Posts tagged exercise
PRP Effects On Tendon Injury Attributed To Post Injection Physical Therapy
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Patellar tendinopathy is one of the more common sports medicine conditions seen in our Boulder Physical Therapy clinic. This condition causes increased pain along the front of the knee just beneath the knee cap and leads to pain with jumping, running, and squatting activities. Current medical evidence has described an absence of inflammatory cells and instead we find an increase in cells responsible for tendon repair. These immature cells are initially laid down in a disorganized pattern and require progressive, optimal loading through exercise to reach a mature, healthy state. In addition to exercise some physicians have advocated for PRP injections into the injured tendon in an effort to accelerate the healing process, but well constructed research trials have not been conducted and this treatment is still considered experimental. A recent research trial examined the effectiveness of PRP for patellar tendinopathy.

A well done randomized controlled trial in the American Journal of Sports Medicine examined the effectiveness of PRP vs. placebo (saline) in patients with patellar tendinopathy (> 6 months of symptoms) (Scott et al. 2019). Patients were randomized to one of three injection groups under ultrasound guidance leukocyte rich PRP, leukocyte poor PRP, and saline. Each group then received 6 weeks (3 times per week) of supervised Physical Therapy including heavy slow strength training (concentric and eccentric loading). Patients were folllowed up at 6,12,36, and 52 weeks. Authors found an improvement in all three groups but no difference in pain, function, or recovery between the three groups. If PRP added to the recovery we should have seen a superior effect of PRP and PT vs. saline and PT, but because all groups were similar we can attribute this change in function to the Physical Therapy strengthening program. This evidence supports our current view on the limited benefits of injections for tendon pain. Patients are encouraged to use a Physical Therapy exercise program consisting of progress, loading exercises to accelerate their recovery from tendon injury.

Does Hamstring Stretching Improve Muscle Length?
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Stretching either dynamically or statically has long been shown to create both short and long term improvements in flexibility, but the mechanism of action behind this form of exercise continues to evolve. Changing human tissue takes considerable time and consistent forces. For example, consider muscle growth or bone density adaptions to exercise. Previous research on the benefits of stretching assumed a structural change in the muscle (sarcomeres in series) was responsible for improvements in muscle flexibility, but more recent research demonstrates improvements in stretch tolerance are more responsible for these positive changes. A recent article examined these mechanisms in a group of individuals with limited hamstring length.

Brusco and colleagues assessed the impact of static hamstring stretching in a group of individuals with limited hamstring flexibility (Eur J App Physiology. 2019). Participants performed a seated hamstring stretch on an isokinetic machine to their maximum tolerance. Hamstrings were stretched for 8 bouts of 60 seconds, twice a week for 6 weeks. Total duration under stretch equaled 96 minutes over the 6 weeks. Authored measured both flexibility and muscle characteristics before and after the study. Consistent with prior research each individual’s range of motion improved but no changes in muscle tendon mechanical properties were noted. This indicates improvements in flexibility were secondary to the improvements in an individual’s tolerance to stretch. Thus, trained individuals were conditioned to tolerate more stretch as they moved through the study.

Physical Therapy Headache Solutions
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Headaches remain a significant source of pain and disability for patients in our country costing over $30 billion dollars each year. Symptoms can be driven by different types of headache including tension, migraine, and cervicogenic (driven from the neck). Cervicogenic headaches can be found in 4% of the general population, 20% of all patients with headaches, and up to 50% of patients with headaches after a whiplash mechanism of injury.

The upper neck vertebrae are most commonly associated with these symptoms with the 2nd and 3rd vertebral joint driving 70% of headaches. The clinical diagnosis can be made based on the following criteria

  1. Pain that originates in the neck and radiates to the frontal and temporal regions

  2. Unilateral symptoms (may be bilateral but never together)

  3. Radiates to ipsilateral shoulder and arm

  4. Provocation of symptoms with neck movement

  5. History of neck pain

Physical Therapy remains a first line treatment for cervicogenic headaches. Researchers advocate for a mulitimodal approach including spinal manipulation, neck and upper back strengthening (see videos). These interventions have received the highest grade (A) of evidence for treatment of this condition. Specifically, evidence supports the use of manual therapy and exercise over primary care management, manual therapy or exercise alone in patients with neck pain and headache. These benefits are sustained at 1 and 2 year follow up time periods. Finally, the number needed to treat (NNT) is 2 for patients with neck pain treated with manual physical therapy and exercise to achieve one additional successful outcome than would have occurred if patients received an alternative treatment.

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Should I Use R.I.C.E. Or Call The P.O.L.I.C.E. After An Injury?
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The acronym R.I.C.E. (rest, ice, compression, and elevation) has been utilized for decades in the clinical and self management of acute injuries. Clinicians have updated RICE to PRICE adding in protection of the injured area, but this acronym needs further updating. In general, the 4 of the components of this self treatment approach have merit for injuries, but rest is being challenged in injury management. Immediate rest, 2-3 days, is required after a ligament, tendon, or muscle injury to facilitate the healing process, but newer research has highlighted the importance of exercise to facilitate an optimal recovery

A clinical commentary in the British Journal of Sports Medicine advocates for a new acronym in acute injury management, POLICE, which includes progressive optimal loading ice compression and elevation (Bleakley et al. 2011). Physical therapists are now utilizing progressive, optimal loading strategies due to research documenting accelerated recovery compared to an immobilization approach. For example, both ankle sprains and tendon injuries respond best to early mobility vs. prolonged rest. Progressive loading of injured tissues creates a beneficial cascade of events in the body through a process called mechanotransduction. Early exercise creates cellular changes in injured tissues allowing them to remodel into stronger, healthier tissues.

Authors state the difficulty in recovering from injury is finding the balance between rest and exercise. Many factors including, but not limited to, the patient, injured tissue, time since injury, severity and irritability of the injury play important roles in this decision making. In many cases, moving from rest into incremental exercise accelerates the recovery process and optimizes a patient’s return to activity. Patient’s are encouraged to work with their local Physical Therapist to determine which progressive, optimal loading interventions are best for their specific injury.

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Research Documents Strong Children Are More Likely To Become Fit Adults
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In America we face a energy crisis where the CDC reports 1 in 3 adults and shockingly 1 in 5 kids are obese. The imbalance between caloric intake and caloric expenditure has literally tipped the scales and created an growing obesity problem. In Colorado we have seen our blue state (low levels of obesity) turn pink due to an increase in obesity especially among children. Aerobic and resistance training has been found to be both both safe and effective in children and teenagers leading to improvements in mental, emotional, and physical health. A recent review of the medical literature documents the impact of childhood and adolescent fitness on their transition to adulthood.

In the journal Sports Medicine Garcia-Hermoso and colleagues analyzed the available research to determine the association between muscular fitness in childhood and future health (2019). Authors included 30 studies on a total of 21,686 participants between 3 and 18 years old. As expected they reported a significant, moderate to large effect between baseline muscular fitness and future body mass index, fat mass, metabolic blood levels, and cardiovascular status as adults. In short, fit children and adolescents became fit adults. Embracing the American College of Sports Medicine’s Exercise is Medicine campaign, especially in children, may help our country regain the energy balance they need to live their best life.

Impact Of Walking On Chronic Low Back Pain
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Low back pain remains the most common musculoskeletal diagnosis seen by primary care providers including Physical Therapists. While the majority of cases of low back pain are not serious in nature symptoms tend to be recurrent and can become chronic (> 3 months) if left untreated. As low back pain progresses from acute to chronic in nature changes in the both the peripheral and central nervous systems can occur leading to increased symptoms and loss of function. Patients with signs and symptoms consistent with nervous system changes are often prescribed pain science education and graded exercise to improve their symptoms and most importantly participation in life, work, and recreational activities. A recent review of the research examines the impact of walking vs. general exercise on patients with chronic low back pain.

Vanti and colleagues reviewed the available research on the effects of walking alone compared to exercise, as well as, the impact of the addition of walking to other forms of exercise (Disabil Rehabil. 2019). They reviewed 5 randomized controlled trials on the topic and make recommendations based off this evidence. In general, most forms of exercise including walking, showed a positive effect on a patient’s low back pain, fear of activity, and disability. Authors noted walking was not superior to other forms of exercise, but may be more easily implemented because of its’ ease of implementation compared to other forms of exercise. This study confirms prior research advocating for increasing the activity levels of patients with chronic back pain.

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