Pillars of Rehab Success

Turns out pain is very complicated (see previous blog about pain science). The medical world has come a long way in understanding and treating pain, but we still haven’t found that magic pill for resolving pain. However, we do know pain is much more than just the body part involved and impacts (and is impacted by) other body systems. The goal of this post is to identify and discuss a few key lifestyle behaviors that can greatly impact the recovery process. Addressing these “Pillars of Rehab Success” along with following the guidance from medical providers will greatly increase your chances of overcoming or better managing whatever physically ails you. There are many lifestyle choices that can impact recovery, but the pillars we will be discussing in this article are sleep, diet, stress, and exercise.

 

Sleep is arguably the most impactful modifiable lifestyle behavior as sleep plays a role in nearly every bodily system and function. Regarding pain and recovery, our naturally produced growth hormone spikes in the deep sleep cycles. This hormone is responsible for rebuilding and growth. Additionally, our stress hormone cortisol is lowest while we sleep. This flip in hormone levels is one reason why sleep is considered restorative. The less quality sleep we get, the less restoration we achieve. Additionally, since the mental, emotional, and cognitive effects of sleep deprivation are processed in the brain alongside pain processing, there can be some crosstalk between them. It’s very common to have increased pain symptoms after a night or two of poor sleep. For most adults, we should aim for at least seven hours of sleep but try for eight or more, if possible. This typically requires being more mindful of when we need to be in bed and practicing good sleep hygiene before bedtime (avoiding stimulants, dimming lights, reducing screen time, etc.).

We know food is certainly good for the soul and the way to anyone’s heart; however, the quality of food consumed can impact pain and the recovery process. Most importantly, we need to remember the original purpose of food is to provide the appropriate nutrition to fuel our bodies. What we put into our bodies will be what our body uses to provide energy, grow, and recover. Simply put, crappy nutrition will lead to crappy fuel. Additionally, highly processed “unhealthy” foods can irritate the gastrointestinal system, generating local inflammation than can have a systemic effect. This effect can then be like fuel to a fire for someone already in pain and dealing with an injury. Ideally, we would eat a 100% healthy diet full of veggies, fruits, lean meats, fish, seeds, nuts, healthy fats, and whole grain carbs. However, going on a fulltime strict for most of us eventually leads to mental irritability and eventually caving in. If this is you, my recommendation is to aim to eat “healthy” 85-90% of the time each week. This still allows for some splurge meals/snacks while maintaining the overall fairly healthy diet for proper fueling.

Research has shown a link between persistent pain and sympathetic nervous system (SNS) overdrive. The SNS is the “fight or flight” part of our autonomic nervous system responsible for priming our bodies in threatening and extremely stressful moments. A heightening SNS is good when in that moment (facing a bear, in a battle, etc.); however, we ideally only want to spend a small portion of time in this state. Unfortunately, our SNS cannot differentiate between the stress from an actual threat or the stress of our day-to-day lives. Therefore, due to stress, many of us live each day with an amped up SNS, reducing our ability to relax, restore, and recover. If you find yourself in this category, there are several ways to help reduce stress. These include, but are not limited to, finding an appropriate outlet (ex: hobbies, exercising), talking/counseling, gratitude logs, journaling, and meditating.

It’s common to avoid all physical activity when injured or in pain. However, general exercise is very therapeutic and aids greatly in recovery. Actively moving the joints and muscles can reduce swelling better than ice and medication by mechanically pumping the fluid into the lymphatic system. Additionally, the more we move a joint, the more synovial fluid the joint will produce, which is the body’s natural WD40 lubricant. Exercising increases blood flow, bringing in oxygen and nutrition to aid in recovery while flushing out inflammation and other metabolites. Hormonally, exercise has been shown to increase endorphins, growth hormone, and protein synthesis, all of which assist in pain reduction and recovery. Now, I’m not saying to ignore the pain and injury and to train as if 100%. When hurt, it may be advised to rest a healing joint or muscle, but there are usually other ways to exercise without physically aggravating the injury. For example, if one shoulder is injured, the lower body, trunk, and the other arm can be worked. If high impact activities are bothersome, try low-impact machines or get into a pool. If one limb hurts, don’t avoid exercising the other in fear of creating imbalances. Working the non-injured side will actually assist in the injured side’s recovery. It’s important to continue cardiovascular and strength training while hurt, unless advised otherwise by a medical professional.

The above four pillars discussed are only some of the many lifestyle behaviors that can be modified and optimized to improve recovery and pain management. These recommendations are general based on my experience with orthopedic pain and injuries. It’s always recommended to see a medical provider for further evaluation, treatment, and guidance when appropriate. However, regardless of the presence of pain or injury, following the above recommendations will certainly lead to a healthier life!

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To Heel Strike or Not?

If you were to sit and watch a mass of runners going by at the local 5k race, you will see all sorts of varying running forms, techniques, and movement strategies. Noticeable differences include varying head positions, arm swings, elbow angles, spinal postures, hip movements, knee drives, stride lengths, and step cadences. A largely debated topic is landing mechanics, specifically if it’s a running sin or not to heel strike (land heel first). My goal with this article is to discuss the differences in foot landing positions as well as give my opinion as a runner and physical therapist on the subject.

The heel strike landing pattern (also referred to as rearfoot strike (RFS)) became a more widely-accepted and adopted technique with the creation of the cushioned running shoe. Prior to shoe companies adding extra cushion under the heel, it was near impossible for someone to consistently heel strike for miles and miles without crushing their calcaneus (heel bone) into oblivion. Therefore, most (if not all) runners “back in the day” were midfoot or forefoot strikers, allowing the soft tissue structures of the feet and legs to absorb more of the load. Many advocate a midfoot or forefoot landing pattern now since it is more “natural” when not influenced by the modern advancement of the cushioned running shoe.

So what’s the big deal between strike patterns? Great question!

Heel striking is exactly as it sounds and occurs when the runner lands heel first (usually on the outer heel) with their ankle flexed and toes up. Most runners nowadays are heel strikers. The benefits of heel striking include the naturalness of it for most runners (especially novice) and the decreased soft tissue strain when compared to the other landing types. However, heel striking increases the amount of force experienced by the leg bones, hips, and knees because the foot and ankle is unable to absorb some of the load like with midfoot and forefoot runners. Though the max peak force experienced is similar between the different landing patterns, heel strikers typically experience more overall forces due to 1) an increased initial peak force with landing (see image below), and 2) increased contact time with the ground required to go from landing to push off. The increased force exposure and absorption may increase a heel strike runner’s risk for general joint pains and boney stress injuries compared to forefoot and midfoot runners.

Midfoot striking occurs when a runner lands flat footed with relatively equal distribution of weight throughout the foot while forefoot runners land more on the ball of their foot. These landing patterns are commonly described as more natural styles of running because running barefoot would likely require adopting one of these landing patterns to help distribute the landing forces. Unlike with heel striking, the foot and ankle are able to absorb much of the force, reducing the forces experienced in the leg bones and joints proximal to the ankle. Additionally, these landing patterns usually result in a quicker step cadence, resulting in an overall decreased contact time with the ground. Though there may be reduced stress to the leg bones and joint structures, there is oftentimes increased strain to the soft tissues, especially those in the foot and lower leg. This is why runners transitioning from heel striking to midfoot/forefoot landing are advised to transition slowly. These runners do not experience the same initial contact peak force as heel strikers do; however, the max experienced force is relatively the same.

Source: https://www.researchgate.net/publication/319104024_Common_Running_Overuse_Injuries_and_Prevention

So, is one landing pattern better than the others? Well, it depends on who you ask. Below is this runner’s and physical therapist’s opinion.

If you have ever tried changing your own landing pattern or tried teaching someone else, it is extremely challenging and frustrating for all parties involved. It can be awkward for the runner and can take months to master a new running technique while slowing ramping up mileage to avoid overuse injuries. Plus, many runners cannot accurately identify their own landing patterns (many think they are midfoot/forefoot runners but on video analysis are actually heel striking). Therefore, I do not believe changing the strike pattern is necessary for most runners as there are other components of the running that may be easier to modify with bigger results: foot placement and stride cadence.

A common issue associated with heel striking is overstriding, meaning the landing foot is hitting the ground ahead of the runner. It’s hard to do so when landing midfoot or forefoot. The further out front the foot lands, the harder the impact typically experienced through the leg. Additionally, the foot will spend more time in contact with the ground as it becomes the supporting post for the body transitioning over into the next step. In general, increased time with an external force can increase injury risk. Also, when the foot lands ahead of the body, it creates a temporary braking force. Newton’s Law of Physics states a force will create an equal and opposite force, so a foot landing out in front will create an impact force right back at the runner. If the goal is to keep moving forward, eliminating opposing backward forces would be good, right? If a runner can decrease their stride length so that the foot lands more under their body instead of outfront, it can significantly reduce the overall force absorbed, decrease contact time with the ground, and reduce/eliminate the backward impulse generated.

Source: https://groups.google.com/forum/#!topic/just-south/KdopHHtEU2o

Increasing stride cadence (step frequency) is another fairly easy modification a runner can make to reduce strain and improve running efficiency. Given a set overall speed/pace, the runner with a slower cadence must have a longer stride length than a runner with a quicker cadence. This longer stride increases ground contact time and forces the body has to absorb. Purposefully increasing stride frequency helps reduce stride length and improves foot landing placement, resulting in a more efficient motion (less braking forces) and decreased load. I recommend a cadence of 160-180 steps per minute. If your cadence is significantly lower than this, do not immediately increase your step frequency to match it. Start by increasing your current step frequency by 10% and gradually increase as you get more comfortable with a quicker yet shorter step. I heard from a buddy once that a runner should pretend to be a ninja trying to sneak up on someone (think quick and quiet feet!).

In summary, there are many variances to running form and technique with arguably the most disputed being foot strike pattern. To me, there are pros and cons of each. However, I feel adjusting foot landing placement and stride cadence are more beneficial (and easier) than adjusting foot strike. By focusing on landing more under the body and quickly transitioning into the next step, a runner will likely be more successful in reducing overload forces, improving efficiency, and reducing injury risk. If constantly dealing with overuse running injuries or feeling inefficient with running, try modify one or both of these instead of focusing on how your foot is landing!

Shameless Plug: Having pain with running and issues with modifying running mechanics, come see us at Vertex PT Specialists to have one of our trained therapists evaluate your running form, help address any physical impairments you may have, and get you back to running sooner!

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Trunk and Core Strengthening

It seemed like for a while the biggest fitness craze was core stability training with every fitness and rehab guru flooding the internet and social media with exercises using every combination of positions, movements, and equipment possible. I’m sure I saw someone doing quadruped bird dogs with ankle/wrist weights with a resistance band pulling them one way while maintaining balance on a BOSU ball that a buddy was unpredictably tapping to create perturbations on an unstable service. Yeah, exercises like that can be effective and meet the intent, but it doesn’t need to be that complicated. Additionally, oftentimes such exercises can be too challenging and complex for the “Average Joe”. In this article, we’ll dive into a simple way to progress trunk and core stability exercises. But first, let us quickly dive into a quick anatomy review and the why behind the importance of maintaining a strong trunk.

The trunk musculature can be divided into two categories based on their primary function: movers and stabilizers (note: each trunk muscle can have both a mover and stabilizer function but has a primary role of one over the other). The movers are the bigger muscles located more externally and primarily work to move the body in different directions. This includes the abdominals (flex the spine), paraspinals (extend the spine), and the obliques (side bend and rotate the spine). Stabilizers are deeper and function to maintain a spinal trunk position at rest and during movement. These include the transverse abdominis (TrA), quadratus lumborum (QL), and the lumbar multifidi (LM) muscles.

When looking at the trunk and reviewing its function, it helps to view the entire system as a three-dimensional cylinder around the spine and guts. The abs and anterior portion of the TrA comprise the front of the cylinder, the obliques with the lateral TrA fibers make up the outer walls, and the LM and paraspinals solidify the backside. Like a soda can, this cylinder also has a top (diaphragm) and a bottom (pelvic floor musculature). A healthy and properly functioning cylinder will be able to generate pressure against all walls within it, locking down and stabilizing the trunk during exertion (like the stiffness of a full unopened soda can). A poorly pressured cylinder will not be as strong and stiff (like the walls of an empty opened can). Now, the cylinder does not need to be fully pressurized all day, everyday but only when needed to complete the task. And the amount of pressure generated can and should be based on the demand. For example, generating 100% pressure and stiffness is needed for a max deadlift effort but not for picking up an empty laundry basket. Having an appropriately pressurized cylinder will reduce injury risk by maintaining proper mechanics and evenly distributing the force to the right load-bearing structures.

Now, how do we initiate a trunk strengthening program correctly with a good progression? There are certainly different strategies and approaches out there. For the most part, there isn’t a necessarily “right” or “wrong” way as long as the exercise and dosing is appropriate for the person. For example, it may not be a good idea to perform heavy deadlifts right away for a deconditioned individual with acute low back pain. I personally view trunk strengthening progression as a three phase process:

Phase 1: Isometric holds maintaining a static position for a designated period of time, starting with a shorter time then increasing duration to build endurance and confidence. Examples include front planks, side planks, and back bridges.

Phase 2: Build off the isometric holds from Phase 1 by incorporating an unweighted or minimally resisted dynamic limb movement. The purpose is to train the trunk to remain stable and strong while moving the arms and legs. Examples include bird dogs, dead bugs, and rolling planks.

Phase 3: This phase is where I introduce more dynamic movements and heavier loads to challenge the trunk strength and endurance. These are oftentimes referred to as more “functional” exercises as they replicate natural movements and carry over to tasks we commonly perform during the day. With these exercises, the trunk is usually not the primary focus or working muscle group but serves more of  a supporting role (but extremely important, nonetheless!). Examples include kettlebell swings, deadlifts, and weighted carries.

Check out the videos below for examples of this outlined progression for the lateral and posterior trunk musculature.

 

 

As you can see, phasing a trunk strengthening program like above helps progressively build up the trunk strength and endurance appropriately. It doesn’t seem smart to overload a patient or client with heavy deadlifts if they aren’t able to hold a basic unweighted back bridge for more than ten seconds, right? Overloading a patient or client too soon without the proper baseline strength and endurance will increase injury risk, aggravate an existing injury, create frustration, and/or compromise trust with the provider/trainer. Let’s train and rehab smarter!

This isn’t rocket science but hopefully seeing a phased trunk strengthening progression is beneficial for you. The goal is to start small and progressively build strength and confidence while keeping it simple!

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The Pain is in Your Head!

We oftentimes hear the phrase “pain is in your head” used to motivate others around us while suffering
through a physically intense endeavor. I frequently heard this or similar renditions while in the Army
during training events like our semi-annual fitness tests, long unit runs, and grueling ruck marches. The
meaning of statements like this is to reinforce the power of the mind over the body, to mentally fight
through the physical discomfort. However, it turns out that pain is actually experienced in our heads and
NOT actually where pain is felt. Pain truly is in our heads. Now bear with me as I elaborate.

You see, the painful body part is too “dumb” and not equipped to produce pain. Let’s use tweaking the
low back while lifting something heavy, for example. Within the tissues of the low back are special
receptors and nerves that simply detect whatever might be a threat to the body. This includes local
chemical responses from inflammation, exposure to high forces of pressure, and extreme heat or cold.
These nerves detect this stimulus but do not know how to utilize this information; however, they know
who does…. the brain! So, these low back nerves that detected a potential threat send a signal away
from the local area to the spinal cord which then relays the message up to the brain for further
processing. Once received, the brain makes note of where the message is coming from, what type of
message was received (a potential threat!), and the current situation (bending over picking up
something heavy). It quickly processes the message to produce the output of pain.

Believe it or not, pain is a blessing protecting us from further harm. If it wasn’t for pain, I wouldn’t be
able to detect the sharp rusty nail I am stepping on and quickly pull my foot away from it, preventing
getting tetanus. Without pain, I wouldn’t know if my appendix was about to rupture, potentially causing
a fatal event. Pain forces me to the doctor to get the appropriate treatment. Pain prevents us from
running on a sprained ankle, causing further harm to sensitive tissue. Without pain to protect us and
guide us, we wouldn’t have survived long as a species!

Not only can the brain receive and process information from pain receptors and nerves, it is also the
body’s headquarters for processing any and all information related to our senses, movement, internal
health, cognitive processing, emotional state, and overall well-being. The brain will use other information
to fine tune the output and can amplify, distort, or weaken the output based on this other data. It can
also suppress the pain output in a life or death situation. For example, a Soldier being shot in the arm in
combat may not realize it until after the firefight is over. During this scenario, the arm’s pain receptors
and nerves detected the threat and relayed the information to the brain for processing. However, the
brain quickly “decided” the arm is less threatening than the potentially fatal situation it was facing, so it
dampened the pain output to deal with it later, when not in a life and death situation.

Because the pain is processed in our heads as well as EVERYTHING else, there can be some crosstalk
between different processes simultaneously occurring that can greatly impact the pain output. For
example, a person with both chronic back pain and depression may experience more back pain if their
depression worsens. What is it about being more depressed that causes more back pathology? Nothing!
But because both the depression and the back pain are processed in the brain, they can oftentimes
negatively impact each other. The opposite is true, too. Feeling more hopeful and optimistic can have a positive effect on chronic pain. This is why managing chronic pain should include a holistic approach (a
topic certainly worth its own article).

Of course, the physiology of experiencing pain is much more complex than explained here, but hopefully
this simple description helps identify the complexity of pain and how it’s not necessarily all about the
painful body part. It’s important to remember this while going through the rehabilitation and recovery
process, especially when there is a lack of progress, worsening of symptoms, or when dealing with other
health issues simultaneously (physical, mental, spiritual, etc.).

So, in summary, the pain you and I feel is actually in our heads. No, we are not all crazy, and the pain
experienced is actual legit pain. We just need to remember this as we recover and heal as there can be
many other factors that can influence the rehab process and pain symptoms. By understanding and
acknowledging this, we are able to identify non-pathological reasons why pain may worsen, and this
gives us a little more control over what often seems to be an uncontrollable situation.

For more information, check out this 5-minute animated video:

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Squatting with Knee Pain

So, your knee is starting to give you a little trouble when you squat. Many times, people come to us having been told they need to stop squatting and rest it, or that “squatting is bad for your knees, you should never go that low.” And don’t get me started on the “knees shouldn’t go past your toes” myth… All of this couldn’t be further from the truth! If your healthcare provider is telling you otherwise, it’s time to find someone else. A big part of getting you back to 100% is volume management. This means your recent squat volume may have been a little too much for your tissues to handle and we need to take some time to calm them down and build them back up. But in the meantime, we can still find ways to get after it in the gym!

An experienced PT will not only assess your knee and design an appropriate loading program, but evaluate your squat mechanics, make future programming recommendations, and most importantly, find a way to keep you moving! Our goal with physical therapy is not about telling you what you CAN’T do, but helping you figure out what you CAN do. Rather than telling you to stop squatting, we work with each patient to figure out a squat variation that allows them to continue moving without increasing their symptoms. This could simply be moving them toward a more hip dominant squat to decrease the demand on the knees.

An easy rule of thumb is to move across the squat continuum to variations that utilize a more vertical shin. For example, if you’re having symptoms when you front squat, try a high bar back squat. When the load moves from the front rack to the upper back, the torso angle changes and the squat becomes more hip dominant vs ankle/knee dominant. Having an issue with high bar back squats? Try a low bar variation, or try box squats. This will let you really load the hips and keep your shins more vertical. From there we can keep adjusting by increasing the height of the box, decreasing range of motion to further remove the demand on the knees. There is a variation out there that will let you keep squatting, you just have to find it!

Over time, as the specific interventions for the knee continue to progress, we can gradually work back into the variation of the squat that was causing symptoms. Your rehab should be an active process, and there is no reason you can’t keep squatting!

Have questions? Send us a message at josh@vertexpt.com

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You Threw Your Back Out! Now What?

Most of us have experienced that sudden unexpected sharp low back pain and the inability to fully stand up erect afterward. If you haven’t yet, chances are you likely will at some point. Unfortunately, we oftentimes do not expect it to happen as it either occurs with the most obscure unthreatening activities (picking up a pencil, wresting with your kids, getting out of the car, etc.) or when we believe we are physically prepared to take on load (deadlifting, squatting, etc.) but the aftermath tells us otherwise. So, when it happens, what should you do?

First, don’t panic. Take a moment to catch your breath and evaluate the situation. Yes, it can be extremely painful and alarming but 99.999% of the time it isn’t life threatening. To assist ruling out more severe pathology (cancer, spinal cord injury, etc.), think about the how the pain started and the resulting symptoms. Below are some criteria to help:

  • Is the pain associated with a low-traumatic specific cause or mechanism (picking something up, twisting, etc.)?
  • Does the pain change with movement and/or position (ex: worsens with bending, better with sitting, better with walking, worse in the morning, etc.)?
  • Are you experiencing any other concerning symptoms (ex: changes in bowel/bladder function, nausea/vomiting, numbness/tingling, unexplained weight fluctuations, paralysis or severe sudden weakness, dizziness, headaches, etc.)?

If you can answer “yes” to the first two questions and “no” to the third, then the pain is likely “mechanical”, meaning it is not life threatening and is associated with the movement-related parts of the body. More severe and worrisome causes of back pain typically present as a constant unrelenting pain without an identifiable cause, pain that does not change regardless of movement/position, and pain along with other worrisome symptoms like those in question three above. Additionally, high-velocity traumatic causes of back pain (high-speed car accident, fall from high surface, etc.) should also be medically evaluated to rule out fractures. If you deem your pain as life threatening or suspect a fracture, definitely get it medically evaluated as soon as possible. If not, then congrats! You are the proud owner of acute low back pain and should keep reading.

Next, keep moving. Old school medical advice directed back pain patients to stay off their feet and oftentimes prescribed “bed rest” for prolonged periods. Turns out this treatment strategy is more harmful than good. Current medical literature supports continued activity, starting with lower level activities and gradually increasing workload until back to prior level of function. Sitting and laying around avoiding aggravating movements may seem logical to allow the body to heal; however, it’s common for individuals to actually feel WORSE after prolonged periods of rest. The longer you stay away from being active, the higher the risk of becoming deconditioned, weaker, and stiffer while potentially developing fear avoidance behaviors and acute depression if avoiding activities typically enjoyed.

With that said, it is not wise to continuously push through painful movements with the “pain is weakness leaving the body” mentality. Doing so can aggravate healing tissues (similar to picking a healing scab) as well as increase your body’s sensitivity to movement, resulting in higher pain levels. (Note: Pain is a very complicated output of the brain after it receives/processes multiple stimuli, to include pain receptors. The complexity is a whole other article on its own, but you can trust me on this!). So, the goal is to avoid the far ends of the activity spectrum: not enough and too much. Like Goldilocks, you need to find the middle “just right” point that keeps you moving without overdoing it. Light range of motion exercises and stretching is typically recommended along with light cardiovascular exercise like walking or riding a stationary bike. Check out the video below for some good exercises commonly prescribed for acute low back pain.

While going through the recovery process, it’s crucial to maintain an overall healthy lifestyle to promote a good healing response. Because physical activity is usually restricted initially, maintaining a well-balanced diet is key to prevent unnecessary weight gain and provide the body the right nutrients to optimize healing. Binge watching Netflix and eating a tub of ice cream is not a good approach. Sleep, too, is very important. One of our biggest healing-promoting hormones is Growth Hormone which naturally spikes during our deep sleep cycles. Additionally, our biggest stress hormone Cortisol (which limits recovery) naturally lowers while asleep. Reducing and disrupting sleep patterns therefore decreases the body’s natural ability to heal by reducing the “good” hormone we need while maintaining elevated levels of the “bad” hormone. I also recommend avoiding tobacco use and heavy alcohol consumption as both can reduce blood flow and the oxygen/nutrients delivered by the cardiovascular system, resulting in delayed healing.

The last piece of advice I can offer is to stay positive, be patient, and embrace the roller coaster ride of recovery. You will get better, it may just take some time. Each injury and person are unique; therefore, timelines, progression, and symptoms will vary. And if you have a history of low back pain episodes, each recovery will be different. Mindset is HUGE when injured (go back to the previous comment about the complexity of pain output). Feeling down and out mentally can carry over to how you feel physically. Also, remember that recovery is not a smooth ride with predictable improvements each day but more like a bumpy roller coaster ride with ups, downs, and loopy-loops (see below image). It’s common to experience a “bad day” after a “good day”. This does not indicate further harm or reinjury but is a common response as the body progresses.

So, in summary, tweaking your back happens. And, unfortunately, it sucks. However, you will recover. The body is amazing and able to heal despite all the day-to-day abuse thrown its way. There are things you can do to promote the recovery progress as described above: stay moderately active, maintain a healthy lifestyle, and have a positive mindset. Typical acute pain episodes improve over one to three weeks. If your pain persists longer, intensifies, or progresses to include “red flag” symptoms (see question 3 above), you should consult a medical provider to further assist.

Shameless Physical Therapy Plug: Seeing a physical therapist early in the back pain episode can further assist in the recovery process. If your state and health insurance allow for direct access to physical therapy without a referral (like South Carolina), I encourage seeking a physical therapist first to avoid delayed care and possibly unnecessary imaging and medication prescriptions.

I hope this is helpful. Definitely reach out to us at Vertex PT Specialists if you have any questions or concerns. Or if you are in the Columbia, SC area, we would love to help you out if your back pain continues to nag you!


Dr. Pat Casey, PT, DPT, OCS, CSCS, SFMA, CF-L1
pat.casey@vertexpt.com
803.973.0100

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5 Important Factors for Preventing Injury in Tactical Athletes

Baseline Aerobic Capacity

At the heart of every tactical job is the need to escape or mitigate danger when it arises. It doesn’t matter the job: military, police, fire. You have to be able to chase down a suspect, escape an explosion, or go into and come out of a fire. All of that will take a toll on your cardiovascular system – whether it’s the stress on your heart immediately or if it’s your body’s process of using oxygen and expelling carbon monoxide. You have to be able to use your aerobic system efficiently to do your job well – which essentially means making sure you and your team is safe. Does this mean spending 20 minutes on a stair machine or running 5 miles a day? Absolutely not. Endurance based training is not what you’ll be doing on at a fire scene, while jumping over fences in a chase, or when doing obstacle courses. It’s a combination of power based and endurance based systems, so both need to be challenged to create adaptation. You have to create a mixture of long-runs or sustained movements combined with strength and power movements. And you have to work at a specific intensity, AS LONG AS YOUR MOVEMENTS ARE PROFICIENT. And you have to understand how hard your body is working – this is best assessed by listening to your body. We call this “ratings of perceived exertion” – or a rating of how hard you think you’re pushing it. If you feel like your workout is cake, you’re more likely to be at a 1-4/10; this would correlate to between 10-40 % of your heart rate maxium (the total your heart is able to pumped based on your age and other factors). If you felt like you’re working harder – not the hardest you’ve ever worked but definitely breathing hard, and getting tired of the movement, you’re more likely at the desired 6-7/10. This is about 60-70% your heart rate max and will help you push to gain aerobic capacity. You don’t want to get so hard that you can’t keep going – so hard you HAVE to stop is more along the lines of that 10/10, or 100% (at) your heart rate max. You don’t want to be here for long, if at all.

Baseline Load Tolerance

Tactical athletes don’t just run away form or towards danger. They also have to be able to manipulate certain pieces of equipment to do their job. For firefighters, this can be advancing a charged hoseline or moving debris within a home. For police, this may be physically fighting a suspect, carrying a variety of tools/equipment, or moving objects out of the way to apprehend a suspect. For military – this can be anything; carrying a battle buddy, carrying heavy ruck sacks, carrying specific equipment. All areas of tactical athletes do have heavy lifting. To lift heavy efficiently, you have to have a good baseline functional movement pattern. And you have to have a load tolerance. If you go from lifting chips to your mouth while watching TV and try to go directly to carrying your 160# battle buddy – you’re likely to get injured. Your body just doesn’t have a tolerance to that kind of load. You have to safely progress the amount of load/weight that your body is lifting and carrying slowly over a period of time. Any sharp increase in that load can and will lead to injury.

Nutrition

This should be pretty self-explanatory. You get out of your body what you put into it. If you’re consistently putting cheeseburgers and beer into your body, it will not perform up to standard. If you have to go out to a fire scene and your body is dehydrated because you only drink soda and you never drink water, with the amount of sweating you’ll do you’re more likely to pass out; at minimum you won’t be fighting a fire as efficiently as you could be. Whatever you put into your body that’s processed will take longer to be broken down, and won’t be broken down completely. Your body can’t take the nutrients from the food – the protein, fats, and carbs – to utilize them for fuel. And whatever excess you ingest will be turned into fat by your body. The more fat you have, the harder it will be to move with your gear. Not to mention there’s less cholesterol in your system to clog up your arteries. So, if it comes from a bag or a box – it’s probably not good for you. Be an adult, minimize your fast food chicken nuggets in favor of colorful fruits and vegetables.

Stress-Management Techniques

Here’s the topic that means the most to me! Stress management is so important in our tactical athletes. This is a population that sees the unimaginable and keeps going. They come to situation they may or may not live through, then once they do make it – there’s a memory lodged in their brain for the rest of their life. And the only thing they really have is the ability to talk to family members, chaplains, and their brothers (and sisters) to get some closure. A lot of tactical athletes turn to alcohol or other substances to quiet their minds, which obviously takes a toll on your body, dehydrates you, allows you to make bad decisions…the works. Figuring out how each individual tactical athlete deals with stress is the first step. Do they act out in anger, do they drink, do they exercise? Understanding your outlet is huge in being able to manage these actions, ideas, etc. Out of these, healthy exercise to increase chemicals in the brain that improve mood and that benefits their entire system is the best. But only if it’s healthy, structured, and safe; one of the biggest thing involved in this is adequate rest. Without enough sleep, the body can’t recover. Without recovery, it’s just added stress to the body.

Strong back, posterior chain, pelvic floor

Here we are! The strength in the system! Without adequate strength, feeding somewhat back into load tolerance, your system will not be ready to take on the challenge of power-based movements and actions. The specified areas here – the pelvic floor, posterior chain, and back; all of these are areas we typically see needing increased activation patterns in the general public. But the tactical athletes use these systems much more often. With a strong back, meaning one that’s resilient to load tolerances, you can move more efficiently and you reduce your risk of injury to this system. The posterior chain (hamstrings, glutes, calves) is important in all lower extremity and trunk movements. When this system is firing adequately, it will reduce your risk of injury to the back and lower extremity. And finally, the pelvic floor – the one we leave out so often. This system is important in support of your internal organs and to the stability of your overall system. Making sure you know how this area works, and how to properly activate it – will also save you from injury in the future. Notice I never actually said weakness. Many of our systems aren’t “weak.” They have the adequate strength; they just need to be called to action correctly.

If you’re a tactical athlete that has any questions about these areas – in how to implement these principles into your workout routines, in how to find a workout routine, how to eat well, or how to deal with stress better. Please do not hesitate to reach out to me. If I’m not the person, I will find the resources to help. If you’re interested in becoming a tactical athlete or working with tactical athletes, also contact me. I’m always here to help.

tristan@vertexpt.com

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Not all ACL Injuries Require Surgery

Pictured above is the iconic statue of Mickey Mantle outside of Oklahoma City’s Bricktown Ballpark.  Mickey Mantle is the legendary New York Yankees outfielder who started his rookie year in 1951. In the World Series game 2 of that rookie season, he sustained a right ACL injury which was never reconstructed or repaired; however he continued to play for the Yankees receiving 3 MVP awards and a triple crown in 1956. What is the impact of these facts? It means while Mickey Mantle was a professional baseball player he was a very highly competitive, professional athlete who had no ACL. He is what we call a “Coper.”

The ACL – anterior cruciate ligament – is one of the main stabilizers of the knee joint. This ligament keeps the shin bone (tibia) from sliding forward on the thigh bone (femur). The ligament is important in general stability of the knee complex – from side to side movements to running straight. The incidence of ACL tears is fairly high in an athletic population, cited in one study as 68.6 per 100,000 people. These injuries can be contact-related, meaning someone runs into your knee or body in a way that causes the ACL to rupture, or they can be non-contact, which is typically a plant-and-turn motion or a hyper-extension moment. The majority of ACL ruptures are from non-contact injuries, reportedly as high as ¾ of all ACL tears. There is some research that suggests females are more at risk of non-contact ACL ruptures compared to their male counterparts – the reason cited in some research articles as laxity in the ligamentous complex, the hip to knee angle ratios, and hormone differences between men and women.

After an ACL-tear and within management, there is a “rule of threes” suggested. One-third of all ACL-tears can resume normal activities without limitations, one-third will require a decrease in their activity levels or modifications to improve stability, and one-third will require an ACL-reconstruction to return to normal activities. The process of determining management should take the patient’s activity level and their desired return-to-activity into effect. And ACL-reconstructions should serve to return the individual to regular activities.

So, for the general population – is an ACL reconstruction required? Maybe yes, maybe no. BUT. It depends on the activity that you’re trying to get back to. Take for instance the weekend warrior who wants to be able to return to distance running? Maybe – it would depend on what the presentation looked like. Could they weight bear without significant pain? Could they perform a single leg hop? In the very beginning, depending on the swelling, both of these activities may be significantly difficult. But over time, with decreased swelling and increased muscle activation, can they do the same things without an ACL? It’s definitely possible. Secondly, the parent who walks for exercise and just wants to be able to complete regular house or yard work activities or take their kids to the park – does this person need an ACL reconstruction? Likely not.

Research has shown that pre-habilitation is key to improving the overall outcomes of ACL-reconstruction. The pre-habilitation is focused on decreasing swelling, improving muscle activation/firing, and improving movement patterns – not to mention setting expectations for outcomes. All of these interventions are a great way to determine if an ACL-reconstruction will be required. If you can do everything you wanted to do after doing pre-habilitation, then the possibility that you’re a coper is much, much higher.

So, what can you do? When you or your child gets injured, seek a physical therapy (PT) consult first.  Your physical therapist can determine the cause of knee pain is and assist in determining the next best step in your recovery.  Physical therapists see many post-surgical patients, which means we can recommend a good orthopedic surgeon if needed.  We can also get you moving safely – being able to improve range of motion and function much, much faster.  All in all, we can get you better faster.

If you have any questions about ACL injuries, ACL reconstructions, pre-habilitation of ACL injuries, rehabilitation of ACL injuries, or surgical consults please contact Dr Tristan Faile, PT, DPT, OCS at tristan@vertexpt.com.

References:

Plutnicki, K. (2014, May 4). Mantle’s Knee Injury Was Just the Start. https://www.nytimes.com/2012/05/05/sports/baseball/mantle-sustained-yankees-other-famous-knee-injury.html

Kaplan, Y. Identifying Individuals With an Anterior Cruciate Ligament-Deficient Knee as Copers and Noncopers: A Narrative Literature Review. Journal of Orthopedic and Sports Physical Therapy, 2011; 41(10), 758-766

Boden, B., Sheehan, F., Torg, J., Hewett, T. Non-contact ACL Injuries: Mechanisms and Risk Factors. J Am Acad Orthop Surg, 2010; 18(9): 520-527

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Five Most Common Bladder Irritants In My Personal Diet

So, what are bladder irritants anyways? Bladder irritants are anything that causes the inner liner of the bladder and the muscles of the bladder (mainly the detrusor muscle) to contract, causing a feeling of urgency to empty. In most instances, this isn’t any problem at all. You feel you need to urinate, possibly with some urgency, and you find your way to the restroom. However, in individuals with increased sensitivity to the bladder or urinary tract this can become a symptom that controls their life. Diagnoses such as “Overactive Bladder” (OAB) or Interstitial Cystitis can become extremely frustrating, however these diagnoses aren’t the end-all-be-all. These diagnoses can be controlled with food restrictions/choices, pelvic floor physical therapy, exercise, and cognitive-behavioral changes.

Now, back to the main title – what do I eat/drink the most often that are bladder irritants?

  1. Coffee: I LIVE off coffee. However, the acidity in this drink causes an irritation of the bladder, which leads to a sense of urgency for urination.

 

  1. Carbonated Beverages: Sodas and carbonated water are bladder irritants, however the reason behind their irritation to the bladder is not well known. In my case, this is carbonated water – I just can’t get enough of the bubbles!

 

  1. Chili and Spicy Food: The reason behind this irritation is the acidity, which irritates the bladder causing a need to empty (and rid the bladder of this irritation). I love the challenge of not sweating through my clothes when eating spicy foods! Or acting like my mouth is not in complete agony.

 

  1. Alcohol: This irritant can be caused by the diuretic properties of the solute, which causes more urine to end up in the bladder. Also, the sweeteners and fruit juices that can be combined with alcohol are also bladder irritants. My alcohol of choice? IPAs – hipster or not, the bitterness of the beer and the sweetness of the fruit of choice is delicious.

 

  1. Acidic Fruits: Tomatoes, oranges, strawberries – all of these fruits have some degree of acidity associated with them. As such, they cause irritation to the bladder liner and urinary tract, which leads to more frequent urination. I eat strawberries/blueberries everyday in my oatmeal and yogurt!

Overall, consuming these foods/drinks won’t cause you to have to run to the restroom. What’s the explanation for that? Solvent! Water! The more water you drink, the more dilute the solution and the less likely your bladder is to become irritated by the acids, sweeteners, and carbonation. The more you understand about your pelvic floor and your digestive system, the better able you are to spot a problem and the better you understand yourself!

If you’re noticing a urinary frequency that is higher than 5-7 times per day, or an inability to control voiding (leakages)– this may be a sign of bladder irritation or pelvic floor dysfunction. At no point is leakage “normal” – regardless of the number of children you’ve carried. If you’re concerned about anything you’ve read or noticed, contact your primary care physician or contact Dr Tristan Faile, PT, DPT at Tristan@vertexpt.com for more information. 

Breast Cancer Fundraisers

October is breast cancer awareness month and we’d like to invite you to participate in several fundraisers we are sponsoring.  As some of you may know, Jim’s wife and our former billing coordinator Nora Floyd has been battling breast cancer since her diagnosis in April of 2018.  She is a fighter and has been doing well with everything so far and we want to continue to support her!

We’re sponsoring a team for the Palmetto Health Breast Center Walk for Life and Famously Hot Pink Half Marathon, 5k + 10k runs and we’d love for you to join us at the walk/run or donate to the cause.  Follow the link below for more information on this!

http://events.palmettohealthfoundation.org/site/TR?pg=team&fr_id=1140&team_id=10256

We’ve also created a special “pink edition” Vertex T-shirt (see picture below) that is co-branded with our training partners (Athlete’s Arena) and will be donating all proceeds from the sales of these to the upcoming Walk for Life fundraiser!  We are selling the T shirts for $20 and they are available for pre-order and purchasing in person at our clinic.  Please let us know by replying to this email or giving us a call if you would like to purchase one!

Thank you to everyone for your support and we hope you have a great day!