Plyometric Shoulder Training

By Kathleen Hank, DPT

Both upper extremity and lower extremity plyometric exercises are used for rehabilitation or performance enhancement. The concept of plyometrics is used as part of functional movement patterns when performing a sport.  Plyometric training uses the physiological phenomenon of a stretch-shortening cycle to enhance the ability of the neuromuscular system to produce maximal force in the shortest amount of time possible. (1)

Plyometric exercises are high-velocity movements that pre-stretch muscles through eccentric contractions, briefly store elastic energy, and then release kinetic energy to produce a powerful concentric contraction.(2)  During overhead sports, the shoulder must accept high joint loads generated by the lower extremity and trunk and efficiently transfer that energy to the upper extremity.(2)  

The term amortization is used to describe the time from the end of the eccentric pre-stretch to the onset of the concentric action.(3) This phase is key to the performance of plyometrics. Plyometric movement is more effective and powerful with a shorter amortization time because the stored energy is used efficiently during transition.(3)

Potential Training Benefits of Plyometric Exercises:

-increased average power and velocity

-increased peak force and velocity of acceleration

-increased time for force development

-increased levels of muscle activation

-evokes stretch reflexes

-improved neural efficiency

-improved proprioception

-increased neuromuscular performance

Training programs should be individualized to each athlete and his or her sport to develop the best motor performance pattern through neuromuscular dynamic stability.(3) Plyometric training for the upper extremity should coincide with other resistance and flexibility training. Plyometric exercises can be performed in both closed and open kinetic chain positions of the upper extremity.

Examples of plyometric exercises for the shoulder complex:

-two hand chest pass

-two hand rotations from side

-two hand overhead throw

-one hand side arm throw

-90°/90° baseball throw

-eccentric deceleration followed by trunk rotation and concentric tosses

Blog Post written by Kathleen Hank, DPT.  At the time of publishing Kathleen was in her Sports Ortho Clinical with me at Catz Physical Therapy.

References:

1. Gjinovci B, Idrizovic K, Uljevic O, Sekulic D. Plyometric training improves sprinting, jumping and throwing capacities of high level female volleyball players better than skill-based conditioning. J Sports Sci Med. 2017;16:527-535.
2. Swanik KA, Thomas SJ, Struminger AH, Bliven KCH, Kelly JD, Swanik CB. The effect of shoulder plyometric training on amortization time and upper-extremity kinematics. J Sport Rehabil. 2016;25(4):315-323. doi:10.1123/jsr.2015-0005
3. Davies G, Riemann BL, Manske R. Current concepts of plyometric exercise. Int J Sports Phys Ther. 2015;10(6):760-786.

Brain Vandalism

   

By Nick Hannah, PT

I need to begin this blog by emphasizing a very important fact about your body: YOUR JOINTS ARE INHERENTLY STRONG AND STABLE! In the absence of rare circumstances like severe traumas (i.e. joint dislocations) and certain genetic disorders that can physically make your joints ‘loosey-goosey,’ the joints making up your body simply won’t go out of place from day-to-day activities.

However, there are times you could swear they really WERE out of place. Joints and body parts can feel shifted, “off,” “out-of-sorts,” wonky—sometimes as if they were no longer a part of you. These kinds of perceptions are NORMAL and many feel this way. Weird right? So how can it be that your joints FEEL out of place when in reality they’re rock solid? Let’s find out. 

Within your brain different cell groups build a DETAILED map of your body—a helpful analogy is to think of this body map in the brain like a detailed painting (every nook, cranny and unique aspect of your body is represented and accounted for). This means that certain brain areas control the movements and feelings of certain body parts. It’s more complicated than this but that’s the gist of it.

When we have pain in a certain body area (i.e. a hip), our body painting changes—that once crisp, clear image of the hip in the brain gets smudged. The actual brain tissue changes: we call this neuroplasticity. If the pain persists long enough, the brain’s representation of the hip gets even more distorted—the smudging grows and spreads to surrounding body parts of your painting (your once beautiful work of art is under ruin).

With time, this brain ‘vandalism’ alters how you perceive and control movement of the hip & surrounding body parts. THIS is why you feel weird, out of place, and ‘off.’ It also accounts for why pain spreads, and it can happen to any body part.

Side note: these changes aren’t unique to pain. Ask any seasonal golfer what their VERY first swing feels like after many ‘golf-less’ months in the winter—it feels weird! More smudging at work here.

So how do you improve your ‘brain vandalism’?

• First, find yourself a good physiotherapist (or another health professional—I’m biased of course). Education is paramount here: you must understand that the strategies adopted early on and meant to protect you—like fear avoidance, limiting painful movement, rest etc.—are now creating maladaptive changes in the brain and actually making things worse.
• Second, slowly but surely re-expose the painful body part to the normal movements and activities it once performed. This is called graded exposure—and the starting point for everyone will be different. In this way you start to re-trace what was smudged, and begin the process of re-painting the body part as represented in the brain.

Stop thinking you’re out of place. You might FEEL like it, but now you know why.

As always. Don’t sit still. Make moves.

Blog post written by Nick Hannah, PT.  Nick is the winner of the Blog Post Competition I challenged my Instagram followers with this July.  You can find Nick on Instagram @hannahmoves.

What is Kinesiophobia?

 

   

By Ashley Pena, DPT Student

Patients with re-occurring injuries that become chronic conditions such as chronic low back pain or chronic ankle sprains can be a challenge for medical professionals for many reasons. Risk factors for the array of chronic conditions have been studied and identified. However, one problem in this population that is less frequently discussed is that of Kinesiophobia. Kinesiophobia (KPB), or Fear Avoidance Beliefs, are defined as “excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury.”8 While this may sound like an extraordinary occurrence, these beliefs to some degree are often a factor in chronic conditions.

To summarize, KPB can be broken down into “Harmful factors” (HF) which reflect the patient’s belief that something is seriously wrong with the body; and “Activity avoidance factors” (AAF) which represent the belief that avoiding exercise/activity will prevent an increase in pain. These beliefs generally lead to a vicious cycle involving an avoidance of movement or any activities that might cause pain or reinjury (see Figure above). Over time, the inactivity that stems from this fear leads to physical consequences such as muscle atrophy, loss of spinal range of motion, and psychological consequences. Psychological consequences include reduced calibration to painful stimuli and behavioral changes. This in turn can affect patient prognosis and healing times.10

Figure 2

The physiological and psychological changes that occur in chronic pain conditions are well- studied and is described in David Butler’s “Explain Pain.”1 Essentially, your body adapts to what is being sent it’s way, so if pain or “danger” messages keep being sent to the brain, the sensory neurons become more sensitive to incoming excitatory chemicals, the sensors stay open longer, eventually more sensors are produced and neuronal sprouting can occur. Another change which occurs in the brain is homunculus “smudging”. With this occurrence, the area of the cerebral cortex which is devoted to sensation and representation of the involved body part becomes larger, with less distinct outlines and overlaps with surrounding areas of the cortex. All of these things can contribute to perpetuating pain.

Figure 3

The good news: many of these changes are reversible. As depicted below, after injury the body has a new tissue tolerance level (Figure 2). The key to combating this over-sensitivity is pacing and graded exposure (Figure 3). Finding a Baseline tolerance to a task which you can perform without a flare up is essential, since your body will alert you of the need to stop at the “New Protect By Pain” line (Figure 2). By exercising just below the “Flare Up” line one can begin to slowly make changes in their tolerance and eventually resume to their original Tissue Tolerance.1

Blog Post written by Ashley Pena, DPT Student from Cal State Northridge. Ashley is currently in her final clinical rotation with me at Catz PTI.

References:

1. Butler DS, Moseley GL. Explain pain. Adelaide: Noigroup Publications; 2015
2. Crombez G, Vlaeyen JWS, Goubert L. Muscle Pain, Fear-Avoidance Model. Encyclopedia of Pain 2013:1963–1966. doi:10.1007/978-3-642-28753-4_2531.
3. Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 1999;80(1):329–339. doi:10.1016/s0304-3959(98)00229-2.
4. Feitosa AS, Lopes JB, Bonfa E, Halpern AS. A prospective study predicting the outcome of chronic low back pain and physical therapy: the role of fear-avoidance beliefs and extraspinal pain. Revista Brasileira de Reumatologia (English Edition) 2016. doi:10.1016/j.rbre.2016.03.002.
5. Guclu DG, Guclu O, Ozaner A, Senormanci O, Konkan R. The relationship between disability, quality of life and fear- avoidance beliefs in patients with chronic low back pain. Turkish Neurosurgery . 2012. doi:10.5137/1019-5149.jtn.6156-12.1.
6. Heymans MW, Ford JJ, McMeeken JM, Chan A, de Vet HC, van Mechelen W. Exploring the contribution of patient-reported and clinician based variables for the prediction of low back work status. Journal of Occupational Rehabilitation 2007; 17(): 383-397. doi:10.1007/s10926-007-9084-1.
7. Lethem J, Slade P, Troup J, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception—I. Behaviour Research and Therapy 1983;21(4):401–408. doi:10.1016/0005-7967(83)90009-8.
8. Neblett R, Hartzell M, Mayer T, Bradford E, Gatchel R. Establishing clinically meaningful severity levels for the Tampa Scale for Kinesiophobia (TSK-13). Eur J Pain European Journal of Pain 2015;20(5):1–10. doi:10.1002/ejp.795.
9. Peña A, Plotkin L, Eagle M, Riehl J, Mathiyakom W. American Physical Therapy Association: Combined Sections Meeting. In: San Antonio; 2017.
10. Vlaeyen JW, Kole-Snijders AM, Boeren RG, Eek HV. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 1995;62(3):363–372.

BFR & Post-op ACL

   

One of the biggest challenges in ACL rehab is regaining adequate strength in the surgical leg. Even at 1 year post-op, many patients still demonstrate significant strength deficits compared to the non-surgical leg. Traditional early post-op ACL rehab consists of ROM, swelling control, gait training, muscle activation and proprioceptive exercises. Unfortunately the leg continues to atrophy and remain in a state of anabolic resistance caused by the trauma of the surgery and subsequent relative or literal immobilization. Early post-op treatments and exercises, while necessary, do very little to help the muscles hypertrophy. The ACSM recommends that in order for hypertrophy to occur, resistance training needs to be loaded at 70% of 1RM. While in the early stages of rehab, loads in that range are unrealistic and potentially dangerous.

Blood Flow Restriction Therapy can be introduced as early as a few days post-op and can also help stop anabolic resistance by initiating protein synthesis, which leads to muscle hypertrophy even at loads of 30% of 1RM and lower. This is possible because the tourniquet creates a hypoxic environment which forces the recruitment of type 2 muscle fibers, even though the load is more appropriate for type 1. Type 1 muscle fibers require oxygen and are important for endurance and low load exercises. While exercising under BFR the stored oxygen becomes depleted and the remaining reps are carried out by type 2 muscle fibers. Type 2 muscle fibers are responsible for speed and power and their byproduct is lactate. The cuff not only restricts the venous return flow, it also holds the lactate in the limb which initiates a systemic response that causes the pituitary gland to release Growth Hormone.  Growth hormone is responsible for collagen synthesis which is how muscle, tendon, ligament, cartilage and bone heal.

Equipment

Tourniquets are considered medical devices and their use needs to be monitored, there are inherent dangers to improper use of tourniquets. Currently a few types of BFR tourniquet systems and wraps are available and present on social media, but only one is FDA approved as a medical device. The Delfi Personal Tourniquet System contains a Doppler that can accurately measure the amount of blood flow restriction and can adjust for pressure changes during exercise. The Delfi System comes with 3 cuff sizes, each one is wide and tapered for comfort and safety. When deciding to incorporate BFR into your rehab, look for a certified provider on the Owens Recovery Science website.

Treatment Session

A typical treatment session will usually consist of 3-5 different exercises.  Each exercise will be performed for 75 reps broken down into 4 sets.  1 set of 30 reps and 3 sets of 15 reps.  There is a 30 second rest period between sets with the cuff inflated.  The cuff will be deflated for at least 1 minute between exercises.  You can expect to see swelling, color change and muscle fatigue after each treatment.  Because loads are very low there is no muscle breakdown and little to no subsequent DOMS.

For more information visit  OwensRecoveryScience.com

Lateral Ankle Sprains

    

By Michael Joseph, DPT Student

Ankle sprains are a common injury; in the United States there is an incidence rate of 2.15 ankle sprains per 1000 people every year. Nearly half of all ankle sprains (49.3%) occurred during athletic activity, with basketball (41.1%), football (9.3%), and soccer (7.9%) being associated with the highest percentage of ankle sprains during athletics.

This article will focus on lateral ankle sprains, which occur as a result of excessive ankle inversion, when the foot rolls inwards under the leg. The three lateral ligaments that may be affected are the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. Ankle sprains are divided into three categories: Grade I, where the ligament is stretched and may have slight tears. Grade II where the ligament is partially torn. And Grade III where the ligament is completely torn.

Management:

The PRICE (Protection, Rest, Ice, Compression, Elevation) protocol is an important part of treatment during the acute phase, as it is an effective method for reducing pain and inflammation. However, combining PRICE with exercise may be more beneficial. A randomized controlled trial from Bleakley, et al. evaluated the effectiveness of accelerated rehab after an ankle sprain. One group of subjects followed the PRICE protocol for the first week after injury and then began exercise rehab during the following four weeks. The experimental group began the PRICE protocol and exercise rehab immediately, during the first week post injury, and then followed the same 4 week exercise rehab. The authors stated the early exercises were from a “general protocol” that included ankle range of motion and strengthening exercises. The study found short term outcomes (4 weeks) were significantly better in the group that began exercising immediately, but there was no significant difference in long term outcomes (16 weeks).

 Rehabilitation and Prevention:

There is some evidence to support that taping and/or bracing is effective at reducing the risk of recurrent ankle sprains in sports. However, the decision between tape or bracing depends on the individual and the requirements of the sport. There is no evidence that one is significantly more effective than the other.

Kerkhoffs et al, identified four intrinsic risk factors that predispose individuals to lateral ankle sprains: strength, proprioception, range of motion, and balance. A rehab exercise protocol should address all four of these risk factors in order to prepare the athlete to return to sport and to prevent recurring sprains. Proprioception exercises should be sport specific and should focus on the demands of the sport. For example, a basketball player’s program needs to include takeoff and landing ankle mechanics in an square stance (jump shot) and off of one leg (lay up).

Blog Post written by Michael Joseph, DPT Student at Mount Saint Mary’s University. Michael is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources:

1. Bleakley CM, O’connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964.
2. Kerkhoffs GM, Van den bekerom M, Elders LA, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012;46(12):854-60.
3. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):2279-84.

Straight Bar Deadlifts vs. Hex Bar Deadlifts

By Michael Joseph, DPT Student

The deadlift is one of the most effective and widely used exercises to build raw strength. There are many variations of the deadlift, including conventional deadlifts, sumo deadlifts, stiff leg deadlifts, Romanian deadlifts, and the popular hex bar deadlift (HBD). As opposed to a straight bar deadlift (SBD), where the bar is sitting in front of the body, this bar allows the lifter to stand within a hexagon-shaped frame and lift the weight from the ground. But, what is the difference between a straight bar and a hex bar? And why would you use one instead of the other?

Research

In a study by Swinton et al, a group of competitive powerlifters were recruited to compare the biomechanical differences between the SBD and HDB. Subjects tested their 1 rep max and submaximal lifts on both bars. 3-D motion analysis was used to measure body position and velocity and acceleration of the bar. The study found the powerlifters were able to lift an average of 45 lbs. more using the hex bar, compared to the straight bar. In addition, across submaximal loads deadlifts using the hex bar produced greater peak force, peak velocity, and peak power compared to the straight bar. This suggests that the HBD is a more effective exercise due to the greater mechanical stimulus produced during submaximal loads. 

A follow up study was done by Camara et al, comparing electromyography, force, velocity, and power characteristics between the two bars. Surface EMGs were placed on the vastus lateralis (quadriceps), biceps femoris (hamstrings), and erector spinae (low back) muscles. Force, velocity, and power were measured by attaching a velocity transducer to the barbells. This study also measured subjects’ 1 rep max and submaximal loads. EMG results found greater quadriceps activation during the HBD, but greater hamstrings and low back activation during the SBD. However, there was not a significant difference in the 1 rep max lifts. This study also confirmed higher peak velocity, peak force, and peak power with the HBD than the straight bar deadlift.

Clinical Application

Both studies confirm the SBD puts greater stress on the hamstrings and low back, while the HBD distributes loads more equally, putting greater stress on the quads. For individuals with low back pain or who are rehabilitating a low back injury, using a hex bar to deadlift may be a safer alternative to using a straight bar. Similarly, for a patient who may not be ready to perform a loaded squat, the HBD may be used as an effective alternative to strengthen the quadriceps.  

Both studies also agree that the HBD produced greater peak force, velocity, acceleration, and power. This suggests the HBD is a better exercise for overall strength training. The HBD may be a more beneficial deadlift variation than the SBD for athletes because it is more effective for improving overall strength, while putting them at less risk of a low back injury. So when should the SBD be used for patients and athletes? If the goal is to strengthen hamstrings and low back extensors specifically, the SBD will be more effective. Similarly, if the SBD is specific to the athlete’s sport, (for example, powerlifting or CrossFit) training the SBD may be more beneficial.

Blog Post written by Michael Joseph, DPT Student at Mount Saint Mary’s University.  Michael is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

References

1. Swinton PA, Stewart A, Agouris I, Keogh JW, Lloyd R. A biomechanical analysis of straight and hexagonal barbell deadlifts using submaximal loads. J Strength Cond Res. 2011;25(7):2000-9.
2. Camara KD, Coburn JW, Dunnick DD, Brown LE, Galpin AJ, Costa PB. An Examination of Muscle Activation and Power Characteristics While Performing the Deadlift Exercise With Straight and Hexagonal Barbells. J Strength Cond Res. 2016;30(5):1183-8.

Movement of the Week: Med Ball Pitching Step Up

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*Blog Post (link in bio)* Building strength in the stride leg of a pitcher is essential for developing a stable balanced support as the arm and body aggressively enter the acceleration and deceleration phases of throwing. #CatzPT #AGatCatz #PhysicalTherapy #PhysicalTherapist #Physio #PhysioTherapy #dptstudent #ptstudent #sportsmed #sportsmedicine #cscs #strengthtraining #fitness #pasadena #sportsrehab #catzpasadena #athleticgaines #armcare #baseball #baseballtraining #pitching #pitchingdrills

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Feb 22, 2017 at 6:52am PST

Building strength in the stride leg of a pitcher is essential for developing a stable balanced support as the arm and body aggressively enter the acceleration and deceleration phases of throwing.  The arm reaches its highest velocity and greatest range of motion during these two phases, so it’s critical for the pitcher to land on a solid, stable base.  This is a task specific a drill that can be added to a traditional strength training routine for building stride leg strength while rotating and weight shifting  from back to front and right to left.

Patellar Dislocation Surgery: Alison

 I sustained a Grade 2 MCL sprain on my left knee while playing a collegiate spring game in my freshman year. I found out that the recovery time would take about 3 months, and though it was a difficult time, I knew I would be back in time to compete for the fall season. As the therapy progressed and I got stronger, I was cleared to come back to play a few games to see what I was capable of doing. Unfortunately, on my first day back I ended up dislocating my left knee cap. Finding out that my injury would now take an additional 6 months to recover was devastating. This means I would have to sit out my sophomore year of soccer. After my knee operation, with the guidance from Chris, the Catz staff, and my Athletic Trainers at Cal Poly Pomona, I was able to stay positive and comeback both mentally and physically stronger than before. The help of Chris’ unique humor made me enjoy the journey back, and his therapy techniques helped push me to discover my limits. I am grateful to have Chris as my physical therapist and am excited to be competing at the collegiate level again!

-Alison Kung