Prehabilitation: Resistance Training

The summer season is post-season for many of my collegiate athletes, the perfect healing time to rebuild and rebalance some of the overworked structures in their bodies with resistance training. This is an extremely important phase in the training cycle for injury prevention as well as for performance. Adhering to a resistance training program appropriate for your sport is essential during this period.

Utilizing a personal trainer to help tweak the program your CSCS provided you is my first recommendation for a successful post season. With their expertise and objective perspective they can detect dysfunctional patterns that we cannot see in ourselves and they have the tools to get the job done at their disposal. If your CSCS is also a personal trainer and has hours available to you, that’s even better since they have specifically studied your sport (and often participated in it in college!).

If you feel going it alone this summer with the training program you have been given is your only option, follow it carefully and consistently. Most of the resistance programs that have been brought to me to review make sense in their structure and frequency. They do seem to assume the athlete knows the correct exercise sequence. Correct exercise sequence is important not only for optimal development but also for injury prevention. Dysfunctional patterns can develop through compensation due to fatigue. Strains, and trauma due to accidents, can also occur as a result of trying to perform the wrong exercises in a fatigued state. Below is listed an exercise sequence designed to protect the athlete and allow them to develop their greatest potential by themselves. (1)

1. Explosive whole power body lifts: Power cleans, Snatch, etc.

2. Multi-joint exercises: Bench press, squats, shoulder press, seated row

3. Single joint exercises: Triceps extensions, knee extensions, biceps curl
 
This may seem trivial to some, especially with the complexity of some of the more elaborate functional exercises woven into their programs as they progress, but the sequence is extremely important.

A final note: great form is essential. One of the themes of post/off season training is to correct, to some degree, the dysfunctional patterns developed by the athlete during the season through repetitive movements and postures necessary for their sport. This is something we always must work to perfect. If you cannot afford the time or money to employ a personal trainer, please book an appointment with me for a functional movement screen. This is not a substitute for a good personal trainer, but it can identify your major functional weaknesses so you can work on them to help prevent injury. If a personal trainer is an option for you, I’ve listed some of the best local independent trainers (they work in training facilities – no membership required) in the Cambridge/Somerville area below.

Maren Kravitz and Heidi Brown, The Training Room, Porter Square, Somerville
http://thetrainingroomboston.com/tr/home
 
Callie Durbrow, Durbrow Performance, Central Square, Cambridge
http://durbrowperformance.com

References:
1. Essentials of Strength and Conditioning, second edition p.404-405
    Baechle, Thomas; Earl, Roger  Human Kinetics, Champaign, IL 2000

"Summer's Back!" - ouch!

As spring passes into summer and the bulk of my client population switches from student athletes to weekend warriors and garden gladiators, so do to the bulk of the "c/o's" from peripheral conditions to back pain, specifically low back pain. Three new cases just last week!

Back Pain is not easy to assess for the therapist or diagnose for the physician, either medical or chiropractic, and can be even harder to explain to the client or patient. This is because there can be, and usually is, more than one factor causing the pain. If there is one dominant factor directly causing the pain, then this is addressed first. Decreasing the major cause of pain allows for greater range of motion which will facilitate the natural healing process of the body as well as allow the therapist to address the imbalance that caused the pain, if this is possible. Sometime the lack of integrity in structures leaves no alternative but surgical intervention. Fortunately, this is usually not the case.

Who do I see about my pain?

If your pain is locally sharp and disabling, it's my duty to refer you out to an orthopedic physician and I recommend that you pursue that course before you see me if those are the symptoms you are experiencing. Be sure your physician is paying close attention to your history and takes the time to perform manual clinical tests on you. MRI's are not enough. In fact, MRI's can present very clear but misleading images. In the case of herniated nucleus pulposus (HNP) they have a 25% false positive rate (1). Where the pain is being referred from and what structures are referring the pain (nerve, ligament, joint or joint capsule) can and should, in my opinion, all be tentatively identified before radiographs are ordered. Medication or injections to decrease inflammation may be options as well as, in severe cases, surgery. Most Physicians will prescribe the most conservative treatment possible.

If your pain is not is not disabling and the pain is local, chiropractic care has been shown to be very effective on acute conditions, especially within the first 6 weeks. A good chiropractor will educate their patient about their condition and provide them with advice about how to prevent the condition from returning, if that is possible.

If physical therapy has been ordered by your physician, it can be the best road to travel toward healing if the patient is compliant. This is because many of the causes of low back pain are due to weaknesses and imbalances that the physical therapist can address. The mantra "Everything heals in the presence of motion" is most relevant in the case of low back pain where inactivity is often one the greatest contributing factors to onset as well as one of the greatest obstacles to healing.

There is much controversy about the role of passive manual therapy, specifically massage therapy, with respect to severe low back pain. For example, in the case of HNP, it has been noted by some that massage is often engaged during the natural healing cycle in which the natural spontaneous re-absorption of the effused nucleus pulposis would have occurred with normal return to movement regardless of the techniques applied. I have to disagree. Is massage is not contraindicated for the pain I would encourage the patient to engage the services of a therapist. Skillfully applied massage will help decrease both inflammation and tension which will facilitate movement, which will in turn aid the natural healing process. Everything heals in the presence of motion - massage therapy can help you regain that motion.

Summer is short! So if you are having back pain, please schedule an assessment with me so we can find the right direction for you to heal the fastest.

References:

1. http://emedicine.medscape.com/article/1263961-overview

References utilized:

Hammer, Warren I. “Functional Soft Tissue Examination and Treatment by Manual Methods, 3rd Edition” Sudbury, MA Jones and Bartlett Publishers, 2007

PRP and Blood Flow Restriction Exercise VS Dynamic Muscular Therapy

Great strides are being made in developing new techniques that allow active people to remain active into the later decades of their life. Research is being conducted on methods of healing injuries to muscle tissue, primarily by manipulating or eliminating scar tissue formation. Unchecked scar tissue formation within muscle tissue after an injury can impede healing and result in weak connective tissue leading to increased probability of re-injury and muscle weakness. Platelet-rich plasma therapy (PRP) shows considerable promise, but much research still needs to be done to understand the exact mechanisms involved to determine the “when, where and how much” for safe effective prescription. Presently, injections are expensive and, without a universal protocol, show mixed results.

Research is also being done on popular methods of rebuilding active muscle tissue, such as blood-flow restriction exercise which tricks the body into believing it needs to boost the protein necessary to build muscle tissue. Although the potential benefit to older active adults would considerable, the safety of this procedure for older adults is still being studied, blood clotting being a major concern.

Fortunately, there is a time proven method for controlling scar tissue formation and maintaining optimal tissue health in active adults and athletes of all ages – sports massage and dynamic muscular therapy. Sports massage during training and competition can prevent the need for medical intervention later and dynamic muscular therapy can resolve many chronic athletic injuries years after they have occurred – without the need of medication, injections or surgery.

Continued research into methods of medical intervention is essential and I believe breakthroughs for those people who need those options are close at hand. However, the most conservative, safest and effective method for maintaining musculotendinous health is still guided exercise reinforced and maintained by manual therapy.



References utilized:

http://www.boston.com/lifestyle/health/articles/2011/02/21/targeting_sports_related_injuries_with_new_treatments/

Sports Massage: maintaining your edge

Where dynamic muscular therapy is all about treating chronic repetitive athletic injuries and resolving dysfunctional movement patterns, sports massage is all about maintaining your hard earned training gains and managing chronic conditions at their best possible level. That is, maintaining the most appropriate range of motion (for their event), minimizing discomfort and maintaining optimal tissue health in the athlete. 

How often and when?

How often to receive sports massage and when to receive depends entirely on what type of work you need to maintain your conditioning and when your major events occur. With respect to timing, therapists will often provide a set schedule themselves. This may or may not be appropriate, depending on how much experience a client has in judging their body’s needs. For a non-athlete or an inexperienced athlete, a set schedule determined by the therapist may be the best alternative until the client develops a sense of their need for massage. For the experienced athlete, I prefer to have them note how they feel and perform 24 to 48 hours after treatment and track how long it takes to start lose that “edge” they’ve gained from the work. We want to time the work to make sure the edge stays sharp, not to wait until it gets dull. This is important for both excelling at your event and for injury prevention. At the point when their performance starts to waiver, an athlete will strive to keep up with their competition by pushing their performance past their current conditioning, compensating any which way we have to, risking both traumatic and chronic injury. So tracking when you start to lose your edge, rather than waiting until you are in pain, is important for considering how often an athlete needs to schedule sports massage.

Timing around intense events (workouts, games, meets) is also very important. If the athlete has a chronic injury that has tendency to adhere to the tissue around it, this may require more intensive work that may not be appropriate close to an intense workout or event, so the bodywork has to be scheduled with this in mind. Less intensive work may be extremely beneficial to the athlete’s performance directly before, during and after an intensive event. All of this must be considered by both the athlete and the therapist as a team when considering when treatment is most beneficial.

Learning to make these judgment calls is part of the athlete’s educational process and is why education plays such a significant role in treatment at Soarbody Therapeutics.

Treating Chronic Injuries: How long, how often?

Two services are offered at Soarbody Therapeutics: Dynamic Muscular Therapy and Sports Massage. The goal of sports massage is maintenance of the client’s tissues for optimal performance. The treatment plan is short, simple, and completed within each session. The goal of Dynamic Muscular Therapy is to resolve chronic athletic musculoskeletal conditions. The treatment plan may be quite complex and take several weeks to complete. There is often some doubt among new clients about the need for the frequency and the duration of the treatments. A clear and simple explanation is provided below.

Chronicity: practice makes permanent; history is everything

The old saw practice makes perfect may be true, but with respect to how the body is wired, a more appropriate expression may be practice makes permanent. When you practice the piano, for example, the nervous system is programming specific pathways to fire in certain patterns, specific muscles are developing characteristics (strength, speed, local endurance) based on what the nervous system is demanding, and the fascial system adjusts itself to support the needs of the muscular system. The earlier you learn to play and the more often you practice, the more ingrained these patterns become.  This is a good thing! If basic patterns were not executed thoughtlessly and effortlessly, we couldn’t so much as walk never mind play the piano. However, if one learns in their mid thirties that they have been playing the piano incorrectly since they were eight years old, it’s going to be more difficult to reroute the nervous system and create the changes in the soft tissues needed to form new patterns.

So it is with chronic injuries. There may indeed be a specific lesion that needs to be directly addressed (hamstring strain, lateral epicondylitis, etc), but the lesion may well be only the head of the dandelion – eliminating only the flower leaves the root cause of the injury intact to come back with even more devastating effects. Additionally, the body is smart! Once you’ve incurred an injury to one part of the body, the rest of the body will compensate around the injury to continue to meet the demands placed upon it. This compensation can allow movement and eliminate pain for some time – sometimes many years. But these compensational patterns are always inefficient and will eventually fail. For a great many clients, they don’t seek help until these compensational patterns fail, more damage is done and they cannot continue their activities effectively.

Duration: How long will treatment take?

Obviously, the sooner we can stop the body from practicing these compensational patterns, the easier it will be to heal the lesion and learn efficient movement patterns. This is why you have to fill out such an extensive history of activities, injuries, and surgeries, from childhood to present day, for your initial assessment. It provides us with clues as to the root cause of the pain as well as providing a rough idea as to how long it will take to resolve the root cause to best state possible. The older the inefficient patterns, the longer the duration of the treatment plan is likely to be.

Frequency: How many times per week will I need to have treatment?

The appropriate frequency of treatment in a treatment plan is crucial to success. After the first the first manual treatment the client will experience a decrease in pain and an increase in freedom of movement – for a little while. After that short relief, their condition will return back to it’s about its initial state. This makes sense – we can’t expect our piano performance to improve much if we practice once a week. But if we practice several times per week we can capitalize on the success of each subsequent practice, starting at a slightly higher performance level each time. There will be diminishing returns of course as we meet our potential, at which point we have the option of moving on to practicing different, more challenging pieces, which incorporate maintenance of our older skills.

So it is with treatment for chronic injuries. Without the proper frequency to improve at steady rate, the condition is not going to change significantly. We have to catch the improvement after each treatment to start at a higher level than the previous session in order to make steady improvement. See the graphs below.

Graph A illustrates little progress with a frequency of one treatment per week. This may be effective for optimal maintenance of the tissue’s condition once the lesion is healed and the patterns have been changed, but this frequency will probably not be effective for creating the change necessary to heal the lesion and change compensational patterns.

Graph B illustrates effective progress when the frequency of treatment is great enough to capitalize on the improvements made in each prior treatment. Progress is made more quickly and optimal tissue condition is achieved sooner.

Extensive patterns, conditions: Why must I see other practitioners?

Dysfunctional patterns often extend beyond the musculoskeletal system. Such patterns fall outside my scope of practice, which is why I have an extensive referral list of nutritionists, psychologists, physical therapists, structural integration practitioners, chiropractors and physicians. We are multidimensional beings and sometimes require a multidimensional approach to healing.     

References utilized:

Joseph E. Muscolino, DC (2011) Treatment Planning and Client Education Massage Therapy Journal, Winter 2010, 4(4) 91-95


Hammer, Warren I. “Functional Soft Tissue Examination and Treatment by Manual Methods, 3rd Edition” Sudbury, MA Jones and Bartlett Publishers, 2007

Injury prevention - Falls over 50

Some sobering facts and suggestions as a follow-up to the June, 2010 entry about sarcopenia. Falling is the leading cause of accidental death in adults over 70 years of age and after 50 the incidence of hip fracture, often resulting in a fall or from a fall, increases dramatically and many of those victims do not survive the injury or are left immobilized and institutionalized. Some of the factors that increase fall risk are arthritis, orthostasis, decreased muscle strength, balance, coordination, reflexive response time, and the use of 4 or more prescription medications. (1)

There are a number of interventions that are very effective to decrease these factors or their effects. Tai Chi is great discipline as a functional approach to intervention. Resistance training is the most overall effective tool to deal with these factors and slow the onset of the effects of aging. Strength, power, flexibility, balance and coordination can all be very effectively enhanced with resistance training. For the above 50 population, however, this will require a well trained and experienced trainer. For those individuals with little experience in resistance training, a trainer that can accurately evaluate your baseline condition and that understands the special needs of this population is a must for safe training that yields significant results. For those with extensive experience in resistance training, a skilled trainer is essential for guidance and to break poor habits which, although have been tolerated up until now, could spell disaster if not corrected. I have an extensive referral list of very talented personal trainers all around the greater metropolitan area of Boston, so please feel free to ask me for a referral.

Although a good trainer will train the whole person, incorporating all aspects of the body, the lower extremities, hips and pelvis often take longer to recover than the arms, neck and torso. Sports massage can be tremendously beneficial in helping recover from intense workouts and help to maintain appropriate flexibility and elasticity for your activities of daily living and sports. So always consider including sports massage in your training program.

References:

1. Christina A. Geithner, PhD, Diane R. McKenny, BS (2010) Strategies for Aging Well. Strength and Conditioning Journal, 32(5), 36-49

Health & Safety - winter feet

 Dry, cracked feet and toe nails are an invitation to infection. This is common among all people, but especially so in winter athletes. Although TV commercials push products to treat relatively harmless bacterial colonization under the nail, more serious infections, like cellulitis, which can be life threatening if left untreated, can invade the body through cracks in the callus. Streptococcus or staphylococcus are the most frequent bacteria involved, but although cuts, abrasions, and dried, cracked compromised skin are all avenues for infection, why some people are more susceptible is not clear. Nobody is immuned. The symptoms are not always clear either. Where most people will experience inflammation and point tenderness, some people feel little. Cellulitis can spread quickly, become systemic and, if left untreated, can be fatal.

The bottom line here is to take care of your feet. One good option is a medical pedicure (a medi pedi) offered by some podiatrists. One stop shopping - foot care and a check-up for your feet! What better way to keep you on the top of your game? Check out what Dr. Jordana Szpiro has to say about medical pedicures at
http://www.bostoncommonpodiatry.com/content/view/47/57/   

Take care of those feet and I hope to see you in the treatment room soon!