Comparing Muscle Forces During Lower Quarter Strength Training Exercises
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Strength training is an essential part of an individual's weekly exercise program.  It's numerous benefits include reduced injury risk, increased sports performance, and improved function in life activities.  Time is finite resource and a commonly cited barrier to exercise.  In our Boulder Physical Therapy practice we strive to prescribe the most effective and efficient exercises for each client to maximize time spent exercising.  A recent research article adds insight into which lower body exercises are most effective at recruiting muscles in the core and legs. 

Schellenberg and colleagues studied the muscular responses of 11 healthy participants as they performed a deadlift, good morning, and split squat exercise (BMC Sports Science, Medicine and Rehabilitation. 2017).  The authors found the split squat was most effective at targeting the gluteus maximus muscle in the front leg, but the deadlifts were found to effective at recruiting this muscle over a larger range of motion at both the knee and the hip.  As expected, good mornings recruited the posterior chain muscles including the hamstring more statically than the dynamic deadlift exercise.  Surprisingly, the quadriceps were recruited best in the back leg during the split squat, but the highest quadricep load was found in the deadlift.  Overall, this study highlights the differences between lower body exercises and reinforces the effectiveness of the deadlift for overall lower body muscle recruitment over a large range of motion.

To learn more about maximizing your strength training program contact your local Physical Therapist. 

Early Improvements in Low Back Pain Predict Long Term Improvements
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In our Boulder Physical Therapy practice we aim to help accelerate a patient's recovery by optimizing outcomes in fewer visits.  Consistent with the medical evidence, manual therapy in our practice rapidly reduces a patient's pain allowing them to resume normal activities and exercise often in 1-2 visits.  As clinicians, we know this rapid improvement is important not only because it positively impacts a patient's symptoms but also because it strengths the clinician's reasoning process on the appropriateness of a given treatment intervention.  Previous research has highlighted the importance of these early changes and a new article sheds light on how early changes in symptoms can help predict future change.

Cook and colleagues retrospectively examined patients with low back pain who received two weeks of Physical Therapist directed manual therapy (Physiother Theory Pract. 2017).  Patients were followed up to 6 months to determine if early changes in a patient's pain helped predict who improved the most at 6 months.  The authors reported patients whose pain dropped by 1/3 at 2 weeks were 5-7 times more likely to have reduce pain and disability at 6 months.  Patients whose pain dropped by greater than 50% in first two weeks had similar success at 6 months.  This study supports the re assessment of low back pain patients to help predict long term reductions in pain and disability.

Q and A with Zach Long, PT, DPT, SCS
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In my opinion, Physical Therapy patients are often under exercised and do not return to prior levels of activity due to a lack of rehabilitation intensity.  What are some of your recommendations for implementing higher level exercises and strength and conditioning principles for practicing Physical Therapists?

We have a problem in the physical therapy profession where we are fearful of overloading patients in the clinic. Unfortunately many injuries to tissues happen when the demands placed on that tissue exceed what they we prepared to handle. So if we underload we won't build tissue capacity up to a high enough level to reduce future re injuries. 

My biggest reccommendation for orthopedic clinicians wanting help implementing higher level rehab exercises is to work as a coach! I've learned as much in the past year from working with one gymnastics coach as I did from anyone in the actual rehab professions. For those that can't coach, start reading and following some of the more prominent names in strength and conditioning. See what they are doing and the gaps between that and your rehab programs. Then game plan how to close that gap as much as possible. 

2.  In many athletes, a lack of joint mobility presents as a stability or motor control problem.  What are some common clinical patterns/presentations you observe in these athletes and how are you teasing the mobility vs. stability impairment out during your exam?

Before ever assuming mobility or motor control problems, I always perform both active and passive available motion in all joints making up the larger movement pattern we are working on. Skipping this step often leads athletes and clinicians to working on the wrong thing. 

3.   What role does blood flow restriction training play in your clinical practice.  Which patient populations benefit most from this intervention?

Blood flow restriction is a huge part of my practice for anyone needing improved strength and/or hypertrophy that cannot tolerate heavy loading. This may be after a surgery, acute injury, or someone just fearful of heavier movements. BFR allows us to get similar strength and hypertrophy changes at loads as low as 20-3% of their one rep max that we see lifting loads heavier than 70%. 

BFR also has some very cool hormonal benefits such as improved growth hormone release vs heavy training which can potentially help with bone healing, tendon and ligament rehab, and greater reductions in patient reported pain levels. 

4.  The Tar Heels had a great run in the tournament can we expect a repeat in 2018?

Despite being a die hard TarHeel, I'm actually not much of a basketball fan. I was fortunate enough to work with the football team for two years and tend to follow them more. Hopefully having the Number two draft pick in this year's NFL draft will help.

Core Strengthening Improves Running Times
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Strength training in endurance athletes is an essential part of any injury prevention and conditioning program.  Our previous blogs have highlighted the importance of these exercises for improving an athlete's efficiency during training and competition.  Endurance athletes who strength train are more economical and therefore faster than their weaker peers.  Strength training exercises should involve the core and key muscles associated with each sport.  Runners should spend time focusing on their core and hip muscles, as well as, the muscles surrounding the knee, foot, and ankle.  A new study highlights the importance of this training for improving running performance. 

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Clark and colleagues in the Journal of Strength and Conditioning Research followed 35 cross country athletes' running performances over the course of a season (2017).  The runners were randomized to either a control (normal run training) or a strength group who performed core and hip strengthening 3 times a week for 6 weeks in addition to their run training.  Both groups showed faster times over the 6 week period, but as expected the strength group demonstrated faster running times compared to their peers who did not implement strength exercises. 

Association Between Ankle Mobility and Knee Alignment
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The ankle plays a critical role in the ability of the knee to stay over the foot during functional tasks such as walking, running, and stair climbing.  Under normal conditions the mobility of the ankle allows the leg to move forward over the weight bearing foot.  If this range of motion is limited, the leg moves inward causing the knee to move inside of the weight bearing foot.  This position, known as knee valgus, is a common cause of IT band pain, knee pain, patellofemoral pain, and acute ligamentous and meniscal injuries to the knee.  In our Boulder Physical Therapy practice we find many individuals with knee pain who lack adequate ankle mobility.  A recent review article analyzed the available literature associating this mobility with proximal knee stability.

Lima and colleagues reviewed the available literature on the association between ankle mobility, dorsiflexion, and knee position (Physical Therapy in Sport. 2017).  The authors pooled the results of 17 studies and found an association between ankle mobility and dynamic knee alignment.  In addition, they found measurements of the ankle in weight bearing and non weight bearing were both significant for dynamic knee valgus.  This study lends further support to the importance of examining and treating ankle impairments in patients with knee pain.

 

Q and A with Dan Lorenz, PT, DPT, LAT, CSCS
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Photo Credit: ssorkc.com

1.  You have published a few articles on the utilization of strength and conditioning principles with Physical Therapy patients.  In my opinion, these valuable principles are under utilized in our profession.  In your experience, how can practicing clinicians improve their patient outcomes using these principles?  

Well I think one of the more basic things you can do is hang out with sports performance coaches/strength and conditioning coaches.  Spend some time in the weight room.  Talk to them about energy system development for example or long-term planning for an athlete.  A majority of PT's only see patients for a small window of time, not the whole training cycle.  Similarly, consider shadowing or spending time with PT's that are doing this everyday.  They're out there and they would be a fantastic resource to talk about this.  Additionally, I would consider joint the National Strength and Conditioning Association.   They have two journals you get as a member and lots of other newsletters.  I shutter to say social media because there's quite an array of "experts", but seeking out those experts and finding out who they trust and respect isn't a bad idea either. 

2.  At Specialists in Sports and Orthopedic Rehabilitation you have implemented a multidisciplinary journal club.  How has this journal club impacted the development of your staff and your relationships with referral sources? 

I like to think that it's helped them a lot.  I feel it helps us stay current, but also makes sure that we're always striving to be better and questioning what we're doing.   For example, we review the latest information on patellar tendinopathies to make sure we're not just doing eccentrics like we did in the 90s, but also we review things that make us squirm a little.  Dry needling articles are a good example of that.  It's a service we offer, but the literature is pretty weak right now.  I think it's important that we have resources for our patients, but also that we're not in denial about what the evidence shows. 

From a referral standpoint, we've had physicians join us at journal club which is obviously great for dialogue and for education of all of us.  I send out the articles we're reviewing to a number of physicians.  I don't know if they even review them but I think it's definitely a feather in our cap compared  to competitors because I believe we're very unique in this regard.  I think it's important they know that we're on top of things.  I will say that many reach out to us about their protocols and what they should look like.  I think they do that for two reasons - they know we take care of our folks and our outcomes are outstanding but also that they know we know what the evidence shows. 

3. The risk of a subsequent ACL injury, either in the involved or uninvolved knee, in our patients remains significant.  In your review of the literature and your experience what are some key areas Physical Therapists must focus on to reduce this risk of re injury?

Oh Gosh.  How complex a question! I think the first thing is education.  We have to educate our patients that the "6 months" return to play is frankly, a terrible idea.  We've gotten stuck on that time frame and hardly anyone is legitimately ready at that time.  Tim Hewett and Chris Nagelli published a really thought-provoking (yet probably not very practical!) article about how 2 years is more ideal for return to play.  They presented some compelling data! It will likely never happen, but the research is clearly showing that extending return to play reduces the risk of re-tear.

Along with that is a comprehensive, thorough screening and testing procedure.  Frankly, I think these are still evolving and clearly we need work on them because the re-tear rate is pretty high!  Secondly, PT's need to make sure that any movement deficits that contributed to the tear in the first place are addressed and for gosh sakes, on both sides!  It's striking to me how many re-tears I see that the patient tells me they never worked the uninvolved side in their rehab!  That's insane!  Whether it's poor knee and hip control or improper cutting techniques, we have to pin those things down during the rehab process.  

Lastly, I think we need to be better about long-term planning for their strength training.  Several papers have shown persistent deficits in strength and power in the quads as well as "unconscious loading" of the uninvolved limbs.  These athletes are being sent back out there with out these factors being addressed properly.  Making sure that their athletes are willing to load that limb and that the involved limb has appropriate strength and power is so important.  In some respects, we have to abandon having that typical "PT mindset" of being terrified to load someone for fear of swelling or pain.  It's OK people, put another plate on the bar, they'll be fine!  I would actually argue the other way - we're doing a disservice to our athletes by not making them adapt to loads! Of course I'm not advocating being foolish or progressing too fast, but 3 x 10 isn't making anyone stronger or more powerful

4.  What is your prediction for the Chiefs this season?

Ha Ha, haven't thought too much about that yet.  Andy Reid always puts a solid product on the field.  There's some questions at wide receiver after losing Jeremy Maclin.  Defensively on paper they look pretty awesome, it's just if key players produce - Justin Houston, Tamba Hall, and Dee Ford are there that come to mind.  They have a proven leader and veteran QB in Alex Smith.  I think they'll definitely content for if not win the AFC West.  Of course the x factor every year is always what happens with that pesky injury bug.