Why are Strong Glutes Important?


By Grant Uyemura, DPT Student

What do the glutes do?

The glute is made up of 3 muscles glute maximus, medius, and minimus. The main action of the glute maximus is hip extension and external rotation. The glute medius acts as a hip abductor with anterior fibers assisting internal rotation while the posterior fibers aid in external rotation. The glute minimus is responsible for hip abduction and internal rotation.Why are strong glutes important?

Weak glutes can cause low back/hip pain, iliotibial band syndrome, patellofemoral pain
syndrome, and chronic ankle sprains.

Best exercises for glutes?

According to Distefano et al. they found the best glute medius exercises were side-lying hip abduction and the best glute maximus exercises was the single leg deadlifts and single leg squat. Boren et al. found that a front plank with hip extension was the best glute maximus exercise while a side plank with hip abduction was best for the glute medius. Both studies found that the best overall exercise for glute strengthening was a single leg squat.

img_2534Blog post written by Grant Uyemura, DPT Student from University of St. Augustine. At the time of publishing Grant was in a clinical rotation with me at Catz PTI.

1. Boren K, Conrey C, Le Coguic J, Paprocki L, Voight M, Robinson TK. Electromyographic
analysis of gluteus medius and gluteus maximus during rehabilitation exercises. Int J
Sports Phys Ther. 2011;6(3):206-223.

2. Distefano LJ, Blackburn JT, Marshall SW, Padua DA. Gluteal Muscle Activation During
Common Therapeutic Exercises. J Orthop Sport Phys Ther. 2009;39(7):532-540.
doi:10.2519/jospt.2009.2796.

3. Macadam P, Cronin J, Contreras B. an Examination of the Gluteal Muscle Activity
Associated With Dynamic Hip Abduction and Hip External Rotation Exercise: a Systematic Review. Int J Sports Phys Ther. 2015;10(5):573-591.

What is Femoroacetabular Impingment?

By Grant Uyemura, DPT Student

Femoroacetabular Impingement (FAI) is abnormal contact between the femoral head and acetabulum, which can cause hip pain, labrum, and/or cartilage damage. There are three different types of FAI’s: Cam, Pincer, and mixed. Cam impingement lesions are more prevalent in younger males than in females. Pincer lesions are more common in middle aged, active women.1 A study by Tannast et al. found that 86% of patients have a combination of both cam and pincer impingement.2

Types of FAI

Cam: Aspherical femoral head tries to fit into a spherical socket. Can cause chondrolabral junction separation due to shearing force.

Pincer: Over coverage of acetabulum socket, can cause labrum crushing and degeneration/ ossification.

Mixed: Combination of cam and pincer deformities.
Clinical Presentation

• Anterior or anterolateral hip/groin pain

• Stiffness

• Painful hip flexion past 90º and internal rotation

• Pain with prolonged sitting

What Physical Therapy can do?

The goal of physical therapy is to increase range of motion, increase strength, and decrease pain in order to maximize function and return to your prior level of function. Surgery should only be considered when conservative treatments do not control symptoms or functional limitations are unacceptable.4

 Blog post written by Grant Uyemura, DPT Student from University of St. Augustine. At the time of publishing Grant was in a clinical rotation with me at Catz PTI.

References:

1. ​Kuhns BD, Weber AE, Levy DM, Wuerz TH. The Natural History of Femoroacetabular Impingement. Front Surg. 2015;2(November):1-7. doi:10.3389/fsurg.2015.00058.

2. ​Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement: Radiographic diagnosis – What the radiologist should know. Am J Roentgenol. 2007;188(6):1540-1552. doi:10.2214/AJR.06.0921.

3. ​Stephanie Pun, MD, Deepak Kumar, PT, PhD, and Nancy E. Lane M. Femoroacetabular Impingement. Nih. 2016;67(1):17-27. doi:10.1002/art.38887.Femoroacetabular.

4. ​Enseki K, Harris-Hayes M, White DM, et al. Nonarthritic Hip Joint Pain. J Orthop Sport Phys Ther. 2014;44(6):A1-A32. doi:10.2519/jospt.2014.0302.

 

 

 

Progressive Overload: A Strength Training Model for The Rehab Professional


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By Teddy Wilsey, DPT, CSCS

It is well known that the body must be broken down in order to build up. This is the fundamental principle of exercise: stress adaptation occurs in order to strengthen our bones, condition our cardiovascular system, maintain our joint range of motion, and optimize our muscular function. If you don’t use it, you will lose it. This idea of invoking stress is an area that rehabilitation professionals often fall short in. The physical therapy curriculum is designed to prepare a generalist who can work with all levels of patients including pediatrics, hospital work, and neurological rehab. These are all very important aspects of healthcare, however, the major downfall of a generalized therapist degree is a lack of knowledge in sports rehab and basic strength and conditioning. This article will touch on the need to stress the system in orthopedic rehabilitation and the idea of progressive overload within a linear periodization rehabilitation model.

Performance is a relative term, as the performance ceiling for a 75 year old recovering from a knee replacement is vastly different than that of a college basketball player recovering from an ACL rupture and patellar tendon autograft. Either way, they are both knee injuries and the principles remain the same. Regaining quadriceps strength will be an integral part of both of their programs, and the exercises might be very similar at the beginning phases. As mentioned in the introduction, physiological adaptation and increases in performance require stress to the system. It’s important to understand that stress is relative. An exercise or weight load that might cause stress and elicit strength and gains for the 75 year old would probably not be of the same benefit for the college basketball player. This same weight could even create negative adaptations over time if it is not sufficient to stimulate the system. For example, if a 400 lb. squater is only doing goblet squats with 25 lb., they will actually get weaker while working with you.

The therapist’s job is help their patients increase function. From an orthopedic recovery standpoint, therapists must cause some amount of stress in order to help their patients improve function. Most therapists typically see their patients for 2-6 months at the most, depending on the injury. Although linear progress is not a long term solution to training, it lends itself well to this shorter time period and rehabilitation type of recovery where exercise selection is constantly being progressed. Strength and conditioning periodization models are helpful to understand from a theoretical standpoint, but are typically more complex than we need for therapy. In the simplest of terms: just make sure your patient is doing more than they were two weeks ago.

To examine progressive overload, stress, and a linear model, let’s look at integrating the squat into rehabilitation for both of these patients. Outside of gait, the squat is arguably the most functional movement that exists. Standing up is an essential skill for nearly everyone. To start with the 75 year old patient s/p total knee, their sit to stand would likely begin with an upper extremity assist and a very short range of motion to a high box. Loading the knee will assist in gradually restoring range of motion and alleviating stiffness. Manual therapy, stretching, and other passive modalities can help with managing pain and improving range of motion as well. This patient’s knee will likely be stiff, and the soft tissue structures surrounding the knee may be weak and shortened as well. The typical arthritic knee experiences months to years of progressive weakening and range of motion loss prior to surgery. Rehabilitation prior to surgery should focus on maintaining and regaining full range of motion and improving strength to tolerance.

The first day or two after surgery for these two patients might look very similar. The college basketball player ACL repair will also start a squat with a TRX. After the second or third PT session, the college athlete will require much more challenge to make progress. They might be more comfortable achieving parallel depth sooner, as their tissue was supple prior to surgery. In this patient, there will also be a need to be emphasize slowly increasing the stretch across the patellar tendon. This is due to the patellar tendon autograft. The squat will start with a vertical tibia, and the therapist will gradually cue the patient and modify exercises to allow more dorsiflexion and knee flexion over time in order to rebuild the surgical site and increase patellar loading.

By 6-8 weeks, both of these patients should be squatting with weight. The total knee might be nothing more than 10-20 lb. goblet squat, or it could be up to a 50 or 60 lb. goblet squat, depending on their prior function. The basketball player might be in that 40-60 lb. range for a goblet, or even back squatting 135 lb. or more. Again, this depends on prior strength levels.  Both of these patients should be exposed to similar relative stressors. They should both feel muscular soreness at times. They might both even feel some increased knee soreness during periods of introducing new movements or taking big steps forward. That’s usually OK. The important distinction here is that the stress for a college athlete’s rehab needs to be significantly higher than that of a knee replacement patient in order to evoke adaptation.

Rehabilitation professionals often fall short in is creating enough stress and adaptation for their higher level athletes. The typical outpatient therapist’s caseload is probably only 10-20% athletes, at the most. Hence, the potential blind spot and need for a greater understanding of how to help challenge athletes. The concepts are the same across the board, but there needs to be a greater understanding of the nuances of higher level and more challenging exercise and movement. Remember, without stress and progressive overload, there is very minimal adaptation.

To learn more about how to challenge athletes and what exercises to use, check out my instagram at @strengthcoachtherapy.

Healthy-Baller-Teddy-300x300Dr. Teddy Willsey, DPT, CSCS, is the director of sports medicine at Healthy Baller, a sports performance gym located in Rockville, MD, a suburb of Washington D.C. In addition to his daily practice, Teddy writes, speaks, and posts on social media regularly with the goal of educating therapists, fitness professionals, and recreational exercises on practical approaches to exercise and rehabilitation with a sports medicine and performance focus. Teddy’s work can be found on Instagram: @strengthcoachtherapy

Meniscal Tears & Consideration of PT Instead of Surgery

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By Greg Louie, DPT

The menisci lie between the tibia and femur. They stabilize the knee into flexion and extension, assist in joint lubrication and nutrition, and distribute compressive forces to reduce stress on the articular cartilage with load-bearing and load transmission.(1) Meniscal tears are quite common,the mean annual incidence of meniscal injuries are 66 for every 100,000 individuals.(2)

There are two classifications of meniscal tears: traumatic and degenerative. For a meniscus tear to classified as traumatic, the meniscus must be healthy and there must be an injury to the knee as a result of a forced movement.(3) These types of tears are higher amongst young adults because of an increased percentage of this population participating in high-level activities and sports.(4) A forced twisting movement with the knee bent is the common mechanism of injury for traumatic lesions. Degenerative tears occur in the absence of trauma and result from deterioration of the meniscus from abnormal loading forces to the knee.(3) Individuals with a body mass index greater than 25, those who are older then 60, and those who work in jobs requiring increased kneeling, squatting, and stair climbing are at a significantly higher risk for degenerative meniscal tears.(4)

Meniscus injures are often accompanied by other ligamentous injuries of the knee.(3) A combination of injury to the meniscus, medial collateral ligament, and the anterior cruciate ligament is known as the unhappy triad of the knee.(5)

In the United States, partial meniscectomies are the most common orthopedic surgical procedure(6) but does this mean everyone with a torn meniscus should opt for surgery? Several studies have found that surgery is not always necessary and that physical therapy should be considered prior to surgery. Sihvonon and associates found no difference in partial menisectomy compared to sham surgery.(7) Katz and colleagues found no difference in outcomes with arthroscopic partial meniscectomy combined with physical therapy compared to physical therapy alone.(8) Surgery should be considered as a last resort when all other interventions (including physical therapy) have failed.

A physical therapist will assess the severity of the tear and provide interventions to control the pain, inflammation, and swelling. As the knee beings to heal, they can help you regain full range of motion, get you back walking pain free, and build strength and coordination to prevent reinjury.

Greg Blog post written by Greg Louie, DPT Student from University of St. Augustine. At the time of publishing Greg was in a clinical rotation at Catz PTI. Follow him on Instagram @sportsperformancerehab

References:

1. Makris EA, Hadidi P, Athanasiou KA. The knee meniscus: structure-function, pathophysiology, current repair techniques, and prospects for regeneration. Biomaterials. 2011;32(30):7411-7431.

2. Hede A, Jensen DB, Blyme P, et al. Epidemiology of meniscal lesions in the knee. Acta Orthop Scand. 1990; 61:435–437.

3. http://www.physio-pedia.com/Meniscal_Lesions

4. Snoeker BA, Bakker EW, Kegel CA, Lucas C Risk factors for meniscal tears: a systematic review including meta-analysis. J Orthop Sports Phys Ther 43: 352–367. 2885

5. Sbourne K, Nitz P. The O’Donoghue triad revisited. Combined knee injuries involving anterior cruciate and medial collateral ligament tears. Am J Sports Med. 19(5):474–7.

6. Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008; 359:1108-1115.

7. Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013; 369(26): 2515–24.

8. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013; 368:1675-1684

Rotator Cuff Rehab Management

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By Garrett Holle, DPT Student

The function of the rotator cuff is colossal in the performance of our athletes and everyday individuals.  So much so, in fact, it has formerly been called the kiss of death for the career of overhead athletes.  Rotator cuff injury in sports is climbing in part due to an increased emphasis on strength in college programs. Moreover, in a study of NCAA college football players, rotator cuff injury was the 3rd most commonly reported shoulder injury (1). This high rate of occurrence holds true in the general public as
this study showed that of a random sample, 20.7% of patients had full-thickness rotator cuff tears (3).

As you can see, the ability to treat rotator cuff injuries and treat them well is going to be a valuable skill in your practice. The rehab is not easy, but we can make a huge difference with our patients if we handle them correctly.

How to Avoid a Common Oversight of Rotator Cuff Rehab

When prescribing exercise for the small intrinsic muscles of the cuff, it can be easy to throw the typical 3 sets of 12 to a patient.  However, I think we should reconsider this.  In addition to the typical explanation that every patient is different, there is also physiological evidence that supports this notion. This study explored the fiber composition of the rotator cuff muscles, indicating a mixed composition of fast and slow twitch (2). Although 44% of rotator cuff fibers labeled positively as slow twitch, the remaining fibers lie somewhere on the fast-twitch continuum.

Now if that study is a little too far into the physiology for you, let me make this applicable.

This knowledge of fiber type composition allows us to better determine and prescribe exercise volumes and intensities that satisfy the demands for muscle development. This concept aligns with the strength and conditioning principle of specificity. In the training realm, if you’re working with a sprinter, you’re going to utilize high intensity, low volume and if you’re training an endurance runner, you will use lower intensity with higher volumes. This example applies to training of the rotator cuff as well.

This concept is no nuance in the strength and conditioning realm, and it is a great illustration of how we can successfully begin to close the chasm between our two professions.

Garrett 2 Garrett Holle is a DPT student at the University of Kansas Medical Center. You can find him on all social media platforms @Holle_Per4mance 

References

1. Kaplan, L. D., Flanigan, D. C., Norwig, J., Jost, P., & Bradley, J. (2005). Prevalence and Variance of Shoulder Injuries in Elite Collegiate Football Players. The American Journal of Sports Medicine, 33(8), 1142–1146. https://doi.org/10.1177/0363546505274718

2. Lovering, R. M., & Russ, D. W. (2008). Fiber Type Composition of Cadaveric Human Rotator Cuff Muscles. Journal of Orthopaedic & Sports Physical Therapy, 38(11), 674–680. https://doi.org/10.2519/jospt.2008.2878

3. Yamamoto, A., Takagishi, K., Osawa, T., Yanagawa, T., Nakajima, D., Shitara, H., & Kobayashi, T. (2010). Prevalence and risk factors of a rotator cuff tear in the general population. Journal of Shoulder and Elbow Surgery, 19(1), 116–120. https://doi.org/10.1016/j.jse.2009.04.006

4. Rotator Cuff Image: Henry Vandyke Carter [Public domain], via Wikimedia Commons

 

Groin Strains

groin 2

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By Ashley Pena, DPT

Groin strains make up 8- 18% of all soccer injuries and also occur in many other high intensity sports such as Ice Hockey, Football, Basketball, and more. They are typically found to occur during kicking, cutting, pivoting, changing directions, or when planting the lead foot. In a prospective research study looking at the athletic population, Serner et. al. found that in soccer players, kicking was the most common mechanism of injury at 40%. In other sports, changing directions was the most frequent mechanism at 31%. In addition, Serner found that 66% of these groin strains resulted in injuries to the Adductors (primarily Adductor Longus). Iliopsoas and Proximal Rectus Femoris were also found to be frequently injured with 15-25% of the groin strain participants sustaining these injuries.

Some factors which have been found in past research to be related to an increased risk of groin strains include older age, level of competition or experience, decreased range of hip abduction and rotation, isometric adductor muscle weakness or high abductor/adductor strength ratio, and poor performance in vertical jump tests. Specifically, in a cohort study done by Moreno-Perez et. al. it was found that players with groin injuries showed weaker isometric hip adductor strength and smaller Adductor/Abductor strength ratios than those without groin injuries giving evidence that screening for adductor strength deficits or Add/ Abd. muscle imbalances may be helpful in avoiding groin injuries.

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​❗️Groin Strains❗️ A study by Moreno-Perez et. al. found that athletes with groin injuries showed weaker isometric hip adductor strength and smaller Adductor/Abductor strength ratios than those without groin injuries. 🏈🏀⚽️ Screening for adductor strength deficits or Add/ Abd. muscle imbalances may be helpful in avoiding groin injuries. 🎥🎥🎥 Above are some advanced SL bridge variations that can help with controlling hip Add/Abd & ER/IR control. 💻 Blog Coming 🔜 ❤️💬Share 📚📚📚 Moreno-Pérez et al. Comparisons of hip strength and countermovement jump height in elite tennis players with and without acute history of groin injuries. Musculoskeletal Science and Practice. 2017 🎵.rl

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on

ashleyBlog Post written by Ashley Pena, DPT Student from Cal State Northridge. At the time of publishing, Ashley was in her final clinical rotation with me at Catz PTI.

References:

  1. Elattar O, Choi H-R, Dills VD, Busconi B. Groin Injuries (Athletic Pubalgia) and Return to Play. Sports Health: A Multidisciplinary Approach. 2016;8(4):313-323. doi:10.1177/1941738116653711.
  2. Moreno-Pérez V, Lopez-Valenciano A, Barbado D, Moreside J, Elvira J, Vera-Garcia F. Comparisons of hip strength and countermovement jump height in elite tennis players with and without acute history of groin injuries. Musculoskeletal Science and Practice. 2017;29:144-149. doi:10.1016/j.msksp.2017.04.006.
  3. Serner A, Tol JL, Jomaah N, et al. Diagnosis of Acute Groin Injuries. The American Journal of Sports Medicine. 2015;43(8):1857-1864. doi:10.1177/0363546515585123.
  4. Tyler TF, Silvers HJ, Gerhardt MB, Nicholas SJ. Groin Injuries in Sports Medicine. Sports Health. 2010;2(3):231-236. doi:10.1177/1941738110366820.

Brain Vandalism

brain vandalism

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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. Nick Hannah 2

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.Nick Hannah 3

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).Nick Hannah 4

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.Nick Hannah 5

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.

Nick HannahBlog 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?

 Kinesiophobia
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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

image1
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.

image2
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

ashleyBlog 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

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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

Forward Head Posture


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By Ashley Pena, DPT Student

Although “forward head posture” (FHP) has long been regarded as a problem leading to pain and disability, with increased time spent on smartphones in recent years, it is becoming a very common source of pain. In a study performed by Kim et. al. which studied the effect of duration of smartphone use on muscle fatigue and pain caused by forward head posture in adults using EMG analysis, it was found that prolonged smartphone use resulted in increased upper trapezius and cervical erector spinae fatigue.

As a result of FHP, compensatory motions occur such as severe extension of the upper cervical spine. Often seen in conjunction with FHP, rounded shoulder posture (RSP) occurs when the acromion protrudes anterior to the shoulder joint. Scapular elevation, protraction, and downward rotation are also seen. Several studies have found that this combination of FHP and RSP promote an imbalance in muscle strength and length leading to Janda’s Upper Crossed Syndrome:

  • Weakness of the deep neck flexors, middle and lower trapezius, and serratus anterior
  • Stiffness of the pecs, upper trapezius, levator scapulae, SCM and suboccipitals.

Together, these impairments can lead to dysfunctions at the OA joint, C4/C5 segment,  CT junction, or GH joint resulting in neck and/or shoulder pain and increased disability.

Below is a 3 part video series to help you gain mobility and build postural strength to combat our love affair with cell phones and laptops.

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. Kim E-K, Kim JS. Correlation between rounded shoulder posture, neck disability indices, and degree of forward head posture. Journal of Physical Therapy Science. 2016;28(10):2929-2932. doi:10.1589/jpts.28.2929.
  2. Kim S-Y, Koo S-J. Effect of duration of smartphone use on muscle fatigue and pain caused by forward head posture in adults. Journal of Physical Therapy Science. 2016;28(6):1669-1672. doi:10.1589/jpts.28.1669.
  3. Kwon JW, Son SM, Lee NK. Changes in upper-extremity muscle activities due to head position in subjects with a forward head posture and rounded shoulders. Journal of Physical Therapy Science. 2015;27(6):1739-1742. doi:10.1589/jpts.27.1739.
  4. Upper Crossed Syndrome. Muscle Imbalance Syndromes RSS. http://www.muscleimbalancesyndromes.com/janda-syndromes/upper-crossed-syndrome/. Accessed June 13, 2017.