First Fan Mail!!!

Dear Josh,

First time writer, long time follower. I’ve loved your blog from back in the early 2010’s. Those were wild times. However I have several questions for you in lettered format for easy answer and organization purposes.
1) Is it really necessary to warm up by jogging a bit to get your blood flowing BEFORE you start stretching?
2) I hate warming up before jumping into activities. I don’t start off with heavy weights but I normally do some martial arts routines as a start to warm up. Is that simply enough or would I further just hurt myself?
Thanks for taking time out to read the letter. I hope I don’t owe you money and keep up the good work.

Mike
Pudding Bordello

Hey Mike,

http://www.innocentenglish.com/funny-pics/
lolcats/cute-kitten-loves-mommy.jpg

First off I would like to thank you for reading my blog… I was pretty sure no one was reading until now. Well, except my mommy… she loves me :-). Anyways, let’s talk about your question. This is actually not a straightforward answer. Surprisingly, the evidence in regards to stretching, warm-ups, and injury are mixed. But, I’ll do my best to give you some guidance

The Theory:

For stretching, the theory is simple: make the muscle fibers longer and extensible so they are less likely to tear or cramp during exercise.

For warm-ups, the theory is a bit more involved. There are actually several proposed benefits, but I’ll only describe a few. First, doing a light warm up raises the temperature of muscles and other tissues. Just how putty becomes more pliable with heat, muscles become more extensible, so again, less likely to tear or cramp during exercises. Other benefits include increasing speed of nerve impulses, increasing delivery of oxygen to muscles, and promotion of sweating. All of these benefits can enhance performance as well as reduce chance of injury.

The Application:

The Simpson's: Bart Gets an Elephant

Homer Simpson once said: (In response to Marge not wanting Bart to have an elephant) “Marge, I agree with you… in theory. In theory, communism works. In theory.”

In their wonderfully satirical way, the Simpson’s were making a point when it comes to theory and practical application. There are many human and environmental factors that make it difficult to directly measure if warming up and stretching reduces injury. For example: some people may be prone to injury, or some sports may have high injury rates.

The Research:

In a 2006 systematic review by Fradkin et al., they investigated the results of several studies that looked to see if a “warm-up” routine would reduce the risk of injury. Warm-up, in this study, was actually defined with three factors: aerobic exercise to increase body temperature, sport-specific stretching, and a period of activity with sport-specific movements. Five studies were found that met this criteria as well as other criteria to ensure the studies were of good quality.

Of the five, three found that a warm-up routine reduced the risk of injury. The other two found a warm-up routine to have no benefit compared to control groups (those who did not participate in a warm-up routine). Based on these findings, Fradkin et al. could not make a definite statement that a warm-up routine reduced the risk of injury. It’s basically inconclusive.

Inconclusive??
http://www.hamovhotov.com/fun/wp-content/uploads/2007/10/confused-which-way-to-go.jpg 

Thanks a lot, Fradkin. You’ve wasted my time with reading your confusing systematic review. I could have been eating ice cream and watching a Halloween special of The Simpson’s. I’m completely joking. The study did raise some interesting ideas though.

According to the authors of the study, the three studies that did show a benefit had warm-up routines that stressed aerobic exercise more than stretching. While the two that found no benefit stressed stretching more than aerobic exercise and sport-specific movements.

(*Side note: there were other limitations to the two “no benefit” studies, but I won’t go into detail about that.)

Whoa… looks like I’m starting to make a point here. Although the statements in the previous paragraph were observations by the authors and not actually conclusive evidence, it still supports the idea that short, non-fatiguing aerobic exercise before the main workout helps reduce the chance of injury.

Back to Your Question:

My answer to your question is… Don’t be lazy, warm up!

Enter the Dragon

Okay, so I only looked at one article. Well, technically I looked at three. But, I didn’t feel like talking about three, nor do I want you to go to sleep faster while reading this than you probably have already. But, based on the systematic review by Fradkin et al., you can’t go wrong with doing some light jogging or martial arts before hitting the weights. Assuming you aren’t trying to be Bruce Lee and overdue it on the martial arts, then the warm-up won’t hurt you; it can only help.

In my experience, I notice a difference if I just jump into activity. Old injuries start to become aggravated. My warm-up routine typically consists of stretching first, then some sport-specific movements. I’ll admit I don’t care for jogging beforehand either. But I’m just lazy… remember, I’d rather eat ice cream and watch The Simpson’s.

Mike, I hope this answers your questions. I won’t charge you just because I know you personally, and you probably won’t pay me anyways. Plus, I like your blog. Thanks for reading, and best of luck with your workouts!




Reference and Abstract:


Fradkin AJ, Gabbe BJ, and Cameron PA. Does warming up prevent injury in sport? The evidence from randomised controlled trials? Journal of Science and Medicine in Sport. 2006;9:214-220


Summary
Background: The practice of warming up prior to exercise is advocated in injury prevention programs, but this is based on limited clinical evidence. It is hypothesized that warming up will reduce the number of injuries sustained during physical activity. Methods: A systematic review was undertaken. Relevant studies were identified by searching Medline (1966—April 2005), SPORTDiscus (1966—April 2005) and PubMed (1966—April 2005). This review included randomised controlled trials that investigated the effects of warming up on injury risk. Studies were included only if the subjects were human, and only if they utilised other activities than simply stretching. Studies reported in languages other than English were not included. The quality of included studies was assessed independently by two assessors. Results: Five studies, all of high quality (7—9 (mean = 8) out of 11) reported sufficient data (quality score >7) on the effects of warming up on reducing injury risk in humans. Three of the studies found that performing a warm-up prior to performance significantly reduced the injury risk, and the other two studies found that warming up was not effective in significantly reducing the number of injuries. Conclusions: There is insufficient evidence to endorse or discontinue routine warm-up prior to physical activity to prevent injury among sports participants. However, the weight of evidence is in favour of a decreased risk of injury. Further well-conducted randomised controlled trials are needed to determine the role of warming up prior to exercise in relation to injury prevention.

Your Back Bone is Connected to Your… Shoulder Bone

I randomly watched this video on YouTube recently and it got me thinking about an article I read a few months ago, which investigated new ways to treat shoulder pain by focusing on the spine.

http://www.youtube.com/watch?v=pBOX_YbwT9c

Shoulder Impingement Syndrome (SIS) describes a common injury in which muscles, tendons, or other tissues of the shoulder joint become pinched and inflamed. With impingement comes damage, with damage comes pain, and with all three comes reduced movement, strength, and use of that arm.
 
So why the heck are we talking about the spine if it’s the shoulder that hurts?! Well, I’ll tell ya. The YouTube song linked above is the key. It’s a very old song, with several versions. And while lacking in exact technical terms, it’s actually true.

Uh… duh, Josh.

I know I know. But think about that more deeply for a moment. If two parts of your body are connected, then the actions of one affect the actions of the other. Our spine is connected to our shoulder via muscles and bones, so a dysfunctioning spine can cause a dysfunctioning shoulder.

The Simpson's- Brother From the Same Planet

So now we can get into the research article describing how spinal manipulations can help reduce symptoms of SIS. (*Side note: manipulation basically means cracking joints. Just like cracking your knuckles. It is not bad for you. Well... unless you do it like Homer did to the right.)

The 2008 article by Boyles et al. describes a study they performed on 56 patients to see how their SIS improved with upper spine manipulation. Essentially: the researchers assessed patients to determine if they had SIS, then measured their pain and function, then performed upper spinal manipulations, and finally took values of their pain and function two days later. In short, their findings showed the patients had significantly less pain and improved function two days after upper spine manipulation. Cool!! But wait… there’s a catch. A recurring theme for The Movement Enhancement Project, and research in general, is the evidence is not as clear as it seems. I will explain further why the evidence in this study is muddy.

This study was actually an exploratory study. An exploratory, or preliminary study is a lot like a rough draft. Typically filled with, holes and mistakes, but an important step on the road to a final draft. So what kind of mistakes and holes did this study have?

Well, the most important one to note is there was no control group. Control groups are those people whom nothing happens to during the study. Hypothetically, in this study, a control group would NOT receive spinal manipulation. They would probably wait in the physical therapy office twiddling their thumbs, and then told to go home. That would suck for them. But, in this study, everyone did receive spinal manipulations, so there was no control group, and no one wasted their day in a PT office reading old magazines from last December.

Control groups are important however, because if the group who got spinal manipulations and the group who twiddled their thumbs in the PT office both improved after two days, then that means the spinal manipulations probably did nothing special. Having pain that randomly disappears after a couple days is a common thing.

So what should you take away from this study? Well… I believe this study provides promising rough draft results to the benefits of performing upper spine manipulations to treat SIS. For the person with SIS, this may directly benefit you in the near future. If more studies find strong evidence stating treating the back will benefit the shoulder, then activities like spinal manipulations, back stretches, and back posture education can now be added to you and your therapist’s repertoire of treatment options.

*On a side note: some other recent developments in research state that with manipulation, the body releases pain-relieving chemicals. So even if the manipulation doesn’t fix the back, at least it triggers the body to release drugs to temporarily relieve pain. COOL. Makes sense though; it always feels good after I manipulate my spine and knuckles.

So, swallow those benefits with a few grains of salt, for the reasons I gave above. There are several holes to the study, and in the interest of your time and boredom, I only gave one example. This is the world of research. It is a lot of questioning what you been told. It makes me feel like a kid again. “Mom, what’s that? Mom, where do babies come from? Why mommy? Why? Why? Why? …

I encourage you to read the study for yourself, and find as many holes as you can. It’s heavy on the terminology, but if you find this fun, then you are a nerd, and can join the party with me and the other research geeks. We’ll be watching Star Trek: TOS. Unfortunately, I cannot provide a full text version of the study, as I would likely be infringing on copyrights. But, I will give you the reference information and the abstract below.

Thanks for scanning with CN III and transmitting through CN II. Peace!

Article Reference and Abstract:
Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH, Koppenhaver SL, and Wainner RS. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Therapy. 2009;14:375-380

The study was an exploratory, one group pretest/post-test study, with the objective of investigating the short-term effects of thoracic spine thrust manipulations (TSTMs) on patients with shoulder impingement syndrome (SIS). There is evidence that manual physical therapy that includes TSTM and non-thrust manipulation and exercise is effective for the treatment of patients with SIS. However, the relative contributions of specific manual therapy interventions are not known. To date, no published studies address the short-term effects of TSTM in the treatment of SIS. Fifty-six patients (40 males, 16 females; mean age 31.2+/-8.9) with SIS underwent a standardized shoulder examination, immediately followed by TSTM techniques. Outcomes measured were the Numeric Pain and Rating Scale (NPRS) and the Shoulder Pain and Disability Index (SPADI), all collected at baseline and at a 48-h follow-up period. Additionally, the Global Rating of Change Scale (GRCS) was collected at 48-h follow-up to measure patient perceived change. At 48-h follow-up, the NPRS change scores for Neer impingement sign, Hawkins impingement sign, resisted empty can, resisted external rotation, resisted internal rotation, and active abduction were all statistically significant (p<0.01). The reduction in the SPADI score was also statistically significant (p<0.001) and the mean GRCS score=1.4+/-2.5. In conclusion, TSTM provided a statistically significant decrease in self reported pain measures and disability in patients with SIS at 48-h follow-up.

The Heel of Achilles Affects Mortal Men

The Simpson's episode: "New Kids on the Blecch"

Guess who hurt himself this weekend? That’s right, this guy! You know those people who think they can go out and run a marathon without any training? Well, I’m not quite that crazy, but the mental hospital is not far off the horizon for me. I haven’t ran over 2 miles since high school, and while I’m in pretty good shape thanks to cycling and rowing, running 10 miles is a different story. That’s right, 10 miles. I won’t go into detail about why I did this, or the physical trials I endured. What’s important is I finished, and I did it while sustaining only three injuries! The most painful being plantar fasciitis.

Plantar Fasciitis is also commonly known as heel pain. “Plantar” means bottom of foot, and Fasciitis means inflammation of fascia tissue. Fascia is similar to a tendon, but flat like plastic wrap, and spread out over a larger area. Basically, plantar fasciitis is like a tendonitis on the bottom of your foot, typically focused on the heel. It can be very painful and will limit how much weight you can put through that foot, and how much walking you can tolerate.

Image by A.D.A.M.

There’s a problem with plantar fasciitis, other than the pain and limited function it causes; it’s also not fully understood. There are many possibilities to what causes it, some are clear and some are hazy. An example of a clear cause would be a hard fall onto your heel. Lets say you slipped off a ladder and landed on your heels first. Not a graceful way to land on your feet. Landing normally on the balls of your feet helps to absorb the force of the fall. If you hit the heels first, you’ll take a lot of force through a stiff area of your foot, a recipe for injury.

Let’s go through a hazy cause. Billy’s car has transmission problems and will be in the shop for a few weeks… he’ll probably be broke afterward. So Billy has to walk to the bus stop a half mile away so he can take the bus to work. Well, that’s a one-mile round trip walk everyday. After a week of this, he starts to get heel pain. What’s the cause? Well, your first thought is probably the extra walking he is doing. Correct! … Partially.

Yes, the foot pain timed well with the extra walking, but one mile a day really isn’t that far to walk. Humans are made to walk long distances. Some other causes to think about are: type of shoes he wears, his weight, the way he walks, or his age. All of these can decrease the tolerance to walk one extra mile a day. I remember in undergrad walking a mile a day for a few weeks in dress shoes, and developed a nasty corn on my big toe. I know, a great image to throw in here. The corn is gone now; my feet are beautiful again.

So, my latest article read deals with possible causes of plantar fasciitis. This article by Irving et al. is actually a systematic review. This type of article provides strong evidence, since they compare information from multiple articles on the same topic. It’s similar to when you buy a car and review different sources, like Consumer Reports or Auto Trader, to help you find the best car. Since there are hundreds of articles related to plantar fasciitis, they have to weed out the crappy ones. I won’t go into detail the process they use to select articles to review, but it’s fairly rigorous.

The higher up the pyramid, the stronger the evidence. Filtered info means they weeded out the unimportant articles.

So what did they find out? Well in short they found that increased weight in non-athletic populations, increased age, decreased ankle and big toe motion, prolonged standing, and bone spurs on the heel all show some association with plantar fasciitis (*Remember that I said ‘association’, this will be important later).

The Breakdown:

1. Increased weight in non-athletic populations is pretty self-explanatory. Extra weight means more stress on your heels. Athletes may be able to get away with it because they have stronger bones or muscles to support their heels.

2. Increased age is also somewhat self-explanatory. The body in old age just does not withstand stress or heal as well as the body of a young individual. Sucks, huh?

http://sports.jrank.org/article_images/sports.jrank.org/dorsiflexion.1.jpg

3. Decreased ankle and big toe motion is a tricky concept. The specific motion is called dorsiflexion. You dorsiflex your ankle when you raise your foot to the sky while keeping the heel on the ground. Just like tapping your foot when listening to music. Dorsiflexion of your big toe is similar; just raise that piggy up off the ground toward the sky. Essentially, if you have poor flexibility in this motion for the ankle and big toe, it can cause excess stress on the heel (I can describe in detail but it would likely take another long blog to do it).

4. Prolonged standing is also somewhat self-explanatory. Standing is low stress on the heel, falling off a ladder is high stress on the heel. Low stress, over a long time can still cause injury.

5. Bone spurs don’t always cause problems. But, if they grow too big, or into sensitive tissues, then that’s when they make your life troublesome. Bone spurs on the heel are the same way; therefore, not everyone with bone spurs on the heel has plantar fasciitis.

The Catch:

*Side Note: Correlation is very similar to association, but both are different from causation.

Remember that word ‘association’? Association is different from cause. Try as they could, Irving et al. only found articles that could find associations instead of causes. Basically, that means the five factors above are commonly seen with plantar fasciitis, but they do not necessarily cause it. For example: increased weight could have caused plantar fasciitis, or the pain from plantar fasciitis caused Bob to walk less and gain more weight. The studies did not address this Chicken or Egg conundrum.

So the point of this?? To screw with your mind… jk. Yes, the four factors listed above are associated with plantar fasciitis, but it has yet to be determined if one causes the other. But, 3 out of 5 can be controlled. Loosing weight, increasing ankle/big toe dorsiflexion, and avoiding excessive periods of standing are common treatments physical therapists give patients with plantar fasciitis.

Well, I’m off to treat my plantar fasciitis. Got to increase my ankle dorsiflexion and stop aging. I left an abstract below for you to reference. It is heavy on the terminology, but if you’re a PT then it shouldn’t be too bad.

Thanks for scanning with CN III and transmitting through CN II. Peace!

Article Reference and Abstract
Irving DB, Cook JL, and Menz HB. Factors associated with chronic plantar heel pain: a systematic review. Journal of Science and Medicine in Sport. 2006;9:11-22

Chronic plantar heel pain (CPHP) is one of the most common soft tissue disorders of the foot, yet its aetiology is poorly understood. The purpose of this systematic review was to examine the association between CPHP and the various aetiological factors reported in the literature. Seven electronic databases and the reference lists of key articles were searched in August 2005. The resulting list of articles was assessed by two independent reviewers according to pre-determined selection criteria and a final list of articles for review was created. The methodological quality of the included articles was assessed and the evidence presented in each of the articles was descriptively analysed. From the 16 included articles, body mass index in a non-athletic population and the presence of calcaneal spur were the two factors found to have an association with CPHP. Increased weight in a non athletic population, increased age, decreased ankle dorsiflexion, decreased first metatarsophalangeal joint extension and prolonged standing all demonstrated some evidence of an association with CPHP. Evidence for static foot posture and dynamic foot motion was inconclusive and height, weight and BMI in an athletic population were not associated with CPHP. The findings of this review should be used to guide the focus of prospective cohort studies, the results of which would ultimately provide a list of risk factors for CPHP. Such a list is essential in the development of new and improved preventative and treatment strategies for CPHP.