Evolution Sports Physiotherapy Blog

Running and Injury Prevention

Tue, 11 May 2021 18:05:22 GMT

Running is one of the most common and popular methods of fitness in the world, with many cities and communities taking part in establishment of running events from 5k to marathon level and above, to smaller running cohorts, and for social events. However, while running has a high link to overall improved cardiovascular wellbeing, it is also one of the most injury prone athletic populations in world with injury incidence of up to 80%! Fortunately, there are many strategies to help combat and prevent running related injuries for any skill level.

TRAIN APPROPRIATELY!

As with any other sport, training for the specific demands of running can greatly reduce the risk of injury. The World Health Organization (WHO) recommends a minimum of 150 minutes of moderate-intensity aerobic physical activity or 75 minutes of vigorous-intensity physical activity throughout the week, based on strong evidence of health benefits and reductions upon mortality rates. While many factors influence risk of injury, there are a few significant ones for any running athlete:

Type of exercise
Find the aerobic exercise that you are passionate about! However, limiting yourself to the same route and same type of run could increase your risk for injury. Cross training with other modes of exercise including strength training or different types of runs could help reduce risk of chronic and acute injury!
Exercise frequency and progression
Novice runners may benefit from having more days of recovery, especially in the beginning. However, knowing when to progress overall speed, distance, or number of training days can be tricky! Remembering to increase only one variable at a time can help mitigate risk of injury.
Exercise intensity and duration
Having trouble with determining how intense your run is? Heart rate is an excellent measure of overall cardiovascular output.
An easy calculation for determining your Heart Rate maximum is: 220-age
As stated prior, recommended minimums for health benefits are 150-300 minutes of moderate intensity, or 75-150 minutes of vigorous intensity per week that typically are broken up into 3-5 days during the week. However, do not let these recommendations deter you from running if you cannot reach them!
Calculate using % of Maximum Heart rate, Moderate intensity for aerobic exercise 60-75% of your calculated Heart Rate max; vigorous intensity 75-90% of maximum Heart Rate

Equipment Matters!

In a recent systematic review of 15 studies there was moderate to strong evidence of higher injury prevalence with persons who had sustained a previous injury, as well as the use of orthotics and the same pair of running shoes for longer than 4-6 months. While there are many different brands and trends within the running shoe and orthotic industry, it is important to note that finding the right pair of shoes for you may take time! Additionally, according to a study on use of multiple shoes during training, results found that there was a 39% decrease in running related injuries over a 22-week period when athletes used at least one more pair of running shoes during the week.

Rehab potential

80% of all running injuries are result of overuse or chronic pathology, which may be a result from overtraining or limited tissue adaptations from the amount of load produced on the body during activity. Different types or locations of injury require methods of individualized rehabilitation, and the therapy experts at Evolution Sports Physiotherapy are well versed in the appropriate rehabilitation and progression of any running related injuries. So, whether you are a seasoned runner looking for a full evaluation of running form, or a beginner working towards your first 5K, our approach towards integration of best available evidence within clinical practice and dedication to patient care provides our patients with optimal rehabilitation potential.

If you or anyone you know has suffered a running related injury, please contact us via phone at 410-628-0520 or email at chris.mooney@evolutionsportspt.com. We look forward to answering any of your questions and assisting with all of your rehab needs!

References

1. Kozlovskaia M, Vlahovich N, Rathbone E, Manzanero S, Keogh J, Hughes DC. A profile of health, lifestyle and training habits of 4720 Australian recreational runners-The case for promoting running for health benefits. Health Promot J Austr. 2019 Apr;30(2):172-179.

2. van der Worp MP, ten Haaf DS, van Cingel R, de Wijer A, Nijhuis-van der Sanden MW, Staal JB. Injuries in runners; a systematic review on risk factors and sex differences. PLoS One. 2015;10(2):e0114937. Published 2015 Feb 23

3. Francis P, Whatman C, Sheerin K, Hume P, Johnson MI. The Proportion of Lower Limb Running Injuries by Gender, Anatomical Location and Specific Pathology: A Systematic Review. J Sports Sci Med. 2019;18(1):21-31. Published 2019 Feb 11

4. Malisoux L, Ramesh J, Mann R, Seil R, Urhausen A, Theisen D. Can parallel use of different running shoes decrease running-related injury risk?. Scand J Med Sci Sports. 2015;25(1):110-115.

Ultrasound Guided Dry Needling for Tendinopathies

Tue, 11 Aug 2020 18:18:17 GMT

Musculoskeletal diagnostic ultrasound imaging is one of the many state of the art technologies that we have here at Evolution Sports Physiotherapy. Ultrasound imaging can be used to look at different tissues in the body including, but not limited to tendons, ligaments, bursa, nerves, and muscles. Some advantages of ultrasound over other types of imaging modalities such as an MRI and X-rays are the ability to complete dynamic imaging, to easily compare side to side, its portability, and lower cost. Musculoskeletal diagnostic ultrasound is effective is visualizing tendinopathy, tendon/ligament tears, bursitis, synovitis, joint erosions, calcifications, muscle tears, loose bodies, foreign bodies and nerve entrapment/subluxation. This blog post will focus on how to use musculoskeletal diagnostic ultrasound to identify tendinopathy as well as the use of ultrasound to guide dry needling to treat tendinopathy.

The three key findings on ultrasound that serve to identify tendinopathy are increased cellularity, neovascularization, and disrupted fibers. Increased cellularity is defined as thickening of the tendon and a mix of hyper and hypo echoic tissue on the image where as a healthy tendon would be all hyperechoic. A healthy tendon does not get much blood flow, so when neovascularization (formation of new blood vessels) is seen in the tendon, this is indicative of tendinopathy. A healthy tendon also has very linear fibers so that when the fiber orientation is not as linear or disrupted, it can indicate tendinopathy. In the picture below on the left, you can see a healthy biceps tendon and the picture on the right show biceps tendinopathy.

Diagnostic ultrasound is not only beneficial to identify tendinopathy, but also provides another way to track progress over time. Decreased thickening, decreased neovascularization, and increased hyperechoic texture are all improvements that can be seen and objectively measured through ultrasound imaging. This can help us as Physical Therapists in determining how to progress treatment as well as safely returning someone back into more rigorous physical activity.

There are many different ways to treat tendinopathy including activity modification, strengthening, and bracing, but we will focus on how dry needling can help in the resolution of tendinopathy and its associated pain. In dry needling, a needle is used to penetrate the affected tendon, which creates local bleeding and inflammation to disrupt the chronic degeneration and kick-start the healing process. The research shows that individuals with tendinopathy have significant reductions in pain following this procedure and is a quick and easy treatment with no reported adverse outcomes.

There is even greater evidence supporting the use of ultrasound to guide dry needling treatments. Using ultrasound to visualize the needle has been shown to significantly improve the accuracy of the user to target the affected area compared to relying solely on palpation and anatomical landmarks. As a result, this can improve outcomes related to pain and function, as the affected area is consistently getting the treatment that is needed.

Here at Evolution Sports, our goal is to get patients back to a pain free and fulfilling life. We are able to integrate the latest research and implement it into clinical practice by utilizing ultrasound and dry needling. It is one of the many ways that sets us apart from other clinics and proves that we are dedicated in giving each patient the best care possible.

References

1. Daley EL, Bajaj S, Bisson LJ, Cole BJ. Improving injection accuracy of the elbow, knee, and shoulder: does injection site and imaging make a difference? A systematic review. Am J Sports Med. 2011;39(3):656-662. doi:10.1177/0363546510390610

2. Finnoff JT, Hall MM, Adams E, et al. American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine. PM R. 2015;7(2):151-68.e12. doi:10.1016/j.pmrj.2015.01.003

3. Housner JA, Jacobson JA, Misko R. Sonographically guided percutaneous needle tenotomy for the treatment of chronic tendinosis. J Ultrasound Med. 2009;28(9):1187-1192. doi:10.7863/jum.2009.28.9.1187

4. Jacobson JA. Fundamentals of Musculoskeletal Ultrasound. 3rd ed. Philadelphia, PA: Elsevier - Health Sciences Division; 2017.

5. Kanaan Y, Jacobson JA, Jamadar D, Housner J, Caoili EM. Sonographically guided patellar tendon fenestration: prognostic value of preprocedure sonographic findings. J Ultrasound Med. 2013;32(5):771-777. doi:10.7863/ultra.32.5.771

6. Krey D, Borchers J, McCamey K. Tendon needling for treatment of tendinopathy: A systematic review. Phys Sportsmed. 2015;43(1):80-86. doi:10.1080/00913847.2015.1004296

7. Lee DH, Han SB, Park JW, Lee SH, Kim KW, Jeong WK. Sonographically guided tendon sheath injections are more accurate than blind injections: implications for trigger finger treatment. J Ultrasound Med. 2011;30(2):197-203. doi:10.7863/jum.2011.30.2.197

8. Moore RE. Sonography of the Extremities Techniques and Protocols. 4th ed. Cincinnati, OH: General Musculoskeltal Imaging, Inc.; 2016.

9. Muir JJ, Curtiss HM, Hollman J, Smith J, Finnoff JT. The accuracy of ultrasound-guided and palpation-guided peroneal tendon sheath injections. Am J Phys Med Rehabil. 2011;90(7):564-571. doi:10.1097/PHM.0b013e31821f6e63

10. Nagraba Ł, Tuchalska J, Mitek T, Stolarczyk A, Deszczyński J. Dry needling as a method of tendinopathy treatment. Ortop Traumatol Rehabil. 2013;15(2):109-116. doi:10.5604/15093492.1045947

11. Settergren R. Treatment of supraspinatus tendinopathy with ultrasound guided dry needling. J Chiropr Med. 2013;12(1):26-29. doi:10.1016/j.jcm.2012.11.002

12. Soh, E., Li, W., Ong, K.O. et al. Image-guided versus blind corticosteroid injections in adults with shoulder pain: A systematic review. BMC Musculoskelet Disord 12, 137 (2011). https://doi.org/10.1186/1471-2474-12-137

Running Mechanics - The Pull from the Ground

Fri, 12 Jun 2020 16:12:45 GMT

Emphasize quick turnover

The final phase in our discussion of running mechanics is the Pulling Phase. The pull of the stance foot off the ground is the only “active” part of running in the Pose Method. We have previously reviewed how to utilize gravity and maintain stability/balance in order to increase speed and maintain forward progression effortlessly. Working on the form of pulling can help promote efficiency to quickly transfer weight. This is done by slight intentional effort via the hamstrings.

Force Management

The concept of pulling may be new to some runners as traditional thought has focused on “driving” the knees or “pushing off” the ground as active cues. In reality, if a runner is able to utilize the free source of gravity’s energy by falling, then pulling the foot quickly off the ground will facilitate the forward fall by continuing the motion uniformly. If the runner uses the swing leg to “drive the knee forward” or push off the stance foot, the resulting trajectory of those forces will be somewhat vertical for the Center of Mass (CoM). Let’s refer again to the model of the ball rolling downhill (downhill allows us to visualize the assistance from gravity due to the fall angle). If a force coming from the Center of Mass (such as hip flexion from the cue “knee drive”) finishes anterior or above the CoM, then the resultant line of force will add a component forward AND upward.

Similarly, if the runner were to push off from the ground via the knee or ankle the force line would again be upward. The Pose Method attempts to keep the energy horizontal and minimizes any bounding or vertical motion. This is all wasted energy from a physics standpoint.

Energy Consumption

A second foundation of the pull theory is the concept of elasticity. Elasticity is the idea that contractile tissue, such as the hamstring muscles and tendons, have the capability to return to their original state after a stretch is applied. Using the elasticity theory will prolong the aerobic state of the runner and minimize going into an anaerobic state early. This is done through keeping the stretch/reach of the muscle at an ideal length so that it can retract back to original state independently; thus less energy expended. Remaining in an aerobic state longer will spare ATP (or muscle fuel).

An image I like to use for the pulling concept is that of pistons. The feet should quickly be switched underneath or very close to the CoM.

This makes for quick turnover and allows the runner to maximize elasticity. If the trail leg is left too far behind the CoM, it will take longer and require more effort to bring that leg back down again. This has implications for efficiency during straight-line running but also for field/court effectiveness. If an athlete is closing in on an opponent, the step rate should be higher in order to keep balance and be able to change direction quickly. If it takes longer to get your foot into position to make the cut or change direction, think how much slower the resulting motion will be.

Lastly, cadence (step rate) attention is much more important than the height of the pull. As mentioned, high cadence will allow the body to tap into elasticity more easily. This is a theory regarding elite athletes - they may have a more innate awareness/perception of the body’s ease during activities. Their bodies may naturally seek and maintain that sense of balance between elasticity/effort/gravity. But this concept can also be practiced - through repeated, exaggerated drills to improve the brain’s perception of where your limbs are in space. Strengthening drills may be necessary for the hamstrings in addition to neuromuscular retraining drills that emphasize timing and rate of the pull.

To find out more regarding specialized drills or for an individualized running assessment, follow us on Instagram @evosportspt or Facebook. You can also reach out directly to the PTs at Evolution Sports.

Gravity - it's FREE!!!

Thu, 04 Jun 2020 00:41:24 GMT

Running Mechanics - The Fall

The first installment in our running mechanics series discussed the importance of stability and striking your support leg under your hips. This Pose position will allow the runner to absorb forces more readily and prepare more efficiently for the next movement. The next movement in the Pose Method is the Fall. The purpose of this phase is to increase speed and since the Pose Method is all about “effortless running,” optimal body alignment will allow gravity to do the brunt force of the work.

Running, like all upright activities, is gravity-dependent. Take a look at the boxes above. If your goal is to move the box forward, you could do one of two things: (1) push the box at a low angle to slide the box along the floor or (2) you could tilt the box from above at an angle, eventually letting gravity complete the tipping process until the box is on its side. In the latter example, half of the movement is done with little to no effort. Our bodies are similar during running. Remember that running is a series of steps in a forward motion. Gravity can keep us moving forward simply by allowing our body to fall. In order to fall, the runner must optimize body alignment to allow gravity to assist in the motion. If the runner’s angle is very vertical, such as box A above, gravity will give very little assistance. If the runner’s body line is closer to box B or C, the runner will be able to capitalize on the natural forces and move forward.

That fall line of our body has also been compared to that of a gas pedal – the further you push the pedal, the faster your car goes. That’s a great analogy in more ways than one. If I push the top of the pedal with my foot, I have much less control of the pedal. Similarly, if a runner were to try to “fall” by bringing the top of the body – head and shoulders – forward, increased strain at the back and lack of stability through the body will result. Keeping the ears, shoulders, hips and ankles in alignment during the Fall will allow for balance. More balance = less effort. By utilizing the free energy of gravity moving us forward, we use less effort continue forward and it will increase running speed. That’s right, increasing running speed should be done by DOING LESS.

When we try to focus on driving the knees higher, pumping the arms faster or pushing off the ground harder it can throw off a runner’s balance. It is also difficult to sustain an atmosphere of “pushing harder” throughout a race, particularly longer runs. All the extra work of those actions will demand further work to maintain stability. This extra work, in turn, will cause the runner to feel more tired and exhaust more quickly.

Dr Nicholas Romanov, creator of the Pose Method, has found the theoretical peak angle of human ability while running to be 22.5 degrees. The steepest angle ever recorded was Usain Bolt's; he fell at 21.4 degrees during his 9.58-second 100-meter world record. Sprinters will have higher fall angles than distance runners because of their need to harness speed quickly. Most recreational runners will have an average angle in the single-digits but a well-trained marathoner will be in the mid-teens. By ensuring flexibility and core strength, you can perform running technique drills that improve your natural fall angle.

To learn more about how to break down and optimize your running mechanics, contact the PTs at Evolution Sports today!

The Pose Method and Effortless Running

Wed, 27 May 2020 16:08:02 GMT

What is Pose Method?

The Pose Method of running allows one to identify and promote a running form that maximizes gravity along with the body’s effort and stored energy (elasticity) to create efficient movement. In essence, it makes running easier and less physically stressful to the body.

There is a lot of debate surrounding running form. Some even question if it’s necessary to promote a particular way of running. However, it is a universally accepted foundation that every activity has a “best practice” - from changing a tire to playing basketball to cooking. As able-bodied individuals, we are all physically capable of performing such activities, but how long it will take to complete? How many unnecessary steps do we take? How much additional effort and load do we put on our bodies mentally and physically? These questions can be addressed by learning and PRACTICING ideal mechanics. Sure, you can go out on a 1-mile run in a recommended shoe to begin your fitness journey but would you start your golf journey on the tee box of Hole 1 with your newly purchased clubs? No, likely you would work with a knowledgeable person on how to hold the club, general swing mechanics and practice several range balls before venturing to the course. Why should running be any different? Particularly in a sport where “novice” runners have a much higher risk of running related injuries (RRI) compared to experienced runners. In a study completed in 2018, authors found a 2x-injury rate in novice runners compared to experienced runners over a 4-yr period. Secondly, running is the cornerstone of several other sports so as you go out to shoot 100 free throws every day to practice your form, why wouldn’t you add drills to improve the form of getting from Point A to Point B on the court? It makes sense to make use of the studies on running form and body mechanics to begin a new fitness goal in order to give us an advantage - how many YouTube videos do you watch before endeavoring to fix the washing machine? Knowledge is power.

The Pose Method works by identifying repetitive “poses” during a running cycle through which every runner must pass: they have been described as Pose (the typical running “picture”), Pull and Fall. For the next few weeks, we will be breaking down each phase. We will start with “the Pose.”

The Pose (Picture #1) equates to landing with your mid-foot directly under your Center of Mass (CoM). Landing with the foot directly under the hips allows us to continue momentum with limited braking force. Imagine a ball rolling downhill with long, purple spikes poking out from the borders: every time one of those spikes hits out in front of the ball, there will be an interruption to the flow of movement that will ultimately SLOW down the smooth progression of the ball. It will keep rolling downhill despite the slight momentum disruption because gravity and the slope/fall line are a greater force.

Any time the purple spike hits directly under the ball's center of rotation, it will hit the downhill slope in a manner that will promote effective force transmission into the same direction the ball is currently traveling. Our feet are the same way - landing with a foot out beyond the CoM actually causes a force in the direction opposite to forward motion of the body. The foot then needs to remain in place until the CoM “catches up” to the base of support and is positioned over the foot in order to effectively carryover the forward momentum. Longer time on the ground = slower step turnover. Aside from creating a brake force from an outstretched leg, there is another consequence of the foot remaining on the ground longer: increased chance of injury. The more “ground” time, the more opportunities for injury to occur. We will tackle injuries in separate blog.

An additional benefit to landing with the foot under the hips is stability and balance. The most effective support is centered. This will allow the body to move in any direction (hint, hint field and court athletes) in response to an external change in external force, such as an uneven trail or slippery mud or an opponent changing direction in competition. The Pose Method creator, Dr Nicholas Romanov, loves to use the analogy of running (or walking) on ice. When you knowingly encounter of patch of ice, do you take long strides or shorten your steps? Smaller steps keep your center of mass over your base of support. Taking a big step will stretch out your base of support and forces will no longer be “stacked” vertically into a stable pillar. When you take that big step and lose your balance, all kinds of accessory movement come into play in effort to return to balance... and if you don’t return to balance, you will likely encounter a significant NEGATIVE force directed to your tailbone or wrists. Landing with your foot underneath you is the most stable position to land and the most effective for transitioning to the next phase.

Which brings me to my last point. The Pose phase sets up the athlete for ideal carryover to the next movement by harnessing the power of the previous movement. Running is a series of perpetual movements brought about by gravity’s force on our body. The more we can learn to maximize this FREE ENERGY source, the more effortless and efficient running can become.

It is important to note that this method of running mechanics does not stress what part of your foot contacts the ground; however it is inherent in landing with your base of support under your CoM that you will land at mid to forefoot vs your heel. It is virtually impossible to land on your heel with your foot underneath you and feel “fluid” or “soft” or “light.” If you tried to jump up and down by landing on your heels, you would feel the sensation of having to start and stop and start again to jump repetitively. To the contrary, if you jump in-place on the balls of your feet the impact is much less and the carryover of energy takes you into your next jump rather seamlessly. The Pose Method does not necessarily promote forefoot (midfoot) running, instead the strike of your mid/forefoot is a byproduct of initial contact being made under your CoM.

Follow along as we continue to dissect the phases of running as well as provide drills and ideas to improve your running efficiency by decreasing the effort.

1. Ellen Kemler, Donna Blokland, Frank Backx & Bionka Huisstede (2018) Differences in injury risk and characteristics of injuries between novice and experienced runners over a 4-year period, The Physician and Sportsmedicine, 46:4, 485-491, DOI: 10.1080/00913847.2018.1507410
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What You Need To Know About Stretching

Thu, 26 Mar 2020 16:56:18 GMT

Chances are, at some point in your life you have been told that you need to stretch more. But is stretching actually worth it? The claimed benefits of stretching are that it increases flexibility, improves performance, and decreases the risk of injury. However, recent research on stretching is varied and controversial. Because of the discrepancies in the research, it’s logical to question if stretching is actually worth it.

Overview and Background Information:

Range of Motion (ROM) is defined as the degree of movement that occurs at a joint. Flexibility is a measure of that range of motion and it has both a static and dynamic component to it. Static flexibility is the range of movement at a joint and its surrounding musculature that occurs with passive movement. Static flexibility does not involve any voluntary muscle activity and is done using gravity, a partner, or a machine. Dynamic flexibility is the available range during active movement and requires voluntary muscle action. Although a certain degree of motion about a joint is considered “normal”, the relationship between flexibility and performance is questionable. Therefore, it’s important to understand that normal range of motion does not necessarily guarantee normal movement. Other factors such as muscle strength and motor control are needed for normal movement. Another key concept to understand is that the amount of range of motion an individual requires depends on the demands they place on their body. For example, a gymnast or a dancer require more flexibility than a powerlifter or football player. Therefore, it is important to keep in mind that the flexibility demands for each person may vary.

Types of Stretching:

Static Stretching: Defined by the American College of Sports Medicine (ACSM) as a technique that involves a slow and constant stretch at end range or point of mild discomfort that is typically held for 15-30 seconds. This type of stretch is considered static because it is held at end range for a period of time, without any additional movement. Because static stretching is done in a controlled manner it is considered appropriate for all individuals for increasing flexibility.

Ballistic Stretching : Ballistic stretching is defined as stretching that involves active muscular effort and uses a bouncing-type movement. The ASCM no longer recommends this type of stretching for increasing range of motion and flexibility, even though ballistic stretching just as effective as static stretching at increasing range of motion. This is due to the high-intensity nature this type of stretching and the degree of muscle tension that occurs during ballistic stretching puts the individual at an increased risk for injury thus making it inappropriate for some individuals. Ballistic stretching is also more likely to stimulate receptors within the tissue that lead to muscle guarding and therefore full range of motion may actually be limited.

Dynamic Stretching : Dynamic stretching is similar to ballistic stretching, in that it involves active muscle contraction, however unlike ballistic stretching, it avoids bouncing and is performed in a more controlled manner. Dynamic stretching is not only more controlled but it also uses sport-specific movements to help prepare the body for activity. Dynamic stretching is designed to increase core temperature, enhance activity-related flexibility and balance, and prepare the body for performance. This type of stretching is typically done prior to exercise, whereas static stretching is done post-exercise.

Proprioceptive Neuromuscular Facilitation (PNF) Stretching : Originally developed for patients with muscle tone issues due to neurological conditions, PNF stretching helps to facilitate muscle relaxation. PNF stretching is typically performed with a partner and combines both active and passive muscle actions. There are three types of PNF stretching, all of which include a passive stretch and an active muscle contraction, which is then followed by a passive stretch. The three types of PNF are hold-relax, contract-relax, and hold-relax with agonist contraction. Some studies have concluded that PNF stretching is superior to static stretching and ballistic stretching at improving range of motion, but the research is varied and controversial.

Factors Affecting Flexibility

Joint Structure : The structure of a given joint determines the amount of available motion at that particular joint. Ball-and-socket joints (hip and shoulder) have the greatest degree of available motion and are able to move in all planes of motion. Therefore, these types of joints are expected to have a larger degree of motion than hinge joints (elbow and knee).

Age and Gender : As we age, a process called fibrosis takes place throughout our body, in which fibrous connective tissue replaces degenerating muscle fibers. This fibrous connective tissue is not as elastic as the muscle fibers it replaces and therefore the pliability of the tissue decreases along with the available range of motion. Gender also plays an important role in flexibility, due to the anatomical and hormonal differences between females and males. Anatomical differences in pelvic shape and size between males and females, along with increased estrogen and progesterone production in females account for increased flexibility in females when compared to their male counterparts.

Muscle and Connective Tissue : Elasticity is the ability to return to original resting length after passive stretch, while plasticity is the ability to assume a new and greater length after passive stretch. Both the elasticity and the plasticity of the tissue affect the flexibility and the available range of motion. There is a variety of different tissue types throughout the body (muscle, tendon, ligament, fascia, etc.) and each type has its own degree of elasticity and plasticity. Therefore, the characteristics of the surrounding tissue will determine the available range of motion.

Activity Level : Active individuals tend to be more flexible than inactive individuals. This is particularly true if the individual performs activities that require a high degree of flexibility (yoga, gymnastics, etc.) Although active individuals tend to have a greater degree of flexibility, activity level along does not improve flexibility. A comprehensive training and stretching program is needed in order to positively affect range of motion and overall flexibility. It is also important to exercise and move a joint throughout its full range of motion. In doing this not only is flexibility maintained but the surrounding muscles are strengthening at all ranges of motion but joint health is also facilitated.

Stretch Tolerance : Stretch tolerance is the ability of an individual to tolerate the discomfort of a stretch. Those with a greater stretch tolerance tend to have a greater degree of flexibility and therefore greater range of motion. The discomfort from stretching comes from stimulation of receptors within the tissue. These receptors help to sense the amount of stretch and tension that is occurring in the tissue and activation of these receptors can lead to discomfort during stretching as well as increased muscle guarding and tension.

Muscle Spindles & Golgi Tendon Organs (GTO)

With the muscle, there are two important receptors that determine muscle length and muscle tension and therefore can affect flexibility and the available range of motion during stretching. Muscle spindles are located within the muscle fiber and sense changes in the muscle length. If the muscle is rapidly stretched, the muscle spindle is activated and causes the muscle to contract and shorten in length, therefore limiting the degree of motion. However, if the stretch is performed in a slow and gradual manner, the muscle spindle is not activated and the muscle is able to lengthen to its full extent. Because of the slow movement that occurs in static stretching and PNF stretching, these stretching techniques are typically favored when it comes to increasing flexibility and range of motion, while dynamic and ballistic stretching are not. The Golgi tendon organ (GTO) is another receptor that is located at the musculotendinous junction (where the muscle merges into the tendon). The GTO is sensitive to the amount of muscle tension within the muscle. When muscle tension reaches a certain level of intensity, the GTO is stimulated and results in muscle relaxation and therefore a reduction in the amount of tension developing within the muscle. Manipulation of the GTO can be beneficial when it comes to trying to improve the flexibility of a muscle, because a relaxed muscle with have greater motion than a muscle that is guarding or has increased tension.

When, How Much, and How Long?

So if you do stretch, how long and how often should you be stretching? Just as the types and benefits of stretching are controversial, so is the duration and frequency of stretching. According to the American College of Sports Medicine and the National Strength and Conditioning Association (NSCA), static stretching should be held for anywhere between 15-30 seconds, although some sources say as low as 10 seconds is sufficient, and that the stretch should be repeated no more than 4 times (because there were only minimal gains with additional repetitions). When an individual should stretch depends on the type of stretching being performed. The NSCA states that stretching with the goal of improving ROM and flexibility should be done following activity (within 5-10 minutes after activity) and as a separate session. When stretching is done as its own session, it should be proceeded by a general warmup in order to allow an increase in muscle temperature which is necessary for effective stretching. While most sources advocate 15-30 second hold for static stretching, recent research has explored the effectiveness of different durations of stretching along with total stretching time. While the research regarding the effectiveness of different durations of stretching is controversial, what is consistent is that at least 4 repetitions of a particular stretch should be performed and any additional repetitions performed after 4 resulted in only minimal improvement. The biggest limitation with a lot of the research on stretch frequency and duration is the limited subject pool. The majority of the stretching research has been conducted using healthy individuals under the age of 40 meanwhile, those individuals who may benefit the most from stretching (ex. elderly and post-surgical patients) are excluded. According to an article that look at stretching in the elderly population (>65 years old), holding a stretch for 60 seconds was more effective at increasing ROM than holding the stretch for only 15 or 30 seconds. Although, stretching for all three durations lead to increases in ROM, holding the stretch for 60 seconds lead to a faster rate of ROM improvement compared to the 15 second and 30-second stretch. Older individuals and the elderly may benefit from longer durations of stretching, due to the effect that aging has on flexibility and the fibrotic changes that occur throughout the body with increasing age.

So Is It Worth It?

Although some stretching techniques have been found to be more effective than others and there are inconsistencies in the research. However, stretching can help to improve flexibility and range of motion and therefore is an important factor when it comes to overall musculoskeletal health. Static stretching is considered the safest and everyone is able to safely perform static stretching so along a proper technique is used. Although 4 repetitions held for 15-30 seconds is the accepted dosage for static stretching, the evidence regarding the value of holding a stretch for 15 seconds versus 30 or 60 seconds is controversial and continues to be a topic of debate. Due to the effect aging has on flexibility, holding a stretch for longer durations (60 seconds) may be more beneficial in older or elderly populations. Although most individuals would benefit from incorporating a stretching routine into their daily lives, there are times when stretching may be contraindicated. In individuals who have Ehlers-Danlos Syndrome or Marfan Syndrome, aggressive stretching is contraindicated because these individuals are hypermobile and therefore have an increased amount of available motion to being with. Therefore, stretching for these individuals can actually lead to excessive motion and instability at the joints. The primary concept to understand is that each individual’s needs are specific and unique. Although most individuals would benefit from general stretching and flexibility exercises, individuals suffering from injury or pain may have specific needs that may not be addressed with a generalized program and require input from a trained strength and conditioning coach or physical therapist.

If you or anyone you know has questions regarding stretching or how it may benefit you please call us at 410-628-0520.

References:

1. American Heart Association. (2020). Flexibility Exercise (Stretching). [online] Available at: https://www.heart.org/en/healthy-living/fitness/fitness-basics/flexibility-exercise-stretching [Accessed 19 Feb. 2020].

2. Bandy, W. and Irion, J. (1994). The Effect of Time on Static Stretch on the Flexibility of the Hamstring Muscles. Physical Therapy, 74(9), pp.845-850.

3. Feland, J., Myrer, J., Schulthies, S., Fellingham, G. and Measom, G. (2001). The Effect of Duration of Stretching of the Hamstring Muscle Group for Increasing Range of Motion in People Aged 65 Years or Older. Physical Therapy, 81(5), pp.1110-1117.

4. Haff, G. and Triplett, N. (2016). Essentials of strength training and conditioning. 4th ed. Champaign, IL: Human Kinetics, pp.317-328.

5. Hoffman, J. (2012). NSCA's guide to program design. Champaign, Ill.: Human Kinetics, pp.51-70.

6. Magyari, P., Lite, R., Kilpatrick, M. and Schoffstall, J. (2018). ACSM's Resources for the Exercise Physiologist. 2nd ed. Philadelphia: Wolters Kluwer, pp.121-127.

7. Mayo Clinic. (2020). Stretching is not a warm up! Find out why. [online] Available at: https://www.mayoclinic.org/healthy-lifestyle/fitness/in-depth/stretching/art-20047931 [Accessed 19 Feb. 2020].

8. Page, P. (2012). Current Concepts in Muscle Stretching for Exercise and Rehabilitation. The International Journal of Sports Physical Therapy, 7(1), pp.109-119.

A New Approach for Return to Sport Testing of the ACL Athlete

Thu, 12 Mar 2020 18:45:36 GMT

Physical performance measures such as single-leg hop tests are frequently used to assess the functional status of an athlete, detect limb asymmetries and monitor progression throughout an intervention. Typical return to sport after ACL reconstruction may consist of at least 9 months of rehab post injury, >80% quadricep strength of involved vs. uninvolved side, and scoring >85% of involved vs uninvolved on hop testing (single leg hop, triple hop, crossover hop, and timed hop). However, there is new research in regard to medial hop testing that may be more likely to show limb asymmetries in ACL reconstructed participants compared to traditional forward hop testing.

Athletes move in multiple directions with pivoting sports, thus a limitation of the original hop tests battery is that they predominantly consist of straight movements in the forward direction. Dingenen et. Al 2019 looked at medial side triple hop for distance (MSTH) and 90° medial rotation hop for distance (MRH) and examined the test-retest reliability in addition to discriminative ability to detect leg asymmetries in ACL reconstructed athletes. Excellent test-retest reliability of forward, medial, and rotational hop testing was found in addition to concluding that medial and rotational hop tests were more likely to show limb asymmetries in ACL reconstructed patients.

Decreased performance on the traditional set of hop tests has been related to self-reported function and re-injury risk after ACL reconstruction. Leg asymmetries in hop distances were more likely revealed with medial and rotational hop tests, compared to forward hop tests alone.

Nonetheless, future prospective studies are needed to validate whether multidirectional hop tests can improve return to activity, return to sport or return to performance decision-making. Current return-to-sport approaches emphasize that passing hop tests is only one of the factors allowing athletes to progress towards more sport-specific late-stage rehabilitation phases, including on-field rehabilitation and physical reconditioning with progressively increased workloads. However, the final decision to return to sport is multifactorial and should be considered within a multifactorial biopsychosocial perspective [2,3,4].

If you or anyone you know has suffered an ACL injury please contact us via phone at 410-628-0520 or email us at morgan@evolutionsportspt.com. We look forward to answering any of your questions and assisting with all of your rehab needs!

References

[1]Dingenen, B., Truijen, J., Bellemans, J., & Gokeler, A. (2019). Test–retest reliability and discriminative ability of forward, medial and rotational single-leg hop tests. The Knee. doi:10.1016/j.knee.2019.06.010

[6] Dingenen B, Gokeler A. Optimization of the return-to-sport paradigm after anterior cruciate ligament reconstruction: a critical step back to move forward. Sports Med 2017;47:1487–500.

[45] Buckthorpe M. Optimising the late-stage rehabilitation and return-to-sport training and testing process after ACL reconstruction. Sports Med 2019;49:1043–58.

[46] Buckthorpe M, Frizziero A, Roi GS. Update on functional recovery process for the injured athlete: return to sport continuum redefined. Br J Sports Med 2019;53: 265–7.

Central Effects of Dry Needling

websites@hibu.com (Hibu Websites) — Thu, 05 Mar 2020 16:37:11 GMT

In our previous blog post, we highlighted the peripheral mechanisms of dry needling into muscle tissue. The benefits of trigger point dry needling have been well documented in the literature. However, this is only one component of needling in the treatment of neuro-muscular dysfunction.

A comprehensive definition of dry needling should include nerves, ligaments, tendons, scar tissue, bone and teno-osseus junctions.1 This requires expanding beyond the trigger point model to consider additional peripheral, spinal and supraspinal mechanisms. The classic local twitch response is thought to be a strong neural impulse triggered from needling into multiple sensitize loci. Mirror local twitch responses have been recorded in the opposite trapezius muscle during dry needling of the symptomatic trapezius. This example suggests a consideration of central mechanisms in addition to local muscle dysfunction.1

A brief review of pain physiology is helpful in consideration of central dry needling mechanisms. Pain sensation originates in peripheral nociceptors that continue into sensory fibers, which feed into the central nervous system through the dorsal horn of the spinal cord.2 After connecting with spinal neurons, the pathway continues up the spinothalamic and spinoreticulothalamic tracts. These lead to supraspinal locations including the thalamus, parabrachial nucleus and amygdala. There is significant potential for both dysfunction and pain relief within this neural system.2

Throughout this discussion, the terms acupuncture and dry needling will be used interchangeably.1 While many studies use the term “dry needling,” others commonly use terms including TrP acupuncture, acupuncture needling and electroacupuncture. Several studies have used acupuncture and dry needling in the same title. All of these cases meet the strict definition of “dry needling”. This trend of discussing dry needling as acupuncture is commonly seen in the UK, Canada, USA and Germany.1

Acupuncture randomized control trials and other studies have commonly used western medical diagnoses including neck pain, knee osteoarthritis and plantar fasciitis.1 Furthermore, these studies applied needles into “Ah-Shi points,” which is Chinese for “auwh that’s where it hurts” or “that’s it.” These are synonymous with trigger points and are used in combination with non-trigger point targets. In this sense, it is beneficial for physical therapists to recognize the findings of appropriate biomedical acupuncture research.1

Studies have demonstrated that electroacupuncture involves many different mechanisms and bioactive substances, both peripherally and centrally for pain conditions.3 Peripheral release of endogenous opioids originate from lymphocytes, monocytes/macrophages and granulocytes. Sympathetic nerve fibers are additionally activated for opioid response. These opioids activate receptors on peripheral nerve terminals to decrease pain signaling back to spinal and supraspinal structures.3

Electroacupuncture has been shown to inhibit the sensory component of pain through spinal mechanisms including opioids, serotonin, norephinephrine and glutamate.3 Spinal opioid receptors are targeted to inhibit thermal hyperalgesia and mechanical pain thresholds. Low and high frequency electroacupuncture have been found to inhibit thermal pain during acute pain. Thermal, mechanical and spontaneous pain are inhibited in persistent pain conditions. Electroacupuncture influence on opioid receptors is thought to occur on both presynaptic primary afferent fibers and postsynaptic dorsal horn neurons.3

Electroacupuncture studies have also confirmed the involvement of spinal serotonin and norephinephrine in pain inhibition.3 This includes serotonin-containing nucleus raphe magnus neurons and norepinephrine-containing locus coeruleus neurons. Electroacupuncture also decreases glutamate receptor activity and induces release of spinal norepinephrine, which each inhibit pain signals at the spinal level. Pain reduction has also been noted with changes in glial cells, cytokines, signal molecules/pathways, dopamine and acetylcholine at the spinal level.3

Electroacupuncture benefits via supraspinal mechanisms have been noted with the contribution of many nuclei.3 Sensory components are mediated via nucleus raphe magnus, periaqueductal gray, locus coeruleus, arcuate, preoptic area, nucleus submedius, habenular, accumbens, caudate, septal area and amygdala. Opioid activity in the arcuate-periaqueductal gray-nucleus raphe magnus-spinal dorsal horn pathway are thought to be particularly important in this sensory realm. Several studies have shown that endorphin release blocks affective pain responses while controlling for sensory pain inhibition. This selective supraspinal influence on affective and sensory components of pain is a similar consideration for drug efficacy in pain management, including the use of morphine.3

The physical therapists at Evolution Sports Physiotherapy have been trained in a variety of needling techniques to meet the individual needs of our patients. Our comprehensive treatment approach respects localized tissue dysfunction in addition to central considerations based on clinical findings and assessment. Please contact us with any questions concerning dry needling and treatment options.

References:

1. Dunning J et al. Dry needling: a literature review with implications for clinical practice guidelines. Physical Therapy Reviews 19(4):252-265, 2014

2. Cagnie B et al. Physiologic effects of dry needling. Curr Pain Headache Rep. 17:348, 2013.

3. Zhang R et al. Mechanisms of acupuncture- electroacupuncture on persistent pain. Anesthesiology. 120:482-503, 2014.

Peripheral Effects of Dry Needling

websites@hibu.com (Hibu Websites) — Wed, 04 Mar 2020 18:40:45 GMT

This is probably the most common question asked by patients when dry needling is presented to them as a viable treatment option. The answer to this question is multifaceted. In this post, I will review the peripheral indications and effects of dry needling and will break down and discuss multiple attributes of the treatment.

Dry needling is much more than simply inserting an acupuncture needle into a painful trigger point, tight muscular knot, or muscle spasm. Before we understand how the needle itself effects healing and pain levels, it is important to understand the body’s mechanisms that allow these conditions to form in the first place.

Trigger points, or knots, can form for a variety of reasons to include acute trauma, repetitive micro-trauma, overuse, and stress. All of these conditions elicit an inflammatory healing response from the body, which creates compression of local blood vessels and decreases circulation and oxygen delivery to the area. This impaired circulation combined with the increased metabolic demands of the hypertonic muscle leads to the depletion of Adenosine Triphosphate (ATP), the cells energy source used to fuel metabolic processes.

The “energy crisis” created via the decrease in available ATP creates compensations at the neuromuscular end plate, both pre- and post-synaptically . Pre-synaptically, in the nerve terminal, ATP is directly responsible for the inhibition of acetylcholine (ACh) release. Acetylcholine is a neurotransmitter used at the motor end plate to elicit a muscle’s action potential and therefore a muscle contraction. The depletion of ATP perpetuates the release of ACh, thus perpetuating a muscle contraction in an already hypertonic muscle.

Post-synaptically, ATP fuels the calcium (Ca2+) pump, which is responsible for maintaining the electrochemical gradient required to signal skeletal muscle cells to contract. The calcium pump is utilized by opening to allow a stimulus signal to pass and thus allow Ca2+ to flood they cytosol, but also to immediately pump ca2+ out of the cytosol when muscle activation is no longer required. The depletion of ATP mentioned above allows these channels to remain open, therefore, the muscles continually receive the signal to contract. Both of these actions compound upon one another to create a vicious cycle of muscle hypertonicity.

When the increased metabolic demands of the hypertonic muscle cell are not met, the cells begin to panic and essentially yell for help. This is achieved by releasing algogenic chemicals such as bradykinins, cytokines, serotonin, histamine, potassium, prostaglandins, leukotrienes, somatostatins, and substance P in order to activiate local nocicepors, to elicit a healing response from the body. Thus, we have the development of a trigger point and the subsequent tenderness and pain associated with it. The effects of prolonged exposure to algogenic substances have been shown to lead to demyelination of local nerves and abnormal nociceptive impulses, which perpetuate the pain cycle.

One of the key components of the dry needling treatment is often the aim of eliciting a “twitch response” by inserting the needle directly into a trigger point and tapping onto a sensitive loci. Although this effect is not required for a successful dry needling treatment it is a key component in clearing the excessive build up of ACh from the synaptic cleft and returning the motor end plate to a homeostatic state.

Needle manipulation also plays a key role in the effects of dry needling. Multiple techniques are used to achieve a variety of goals. The techniques of pistoning or fanning of the needle are often utilized to create microtrauma and to elicit twitch responses by tapping onto multiple sensitive loci in the desired area. Periosteal pecking is a technique often used at the teno-osseous junction to achieve small amounts of bleeding and microtrauma to a tendon that normally has very little blood supply, in order to elicit a healing response. This technique is performed by a series of rapid tapping motions through the tendon and onto a bony backdrop.

Lastly, the needle manipulation technique of twisting the needle has been shown to have numerous effects on local tissues as well as pain relieving properties. Of all of the techniques discussed, only rotation of the needle has been shown to definitively change the appearance of the local connective tissue surrounding the insertion point. Marked thickening of the subcutaneous connective tissue along with deformation of the extracellular matrix have been observed in tissue samples taken after dry needling treatments with needle rotation. Deformation of the extracellular matrix is believed to signal therapeutic effects via the alignment of collagen fibers and fibroblasts. This technique has also been shown to be the only technique that elicits an endogenous opioid release creating true pain reduction from the treatment.

If you have any further questions about Dry Needling or feel you could benefit from this treatment technique, please contact Morgan or call our office to speak with one of the therapists at 410-628-0820. Stay tuned for our next newsletter where we will discuss the impact of Dry Needling on the Central Nervous System.

References

Chu, J. "Does EMG (dry needling) reduce myofascial pain symptoms due to cervical nerve root irritation?." Electromyography and clinical neurophysiology 37.5 (1997): 259-272.

Chu, Jennifer. "Twitch-obtaining intramuscular stimulation: observations in the management of radiculopathic chronic low back pain." Journal of Musculoskelatal Pain 7.4 (1999): 131-146.

Langevin, Helene M., David L. Churchill, and Marilyn J. Cipolla. "Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of acupuncture." The FASEB Journal 15.12 (2001): 2275-2282. http://www.acupmedvet.com/artigos%20cient%C3%ADficos/Langevin%20et%20al.,%202001b.pdf

Langevin, Helene M., et al. "Dynamic fibroblast cytoskeletal response to subcutaneous tissue stretch ex vivo and in vivo." American Journal of Physiology-Cell Physiology 288.3 (2005): C747-C756. http://ajpcell.physiology.org/content/288/3/C747.short

Langevin, Helene M., et al. "Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: Evidence for a mechanotransduction‐based mechanism." Journal of cellular physiology 207.3 (2006): 767-774.

Shah, Jay P., et al. "Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points." Archives of physical medicine and rehabilitation 89.1 (2008): 16-23. http://triggerpoint-tutorial.com/pdf/Shah_Biological_milieu_of_MTP.pdf

EvoSports Weightligting - Olympic Weightlifting Camp - Winter 2019

Wed, 23 Oct 2019 14:12:05 GMT

Benefitting All Athletes

In sports, we far too often focus on immediate success. Parents and coaches want the best for their children and athletes, but don’t necessarily choose the best path for reaching success. We need to explore implementing long-term athlete development programs to develop injury resistant and strong athletes.

In another blog , Morgan delves into this idea with further complexity. The point is, all athletes, children especially because of their age, need to build a solid foundation in lifting mechanics, overall strength, and proper technique.

Long-term athletic development programs have functional carryover for sport in terms of force displacement (strength and power) and kinesthetic awareness. What I mean by this is that we can train our athletes to be stronger, and more effective with basic lifting patterns and incorporate Olympic lifting techniques. These methods of training also help to develop kinesthetic awareness and enhance proprioception. These mechanisms provide us with a sense of joint position in space. Enhancing them allows for increased neurological feedback for the control of muscular actions and serves to protect against excessive strain on passive joint restraints and serves to reduce recurrent injury . (1) Basically, smarter training equals a smarter body, which translates to safer and stronger athletes.

One of the most effective methods of training to promote the aforementioned benefits is strength training through Olympic lifting. Contrary to popular belief, this style of training is incredibly beneficial, especially in young athletes. With proper coaching, structured warm-ups, individualized programming and proper recovery, there’s only heaps of benefits to reap. Children can improve strength by 30% to 50% after just 8 to 12 weeks of a well-designed strength-training program. (2) Another common misconception regarding weight training in children is that they injure themselves and stunt their growth. However, this is not the case. An article from the National Center for Biotechnology Information states that a well-designed strength training program following the recommended loads, sets, and repetitions appropriate for the young athlete’s age and body habutis should not excessively stress growth plates. Sports such as gymnastics and baseball, which involve repetitive impact and torque, provide a greater risk of epiphyseal injury. (2)

Our goal is to train smarter and more effectively to produce faster, stronger, and SAFER athletes that can continue to enjoy the sports and activities they love for as long as possible. One way we’re striving to do this is with our Olympic Weightlifting Camp. It is taking place Saturday December, 7th, 2019 .We will be offering two "camps" , the first from 8am-12 pm . The second from 1pm- 5pm . During this 4-hour workshop you’ll learn proper programming and mobility to excel in your training. Our staff of highly qualified coaches (certified through USAW and Totten Training Systems) will analyze, break down, and correct any form/mechanics issues. The price for this camp is only $99 per participant. We are offering EARLY BIRD REGISTRATION for $89 if you sign up before November 11th. We will be limiting each camp to 24 lifters to maintain an intensive focus on your skill development.

In addition to our Olympic Weightlifting Camp, we also have a barbell club every Saturday morning. The beginner class begins at 9AM, focusing on the fundamentals of Olympic lifting to establish proper technique. For those with a background in weightlifting, we have an advanced level class at 10AM. Alternating every week, we begin with a dynamic warm up, plyometrics, and then focus on either the clean and jerk or snatch, following with complementary strength work. For only $15 \ per session, this is perfect for those looking to receive great coaching and a phenomenal workout.

Be sure to contact our Director of Human Performance, Chris Fusco , for more information!

Long Term Athletic Development

Wed, 23 Oct 2019 14:10:25 GMT

Every parent wants the best for their child.

That could be happiness, confidence, social circles, academic aptitude, fitness, and even athleticism. But somewhere along the way, we've overvalued the importance of skill development within specific sports, believing that it will make us better athletes at that sport when our kids are older. Some of us do so because we were great at a sport and want to see our child be just as good, some of us were never that good at all and live vicariously through our kids, seeing their aptitude as superior to our own at that age, and some of us want for our kids what we didn't have ourselves in terms of resources and training. All of those are great intentions but we can't look past the holistic health of our children and the value of generalized athleticism compared to specializes sport skill sets. When we do, we end up with weak, fragile kids, with good skills, but poor overall constitution,...and limited opportunities, ....and higher risk for injuries, and ultimately, a lower ceiling for athletic participation throughout life. We have to ask ourselves: What is best for my child overall? Is my child happy and balanced? Do we put too much emphasis on one thing too early in life? Is my child prepared to do other physical activities or change sports if they are unhappy with the one they've chosen (or the ones we've chosen for them)? Will my child grow up to be a healthy, fit, individual who is injury-proof and capable of doing many activities throughout their lifetime? I'll delve into each of these issues throughout this article.

Recently, The National Strength and Conditioning Association (NSCA) wrote a Position Statement on Long-Term Athletic Development1 which points out that " Because of their unique physical, psychological, and social differences, children and adolescents should engage in appropriately prescribed exercises programs that promote physical development to prevent injury and enhance fitness behaviors that can be retained later in life. Irrespective of whether a cild is involved in organized sport or engages in recreational physical activity, there remains a need to adopt a structured, logical, and evidence-based approach to the long-term development of athleticism." Our 32nd President, Franklin D. Roosevelt once said "We cannot always build the future for our youth, but we can build our your for the future."

The reason for writing this article is to point out that we've got it all wrong... And encourage a change in mindset and initiate discussion amongst parents, our kids, coaches, gym teachers, Health Professionals, Trainers, and Directors of Club Teams about our perspectives on what is best for our Kids. Ultimately, it is the parent who must decide. Ultimately, the parent must resist what others want for our children and make that intelligent decision with our child's input. We want so bad for our kids to be awesome at sports that the whole system has gotten away from us. We've put the carriage before the horse. We look at skills as the pre-requisite for awesomeness and have overlooked the role of developing foundational athleticism and its implications on a healthy adult society, one that excels at sports. Because of this we see more and more sports injuries occurring in the pediatric and adolescent populations. Little leaguer's Elbow, Patellofemoral Syndrome, Ilial Apophysitis, Sever's Disease, repetitive muscle strains, over-training syndromes, Shin splits, stress fractures/ periostitis, and yes, ACL ruptures with or without meniscal or other ligamentous complications.

I have personally approached a multitude of local Club Soccer and Lacrosse teams in the Baltimore area and presented both the research and the program we've devised for ACL Prevention programs and I've been turned away with statements such as " We already ask too much from our parents... it is so expensive that we can't ask them to pay more for a prevention program" or "we need to spend more time on skills practice..we've left it up to the kids to do their conditioning outside of club practice". The club teams would love for you to pay to play a sport year round, and go to tournament, after tournament, combine after combine, and play during the off-season, effectively leaving no "off-season". The following season, a particular women's club lacrosse team who turned down the idea of an injury prevention program, had 6 non-contact ACL injuries amongst its players playing for a local girl's private high school team. Unfortunately, this mindset does not have the children's well being in mind. They are worried about their season, the parents' bank account, the skills practice. Parents need to have the option and the gumption to think for themselves and not just follow the herd.

In many countries in Europe, children grow up with soccer, swimming, and gymnastics until they are heading into highschool. Additionally, many of them also incorporate Olympic Lifting into their regimen. What results is a base of healthy adolescents, who have good movement mechanics and joint mobility, flexibility, muscular endurance, speed, excellent kinesthesia (understanding where their body is in space), and resistance to exercise. Going into high-school, they increase their calisthenic training, progress Olympic Lifting, and then begin to specialize. What is there first and foremost is overall athleticism and foundational strength. They worry about the skills later. We do the opposite. We starting pushing the skills at an early age, overlooking the mechanics and overall athleticism. Even the trainers we send our kids to have a non-specific "binder workout" or "group workout" that lacks a thorough health history, physical screen, and objective testing and further lacks individualized exercise prescription based on an individual athlete's needs analysis. We want better athlete's now...we don't want to wait for them. Even the colleges are starting to recruit female lacrosse players out of middle school and ninth grade because they too need to get their hands on the best athletes immediately. This is part of the problem, not part of the solution. These girls have barely gotten through puberty and their bodies have a lot to catch up to. Their development of athleticism needs to start here, not end here. With this attitude, we have kids that are great for their age at 14 and often injured before they get out of high school.

I hope that I've got some people thinking and talking, because that is what the Health Professionals at Evolution Sports are doing. We are trying to demonstrate that there is a better way to do things. A proper long-term athlete development program can create a better athlete, with good, well rounded physical abilities, that will ultimately produce a better lacrosse attack, a better soccer player, a better baseball pitcher, a better football quarterback, or gymnast. And we can do all of this whilst reducing the number of injuries that we are seeing in our children. Injuries that have already been shown to lead to early OA in the knee and need for joint replacements, as is the case with female ACL reconstructions. Do we want that for our kids? Is it worth it to them to play lacrosse for 8 years and get recruited at an early age, if they are getting a knee replacement when they're 45 of 50? That's what the research is showing.2,3 Let's change our mindset...and let's do it together.

In a future blog, we will go through these pillars of athletic development in a little more detail and discuss the construct of a proper Long-Term Athletic Development Program and how Evolution Sports will look to implement it in the local community. We'll start there and hopefully the rest of the country will catch on....

For more information on the Long-Term Athletic Development Program at Evolution Sports, please feel free to contact Chris Fusco.

1. Lloyd, R, Cronin, J, et al. National Strength and Conditioning Association Position Statement on Long-Term Athletic Development. Journal of Strength and Conditioning Research. 30(6)/149-1509

2. Suter, LG, et al. Projecting Lifetime Risk of Symptomatic Knee Osteoarthritis and Total Knee Replacement in Individuals Sustaining a Complete Anterior Cruciate Ligament Tear in Early Adulthood. Arthritis Care Res (Hoboken). 2016 May 23.

3. Simon, D, et al. Review Article: The Relationship between Anterior Cruciate Ligament Injury and Osteoarthritis of the Knee. Advances in Orthopedics, Volume 2015 (2015), Article ID 928301, 11 pages

Concierge Physical Therapy

Wed, 25 Sep 2019 19:20:35 GMT

Preventative Medicine the Way it Should Be

It is costing Americans an increasingly larger amount for healthcare, meanwhile, our insurance companies are taking less and less responsibility for these increasing costs. Ultimately, we are paying more, on both ends. Additionally, individuals are seeing the benefits of maintaining a close relationship with their physician, which is why concierge medicine has emerged.

Concierge medicine programs, like MDVIP , has evolved because our general level of healthcare has drastically declined and people realize in order good healthcare, they need to invest more. In the long run, concierge medicine costs less than treating cumulative chronic conditions by early and timely intervention. You get specific and specialized care, tailored to your individual needs.

Evolution Sports has recognized a trend amongst its clients. They have realized the benefits of early intervention on reducing costs to treat musculoskeletal conditions, and the benefits of maintaining their level fitness, thus appreciating a higher quality of life while appreciating reduced health care costs. Being sick is expensive for everyone. With increasing deductibles, co-pays, costs for lab/diagnostic imaging tests, and prescriptions, we pay thousands of dollars a year on our own healthcare. It has been shown over and over again that prevention is a lot cheaper than the cost of treating chronic conditions . For example, People with diabetes spend 200 percent more on healthcare than people without, and have 2.5 times more out-of-pocket costs. Furthermore, the average American will spend $8000 per year on healthcare and almost half of that goes towards treating Musculoskeletal conditions. Those with multiple conditions will see an exponential increase in their healthcare costs.

Evolution Sports realizes that individuals are genuinely invested in living a healthier lifestyle. Therefore, we have created our Concierge Health & Wellness Packages . We recognize that some individuals have a higher need for skilled manual therapy and others for strength and conditioning services. Either way, we’ve got you covered. We’ve created two different packages, one for each group, and for those in between, we have offered the ability to add additional services as an a la carte service.

The Concierge Health and Wellness Package incorporates one on one personal training services along with comprehensive Manual Therapy care provided by one of our highly skilled Physical Therapists. As a concierge client, you get these services when you want it and receive priority to obtain PT appointments within 48 hours, if not sooner. We will also conduct an on-boarding physical exam and systems review including calculation of BMI, LBM, and BF%. We will take your past medical history into account when planning you training and therapy prescriptions. Instead of charging expensive retainers to serve you, we are discounting the cost of our services for those willing to make a personal commitment to their health by signing up for a year’s package of services. This cost is broken up into two semi-annual payments to make this commitment affordable. If you are interested in making a commitment to your health, email Morgan to begin your Evolution today!

Can Physical Therapists Treat Temporomandibular Joint Dysfunction?

7015647171 — Mon, 03 Jun 2019 15:15:00 GMT

Of course! The TMJ is not unlike any other joint in the body, it contains a joint capsule, ligaments, and periarticular musculature. If it is not unlike any other joint, then why is it so intimidating to treat and why do such a small percentage of patients with jaw pain seek care?

Many Physical Therapists are intimidated to treat the TMJ due to the increased working knowledge of anatomy and biomechanics required to treat patients in this niche population, as well as the regional interdependence with the cervical and thoracic spine.

Chronic TMD

Chronic TMJ pain is cited to be the third most prevalent chronic pain condition worldwide, after tension headaches and low back pain. However, it is very underrepresented in physical therapy clinics, which I believe is in part due to the general population being unaware of how much a Physical Therapist can help with their condition.

Another variable that is associated with the chronicity of TMJ pain, is central sensitization. Central sensitization is defined as increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input. In other words, with chronic pain your brain may become sensitive to input and perceive this as pain during stimulation that was previously painless. Physical therapists are trained to decrease this sensitization with modalities and exercise, which will be discussed later

So what can a Physical Therapist do for Temporomandibular Joint Dysfunction (TMD)?

First, we must look at the anatomy of the joint:

In the highlighted square, you will see the TMJ, with the bony components comprised of the condyle and the articular eminence. In between these bones you will see the articular disc, which serves to increase the congruency of the joint, similar to the menisci in the knee. However, the disc must move to maximize the available opening range of motion. In the pictures below, note how the disc moves forward when opening the mouth, and how the condyle remains under the disc.

Generally speaking, the initial goal of Physical Therapy (PT) will be to restore the normal biomechanics of the TMJ illustrated above, and identify which structures are preventing this from happening. The most common culprit of TMJ pathology, is the lateral pterygoid, which is the muscle pictured on the right side that attaches to the disc. If this muscle is tight or in spasm, it will pull the disc forward, which can lead to increased pain due the disc being pinched with opening and the lack of congruency of the joint in a resting position.

This is where the expertise of a skilled physical therapist is required. If a patient has tight quads or upper traps, it is relatively simple to perform soft tissue mobilization, stretching, or other modalities to address this tightness. However, it is less obvious how to address lateral pterygoid irritation.

While the lateral pterygoids play a large role in TMD, you will see below that there are several other muscles that assist in causing motion at the TMJ:

The temporalis and the masseter are much easier to locate, and you will be able to feel them contracting when clenching your jaw.

What does the research say about interventions to address TMD?

Soft tissue release/mobilization: Manual soft tissue techniques targeting the temporalis and masseter have been shown to effectively decrease pain (Gauer and Semidey, 2015). However, the ability to palpate and perform soft tissue mobilization to the lateral/medial pterygoids is much less reliable (Stelzenmueller et al 2016).

Bottom line: Manual soft tissue techniques have a positive effect on accessible muscles such as the temporalis and masseter, thereby improving symptoms associated with TMD, but they are unlikely to reach the pterygoid muscles that are not only more intimately related to the joint itself, but also more likely one of the primarily etiologic factors in TMD (Dunning et al 2017)

Dry Needling (DN): Due to difficulty palpating and mobilizing the pterygoids, increased focus has been placed on DN to address muscular irritation. As previously mentioned, the pterygoids are more likely to contribute to TMD, which increases the importance of addressing them with skilled physical therapy. Mesa-Jimez et al. performed DN 3x/week to the lateral pterygoids, and reported statistically significant within group improvement in pain and jaw range of motion, which was maintained at follow up 6 months after the intervention. A more recent study by Gonzalez-Perez et al. reported significant between group reductions in pain when comparing lateral pterygoid dry needling to methocarbamol (muscle relaxer).

Joint Mobilization: For any joint to achieve full range of motion, you also need appropriate movement of the bones on each other (arthrokinematics). While arthrokinematics are beyond the scope of this blog, understand that the condyle must first roll under the disc, and will then need to slide forward with the disc towards the articular eminence.

To determine if the TMJ is having difficulty rolling or sliding, your Physical Therapist will want to observe full opening, and will determine if the mouth opens straight down, or deviates to a certain side. If this is the case, joint mobilizations may be performed by a Physical Therapist to restore normal arthrokinematics. Martins et al. notes a general consensus in the literature that supports joint mobilization for improving pain and range of motion patients with TMD. They also reported a large effect and a significant difference in active mouth opening and pain reduction of manual therapy compared to other active interventions such as home exercise, massage, and splint therapy.

So now that I am out of pain, how do I prevent this from happening again?

As mentioned earlier, the initial phase of Physical Therapy is to decrease pain and restore motion for the TMJ, but how do we make sure this pain does not return? The mainstay of avoiding return of TMD is addressing postural deficits. If you are reading this, I want you to sit up nice and tall and open your mouth as wide as you can, now close and repeat opening while in a slumped forward posture. When slumped forward, the TMJ experiences increased stress on the capsule, as well as increased muscular demand to maintain the joint in appropriate position.

How can a Physical Therapist fix my posture?

Postural deficits are multifactorial in nature with some of the most common deficits being:

- Prolonged sitting

- Weak scapular stabilizers

- Weak cervical flexors

- Joint restrictions in thoracic or cervical spine

Regional interdependence:

Addressing the above deficits is essential to avoiding future TMJ issues, and should be started from day 1 in Physical Therapy. Looking at the picture above for reference, you can imagine that if the cervical/thoracic spine is not moving as much as it should, it will be difficult to maintain your head in the optimal position for the TMJ. This is why your Physical Therapist may recommend cervical and thoracic spinal manipulations, which is evidenced by numerous studies in a systematic review by Armijo-Olive et al. to have a statistically significant impact on TMD.

When this new range of motion is attained and the TMJ is in a good resting position, it is imperative to prescribe therapeutic exercises to maintain this position. Some examples of these exercises are chin tucks, mid trap rows, and cervical isometrics.

Cervicogenic headaches are also common to see with people suffering from chronic TMD. Cervicogenic headaches are defined as a chronic headache that arises from the upper cervical joints and/or musculature. They are believed to occur at the converging of the trigeminal and cervical afferents at the trigeminocervical nucleus within the upper cervical spinal cord. In other words, this converging of sensory fibers allows for the referral of pain signals from the upper cervical spine to areas of the face and head. This can be addressed by the use of upper cervical spine manipulation, as well as dry needling. For more information on cervicogenic headaches, see previous blog post written in November 2018.

Conclusion:

TMJ pathologies are multifactorial in nature, and are closely intertwined with adjacent areas. A Physical Therapy plan of care is not complete unless it addresses all of these factors, at the risk of symptoms returning. The Therapists at Evolution Sports Physiotherapy understand the complexity of the TMJ and how to treat it thoroughly..

Sources:

1. Butts, R. Dunning, J. Pavkovich, R. Metille, J. Mourad, F. Conservative management of temporomandibular dysfunction: A literature review with implications for clinical practice guidelines (Narrative review part 2). Journal of Bodywork & Movement Therapies 2017

2. Gauer, R.L., Semidey, M.J. Diagnosis and treatment of temporomandibular disorders. Am. Fam. Physician . 2015;91:378–386

3. Stelzenmueller, W., Umstadt, H., Weber, D., Goenner-Oezkan, V., Kopp, S., Lisson, J. Evidence - the intraoral palpability of the lateral pterygoid muscle - a prospective study. Ann. Anat. 2016;206:89–95

4. Dunning, J., Butts, R., Mourad, F., Young, I., Flannagan, S., Perreault, T. Dry needling: a literature review with implications for clinical practice guidelines. Phys. Ther. Rev. 2014;19:252–265

5. Dunning, J.R., Cleland, J.A., Waldrop, M.A., Arnot, C.F., Young, I.A., Turner, M., Sigurdsson, G. Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial. J. Orthop. Sports Phys. Ther. 2012;42:5–18

6. Gonzalez-Perez, L.M., Infante-Cossio, P., Granados-Nunez, M., Urresti-Lopez, F.J., Lopez-Martos, R., Ruiz-Canela-Mendez, P. Deep dry needling of trigger points located in the lateral pterygoid muscle: efficacy and safety of treatment for management of myofascial pain and temporomandibular dysfunction. Med. Oral Patol. Oral Cir. Bucal . 2015;20:e326–333

7. Armijo-Olivo, S., Pitance, L., Singh, V., Neto, F., Thie, N., Michelotti, A. Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: systematic review and meta-analysis. Phys. Ther. 2016;96:9–25

Army Combat Fitness Test (ACFT)

Tue, 02 Apr 2019 13:02:34 GMT

The new fitness standard.

The Army Combat Fitness Test (ACFT) has evolved. It is no longer your grandpa’s old calisthenics, running and push up program. The Army has implemented a series of functional exercises to test a recruit’s strength, endurance and over all physical readiness for combat while also reducing injuries as a recruit enters bootcamp.

The six-event assessment, is intended to replace the current three-event Army Physical Fitness Test, which has been around since 1980.

Beginning in 2020, all Soldiers will be required to take the new gender- and age-neutral test. At least six years of significant research went into the test's development as researchers looked at what Soldiers must do fitness-wise for combat.

"Throughout that research and testing, the goal was to provide our leaders with a tough, realistic, field-expedient assessment of the physical component of their Soldiers' individual readiness," said Sgt. Maj. of the Army Daniel A. Dailey.

Roughly 2,000 Soldiers have already taken the test, previously called the Army Combat Readiness Test. They also provided feedback as part of the Army Training and Doctrine Command and Forces Command pilots that began last year at several installations.

"The current PT test is only a 40 percent predictor of success for performing in combat and executing warrior tasks and battle drills," Frost said. "This test is approximately an 80 percent predictor of performing based on our ability to test the physical components of combat fitness."

The Six Events

Strength deadlift : With a proposed weight range of 120 to 420 pounds, the deadlift event assess lower body strength. The ACFT will require Soldiers to perform a three-repetition maximum deadlift and the weights will be increased. The event replicates picking up ammunition boxes, a wounded battle buddy, supplies or other heavy equipment.

Standing power throw : Soldiers toss a 10-pound ball backward as far as possible to test muscular explosive power that may be needed to lift themselves or a fellow Soldier up over an obstacle or to move rapidly across uneven terrain.

Hand-release pushups : In this event, Soldiers start in the prone position and do a traditional pushup, but when at the down position they release their hands and arms from contact with the ground and then reset to do another pushup. This allows for additional upper body muscles to be exercised.

Sprint/drag/carry : The soldier will dash 25 meters five times up and down a lane, Soldiers will perform sprints, drag a sled weighing 90 pounds, and then hand-carry two 40-pound kettlebell weights. This can simulate pulling a battle buddy out of harm's way, moving quickly to take cover, or carrying ammunition to a fighting position or vehicle.

Leg tuck : Similar to a pullup, Soldiers lift their legs up and down to touch their knees/thighs to their elbows as many times as they can. This exercise strengthens the core muscles since it doubles the amount of force required compared to a traditional situp.

2-mile run : Same event as on the current test. In the ACFT, run scores are expected to be a bit slower due to all of the other strenuous activity.

As part of its culture change, the Army is building a Holistic Health and Fitness System to produce healthier and fitter Soldiers. The new test is only one piece of the new system. There will also be improvement of fitness centers, and healthier options of food for the Soldiers.

Here at Evolution, we strive to make sure that our training programs incorporate strength, endurance, mobility and injury prevention exercises. We offer in person group, individual and online programming options. All of the exercises our strength coaches prescribe are designed to address your specific weaknesses and build on your strengths. Our main goal, for all our clients, is to maximize their potential and make sure they achieve their goals whether or not they are performance based.

The fitness tests and standards are evolving. Why shouldn’t your training?

Keep an eye on our website for more tips about the exercises and how to advance through them safely!

Check out our Strength and Conditioning page on our website and get started today!

Source:

https://www.army.mil/article/208189/army_combat_fitness_test_set_to_become_new_pt_test_of_record_in_late_2020

BPP-what?

Mon, 03 Dec 2018 21:43:16 GMT

Time to stop the room from spinning (~5 min read)

Dizziness is a common complaint among the general population and can have many underlying causes but typically results as a disruption in the visual, somatosensory or vestibular system. Up to 42% of patients with complaints of dizziness or vertigo end up with the diagnosis of Benign Paroxysmal Positional Vertigo- or BPPV.(1) This is one of the most common issues with our inner ear and is defined as a disorder characterized by repeated episodes of positional vertigo.

What is BPPV?

While the name sounds intimidating, the good news is BPPV is one of the easiest vestibular conditions to treat which is critical because quality of life can be significantly impacted when living with BPPV. Patients with BPPV are at increased risk for falls, experience impairment in performance of daily activities and may have associated episodes of nausea.(2)

Breaking it down:

- Benign suggests that this is a non-life threatening condition of the central nervous system with a good prognosis- if left untreated 50% of individuals will have complete resolution of symptoms within 3 months, however with treatment it can resolve much faster.(2)

- Paroxysmal means that the symptoms are not constant but rather they rapidly or suddenly occur

- Positional suggests symptoms occur or are triggered by various movements of the head, and

- Vertigo means individuals experience the sensation of “ spinning ” or motion, either they are spinning or that the room is spinning around them.

Relationship of ear anatomy to BPPV

To fully understand the underlying mechanisms of BPPV it is essential to have a basic understanding of the anatomy of the ear. The outer ear, funnels sound vibrations from the external environment down the ear canal to the ear drum. Sound crosses the eardrum entering the middle ear, where it is conducted by 3 tiny bones called the malleus, incus and stapes to the inner ear (Figure 1).

The inner ear is where the magic happens and is divided into two parts, sound information is processed in the cochlea and transmitted to the brain via the cochlear nerve which is how we recognize and interpret “sound.” The other part of the inner ear is the vestibular system (Figure 2), which consists of a complex bony labyrinth with 3 semicircular canals that are filled with fluid and each situated in a plane in which our head moves. The 3 semicircular canals (anterior, posterior and horizontal) respond to angular acceleration of the head (think shaking your head yes (vertical) or no (horizontal)) and the various orientations at 90 degrees to each other help us detect different directions of movement. When we move or change position, the fluid is displaced within the canals, flows into an expansion of the canal termed the ampulla and stimulates specialized hair cells in the cupulla to send feedback to the vestibular nerve to tell our brain which direction our head is moving. This signaling is essential to our ability to maintain balance and coordinate head and eye movements.

The vestibular system uses two other organs termed the otolith organs , which detect and respond to linear acceleration of the head and are sensitive to gravity. There are two otolith organs, the utricle which detects movement in the horizontal plane (think driving in a car), and the saccule which detects movement in the vertical plane (think riding in an elevator). Within the utricle and saccule there is a gelatinous membrane where calcium carbonate crystals called otoconia sit. The otoconia shift in response linear acceleration leading to movement in the layers of membrane below the otoconia and displacement of hair cells to again signal to our brain in which capacity our head is moving. If you’re feeling confused about the anatomy of the ear and have some free time check out this video for a moderately entertaining and more in depth explanation.

Why does BPPV occur?

So, you’re telling me there are crystals in my ear? Yes, that is correct! And these crystals are the leading culprit in symptoms of vertigo. BPPV results when the crystals are dislodged from the gelatinous membrane that they sit on in the otolith organs, and get misplaced into one of the semicircular canals. This may occur without any mechanism of injury but can also occur following trauma to the head. When the crystals are floating in the canals where they do not belong, they disrupt the movement of fluid which changes the firing rate of the hair cells and triggers the rapid onset of vertigo. Specific to BPPV the actual “spinning” sensation is only temporary (most commonly a few seconds to 1 minute) because when the crystals float and settle down on the bottom of the canal the sensation stops—however, when you go to move your head again the crystals are again floating in the canal and the symptoms will resume.

How do I fix BPPV?

The most common occurrence of BPPV is canalithiasis, with crystals displaced into the posterior semicircular canal 85% of the time.(5) Physical Therapists will examine the presence and direction of abnormal eye movements while the patient is in a symptom provoking position, to determine which canal the crystals are displaced (posterior, anterior or horizontal), which ear is effected (left, right or both) and what type of BPPV is occurring (canalithiasis vs. cupulolithiasis). It is essential to have an appropriate diagnosis initially to determine treatment moving forward, therefore, despite a plethora of information on the internet, it is recommended to see a physical therapist trained in vestibular rehab.

There are 3 maneuvers to test for BPPV, the dix-hallpike test or the side-lying test (for those without cervical ROM to perform dix-hallpike or who cannot lie on their back) for the posterior canal.(6) To test the horizontal canal therapists will use the roll test.(7) These maneuvers may be completed with frenzel lenses or infrared lenses to maximally visualize eye movements. The direction of torsion within the eye is indicative of which canal the crystals have been displaced. Once it has been determined which canal the otoconia are dislodged, there are various canalith repositioning maneuvers for treatment to return the crystals back to where they belong and ultimately reduce symptoms.

Who can help me?

If you or someone that you know may be experiencing BPPV then schedule an initial evaluation with one of the therapists at Evolution Sports for thorough and individualized care to return you to your prior level of function!

References

Bhattacharyya, N., Gubbels, S., Schwwartz, S., Edlow, J., El-Kashlan, H., Fife, T., et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology Head and Neck Surgery . 2017:156:S1-S47.
Lopez-Escamez JA, Gamiz MJ, Fernandez-Perez A, et al. Long-term outcome and health-related quality of life in benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol . 2005; 262: 507-511.
Burton MJ, Eby TL, Rosenfeld RM. Extracts from the Cochrane  Library: modifications of the Epley (canalith repositioning) maneuver for posterior canal benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg . 2012;147:407-411.  
von Brevern M, Bertholon P, Brandt T, et al. Benign paroxysmal positional vertigo: diagnostic criteria. J Vestib Res . 2015;25:105-  117.  
Parnes LS, Agrawal SK, Atlas J. Diagnosis and manage- ment of benign paroxysmal positional vertigo (BPPV). CMAJ . 2003;169:681-693.
Viirre E, Purcell I, Baloh RW. The Dix-Hallpike test and the canalith repositioning maneuver. Laryngoscope . 2005;115:184-187.  
Casani AP, Nacci A, Dallan I, et al. Horizontal semicircular canal benign paroxysmal positional vertigo: effectiveness of two different methods of treatment. Audiol Neurootol . 2011;16:175-184

Manipididoodads

Wed, 28 Nov 2018 20:46:14 GMT

The WHY behind Spinal Manipulation

If you have been to a Physical Therapist, Chiropractor, or Osteopath in the past, you may be familiar with one of the common manual therapy techniques utilized across all disciplines known as manipulations. Manipulations involve one high-velocity, low-amplitude thrusting motion administered with the purpose of creating an analgesic (pain reducing/relieving) effect. Manipulations can be performed on joints throughout the body, however most commonly they are performed on the vertebrae of the spine to address cervical, thoracic, and/or lumbar pain.

Clinicians regardless of profession treating similar orthopedic conditions should not use manipulations as the only form of treatment. They should rather use manipulations as one component of their treatment other interventions and with a combination with specific exercises to target a patient’s impairments. Multiple studies have shown that patients reported similar improvements in symptom reduction following either spinal manipulation or an exercise program. However, patients reported the greatest improvement in symptom reduction when spinal manipulations were combined with an exercise program.

Several studies have looked at the analgesic effects of spinal manipulations by analyzing pain pressure threshold values prior to and following a manipulation. Pain pressure thresholds (PPTs) are defined as the minimal amount of pressure required for patients to perceive as painful. Following spinal manipulations, patients have experienced increased pain pressure thresholds meaning their tolerance of a painful stimulus increased. Manipulations have been shown to not only have a local analgesic effect to the joint manipulated, but also an overall reduction in the body’s sensitivity to pain. This is due to the effects that manipulations have on central sensitization. Central sensitization is a neurological process of the body in which increased sensitization is correlated with chronic pain syndromes. Manipulations have been shown to have a reducing effect on central sensitization, therefore potentially being beneficial for patients presenting with chronic pain or chronic pain syndromes.

One aspect that anyone who has received a manipulation or observed a manipulation being performed probably has experienced is a “popping” sound known as a cavitation. The sound produced by a cavitation was previously thought to be a collapse of an air bubble within the joint, however evidence suggests this sound is not related to air bubbles but is due to a cavity formation in the joint when a manipulation is performed. Cavitations do not necessarily suggest that a manipulation has been effective or therapeutic, however they are widely considered a hallmark of a successful manipulation. Absence of cavitation also does not necessarily mean the manipulation did not have some therapeutic effect. Often with spinal manipulations it is common to hear multiple cavitations within one manipulative movement as multiple spinal levels can be targeted at once. Ultimately, cavitations are a very common part of manipulations and should not be considered a signal of damage or adverse outcome.

Much like any intervention implemented by a PT or other health professional, there are some contraindications to performing manipulations on patients that have a specific past medical history or previous pathology. Contraindications are reasons for not performing a specific intervention as it may lead to harm for the patient. Contraindications for spinal manipulations are as follows: malignancy/cancer in the area of manipulation, rheumatoid collagen necrosis, recent/unhealed fracture in the area of manipulation, ligament rupture or instability of joint being manipulated, metabolic bone disease, bony fusion or ankylosis of joint being manipulated, and osteomyelitis. If any of these conditions apply to you, be sure to inform your health professional prior to receiving a manipulation.

Manipulations are not the end all, be all; but they are an important part of a Orthopedic Manual Physical Therapy skillset, one the therapists at Evolution Sports Physiotherapy possess. Our therapists have had extensive training through a number of organizations including but not limited to MAPS and AAMT to develop an eclectic and thorough application of manual therapy. If you have not had successful treatment for neck and back conditions thus far or are curious as to whether or not these techniques may be appropriate for you, please feel free to contact us for an evaluation.

Resources:

1) Bialosky, Joel E., et al. “How Spinal Manipulative Therapy Works: Why Ask Why?” Journal of Orthopaedic & Sports Physical Therapy, vol. 38, no. 6, 2008, pp. 293–295., doi:10.2519/jospt.2008.0118.

2) Bialosky, Joel E., et al. “Spinal Manipulative Therapy–Specific Changes in Pain Sensitivity in Individuals With Low Back Pain (NCT01168999).” The Journal of Pain, vol. 15, no. 2, 2014, pp. 136–148., doi:10.1016/j.jpain.2013.10.005.

3) Coronado, Rogelio A., et al. “Changes in Pain Sensitivity Following Spinal Manipulation: A Systematic Review and Meta-Analysis.” Journal of Electromyography and Kinesiology, vol. 22, no. 5, 2012, pp. 752–767., doi:10.1016/j.jelekin.2011.12.013.

4) Dunning, James, et al. “Bilateral and Multiple Cavitation Sounds during Upper Cervical Thrust Manipulation.” BMC Musculoskeletal Disorders, vol. 14, no. 1, 2013, doi:10.1186/1471-2474-14-24.

5) Kawchuk, G., et al. “Visualization of Joint Cavitation in Realtime.” Physiotherapy, vol. 101, 2015, doi:10.1016/j.physio.2015.03.3595.

6) “United Kingdom Back Pain Exercise and Manipulation (UK BEAM) Randomised Trial: Effectiveness of Physical Treatments for Back Pain in Primary Care.” Bmj, vol. 329, no. 7479, 2004, p. 1377., doi:10.1136/bmj.38282.669225.ae.

7) Voogt, Lennard, et al. “Analgesic Effects of Manual Therapy in Patients with Musculoskeletal Pain: A Systematic Review.” Manual Therapy, vol. 20, no. 2, 2015, pp. 250–256., doi:10.1016/j.math.2014.09.001.

Time to Get Your Swole On

Mon, 26 Nov 2018 18:02:30 GMT

Blood Flow Restriction - A Five Minute Read

Blood flow restriction, “BFR”, occlusion training, hypoxic training, KAATSU—just a couple of different names for a training technique that is becoming increasingly popular in both the strength and conditioning and rehabilitation worlds.

What Is It?

Blood flow restriction is a training technique utilized to partially restrict blood flow during exercise, causing blood to pool in the limb. When BFR is combined with low load resistance training (20-40% 1RM) it produces increases in muscle size and strength, like the effect observed with high load resistance training (Scott et al., 2014). BFR is a technique used to create the necessary metabolic stress required to promote physiological changes without the same mechanical stress on the body (cool!).

How does it work?

To train using BFR it involved wrapping a pressure cuff around the top portion of a limb (upper arms if performing upper body exercises, and upper thigh if performing lower body exercises), to restrict blood flow out of the working muscle. When utilized appropriately arterial blood flow (blood leaving the heart and running TO the muscle) can enter the exercising muscle, but venous outflow (or the blood leaving the muscle to return to the heart) is restricted (Loenneke et al., 2014).

While the underlying physiology is not completely understood, there are a few proposed mechanisms for how BFR promotes skeletal muscle hypertrophy. First is the that when metabolic byproducts are contained in the muscle it produces a more acidic environment and initiates anabolic metabolism. This change in cellular environment increases the amount of growth hormone and IGF-1 which have a direct impact on protein synthesis, stimulating muscle hypertrophy (growth). Additionally, BFR has been thought recruit type II muscle fibers more rapidly, reversing how our body would volitionally recruit muscles per Henneman’s size principle. It may also increase the activation and number of myogenic stem cells, enhancing the overall hypertrophic response (Nielsen, 2012). While more research is underway to establish exactly what is occurring at the cellular level, the basic idea is that occluding blood flow allows individuals to train with lower weights and see the same strengthening results with less mechanical stress to the body.

Why do we care?

BFR has frequently been used in strength and conditioning programs to help healthy individuals maximize their strength, however, the argument for using this technique in a rehabilitation setting is particularly compelling. This process of creating an anabolic environment within the muscle to promote physiological adaptations usually only occurs during high intensity and high volume strength training. The problem is that high intensity and high volume strength training are not always an option in certain populations and have other inherent risk associated due to the mechanical stress on the body.

Typically, in strength training one must lift at least 70% of their 1RM to promote muscle hypertrophy, however, an athlete following surgery or an elderly individual who has been immobilized after a fall will likely not be able to lift at such a high intensity. BFR has been shown to reduce muscle atrophy seen with cast immobilization and has been shown to limit functional declines in muscular strength (Kubota et al. 2011). This is encouraging in the rehab setting because it can be utilized to promote changes in skeletal muscle using reduced loads to comply with tissue healing after surgery, helping individuals build strength and recover faster (Ozaki et al., 2011).

Cuff application:

In general wider cuffs have been shown to increase rating of pain with exercises and restrict arterial blood flow at lower pressures compared to narrow cuffs (Loenneke et al., 2012). Generally, try to use a cuff that is as wide as possible requiring less pressure to reduce arterial inflow.

- Upper extremity: proximal to the biceps muscle belly, just below the deltoid tuberosity

- Lower extremity: as proximal on the thigh near the gluteal fold as possible

- Limb occlusion: each person requires an individualized pressure for effective use of BFR. Literature suggests that a cuff pumped up to 7/10 perceived tightness has been most effective to allow arterial inflow and occlude venous outflow- however, use manual palpation of the radial or brachial artery to ensure arterial blood flow is not occluded. Best practice would be to use a Doppler ultrasound device to ensure arterial blood flow is not occluded.

Exercise recommendations

- Repetitions The typical protocol seen throughout current literature is training with BFR for 4 total sets. The first set is of 30 repetitions, followed by 3 sets of 15 repetitions.

- Load should be around 20-30% of your maximum weight—training at a higher percentage has not been shown to yield further benefit

- Rest period 30-60 seconds between sets, without releasing occlusion

- See the evidence-based recommendations below (Scott et al., 2014)

Troubleshooting

You should not be experiencing pain prior to initiating exercise—if this is the case the wraps are likely too tight. The discomfort experienced with BFR should be due to the buildup of metabolites, not the cuff pressure. If you are not able to complete the 30-15-15-15 repetition protocol then either the load you are using is too high or the cuff occlusion is too tight. Check that you are using the 20-30% max load and then assuming the load is correct, loosen the cuffs.

Recap

To wrap it all up here—combining BFR with low load resistance training exercises improves muscle hypertrophy and strength, and has important implications for individuals who are not able to train using heavy load.

Using BFR to rehab

If you are interested in learning more about blood flow restriction or incorporating it into your rehabilitation program, schedule an initial evaluation with one of the therapists at Evolution Sports for thorough and individualized care to return you to doing what you love!

References

Scott et al., 2014. Exercise with Blood Flow Restriction: An Updated Evidence-Based Approach for Enhanced Muscular Development. Sports Med. DOI 10.1007/s40279-014-0288-1
Slysz J, et al. The efficacy of blood flow restricted exercise: A systematic review & meta-analysis. Journal of Science & Medicine in Sport . 2016; 19: 669-675.
Cook CJ, Kilduff LP, Beaven CM. Improving strength and power in trained athletes with 3 weeks of occlusion training. Int J Sports Physiol Perform. 2014;9(1):166–72.
Loenneke JP, Thiebaud RS, Abe T, et al. Blood flow restriction pressure recommendations: the hormesis hypothesis. Med Hypotheses. 2014;82(5):623–6.
Luebbers PE, Fry AC, Kriley LM, et al. The effects of a seven- week practical blood flow restriction program on well-trained collegiate athletes. J Strength Cond Res. 2014;28(8):2270.
Loenneke JP, Fahs CA, Rossow LM, et al. Effects of cuff width on arterial occlusion: implications for blood flow restricted exercise. Eur J Appl Physiol. 2012;112(8):2903–12.
Loenneke JP, Kim D, Fahs CA, et al. Effects of exercise with and without different degrees of blood flow restriction on torque and muscle activation. Muscle Nerve. Epub 2014 Sep 3. doi:10.1002/ mus.24448.
Kubota A, Sakuraba K, Koh S, et al. Blood flow restriction by low compressive force prevents disuse muscular weakness. J Sci Med Sport. 2011;14(2):95–9.
Soto GA, et al. The Effects of Short-Term Resistance Training with & without Blood Flow Restriction on Neuromuscular Adaptations. International Journal of Exercise Science . 2017. 2(9): Article 14
Nielsen JL, Aagaard P, Bech RD, et al. Proliferation of myogenic stem cells in human skeletal muscle in response to low-load resistance training with blood flow restriction. J Physiol. 2012;590(Pt 17):4351–61.
Ozaki H, Sakamaki M, Yasuda T, et al. Increases in thigh muscle volume and strength by walk training with leg blood flow reduction in older participants. J Gerontol A Biol Sci Med Sci. 2011;66(3):257–63.
Takarada Y, Takazawa H, Sato Y, Takebayashi S, Tanaka Y, and Ishii N. Effects of resistance exercise combined with moderate vascular occlusion on muscle function in humans. J Appl Physiol 88: 2097–2106, 2000.
Takarada Y, Nakamura Y, Aruga S, Onda T,Miyazaki S, and Ishii N. Rapid increase in plasma growth hormone after low-intensity resistance exercise with vascular occlusion. J Appl Physiol 88: 61–65, 2000.

Not Just Another Ordinary Headache

Wed, 21 Nov 2018 16:37:25 GMT

Diagnosis and Treatment of Cervicogenic Headaches at Evolution Sports

Headache disorders can be complex and dynamic disorders that, according to the World Health Organization (WHO), are very rarely appropriately diagnosed and treated. In 2004, the International Headache Society (IHS) published the second edition of headache classification in order for patients and healthcare providers to better understand and effectively treat the disorder. There are two basic categories: Primary and Secondary. Primary disorders are idiopathic, meaning there was no overt trauma or progressive disease process that underlies the headache. Primary headaches also have a direct link back to a structure within the brain or skull. Types of primary headaches, which are the most common, include migraines and tension-type headaches. Secondary headaches arise from other sources, such is the case with cervicogenic headache (CGH) or sinus headaches. The focus of this post will be on cervicogenic headaches, meaning a headache originating from the neck. Watson estimates that 14-18% of chronic headaches are CGH. It has also been reported in his research that many people suffer from more than one type of headache (1). The criteria used to classify cervicogenic headaches include:

Symptoms and signs involve neck movement
Precipitation of comparable head pain by neck movement, awkward posture and/or external pressure over upper cervical spine segments on symptomatic side
Restriction of neck movement may reduce pain
Pain in neck, shoulder or arm on the same side
Confirmatory evidence by diagnostic block/anesthetic injection
Head pain with the following characteristics

Moderate to severe intensity
Non-throbbing, non-lancing
Episodes varying in duration
Fluctuating continuous pain (2)

Based on the neuroanatomy of the upper cervical spine, there is convergence between central and peripheral nerves in the upper three segments of the spine - C1, 2, 3. This area is therefore vulnerable to disorders of the nerves that can refer pain throughout the head/face and neck if the upper cervical spine is not moving properly. There have been many research studies that demonstrate a correlation of noxious (painful) stimulation or anesthetic blocks to the upper cervical facet joints and pain recreation or relief to areas of the upper neck, head and face. Here are two diagrams supporting such findings:

Effective treatment of headache disorders requires proper screening of the area/quality of pain, associated symptoms, and irritability levels. Physical therapists have the knowledge to properly screen and classify headaches as well as the ability to provide an array of treatment interventions such as manual/manipulative therapy, cervical and postural exercises, dry needling with and without direct current electrical stimulation, and myofascial decompression . Studies have shown that both upper cervical and upper thoracic manipulations have been more effective in improving patients’ pain levels and reported disability than mobilization and exercise alone (3,4). Dry needling has also been shown to assist with modulating descending pain pathways to further reduce pain in the area where a patient may be having symptoms (6,7,8).

If any of the symptoms listed above describe the pain you are currently dealing with, please contact us to come in for an evaluation at either of the Evolution Sports Physiotherapy locations. Our expert clinicians will perform a thorough examination to identify relevant impairments and create a customized treatment plan for you!

Sources:

1) Watson DH, Trott, PH. Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance. Cephalalgia. 1993; 13: 272-284.

2) Sjaastad O, et al. Cervicogenic headache: diagnostic criteria. The Cervicogenic Headache International Study Group. Headache . 1998: 38(6):442-5.

3) Cook, C., Hegedus, E., Showalter, C., Sizer, PS. Coupling behavior of the cervical spine: a systematic review of the literature. J Manipulative Physiol Ther. 2006 Sep;29(7):570-5.

4) Cook, Chad. Orthopedic Physical Examination Tests – An Evidence Based Approach, 2nd Edition . Cook, C. and Hegedus, E. Pearson Education, Inc. 2013

Which type of programming periodization is best for you?

Tue, 20 Nov 2018 19:52:03 GMT

Understanding Periodization

There are many methods of training periodization within the realm of strength and conditioning that encourage long-term athletic development. However, it can often be overwhelming to discern which type is most beneficial for you, or whom you’re training. In this blog we’ll aim to shed some light and highlight similarities between undulating, linear, block, and conjugate periodization.

The main goal behind any model of periodization is to provide a stimulus, encouraging growth and adaptation through recovery. According to the NSCA, periodization is the logical and systematic process of sequencing and integrating training interventions in order to achieve peak performance at appropriate time points (1). The General Adaptation Syndrome (GAS) is the basic, underlying principle within periodization. It is a three-stage response to stress including: alarm, resistance, and exhaustion.

Linear periodization refers to breaking the training program into macro-, meso-, and microcycles (longer versus shorter duration) and increasing intensity while decreasing volume over time. The primary goals include reducing the potential of overtraining, peaking at the appropriate time, and providing maintenance for sport within the specific season.

Undulating periodization refers to the later introduced alternative model to linear periodization. It involves large daily (within the microcycle) fluctuations in the load and volume of assigned core resistance training exercises (1). More specifically, the first day of the week an athlete may have a strength focus, while in the middle of the week there is a hypertrophy focus, and later in the week there is a power focus. This model of periodization encourages results in shorter phases of training and stresses the neuromuscular system through continuous change that helps to overcome plateaus.

The conjugated sequence model is more complex than the aforementioned models. It’s typically composed of three mesocycles in which training is concentrated to ultimately accomplish one major goal such as speed development. This model is usually structured for more advanced athletes with its central principles including concentrated loading, transmutation, and recovery mesocycles in order to take advantage of delayed training effects (2).

The macrocycle of block periodization is divided into several phases (blocks) each with a unique goal and duration varying from 2-6 weeks. Each block focuses on developing a few selected abilities using concentrated stimuli (3). They transition from hypertrophy, to strength, to power. Studies show that this model has found significant maximal strength increases in participants of both genders and greater improvements after weekly undulating and linear periodization models compared with a daily undulating periodized program (3).

Ultimately, there’s no right or wrong model of periodization. Each has it’s own time and place dependent upon the needs and time available to reach them.

If you're looking for help building a program or would like to have an individualized program built for you, take advantage of our Online Programming Services! Our in house strength coaches will take you through a fitness screen and needs analysis to build the best program possible to help you reach your fitness goals. We've worked with beginners all the way up through elite athletes and everyone has seen great results! To get started contact our Strength Coach Tyler Ackerman at tyler.ackerman@evolutionsportspt.com.

Blog written by: Strength and Conditioning intern Christopher Fusco

References:

1. Haff, Greg, and N. Travis Triplett. Essentials of Strength Training and Conditioning . Human Kinetics, 2016.

2. Haff, Greg, and Erin Haff. “Understanding the Conjugated Sequencing Model.” NSCA , www.nsca.com/education/articles/understanding-the-conjugated-sequencing-model/ .

3. Bartolomei, Sandro, et al. “Block vs. Weekly Undulating Periodized Resistance Training... : The Journal of Strength & Conditioning Research.” LWW , Journal of Strength and Conditioning Research, Oct. 2015, journals.lww.com/nsca-jscr/Fulltext/2015/10000/Block_vs__Weekly_Undulating_Periodized_Resistance.1.aspx.

Concussion Assessment & Management

Wed, 03 Oct 2018 14:57:08 GMT

A look at treatment options and rationale for application

Sports concussion management has become a hot-topic recently as athletes have become faster and stronger equating to higher impact collisions with opponents, playing fields, equipment and teammates. Youth are getting involved in organized sports at younger ages putting a greater number of children at-risk for injury. Large amounts of money, notably driven by the NFL and NCAA, have poured into research in order to identify risk factors, indicators of recovery, effective rehab programs and prevention measures with respect to concussions. Concussions often occur in sports arenas; however they are also a concern following head trauma as the result of falls, blast-type injuries from military service, motor vehicle accidents or even non-contact whiplash injuries. Each of these scenarios can include similar presentation of symptoms, but some characteristics are often unique to the trauma involved. Along with physical trauma to the brain which can create further vascular and chemical effects that perpetuate prolonged effects, other systems can also be involved which can contribute to the clinical picture. Commonly reported symptoms are headache, dizziness, difficulty sleeping, imbalance and irritability.

These symptoms are often reported in issues involving the cervical spine (cervicogenic) as well as the vestibular system – without head trauma . Therefore it is essential for healthcare providers to determine the system and pathology that is causing prolonged symptoms. Researchers agree that most symptoms resolve in 7-10 days, however in 10-15% of the cases, individuals notice symptoms persisting weeks to months. [1] There are also factors suggesting who may be more vulnerable to persistent symptoms such as younger populations, females, and those with a pre-existing cognitive disorders (ADHD) or affective disorders (depression, anxiety). [2] It is important to determine in these cases if the pathophysiology of concussion is still at fault for symptoms or an independent system such as the neck (cervical) or inner ear (vestibular) or visual system.

The overlapping nature of the cluster of symptoms makes it important to clinically test each system’s influence on the patient’s presentation in order to fully address any impairment. For example, rest may be the best treatment of the physical and chemical trauma to the brain however prolonged rest (>2-3 days) may only exacerbate cervicogenic, physiologic or vestibular dysfunctions. This makes for protracted symptoms and potentially worsening symptoms if an athlete attempts to return to their sport.

Consensus on best practices for the management of concussion patients is marginal – guidelines are presented and revised, different groups have specific parameters for measuring progress through phases and benchmarks for return to sport. Guidelines and protocols are likely difficult to nail down due to the individual nature of the type of injuries, pre-injury status of all the systems involved and effects of treatment strategies on the various structures involved in a rehab program. The important components of a rehab program need to address the cognitive, vestibular, physical and psychological dysfunctions that can be present in individuals who have suffered concussions.

The American Physical Therapy Association (APTA) has a recommendation for the evaluation and management of concussions based on the most recent evidence which includes:

1. Rest from both cognitive and physical exertion – evidence is supporting that prolonged rest is not necessarily better than progressive return to activities [3] . Knowing when to begin and how intense activity should be is an essential element to the plan of care.

2. Protection from additional injury . There is increased vulnerability for repeat concussion while the brain is healing from a current concussion (Second Impact Syndrome). Second Impact Syndrome is rare, but catastrophic. It occurs only in young people (<23 years) and has a mortality rate of 50% when it occurs.

3. Neurocognitive assessment helps determine recovery stage, which is often performed by neuropsychologist, the individual’s school or allied health professional.

4. Balance Testing is helpful to establish presence of concussion and track of recovery

5. Physical therapy such as manual interventions and stabilization training for persistent neck pain and headaches when indicated; as well as threshold controlled strength and conditioning to improve physiologic homeostasis; vestibular and/or visual training for dizziness and imbalance

The APTA’s position and experience from the clinical evidence on physical therapy for concussions shows that up to 79% of patients report dizziness and 56% experience balance impairments following a sports concussion [4] . Post-concussive dizziness and headaches may arise from several sources including benign positional paroxysmal vertigo (BPPV), visual disturbances, post-traumatic migraines, labyrinthine concussion, neck dysfunction. Vestibular therapy has been shown to be effective in managing patients following concussion who continue to experience ongoing imbalance or dizziness without spontaneous resolution [5] . Specific interventions for cervical issues can also help to address headaches, neck & facial pain, dizziness and balance issues. A separate blog article touches on the pathology of a mild traumatic brain injury here . Evolution Sports has created a treatment and assessment algorithm to identify the full cause of unrelenting symptoms: physiologic (HR/BP), cervicogenic, vestibular, visual.

Pain referral patterns in upper cervical dysfunction

The physical therapists at Evolution Sports have specialty training in manual therapy, differential diagnosis as well as vestibular diagnosis and treatment in addition to having a special interest in return to sport training. They are all certified or working toward completion of certification in manual therapy. They have access to a team of neurologists, pediatric orthopedists and audiologists as referral resources if your care exceeds the scope of physical therapy or additional testing is necessary for progression of your plan of care. Your physical therapist at Evolution Sports is looking forward to developing a patient and symptom-specific rehab guideline for you or your loved one based on the most up to date research.

[1] McCrory P, et al. Consensus Statement on Concussion in Sport – 4th International Conference on Concussion in Sport held in Zurich Nov 2012 . Clin Sport Med. 2013 Mar; 23(2). 89-117.

[2] McCauley SR, Boake C, Levin HS, Contant CF, Song JX. Post-concussional Disorder Following mild to moderate TBI; Anxiety, Depression and Social Support as Risk Factors and Co-morbidities. J Clin Exp Neuropsychol. 2001 Dec; 23(6): 792-808.

[3] Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. 2010 Jan; 20(1):21-7.

[4] Lovell MR, Iverson GL, Collins MW, Podell K, Johnston KM, Pardini D, Pardini J, Norwig J, Maroon JC. Measurement of sypmtoms following sports-related concussion… Appl Neuropsychol. 2006; 13(3): 166-74.

[5] Alsalaheen BA 1, Mucha A , Morris LO , Whitney SL , Furman JM , Camiolo-Reddy CE , Collins MW , Lovell MR , Sparto PJ . Vestibular Rehabilitation for Dizziness and Balance Disorders after Concussion . J Neurol Phys Ther. 2010 Jun; 34(2):87-93.

Concussion By The Numbers

Tue, 18 Sep 2018 19:18:13 GMT

A look at the pathophysiology and incidence rates of concussion

Concussions, also known as traumatic brain injuries (TBI), have been a common topic in the news and medicine recently. The Centers for Disease Control and Prevention (CDC) recently rolled out new guidelines for the identification and management post-concussion. The CDC states that a TBI can range from mild (brief change in mental status or consciousness) to severe (an extended period of unconsciousness or memory loss after the injury. Mild forms of TBI are commonly called concussions [1] . We know that brain injuries can happen anywhere – from a fall in the yard to a motor vehicle accident – and they can happen at any age. However there are an increasing number of sports-related concussions and the greatest demographic affected by such head injuries are high schoolers. Some of the reasons for this are behavioral, environmental and physiological. Kids are entering structured sports at earlier ages giving them more potential "exposures" for injury. The brains of children are also still developing and injuries at younger ages will have longer potential effects.

Head injuries will cause a double impact scenario: 1) head contacts object 2) object propels head in the reverse direction causing a second impact on the opposite side of the brain. However the idea of getting your “bell rung” belies the true issue and long term implications of a mild TBI.

It’s not simply deciding how bad the goose egg will be or icing down the inflammation from the hit. The impact of the head and the shearing of connections between the head and brain sets off a cascade of metabolic, physiological and microstructural injuries to the brain. The whiplash injury that can occur from the neck can cause headaches, dizziness and/or neck pain. Traumatic brain injury can affect the control center of our bodily functions not under conscious control, such as breathing, heartbeat and digestive processes. This system is called the autonomic nervous system (ANS). Concussions also can affect the control of both the cerebral brain flow (CBF) and cardiac rhythm. [2] Disrupting this chemical and metabolic system can cause potential concentration issues, dizziness and exercise-induced symptoms, among other complaints. The pathophysiology needs to be understood in order to best treat the wide-ranging presentation of symptoms.

With media attention turned toward long-term effects as well as untimely deaths related to head injuries, professional sports and the NCAA have invested large amounts of money into current research for assessment and treatment of concussions. As healthcare professionals we are now trying to utilize this information to best identify and treat patients.

Here are some numbers from the CDC on concussion overview…

In 2013, about 2.8 million TBI-related ER visits, hospitalizations and deaths occurred in the US
Over the span of six years (2007-2013), TBI-related ER visits increased by 47%
In 2012, an estimated 329,290 children (age 19 or younger) were treated in US ERs for sports and recreation-related injuries that included a diagnosis of concussion or TBI
From 2001 to 2012, the rate of ER visits for sports and recreation-related injuries with a diagnosis of concussion or TBI, alone or in combination with other injuries more than doubled among children.

The increased reporting is not surprising given the recent attention, but expect education from healthcare providers instead of a slew of medical testing at an initial medical appointment. Recent evidence has not supported routine imaging (x-rays, MRI) or blood tests to identify the presence or severity of a concussion. [3] For further potential treatment in the case of prolonged symptoms, see our separate blog here .

As stated earlier, concussions can happen anywhere to any person. The CDC reports that falls are the leading cause of head injuries reported to the ER for all but one age group: 15-24 year olds. Being struck by or against an object was the leading cause of TBI-related ER visits for this age group. In a study conducted by Meehan, et al in 2011 found that approximately 9% of all high school sports injuries are concussions – that’s almost 1 out of 10 injuries! [4]

Concussion Rates per Sport

The below numbers indicate the amount of sports concussions taking place per 1,000 athletic exposures. An athletic exposure is defined as one athlete participating in one organized collegiate athletic practice or competition, regardless of the amount of time played.

Injury Rate Per Exposure Based on Sport in Collegiate Athletes 1998-2004 [5]

Women’s Ice Hockey	0.91
Men’s Football (American)	0.54
Men’s Ice Hockey	0.41
Women’s Soccer	0.41
Men’s Soccer	0.28
Men’s Lacrosse	0.25
Women’s Lacrosse	0.25
Women’s Basketball	0.22

To learn more about Concussion Management , contact the Physical Therapists at Evolution Sports ! Early treatment is key to a successful outcome!

1. Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the US: steps to prevent a serious public health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003.

2. Leddy J, Baker JG, Haider MN, Hinds A. A Physiological Approach to Prolonged Recovery from Sports-Related Concussion . J Athl Train 2017 Mar; 52(3). 299-308.

3. Lumba-Brown A, Yeates KO, Sarmiento K. Diagnosis and Management of Mild Traumatic Brain Injury in Children . JAMA Pediatr. Published online Sep 4 2018. doi 10.1001

4. Meehan WP. Assessment and Management of Sports-Related Concussion. AM J Sports Med. 2011 Nov; 39(11): 2304-10.

5. Hootman J, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports … J Athl Train. 2007; 42(2): 311-319.

Femoroacetabular Impingement (FAI) and Labral Tear

Mon, 20 Aug 2018 19:45:34 GMT

Current Concepts in Diagnosis and Treatment

Many people can suffer from pain in their hip or groin for prolonged periods of time before receiving a correct diagnosis. The hip is a ball and socket joint, in which the head of the femur inserts into the acetabulum. Surrounding the acetabular cup is the labrum, which is a fibrocartilaginous tissue that helps to deepen the acetabular socket. It is believed that the labrum can act as a lubricator by helping to prevent direct contact with the cartilage. Hip labral tears are becoming a common hip injury. There are several factors that can contribute to a labral tear, one of which is a Femoroacetabular Impingement (FAI).

FAI is caused by abnormalities in the bone structure of the hip joint. There are two types of impingements that can occur: CAM and Pincer . While a person can suffer from only one of the impingements, approximately 86% of patients suffer from both.1 A CAM type impingement occurs when there is an abnormality in the femoral head, compared to a pincer impingement that occurs as a result of an abnormality in the acetabulum.3 Women are at a higher risk of developing a pincer impingement.1 Maximal contact between the acetabular labrum and the anterosuperior femoral head-neck junction occur during internal rotation and flexion of the hip.3 Repetitive movement can cause the labrum to tear. It is also believed that FAI can eventually lead to the onset of osteoarthritis.1, 4 FAI can be either asymptomatic or symptomatic, but if it is symptomatic surgery may be required.

Arthroscopic surgery is performed for those who meet the criteria for hip labral surgery . Arthroscopic hip surgery has seen a tremendous increase in popularity over the last 10 years, with an increase in occurrence of 250% between 2007-2011.5 During surgery, the surgeon will correct any bone abnormalities present and reattach the labrum to the acetabular rim. If one does not have enough labrum, the doctor may use an autograft or cadaver allograft using Iliotibial band (IT band) in order to perform a Labral Reconstruction .

Post-surgical rehabilitation generally takes about 12 weeks and is supervised by a physical therapist. Unlike many surgeries, rehabilitation will begin either the same day as surgery or the next morning. The patient will begin the ride a stationary bike as soon as possible, sometimes the same day depending on the doctor’s protocol. External rotation and abduction of the hip are limited by a hip brace. In addition, anti-rotation bands may be used to help limit tension to the repaired structures. Patients will typically remain non-weight bearing through the first phase of therapy, which can last about 4 to 6 weeks. The first phase of rehabilitation focuses on circumduction and passive motion. Phase two of rehabilitation focuses on early strength exercises, aimed at restoring the hip flexors, hamstrings, quadriceps, glutes and IT band.4 It also encompasses neuromuscular re-education and stabilization exercises for the hips and spine. For patients who will be returning to sports, functional rehabilitation may also begin at this stage. The last phase continues to focus on strength training and sport-specific exercises. Patients can sometimes return to sport as soon as four months after surgery.4

It is important to note that conservative or nonoperative management can be a viable and successful option for patients who may be suffering from symptoms related to FAI or Hip labral pathology. A recent systematic review of research studies looking at nonoperative treatment of FAI demonstrates that there are favorable findings for conservative intervention with hip impingement patients.6 Given the various disorders capable of causing hip pain, it is important that a careful and comprehensive examination of the hip joint and its surrounding structures be completed prior to patients immediately opting for surgical intervention. Physical therapists are wonderful resources to utilize for these examinations and subsequent treatment to address any deficits or biomechanical errors. Physical therapists have the ability to perform and interpret findings of diagnostic ultrasound in order to further evaluate the integrity of the internal hip capsule. This offers patients the opportunity to have a picture of their hip joint without the hassle of setting up an appointment for an MRI and waiting for the results to be given by a radiologist.

In terms of the physical exam, the deficits typically seen with hip impingement cases include poor posterior joint play, increased hip adduction and/or internal rotation during functional activities (running, cycling, jumping, etc.), as well as weak and/or tight surrounding hip/gluteal musculature.7 The development of a precise, individualized physical therapy program to address each patient’s deficits can assist with patients avoiding surgical intervention. Physical therapists will employ various manual therapy techniques and therapeutic exercises/activities that will improve posterior hip joint play, strengthen hip musculature in closed and open chain positions while working in all three planes of movement, and correcting faulty biomechanics/movement patterns in order to reduce the stresses placed on the hip joint and decrease instances of hip impingement.

Hip impingement and hip labral tears are becoming more understood, and more doctors and physical therapists are competent in the differential diagnostic process in recognizing this pathology.

For more information on evaluation and treatment at Evolution Sports , click here .

References:

1) Alradwan, H., Philippon, M.J., Farrokhyar, F., Chu, R., Whelan, D., Bhandari, M., & Ayeni, O.R. (2012). Return to preinjury activity levels after surgical management of famoroacetabular impingement in athletes. Arthroscopy, 28 (10).

2) Ayeni, O.R., Adamich, J., Farrokhyar, F., Simunovic, N., Crouch, S., Philippon, M.J., & Bhandari, M. (2014). Surgical management of labral tears during famoroacetabular impingement surgery: a systemic review. Knee Surgery, Sports Traumatology, Arthroscopy, 22 (4).

3) Emara, K., Samir, W., Motasem, EL.H., & Ghafar, K. (2011). Conservative treatment for mild femoroacetbaular impingement. Journal of Orthopaedic Surgery, 19 (1).

4) Philippon, M.J., Goljan, P., & Briggs, K.K. (2010). FAI: From diagnosis to treatment. Techniques in Orthopaedics, 27 (3).

5) Marin-Peña et. al (2017). The current situation in hip arthroscopy. EFFORT Open Rev., 2017 Mar; 2(3): 58-65.

6) Wall, P.D. et al (2013). Nonoperative treatment for femoroacetabular impingement: a systematic review of the literature. PM & R, 5 (5), 418-426.

7) Loudon, J.K. & Reiman, M.P. (2014). Conservative management of femoroacetabular impingement (FAI) in the long distance runner. Physical Therapy in Sport , 15: 82-90.

Autoregulatory Progressive Resistance Exercise (APRE)

Wed, 15 Aug 2018 15:05:54 GMT

How to Individualize Your Training Program for Maximum Gains

The Autoregulatory Progressive Resistance Exercise(APRE) program was created by Dr. Bryan Mann, which he adapted from Dr. K.L. Knight (DAPRE) and Mel Siff (APRE). The whole concept of Dr. K.L. Knight and Mel Siff’s program design was that the number of repetitions performed determined the weight that the athlete would use the next set or the following week (Verkoshansky & Siff, 2009, p. 259). The purpose of this design was to increase the weight based off the progress of the athlete. This style of training is superior to a traditional linear based program because it auto-regulates the program based on how the athlete is feeling that day. There are many stressors that will effect how athletes perform that day, sleep, how much they ate, school, relationships etc., APRE takes these into consideration.

APRE has three different programs depending on the desired physiological adaptations that need to be achieved. APRE10 would be used for athletes that need more hypertrophy (muscle gain) or endurance athletes. APRE 6 would be used for athletes that need hypertrophy and strength gains. APRE3 would be used for athletes that need to get stronger.

HOW IT WORKS

For each of the APRE programs, the warm up weights are based off of repetition maximum of the specific program. For example, APRE3 is base off the athlete’s 3RM or 92% of their 1RM (APRE6-82%; APRE10-75%). The workout consists of a warm up, a set at 50%, and a set of 75% with the number of repetitions expressed (Table 1). The third set would be the first maximal set, for this set the athlete wants to get as many repetitions as they can. This is because the number of repetitions they get determines what weight they use for the fourth set (Table 2). For example, if an athlete is using APRE6 and for their third set they squatted 300lbs for 10 repetitions, the weight they would use for their fourth set would be 305-310lbs. The fourth set is also a maximal effort set, where the athlete performs as many repetitions as they can. The next week the athlete’s first max out set would be the fourth set from the week prior and follow the same protocol.

Table 1. The APRE routines.
Set	3RM routine	6RM routine	10RM routine
0	Warm up	Warm up	Warm up
1	6 reps at 50% 3RM	10 reps at 50% 6RM	12 Reps at 50% 10RM
2	3 reps at 75% 3RM	6 reps at 75% 6RM	10 reps at 75% 10RM
3	Reps to failure at 3RM	Reps to failure at 6RM	Reps to failure at 10RM
4	Adjusted reps to failure	Adjusted reps to failure	Adjusted reps to failure

Table 2. The adjustment table for APRE
3RM routine	6RM routine	10RM routine
Repetitions	Set 4	Repetitions	Set 4	Repetitions	Set 4
1-2	Decrease 5-10lbs	0-2	Decrease 5-10lbs	4-6	Decrease 5-10lbs
3-4	Same	3-4	Decrease 0-5lbs	7-8	Decrease 0-5lbs
5-6	Increase 5-10lbs	5-7	Same	9-11	Same
7+	Increase 10-15lbs	8-12	Increase 5-10lbs	12-16	Increase 5-10lbs
		13+	Increase 10-15lbs	17+	Increase 10-15lbs

FINER POINTS

There are a couple of points that you want to take into consideration when you decide to run APRE. The first point that you or your coach wants to take into consideration is that form may break down during the maximal effort sets. Any time there is a maximal effort set, whether it’s for 1 rep or 20 reps, fatigue sets in, this could cause the weak areas in form to be exposed. Your coach or training partners should recognize these flaws and stop the set. Once weak areas are exposed, identify and add accessory exercises to correct them.

The second point that you want to consider when running APRE is that you want a good coach or training partner. You want them not only to check form but psychological support. When you have a good group around you, you will push harder than if you are lifting by yourself. For instance, if you are tired or having a bad day they can help motivate you to push harder. This brings out the competitive spirit in almost everyone. Training partners are not the only psychological effect you may experience, when you run APRE you set different repetition records every week. Use this momentum to help push your strength and hypertrophy gains further.

The last point to consider when running APRE is for female athletes or athletes that have lower maxes. When you have a lower max a 15 lbs. jump between your maximal sets may be too much. For instance, if you have a 100 lbs. bench press your first max set may be 80 lbs. If you add 15lbs because you got 13 reps that would put you at 95 lbs. or 95% of your 1RM. This is not feasible for most lifters to try and get multiple repetitions with. Be cautious with your jumps from one max set to the next and take into consideration what percent that may be of your one repetition maximum.

THE WAY THAT I HAVE USED APRE

I have the pleasure of knowing Dr. Mann personally and I’m happy to call him a friend of mine. I have used APRE for the past 5 years with teams that I have worked with and results are always incredible. I have seen athletes add over a 100lbs to their squat in less than a year alone. So the methods obviously work.

When I was at Southeast Missouri State I was the only strength coach for football so I had to change up the routines a little bit because I couldn’t change 100 programs every week. Talking to Dr. Mann, I decided to add some linear block periodization to APRE. I would run athletes through three week block going up 2.5% each week taking all percentages from their predicted 1RM. Week 1 the athletes would squat 75% for their first max set of APRE6. For example, if you have an athlete who has a 300lbs 1RM, 82% (6RM) would be 246lbs. Then take a training max of 90% to allow for growth to get 221lbs. This works out well because 75% of 300lbs is 225lbs. To allow for growth I would then program week 2 at 77% (231lbs) and week 3 at 80% (240lbs) to anticipate growth. Week 4-6 I would repeat the percentages and just add 2.5% (77%, 80%, 82%). Increasing by 2.5% each week anticipates making your fourth set your first max set for the next week.

One other thing that I wanted to add to APRE was another set to break up some of the big jumps leading up to the max sets, I personally do not like making huge jumps in weights. In table 1 you see that the athlete goes from 50% to 75% to 92% for APRE3. An athlete with a 400 lb deadlift would lift 184 lbs for 6 reps for the first set, 276 lbs for 3 reps for their second set, and 368 lbs for their third set. I did not care for these big jumps, so I would make the first set of 6 reps at 50% (200 lbs), the second set of 3 reps at 70% (280 lbs), the third set of 1 rep at 77% (308 lbs), and the first max out set at 85% (340 lbs) for the first week. These jumps are more manageable for most athletes than making 100 lbs jumps each set. For APRE6 the repetitions for each set would be 10reps, 6reps, and 3reps, then the max sets. Adding an extra set may not work for everyone but from my experience it has worked out really well.

APRE is a very good program if you are looking to get stronger, put on some size, and see results quickly. This program is good for all levels of training experience, from the beginner to the advance lifter going through a hypertrophy phase. Find good training partners or a good coach that will push you for each sets to get the full benefit.

The Strength Coaches at Evolution Sports understand how to implement a number of training methodologies into an individualized program that will help maximize your training and achievement of training goals. If you have an interest in finding out what they can do for you visit our Strength and Conditioning home page or contact them directly.

REFERENCE:

Mann, B., Dr. (2011). The APRE: the scientifically proven fastest way to get strong.

Verkhoshansky, Y., & Siff, M. C. (2009). Supertraining (6th ed.) Rome, Italy: Verkhoshansky

Degenerative Disc Disease

Tue, 07 Aug 2018 20:01:47 GMT

What's happening and how physical therapy can help

First of all, what is a disc? What does it do? Why is it so important? Intervertebral disks are the shock absorbers of your spine, similar to the function of the meniscus in the knee or the labrum in the hip. These discs can be found in between each vertebral body from C2 all the way to S1. The discs themselves are made up of an outer layer called the annulus fibrosus and an inner layer called the nucleus pulposus. The annulus fibrosis is a tough tissue made up of many layers of collagen, which is also found in your skin, teeth, and scars [1]. The annulus fibrosus surrounds the nucleus pulposus which is a made up of a gel like semifluid also made up of a more elastic type collagen, which aids in shock absorption and distribution of forces placed upon the spine. You can think of these discs as a jelly doughnut, the annulus being the dough and the nucleus being the jelly. These discs are important because they allow you to place stress on your spine without causing abnormal load on the spinal column or the nerves that exit the column [1]. Each vertebral body that is associated with a disc has an endplate; these endplates provide protection of the inner layer of the disc as well as nutrition and blood flow to the discs, which allow the discs to heal if injured [1].

As we age, many changes occur throughout the body, and the spinal column and discs are no exception. When we are born, the annulus fibrosus is highly vascularized through the vertebral endplate, as we begin to walk the vasculature begins to retreat, and by age 5, only the peripheral aspect of the annulus fibrosus is vascularized [2]. This vascular retreat causes cellular changes within the disc that decreases its ability to heal. Once the body has reached full maturity, the gel-like nucleus pulposus becomes less hydrated, due to loss of water attracting cells, creating a pressure change that causes the disc to begin to bulge slightly. By age 40, the disc has gone through a dramatic change ultimately leading to a more fibrous nucleus, and a more elastic annulus, shown in Figure 1 [3]. These changes decrease the discs’ ability to heal as well as weakening the structural stability to withstand forces. This leaves the disc vulnerable to herniation, which is where the nucleus begins to push through the weakened annulus, potentially compressing the nerves that exit the spine [2].

Although this seems like an inevitable recipe for disaster, research shows that the changes in the discs do not mean that there will be a definite herniation, however, there is an increased risk due to the compromised structural stability. This does not mean that as we age we should stop being active, this just means we should be smarter in the activities we choose. Activities that involve modest loading on the spine such as walking or activities that create gradual loading on the spine have actually been found to be beneficial in slowing the degradation process [2]. On the other hand, those who have unfortunately acquired a disc herniation, there are things physical therapy can do in order to help reverse the process and promote healing. Intervertebral disc healing follows a very similar path that tendons and ligaments do. Using the same treatment concepts, physical therapy can be utilized in all phases of the injury process. In the initial phase, also known as the inflammatory phase (0-3 days), it has been found that avoiding painful motions (forward bending) can facilitate healing of the weakened outer layer of the disc. Specifically early in the morning, forward bending of the spine can cause undo stress upon the healing outer layer of the disc, so avoiding this motion can help decrease recurrent bouts of back pain [2]. During the second phase of healing (the reparative phase 1- 6weeks), your physical therapist can initiate controlled mobilization of the segment that can facilitate healing in the vertebral endplates, as well as promote movement, and decrease pain caused by muscle spasms without disrupting the healing process of the disc [2]. Finally, during the third phase (remodeling phase: 6-8 weeks) your therapist can continue mobilizations to decrease pain and provide exercises that can create an adequate amount of stress to promote continued healing of the disc. Once your therapist has determined that healing has been completed they can provide education on motions to avoid, activities that are safe and will decrease your risk for re-injury, as well as improve health and fitness. Although this may not be the quick fix, physical therapy can provide a longer lasting solution and leave you with a greater understanding of your body and how to safely improve your quality of life.

If you have been struggling with low back and are wondering what the Physical Therapists at Evolution Sports can do for you, Please give us a call at 410-628-0520.

References:

1. Dutton M. Orthopaedic Assessment, Evaluation, and Intervention . New York: McGraw-Hill Medical; 2008.

2. Adams MA, Stefanakis M, Dolan P. Healing of a painful intervertebral disc should not be confused with reversing disc degeneration: Implications for physical therapies for discogenic back pain. Clinical Biomechanics . 2010;25(10):961-971. doi:10.1016/j.clinbiomech.2010.07.016.

3. Tomaszewski KA, Saganiak K, Gładysz T, Walocha JA. The biology behind the human intervertebral disc and its endplates. Folia Morphologica . 2015;74(2):157-168. doi:10.5603/fm.2015.0026.

Getting Buried in your Clean? Fix It!

Fri, 26 Jan 2018 16:05:58 GMT

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If you’re having trouble standing up a big clean after catching it in the bottom position, you’re not alone. A lot of lifters get to a point where they get buried by heavy cleans. Some lifters can jerk more than they can clean, but if you can’t stand up out of a clean, you wont even get a shot to jerk the weight. If you’re the one getting pinned deep from a heavy bar, lets discuss a few things that might be happening and how to fix them.

Strong squat and Posture during squat:

A lack of squat strength is the most obvious but probably the least common. And if it’s the problem, you probably already know it. Somewhat less obvious is postural weakness in the front squat position. What I mean is, you’re not able to recover from a heavy squat with your trunk upright and consequently dump your heavy cleans forward.

How to fix it?

Keep squatting. Focus on using weights that are heavier but allow you to maintain good upright posture throughout the entire movement. Also, working in pause squats and banded squats into your program will help build strength coming out of the bottom position.

Balance:

If you’re off balance catching your clean, chances are you’ll struggle standing it up. If you think of a spring, pressing down on it evenly will result in it shooting straight up. Pressing on it unevenly will result in it shooting off in a different direction or falling over completely. This problem might not be a huge deal while just squatting or pulling. As soon as you add an explosive component to it, all those problems get compounded quickly.

How to fix it?

Getting a feel for proper balance by performing accessory exercises such as slow pull cleans; clean pulls and deadlifts will help. Make sure you’re not on the balls of your feet. Pressure should be evenly distributed through the foot with a slight favor towards your mid foot and heal.

Bad rack position in the catch :

When catching a clean you have to make sure you’re catching the bar in a tight front rack position. This means catching the bar on your shoulders, not in your hands with your elbows down. If you have a poor rack position while catching, most likely the bar will fall forward and collapse back down to the floor.

How to fix it?

Most athletes and beginners have a mobility issue in the shoulders and wrists. If that’s the case, working mobility drills into your warm-up will help. If your lats and shoulders are tight from lots of pressing and pulling; spending time stretching and foam rolling will help. Your coach should be able to help you identify what areas you are struggling with and help you with drills to fix them. The goal is always to have the elbows up and drive them up as hard as you can to keep that bar on the shoulders.

Soft Core:

Just like squatting, deadlifting or benching, you need to have good thoracic pressure while doing cleans to be able to absorb the load of the bar crashing down on you. If you fail to do this, you’re almost guaranteed to miss a heavy lift.

How to fix it?

During your warm-u; do some crunches, supermans and bird dogs to wake up your abs and extensors. Creating solid thoracic pressure before the start of the lift is also key. Take a deep breath in and brace your core as if you were bracing to take a punch. This will keep your trunk rigid and help you drive out of the bottom of the catch.

Mindset:

If you walk up to the bar to attempt a big lift and there is doubt in your mind, then you’ve already missed it. Being confident is crucial when lifting near max loads.

How to fix it?

I talk to all my athletes about having the right mindset. Having the right mindset goes beyond the weight room too. Mindset is important in practice, games and in the classroom. Everyone has different ways of pumping themselves up. Positive self-talk, a coach who will hype you up or the right workout playlist. Whatever it may be, it all boils down to you being confident and giving max effort. Be ready to explode up when that bar comes crashing down on you.

Hopefully this article helps anyone who has been getting stuck with their clean. For any coaching tips or programs contact Director of Human Performance Tyler Ackerman at tyler.ackerman@evolutionsportspt.com.

Blood Flow Restriction Training Is Here!

Thu, 16 Nov 2017 15:19:02 GMT

Evolution Sports Physiotherapy is excited to offer one of the newest training tools for rehab and performance – Blood Flow Restriction (BFR) training. Blood Flow Restriction training allows an individual to make strength gains at lower loads with the use of occlusion cuffs to create anabolic (positive) changes. Research on traditional loading requirements for hypertrophy, an increase in the size of skeletal muscle, suggests loads of >65% should be used in order to make gains. So an individual who can bench press 200lb for a one rep max must bench loads of over 130lbs in order to create a gain response on a typical training day. Research on BFR training shows that loads as low as 20-30% of a person’s 1 rep max can stimulate the same hypertrophy response [1] . During BFR training, that same lifter now only has to lift 50# to make gains. Rehab settings are the perfect scenarios for this as typically one is recovering from surgery or an injury that does not allow lifting heavy loads until further along in the recovery process. BFR training allows the therapists at Evolution Sports to begin physiologically creating an environment for increasing growth hormone and muscle protein synthesis from as early as tolerating limb weight in some cases.

How does BFR training create these effects? During traditional resistance exercise, the loading of muscle tissue creates a catabolic (destructive) and, in turn, an inflammatory response which will break down muscle protein. This is part of the normal tissue response and causes the delayed-onset muscle soreness (DOMS) that you feel after a workout. The inflammatory response is what brings on the muscle gains. When we use BFR training, we create an oxygen-limited environment, similar to that of high intensity training. The limited oxygen means that you are able to recruit Type II muscle fibers moreso than Type I fibers which are typically recruited during the type of activities you are performing at the beginning phase of rehab and strength training. Type I fibers eat up more oxygen than Type II for their energy and without the fuel (low levels of oxygen), the Type II fibers are then activated. Therefore BFR training allows us to get a head start on high-intensity benefits with low intensity loads. The lactic acid built up during BFR training (the muscle “burn” of fatigue) allows growth hormone secretion to increase 170% after a workout vs traditional exercise training [2] . And, as an added benefit creatine kinase (catabolic) levels are significantly lower. The increased growth hormone actually serves as a protective role for tendons and muscle collagen as it increases collagen synthesis (creation) – an ideal environment for the rehab of a structure.

To sum up, BFR allows a large increase in protein synthesis with less muscle damage than traditional exercise, all in quicker timeframes than traditional adaptations from high intensity training. Ready to get started? Call the trained professionals at Evolution Sports to find out how BFR training can help get you back to doing what you love to do.

[1] Takarada Y, Takazawa H, Sato Y, Takebayashi S, Tanaka Y, and Ishii N. Effects of resistance exercise combined with moderate vascular occlusion on muscle function in humans. J Appl Physiol 88: 2097–2106, 2000.

[2] Takarada Y, Nakamura Y, Aruga S, Onda T,Miyazaki S, and Ishii N. Rapid increase in plasma growth hormone after low-intensity resistance exercise with vascular occlusion. J Appl Physiol 88: 61–65, 2000.

Maryland Presents New Dry Needling Regulations

Thu, 16 Nov 2017 15:18:12 GMT

The State of Maryland was one of the first states to recognize and allow Dry Needling as an intervention provided by licensed Physical Therapists. This started with a positive Attorney General Statement in 2010. As one of the few PT’s from Maryland who had a long history of Dry Needling experience, I served on the Task Force to help define the language and regulations that would be adopted by Maryland’s State Board of Physical Therapy. After several years of debate with Maryland’s Acupuncture board, we were able to come to an agreement on definitions of Dry Needling and the regulations that would sever the major goal of public safety. In 2012, the Maryland PT and Acupuncture Boards co-authored a Document as a result of this agreement. It has taken 6 more years to finalize these regulations and ratify the Maryland State Practice Act with a chapter regarding Dry Needling. These regulations go into effect June 19th, 2018, allowing one year for all PTs to obtain and provide evidence of the necessary level of training. In my opinion, these are some of the strictest guidelines across the country in terms of requirements to be able to perform dry needling, and while I don’t agree with them, it is a big step forward for our profession since this involved a collaborative effort with our local Acupuncture Board. Regulations can always be changed. Currently, there are only 660 clinicians in MD that perform Dry Needling.

To summarize Marylands Regulations:

· You must be a licensed Physical Therapist in the State of Maryland and have at worked as a PT for at least 2 years

· You must have 80 hours of training and/or mentorship with:

-at least 40 hours of Clinical Education in the form of an approved Continuing education course.

-at least 40 hours of Clinical Mentorship with a PT who meets the requirements and has at least 5 years of experience with Dry Needling.

· PT’s will be required to register with the State and provide evidence of coursework or documentation on clinical mentorship.

· Dry Needling is strictly performed by a licensed PT and not within the scope of limited physical therapy.

Currently, most recognized continuing education courses in the country do not entail 80 hours of training as part of their certification process. Therefore, Certified physical therapists will still be required to document 15-20 hours of clinical mentorship. The expert clinical staff at Evolution Sports will be offering this necessary mentorship opportunity to any qualified PTs who want to ensure that they meet MD’s new regulations at a cost significantly cheaper that attending an additional weekend course. We will be posting a link for this mentorship opportunity under our “ Courses ” page. If you are interested in signing up for clinical mentorship please click on the link above or contact Morgan Johnson for more details.