shoulders, rather than the waist. Exercises like standing cable rows and presses, mat exercises with a neutral spine, squats and RDLs. If the patient has too much pain for active exercise at first, I will start with electric muscle stimulation not just to the painful region but concurrently throughout the abdominal region which gives a 2 for 1 benefit of immediate pain reduction while improving core strength.

    All of the above  largely complements much of the Stuart McGill research that I am a fan of. However what was new to me was a citation that it is facet joint strain from flexion stretches that most likely contributes to muscle spasms. This agrees with my clinical observation that most often when you correct postures and improve core/hip motor control, strength and endurance, muscle spasms and “trigger points” go away. However if you just massage them or poke them with acupuncture or dry needling you are merely treating the symptom but not the cause, and if a physical therapist gives the patient typical spine flexion exercises like knee to chest and pelvic tilts, you are actively making the patient worse. What’s unfortunate  is that I know a number of “back pain specialists” who still adhere to 1930s based Williams flexion exercises, and 1980s based McKenzie exercises (generally the latter part of his program only) both of which stretch the spine into flexion.

    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.

  • Without Aggressive Rehabilitation Function Usually Diminished 1 Year Post-Op after Total Knee Replacement

    Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects. Physical Therapy. 1998 Mar;78(3):248-58.

    From the study:

    SUBJECTS:
    Twenty-nine individuals 1 year following TKA (13 women, 16 men) and 40 age- and gender-matched control subjects (18 women, 22 men) were assessed.
    METHODS:
    Walking speed, stair-climbing ability, knee torque (in newton-meters), and total work performed during 15 repeated contractions were evaluated.
    RESULTS:
    Walking speeds for men with TKA were 13% and 17% slower at normal and fast speeds, respectively. Their stair-climbing ability was even more compromised (51% slower). Walking speeds for women with TKA were 17% and 18% slower at normal and fast speeds, respectively. Similarly, their stair-climbing time was more compromised (43% slower). Men with TKA were 37% to 39% weaker and performed 36% to 37% less total work of their knee extensors compared with the control subjects. Similarly, women with TKA had knee extensor strength deficits of 28% to 29% and performed 24% less total work.
    CONCLUSION AND DISCUSSION:
    One year after TKA, marked physical impairments and functional limitations persisted. [Walsh M, Woodhouse LJ, Thomas SG, Finch E. Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects.

    Chad’s comments:

    I recently did a blog on a similar study but what I liked better about this older one was the quantification of gait speed and hamstring strength between those who are post-op total knee replacement and age matched normal subjects without knee pathology. The entire article should be read by physical therapists as it is full of great information that should affect how we practice. Normal gait speed of women aged 62 years old was 3.1 mph, but if they were asked to walk fast it was 3.7 mph. For men aged 64, normal gait was 3.4 mph but when walking fast could do 4.1 mph. I test most of my patients on gait speed as it correlates with so well not with knee function but also longevity for a host of reasons (future blog) and 3.7 to 4.1 is pretty fast for any age and a post-op knee replacement should be able to get there. Also of note was the citation that you need to walk 2.68 mph to safely cross an intersection and that 55% of the total knee patients studied had to walk at a faster pace than usual to get there, and a full 17% just weren’t capable even though the subjects in the total knee replacement group women were only 61 years old, and the men 66.

    Also of interest to me was the was the hamstring strength loss of 27% in women and 35% in men which was pretty similar to the 29% and 27% female and male quadriceps strength loss, yet most of the focus on rehabilitation programs and research is on the quadriceps. This includes the abstract of this study that did not mention the profound knee flexor strength loss.  In fact every EMS study I have blogged on, has only put the EMS on the quadriceps, yet strength and conditioning research shows it works, and is complementary with progressive resistance exercise on all muscles. Taken with other studies showing the importance of hip musculature in post-op knee function it is clear that the entire leg needs to be strengthened and it probably wouldn’t be a bad idea address core musculature as well.

    The good news is that this study is 16 years old and total knee replacement surgery has progressed since, then, the procedure is often less invasive, with a faster return of function and quicker resolution of pain. Also since then newer research has been done showing early aggressive rehabilitation is both effective and well tolerated, while EMS technology has become better and less expensive making home use practical. However bad new is regardless of advancements in technology and knowledge, newer studies show not a lot has changed in recent years and deficits usually persist long after total knee replacement. So probably if you are spending valuable therapy time being iced, heated, rolled on a foam cylinder, and massaged with various implements you probably aren’t optimally setting yourself up for success.

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

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

  • EMS Better than TENS for Pain

    Combined neuromuscular electrical stimulation and transcutaneous electrical nerve stimulation for treatment of chronic back pain: a double-blind, repeated measures comparison. Arch Phys Med Rehabil. 1997 Jan;78(1):55-60. Moore SR1, Shurman J.

    INTERVENTIONS:
    Subjects self-administered NMES, combined NMES/TENS, TENS, and placebo treatments. Each treatment had a duration of 5 consecutive hours per day over 2 consecutive days, with a 2-day hiatus between treatments to minimize carryover effects.
    MAIN OUTCOME MEASURES:
    Pain reduction was assessed through pretreatment to posttreatment differences on the Present Pain Intensity (PPI) scale, and a visual analogue scale of Pain Intensity (VAS-I). Posttreatment pain relief was assessed using a visual analogue scale of Pain Relief (VAS-R).
    RESULTS:
    Combined treatment, NMES, and TENS each produced significant pretreatment to posttreatment reductions in pain intensity as measured by both the PPI and VAS-I (p < .05). Combined treatment was superior to placebo on pain reduction (p = .001, p = .016) as well as pain relief (p < .001). Combined treatment was also superior to both TENS and NMES for pain reduction and pain relief (p < .01). NMES and TENS were superior only to placebo for pain relief (p < .001).
    CONCLUSIONS:
    Combined NMES/TENS treatment consistently produced greater pain reduction and pain relief than placebo, TENS, or NMES. NMES alone, although less effective, did produce as much pain relief as TENS. Although preliminary, this pattern of results suggests that combined NMES/TENS may be a valuable adjunct in the management of chronic back pain. Further research investigating the effectiveness of both NMES and combined NMES/TENS seems warranted.

    Select quotes from the article:
    “Research with animals suggests that NMES may reduce pain by stimulation of the release of endogenous analgesics as well as vasoactive substances affecting blood flow and possibly temperature. Its also possible that NMES reduces pain through muscle toning and prevention of disuse atrophy and the muscle degeneration frequently associated with chronic myofascial pain.”
    “Group trends show that TENS was remarkably similar to placebo on every measure except the VAS-R, in addition to being inferior to both combined treatment and NMES on every measure. In contrast trends for NMES were in the direction of greater effectiveness than both placebo and TENS on every dependent measure.

    TENS Parameters used:

    • Waveform: asymmetrical biphasic square wave
    • Duty Cycle: continuous
    • Duration: 5 hour
    • Rate: 100 hz
    • Pulse Duration: 100 mS
    • Intensity: machine max 60 mA, instructed “to an amplitude that produced comfortable tingling sensation”
    • Training Frequency: 5 hours per day for 2 days

    NMES Parameters used:

    • Waveform: symmetrical biphasic
    • Duty Cycle: 5s on 15s off
    • Duration: 10 minutes
    • Rate: 70 Hz
    • Pulse Duration: 200 mS
    • Intensity: 10 mA max, instructed “strong and perceptible, but not painful contractions of the muscle under each electrode”
    • Training Frequency: 3 times in 5 hours with 130 minutes rest between, for 2 days

    Chad’s comments:

    This is a great study that nobody knows about, and every physical therapist should.

    For the record, a lot of practitioners and I use the term “EMS” (electrical muscle stimulation) interchangeably with “NMES” (neuromuscular electrical stimulation), as the same currents used with the purpose of increasing muscle strength, while TENS (transcutaneous electrical nerve stimulation) being used with the intention of decreasing pain.

    The combination group had the greatest reduction in pain, but that isn’t what intrigues me. What I find most interesting (because I find it in my physical therapy office as well) is that EMS currents did a better job at reducing pain than did the TENS currents. The study was only over 2 days, so that is not enough time for muscle strengthening to have an effect in pain, therefore the greater effect of EMS has to be from the current itself. Most proponents of TENS cite gate control theory (which simplified suggests that increasing general sensation to the brain inhibits the brains ability to detect pain) as being a large part of the reason why pain is decreased with TENS. Gate control theory does seem to be holding up as legitimate over time, and what I think EMS does better than TENS is it uses much stronger stimulus. My way of thinking, which works great with my physical therapy patients (whether it be low back pain, neck pain, arthritic pain, or even headaches) is that if you are going to exploit gate control theory to reduce pain, EXPLOIT THE THEORY, which EMS does with overwhelming sensory input with intensities great enough to cause strong muscle contractions. The side with a benefit of EMS being you get a two for one benefit of also increasing strength, which for most people (especially those in pain) is a pretty big benefit.

    Also I shouldn’t ignore the primary finding of this study which was that the combined TENS and EMS was best overall, so I’ll have to think about that and how that can be best implemented in practice. I don’t think that just doing EMS solely to the muscles that hurt is ideal, nor do I think you should just anesthetize the body to pain with strong electrical currents all day long is ideal if doing so allows the patient to continue maladaptive behaviors that will lead to further physical decline. So like many things it is all about balance.

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

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

  • Electric Stimulation Increases Strength and Decreases Pain in Patients with Osteoarthritis

    Neuromuscular electrical stimulation (NMES) reduces structural and functional losses of quadriceps muscle and improves health status in patients with knee osteoarthritis. J Orthop Res. 2013 Apr;31(4):511-6.

    From the study:

    “OA patients presented smaller vastus lateralis thickness (11.9 mm) and fascicle length (20.5%) than healthy subjects (14.1 mm; 24.5%), and also had a 23% smaller knee extensor torque compared to the control group. NMES training increased vastus lateralis thickness (from 12.6 to 14.2 mm) and fascicle length (from 19.6% to 24.6%). Additionally, NMES training increased the knee extensor torque by 8% and reduced joint pain, stiffness, and functional limitation. In conclusion, OA patients have decreased strength, muscle thickness, and fascicle length in the knee extensor musculature compared to control subjects. NMES training appears to offset the changes in quadriceps structure and function, as well as improve the health status in patients with knee OA.”

    “The intervention program promoted a reduction of 38% in joint pain, 29% in joint stiffness, and 34% in functional limitations.”

    Parameters used:

    • Wave form: rectangular biphasic symmetrical
    • Duty Cycle: 10s on 50s off, with lessening rest period over time to 10s on 20s off the last 2 weeks
    • Duration: 18 minutes
    • Rate: 80 Hz
    • Pulse Duration: 400 uS
    • Intensity: maximum comfortably tolerated
    • Electrodes: two 5×13 cm (65 square cm)
    • Training Frequency: 3 x per week for 8 weeks

    Chad’s comments:

    What’s interesting about this study is researchers were not using EMS to recover from surgery as in the recent total knee replacement (TKR) blogs I have done but used it as a stand alone treatment on those with knee osteoarthritis (OA), to see what effect they would get without the replacement. Results were pretty good with regards to increasing strength and function as prior research would suggest, but also interestingly decreasing pain 38%. Which agrees with my observations that EMS type currents work to decrease pain as well or better than TENS type currents, and you get the two for one benefit of improving muscle performance.

    While strength training exercises are generally well tolerated in those with osteoarthritis, and I used them regularly with my physical therapy programs, I do have to closely monitor intensity levels and exercise selection to maximize strength gains and minimize any increases in pain. EMS gives my patients a large boost as I can generally get strong muscle contractions with minimal joint stress while it significantly lessens pain. Also many patients who are seeking physical therapy have muscle inhibition secondary to pain and may not be able to voluntarily contract their muscles hard enough to maximize strength. This combined with the expense of therapy and limitations from insurance plans, does not allow full recovery of function in their allotted number of visits. In such cases,doing EMS at home in addition to and beyond physical therapy helps to maximize functional return. The decrease in pain combined with the increased strength can then lead to greater physical activity and health, which goes a long way towards improving outcomes should the patient require joint replacement later down the road. I was speaking with an orthopedic surgeon yesterday who specializes in partial and total knee replacements and he said a mild to moderately arthritic knee still works better than a replaced knee so if if you can continue to stay and active and live with a little pain, you are better off for it.

    I do want to talk about the treatment parameters of the study. Rate and pulse duration sound good, duty cycle started off 10s on 50 off, which is my go to duty cycle but they progressed it down to 10 on 20 off over coming weeks, which may be better, or may be why the researchers were only able to increase knee torque by 8%, which is on the low side (but could also reflect the fact that these knees are still arthritic). 10s on 50s off 10 times was the favorite of Kots and the old Russian stimulation parameters from which sports conditioning with EMS began. The idea is that being that a long 50s rest gives you enough time to fully recover between contractions so that the muscle can contract maximally with each repetition. Bringing the rest period down to 20 seconds according to Kots, and according to my experience causes a build up of fatigue so that subsequent contractions are weaker. However I notice that each time the contractions weaken, if you have a powerful enough machine you can turn it up and get a stronger contraction, apparently reaching deeper fresher muscle fibers with the increased current. In theory I could see this resulting in still better strengthening but this is still untested as far as I have seen. I think you would really need a randomized controlled trial to tell because as a user you just feel yourself getting fatigued, and it takes weeks to tell if you are getting stronger and even then it is difficult to compare yourself to other duty cycles you have done or could have done due to many confounding variables. So as of yet the science is not there, at least not in English, so some sports conditioning coaches using EMS are varying routines loosely based sports conditioning periodization programs. Interestingly, most of the European preset programs for muscle strength and hypertrophy are using shorter rest periods, and generally shorter contraction times as well, but I have yet to see any research demonstrating them superior to the Kots duty cycle. However, EMS is becoming a fairly hot area of study for sports conditioning and recovery so I would expect some of these answers to emerge sooner rather than later.

    I’ll also comment that this is one reason why I like programmable EMS units, rather than ones that have only  preset programs. Programmable machines allow for endless variety and experimentation and If new research comes out with a new duty cycle, and your EMS unit is programmable, like the EV-906 or the upper level Globus models you can instantaneously program those parameters into your machine and there you go. If your machine only has preset programs you are stuck with them, some are better than others, and a lot of them don’t allow for duty cycles anywhere near the ballpark of what is generally found successful for strengthening.   For example, so far none of the preprogrammed EMS units I have reviewed allow for my, Kots’, and famous track coach Charlie Francis’, preferred 10 on 50 off duty cycle.

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

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

  • Electric Muscle Stimulation Prevents Atrophy after Total Knee Replacement

    Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial. Physical Therapy. 2012 Feb;92(2):210-26. Stevens-Lapsley JE1, Balter JE, Wolfe P, Eckhoff DG, Kohrt WM.

    From the study:

    “Sixty-six patients, aged 50 to 85 years and planning a primary unilateral TKA, were randomly assigned to receive either standard rehabilitation (control) or standard rehabilitation plus NMES applied to the quadriceps muscle (initiated 48 hours after surgery). The NMES was applied twice per day at the maximum tolerable intensity for 15 contractions. Data for muscle strength, functional performance, and self-report measures were obtained before surgery and 3.5, 6.5, 13, 26, and 52 weeks after TKA.”

    “At 3.5 weeks after TKA, significant improvements with NMES were found for quadriceps and hamstring muscle strength, functional performance, and knee extension active range of motion. At 52 weeks, the differences between groups were attenuated, but improvements with NMES were still significant for quadriceps and hamstring muscle strength, functional performance, and some self-report measures.”

    “The addition of NMES treatment to the quadriceps muscles effectively attenuated loss of quadriceps muscle strength and improved functional performance following TKA. Although the effects were most pronounced and clinically meaningful within the first month after surgery, benefits persisted through 1 year after surgery.”

    Parameters used:

    • Machine type: Empi 300PV ( researchers noted it was comparable to the VersaStim 380 but could be used at home)
    • Wave form: biphasic symmetrical
    • Duty Cycle: 15 sec on (including 3 sec ramp) 45 sec off
    • Duration: 15 contractions
    • Rate: 50
    • Pulse Duration: 250 uS
    • Intensity: maximum tolerated (up to 100 mA)
    • Electrodes: Two 7.6 x 12.7 cm (96.52 square cm per pad)
    • Training Frequency: 2 times per day for 6 weeks

    Chad’s comments:

    I think this study has a lot of things worked out. The Empi unit sounds like a quality unit, but it retails for >$900, which I think is overpriced for a 2 channel unit and is more than most patients are going to want to absorb for home use. Also though it is only a 2 channel unit, they still only used one channel. The other channel could have been put on the hamstring muscles, and with a 4 channel unit they could have doubled up on both. What I have noticed and my patients have confirmed is that you can only turn up one channel so much before the contractions become intolerable, but you can add channels at equal intensity which increased muscle fiber recruitment while keeping contractions equal if not more comfortable. Such that in practice I think you may be able to get even better results than what these researchers achieved.

    The researchers did stimulation on the same muscle 2 times per day daily, which while effective they gains of the patients were best in the initial 3 weeks rather than the latter 3 weeks so they may have been overtraining the muscles with the stimulation once patients worked up to higher intensities of stimulation. In most strength training studies they did not find further increases in strength when they trained more than once per day 3-4 times per week, however that was with electric stimulation applied to healthy subjects, not those with muscle inhibition post surgery.  Alternatively, initially post-op is when patients have muscle atrophy, so this time period may be when EMS is more effective by preventing muscle loss in the first place compared to restoring it after it’s gone.  It will be interesting to see what future research shows in this area as it seems very clear that electric stimulation increases strength and improves recovery and we have general guidelines as to parameters that are effective, but as of yet optimal parameters are still unknown.

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

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

  • Physical Therapy after Total Knee Arthoplasty: Neuromuscular Electrical Stimulation Causes a Significant Boost in Quadriceps Strength

    Neuromuscular electrical stimulation for quadriceps muscle strengthening after bilateral total knee arthroplasty: a case series. Journal of Orthopaedic & Sports Physical Therapy. 2004 Jan;34(1):21-9.

    Abstract
    STUDY DESIGN:
    A case series.

    OBJECTIVES:
    The purpose of this case series was to assess the effect of high-intensity neuromuscular electrical stimulation (NMES) on quadriceps strength and voluntary activation following total knee arthroplasty (TKA).

    BACKGROUND:
    Following TKA, patients exhibit long-term weakness of the quadriceps and diminished functional capacity compared to age-matched healthy controls. The pain and swelling that results from surgery may contribute to quadriceps weakness. The use of high-intensity NMES has previously been shown to be effective in quickly restoring quadriceps strength in patients with weakness after surgery.

    METHODS AND MEASURES:
    All patients were treated for 6 weeks, 2 to 3 visits per week, in outpatient rehabilitation. Five patients (NMES group) participated in a voluntary exercise program for both knees and NMES for the weaker knee. Three patients (exercise group) participated in a voluntary exercise program for both knees without NMES. For each treatment session, 10 isometric electrically elicited muscle contractions were administered at maximally tolerated doses to the initially weaker leg of the NMES group. Quadriceps strength and muscle activation were repeatedly assessed up to 6 months after surgery using burst superimposition techniques.

    RESULTS:
    At 6 months, the weak NMES-treated legs of 4 of 5 patients in the NMES group had surpassed the strength of the contralateral leg. In contrast, none of the weak legs in the exercise group were stronger than the contralateral leg at 6 months. Changes in quadriceps muscle activation mirrored the changes exhibited in strength.

    CONCLUSION:
    When NMES was added to a voluntary exercise program, deficits in quadriceps muscle strength and activation resolved quickly after TKA.

    Chad’s comments:

    This study showed some serious results and was a very interesting read, particularly for a study that was done 10 years ago. Parameters used were:

    • Machine type: Versastim 380
    • Wave form: 2500 Hz alternating sinusoidal, 50 bursts per second
    • Duty Cycle: 10s on 80s off
    • Duration: 10 contractions
    • Intensity: maximum tolerated
    • Electrodes: 2 20 cm square placed on quadriceps

    Having the weak leg with EMS surpass the strength of the strong leg is very meaningful with percent increases of the weak EMS leg increasing 221-451% compared to weak leg of the controls (that did exercise only) increasing 41-148%. Research also noted a greater increase in strength with those who tolerated greater intensity of electric stimulation. The exercise program in this study was pretty close to what would be considered “typical” and inferior to more intensive exercise programs. Such that optimal recovery from a total knee replacement should include the best of EMS and exercise programs.  Patients, therapists and physicians should understand that the patient is not just trying to recover strength loss from the surgery but typically from years of disuse due to the the arthritis in the first place.

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

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

  • Physical Therapy and EMS after Total Knee Arthoplasty: More Current = More Muscle

    Relationship between intensity of quadriceps muscle neuromuscular electrical stimulation and strength recovery after total knee arthroplasty. Physical Therapy. 2012 Sep;92(9):1187-96.

    Abstract
    BACKGROUND:
    Neuromuscular electrical stimulation (NMES) can facilitate the recovery of quadriceps muscle strength after total knee arthroplasty (TKA), yet the optimal intensity (dosage) of NMES and its effect on strength after TKA have yet to be determined.

    OBJECTIVE:
    The primary objective of this study was to determine whether the intensity of NMES application was related to the recovery of quadriceps muscle strength early after TKA. A secondary objective was to quantify quadriceps muscle fatigue and activation immediately after NMES to guide decisions about the timing of NMES during rehabilitation sessions.

    DESIGN:
    This study was an observational experimental investigation.

    METHODS:
    Data was collected from 30 people who were 50 to 85 years of age and who received NMES after TKA. These people participated in a randomized controlled trial in which they received either standard rehabilitation or standard rehabilitation plus NMES to the quadriceps muscle to mitigate strength loss. For the NMES intervention group, NMES was applied 2 times per day at the maximal tolerable intensity for 15 contractions beginning 48 hours after surgery over the first 6 weeks after TKA. Neuromuscular electrical stimulation training intensity and quadriceps muscle strength and activation were assessed before surgery and 3.5 and 6.5 weeks after TKA.

    RESULTS:
    At 3.5 weeks, there was a significant association between NMES training intensity and a change in quadriceps muscle strength (R(2)=.68) and activation (R(2)=.22). At 6.5 weeks, NMES training intensity was related to a change in strength (R(2)=.25) but not to a change in activation (R(2)=.00). Furthermore, quadriceps muscle fatigue occurred during NMES sessions at 3.5 and 6.5 weeks, whereas quadriceps muscle activation did not change.

    LIMITATIONS:
    Some participants reached the maximal stimulator output during at least 1 treatment session and might have tolerated more stimulation.

    CONCLUSIONS:
    Higher NMES training intensities were associated with greater quadriceps muscle strength and activation after TKA.

    Chad’s comments:

    This one is simple. More current equals more muscle.

    Researchers used the following parameters:

    • Biphasic symmetrical wave form
    • 50 Hz
    • 15 seconds on (including 3 second ramp up), 45 seconds off
    • 15 contractions per session
    • 250 uS
    • mA as tolerated

    Also the subjects in this study were able to reach higher intensities of current with means of 83.7 mA with some reaching 100 mA, which is approximately double that of the last blog I posted. In part because they were using square wave currents (my favorite) and electrodes used were 96 cm (what I think is about right) vs 20 cm in the last study. Current intensity is difficult to compare however, because pulse durations were different making direct comparisons difficult. With several of their subjects maxing out their machines with at 100 mA with a pulse duration of 250 uS, they could have raised the pulse duration to 300-400 as the EMPI 300PV used in the study has the ability to 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.

  • Electric Muscle Stimulation Well Tolerated by Patients at Sufficient Intensities to Strengthen Muscle after Total Knee Replacement

    Response of male and female subjects after total knee arthroplasty to repeated neuromuscular electrical stimulation of the quadriceps femoris muscle. Am J Phys Med Rehabil. 2010 Jun;89(6):464-72.

    Abstract
    OBJECTIVES:
    To examine responses to repeated neuromuscular electrical stimulation of the quadriceps femoris muscle in male and female subjects after total knee arthroplasty.

    DESIGN:
    Sixty-four subjects who underwent total knee arthroplasty were treated with neuromuscular electrical stimulation two to three times a week for 6 wks in addition to an exercise program. Measures of the quadriceps femoris muscle’s maximal voluntary isometric contraction (MVIC), maximal electrically induced contractions, and current intensity, in response to ten electrically induced contractions per session over 15 treatment sessions, were monitored with an isokinetic dynamometer.

    RESULTS:
    Mean (SD) of maximal electrically induced contractions expressed as percentage of MVIC (%MVIC) was 44.5% (18.2%). Forces of MVIC and maximal electrically induced contractions were significantly stronger in the male subjects. However, there were no gender differences in %MVIC. All force measures increased significantly across time. Male subjects tolerated higher current intensities, with both sexes showing a similar pattern of habituation to current intensity.

    CONCLUSIONS:
    After total knee arthroplasty, most elderly subjects can tolerate neuromuscular electrical stimulation at current intensities sufficient to elicit quadriceps femoris muscle contractions within the therapeutic range recommended for muscle strengthening. Although male subjects can tolerate stronger current intensities, similar %MVIC is activated in female and male subjects with impaired muscle function, indicating a similar potential for treatment effectiveness.

    Chad’s comments:

    This was a study to see if the average post-op total knee arthroplasty patient could tolerate enough electric stimulation intensity to increase muscle strength. They found they could but current intensity reached in the study was less than what I regularly get with my patients and I think there are a number of reasons why.

    Parameters used appear to be older style “Russian stimulation” currents with a 2500 Hz simusoidal alternating wave form, with 50 Hz burst modulation, 10 seconds on and 80 seconds off for 10 contractions. Males worked to an average of 54.8 mA current intensity and females 46.6 mA. They used two electrodes 7.6 cm x 2.7 cm on the quadriceps and trained 2-3 times per week for 6 weeks.

    While they found positive effects I think they could have improved on their results by:

    1. Using a biphasic square wave current with a wide pulse duration such that they could get a stronger muscle contraction with less current intensity.
    2. Using larger area electrodes, so that there is less current density traveling through each part of the skin. Their electrodes were only 20.5 cm square, which is on the small side. The electrodes I use are almost round giving 81 cm square, decreasing current density and increasing comfort substantially.
    3. Using more electrodes, EMS machines with multiple electrodes these days are inexpensive. Less than 4 channels and 8 electrodes seems like a waste. There is little reason to put 2 electrodes on a quadricep when you can fit 4 giving better muscle coverage, and while you are at it put 4 on the hamstrings which can’t be too strong following a knee replacement.
    4. 80 seconds of rest sounds like it is on the long side and while it is still unknown what duty cycle is optimal for increasing muscle strength the 12.5% duty cycle is considerably less than what is being used in the majority of EMS and strength research, and taking such a long rest period between bursts might lessen the patients ability to get used to the stimulus and work up to higher intensity.

    Improving EMS comfort is important because it makes rehabilitation enjoyable rather than drudgery and increasing the comfort of the current means you can get better muscle contractions with the stimulation and subsequently a greater recovery of muscle strength, return of function and less stress on other ailing lower extremity joints.

    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.