MTDC Articles of the Week

Here is the latest newsletter from Jamie Johnson at the Massage Therapy Development Centre with a selection of great articles from the last week!

Some extremely interesting, progressive pieces to help keep you up to date with current understanding and practice.

Follow the links below to be directed to the full articles….

Articles Of The Week January 20, 2019

 

Coming out of college, everything seemed so straightforward! You’ve got a toolbox of techniques and you may even look to specialize in one of them, all the while helping as many patients as you can. Well, things aren’t so straightforward, and the times they are a changing. With it usually taking 17 years for new research to be applied in practice, we need to stay on top of the new and evolving research, along with a strong alliance with those patients.

“Manual Therapists: Have You Lost That Loving Feeling?” – Paul E. Mintken, Jason Rodeghero & Joshua A. Cleland

Patient centred care means different things to different people. Because it has different meanings for different people, there may also be ethical dilemmas surrounding the topic as well. This article delves into some of these topics, while also having you reflect on what this topic means to you.

“‘Patient-Centred’ – What Does It Mean And How Achievable Is It?” – Andreas Laupacis & Jennifer Gibson

Using unstable surfaces for strength training and rehab has been a popular practice for quite some time. However, does it really work? Well, it depends on the patients goals, your scope of practice, and just plain sticking to the basic principles of exercise program design.

“Is Unstable Surface Training A Waste Of Time?” – Nick Ng

He has been at the forefront of pain research over the past number of years and Peter O’Sullivan is always worth listening to. No different with this article, where it shows how he and his team are using ‘Cognitive Functional Therapy’ to treat back pain.

“The ‘Mythbusters’ Of Back Pain Believe They Can Treat It – With Words” – Liam Mannix

We published a post earlier this week about when NOT to treat a patients thoracic pain, but when you can, this is a good post. Dean goes through a few different drills and exercises to help increase thoracic rotation, most of which you can do right in your treatment room.

“Cleaning Up Thoracic Rotation” – Dean Somerset

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How Can Strength Training Help Runners? – Mike James

How Can Strength Training Help Runners?

Sports Injury Fix’s resident running expert Mike James recently wrote his top tips on injury free running and follows this up by expanding his thoughts on the hot topic of strength training for runners. 

Original Article:
https://www.sportsinjuryfix.com/blog/how-can-strength-training-help-runners?fbclid=IwAR3gjKCWw8zcmKq8O4RT_c6P09SVJgB6W6qGqc5sYyERL4mXjz8-ArobTEI

Barbell for strength training
Benefits of Strength Training 
The injury incidence among runners varies between 11–85%, or 2.5 to 38 injuries per 1000 hours of running.1,2 Research suggests that the top 3 benefits of strength training are:

1. Reduce overuse injuries
2. Improve running economy
3. Improve performance

Strength training has been shown to reduce overuse injuries by up to 50% and improve performance.3,4 A recent review found that strength training improved running economy by 2-8% and time trial performance by 2-5%. It also dispelled many common misconceptions relating to strength training being detrimental to endurance activity as maximum oxygen uptake, blood lactate and body composition all appeared unaffected.

Get strong and stay strong, coupled with appropriate management of training load and recovery appear to be the biggest factors we can actively affect in reducing injury risk and improving performance.

Despite such obvious benefits a large proportion of runners do not undertake regular strength training.  In fact, a study of 2008 US Olympic marathon triallists found that roughly half did not do any whatsoever.6 This statistic is anecdotally supported whenever I question runners in clinic, at race events or during the courses and workshops that I present.
Kettle bell on the floor with person about to pick it up
Misconceptions of Strength Training 
I believe many age old, long held misconceptions exist regarding within the established running community. The top six misconceptions on strength training are:

1. Fear that it will negatively impact endurance performance
2. Increases in body mass
3. Be detrimental to their training
4. Are not ‘functional’ for running
5. Are less important for injury reduction than stretching
6. That it is complicated to master and needs instruction from an expert

When these are combined with time constraints, work and family commitments, the belief that it needs to be undertaken in a gym, and a failure to appreciate the potential positive benefits then it is understandable why it hasn’t become a staple part of the runners training regime.

Making the Most of Strength Training 
When I do come across runners who perform some degree of strength training, then they often do so with the outdated belief that as an endurance athlete they should perform high reps/low resistance workouts to target endurance capacity. Whilst this may be more beneficial than performing zero strength training, it may fail to maximise the benefit available. Eventually, when skill acquisition and confidence of the low load exercises is achieved, low repetition, high load appears more beneficial to the runner than remaining at high repetition and low load. Building a greater capacity to tolerate forces and generate power will ultimately provide a greater stimulus for the system to perform and reduce injury risk. The current evidence appears to support the notion of performing concurrent strength and endurance training for maximum benefit that includes increased movement economy 7, reduced / delayed fatigue 8, increased maximal speed and enhanced capacity anaerobically. 9 As with all training regimes though, compliance is key.

In summary I believe strength training has the potential to produce a more robust, economical runner with a reduced likelihood of injury when coupled with appropriate training and recovery schedules. Happy athlete with hands in the air
How to Start Strength Training?
So, we’ve established that strength training is worthwhile but how and where do you start? Do you have to join a gym? The key is to keep it simple and then progress as you feel comfortable and see benefit. We know that a large proportion of people fail to adhere to exercise, even when part of a rehabilitation plan, and a major factor in this is unclear instructions 10. For that reason I believe that  the top two tips when starting are:

1. Do it at home
2. Use Bodyweight exercises

The guide below gives a simple regime of 6 exercises that can be completed 2-3 times a week and less than 20 minutes a session.

A beginner’s guide to strength training for runners at home: 
As with all training regimes, compliance is key, and I have designed a simple regime of home, bodyweight-based exercises for the runner to try. Blagrove et al 5 states that the most effective type of training prescription is difficult to identify at present but suggests an optimal dosage may be 2-3 x week for 6-14 weeks (longer is better!) and when run training increases in the lead up to a race, then once weekly may be sufficient to maintain gains.

On a practical level, try to allow 3 hrs after high intensity running before performing strength training, and allow at least 24 hrs recovery afterwards before completing high intensity running.

Aim to complete 4 sets of 8-12 repetitions of each exercise. This can be performed as a circuit or one exercise at a time. Allow around 30-60 seconds rest between sets as required.

Should the exercises become easy, or you are already performing bodyweight exercises, then adding some resistance as shown below is advised. Simple equipment such as water bottles, sand bags, rucksacks filled with books will add extra resistance, however, if you have access to simple fitness equipment such as dumbbells, kettlebells and resistance band, then they work well also. Again, aiming for 8-12 repetitions per set, 3-4 times.

This is by no means an exhaustive list of exercises for the runner. They are simply an introduction to strength training at home. Exercise dosages are simply a starting point for the general runner and should the runner wish for further progression and/or to develop specific components of strength, such as power or plyometric ability, then guidance should be sought from an expert.

Exercise 1 – Squat
Squatting is a common daily task that is common place in many strength training regimes.  When we look for “most bang for your buck” type exercises, then it’s no surprise the squat is at the top of the list. By nature of its multi joint strength and control demands encompassing many types of muscle contraction, then it becomes a fundamental exercise for the runner.

squat exercise start and finish mike james

Air squat – feet shoulder width apart, stay tall and strong, lower with control to a depth you can control and then drive through the legs to return to the start position.
goblet squat start and finish mike james
Progression – add resistance – this variation is called the goblet squat and adds both resistance to the lower limb and trunk control. Wearing a ruck sack converts the exercise to a traditional back squat type movement.  Try to avoid excessive forward lean, knees tracking over the toes and the knees collapsing inwards at the bottom of the squat. Try to keep the chest up as if to show off your favourite race T-shirt to someone in front of you. Progression through to heavier resistance and / or a single leg squat variation would be appropriate.

Exercise 2 – Deadlift 
Another fantastic multi joint movement with excellent emphasis on the posterior chain. Whereas the squat is a knee driven exercise, the deadlift is a hip driven movement, meaning, most movement is a pivot / hinge at the hip whilst keeping an upright strong trunk. The knees will need to bend when you feel the hamstrings pull. Only lower as far as you feel you can control, then drive back to start.

deadlift BW Start and finish mike james
The deadlift can be a difficult exercise to master and may require practise of a simple hip hitch movement before developing into the full technique. A simple technique is to stand a few inches from the wall, try to touch your buttocks against the wall without bending the trunk or knees.

 

deadlift with weights start and finish mike james

If performing well, add resistance as above, or try a single leg version (below). Running involves significant amounts of single leg support and control and this is an excellent exercise for targeting this. It is an advanced technique and takes time to master.

singe leg deadlift start and finish mike james

For each deadlift variation, aim to keep your hips higher than your knees, your buttocks moving back rather than down, and your trunk and upper limbs square and facing forward. Add resistance again as tolerated.

Exercise 3 – Calf Raise 
An essential exercise for runners. The calf complex and Achilles tendon transmit and absorb massive forces and increased capacity in these tissues will almost definitely benefit the runner. Begin with a finger tip supported drill if required, potential strength gains and loading should not be affected by limitations in balance and coordination. Always concentrate on full range movement right up onto tip toes and with control. Time under tension is crucial for these muscles.

calf raise straight leg start and finish mike james

 

calf raise bent leg start and finish mike james
Perform with both straight leg (Gastrocnemius biased) and bent leg (Soleus biased) variations to maximise effect. The key cue is to always move in a vertical direction with the ball of your foot in contact with the floor.

Performing on single leg is an effective progression (straight leg shown only but remember to perform with bent leg also.

single leg calf raise start and finish mike james
Finally, performing both types over a step / stair will allow you to take the heel “below the level of the floor” and increase the range the muscles can work through. An effective strategy for increasing resistance safely is to use a rucksack with weight in it. This will allow you to maintain your hands in a free position should fingertip support be required. These progressions are merely options and do not all necessarily need to be performed to progress. Simply adding load and / or more time under tension (taking longer to perform the repetition) may be appropriate.

step calf raise options finish only mike james
Exercise 4 – Bridge 
Another fantastic posterior chain activity, easily performed at home without the need for expensive, complicated equipment. Begin with the double leg variation. Raise your buttocks/trunk off the floor, aiming to achieve an imaginary straight line running through your knees, hips and shoulders, variations include a very slow and controlled raise/lower or a faster raise and lower with a small pause at the top position.

basic hip bridge start and finish

Key errors to avoid are overarching of the lower back, failure to raise to the top position and holding the breath throughout the movement. Play around with foot positions to bias certain muscle groups more or less than others. Bringing the heels closer will increase Gluteal work, whilst moving them further away will increase hamstring activity – be careful they don’t cramp!

bridge variations finish only mike james

To progress either move onto a single leg variation or add resistance across the pelvis as illustrated below.
The resistance band can also be performed on the single leg variation as required.

Exercise 5 – Step Up
Another great fundamental exercise that demands stability and control throughout the single leg as per the actions required for every stride when running.  Be cautious when selecting the height of the step to be used. Don’t get too ambitious too soon if new to this exercise. Key coaching cues include driving up through the weight bearing foot/leg and maintain control throughout. Many runners perform this exercise based on the momentum generated from the movement and this should be avoided.  Remember the resistance level used shouldn’t compromise the control on the down phase whilst returning to the floor.

step up start and finish mike james

Adding an upper limb movement that replicates a running pattern whilst progressing to a high knee step up variation is an effective technique for runners to develop. Once mastered, adding resistance to the step up (again, a loaded rucksack is often sufficient) can be effective. Other techniques to increase resistance include the following. Give them a go and see which ones you find the most beneficial.

step up options
Exercise 6 – Core
The topic of core strengthening is much debated and controversial. Many exercises such as the plank have been advocated as effective exercises for runners. Personally, I feel core work needs to include two aspects: controlled rotation and an anti-rotation element to encompass the demands of running. Here are two variations that focus on these aspects.

6a. Anti-Rotation via Pallof press 
I find resistance band is perfect for this drill. A resistance band can be found in many high street shops and/or online. It is manufactured in different grades of resistance differentiated by colour.
For this exercise – position yourself so that there is enough tension on the band to make you feel like your trunk wants to rotate towards the band. Whilst resisting the rotation, drive /push your arms forward, this will increase lever length and increase the effort needed to resist rotation towards the band. Perform with the band pulling from both sides of your body. It can be performed in kneeling or standing depending on level of ability. I particularly like the single leg standing variation as a high-level drill, but as with all the exercises, this requires time and patience to master and progress to.

kneeling pallof start and finish mike james

standing pallof start and finish mike james
6b.  Rotations 

For this exercise the intention is to do the exact opposite of the Pallof press. We are aiming to rotate against the band whilst maintaining control throughout. Focus on trying to rotate through the trunk and not by simply turning the hips and pelvis. Again, perform in kneeling, standing or eventually on single leg, progressing only when control is effectively maintained. It is important to maintain control on the return to the start; a common mistake is to use a resistance that is too heavy, and the return phase becomes a recoil as opposed to a controlled movement.
kneeling rotation start and finish mike james

standing rotation start and finish mike james
Hopefully you may find these helpful and effective at improving your running and reducing injury risk. We’re really excited to hear how you get on so please let us know via social media Twitter and/or Facebook

If you have any queries, please seek the assistance and advice of a running specialist via sportsinjuryfix.com

Bottom of trainer

References
1.Buist I, Bredeweg SW, Bessem B, et al. (2010) Incidence and risk factors of running-related Injuries during preparation for a 4-mile recreational running event. Br J Sports Med.  44(8), 598-604.
2.van Gent R, Siem D, Van Middelkoop M, et al. (2007) Incidence and determinants of lower extremity running injuries in long distance runners: A systematic review. Br J Sports Med. 41(8):469–480.
3.Bredeweg S, Zijlstra S, Bessem B, et al. (2012). The effectiveness of a preconditioning programme on preventing running-related injuries in novice runners: a randomised controlled trial. Br J Sports Med.46:865-870.
4.Lauersen J, et al. (2014). The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. Br J Sports Med.  48:871–877.
5.Blagrove R, Howatson G, Hayes P. (2018) Effects of strength training on the physiological determinants of middle- and long- distance running performance: A systematic review. Sports Med 48:1117-1149.
6.Karp J. (2007) Training characteristics of qualifiers for the U.S. Olympic Marathon Trials. Int J Sports Physiol Perform. 2:72-92.
7.Storen O, Helgerud J, Stoa E. et al (2008) Maximal strength training improves running economy in distance runners. Med Sci Sports Exerc 40:1087-1092.
8.Aagaard P. (2003) Training-induced changes in neural function. Exerc Sport Sci Rev 31(2):61-67.
9.Mikkola J, Rusko H, Nummela A. et al. (2007) Concurrent endurance ad explosive type training improves neuromuscular and anaerobic characteristics in young distance runners. Int J Sports Med 28(7):602-11.
10. Sluijs, E, Kok, G, & van der Zee, J. (1993) Correlates of exercise compliance in physical therapy. Physical Therapy, 73(11), 771-782.

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Lous Gifford and his legacy – 50 top quotes!

Louis Gifford and his legacy

louis-legacy

I have for some years now, been reading articles by the legendary physiotherapists Louis Gifford. Some of these quotes are from articles and some from scientific papers. Louis Gifford is one of the lesser known pain experts, but in my opinion he deserves a lot more attention, for the great legacy he leaves behind after his death. His pioneering teaching about pain science and pain management has influenced a generation of physiotherapists and continues to do so.

Louis Gifford was a clinician for over 30 years, and a lecturer and writer about pain and physiotherapy. From the early 1990’s through to 2007 he spent a great deal of time lecturing about pain biology, pain management and treatment. In the late 1990’s and early 2000’s there was a massive pain science revolution in physiotherapy, that Louis was very much involved in.

His book series on pain science called Aches and Pains, are highly recommend, and so are all his articles, and scientific papers. He was also the editor of the “Topical Issues in Pain” (1-5) series, that marked a milestone for the understanding of pain and physiotherapy.

Without further ado, here are 50 quotes from legendary physiotherapists Louis Gifford:

“Pain is multidimensional, and so should management be, that is what we are grappling with and it is not at all easy at present, but it will be before long. Important changes take time to integrate and get right. Things are changing for the better and the physiotherapy profession in this country stands to gain a great deal of respect for the way in which it is taking on this material. Patients and society should also benefit, and as Gordon Waddell (1998) powerfully points out, if medicine can create a low back pain disability epidemic, then it can also reverse it.” Louis Gifford

“If your therapist only does a ‘treatment’ to you and misses out the ‘get it moving/rehab/ graded recovery/functional recovery process – then its my opinion that your therapist is a complete waste of time” Louis Gifford

“Integrating psychological and social issues into practice is not an easy matter for professions that are linked historically to tissue/injury/pathology-based explanations and treatments for all pains. Overcoming a natural antipathy to integrate ‘other’ issues, concepts and explanations is a major step towards effective practice change.” Louis Gifford

“Most of us tend to think of pain as an unpleasant, distressing sensation that originates in traumatized tissues and courses its way along neural pathways to the brain and consciousness. Thus, the amount of pain perceived fits with the amount of damage done and the pain happily recedes in direct relation to the pace of healing.

The problem is that our clinics and departments are full of patients who have ongoing pain with no clear trauma or disease process, or who have suffered trauma but the pain continues on long after a reasonable healing period.” Louis Gifford

“A significant problem for physiotherapy is that it is by nature a physical therapy, and that while the inclusion of psychological and sociological factors are acknowledged in training, many see them as being outside the remit of our profession or of relevance only in some complex chronic pain states. Because increasing research into low back pain demonstrates that outcome is determined by psychosocial factors as much or more than by physical factors, this omission can no longer be justified” Louis Gifford

“It is also about our relationships with our patients, and their’s with their pain and their families. With changes in practice there is a necessary extension of traditional thinking into new territories and new skills to be taken on. We need to encourage those who are involved in the early treatment and management of pain to take on new information and new assessment and treatment approaches; the burden of responsibility for chronic pain prevention is with them.” Louis Gifford

“The biopsychosocial model proposed by Waddell (1987) draws attention to the impact of the patient’s response to their situation, and the impact of their work and social environment, as well as the impact of any tissue abnormality, the pain, and relevant biomedical factors on their progression through the problem and eventual outcome. Psychosocial factors are now acknowledged to predict low back pain outcome far better than do the available physical and biomedical findings” Louis Gifford

“Shifting therapist and patient thinking, from a largely unidimensional biomedical model based approach, to incorporating a multifaceted and multidimensional model, is the great philosophical and practical challenge confronting clinicians.”  Louis Gifford

“Pain is distressing and high levels of distress do not help recovery, are likely to maintain tissue unhealthy behaviors, and may ultimately play a part in maintaining a low or weak physiological profile that inhibits reasonable recovery and normal coping mechanisms. The science of psychoneuroimmunology testifies to the importance of psychological well-being to recovery and fitness of the immune system, for example” Louis Gifford

“Physiotherapists must confront the problem of ‘if you look you will find’ when assessing tissues in on-going pain states. This means that clinicians will always find something wrong in the tissues, but it may not be relevant to the patient’s problem and focusing on it may divorce the patient from the full extent of the problem.” Louis Gifford

“Without doubt, ongoing unrelenting pain that escapes an adequate explanation and diagnosis and whose legitimacy is challenged is distressing, disabling and the cause of much suffering. The mature literature on chronic pain states, powerfully avoids using psychological status as a tool to use in order to blame the patient for their condition. However, psychological status and health beliefs strongly contribute to the level of physical disability” Louis Gifford

“Patients in chronic pain states also suffer from an excessive pain ampli®cation response and spread of pain to physical movements/activities and testing procedures. The pain response often increases with repetitions of a movement or test (the windup phenomenon) and it often continues for many hours or days afterwards.” Louis Gifford

“Acute adaptive pain signals threat. Its major purpose, in parallel with the biologically linked emotional reactions like fear and anger, is to motivate and bring about an alteration in our behaviour in order to further our chances of recovery and survival” Louis Gifford

“The weakness of the tissue based model for diagnosing and treating on-going pain has been highlighted because there is powerful evidence that it does not help and that it may actually be making matters worse”  Louis Gifford

“Recent revelations about the capacity of axons to become pathophysiologically sensitised and active self-generators of impulses, goes a long way to help explain the way in which pain behaves clinically. Injured or degenerate/regenerating axons within nerve trunks or nerve roots can become sites demonstrating enhanced sensitivity as well as sources of ongoing and self-sustaining barrages of impulses that have the potential to cause long lasting and high intensity pains” Louis Gifford

“It is not surprising that in our attempts to help our patients, legitimise their pain and find something for them, that we have plunged into greater and greater depths of skilled tissue testing and focused analyses of the behaviour of pain. A fundamental reasoning error may be made by labelling a tissue as faulty on the basis that passive manual testing can reproduce the patient’s pain. The reasoning error is to assume that a sensitive tissue evoking pain on mechanical testing is responsible for the pain rather than a reflection of the sensitised state of the nervous system.

The strength of the tissue basis of pain construct can be further reinforced by the application of apparently successful techniques and interven- tions to the ‘blameworthy’tissues. For example, successfully relieving pain by mobilising, manip- ulating or injecting the cervical zygapophyseal joints of a patient who complains of neck and arm pains can be seen as validating the targeted joint as being the source of the problem. This logical application of reasoning unfortunately omits a broad understanding of the effects of factors” Louis Gifford

“Physiotherapists are pulling ahead and some, are way ahead. These are those who base their day to day work practices around a multidimensional and biopsychosocial model of pain. Those who read, understand, feel at ease with and implement the kind of material found in the Topical Issues in Pain series! No arguments, no political manoeuvring, no in-fighting, but sound and well reasoned agreement around a very sound model secured by outstanding and continually growing scientific support – it’s powerful, it fits, it works – but will it endure?” Louis Gifford

“Clinicians involved in the diagnosis and management of all benign pain states have two major problems. First, evidence of pathological changes in tissues underlying the painful area and in tissues which can refer pain to the area is often lacking. Secondly, there is a large body of evidence demonstrating tissue pathology in the absence of pain”  Louis Gifford

“Unfortunately physiotherapists have rarely questioned this paradox and have persevered with highly skilled physical tissue analyses aimed at validating the tissues and peripheral nerve trunks and roots as definitive sources of ongoing pain in the great majority of patient presentations. This is hardly surprising, considering that the only alternative status for on-going pain states that medicine cannot fit within a tissue abnormality/disease based construct, is the unsavoury and unproductive ‘psychogenic pain’ label. So often the implied message for the patient is that if nothing can be found, nothing can be wrong and the patient is therefore to blame” Louis Gifford

“The powerful links between the neuroendocrine and sympathetic systems and the immune system are also well recognised. The important clinical implication is that if we can positively change the way people feel emotionally, by for instance changing their knowledge and beliefs about their problems or situations, we can beneficially change activity in the output systems”  Louis Gifford

“Even though tissue damage and subsequent nociceptor activity can be seen as a dominant mechanism in acute pain it should be appreciated that psycho- social factors have a powerful role in determining and modifying the implicit physiological outputs and explicit behavioural patterns that are such an important part in recovery.

In the chronic pain situation, similar sampling- scrutinising-output analysis applies, it is just that the pathobiological pain mechanism focus shifts from the tissue and nociceptor mechanisms in the periphery to focus more on maladaptive and widespread reactivity and sensitivity of the whole sampling-scrutinising-output systems.” Louis Gifford

“Evolution of practice is unstoppable; there are always changes going on and there always will be. New material is often integrated inappropriately, and occasionally dangerously, and failures will always occur, especially in the untrained and unwise. Good therapy and management skills endure, like good inventions. Some changes are for the better, some are not, and many are fads that come and go.

It is the same in medicine as it is in physiotherapy. Fads are based on beliefs, anecdote and charismatic individuals. We have all been seduced. As followers we tend to believe that revered and published therapists are highly effective with all patients. Yet when we try to emulate them we often struggle and get frustrated. I do not know of any outcome studies with long-term follow-up using multiple measures that have included a ‘guru’ in the therapist population.” Louis Gifford

“I have always believed that every patient who goes to see their doctor wants to know the following:

  • – Doctor, what’s wrong with me?
  • – Doctor, how long is it going to take to get better?
  • – Doctor, is there anything that I can do to help it get better?
  • – Doctor, is there anything that you can do or give me to help it?

The order of importance to each individual may alter slightly, but for most, a reassuring answer to the first question is always somewhere near the top. Implicit here is a simple desire to know whether there is something seriously wrong. It is often the most important starting point for a successful treatment outcome.

Perhaps clinicians need to think about this more, because without a thorough understanding and without reassurance, the patient’s progress is likely to be hampered by feelings of uncertainty and insecurity.” Louis Gifford

“The therapist can then use the knowledge to provide the patient with a well-reasoned explanation. For example, where maladaptive central mechanisms are operating, the pain is likely to be mysterious and worrying, and often been given inadequate explanations from previous medical encounters. These patients are often grateful to receive a well-supported and rational explanation for their pain. An explanation that reconceptualizes the problem away from the notion of tissue weakness and harm is often the point from which patients start to be able to move on towards a productive recover}” pathway.”  Louis Gifford

“Physiotherapy is attempting to move away from a largely inefficient unidimensional focus on pain relief pain response towards function and normal movement in parallel with appropriate pain relief modalities, medications, and pain management. Movement undertaken with fear and trepidation is likely to result in a great deal of tension or guarding as well as increased attention to pain. Conversely, appropriately guided goal-oriented movement, in which the patient feels in control, is approached in the context of no or little fear can provide a wonderful starting point and focus for recovery. This takes a great deal of skill and the integration of cognitive-behavioural principles.”  Louis Gifford

“Integration takes time, mistakes are made and those critics who seem unwilling to learn, listen and change in the face of the growing body of sound findings are likely to be in a minority in the future.” Louis Gifford

“At last year’s CSP Annual Congress, Nick Kendall, one of the primary authors of the yellow flag assessment tool, indicated that those unwilling to change may well be forced to do so, and that peer pressure may be the key factor in seeing to it. This sounds like bullying, but like it or not, the pressures are on. Do not moan about them, get out and find out more — but be careful who you listen to before you make your judgements.” Louis Gifford

“The overwhelming message coming from respected researchers, clinicians and writers on the way forward with ‘pain’ is for patient empowerment via education and active rehabilitation of function rather than over-reliance on passive therapies”  Louis Gifford

“The literature also recommends that this approach should be augmented with the recognition, assessment and adequate therapeutic focus on psychosocial factors that have been repeatedly shown to have great predictive value for chronicity and therapeutic outcome”  Louis Gifford

“To identify patients who are at risk of developing chronic pain and associated disability problems, physiotherapists are being encouraged to actively screen for, identify, and then appropriately manage relevant psychosocial components” Louis Gifford

“I believe that physiotherapists in outpatient settings are working in one of the most difficult and most stressful areas in medicine – musculoskeletal pain and particularly chronic pain and disability. Day in and day out well-meaning physiotherapists do their utmost to try and help incredibly complex pain problems. Pain patients cause many physiotherapists to burn out — we often blame ourselves for the failure, and patient overload with severe time constraints is a big problem.” Louis Gifford

“Education about pain that includes the modification of commonly held ‘abnormal structure/ mechanics’ related beliefs about pain is seen as vital to successful rehabilitation and outcome. On-going pain states are best explained to patients in terms of an altered sensitivity state as a result of altered information processing throughout the system, and not solely a result of damaged and degenerating tissues. This helps patients accept the notion that hurt does not necessarily equate with harm – which leads on to the positive message that carefully graded increases in physical activity mean stronger and healthier tissues. This is reinforced when patients achieve improved physical function. By contrast, continued focus on a tissue as the pain source reinforces fear of movement and activity, the need to be constantly vigilant for pain and the desire for increasingly expensive passive therapeutic interventions that are yet to demonstrate convincing efficacy.”  Louis Gifford

“Patients with intense acute nerve root pains rarely find consistent positions of relief and if they do it is only for a brief period of time. A key feature is that the patient becomes physically restless with the pain and greatly appreciates an understanding of this problem. ‘The doctor told me to take paracetomol and lie down and rest for 10 days’. . . ‘The last physiotherapist insisted I sat up straight and kept my neck in perfect posture. I’m sorry I just can’t keep it up, at first its better for a short time then I have to move and get relief by bending my neck forward’ – are frequent comments from patients.” Louis Gifford

“Graded exposure tackles activities and physical tasks that are feared and/or avoided because of pain or the belief that they will cause further pain and damage. The process helps the patient to restore physical confidence via agreed graded progressions and pathways. For example, a patient with back pain who fears bending may agree with confidence to begin gentle pelvic rocking or flexing exercises lying and progress to bending while sitting before making attempts standing. As confidence and skills are improved, the later stages may include increased loading and more functional tasks, as well as performing the tasks faster.”  Louis Gifford

“The clinical significance of this is that many tissues that produce pain when physically tested by manual techniques using physiological movements, static muscle tests or palpatory pressures may be relatively normal. Thus, the central consequences of tissue/ peripheral nerve injury may easily result in ‘false’ positive findings in examined peripheral muscles, nerves, joints, skin and any other soft tissues in areas segmentally related to the nerve, and in extreme/severe cases, tissues well beyond normal segmental limits.” Louis Gifford

“Pain science is now amassing experimental evidence to support the organic basis of chronic pain, regardless of whether signs of physical impairment are thought to fit or not fit with the `evident’ tissue injury. While the original lesions for a whiplash patient may be in the tissues of the neck, the legacy and the central focus of ongoing pain pathobiology in the literature, is on altered central nervous system excitability and altered central nervous system processing of normal inputs” Louis Gifford

“Thus, the mechanisms that produce the pain change and move with time – and for those that develop marked and severe chronic pain states the pain is said to be `maladaptive’ in nature. This means that it serves no productive purpose in protecting the tissues concerned, which have long since done their best to heal anyway. Its most powerful impact is on the life and happiness of the patient ± causing much distress, loss of physical confidence, loss of self-esteem, often powerful feelings of guilt and a sense of hopelessness and despair. Many chronic pain patients become clinically depressed, or demonstrate signs of clinical depression” Louis Gifford

“It should be clear from the above discussion that past injuries and past pain states predispose the individual to vulnerability to future problems. This needs to be looked at in two ways. Firstly, if previous injuries have occurred, tissue weaknesses are likely to remain and degeneration has the potential to be faster than normal ± the tissues themselves are therefore vulnerable. Secondly, long-term neural sensitivity changes or `memory’ throughout the whole nervous system, may remain after the recovery of an injury. As such this means that further injury may easily re-kindle past neural representations and past neural activity of pain and symptoms related to the same, or closely related, tissues.” Louis Gifford

“In other words, if the pain and posture are adaptive, what right do we have to get rid of them?  have to get rid of them?  If we do deem such a posture and pain to be adaptive, evolutionary reasoning would predict that too early a resolution of the pain, or too rapid a correction of the posture might not be a good thing, may prolong recovery and lead to more episodes later on. This is a very useful type of research question that is challenging to several physiotherapy method – and which needs answering. Clearly, whenever we examine a patient it is important to reason whether what we observe can be viewed as adaptive, maladaptive, or an imperfection/defect.” Louis Gifford

“The biomedical, or ‘disease’ model of pain is a single level construct which may be fine where a problem’s cause can be established and which has a remedy available for it. The biomedical model assumes that an individual’s complaints should result from a specific disease state represented by a focus of disordered biology, the diagnosis of which is confirmed by data from objective tests of physical damage and impairment.” Louis Gifford

“Intervention is directed specifically toward correcting the organic dysfunction or the pathology and if this doesn’t work the patient, rather than our inadequate understanding, is frequently blamed. Thus, the traditional medical approach adopts a simple dichotomous view: symptoms are either somatogenic (real and potentially fixable) or psychogenic (not real and hence of little or no interest).  Although variations of this view still pervade, supporting evidence is lacking. If we really want to explain and understand pain, pain disability and pain response and prevent them from continuing to be major health care problems, we need to adopt a much more open minded multidimensional approach. We need new broader based models to help us understand chronic pain and incapacity and its development. This is what many in the vanguard of pain management and disability prevention are suggesting.” Louis Gifford

“Waddell’s writing is pithy, smart, and makes intuitive sense. The messages are sound, evidence based, clear, and easy to follow. Like many others, he argues that the biomedical approach to back pain has not solved the problem and may even be adding to it via inappropriate intervention. He advocates passionately that we should all adopt a biopsychosocial framework. “ Louis Gifford

“The physiotherapy and medical professions involved in pain diagnosis and management are facing major challenges.  These are exciting times that should reap the rewards of the mature and well controlled research that is now available.  Our professional profile can only benefit if we start to show that we are acting on the knowledge and messages coming from this high quality work.  In a very timely editorial to the journal ‘Pain’ Steven Linton (1998) persuasively argues the case for the instigation of early preventative programmes in the management of acute low back pain: …..“we found that a secondary prevention program in primary care, for first time sufferers, significantly reduced disability and reduced the risk of becoming chronic by 8-fold as compared to ‘treatment as usual’. “ Louis Gifford

“The sensation of acute pain is the conscious signal of a physical threat whose major purpose, in parallel with producing the biologically linked emotional reaction of fear and/or anger, is to motivate and bring about an alteration in our behaviour in order to further our chances of recovery and survival”  Louis Gifford

“Most therapeutic approaches usually consider pain in a single sensory dimension i.e., the perception of where the pain is located, the quality and type of pain, its intensity and the way it behaves over time. However, pain has been considered in terms of three dimensions for quite along time i.e., the sensory dimension as described; the cognitive dimension, which recognises that pain alters our thoughts; and the affective dimension recognising that for every pain we have there is some kind of emotional reaction.”  Louis Gifford

“The following two examples demonstrate how basic science developments have’ changed and directed thinking and practice in physiotherapy. First, knowledge that changes within the central nervous system can contribute to pain states. These central changes may amplify modest incoming nociceptor traffic, and can modulate sensory impulse traffic from normal tissues so that it leads to pain. Even more malignly, it may itself generate nociceptive impulse traffic. Clearly, these central changes have implications for treatment. Traditionally, a flaring pain response was linked to worsening of the tissues, whereas ‘ in fact it may simply reflect maladaptive central sensory processing.

A second research finding to have great impact for physiotherapy is that some of the central changes share a similar biology to synaptic events associated with memory, involving early short- and later long- term potentiation. One implication is that, once established, these central changes may become permanent, just as a long-term memory becomes fixed”  Louis Gifford

“‘Biopsychosocial’ is one of the latest physiotherapy buzz words. Along with ‘EBM’(‘evidence based practice), it is being perceived as threatening to our established and much loved methods and practices. This is unfortunate, because change and challenges in practice are some of the things that makes physiotherapy so exciting. Therapists and therapies need to evolve in parallel with new knowledge and rapidly changing values and culture. The position held here is that integrating the biopsychosocial model into our practice will actually empower some of our practices and methods if we interpret it and use it in the right way.”  Louis Gifford

“The source of a patient’s pain changes over time. This is fundamental to enhancing the general understanding and confidence about pain and its meaning. For the long term pain sufferer it is a great help to start to appreciate that hurt does not equate with harm, and that there is such a thing as maladaptive pain.  The longer pain goes on the more widespread and diffuse become its sources – hence the problems with therapy approaches that over-focus on finding a specific ‘source’ of pain, this is fine for fixing a car but not for fixing complex human pain states. “ Louis Gifford

“When tissues are injured the nociceptive cells innervating that tissue begin to increase their sensitivity and start to fire more easily, some may even fire spontaneously. Increased sensitivity and spontaneous firing is a product of the availability of active ion channels and receptors and their relative numbers”  Louis Gifford

“They may have a point, but the complexity of factors that play a role in precipitating chronic pain and chronic disability are such that some at risk patients require thoughtful and time consuming assessment and management in the early days of their problem. This is the key time. Linton’s (1998, 1999) work, has shown that identifying and addressing the known risk factors in early management of back pain can reduce chronic disability by 8 fold over ‘treatment as usual’. The interventions Linton (1998) used involved understanding and dealing with the anxieties and fears patients have about causing pain and causing structural damage with movement and activity, plus other psychosocial issues” Louis Gifford

 

Article taken from:
http://www.larsavemarie.com/louis-gifford-and-his-legacy/

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Tendinopathy – Rehab Progression

So I have linked to a very interested blog post on the topic of tendinopathy rehab.

This article is quite technical, so a good knowledge of anatomy and physiology will help! But a lot of the runners out there may find it an interesting read!

Please follow the link below to access the post:

Tendinopathy – rehab progression – part 1

Enjoy.

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Foam Rolling Science

Foam Rolling

Foam Rolling

A great infographic from Yann Le Meur looking at the evidence behind Foam Rolling.

Have a quick read and learn how to best utilise foam rolling in your program!

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Nocturnal Cramping: What is it? Who Gets it? And How To Get Rid of it?

Nocturnal Cramping.

One question that I often get asked by my clients at my sports massage clinic is, ‘Why do I keep getting cramps at night?’

Nocturnal leg cramps are pains that people experience at night. They are most frequently experienced in the calves but may also occur in the feet or thighs. Many people often wake up in a state of cramp with the sensation of their muscles contracting and ‘knotting’.

An episode of cramps can last anywhere from a few seconds up to a few minutes. Due to the intense level of muscle contraction involved, nocturnal cramping can leave muscular soreness in the affected area for several days after the event.

The people who tend to experience more common bouts of cramping are the over 50’s, but younger people will also experience it at various times.
Nocturnal Cramps

What Causes Nocturnal Cramping.

There are many theories on what may cause the cramping.

The NHS states that cramping can sometimes be caused by the following:
– Ageing
– Exercise
– Pregnancy
– Not drinking enough fluids
– Liver Disease
– Medication to lower cholesterol, or high blood pressure

Other possible causes include:
– Alcoholism
– Parkinson’s Disease
– Neuromuscular Disorders
– Arthritis
– Respiratory Disease

Some researchers have theorised that our modern day lifestyle may contribute to cramping. They link the enhanced tissue health from the time our ancestors spent resting in the squat position (stretching & strengthening the soft tissues), to the modern day where our need to squat has all but been removed.

It has also been theorised that when we lay in bed, our feet are generally kept in a ‘plantar-flexed’ position. This meaning that our toes are pointed. In this position the tissues of the calf are in a shortened state. After being in this shortened position for long periods of time, even a slight movement could trigger cramping.

There is some evidence, the strength of which is questionable, that Magnesium and Calcium deficiencies play a part in these cramps. There is also research to show that people who stand up for long periods of time during the day are more likely to suffer than those who do not.

Cramps

How Can Nocturnal Cramps be Prevented?

There is some evidence that stretching before bedtime, targeting the hamstrings and calves, could reduce the frequency of cramps by nearly 60%. However, there are also studies which show no correlation!

Increasing the intake of magnesium may have positive effects, as many people do not consume adequate amounts within their diet.

Consuming a larger intake of liquid throughout they day may also be beneficial. The standard recommended amount of water to consume per day is 2 litres. Although, I am not sure how much of that advice is solid evidence based. Either way, as long as you drink when you are thirsty, maintain a pale, straw like urine colour and increase your fluid intake when physically active, you will be fine!

In essence – there is no rock solid reliable approach to getting rid of nocturnal cramps as it is not fully understood yet exactly what may be causing them. So, the best approach would be somewhat trail and error. Making changes based on what could potentially work and seeing how the body responds.
Cramp Massage

If cramping has been experienced then stretching and sports massage therapy can be very effective in reducing the muscular soreness experienced. I treat many people at my Nottingham sports massage clinic who have experienced bad cramps and the combination of soft tissue massage, advanced stretching techniques and dry needling can be very effective.

Thanks for reading,
Alex

References:
https://jamanetwork.com/journals/jama/article-abstract/372582?redirect=true
https://jamanetwork.com/journals/jama/article-abstract/372582?redirect=true http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD009402/full https://www.ncbi.nlm.nih.gov/pubmed/21846281 https://www.sciencedirect.com/science/article/pii/S1836955312700681

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Utilise Sports Massage for your Performance

Sports Massage can benefit your Performance

Exercise massage

Sports Massage is not reserved just for the Elite!

No matter what your level of activity it could benefit your training.

– Boost your recovery between physical activity.
– Address any muscular aches and pains
– Receive education on how you can improve your physical wellbeing and optimise your training.
– Improve your mobility capabilities.

Contact us at info@centralsportsmassage.co.uk for any further information or questions you may have.

See great content at…
https://www.instagram.com/centralsportsmassage/

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Central Sports Massage new treatment room location

Work has now begun on my home sports massage treatment room / gym!

Since moving home to Lowdham in February, I have had my eye on converting the property’s large garden building into a treatment room/gym. I am happy to finally be making progress with the conversion, after focusing initially on the actual house itself!

When embarking upon the conversion I began with the easiest bit! Making sure all of the timber was well treated with wood preserver, before finishing it with some colour!

The images below show what a great difference that process made!
IMG_8346
Treatment Room

 

I am currently in the process of fitting insulation throughout the structure. Next it will need boarding up, flooring installed, painting and decorating, before finally kitting it out with the essential therapy equipment and selected fitness/rehab equipment.

Once it is complete it should be a great facility! I will be able to offer my usual sports massage sessions, but I will also have the benefit of a great selection of fitness and rehab equipment that can be utilised to create more of an active approach to pain management and soft tissue therapy. I am excited to begin working in a way that incorporates this element as I know that it will be of great benefit to my clients.

The conversion will hopefully be up and running by the end of the summer! Watch this space!

Alex

http://www.centralsportsmassage.co.uk

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Effectiveness of the McKenzie Method for Treating Low Back Pain. A Systematic Review

 

Posted on

The McKenzie Method is a classification based system and treatment programme for patients suffering from low back pain (LBP). It was developed in 1981 by Robin McKenzie a PT from New Zealand. This type of classification-based system of diagnosing and treating LBP has been around for some time now and, where as before there was evidence suggesting this was the way to get best results for our patients, now there is a raft of evidence which contradicts this belief.

The McKenzie Method classifies patients into 4 groups: Derangement, Dysfunction, Postural Syndrome and Other. These groups then direct the appropriate treatment required. To find out more about the classifications, what they mean and the relevant treatments please read the Physiopedia page.

A concern with research involving the McKenzie Method, and other classification systems, is the use of underpowered and poor methodological studies as evidence demonstrating their effectiveness (an example).

There has been a Systematic Review (SR) & Meta-Analysis completed before investigating the evidence for suggesting the McKenzie Method is effective at what it sets out to do. In essence it concluded there was a lack of evidence supporting its use and more studies were required. This was over a decade ago and since then more research has been published and, as Tam et al suggest, there were issues with the search criteria used for this SR.

This is the rationale for Lam et al use for performing this updated and stronger SR. They have included the research published in the past decade as well as correcting the mistakes their colleague included in their initial SR.

In terms of the findings from the SR and clinical implications. If we only consider research of an appropriate quality then we can say:

For acute pain:

  1. The McKenzie Method is not clinically superior to all interventions in treating acute LBP but is more effective at reducing pain intensity when compared to manual therapy and exercise combined.

For chronic pain:

  1. The McKenzie Method was more effective at reducing pain and disability than other interventions,
  2. McKenzie Method was more effective at reducing disability but not pain when compared to exercise alone,
  3. McKenzie Method was not more effective than a combined exercise, manual therapy and education intervention.

As always take these findings with a pinch of salt. The effects of the McKenzie Method could be as a result of the fact large groups of patients may not fall into their subgroups and would have benefited from any exercise anyway.  The McKenzie Method is a mechanical-based system and does not account for psychological aspects of pain or alternative theories of pain. It lumps you into a category, disregards psychological aspects or more nuanced aspects of treatments. Still this doesn’t mean McKenzie isn’t a viable option for treatment. Just bare this in mind. Other treatments and assessment tools / strategies have proven as or more effective.

Article copied from https://www.physiospot.com

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Sports Massage Therapy Event Work

ESF EVENTS – Football Festivals.

I have just returned from another busy weeked working at a great football event – ESF Events Football Festivals!

This time round it was a football festival held at Butlins Resort in Skegness. ESF Events hold large junior football events all around the UK over the Spring period.

I travelled up from Nottingham to be in attendace with my Sports Massage Therapy tent and was on hand to provide soft tissue therapy to all cometitors. Whether it be sports massage, assisted stretching, joint mobilisations, sports taping, or just some good old fashioned advice!

The weather was on top form which lead to a great weekend of football in the sun!

Due to the nature of these events, the teams had to compete many times over the course of two days, without much time for recovery. Alot of tired legs passed through my tent and plenty of invigorating sports massage was utilised to keep the player’s body’s firing and ready to go!

Another common complaint for the weekend was knee pain. This was a mix of impact injury and just general overloading of the body. I used tape in a lot of cases to try and off load the relevant structures nad to offer some support, where possible, to the knee.

Not only did I get stuck in with plenty of therapy for the players at the event, and also offered plenty of advice to parents relating to their own musculoskeletal complaints! – The adults need attention too, and so there were various point in the weekend that I had the parents…and even referees, on the treatment table receiving their own much needed sports massage therapy.

RUGBY.

Next weekend sees me return tp Skegness, only this time I will be working at a Rugby League competition. I’m looking forward to seeing what kind of issues the players come to see me with there!

Alex

ESF Events
For more information on ESF Events and the fantasic sporting events that they organise, please click the link below:
http://esfevents.co.uk/

 

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https://www.facebook.com/centralsortsmassage1

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