As a project for my physical therapy program, my group members and I created a warm-up and stretching video for coaches of the Special Olympics of Massachusetts to use during their training. This is a draft and will likely be changed prior to it's completion later this week.
Enjoy!
Sunday, May 1, 2011
Monday, January 17, 2011
Patellofemoral Syndrome Is Not Just For Brazilian Volleyball Goddesses.
When you hear the word “Brazil”, what is the first thing that comes to mind?
Well… what about physical therapy?
… Of course not, neither did I. Why would we when we have those exotic things listed above to distract? But the article I’m about to discuss comes from a group of physical therapy researchers in Brazil who decided to study a particular treatment option for a very common type of knee injury.
There are many names for it: Runner’s Knee, Osteoarthritis, Retro-patellar pain, Chondromalacia, Patellofemoral Syndrome or Patellofemoral Pain Syndrome (PFPS). For convenience we will refer to the injury as PFPS, since that is the terminology used by the article. It is essentially a form of arthritis that develops on the backside of your patella.
PFPS is most commonly associated with athletic females in sports that require a lot repetitive knee bending, such as, volleyball or long distance running. Now, I don’t know about the other male therapist out there, but working with the Brazilian Women’s National Volleyball team would be awesome! And, I’m sure female therapist would love to work with the men’s team too. I mean come on… these people kick butt in volleyball on a worldwide scale, and… they’re hot!
But, alas, this article isn’t about athletes. While PFPS is common amongst athletes, there are still plenty of occurrences in the sedentary population. Fukuda et al. performed a randomized control trial on the effect of hip abduction and lateral rotation exercises on reducing pain and improving function in people with PFPS.
*For those unfamiliar with the terminology: Hip abduction would be keeping your leg straight and lifting it out to the side, away from your opposite leg. Hip lateral rotation would be keeping your leg straight and rotating it on your heel so your foot and knee both move outward.
They divided 70 females into three different groups. The control group had 25 subjects and received no treatment; they were just told to resume their normal daily activity. The Knee Exercise group (KE) had 22 subjects and they were given stretching and strengthening exercises that focused on the knee only. The third group, Knee and Hip Exercise group (KHE), had 23 subjects and they were given stretching and strengthening exercises for the knee and hip. See Table 1 and 2 below for a complete list of exercises.
The study was performed over the course of 4 weeks, with measurements taken before exercises were given, and at the end of the 4-week treatment period. The measurements included: Lower Extremity Functional Scale (LEFS), Anterior Knee Pain Scale (AKPS), single-limb single hop test, and pain while ascending/descending stairs as recorded on an 11-point numerical pain rating scale (NPRS). The LEFS and the AKPS are questionnaires that subjects fill out to help quantify how their injury affects them throughout the day.
So, lets take a look back at the two exercise groups in Table 1 and 2. If you’ll notice, the KHE group has the same exercises as the KE group, plus a few more. These additional exercises are pretty basic to strengthening muscles that perform hip abduction and lateral rotation.
Now, you may be asking, “How does strengthening hip abduction and lateral rotation going to help my PFPS?” Well… try this first:
- Do a push-up. Either on your knees or on your toes (Girl vs. Guy push-ups).
- Now, get ready to do another push-up. Your fingers should be pointing forward.
- Turn your hands inward so your fingers are pointing towards your opposite shoulder.
- If you’re not too uncomfortable holding this position, try a push-up again.
I don’t know about you, but doing push-ups this way hurts my shoulder and elbow. I DO NOT recommend you try it this way in the future.
It’s all about body mechanics. When we squat down, our knees and toes should point forward, or maybe slightly outward (lateral rotation). Many researchers have found, biomechanically, that people with PFPS may be medially rotating their hip (turning their knee inward) as they squat down or ascend/descend stairs. It's similar to having you do that crazy push-up I described above. In the case of your knee, it places awkward stresses on your patella, which over time can cause early degeneration of the cartilage underneath your patella and early arthritis. By strengthening the muscles that perform hip abduction and lateral rotation, hopefully that tendency to medially rotate is reduced.
So what did they find between the three groups in this study?
Well… as expected, the KE and KHE groups both improved significantly at the end of the 4 weeks, while the control group did not. When looking at the changes in LEFS, AKPS, and single-limb single hop test, both KE and KHE groups were equally as affective. But, when looking at changes in NPRS, only the KHE group had significant decreases in pain while ascending/descending stairs.
In addition, the KHE group showed a minimum clinically important difference in all outcome measures, while the KE demonstrated this only in LEFS.
*Minimum Clinically Important Difference (MCID) is the smallest improvement that would be beneficial to a patient. Hypothetical example: imagine you take a medicine to make your nose 25% less congested when you are sick. This is considered a significant improvement in drug development. But come to find out, even at 25% less congested, you still can’t breathe well. That medicine did not provide an acceptable MCID.
The Takeaway Message:
Strengthening hip abductors and lateral rotators may help reduce/prevent PFPS. No definite conclusions can be drawn from one study, but it does show promise. One thing to keep in mind is they only strengthened muscles in this study; they did not address correcting the subject’s movement mechanics. It’s analogous to having someone strengthen muscles in their back, but not learning how to assume and maintain a good upright posture. In my opinion, strengthening is a supplement to teaching good mechanics and posture.
Thanks for reading. I’ll let you guys know when I make it down to Brazil and start working with their women’s volleyball team. My 2012 goal: Going to London with 6-foot tall beautiful women and taking the Gold!
Reference:
Fukuda TY, Rossetto FM, Magalhaes E, Bryk FF, Lucareli P, and Carvalho N. Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: A randomized controlled clinical trial. JOSPT. 2010;40(11):736-742.
Abstract:
STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To investigate the influence of strengthening the hip abductor and lateral rotator musculature on pain and function of females with patellofemoral pain syndrome (PFPS). BACKGROUND: Hip muscle weakness in women athletes has been the focus of many recent studies and is suggested as an important impairment to address in the conservative treatment of women with PFPS. However, it is still not well established if strengthening these muscles is associated with clinical improvement in pain and function in sedentary females with PFPS. METHODS: Seventy females (average ± SD age, 25 ± 07 years), with a diagnosis of unilateral PFPS, were distributed randomly into 3 groups: 22 females in the knee exercise group, who received a conventional treatment that emphasized stretching and strengthening of the knee musculature; 23 females in the knee and hip exercise group, who performed exercises to strengthen the hip abductors and external rotators in addition to the same exercises performed by those in the knee exercise group; and of the 25 females who did not receive any treatment. The females of the nontreatment group (control) were instructed to maintain their normal daily activities. An 11-point numerical pain rating scale (NPRS) was used to assess pain during stair ascent and descent. The lower extremity functional scale (LEFS) and the anterior knee pain scale (AKPS) were used to assess function. The single-limb single hop test was also used as a functional outcome to measure preintervention and 4-week postintervention function. RESULTS: The 3 groups were homogeneous prior to treatment in respect to demographic, pain, and functional scales data. Both the knee exercise and the knee and hip exercise groups showed significant improvement in the LEFS, the AKPS, and the NPRS, when compared to the control group (p<.05 and p<.001, respectively). But, when we considered minimal clinically important differences, only the knee and hip exercise group demonstrated mean improvements in AKPS and pain scores that were large enough to be clinically meaningful. For the single-limb single hop test, both groups receiving an intervention showed greater improvement than the control group, but there was no difference between the 2 interventions (p>.05). CONCLUSION: Rehabilitation programs focusing on knee strengthening exercises and knee strengthening exercises supplemented by hip strengthening exercises were both effective in improving function and reducing pain in sedentary women with PFPS. Improvements of pain and function were greater for the group that performed the hip strengthening exercises, but the difference was significant only for pain rating while descending stairs.
Beautiful women? Exquisite beaches?
 |
| http://brazil4tour.com/wp-content/uploads/2009/04/florianopolis_beach-wow.jpg |
Christ the Redeemer statue? The Amazon?
 |
| Getty Image taken from: http://www.treehugger.com/amazon-jungle-permits.jpg |
Soccer gods?
Well… what about physical therapy?
… Of course not, neither did I. Why would we when we have those exotic things listed above to distract? But the article I’m about to discuss comes from a group of physical therapy researchers in Brazil who decided to study a particular treatment option for a very common type of knee injury.
There are many names for it: Runner’s Knee, Osteoarthritis, Retro-patellar pain, Chondromalacia, Patellofemoral Syndrome or Patellofemoral Pain Syndrome (PFPS). For convenience we will refer to the injury as PFPS, since that is the terminology used by the article. It is essentially a form of arthritis that develops on the backside of your patella.
PFPS is most commonly associated with athletic females in sports that require a lot repetitive knee bending, such as, volleyball or long distance running. Now, I don’t know about the other male therapist out there, but working with the Brazilian Women’s National Volleyball team would be awesome! And, I’m sure female therapist would love to work with the men’s team too. I mean come on… these people kick butt in volleyball on a worldwide scale, and… they’re hot!
 |
| http://blog.casinobeach.com/images/brazil-beach-volleyball.jpg |
But, alas, this article isn’t about athletes. While PFPS is common amongst athletes, there are still plenty of occurrences in the sedentary population. Fukuda et al. performed a randomized control trial on the effect of hip abduction and lateral rotation exercises on reducing pain and improving function in people with PFPS.
 |
| Hip Abduction |
*For those unfamiliar with the terminology: Hip abduction would be keeping your leg straight and lifting it out to the side, away from your opposite leg. Hip lateral rotation would be keeping your leg straight and rotating it on your heel so your foot and knee both move outward.
They divided 70 females into three different groups. The control group had 25 subjects and received no treatment; they were just told to resume their normal daily activity. The Knee Exercise group (KE) had 22 subjects and they were given stretching and strengthening exercises that focused on the knee only. The third group, Knee and Hip Exercise group (KHE), had 23 subjects and they were given stretching and strengthening exercises for the knee and hip. See Table 1 and 2 below for a complete list of exercises.
 |
| Taken from Fukuda et al. |
The study was performed over the course of 4 weeks, with measurements taken before exercises were given, and at the end of the 4-week treatment period. The measurements included: Lower Extremity Functional Scale (LEFS), Anterior Knee Pain Scale (AKPS), single-limb single hop test, and pain while ascending/descending stairs as recorded on an 11-point numerical pain rating scale (NPRS). The LEFS and the AKPS are questionnaires that subjects fill out to help quantify how their injury affects them throughout the day.
So, lets take a look back at the two exercise groups in Table 1 and 2. If you’ll notice, the KHE group has the same exercises as the KE group, plus a few more. These additional exercises are pretty basic to strengthening muscles that perform hip abduction and lateral rotation.
Now, you may be asking, “How does strengthening hip abduction and lateral rotation going to help my PFPS?” Well… try this first:
- Do a push-up. Either on your knees or on your toes (Girl vs. Guy push-ups).
- Now, get ready to do another push-up. Your fingers should be pointing forward.
- Turn your hands inward so your fingers are pointing towards your opposite shoulder.
- If you’re not too uncomfortable holding this position, try a push-up again.
 |
| Builds muscle. |
 |
| Builds hospital bills. |
I don’t know about you, but doing push-ups this way hurts my shoulder and elbow. I DO NOT recommend you try it this way in the future.
It’s all about body mechanics. When we squat down, our knees and toes should point forward, or maybe slightly outward (lateral rotation). Many researchers have found, biomechanically, that people with PFPS may be medially rotating their hip (turning their knee inward) as they squat down or ascend/descend stairs. It's similar to having you do that crazy push-up I described above. In the case of your knee, it places awkward stresses on your patella, which over time can cause early degeneration of the cartilage underneath your patella and early arthritis. By strengthening the muscles that perform hip abduction and lateral rotation, hopefully that tendency to medially rotate is reduced.
So what did they find between the three groups in this study?
Well… as expected, the KE and KHE groups both improved significantly at the end of the 4 weeks, while the control group did not. When looking at the changes in LEFS, AKPS, and single-limb single hop test, both KE and KHE groups were equally as affective. But, when looking at changes in NPRS, only the KHE group had significant decreases in pain while ascending/descending stairs.
In addition, the KHE group showed a minimum clinically important difference in all outcome measures, while the KE demonstrated this only in LEFS.
*Minimum Clinically Important Difference (MCID) is the smallest improvement that would be beneficial to a patient. Hypothetical example: imagine you take a medicine to make your nose 25% less congested when you are sick. This is considered a significant improvement in drug development. But come to find out, even at 25% less congested, you still can’t breathe well. That medicine did not provide an acceptable MCID.
The Takeaway Message:
Strengthening hip abductors and lateral rotators may help reduce/prevent PFPS. No definite conclusions can be drawn from one study, but it does show promise. One thing to keep in mind is they only strengthened muscles in this study; they did not address correcting the subject’s movement mechanics. It’s analogous to having someone strengthen muscles in their back, but not learning how to assume and maintain a good upright posture. In my opinion, strengthening is a supplement to teaching good mechanics and posture.
Thanks for reading. I’ll let you guys know when I make it down to Brazil and start working with their women’s volleyball team. My 2012 goal: Going to London with 6-foot tall beautiful women and taking the Gold!
 |
| http://www.beijingolympicsfan.com/wp-content/uploads/2008/08/img214579742.jpg |
Reference:
Fukuda TY, Rossetto FM, Magalhaes E, Bryk FF, Lucareli P, and Carvalho N. Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: A randomized controlled clinical trial. JOSPT. 2010;40(11):736-742.
Abstract:
STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To investigate the influence of strengthening the hip abductor and lateral rotator musculature on pain and function of females with patellofemoral pain syndrome (PFPS). BACKGROUND: Hip muscle weakness in women athletes has been the focus of many recent studies and is suggested as an important impairment to address in the conservative treatment of women with PFPS. However, it is still not well established if strengthening these muscles is associated with clinical improvement in pain and function in sedentary females with PFPS. METHODS: Seventy females (average ± SD age, 25 ± 07 years), with a diagnosis of unilateral PFPS, were distributed randomly into 3 groups: 22 females in the knee exercise group, who received a conventional treatment that emphasized stretching and strengthening of the knee musculature; 23 females in the knee and hip exercise group, who performed exercises to strengthen the hip abductors and external rotators in addition to the same exercises performed by those in the knee exercise group; and of the 25 females who did not receive any treatment. The females of the nontreatment group (control) were instructed to maintain their normal daily activities. An 11-point numerical pain rating scale (NPRS) was used to assess pain during stair ascent and descent. The lower extremity functional scale (LEFS) and the anterior knee pain scale (AKPS) were used to assess function. The single-limb single hop test was also used as a functional outcome to measure preintervention and 4-week postintervention function. RESULTS: The 3 groups were homogeneous prior to treatment in respect to demographic, pain, and functional scales data. Both the knee exercise and the knee and hip exercise groups showed significant improvement in the LEFS, the AKPS, and the NPRS, when compared to the control group (p<.05 and p<.001, respectively). But, when we considered minimal clinically important differences, only the knee and hip exercise group demonstrated mean improvements in AKPS and pain scores that were large enough to be clinically meaningful. For the single-limb single hop test, both groups receiving an intervention showed greater improvement than the control group, but there was no difference between the 2 interventions (p>.05). CONCLUSION: Rehabilitation programs focusing on knee strengthening exercises and knee strengthening exercises supplemented by hip strengthening exercises were both effective in improving function and reducing pain in sedentary women with PFPS. Improvements of pain and function were greater for the group that performed the hip strengthening exercises, but the difference was significant only for pain rating while descending stairs.
Tuesday, December 7, 2010
Shame On Me
Season's Greetings, Faithful Readers!!
So, I have not been doing my job. It's been well over a month since my last post. But, don't worry... I've already begun punishing myself: I've had a few trips to Taco Bell, and I've botched a couple dates (probably because I took them to Taco Bell).
But don't worry, I will get back to making posts very soon (i.e. after Dec 20th). I've gotten a couple fan mail questions, and I want to do a Christmas related posts. So look for that soon!
Enjoy your eggnog!
So, I have not been doing my job. It's been well over a month since my last post. But, don't worry... I've already begun punishing myself: I've had a few trips to Taco Bell, and I've botched a couple dates (probably because I took them to Taco Bell).
But don't worry, I will get back to making posts very soon (i.e. after Dec 20th). I've gotten a couple fan mail questions, and I want to do a Christmas related posts. So look for that soon!
Enjoy your eggnog!
Tuesday, September 28, 2010
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,
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:
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.
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!
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.
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 |
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.
Sunday, September 12, 2010
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.
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.
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 |
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.
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.
Tuesday, September 7, 2010
The Heel of Achilles Affects Mortal Men
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| The Simpson's episode: "New Kids on the Blecch" |
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.
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| 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.
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.
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| 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?
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| http://sports.jrank.org/article_images/sports.jrank.org/dorsiflexion.1.jpg |
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:
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| *Side Note: Correlation is very similar to association, but both are different from causation. |
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.
Thursday, August 12, 2010
Welcome to The Movement Enhancement Project!!
Well, it’s come to this. Joining the millions out there writing away furiously about something substantially important to them. I have never been interested in writing. In fact, my SAT and GRE scores in writing and language have hovered around the 30-percentile range. Regardless, part of why I’m doing this is because I feel like there is a need for bridging the gap of Physical Therapy and the average person.
Most people have an idea of who physical therapists are and what they do.
- Darn, my shoulder kills me when I reach overhead… see a PT.
- Ouch, I tweaked my back… see a PT.
- This wheelchair cushion is uncomfortable… see a PT (asap, pressure sores are no joke).
- Crap, this cerebrovascular attack has given me ataxia, and right sided partial paralysis with a right foot-drop… see a PT.
That last example probably wouldn’t be uttered in quite those words by a patient, but you get the idea. Physical therapist work in a wide range of fields related to movement disorders and physical rehabilitation. Many people already know this; some have more insight than others. However, I’m not yapping away with this blog to talk about what we do. Instead I’m here to shed some light on research developments in the field of physical therapy.
Essentially, this blog will be for both the average person, AND physical therapists. If I do my job well, then I will present information on research articles in a language appropriate for PT’s, but also understandable and engaging to Joe Blow. Whoa! Seems like a challenge for mister 30-percentile SAT man here. I’m not saying it won’t be challenging. But, I’m not doing this out of selflessness. Because I, Mr. 30-percentile, want to eventually design and conduct research studies, this blog will help me to work on my writing skills and expand my knowledge of current research. Apparently doing research isn’t all number crunching, inductive reasoning, and theorizing. You also have to up your game in the language and writing department… who’d a thunk it??
Ok, that’s nice… research and everything. But, why should I read this blog? Well, Mr. Average Person, unfortunately information like this isn’t easily accessible through Google news or Yahoo news. I know because I skim through both news sites regularly. Most of what is published relates to the Health Care Reform Bill, West Nile Virus, E. coli, or some other internal medicine related topic. I am in no way deemphasizing the importance of these issues. I believe topics such as health care and social security should be understood by all Americans. I’m not too crazy about West Nile and Bird Flu stories, but that’s a topic for someone else’s blog. Anywho, most of the information I will present tends to fall under radar for various reasons. But what’s important is these may directly relate to physical activities you do everyday.
Deciding between two new pairs of gym shoes. Walking down stairs. Lifting up heavy grocery bags. Shoveling after a heavy snowstorm. Running on a treadmill or running outside. Neck brace or no neck brace. Wheelchair accessories to help with playing basketball.
The list goes on… hopefully it does, or doing all this for two weeks’ worth of blog entries would be silly. Short of hanging out with the most scholarly physical therapist on a regular basis, much of this research-based info is not easily accessible. Besides, I doubt such a therapist exist, there is a lot of information out there. Again, I am doing this to help broaden my knowledge on current research, so I’ll be learning with you. What better way to learn, than to teach someone else? Right? It’s slightly cliché, but it’s true.
So, this will be my introductory entry (duh), and I plan to make entries at least 2-3 times a month. I am a student finishing my last year of PT school, so I’ll use that as an excuse to not do more.
Thanks for scanning this page with CN III, and transmitting these words through CN II (Your oculomotor and optic nerves. Respectively controlling eye movement and relaying visual signals to the brain.).
Peace.
Most people have an idea of who physical therapists are and what they do.
- Darn, my shoulder kills me when I reach overhead… see a PT.
- Ouch, I tweaked my back… see a PT.
 |
| http://denvercoloradochiropractic.com/blog/wp-content/uploads/2009/06/back-pain1.jpg |
- Crap, this cerebrovascular attack has given me ataxia, and right sided partial paralysis with a right foot-drop… see a PT.
That last example probably wouldn’t be uttered in quite those words by a patient, but you get the idea. Physical therapist work in a wide range of fields related to movement disorders and physical rehabilitation. Many people already know this; some have more insight than others. However, I’m not yapping away with this blog to talk about what we do. Instead I’m here to shed some light on research developments in the field of physical therapy.
Essentially, this blog will be for both the average person, AND physical therapists. If I do my job well, then I will present information on research articles in a language appropriate for PT’s, but also understandable and engaging to Joe Blow. Whoa! Seems like a challenge for mister 30-percentile SAT man here. I’m not saying it won’t be challenging. But, I’m not doing this out of selflessness. Because I, Mr. 30-percentile, want to eventually design and conduct research studies, this blog will help me to work on my writing skills and expand my knowledge of current research. Apparently doing research isn’t all number crunching, inductive reasoning, and theorizing. You also have to up your game in the language and writing department… who’d a thunk it??
 |
| http://fc.bullis.org/~faith_Darling/FOV2-0001D744/S01105998-01105998.0/PieChartCartoon.gif |
Ok, that’s nice… research and everything. But, why should I read this blog? Well, Mr. Average Person, unfortunately information like this isn’t easily accessible through Google news or Yahoo news. I know because I skim through both news sites regularly. Most of what is published relates to the Health Care Reform Bill, West Nile Virus, E. coli, or some other internal medicine related topic. I am in no way deemphasizing the importance of these issues. I believe topics such as health care and social security should be understood by all Americans. I’m not too crazy about West Nile and Bird Flu stories, but that’s a topic for someone else’s blog. Anywho, most of the information I will present tends to fall under radar for various reasons. But what’s important is these may directly relate to physical activities you do everyday.
Deciding between two new pairs of gym shoes. Walking down stairs. Lifting up heavy grocery bags. Shoveling after a heavy snowstorm. Running on a treadmill or running outside. Neck brace or no neck brace. Wheelchair accessories to help with playing basketball.
 |
| Photo Courtesy of Corey Glynn |
The list goes on… hopefully it does, or doing all this for two weeks’ worth of blog entries would be silly. Short of hanging out with the most scholarly physical therapist on a regular basis, much of this research-based info is not easily accessible. Besides, I doubt such a therapist exist, there is a lot of information out there. Again, I am doing this to help broaden my knowledge on current research, so I’ll be learning with you. What better way to learn, than to teach someone else? Right? It’s slightly cliché, but it’s true.
So, this will be my introductory entry (duh), and I plan to make entries at least 2-3 times a month. I am a student finishing my last year of PT school, so I’ll use that as an excuse to not do more.
Thanks for scanning this page with CN III, and transmitting these words through CN II (Your oculomotor and optic nerves. Respectively controlling eye movement and relaying visual signals to the brain.).
Peace.
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