Posts in general physical therapy
No Differences Found Between Surgery Or Physical Therapy For Tendon Injury
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Overuse tendon injuries can present as an acute inflammatory response (Tendinitis) or a chronic degeneration condition (tendinopathy).   These injuries result when an individual’s volume of activity (type, duration, frequency, and intensity) exceeds the strength and integrity of the tendon.  At MEND, we commonly see these injuries in the tendons of the rotator cuff, knee, ankle or elbow.  Recent studies summarized in our previous blog posts have highlighted the importance of a Physical Therapy exercise program.  Optimal, progressive loading of these injuries is critical to the healing process (remodeling) resulting in decreased pain and improved function.  Despite overwhelming evidence supporting exercise interventions patients may still be provided with a surgical treatment.

A recent study from the British Medical Journal reviewed the available medical evidence to determine the effectiveness of Physical Therapy compared to surgery or no treatment in patients with tendinopathy (Challoumas et al. 2019).  Authors included 12 studies of over 1000 patients to determine the impact of these treatments on a patient’s pain, function, range of motion, strength and quality of life.  Authors reported Physical Therapy was as effective as surgery in both the mid and long term for improving pain, function, and quality of life.  Authors report surgery should be reserved for patients who do not improve with 12 months of a loading program. 

Research Shows Most Participants Select Inadequate Weights For Strength Training
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Money and time is some of the finite resources in life. As our lives become busier with work, family, and life commitments our exercise time must become more effective and efficient. One of the biggest and most common mistakes individuals make in the gym is an ineffective cardiovascular or strength training intensity selection. Although any movement of large body parts will contribute to a caloric deficit, selection of a low intensity of exercise will prevent participants from developing cardiovascular or strength gains. Research shows both novice and experienced weight trainers choose inadequate weights for strength development.

Glass and colleagues found novice lifters selected weights between 42-57% of their 1 repetition maximum (J Strength Cond Res. 2004). A second study found similar mistakes in sedentary individuals who initiated a strength training program (Elsangedy et al. J Phys Ther Sci. 2016). These self selected weights were all found to below the 60% value shown to create muscle growth and strength gains among novice lifters. Surprisingly, the influence of a personal trainer does not ensure participant reach intensities recommended by the strength and conditioning research. Ratamess and colleagues randomized females with weight training experience to either a self selected or a weight intensity selected by a personal trainer (J Strength Cond Res. 2008). Although selected weight intensities were improved (51% vs. 42%) in the personal training group authors found both groups selected weights below recommended intensities.

In our previous blog we discussed the value of using repetition in reserve to determine an appropriate intensity during weight training. This method of selection reduces the human error associated with weight training ensuring selected weights are appropriate for strength gains.

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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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Optimizing Strength Gains Using Repetitions In Reserve
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Strength training remains one of the most important components of your exercise program. Research supports its’ utilization for improving pain, function, flexibility, strength, injury rates, and overall health. While a single session of strength training can lead to significant gains in strength and muscle hypertrophy research supports training large muscle groups 2-3 days per week. Another important component of strength training exercise prescription is intensity. Selecting an appropriate weight for a set of exercises can be challenging for most individuals and errors often lead to less than optimal improvements in injury and sports performance.

Traditionally, individuals would select a weight based off their tested 1 rep max on a given exercise which may or not be appropriate for every individual. More recently Physical Therapists have been advocating for a repetitions in reserve prescription where weights are selected based on how many repetitions an individual could complete at the end of a given set. For example, if a weight was selected and performed 5 times the individual would be asked how more repetitions they could complete with good form. If the answer is more than 2 repetitions the weight would be increased to dial in the appropriate intensity. A recent study compared the benefits of these two methods of repetition selection.

Graham and Cleather in the Journal of Strength and Conditioning Research randomized 31 experienced weight trainers to one of two programs (2019). The first program, fixed load, based weights on a percentage of the athletes 1 rep squat max. Conversely, the second group adjusted their weights based on the number of repetitions in reserve at the completion of their set. Volume (reps, sets, days per week) was standardized between groups. Each individual completed their 12 week squat training program based on these prescriptions. Authors reported both groups improved their front and back squat performance, but significantly better results were found in the repetitions in reserve group.

This study highlights the benefits of the repetitions in reserve model. In short, this model reduces operator error in weight selection because intensity is always adjusted to the individual.

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Benefits Of Manipulation For Patients With Neck And Arm Pain
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Thoracic manipulation by Physical Therapists has previously been shown to improve pain and function in patients with elbow, shoulder, and neck pain. Authors continue to research the mechanisms behind its’ effectiveness including a beneficial cascade of events in the peripheral and central nervous system, as well as, a possible biomechanical change in the spinal joints. Clinically, thoracic manipulation is also utilized in patients with neck and arm pain (cervical radicular pain or cervical radiculopathy). This painful condition is secondary to encroachment of the spinal nerves in the neck as they pass through their respective vertebrae. Patient’s with this condition can experience pain, numbness, and/or pins and needles into their shoulder blade, arm, and hand. If left untreated patients may also notice weakness in their hands. Physical Therapy treatments including manual therapy and exercise aim to improve spacing within the bony neck canals that contain the neck nerves, as well as, optimize movement in the body regions adjacent to the neck to reduce the demands in the affected neck vertebrae. A new recent study highlights the benefits of thoracic manipulation in this patient population.

A randomized controlled trial in the Journal of Orthopedic and Sports Physical Therapy was conducted by Young and colleagues to determine the effectiveness of thoracic manipulation in patients with neck and arm pain (2019). Authors randomized patients to one of two treatment groups including a single session of thoracic manipulation or sham (placebo) manipulation. They assessed immediate and short term (48-72 hours) changes in pain, pain location (centralization), function, neck range of motion and strength. As expected, patients provided with thoracic manipulation reported decreased pain, improved function, and demonstrated improved range of motion at both time points compared to the sham manipulation group.

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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.