Category Archives: Blog

Home Work Station Tips Part 2

Movement

Moving often may be the most important tip for preventing computer-related pain.  Any posture (sitting, standing, slouched, upright, etc.) for prolonged periods can lead to pain in various areas.1-9,34 In fact there’s now a focus on preventing sedentary postures rather than demonizing sitting specifically.  Sustained postures are clinically reported by patients to be the thing that aggravates their pain the most.10 Aside from pain, sedentary behavior in general has been shown to be associated with an increased risk of obesity, hypertension, type II diabetes, metabolic syndrome, venous thromboembolism (blood clots), cardiovascular diseases, cancer and also increased all-cause mortality.4,7,10-12 Sit-stand desks and computer prompting, or just a simple alarm, have been shown to decrease sitting significantly.9,34 Although switching between sitting and standing has been shown to be beneficial, prolonged and uninterrupted standing (2 hours) may be associated with health issues including venous insufficiency, atherosclerotic progression, back and lower limb discomfort, and decreased cognition.4

Changing positions every 20-30 minutes has been shown to have positive effects on musculoskeletal and metabolic issues.2,8,10 An active break, ideally with postural change, for 2-5 minutes every hour or switching from sitting to standing every 30 minutes have both been shown to be beneficial for musculoskeletal (pain), blood glucose, blood pressure, and cardiovascular risk issues.3,5-9,11,13,33

Consider taking 1-2 minutes to perform one or more of the following exercises every 20-30 minutes while working at your computer, or sitting in general.

Active Low Back Extension:  Perform 5-10 slow repetitions, holding for 1-2 seconds.  Do not push through pain.   Sitting is largely a trunk flexion position for many people and this exercise does the opposite, thus lengthening tissues that are in a shortened position for prolonged periods.

Cat Cow:  Perform 5-10 slow repetitions, holding for 1-2 seconds, and taking slow easy breaths.  Breath in through the nose on the way to the cat position (back arched towards the ceiling) and out through pursed lips on the way to the cow position (belly hanging towards the floor).  Do not push through pain.  This is a great exercise for spine mobility while limiting compression on the spine.

Standing Posture with Chin Tucks:  This is a great exercise for postural awareness with the wall providing tactile feedback.  Phase 1 is to simply stand with your back against the wall and ideally the back of your head, in between your shoulder blades, and top of your tailbone being in contact with the wall.  If you can place more than one hand behind your low back, tuck your tailbone under (posterior pelvic tilt) to slightly decrease the curve in your low back.  Imagine there is string pulling from the top of your head towards the ceiling to lengthen your spine.  Perform 5-10 slow easy breaths.  Be aware of your posture as you step away from the wall.  Avoid excessive strain and stiffness throughout the body.  Phase 2 is adding the chin tucks as shown in the video.  Perform 5-10 repetitions, holding for 1 -2 seconds.  Phase 3 is the wall angels described next.

Wall Angels:  This exercise tends to be much harder than it looks.  It helps with posture by strengthening the muscles (in the back and shoulders) that improve posture and stretching the muscles (in the chest and front of shoulders) that tend to pull you into a rounded back posture.  When you place your forearms and elbows on the wall, you will most likely need to tuck your tailbone (posterior pelvic tilt) to decrease the curve in your low back.  You should only be able to place about 1 hand behind your low back.  Take slow easy breaths and perform 5-10 slow repetitions.  Do not push through pain.

Child’s Pose:  Perform 1-2 repetitions holding for at least 30 seconds and taking slow easy breaths.  This is an excellent stretch for your low back, hips, knees, ankles, and shoulders.  Do not push through pain.  If you have pain in the shoulders, slide your arms back so your elbows are resting on the floor.

Childs Pose

Neck Flexion/Extension:  Perform 5-10 slow repetitions.  Do not push through pain.  Many people go through less and less of these end ranges, especially with jobs requiring looking at a computer screen for prolonged periods, which leads to a lack of mobility when you need it.  If you don’t lose it, you lose it.

Neck Rotation:  Perform 5-10 slow repetitions.  Do not push through pain.  This exercise goes with the one above and limitations typically show up with activities like checking your blind spot while driving.  If your limited with these motions, there’s a lot you can do to gradually regain your mobility.

In addition, check out my general strength and flexibility program here.  Regular strength training has been shown to increase strength, increase bone mass density (lower the risk of osteoporosis), improve sleep, decrease depression, decrease all-cause mortality, reduce cognitive decline, decrease the risk of falls, decrease systolic blood pressure, and decrease musculoskeletal pain.14-19  It’s recommended that adults strength train major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms) 2-5 days per week for 30-60 minutes.14

Aerobic Exercise

A good goal to shoot for is 150-300 minutes (30-60 minutes 5 days per week) of moderate to vigorous intensity aerobic exercise per week for adults.14

People who exercise aerobically for this amount of time have been shown to have a decreased risk of diabetes, metabolic syndrome, and increased weight maintenance and executive functioning, all of which have been shown to be adversely affected when people are more sedentary.14,20

Psychosocial Aspects, Stress Reduction, and Breathing

Pain and injury recovery are rarely limited to physical aspects alone.  This is obvious to most folks who have had to deal with a prolonged injury or illness.  Its depressing, frustrating, affects relationships, and can magnify preexisting issues with work, friends, and family life.   Chronic pain, including low back pain, has been shown in numerous studies to have a strong psychosocial component.13,21-31,34 Some specific examples related to the workplace are monotonous work, perceived high workload, pressure of time, lack of decision-making authority, and job dissatisfaction.25,34 And given the current state of our global pandemic, mitigating stress is of huge benefit to keeping our immune systems in top shape.32

There are many ways to address excessive stress.  Simple breathing exercises can be found here (mine) and here (from Jan Goldberg).  Check out the “chronic pain” section of my article here for many other options, including the “4 pillars” of chronic pain intervention (aerobic exercise, education, goal setting, sleep).  Seeking individualized help, from someone we trust and jive with, for stressful situations prevents us all from having to reinvent the wheel.

 

Stay Strong!

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my Facebook page and follow me on Instagram for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

 

References:

1Korakakis V1, O’Sullivan K, et al. Physiotherapist perceptions of optimal sitting and standing posture. Musculoskelet Sci Pract. 2019 Feb;39:24-31.
2O’Sullivan K1, O’Sullivan P, et al. What do physiotherapists consider to be the best sitting spinal posture? Man Ther. 2012 Oct;17(5):432-7.
3Waongenngarm P1, Areerak K2, et al. The effects of breaks on low back pain, discomfort, and work productivity in office workers: A systematic review of randomized and non-randomized controlled trials. Appl Ergon. 2018 Apr;68:230-239.
4Mula A1. Ergonomics and the standing desk. Work. 2018;60(2):171-174.
5Goode AD1, Hadgraft NT, et al. Perceptions of an online ‘train-the-champion’ approach to increase workplace movement. Health Promot Int. 2019 Dec 1;34(6):1179-1190.
6Davis KG, Kotowski SE. Postural variability: an effective way to reduce musculoskeletal discomfort in office work. Hum Factors. 2014 Nov;56(7):1249-61.
7Heneghan NR1, Baker G2, et al. What is the effect of prolonged sitting and physical activity on thoracic spine mobility? An observational study of young adults in a UK university setting. BMJ Open. 2018 May 5;8(5):e019371.
8Sheahan PJ1, Diesbourg TL1, et al. The effect of rest break schedule on acute low back pain development in pain and non-pain developers during seated work. Appl Ergon. 2016 Mar;53 Pt A:64-70.
9Shrestha N1, Kukkonen-Harjula KT, et al. Workplace interventions for reducing sitting at work. Cochrane Database Syst Rev. 2018 Dec 17;12:CD010912.
10Sheeran L1, van Deursen R, et al. Classification-guided versus generalized postural intervention in subgroups of nonspecific chronic low back pain: a pragmatic randomized controlled study. Spine (Phila Pa 1976). 2013 Sep 1;38(19):1613-25.
10Straker LM, Dunstan DW, et al. Sedentary work. Evidence on an emergent work health and safety issue. Final Report, Canberra: Safe Work Australia. Safe Work Australia’s Emerging Issues Programme. March 2016.
11Toomingas A1, Forsman M, et al. Variation between seated and standing/walking postures among male and female call centre operators. BMC Public Health. 2012 Mar 2;12:154.
12Neuhaus M1, Healy GN, et al. Iterative development of Stand Up Australia: a multi-component intervention to reduce workplace sitting. Int J Behav Nutr Phys Act. 2014 Feb 21;11:21.
13Lacaze DH1, Sacco Ide C, et al. Stretching and joint mobilization exercises reduce call-center operators’ musculoskeletal discomfort and fatigue. Clinics (Sao Paulo). 2010 Jul;65(7):657-62.
14Global Recommendations on Physical Activity for Health. WHO Guidelines Approved by the
Guidelines Review Committee. Geneva: World Health Organization; 2010.
15Kraschnewski JL, Sciamanna CN, et al. Is strength training associated with mortality benefits? A 15year cohort study of US older adults. Prev Med. 2016 Jun;87:121-127.
16Seguin R1, Nelson ME. The benefits of strength training for older adults. Am J Prev Med. 2003 Oct;25(3 Suppl 2):141-9.
17Liu-Ambrose T1, Donaldson MG. Exercise and cognition in older adults: is there a role for
resistance training programmes? Br J Sports Med. 2009 Jan;43(1):25-7.
18Pedersen M, Blangsted A, et al. The Effect of Worksite Physical Activity Intervention on Physical Capacity, Health, and Productivity: A 1-year Randomized Controlled Trial. J Occup Environ Med. 2009 Jul;51(7):759-70.
19Van Eerd D1, Munhall C2, et al. Effectiveness of workplace interventions in the prevention of upper extremity musculoskeletal disorders and symptoms: an update of the evidence. Occup Environ Med. 2016 Jan;73(1):62-70.
20Guiney H1, Machado L. Benefits of regular aerobic exercise for executive functioning in healthy populations. Psychon Bull Rev. 2013 Feb;20(1):73-86.
21Curran M1, O’Sullivan L2, O’Sullivan P3, Dankaerts W4, O’Sullivan K5. Does Using a Chair Backrest or Reducing Seated Hip Flexion Influence Trunk Muscle Activity and Discomfort? A Systematic Review. Hum Factors. 2015 Nov;57(7):1115-48.
22Curran M1, Dankaerts W, O’Sullivan P, O’Sullivan L, O’Sullivan K. The effect of a backrest and seatpan inclination on sitting discomfort and trunk muscle activation in subjects with extension-related low back pain. Ergonomics. 2014;57(5):733-43.
23O’Sullivan K1, O’Keeffe M, O’Sullivan L, O’Sullivan P, Dankaerts W. The effect of dynamic sitting on the prevention and management of low back pain and low back discomfort: a systematic review. Ergonomics. 2012;55(8):898-908.
24van Niekerk SM1, Louw QA, Hillier S. The effectiveness of a chair intervention in the workplace to reduce musculoskeletal symptoms. A systematic review. BMC Musculoskelet Disord. 2012 Aug 13;13:145.
25Al-Otaibi ST1. Prevention of occupational Back Pain. J Family Community Med. 2015 May-Aug;22(2):73-7.
26O’Keeffe M1, Dankaerts W, et al. Specific flexion-related low back pain and sitting: comparison of seated discomfort on two different chairs. Ergonomics. 2013;56(4):650-8.
27Gifford, L. Pain, the Tissues and the Nervous System: A conceptual model. Physiotherapy Volume 84, Issue 1, January 1998, Pages 27-36.
28Moseley, L. Reconceptualising pain according to modern pain science. Physical Therapy Reviews 12(3):169-178 · September 2007.
29Louw A1, Butler DS, et al. Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy. Am J Phys Med Rehabil. 2013 May;92(5):446-52.
30Louw A1, Diener I, et al. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011 Dec;92(12):2041-56.
31Louw A1, Nijs J2,3, Puentedura EJ4. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017 Jul;25(3):160-168.
32Vitlic A, Lord JM, et al. Stress, Ageing and Their Influence on Functional, Cellular and Molecular Aspects of the Immune System. Age (Dordr). 2014 Jun;36(3):9631.
33Mongini F, Ciccone G, et al. Effectiveness of an Educational and Physical Programme in Reducing Headache, Neck and Shoulder Pain: A Workplace Controlled Trial. Cephalalgia. 2008 May;28(5):541-52.
34Hoe VC, Urquhart DM, et al. Ergonomic Interventions for Preventing Work-Related Musculoskeletal Disorders of the Upper Limb and Neck Among Office Workers. Cochrane Database Syst Rev. 2018 Oct 23;10(10):CD008570.

Home Work Station Tips Part 1

With lots of folks now working from home, I had some requests for tips to stay healthy and pain free…so here you go!

In addition to the info I sent out previously, here’s some suggestions especially for folks who are sitting and working at the computer, which is probably many of you.  One reason I write these articles is to organize the research I read so I can find it later.  In an effort to minimize many readers’ boredom, while still providing the key points of my ramblings, I’m adding the box below with the 14 most important tips.  Don’t worry about everything being perfect.  Even small changes can make a big difference.

  • Change positions every 20-30 minutes (sit to stand, light brief stretches or mobility exercises, short walk)
  • Ear, shoulder, and hip all in a line when looking from the side
  • Use a backrest
  • Use armrests
  • Hips level with or slightly higher than knees
  • Feet on the floor
  • Forearms, wrists, hands parallel to the floor
  • Monitor at eye level
  • Mouse close to the edge of the desk
  • Slow easy belly breaths and notice areas of tension in your body
  • Minimize stress
  • 7-9 hours of sleep per night
  • Aerobic exercise (walking, running, cycling, swimming, rowing) 5-6 days/week for 30-45 minutes
  • Be mindful of what you put in your body (hydration and nutrition) and have an evaluation with a qualified nutritionist

 

I’m breaking this information into two posts.  The second part will be focused on specific exercise options to help prevent pain and other health-related problems that can coincide with jobs that require a lot of sitting and computer work.  Avoiding sedentary behavior is likely the most important recommendation for preventing pain and health issues, so try to change positions every 20-30 minutes.  This can mean switching between sitting and standing or taking 2-5 minutes to perform some light stretching or mobility exercises, which I’ll talk more about in part 2.3,26-29 Sit-stand desks and computer prompting, or just a simple alarm, have been shown to decrease prolonged bouts of sitting significantly.28,30

Alignment and Posture – “Ergonomics is the relationship between a person and their environment.”1

I was expecting to find plenty of easy answers with lots of supporting research regarding an ideal sitting posture for everyone.  There are lots of classic recommendations, but seemed to be minimal concrete and consistent evidence backing them up.  Theory doesn’t always transfer over to real life, which is why we do research.  Some studies showed it made no or minimal difference in people’s symptoms with changes to their seating arrangements.2-4  This was commonly due to small numbers of subjects, a lack of separating people with different reasons for their pain, and too much variation across the board with types of interventions and outcome measurements between studies.  As with many other areas of life, scratching just a bit below the surface tends to create more confusion.  But with continued digging, things eventually become clearer.

Fortunately, there are some common themes and helpful information that shined through, even though there’s much more research that needs to be done.   Every body is different, so you may have to fine tune these suggestions to fit your situation and I’ll talk more below about why certain recommendations might fit some folks but not others.  Most of our home and workplace set ups are of course less than ideal, and I’ll talk about some great, simple hacks to make the most of what you’ve got.

General guide for a workstation computer set up

 

1. Looking at yourself from the side, if you drop a string from the top of your head to the floor, your ear, shoulder, and hip should all be in 1 line.  See item 4 below for a more in-depth discussion of the importance of spinal alignment.  Using a chair with adjustable height, backrests, and armrests has been shown to decrease muscle activity in the neck, back, and shoulders as well as to decrease spinal disk pressure and pain.1,5,6,8-10 A forward head posture is correlated with increased neck pain, so below are some questions to ponder if you find yourself in that position.6

 If your ear is in front of that line (forward head), determine why that is happening.

Is your monitor high enough?  This is tricky with a laptop.  The key is to find the balance between raising the laptop up as close to within eye level as possible without creating an awkward positioning of your wrists and elbows.

Is your monitor big enough and is the prescription for your glasses or contact lenses up to date so you aren’t straining to see the screen?

Get your eyes checked or get a bigger monitor!

2. Sit all the way to the back of the chair – using a backrest was a commonly agreed upon way of decreasing low back discomfort and excessive low back muscle activation.1,3,8,11-13

Back and arm rests have been shown to decrease discomfort and muscle tension.
3. Your feet should be flat on the floor, or a footrest.1

 

 4.  Hip angle (having the knees and hips at the same height versus having your knees lower than your hips) is a bit confusing and somewhat controversial in the literature.  Bottom line for knees versus hip height (see below for reasoning) – If you have no low back pain or flexion-related low back pain (meaning that pain increases when bending forward and with sitting, while pain decreases with bending backwards and standing/walking), your knees should be slightly (10 degrees) lower than your hips.  If you have extension-related low back pain (meaning that pain increases when bending backwards and standing/walking, while pain decreases with bending forward and sitting), your knees and hips should be even.  Your torso should be upright or slightly reclined.1

Can you adjust your chair by either raising the seat height or tipping the front of your seat down to position your hips higher than your knees?  If not, try putting one or more towels under your “sits” bones to raise your hips.

Consider placing a small rolled up towel in the small of your back to create a gentle curve if your low back is flat or slouched.

Juan is sitting on a small pillow to raise his hips in relation to his knees just a bit (10 degrees). Keep your hips and knees level if you have low back pain caused by bending backwards or that increase with standing and walking (and decreases with sitting).

For most people (aside from folks with extension-related low back pain – see below), your hips should be slightly higher than your knees.  This helps you to maintain a neutral spine position (gentle curve in your low back), which is the ideal position for your spine to be in.11,14  Sitting in this “neutral position”, as opposed to a slouched posture, creates better activation of your core muscles (transverse abdominis in the front and pelvic floor on the bottom) which helps to stabilize and support your trunk, as well as encouraging proper use of your diaphragm during breathing since your diaphragm and pelvic floor work together.15-17  These core muscles are your “base” and turn on prior to all other movements in order to support your trunk and the rest of your body.19-22  It also allows your upper back to rest against the backrest, which decreases activation of your low back paraspinal muscles as well as decreases compressive forces on the discs in your low back.6,8  Forward head posture is also decreased with this positioning.6

Aside from the theories of why this should be helpful, having your knees slightly lower than your hips (10 degrees), has been shown to decrease low back and neck/shoulder discomfort (or provide a feeling of greater comfort in general) for people with no pain and those with flexion-related low back pain.8,11,14,23  Additionally, people with flexion-related low back pain typically sit in a more flexed (slouched) posture.4,24,25  Lowering your knees more than 10 degrees in relation to your hips correlated with increased low back discomfort.11,14

For folks with extension-related low back pain, sitting with the knees lower than the hips correlated with increased pain.  This is largely attributed to these folks already sitting with too much of a curve in their low back, their low back muscles (multifidus) being overly active, and they have a decreased ability to relax these muscles.  So, creating more of curve in their low back by lowering their knees just makes things worse.4,14,24

 

5. Keep the elbows at a 90-120 degree angle, resting on arm rests.  Resting the forearms on the desk, rather than on armrests, tends to increase shoulder discomfort.1,10,30

 

6. Keep your wrists in a neutral (straight) position.1

 

7. Keep the mouse as close to the edge of the desk as possible so you don’t have to reach.  Limiting repetitive shoulder flexion and abduction (moving your elbow away from your body) decreases the risk of shoulder pain.1

 

Consider a mouse with a roller ball if you have wrist, elbow, or shoulder pain.

 

8. The top of screen should be level with your eyes.6

 

9. Now that I’ve made you tense thinking about all this stuff, take some slow, easy breaths.  In through the nose, out through pursed lips.  Notice any areas you may be holding tension (shoulders, jaw, back, abdominals, pelvic floor, toes, etc.) and soften into those areas.

 

Sleep

The benefits of good quality and quantity of sleep can’t be overstated for all aspects of our well being (including the immune system, which is crucial for fighting things like COVID-19).  Check out my review of lots of fascinating sleep research here as well as my evidenced-based sleep hygiene tips.  Feel free to pass it along and note the contact info for Trish McGuire at NIH, just above the references list,  who provides cognitive behavioral therapy for insomnia.

Nutrition

Diet modifications can be helpful for preventing a range of health issues, especially if your job entails a significant amount of sedentary time.  Nutrition is highly individualized and I recommend consulting with one of the highly qualified nutritionists found in our community.  Their contact info can be found under the nutrition section of my evidence-based general wellness recommendations handout.

 

Stay Strong!

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my Facebook page and follow me on Instagram for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

 

References:

1Eggleston ST1. Mouse with your arm™: Facilitating forearm support using the chair armrest to prevent and mitigate musculoskeletal disorders. Work. 2020;65(3):483-495.
2Driessen MT1, Proper KI, van Tulder MW, Anema JR, Bongers PM, van der Beek AJ. The effectiveness of physical and organisational ergonomic interventions on low back pain and neck pain: a systematic review. Occup Environ Med. 2010 Apr;67(4):277-85.
3O’Sullivan K1, O’Sullivan P, et al. What do physiotherapists consider to be the best sitting spinal posture? Man Ther. 2012 Oct;17(5):432-7.
4Dankaerts W1, O’Sullivan P, et al. Differences in sitting postures are associated with nonspecific chronic low back pain disorders when patients are subclassified. Spine (Phila Pa 1976). 2006 Mar 15;31(6):698-704.
5van Niekerk SM1, Louw QA, Hillier S. The effectiveness of a chair intervention in the workplace to reduce musculoskeletal symptoms. A systematic review. BMC Musculoskelet Disord. 2012 Aug 13;13:145.
6Harrison DD1, Harrison SO, et al. Sitting biomechanics part I: review of the literature. J Manipulative Physiol Ther. 1999 Nov-Dec;22(9):594-609.
7Harrison DD1, Harrison SO, et al. Sitting biomechanics, part II: optimal car driver’s seat and optimal driver’s spinal model. J Manipulative Physiol Ther. 2000 Jan;23(1):37-47.
8O’Keeffe M1, Dankaerts W, et al. Specific flexion-related low back pain and sitting: comparison of seated discomfort on two different chairs. Ergonomics. 2013;56(4):650-8.
9Amick BC, Robertson MM, et al. Effect of office ergonomics intervention on reducing musculoskeletal symptoms. Spine (Phila Pa 1976). 2003 Dec 15;28(24):2706-11.
10Van Eerd D1, Munhall C2, et al. Effectiveness of workplace interventions in the prevention of upper extremity musculoskeletal disorders and symptoms: an update of the evidence. Occup Environ Med. 2016 Jan;73(1):62-70.
11Curran M1, O’Sullivan L2, O’Sullivan P3, Dankaerts W4, O’Sullivan K5. Does Using a Chair Backrest or Reducing Seated Hip Flexion Influence Trunk Muscle Activity and Discomfort? A Systematic Review. Hum Factors. 2015 Nov;57(7):1115-48.
12O’Sullivan K1, O’Keeffe M, O’Sullivan L, O’Sullivan P, Dankaerts W. The effect of dynamic sitting on the prevention and management of low back pain and low back discomfort: a systematic review. Ergonomics. 2012;55(8):898-908.
13Pillastrini P1, Mugnai R, et al. Effectiveness of an ergonomic intervention on work-related posture and low back pain in video display terminal operators: a 3 year cross-over trial. Appl Ergon. 2010 May;41(3):436-43.
14Curran M1, Dankaerts W, O’Sullivan P, O’Sullivan L, O’Sullivan K. The effect of a backrest and seatpan inclination on sitting discomfort and trunk muscle activation in subjects with extension-related low back pain. Ergonomics. 2014;57(5):733-43.
15Claus AP, Hides JA, et al. Different Ways to Balance the Spine: Subtle Changes in Sagittal Spinal Curves Affect Regional Muscle Activity. Spine (Phila Pa 1976). 2009 Mar 15;34(6):E208-14.
16Wong AYL1, Chan TPM2, Chau AWM2, Tung Cheung H2, Kwan KCK2, Lam AKH2, Wong PYC2, De Carvalho D3. Do different sitting postures affect spinal biomechanics of asymptomatic individuals? Gait Posture. 2019 Jan;67:230-235.
17Talasz H, Kremser C, et al. Phase-locked Parallel Movement of Diaphragm and Pelvic Floor During Breathing and Coughing-A Dynamic MRI Investigation in Healthy Females. Int Urogynecol J. 2011 Jan;22(1):61-8.
18Hodges PW, Gandevia SC. Changes in Intra-Abdominal Pressure During Postural and Respiratory Activation of the Human Diaphragm. J Appl Physiol (1985). 2000 Sep;89(3):967-76.
19Hodges PW1, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther. 1997 Feb;77(2):132-42; discussion 142-4.
20Hodges PW, Richardson CA. Feedforward contraction of tranversus abdominis is not influenced by the direction of arm movement. April 1997Experimental Brain Research 114(2):362-70.
21Sjödahl J, Kvist J, et al. The Postural Response of the Pelvic Floor Muscles During Limb Movements: A Methodological Electromyography Study in Parous Women Without Lumbopelvic Pain. Clin Biomech (Bristol, Avon). 2009 Feb;24(2):183-9.
22Luginbuehl H, Greter C, et al. Intra-session Test-Retest Reliability of Pelvic Floor Muscle Electromyography During Running. Int Urogynecol J. 2013 Sep;24(9):1515-22.
23Koskelo R1, Vuorikari K, et al. Sitting and standing postures are corrected by adjustable furniture with lowered muscle tension in high-school students. Ergonomics. 2007 Oct;50(10):1643-56.
24Sheeran L1, van Deursen R, et al. Classification-guided versus generalized postural intervention in subgroups of nonspecific chronic low back pain: a pragmatic randomized controlled study. Spine (Phila Pa 1976). 2013 Sep 1;38(19):1613-25.
25Womersley L1, May S. Sitting posture of subjects with postural backache. J Manipulative Physiol Ther. 2006 Mar-Apr;29(3):213-8.
26Straker LM, Dunstan DW, et al. Sedentary work. Evidence on an emergent work health and safety issue. Final Report, Canberra: Safe Work Australia. Safe Work Australia’s Emerging Issues Programme. March 2016.
27Sheahan PJ1, Diesbourg TL1, et al. The effect of rest break schedule on acute low back pain development in pain and non-pain developers during seated work. Appl Ergon. 2016 Mar;53 Pt A:64-70.
28Shrestha N1, Kukkonen-Harjula KT, et al. Workplace interventions for reducing sitting at work. Cochrane Database Syst Rev. 2018 Dec 17;12:CD010912.
29Mongini F, Ciccone G, et al. Effectiveness of an Educational and Physical Programme in Reducing Headache, Neck and Shoulder Pain: A Workplace Controlled Trial. Cephalalgia. 2008 May;28(5):541-52.
30Hoe VC, Urquhart DM, et al. Ergonomic Interventions for Preventing Work-Related Musculoskeletal Disorders of the Upper Limb and Neck Among Office Workers. Cochrane Database Syst Rev. 2018 Oct 23;10(10):CD008570.

Critical Decision Making, Exercise, and COVID-19

COVID-19 gives us fascinating opportunities to hone our critical decision making skills.  This blog post is about the balance between my desire for things to be simple, the reality that they’re rarely as straightforward as they seem and the beauty that the bottom line still doesn’t have to be complicated.

I recently had a conversation about fact checking (which can include a simple google search) information that we’re told or read about and why it’s important to take some time to scratch below the surface.  It may feel like a can of worms has been opened, since that original information seems no longer so cut and dried.  But it gives us a chance to consider all the nuances of a headline that appears straight forward at first glance.  Ultimately we have to make the best decisions possible based off of the current information we have and there may not be an answer that’s absolutely correct one hundred percent of the time.

I’ll discuss one specific example regarding exercise, since it interests me both personally and professionally.

Don’t hike, run, or cycle directly behind someone.

 

The above pic (as well as the “featured image”) is from this article which talks about a recent paper released by Belgium and Netherlands researchers.  I was initially hoping to make a quick post about some interesting information and move on.  As it often-times turns out, there’s more to the story than a catchy headline and pictures.  In a nutshell, the authors, based off of simulation models, recommend increasing the social distancing recommendations from 6 feet (the standard recommendation for our typical community activities) to 13-16 feet for runners, 33 feet for slow cycling, and 66 feet for fast cycling.  This is due to the idea that droplets from saliva particles stay in the air longer as they’re being expelled more forcefully during heavy breathing during exercise.  These numbers are also specific to running or cycling directly behind a person, as this direct line is considered within a person’s “slipstream” where the particles are at a greater volume.

My initial thought was to post this article as is with minimal further comment.  I like to read through articles before posting about them to see if anything weird stands out (who were the subjects, what was the methodology, do the conclusions seem reasonable based on the results) so I did a Pubmed and Google search to find the original paper.  I have yet to find the original paper translated into English, but what I did find were several articles discussing various reasons why these new recommendations might be called into question.  If you’d like to read more in-depth about the issues with these recommendations, check out these articles here, here, and here.  In summary, they discuss the fact that the original paper wasn’t peer-reviewed, the results are based off of simulations from models rather than data obtained from actual people exercising, the many variables (current wind speed, population of the area, level of pollution, etc.) that could change the accuracy of the recommendations, and the fact that there still isn’t a consensus about how exactly the virus travels through the air.

Are any of these things nefarious?  I don’t think so.  We are now pushing many things along faster due to the severity of the situation we’re in, which is the reason for not waiting for the information to be peer reviewed or waiting until actual people can be used.  This is of course a slippery slope.  The concern with promoting unproven medical treatments during a crisis is that there’s the possibility of causing more harm than good.  In this case, the concern is freaking people out to the point where they are no longer going outside to exercise.

Does this mean we can’t use this information to further guide our decisions?  No, the bottom line is to use all the information we have to make balanced decisions with the costs and benefits in mind.  Everyone still seems to be in agreement that:

  1. Getting outside to exercise is important for mental health and immune system function.
  2. Avoiding hiking, running, walking, cycling directly behind someone is a good idea to avoid that “slipstream” area.
  3. Running or cycling diagonally behind someone, or better yet, crossing the street until you can pass, puts you out of that “slipstream” that occurs by being directly behind.
  4. Finding the least crowded time or place to exercise reduces your chances of having to make decisions about how far and at what angle to be behind someone.
  5. Consider taking a bandana or mask along so you can cover your mouth and nose while passing someone or if you hear someone coming up behind you.
  6. Exercising alone is safer at this point.
  7. Give people a heads up when you’re getting close to passing (“on your left!”).

One final point regarding specific activities.  We’re all trying to figure these things out together.  Some activities may seem extreme to some people but not to others.  Taking into account your personal abilities, the likelihood of something happening that will put you in the ER, and the possibility of other people being impacted by your decisions or accidents/injuries can help us all make better decisions.

Some things are more straight forward than others.  For example, backcountry activities add many variables, some of which are not under our control, and also are much more likely to put other people at risk (search and rescue teams).  The possibility of pulling a hamstring while running is most likely not going to effect other people or put extra stress on our medical teams.  Other activities, such as rock climbing, are seen as extreme to the general population but are actually statistically safe in relation to activities that most people don’t think twice about (football, basketball, soccer…and there are even statistics showing more emergency room visits for golf cart injuries than rock climbing!).1,2,3  Does this mean all rock climbing (or any other activity) is completely safe?  No, but there are things to think about to minimize risk to what may be an acceptable level.  High-ball bouldering (or mountain biking, skiing, etc.) at your upper limits or climbing backcountry routes or peaks seem like some obvious irresponsible choices at this time.  Is climbing safely-bolted sport routes that you’re familiar with or mountain biking trails that are below your technical upper limits ok?  Maybe, maybe not.  Whatever you decide, it will be judged.  If the judgement is negative, consider holding off on the urge to become defensive and reevaluate the decision.  There are probably lessons in there somewhere.

Climbers specifically have been shown to take risk factors into account when climbing, even in non-global-pandemic situations.4  We all need to do this with whatever activity we are choosing in order to stay safe, not directly put others at risk, and avoid putting undo stress on our medical providers during this challenging time.

Stay strong and stay safe!

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

1 Schöffl V, Morrison A, Schwarz U, Schöffl I, Küpper T.  Evaluation of injury and fatality risk in rock and ice climbing.  Sports Med. 2010 Aug 1;40(8):657-79.
2 Backe S, Ericson L, Janson S, Timpka T.  Rock climbing injury rates and associated risk factors in a general climbing population.  Scand J Med Sci Sports. 2009 Dec;19(6):850-6.
3 Schöffl V, Morrison A, Schöffl I, Küpper T.  The epidemiology of injury in mountaineering, rock and ice climbing.  Med Sport Sci. 2012;58:17-43.
4 Jaku PM, Shaw DW.  An Empirical Analysis of Rock Climbers’ Response to Hazard Warnings.  Risk Analysis, Vol. 16. No. 4, I996.

Critical Decision Making and the Healing Process: Part 3

7. Healing is a Process, Not an Event

Healing tends to be like a roller coaster rather than a straight line.  Having the expectation that your problem can be resolved overnight is typically not realistic, which leads to increased frustration and disappointment (and often more healthcare visit, procedures, money, etc.).  This causes increased stress which causes your brain to release more stress hormones that negatively effect the healing process.  Furthermore, the belief that your problem can be “fixed” with one simple intervention directs people to focus on passive interventions (medications, surgeries, new/popular machines, creams/oils – something that is being done to your body by someone or something else).  This is as opposed to active interventions, which are ways that you can help yourself such as critical decision making, exercises or self treatments targeting your specific deficits, postural changes, and determining aspects of your life that may be contributing to your problem.  These active interventions take time to get dialed in and are ever evolving.  Using your healthcare guides (physical therapists, physicians, surgeons, psychologists, massage therapists, yoga and Pilates instructors, etc.) as tools to gather information and options allows you to speed up the process by not reinventing the wheel.

Ask a lot of questions, use the tools that work for you, and discard the rest.  Its a more challenging path, but one that leads to greater overall gains with a better understanding of your problem and life, which gives you more control of your situation.

8. A Note on Chronic Pain

I plan to elaborate on this fascinating topic in a separate post for those who are looking for a deeper understanding of the neural and physiological changes that occur when pain becomes chronic.  For anyone with chronic pain or those with a family or friend with chronic pain, I highly recommend Adriaan Louw’s book Why Do I HurtIt’s short, easy to read, and helpful…you can’t beat that.  Much of the information in my articles about this topic come from Dr. Louw’s research and the research he sites in many of his continuing education courses.

I’ve mentioned before that in almost all cases, our bodies have the ability to heal themselves.  We just need to create the environment to allow the body to do what it knows how to do.  Chronic pain occurs when this natural healing process does not occur.  The most important points are 1. what happens at a general level when your pain doesn’t go away, and 2. what do I do about it?

I. What happens when my pain becomes chronic instead of resolving?

Your nervous system is a group of structures in your body that send signals throughout your body to provide information about the state of your body and the environment.  The brain and spinal cord (central nervous system) and the nerves that exit the spinal cord and travel to the rest of your body (peripheral nervous system) are constantly sending signals back and forth.  These signals are being interpreted and modified by many parts of the brain in order to determine what to do next.1-4  Imagine the map of the flight routes in the back of the airline magazine on your last flight.

Your Alarm System
With permission from Adriaan Louw, PT, PhD

In relation to pain, think of your nervous system as an alarm system.  The body has a normal baseline level of sensation.  If you think about it, you can feel the pressure from the chair you are sitting on.  The brain knows that specific sensation isn’t important so its not something in your general awareness.  However, if you are walking barefoot in your backyard and you step on a bee, that normal baseline level of sensation rises to a “what the heck was that!” threshold level as the  nerves from your foot send an immediate signal to your brain and the brain says “danger!”.   You remove the stinger, attend to your wound, and eventually that elevated level of sensation returns to the original baseline.   Your nervous system is protecting you with that initial “danger” signal and the subsequent sensation of pain while you heal in order to prevent you from performing activities that irritate the injury whereby slowing the healing process.1-4

Unfortunately there are times when that baseline level is not reached and your nervous system stays in a hypersensitized state.  This starts out as feeling more intense pain than a given stimulus should be provoking and can lead to feeling pain from a stimulus that shouldn’t be causing pain at all (the touch of your sheets in bed, for example).  Your nervous system is still trying to protect you by keeping the alarm system cranked up.  Think of a home alarm system.  Its supposed to go off if an intruder breaks a window.  Now its going off when you open the fridge.1-5

Hypersensitive Alarm System
With Permission from Adriaan Louw, PT, PhD

There are many reasons your nervous system might stay in this elevated state.   Pain is stressful in many ways.  It obviously doesn’t feel good.  You can’t do what you want.  It can affect your finances if you can’t work.  It can affect your relationships if you can’t perform your normal duties and you have negative interactions because you’re irritable from the pain.  Maybe your family or friends think you should be better by now.  You may have received numerous explanations for your pain from physicians, surgeons, PTs, massage therapists, family, friends, etc.  All of the explanations are different and none of them seem to help.  You may have tried numerous treatments with minimal success, some of which may have even made things worse.  You may have been told some form of “there’s nothing wrong with you”.  All these stressors can create fear and anxiety which crank up the part of the nervous system that controls the alarm system.  This all leads to decreased sleep and mobility which further escalates your problem.

II. What do I do about chronic pain?

The key is to use interventions that gradually and progressively calm the central nervous system, and thus your alarm system, and restore it back to the original set points. There are 22 treatments that have been studied which can help to  resolve this ramped-up state that your nervous system is currently in.12  Below, I’ve added some notes to the ones that may be easiest to implement.  Of these 22 treatments, there are 4 “pillars” that are the most beneficial and that must be done.12  Those 4 are:

a. Pain education – Understanding what is happening with your nervous system has been shown to decrease pain and improve function.3,4,6-11  Check out Adriaan Louw’s book Why Do I Hurt? and stay tuned for my upcoming article specifically about chronic pain.

b. Goal setting – You have to know where you want to go in order to figure out how to get there.  Write down your goals and keep a journal.  Try writing not just about your goals, but how you feel about what’s happening throughout the process.

c. Aerobic exercise13,14,25 – Start slow and listen to your body.  I frequently tell people to start by literally leaving your front door, walk for 5 minutes, and come back.  If you can’t do that, start at 1 minute.  Just get started.  If you walk for 10 minutes and it puts you on the couch for the rest of the day, try 5 minutes the next time.  If you can’t walk, try a stationary bike or swimming.  Consider keeping a log to track your progress and boost accountability.

d. Sleep hygiene – Check out my evidence-based handout for sleep hygiene tips and Matthew Walker’s Why We Sleep.  My article The Role of Sleep Loss in Healing has additional information and references.

The additional treatments that have been shown to be beneficial are:

e. Diet – Consulting with a nutritionist is highly recommended.  This is a lifestyle change which means the changes should be realistic above all else.  You may want to gradually implement small changes into your diet to make it easier to maintain long term.

f. Breathing – Check out an option here.   The simplest way to start is to ignore the pelvic floor part (add this pelvic floor part back in for problems with incontinence and core strengthening).  Focus on expanding the abdomen and bottom of the rib cage, like an umbrella slowly opening, on the inhale.  You can add 4-7-8 breathing to this, where you take 4 seconds to inhale, hold for 7 seconds, and exhale for 8 seconds (as described in some of Dr. Andrew Weil’s books).

g. Biofeedback

h. Graded motor imagery

i. Safe, healing environment – Do you have a healthy support system?  If family members, friends, or work colleagues are less than supportive, consider talking with them about it.  Invite them to read this post.  Consider limiting your time with the folks and situations that add stress to your life.

j. Manual therapy6,15-21 – There are many forms of hands-on treatments.  Myofascial release (sometimes called trigger point release) is a gentle and effective way to treat yourself.  Some resources for this are The Trigger Point Therapy Workbook and my book Beyond Tape.

k. Neural mobilization6,26

l. Modalities – 

m. Yoga22,27 – If you are new to yoga, check out a restorative yoga class or call the instructor, tell them a bit about your limitations, and ask them if they have a low level beginner class that they would recommend.

n. Relaxation and meditation23,27 – An easy way to start this is through the breathing option stated above.  Find a quiet place for 5-10 minutes.  Focus on the breathing.  As your mind drifts off to other things (which it will), take note without analyzing or judging and bring yourself back to the breath.

o. Humor27 Laughter has been shown to decrease the negative effects of stress (calms the alarm system). Crying certainly has is place and is highly therapeutic. That being said, none of us are here for very long in the grand scheme of things, so we might as well laugh as much as possible. I personally love Judd Apatow’s Funny People, with Adam Sandler, although the crude humor is not for everyone.

p. Aquatic Therapy24

q. Medication

r. Social Interaction

s. Coping skills – There are no doubt excellent psychotherapists in your town who can guide you with this.  We learn new skills much faster through guidance.  I have personally benefited greatly from several therapists, as well as through my own reading/study/practice, throughout my life.  As with anything else, this is a process, not an event.

t. Soft tissue/trigger point therapy (myofascial release)6,15-21 – See the “Manual therapy” item above.

u. Spinal stabilization6,25,26These are exercises that strengthen your core (muscles surrounding your midsection).  It would be beneficial to get help with fine tuning a routine that’s right for you.  I typically start folks on a “floor routine” with some form of the dead bug, bridge, and bird dog and then transition into more functional exercises, such as squats and lunges.

v. Journaling

w. Stretching

x. Posture

It is not necessary to do all of these (except for the 4 pillars).  Its important to not get overwhelmed by trying too many things at once.  Trying one thing is better than not trying at all.  You may be able to run through the list right now and pick out options that seem the easiest to implement.  Periodically check back in with the list to see if you can try out 1 or 2 others.  Each person is different, so there will be some options that resonate with you and some that don’t.  Its important to not get discouraged if one of the options doesn’t work for you.  Move on to the next one.  This is a process, not an event.

 

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

1Gifford, L. Pain, the Tissues and the Nervous System: A conceptual model. Physiotherapy
Volume 84, Issue 1, January 1998, Pages 27-36.
2Moseley, L. Reconceptualising pain according to modern pain science. Physical Therapy Reviews 12(3):169-178 · September 2007.
3Louw A1, Diener I, et al. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011 Dec;92(12):2041-56.
4Louw A1, Nijs J2,3, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017 Jul;25(3):160-168.
5Neblett R1, Cohen H, et al. The Central Sensitization Inventory (CSI): establishing clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample. J Pain. 2013 May;14(5):438-45.
6Moseley L1. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4):297-302.
7Louw A1, Butler DS, et al. Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy. Am J Phys Med Rehabil. 2013 May;92(5):446-52.
8Louw A1, Farrell K. The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial. J Man Manip Ther. 2017 Dec;25(5):227-234.
9Louw A1, Zimney K. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016 Jul;32(5):332-55.
10Van Oosterwijck J1, Nijs J. Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study. J Rehabil Res Dev. 2011;48(1):43-58.
11Moseley GL1, Nicholas MK, et al. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004 Sep-Oct;20(5):324-30.
12Louw A. Recorded Webinar: The “How-To” of Teaching Patients About Pain. Medbridge
13Busch AJ, Barber KA, et al. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003786.
14Kuphal KE1, Fibuch EE, et al. Extended swimming exercise reduces inflammatory and peripheral neuropathic pain in rodents. J Pain. 2007 Dec;8(12):989-97.
15Ajimsha MS1, Daniel B2, et al. Effectiveness of myofascial release in the management of chronic low back pain in nursing professionals. J Bodyw Mov Ther. 2014 Apr;18(2):273-81.
16Arguisuelas MD1, Lisón JF, et al. Effects of Myofascial Release in Nonspecific Chronic Low Back Pain: A Randomized Clinical Trial. Spine (Phila Pa 1976). 2017 May 1;42(9):627-634.
17Ceca D1, Elvira L, et al. Benefits of a self-myofascial release program on health-related quality of life in people with fibromyalgia: a randomized controlled trial. J Sports Med Phys Fitness. 2017 Jul-Aug;57(7-8):993-1002.
18Castro-Sánchez AM1, Matarán-Peñarrocha GA, et al. Effects of myofascial release techniques on pain, physical function, and postural stability in patients with fibromyalgia: a randomized controlled trial. Clin Rehabil. 2011 Sep;25(9):800-13.
19Castro-Sánchez AM1, Matarán-Peñarrocha GA, et al. Benefits of massage-myofascial release therapy on pain, anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia. Evid Based Complement Alternat Med. 2011;2011:561753.
20Yuan SL1, Matsutani LA, et al. Effectiveness of different styles of massage therapy in fibromyalgia: a systematic review and meta-analysis. Man Ther. 2015 Apr;20(2):257-64.
21Haller H1, Lauche R, et al. Craniosacral therapy for chronic pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2019 Dec 31;21(1):1.
22Sutar R1, Yadav S1, et al. Yoga intervention and functional pain syndromes: a selective review. Int Rev Psychiatry. 2016 Jun;28(3):316-22.
23Cash E1, Salmon P, et al. Mindfulness meditation alleviates fibromyalgia symptoms in women: results of a randomized clinical trial. Ann Behav Med. 2015 Jun;49(3):319-30.
24Pires D1, Cruz EB2, et al. Aquatic exercise and pain neurophysiology education versus aquatic exercise alone for patients with chronic low back pain: a randomized controlled trial. Clin Rehabil. 2015 Jun;29(6):538-47.
25Ryan CG1, Gray HG, et al. Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: a pilot randomised controlled trial. Man Ther. 2010 Aug;15(4):382-7.
26Beltran-Alacreu H1, López-de-Uralde-Villanueva I, et al. Manual Therapy, Therapeutic Patient Education, and Therapeutic Exercise, an Effective Multimodal Treatment of Nonspecific Chronic Neck Pain: A Randomized Controlled Trial. Am J Phys Med Rehabil. 2015 Oct;94(10 Suppl 1):887-97.
27Robles TF1, Carroll JE. Restorative biological processes and health. Soc Personal Psychol Compass. 2011 Aug;5(8):518-537.
28

Critical Decision Making and the Healing Process: Part 2

5. Internal vs. External Interventions 

External interventions (or passive treatments) are things that are being done to you (surgery, injections, medications, manual therapies, etc.).  Internal interventions (or active treatments) are things you are doing, or not doing, to help your body heal (exercises, self manual treatments, addressing stress, sleep, nutrition, etc.).  There is a place for both and the internal interventions should always be a component to your healing process.  In fact, the goal is to transition away from external interventions and be able to focus solely on your home program of exercises, self manual treatments, education, postural and ergonomic alignment, sleep, diet, etc.  You may require occasional “tune ups” or additional information in order to fine tune your self care.

If “fixing” your body (or mind) was like taking your car into the shop, it would be easy.  You take your car in, have a faulty part replaced, and drive off good as new.  Your body is much more complex, intricate, and interconnected than a machine.  The word “fix” signifies an event that happens, but healing is a process.  A process of physiological phases and lifestyle changes that occur over time.  Additionally, various environmental factors can alter those physical processes.  Those factors can be things such as nutrition, belief patterns, prior experiences, stories you’ve been told, things you’ve read, job issues, family issues, fear, etc.  Without critically thinking about these factors, the healing process can be slowed or stalled as we all tend to go off of autopilot.  More importantly, critical thinking about contributing factors can’t happen without awareness.  Awareness comes from first knowing how these contributing factors can negatively affect the healing process (see the chronic pain section in Part 3) and then listening to the signals your body sends to let you know which ones may be involved for your individual case at this particular time.  Signals such as pain, anxiety, and depression are ways your body communicates to you that something is wrong and should be addressed.

Gaining awareness is also a process, not an event.  Over time, it leads to greater and greater intuition or pattern recognition.  Daniel Kahneman wrote an interesting book called Thinking Fast, And Slow about much of the research he did with his partner Amos Tversky regarding cognitive biases.  In a nutshell, we make many decisions on autopilot, without critically thinking about them.  These decisions are largely based on a culmination of our prior experiences (things we’ve read, have been told, and that have happened to us).  We are sometimes lead down an unhelpful path with these autopilot decisions for various reasons (transferring information from one unique situation to your current situation).  Kahneman was firm in his belief that intuition should never be trusted.  Interestingly, he was open to considering a different view and collaborated with Gary Klein, who believes strongly in the power of intuition.  In the end, they concluded that using intuition is in fact beneficial if 1. the system you’re working with is predictable and 2. the person is able to figure out the patterns that make the system predictable.1   So, in our case, healing is a predictable pattern in that the body sends signals (pain, anxiety, depression) to tell you what to do and not do in order to heal.  Gaining a keen awareness of these signals allows you to see the patterns that lead to healing.

6. Believing vs. Not Believing You Can Heal

The concept of believing that you can heal works on many levels, from the esoteric to the concrete.  From a logical standpoint, when you think the disorder you have is permanent and you can’t get any better, you can imagine understandably reacting in 1 of 2 ways.  You may attempt to do whatever activity you want even though it causes pain.  This can be due to a deep need to continue with your current lifestyle.  It can also be due to fear of progressively sliding downhill and becoming incapacitated if you don’t keep moving.  The second mode of action is to do virtually nothing.  This can be due to an overwhelming frustration that leads you to give up.  It can also be due to fear of making things worse.  In both of these cases, you might stop searching for ways to help yourself and disregard recommendations for exercises or other self treatments, because what’s the use if your problem is hopeless.

Our bodies have an amazing ability to heal themselves in almost all cases.  As you’ll see in the section on chronic pain in Part 3, there are many factors influencing this healing process and lots of ways to gradually restore the body’s natural healing ability.  The first step is to gain as much knowledge as possible, whether through second opinions or your own research.  The second is to determine which of that information is applicable to your individual case.  The third is to implement those interventions.  The fourth is to constantly tweak your current plan to make it better until you reach your goals.  The last is to create a long term maintenance program to prevent recurrence.  Ask lots of questions so you can understand what you’re doing and why.

Doing virtually nothing can be seen as one end of a spectrum with the other end being continuing to plow through pain.  The key is to find the balance by listening to your body.  This takes time.  Healing is a process, not an event.

A final note on the power of belief is the placebo (and her meddling brother, the nocebo) effect.  For an in depth look at these topics, check out the fascinating book Suggestible You by Erik Vance.  Most folks have heard of the placebo effect, which has largely been studied with regards to taking an inactive substance (a sugar pill for example) that produces the same effect as a medication.  There are numerous studies showing that a significant number of people (from 30% to as many as 80%) show the same benefits from taking a placebo as those taking the actual medication.  This effect has been shown for disorders including pain, depression, Parkinson’s, irritable bowel syndrome, and asthma, among others.  The reasons are much more fascinating and complex than simply saying a person’s symptoms were not real or were “all in their head”.  It turns out that when a person believes they are taking something that will help them heal or to have less pain, their brains actually produce the chemicals that allow healing, decreasing symptoms, and/or lessening of pain to occur.2-5  Aside from medications, this effect has also been shown with information and education.  People with chronic pain, for example, experience decreased pain and increased function after receiving education about their pain and nervous systems.6-13  Knowledge is power…and healing.

An important concept to be aware of is the nocebo effect.  This occurs when negative expectations regarding a treatment or disorder cause a more negative outcome than would have occurred without the negative expectations.  Check out the information in Part 1 regarding the results of studies on imaging (MRIs and Xrays).  The “abnormal findings” are frequently not the cause of a person’s pain and dysfunction.  You can imagine that hearing some form of “wow, your spine is a mess” can create much fear and anxiety which can negatively effect the healing process.  If you find yourself in this situation, start by focusing on a belief that you can heal.  The answer is out there somewhere.  Figure out the questions you need answers to that will allow you to create a plan for healing.  Gather information, listen to your body, and focus on providing your body with the environment it needs to do what it naturally knows how to do…heal.

Stay tuned for the 3rd and final part of Critical Decision Making and the Healing Process!

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

1Kahneman D1, Klein G.  Conditions for intuitive expertise: a failure to disagree.  Am Psychol. 2009 Sep;64(6):515-26.
2BEECHER HK. The powerful placebo. J Am Med Assoc. 1955 Dec 24;159(17):1602-6.
3Pacheco-López G1, Engler H, et al. Expectations and associations that heal: Immunomodulatory placebo effects and its neurobiology. Brain Behav Immun. 2006 Sep;20(5):430-46.
4Moseley JB1, O’Malley K, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002 Jul 11;347(2):81-8.
5Jensen KB1, Kaptchuk TJ, et al. Nonconscious activation of placebo and nocebo pain responses. Proc Natl Acad Sci U S A. 2012 Sep 25;109(39):15959-64.
6Moseley L1. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4):297-302.
7Louw A1, Butler DS, et al. Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy. Am J Phys Med Rehabil. 2013 May;92(5):446-52.
8Louw A1, Diener I, et al. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011 Dec;92(12):2041-56.
9Louw A1, Nijs J2,3, Puentedura EJ4. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017 Jul;25(3):160-168.
10Louw A1, Farrell K. The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial. J Man Manip Ther. 2017 Dec;25(5):227-234.
11Louw A1, Zimney K. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016 Jul;32(5):332-55.
12Van Oosterwijck J1, Nijs J. Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study. J Rehabil Res Dev. 2011;48(1):43-58.
13Moseley GL1, Nicholas MK, et al. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004 Sep-Oct;20(5):324-30.

Beyond Tape Donations – Wild Iris

After writing Beyond Tape, I made a commitment to donate all of my net proceeds to local and global non-profit service-oriented organizations.  I’m excited to finally start passing those proceeds along and plan to write articles describing where that money is going and why I’m choosing each organization.

Thanks to all the folks who bought the book as well as the numerous people who donated their pictures, knowledge, and time to help me make Beyond Tape much better than it would have been with just me at the wheel.

My goal with the donations is to shine a light on people and organizations who are working hard to make meaningful and positive changes in their communities, both locally and globally.  It often seems we’re being constantly reminded of how hurtful we can be as human beings, but there are many more true heroes out there doing the tough job of preventing and cleaning up the messes in order to show us there are ways out of the darkness.  My intention is to strive to be more like the light creators.  I hope you’ll join me!  Giving money is great and, taking it a step further, people who volunteer for roughly 100 hours/year with 1-2 organizations tend to live longer and healthier lives.1-4 If the extent of the problems you see in the world seem overwhelming and you don’t know where to begin, start at home.  It’s often easiest to see the tangible good that is being done in your backyard.

Wild Iris is an obvious choice for a donation, in my opinion.  Here are 3 reasons why:

  1. They’ve been helpful to me personally.  In my line of work, I’m fortunate to have people trust me enough to tell me some pretty heavy things that happen in their lives.  I encourage this openness because physical problems are rarely, if ever, only physical.  Sometimes the things people share with me are beyond the scope of my ability to help them and Wild Iris has been an invaluable referral source since the time I moved to Bishop fourteen years ago.
  2. We can all agree domestic violence is a problem and we should do what we can to decrease it.  It’s a problem that affects all of us, whether directly or indirectly.
    •  “Children who witness or are victims of emotional, physical, or sexual abuse are at higher risk for health problems as adults. These can include mental health conditions, such as depression and anxiety. They may also include diabetes, obesity, heart disease, poor self-esteem, and other problems.”5
    • Kids who grow up in abusive households are 3-4X more likely to repeat the cycle in adulthood, whether by becoming an abuser or being abused.6,7   “The single best predictor of children becoming either perpetrators or victims of domestic violence later in life is whether or not they grow up in a home where there is domestic violence. “8
    • “A boy who sees his mother being abused is 10 times more likely to abuse his female partner as an adult. A girl who grows up in a home where her father abuses her mother is more than six times as likely to be sexually abused as a girl who grows up in a non-abusive home.”9

    It’s said that “hurt people hurt people”.  With the help of folks like Wild Iris, we can work to stop the cycle of violence.

  3. Wild Iris is an organization that focuses on treatment as well as prevention.  Aside from their direct client services, they offer the following programs and services (see their website for more information):
  • Parenting and Co- Parenting Classes: Wild Iris offers a FREE 6-week series of parenting and FREE 8-week series of co-parenting classes.
  • Supervised Visitation Monitoring: We provide neutral, professional third parties who can enforce effective safety measures during a child visitation with a non-custodial parent.
  • Youth Violence Prevention: Wild Iris offers a curriculum to students in the local schools that helps the faculty and staff meet their educational standards in areas of mental, emotional and social health, violence prevention and safety, and sexual health.
  • CASA (Court Appointed Special Advocate): Our CASA program provide foster youth with professional volunteer advocate in order to objectively gather information and provide a voice for the child in court as well as provide the child with a consistent adult in their life while in foster care.
  • Groups: Wild Iris offers A Window Between Worlds and Art For Healing programs. Hands-on workshops offer a safe environment for self-expression and self-exploration while using art as a way to heal from trauma, pain, grief, fear or stress.
  • 52- Week Court Ordered Parenting: Wild Iris offers the 52-week Court Ordered Parenting course. Those interested do not need to have a court order to attend classes.

 

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

References:

1 Konrath S, Fuhrel-Forbis A, et al. Motives for volunteering are associated with mortality risk in older adults. Health Psychol. 2012 Jan;31(1):87-96.
2 Sneed R, Cohen S. A prospective study of volunteerism and hypertension risk in older adults. Psychology and Aging, Vol 28(2), Jun 2013, 578-586.
3 Anderson ND, Damianakis T, et al. The benefits associated with volunteering among seniors: a critical review and recommendations for future research. Psychol Bull. 2014 Nov;140(6):1505-
33.
4 https://www.nationalservice.gov/pdf/07_0506_hbr.pdf
5 Monnat SM1, Chandler RF2. Long Term Physical Health Consequences of Adverse Childhood Experiences. Sociol Q. 2015 Sep;56(4):723-752.
6https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/peoplewhowereabusedaschildrenaremorelikelytobeabusedasanadult/2017-09-27
7 https://southbaycommunityservices.org/domestic-violence-awareness-month/
8 https://www.unicef.org/media/files/BehindClosedDoors.pdf
9 Vargas, L. Cataldo, J., Dickson, S. (2005). Domestic Violence and Children (link is external). In G.R. Walz & R.K. Yep (Eds.), VISTAS: Compelling Perspectives on Counseling. Alexandria, VA: American Counseling Association; 67-69.

Critical Decision Making and the Healing Process: Part 1

Image caption:  Crashpads and appropriate spotters are climbing critical decision making 101…double fail!

Critical decision making is one of the most important aspects, and oftentimes the key component, for the prevention and treatment of injuries.  Our bodies (and beings) have the amazing ability to heal themselves in most cases, aside from cases of severe trauma such as displaced fractures.  Its our job to create the environment to allow our bodies to do what they know how to do…heal.

There can be blockages to the healing process so we first have to figure out what those blockages are and then remove them.  This takes having a keen awareness of the things that are limiting the healing as well as those that are promoting it.   Listening to the signals that our bodies send, such as pain, depression, and anxiety, help us find the path that leads to healing.  This awareness ultimately gives us the power to make decisions that allow us to return to the life and activities that we wish for.  Pain and inflammation (discussed below) are important, albeit uncomfortable, parts of the healing process.

Understanding the healing process from a physiological perspective is a helpful start to show that healing is in fact a process, not an event.  For a more in depth description, check out the first chapter of Beyond Tape or the references below.1-11 Simply put, there are three main phases:

 Phases of the healing process
  1. Inflammation (roughly days 0-7):  When an injury occurs, the body sends an increased supply of blood to the area which bring in cells that remove dead or damaged tissue.   When those cells are finished, they call in a new group of cells to come in to lay down new tissue.  In addition to the cells, various chemical messengers are released, some of which signal danger (or pain) that prevent the person from continuing to touch the hot stove, for example.
  2. Proliferation (roughly days 7-21):  New tissue gets laid down.  Initially, the new tissue is disorganized, like a clump of cooked spaghetti.
  3. Remodeling/maturation (roughly day 21-weeks/months):  The disorganized tissue realigns in a more functional way so we can return to normal activities.  This realignment occurs from finding the balance of stressing the tissues (range of motion, stretching, strengthening, functional activities) enough to create healthy adaptation while not stressing them enough to cause more injury.

Now that we have the physiology out of the way, here are some other common themes that hold people back.  I think these topics are fascinating and shifted my personal mindset from seeing my own unhealthy decisions as “bonehead Mike decisions” to ways that I as a human being have a tendency to sabotage myself.   Having the awareness that we’re all subject to things like cognitive biases, allows us to think more critically about a decision before it takes us down a hard and unnecessary road.  Check out the lecture series “The Art of Critical Decision Making” with Michael Roberto from the Teaching Company and Daniel Kahneman’s book Thinking, Fast and Slow for a more in-depth discussion of these types of topics.

1. Sunk Cost Effect

The “sunk cost effect” is a term typically used in economics that applies to many other areas of life as well (we’ll use rock climbing as an example). It is “an irrational economic decision to invest more future resources after a prior investment has been made (costs are sunk) compared to a similar situation
without a prior investment”.12

For climbing, this is exemplified by making the decision to continue climbing when there is an injury present because of the desire to avoid wasting all the time, effort, and possibly money that has been spent training to reach a goal. This may involve working toward specific goals of boulder problems, red points, or summits. The climber finds herself in a situation where there are obstacles to those goals in the form of an injury, illness, or uncooperative weather. The rational decision would be to back off in order to return to climbing in a healthy
state. The irrational decision would be to ignore the obstacles and continue digging further into the hole. These irrational decisions are often easy to see in hindsight, but we are all capable of justifying unhealthy decisions when the sunk cost effect is present. Making the rational decision could mean the difference between returning
to climbing after a sprain or strain heals in a couple weeks versus doing serious damage that eventually puts the climber out for months or a year.

For mountain climbing, the difference could be aborting the mission in order to make another attempt on a later date versus continuing on and risking serious injury or death. The sunk cost effect was thought to be a major factor in the Mt. Everest tragedy in 1996 where 5 climbers died, including 2 experienced expedition leaders.13 Sticking to turn around times and acknowledging approaching ominous weather becomes more difficult the more prior investment has been made. Try to step back and see the bigger picture before ignoring the signs.

2. Good Pain Versus Bad Pain

Most of us were told some form of “no pain, no gain” over and over starting from a young age.  Is this a true statement?  As with most other things in life, it depends.  There is injurious pain (pain signifying injury or danger) and therapeutic pain (discomfort that leads to beneficial results).  Take a person who is training for a race and doing speed work at the track.  It’s hard and is becoming mentally painful to continue, but they know if they do a couple more sprints it will help their performance (therapeutic pain).  If that person broke their ankle, they hopefully wouldn’t continue to run because it will not help their performance (injurious pain).  That’s an extreme example, but you get the point.

This concept also comes up when talking about performing self body work at home.  I practice and teach people to perform myofascial release on themselves, which is sinking into an area that feels tight and tender and holding direct pressure on the area for 2-3 or more minutes of time to release restricted areas.  People often describe this a “good hurt”.  The idea is to work with your body rather than to beat it into submission.

This is a part of what is probably the most important message from this article…listen to the body, as well as to the environment, and to the signals they are sending. As they say, “if you listen to your body when it whispers, you won’t have to hear it scream”. Paige, Fiore, et al describe this perfectly: “Climbers should be encouraged to immediately stop climbing when they feel sharp pain. This is especially true of finger pain and if symptoms appear while “working” a move. This seems obvious, but successful climbers, like other successful athletes, have often conditioned themselves to ignore discomfort and to push through difficulties. Climbers must learn to differentiate between pushing oneself despite exhaustion and muscular fatigue and pushing oneself into a serious connective tissue injury.” 14

3. All or None Versus Modification

A crucial aspect of healing is determining aspects of our lives that either help the healing process or slow it down.  I think it helps to just start with concrete aspects without worrying about how you might modify those aspects.

For example, take a person who loves gardening, which is an activity that increases their pain.  People are often reluctant to even start this conversation, stating, “well I have to garden!” (or work or take care of my kids, etc.).  Starting from a place of either gardening or not gardening prevents us from considering the possibility of modification, or finding the balance between doing what we want but not in a way that causes further injury.  Once we have the aspect (gardening in this case), we can look at variables that might be modified. For example, length of time performing the task.  Instead of gardening for 4 hours straight, is it possible to try 1 hour blocks with a 30 minute rest break in between?  This not only might help the body heal, but it also allows a person to assess their progress over time (start with 1 hour for the first week, increase to 1.5 hours for the next if it feels ok, then 2 hours, etc.).

Some other examples of variables that can be modified might be the various activities (digging vs. watering vs. weeding vs. planting), time of day (does the pain tend to be worse first thing in the morning or in the evening?), the possibility of having someone else temporarily perform some of the more strenuous activities, body position (standing and bending over versus using a stool or bench).  The goal is to create the environment that allows your body to heal itself by making logical, rational decisions.  It helps to see these modifications as temporary, while you’re allowing your body to heal. I often suggest that if a person is having trouble deciding if they should perform a certain activity, pretend a loved one is telling them about this exact situation happening to that loved one.  What advice would you give them?

4. Real versus perceived threat 

I see lots of folks who haven’t tried a certain activity because they think it will hurt.  Oftentimes when we try the activity in the clinic, they find that its either not painful, or we’re able to modify it so they can start to ease into the activity.  Its a powerful feeling to realize that you may be capable of things you thought you were not and that there is at least the possibility you can return to your life.

There are many understandable reasons why we all avoid things that we think will hurt.  Sometimes people are told they shouldn’t do certain things (you should stop running, lifting, squatting, bending, etc.).  There can be important reasons for these suggestions (avoiding bending over or prolonged slouched positions with an acute spinal compression fracture, for example) but that’s not a long term plan.  In most cases, people should be able to return to their normal daily lives after an injury.

Problems that show up on imaging (Xrays, MRIs, etc.) can be disconcerting.  A lot of folks are under the impression that once damage is done (disc herniation, meniscus tear, arthritis, etc.) then it will be there forever.  In reality, these injuries heal the majority of the time15-27,   or may not actually be the cause of the pain.28-39  There are certainly times when your body may require some outside help (surgery, etc.), such as a herniated disc stopping the nerve signal to the area it controls which can cause significant and specific weakness, lack of sensation, or bowel/bladder problems.  Again though, most of the time the body can heal.

What you can do:  Gain greater and greater awareness into the meaning the signals your body sends.  See pain as a crucial tool to help you heal yourself.  Ease into activities in a controlled manner, initially avoiding forceful movements using momentum (starting a lawn mower, for example).  Consider how your body feels during the activity, immediately after, and the next day.   Assume you can heal, you may just not have figured out how yet.  People who believe they can heal make different decisions than those that don’t, which will be discussed further in Part 2.

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

References:

1Kannus P1, Parkkari J, Järvinen TL, Järvinen TA, Järvinen M. Basic science and clinical studies coincide: active treatment approach is needed after a sports injury. Scand J Med Sci Sports. 2003 Jun;13(3):150-4.
2Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J. BoneJoint Surg. 2005; 87:187Y202.
3James R1, Kesturu G, et al. Tendon: biology, biomechanics, repair, growth factors, and evolving treatment options. J Hand Surg Am. 2008 Jan;33(1):102-12.
4Hess GP, Cappiello WL, Poole RM, et al: Prevention and treatment of overuse tendon injuries. S p o r t s M e d 8 : 371–384, 1989.
5Järvinen TA1, Järvinen TL, et al. Muscle injuries: biology and treatment. Am J Sports Med. 2005 May;33(5):745-64.
6Bondesen BA1, Mills ST, et al. The COX-2 pathway is essential during early stages of skeletal muscle regeneration. Am J Physiol Cell Physiol. 2004 Aug;287(2):C475-83.
7Schleip R1, Müller DG. Training principles for fascial connective tissues: scientific foundation and suggested practical applications. J Bodyw Mov Ther. 2013 Jan;17(1):103-15.
8Lu H1, Huang D, et al. Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury. FASEB J. 2011 Jan;25(1):358-69.
9Arnold L1, Henry A, et al. Inflammatory monocytes recruited after skeletal muscle injury switch into antiinflammatory macrophages to support myogenesis. J Exp Med. 2007 May 14;204(5):1057-69.
10Smith C1, Kruger MJ, et al. The inflammatory response to skeletal muscle injury: illuminating complexities. Sports Med. 2008;38(11):947-69.
11Wren TA, Yerby SA, et al. Mechanical properties of the human achilles tendon. Clin Biomech (Bristol, Avon). 2001 Mar;16(3):245-51.
12Strough J1, Karns TE, Schlosnagle L. Decision-making heuristics and biases across the life span. Ann N Y Acad Sci. 2011 Oct;1235:57-74.
13Roberto, M. The Art of Critical Decision Making. The Teaching Company. 2009.
14Paige TE, Fiore DC, Houston JD. Injury in traditional and sport rock climbing. Wilderness and Environmental Medicine, 9,2-7 (1998).
15Benson RT1, Tavares SP, et al.  Conservatively treated massive prolapsed discs: a 7-year follow-up.  Ann R Coll Surg Engl. 2010 Mar;92(2):147-53.
16Saal JA1, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. An outcome study. Spine (Phila Pa 1976). 1989 Apr;14(4):431-7.
17 Yukawa Y1, Kato F, et al. Serial magnetic resonance imaging follow-up study of lumbar disc herniation conservatively treated for average 30 months: relation between reduction of herniation and degeneration of disc. J Spinal Disord. 1996 Jun;9(3):251-6.
18Masui T1, Yukawa Y, et al. Natural history of patients with lumbar disc herniation observed by magnetic resonance imaging for minimum 7 years. J Spinal Disord Tech. 2005 Apr;18(2):121-6.
19Matsubara Y1, Kato F, Mimatsu K, Kajino G, Nakamura S, Nitta H. Serial changes on MRI in lumbar disc herniations treated conservatively. Neuroradiology. 1995 Jul;37(5):378-83.
20Komori H, Okawa A, et al.  Contrast-enhanced magnetic resonance imaging in conservative management of lumbar disc herniation. Spine (Phila Pa 1976). 1998 Jan 1;23(1):67-73.
21Autio RA1, Karppinen J, et al.  Determinants of spontaneous resorption of intervertebral disc herniations.  Spine (Phila Pa 1976). 2006 May 15;31(11):1247-52.
22 Anakwenze OA1, Namdari S, et al. Athletic performance outcomes following lumbar discectomy in professional basketball players. Spine (Phila Pa 1976). 2010 Apr 1;35(7):825-8.
23Hsu WK1. Performance-based outcomes following lumbar discectomy in professional athletes in the National Football League. Spine (Phila Pa 1976). 2010 May 20;35(12):1247-51.
24Mochida K1, Komori H, Okawa A, Muneta T, Haro H, Shinomiya K. Regression of cervical disc herniation observed on magnetic resonance images. Spine (Phila Pa 1976). 1998 May 1;23(9):990-5; discussion 996-7.
25Lee DY1, Park YJ2, et al. Arthroscopic meniscal surgery versus conservative management in patients aged 40 years and older: a meta-analysis. Arch Orthop Trauma Surg. 2018 Dec;138(12):1731-1739.
26Sihvonen R1, Paavola M2, et al.  Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial.  Ann Rheum Dis. 2018 Feb;77(2):188-195.
27Azam M1, Shenoy R2.  The Role of Arthroscopic Partial Meniscectomy in the Management of Degenerative Meniscus Tears: A Review of the Recent Literature.  Open Orthop J. 2016 Dec 30;10:797-804.
28Boden SD1, Davis DO, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8.
29Deyo RA. Magnetic resonance imaging of the lumbar spine. Terrific test or tar baby? N Engl J Med. 1994 Jul 14;331(2):115-6.
30Brinjikji W1, Luetmer PH2, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6.
31Bedson J1, Croft PR.. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskelet Disord. 2008 Sep 2;9:116.
32Beattie KA1, Boulos P, et al. Abnormalities identified in the knees of asymptomatic volunteers using peripheral magnetic resonance imaging. Osteoarthritis Cartilage. 2005 Mar;13(3):181-6.
33Guermazi A1, Niu J, et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ. 2012 Aug 29;345:e5339.
34Schwartzberg R1, Reuss BL, et al. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthop J Sports Med. 2016 Jan 5;4(1):2325967115623212.
35Kälin PS1, Crawford RJ, et al. Shoulder muscle volume and fat content in healthy adult volunteers: quantification with DIXON MRI to determine the influence of demographics and handedness. Skeletal Radiol. 2018 Oct;47(10):1393-1402.
36Nakashima H1, Yukawa Y, et al. Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015 Mar 15;40(6):392-8.
37Register B1, Pennock AT, et al. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. Am J Sports Med. 2012 Dec;40(12):2720-4.
38Alyas F1, Turner M, Connell D. MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. Br J Sports Med. 2007 Nov;41(11):836-41; discussion 841.
39Videman T1, Battié MC, et al.  Associations between back pain history and lumbar MRI findings.  Spine (Phila Pa 1976). 2003 Mar 15;28(6):582-8.

 

 

 

 

 

 

Find Your Balance to Prevent Falls and Boost Confidence

About a third of people 65 years and older fall at least one time each year.1-3  Falls account for over half of all injury-related hospitalizations for the elderly.2

As a community, we can help  our friends and family members by assisting them with the exercises and helping them address any external factors noted below.  As individuals, we can boost motivation by exercising with a friend or taking a class.  Additionally, a common message that is conveyed to older folks is that they are frail and that inactivity and falls are an inevitable part of aging.6 As with many other things in life, its easy to take an aspect of truth and swing our pendulum in an extreme direction.  Its true that sarcopenia, the term given to the loss of muscle mass related to age, occurs.3,6  About two percent of muscle mass is lost per year after the age of 50.6 This loss in muscle mass is one of the main contributors to decreased function, such as rising from a chair, walking, making turns, and balance at rest and while performing activities.3,6,7  However, strength training has been shown to greatly mitigate this decline.5,6  Perhaps even more exciting is that exercises and educational programs have been shown to significantly improve balance and decrease the risk of falls as well as injuries caused by falls.1-13

Aside from the exercises mentioned below as well as my printable balance program, Tai Chi2,14, Pilates21, and Yoga22 have been shown to improve balance and decrease the risk of falls.  If you live in the Bishop area, we’re blessed to have Tai Chi classes taught by Andy Selters and Deo Santos, Pilates at Bishop Yoga and Pilates Center and FlowMotion Pilates, and yoga at Bishop Yoga and Pilates Center, FlowMotion Pilates, Sabine Elia at Inyo Council for the Arts, and Sierra Shanti.

There are many exercise programs geared towards improving balance and decreasing fall risk.  They all tend to have the common themes of addressing strength, flexibility, and balance.  The general consensus recommends one hour sessions three times per week.  The bulk of the program below is taken from the Otego Exercise Program.  This program has been studied extensively and has been shown to decrease falls and the injuries caused by falls by over a third.5,10-12  In addition to the exercises, a discussion of the internal and external factors related to falls will be addressed first as many of these can be modified to greatly decrease a person’s risk of falling.1,4 

 

Internal Factors Affecting Balance:

  1. Vision – Make sure you have the correct prescription for eye wear.
  2. Vestibular system – This is the sensory system in your inner ear that communicates with your brain to tell it where your body is in space.  BPPV and Meniere’s Disease are examples of vestibular system disorders.
  3. Proprioception – These are the sensors in your joints that tell your body where it is in space.
  4. Strength – Weakness in the ankles, knees, hips, and low back/core region have been shown to affect balance and will be addressed below.5,8
  5. Flexibility – Decreased flexibility in the ankles, hips, and spine have been shown to affect flexibility and will be addressed below.5,8
  6. Dual tasking – Walking while adding another task, such as talking, turning your head to look at objects, or reacting to hearing or seeing something that is happening in your environment, is considered dual tasking.  This is a fascinating and overlooked topic that I did my grad school thesis on.  Older folks tend to have a decreased ability to dual task while walking which can increase the risk of falls.  One easy way of determining if you should be working on balance is if you stop walking when you begin talking.15-18
  7. Medical Conditions – Some examples are poor general health, diabetes, arthritis, osteoporosis, stroke, incontinence, medication use, and cognitive/mental health issues (memory, inattention, dementia, depression). Many of these issues can by improved greatly by exercise, nutrition, and lifestyle changes.
  8. Lifestyle Choices – Some examples are exercise, footwear, alcohol use, nutrition, hydration, and fear of falling.4

External Factors Affecting Balance:

  1. Throw rugs and cords or other obstacles
  2. Lack of nightlights for bathrooms/hallways
  3. Lack of handrails
  4. Objects that are out of reach
  5. Uneven ground
  6. Alcohol
  7. Decreased activity level
  8. Fear of falling
  9. Dehydration – The recommendation is about twelve eight ounce glasses of water per day for men and nine for women.19,20
  10. Lack of sleep – See my evidenced-based handout for sleep hygiene tips.
  11. Medication issues
    – Did your balance issues begin around the same time as a medication change?  Talk with your doctor.
    – Lightheadedness/dizziness with a change of position (lying to sitting or sitting to standing) can indicate a blood pressure issue.  Talk with your doctor.
  12. Pets – high energy dogs, for example

Exercises

I. General Guidelines – click on the underlined areas for video demonstrations

  1. A person should be evaluated by a healthcare practitioner familiar with balance disorders and training before performing the exercise program below.  All of the exercises can be modified to be made easier or more challenging and every person’s deficits will be somewhat different.  The best exercise program is one specifically tailored to the individual.  Safety is the most important aspect of any exercise program.
  2. Performing any of these exercises is better than none.  If the program is taking too much time or effort, have your physical therapist remove the exercises that are not as necessary for you.  It is much better to start off doing less than you are capable of and add to that program rather than starting with too much and hurting yourself or hating the program and throwing it in the garbage.
  3. Do not push through pain with any of the exercises, even if it feels like you are “not doing anything”.  Try to avoid having expectations about being able to perform a certain number of repetitions or move in a certain range.  Progress will come with consistent practice.
  4. Notify your physician if you experience dizziness, chest pain, or shortness of breath (ie., you are unable to speak because you are short of breath).
  5. Do not hold onto an object for support that may move (use your kitchen sink rather than a chair for example).
  6. Look ahead when walking on even surfaces or performing the exercises instead of looking down.
  7. Try to add walking into your daily activities as much as possible. For example, park farther away from the entrance when going to the store. Use the stairs when possible instead of an elevator.

II. Warm Up

  1. Walk for 20-30 minutes if time permits (stationary cycling is a good alternative if walking is too unsteady)
  2. Neck rotation – stand tall and turn your head to the side until you feel a stretch, repeat on the other side 5-10X each
  3. Chin tucks – stand tall and tuck your chin as if you are creating a double chin while imagining your spine stretching towards the ceiling, repeat 5-10X
  4. Trunk extension – place your hands on your low back and bend backwards until you feel a stretch, repeat 5-10X
  5. Trunk rotation – keeping your hips and pelvis stationary, rotate your trunk until you feel a stretch, repeat on the other side 5-10X each
  6. Seated ankle range of motion – bring your toes towards your nose, then push your toes down towards the floor, repeat 10X in each direction

III. Strengthening
use a kitchen counter for support for safety and to focus on your technique, as needed

  1. Seated knee extension – straighten your knee and pull your toes towards your nose, feel free to add ankle weights to make more challenging, repeat 10X for 2-3 sets
  2. Standing knee flexion – bend your knee by bringing your heel towards your buttocks, feel free to add ankle weights to make more challenging, repeat 10X for 2-3 sets
  3. Toe/heel raises (double or single leg) – raise up onto the balls of your feet, lower back down and raise up onto your heels, repeat 10X for 2-3 sets
  4. Hip abduction – stand tall and raise your leg out sideways away from your other leg, repeat 10X for 2-3 sets on each side
  5. Marching – stand tall and raise a knee towards your chest, repeat 10X for 2-3 sets on each side
  6. Squatting – keeping a neutral spine position with your chest pointing forwards and your eyes looking straight ahead, squat down until you feel pain or unstable and return to standing (you may want to use a chair to simulate standing up from a seated position and squatting back down until your buttocks barely touches the chair before returning to stand), repeat 10X for 2-3 sets
  7. Lunges (more advanced)
  8. Single leg quarter squats (more advanced)

IV. Static (not moving) Standing Balance
*use kitchen counter for support for safety as needed
*there are 4 progressively more challenging foot positions (1. feet as wide as your hips 2. feet together 3. tandem stance 4. single leg stance) and 4 progressively more challenging variables for each foot position (1. eyes open on an even surface 2. eyes closed on an even surface 3. eyes open on an uneven surface, such as a balance board, dyna disc, or pillow 4. eyes closed on an uneven surface)
*hold all positions for 30-60 seconds and repeat 2-3X

  1. Feet hip width with eyes open (close eyes or stand on an uneven surface to make more challenging)
    feet hip width
  2. Feet together with eyes open (close eyes or stand on an uneven surface to make more challenging)

    feet together
  3. Tandem stance (tightrope) with eyes open (close eyes or stand on an uneven surface to make more challenging) – both sides
    semi tandem stance (easier)

    tandem stance (harder)
  4. Single leg stance with eyes open (close eyes or stand on an uneven surface to make more challenging) – both sides

V. Dynamic (moving) Standing Balance
*
use a wall or counter (hallways can be helpful) for support for safety as needed
*perform each activity for 10 steps (or better yet, measure out 10-15 feet so the dual task of counting while you are walking is not added, at least initially) and repeat 5X

  1. Tandem walking (tightrope) – walk forwards placing one foot directly in front of the other as if walking on a tightrope
  2. Walking with head turns – turn your head side to side as if you are checking out the food on either side of you in the grocery store aisle
  3. Walking backwards
  4. Sideways walking
  5. Figure 8 walking – walk in a figure of 8 pattern
  6. Heel walking – walk on your heels
  7. Toe walking – walk on the balls of your feet
  8. Backwards tandem walking – walk backwards placing one foot directly in front of the other as if walking on a tightrope
  9. Stairs – use one or two rails for support until you feel comfortable walking with no support

VI. Stretching
*
hold stretches for 30 seconds and repeat 2-3X on each side daily

  1. Calf stretches (standing) – a stretch should be felt in the calf of the back leg
  2. Hip flexor stretches (standing) – a stretch should be felt in the front of the hip in the back leg
  3. Single knee to chest (lying on back) – a stretch may be felt in the knee, hip, or back

    single knee to chest
  4. Trunk rotation (lying on back)

    low trunk rotation
  5. Child’s pose (start on your hands and knees and sit back on your heels while bringing your head to the floor)
    Childs Pose

     

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

References:

1Schwenk M, Jordan ED, et al. Effectiveness of foot and ankle exercise programs on reducing the risk of falling in older adults: a systematic review and meta-analysis of randomized controlled trials. J Am Podiatr Med Assoc. 2013 Nov-Dec;103(6):534-47.
2Sherrington C, Whitney JC, et al. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008 Dec;56(12):2234-43.
3Hamed A, Bohm S, et al. Follow-up efficacy of physical exercise interventions on fall incidence and fall risk in healthy older adults: a systematic review and meta-analysis. Sports Med Open. 2018 Dec 13;4(1):56.
4Florida Injury Prevention Program for Seniors (FLIPS) – https://slideplayer.com/slide/8680174/
5McMahon SK, Wyman JF, et al. Combining Motivational and Physical Intervention Components to Promote Fall-Reducing Physical Activity Among Community-Dwelling Older Adults: A Feasibility Study. Am J Health Promot. 2016 Nov;30(8):638-644.
6Papa EV1, Dong X2, et al. Resistance training for activity limitations in older adults with skeletal muscle function deficits: a systematic review. Clin Interv Aging. 2017 Jun 13;12:955-961.
7Gardner MM1, Buchner DM, et al. Practical implementation of an exercise-based falls prevention programme. Age Ageing. 2001 Jan;30(1):77-83.
8Emilio EJ1, Hita-Contreras F2, et al. The association of flexibility, balance, and lumbar strength with balance ability: risk of falls in older adults. J Sports Sci Med. 2014 May 1;13(2):349-57.
9El-Kashlan HK1, Shepard NT, et al. Evaluation of clinical measures of equilibrium. Laryngoscope. 1998 Mar;108(3):311-9.
10Shubert TE, Smith ML, Otago Exercise Program in the United States: Comparison of 2 Implementation Models. Phys Ther. 2017 Feb 1;97(2):187-197.
11Otego Exercise Program PDF – file:///C:/Users/Mike%20Gable/Documents/Originals/Articles/Balance/Not%20Read/Otago%20program%20PDF.pdf.
12Robertson MC1, Campbell AJ, et al. Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J Am Geriatr Soc. 2002 May;50(5):905-11.
13Sherrington C1, Fairhall NJ, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019 Jan 31.
14Taylor-Piliae RE1, Haskell WL, et al. Improvement in balance, strength, and flexibility after 12 weeks of Tai chi exercise in ethnic Chinese adults with cardiovascular disease risk factors. Altern Ther Health Med. 2006 Mar-Apr;12(2):50-8.
15Lajoie Y1, Teasdale N, et al. Attentional demands for static and dynamic equilibrium. Exp Brain Res. 1993;97(1):139-44.
16Wright DL1, Kemp TL. The dual-task methodology and assessing the attentional demands of ambulation with walking devices. Phys Ther. 1992 Apr;72(4):306-12; discussion 313-5.
17Chen HC1, Schultz AB, et al. Stepping over obstacles: dividing attention impairs performance of old more than young adults. J Gerontol A Biol Sci Med Sci. 1996 May;51(3):M116-22.
18Lundin-Olsson L, Nyberg L, et al. “Stops walking when talking” as a predictor of falls in elderly people. Lancet. 1997 Mar 1;349(9052):617.
19Sawka MN1, Cheuvront SN, Carter R 3rd. Human water needs. Nutr Rev. 2005 Jun;63(6 Pt 2):S30-9.
20http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=10925
21Pata RW1, Lord K2, et al. The effect of Pilates based exercise on mobility, postural stability, and balance in order to decrease fall risk in older adults. J Bodyw Mov Ther. 2014 Jul;18(3):361-7.
22Nick N1, Petramfar P2, et al. The Effect of Yoga on Balance and Fear of Falling in Older Adults. PM R. 2016 Feb;8(2):145-51.

Ankle Sprains

What is it?

This is an overstretching or tearing of the ligaments on the outside of the ankle joint and foot.  The ligaments most commonly involved are the anterior talofibular ligament  toward the front of the ankle, the calcaneofibular ligament directly to the outside of the ankle, and less commonly the posterior talofibular ligament toward the back of the ankle.  This is the most common type of ankle sprain, noted as high as 85% of all ankle sprains, and occurs when the foot rolls to the inside with weight bearing activities.  This can occur while hiking on uneven ground especially with a heavy pack or when falling from a boulder problem and landing on the edge of the crash pad.1,2,3  Climbing shoes that are excessively small can also contribute to this injury.4  There has been an increased risk of ankle sprains with bouldering and sport climbing.5

What does it feel like (Symptoms)?

Significant pain and swelling is typically noticed on the outside of the ankle and it may be difficult to walk or bear weight on the ankle.

Prevention

There is a high rate of recurrence after the initial sprain so preventing this injury from occurring is key.  There are four key factors involved with preventing this injury:

  1. Range of motion and flexibility:  Assess and address as needed any differences between the left and right ankles for dorsiflexion, plantarflexion, inversion, and eversion range of motion as well as gastrocnemius and soleus flexibility. (See below)  A lack of dorsiflexion specifically has been shown to increase the risk of spraining the ankle.1,3
ankle dorsiflexion – pull your toes towards your nose
Repeat 10 times, 3-4 times/day in a pain free range.
ankle eversion – move your foot up and out
Repeat 10 times, 3-4 times/day in a pain free range.
ankle inversion – move your foot towards the big toe side
Repeat 10 times, 3-4 times/day in a pain free range.
ankle plantaflexion – push your toes down like you are pushing down on the gas pedal
Repeat 10 times, 3-4 times/day in a pain free range.
gastrocnemius stretch – keep the back knee straight and shift your weight forward until you feel a stretch in the back calf
Hold for 30 seconds and repeat 2-3 times, 2-3 times/day in a pain free range.
soleus stretch – bend the back knee and shift your weight down into the back foot until you feel a stretch in the back calf
Hold for 30 seconds and repeat 2-3 times, 2-3 times/day in a pain free range.

2. Strength:   Assess and address as needed any differences in ankle eversion, inversion, and plantarflexion as well as hip abduction and extensor strength (see below).1,3

ankle eversion strengthening – move your foot up and out
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range.
ankle inversion strengthening – move your foot towards the big toe side
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range.
single leg heel raise – raise up onto the ball of your foot
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range
hip abduction strengthening – move your leg out to the side and return to midline
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range. Feel free to add resistance.
hip extension strengthening – move your leg back and return to neutral
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range. Feel free to add resistance or try a single leg bridge instead.

3. Balance and proprioception:   Proprioception is a joint’s ability to tell where it is in relation to the rest of the body.  Deficits with proprioception can cause the foot to land in a way that increases the chance of a sprain while walking, hiking, or landing from a boulder.6  The best exercises to address this issue are performed while standing on one leg.  The progression of these exercises from easiest to hardest is to stand on one leg on even ground with the eyes open for 60 seconds.  If this is easy, try either closing the eyes or standing on an uneven surface such as a wobble board, Bosu ball, or better yet: a slack line. As this becomes easier, stand on the uneven surface with the eyes closed.  Adding a single leg quarter squat to this can make it even more challenging.1-3,7-9

single leg stance – close eyes or stand on an uneven surface to make more challenging
Hold for 60 seconds, repeat 2-3 times, 3-5 times per week.
single leg quarter squat – stand on 1 foot and squat down in a pain free range making sure your knee is in line with your toes and your pelvis stays horizontal (doesn’t tip down when lowering)
Repeat 10-15 times, 2-3 sets, 3 times per week in a pain free range.

4. Crash pad positioning:   Spotters should always have a sense of where the climber will fall and to place the pad so the climber will fall in the middle of the pad as opposed to on the edge.  While in the gym or outside, make sure all the pads are connected and there are no spaces where the climber’s foot could land in between pads.

Treatment

This injury should be medically evaluated to determine the extent of the injury including any fractures or dislocations.  The Ottawa Ankle Rules were developed to determine if an X ray is necessary.20, 21   An X ray is indicated if any of the following are present:
1. bony tenderness along the back side of the bottom part of the fibula or lateral malleolus
2. bony tenderness along the back side of the bottom part of the tibia or medial malleous
3. bony tenderness at the base of the 5th metatarsal
4. bony tenderness at the navicular
5. Unable to walk at least 4 steps

bones of the foot and ankle

The use of crutches (or walker/cane) and functional support using a brace, wrap, or taping while gradually increasing weight bearing may be required if the pain is causing significant limping.  In an acute injury situation, pain is the body’s way of telling you what to do or not do in order to allow it to heal.  Inflammation is a crucial phase of the healing process, where dead or damaged tissue is removed and special cells are called on to lay down new tissue.  Research is showing that blocking the inflammatory phase of the healing process (with NSAIDS, for example) can actually slow the healing of bone and soft tissue.11-19  That being said, decreasing pain and inflammation should be considered for the first 3 days after the injury if 1. pain is preventing you from sleeping (check here for the importance of sleep) 2. pain is unbearable (stress hormones will be released which can slow the healing process) or 3. there is extreme swelling, theoretically damaging healthy tissue that wouldn’t have been damaged due to the injury.

There is a high rate of recurrence after an initial ankle sprain and many people develop chronic ankle instability, so it is important to address any of the key factors that may be limited due to an ankle sprain including:2

  1. Range of motion/flexibility:    Assess and address as needed any differences between the left and right ankles for dorsiflexion, plantarflexion, inversion, and eversion range of motion as well as gastrocnemius and soleus flexibility. (See figures in the prevention section above as well as a figure below for a  stretch for the tibialis anterior muscle.)  Also, practice tracing the alphabet in uppercase letters with your foot.1-3  When these motions have been regained with minimal pain, strengthening can be initiated.
tibialis anterior stretch – point your back toes down and straighten your knee
Hold for 30 seconds, repeat 2-3 times, 2-3 times per day, 3-5 times per week

2. Strength:   Assess and address as needed ankle eversion, inversion, and plantarflexion as well as hip abduction and extension strength (See the figures in the prevention section above).1-3  Progress to the single leg stance and single leg quarter squats as seen in the prevention section above and add the following lunge.

Forward lunge – step forward, drop straight down, return to start, repeat on the other side
Repeat 10-15 times, 2-3 sets, 3 times per week in a pain free range

After these exercises can be performed pain free, squat jumps can be added with progressively increasing the height of the jumps and advancing from two legs to single leg as strength increases. These exercises will help the climber prepare for landing while bouldering.
3. Balance and proprioception: See details under the prevention section above
4. Trigger points:   Check for any trigger points, especially of the peroneal muscles as stated above

peroneal trigger points
peroneal self trigger point/myofascial release
Hold gentle-moderate direct pressure for 2-3+ minutes on any area that feels tight or tender and feel for a release
Repeat 2-3 times per day

 

5. Functional support:   Bracing and taping for stability have both been shown to decrease the risk of recurrence after the initial ankle sprain.2,3
6. Joint mobility:   Joint mobilizations, including mobilizations with movement, typically performed by a physical therapist, chiropractor, or osteopath, have been shown to be beneficial when range of motion is difficult to regain.1,3,10

 

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

References:

1 Kaminski TW1, Hertel J, et al; National Athletic Trainers’ Association. National Athletic Trainers’ Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013 Jul-Aug;48(4):528-45.
2 Chinn L, Hertel J. Rehabilitation of ankle and foot injuries in athletes. Clin Sports Med. 2010 Jan;29(1):157-67, table of contents.
3 Lin CW1, Hiller CE, de Bie RA. Evidence-based treatment for ankle injuries: a clinical perspective. J Man Manip Ther. 2010 Mar;18(1):22-8.
4 Buda R1, Di Caprio F, et al. Foot overuse diseases in rock climbing: an epidemiologic study. J Am Podiatr Med Assoc. 2013 Mar-Apr;103(2):113-20.
5 Schöffl V, Küpper T. Feet injuries in rock climbers. World J Orthop. 2013 Oct 18;4(4):218-228. eCollection 2013. Review.
6 Sefton JM1, Yarar C, et al. Six weeks of balance training improves sensorimotor function in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2011 Feb;41(2):81-9.
Herman K, Barton C, et al. The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC Med. 2012 Jul 19;10:75. doi: 10.1186/1741-7015-10-75. Review.
Schweizer A1, Bircher HP, et al. Functional ankle control of rock climbers. Br J Sports Med. 2005 Jul;39(7):429-31.
McKeon PO1, Ingersoll CD, et al. Balance training improves function and postural control in those with chronic ankle instability. Med Sci Sports Exerc. 2008 Oct;40(10):1810-9.
10 Travell J, David S. Myofascial Pain and Dysfunction, Vol 1: The Trigger Point Manual. Williams and Wilkins, Baltimore, 1983. pp.355-367.
11 Skjong CC1, Meininger AK, Ho SS. Tendinopathy treatment: where is the evidence? Clin Sports Med. 2012 Apr;31(2):329-50.
12 Hess GP, Cappiello WL, Poole RM, et al: Prevention and treatment of overuse tendon injuries. S p o r t s M e d 8 : 371–384, 1989.
13 Bondesen BA1, Mills ST, et al. The COX-2 pathway is essential during early stages of skeletal muscle regeneration. Am J Physiol Cell Physiol. 2004 Aug;287(2):C475-83.
14 Lu H1, Huang D, et al. Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury. FASEB J. 2011 Jan;25(1):358-69.
15 Arnold L1, Henry A, et al. Inflammatory monocytes recruited after skeletal muscle injury switch into antiinflammatory macrophages to support myogenesis. J Exp Med. 2007 May 14;204(5):1057-69.
16 Smith C1, Kruger MJ, et al. The inflammatory response to skeletal muscle injury: illuminating complexities. Sports Med. 2008;38(11):947-69.
17 Mishra DK1, Fridén J, et al. Anti-inflammatory medication after muscle injury. A treatment resulting in short-term improvement but subsequent loss of muscle function. J Bone Joint Surg Am. 1995 Oct;77(10):1510-9.
18 Cottrell, and O’Connor, P. Effect of Non-Steroidal Anti-Inflammatory Drugs on Bone Healing. Pharmaceuticals, Vol 3, No 5, 2010.
19 Magra M, Maffulli N. Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe. Clin J Sport Med. 2006 Jan;16(1):1-3.
20 Kerkhoffs GM1, van den Bekerom M, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012 Sep;46(12):854-60.
21 Vuurberg G1,2,3, Hoorntje A, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018 Aug;52(15):956.

Tennis Elbow

Anatomy and Injury

common extensor tendon
common extensor tendon

Tennis elbow (lateral epicondylitis) is an irritation of the outer layer of the bony lateral epicondyle (bone on the outside of the elbow) as well as of the common extensor tendon, specifically the extensor carpi radialis brevis.1-4  This injury is typically due to repetitive use of the muscles of the common extensor tendon that extend the wrist (bend it backwards) and that help stabilize the wrist during gripping motions.  Specifically for climbing, it can also occur through repeated finger flexion and gripping movements such as with face climbing, finger jams, the use of ice tools, and rope maintenance.  This is due to the wrist extensor muscles working to keep the wrist in a neutral position as the fingers are flexing.5,6         Tendon overuse injuries (especially when they have been around for 3+ months) are now more accurately called tendinosis, or in this case epicondylosis, rather than the previous label of tendinitis, or in this case epicondylitis, due to studies that have been done on the cells and tissues.  Instead of inflammatory cells, which would be found for tendinitis, the problem has been seen as a disorganization of the tendon tissues.  The disorganized tissues resemble a clump of cooked spaghetti on a dinner plate as opposed to healthy tissues organized in a parallel fashion like uncooked spaghetti noodles in a bag.  All of this is important because the treatment changes from targeting inflammation, which may not be present, to targeting the tissue disorganization.2,4,7-13

This is a very painful disorder that is felt with any gripping or grasping motions as well as with resisted wrist or middle finger extension and passive wrist flexion.  The pain is felt on the lateral epicondyle (outside of the elbow) and can radiate pain down the back of the forearm.  Grip strength is also typically decreased.7,8,14-16

Prevention

The keys to preventing this injury are:
1. Warming up properly:  For climbing specifically, roughly 120 moves or 4 routes/8-12 boulder problems of easy climbing is recommended before attempting climbing near your maximum level of climbing difficulty.17,18.  

2. Gradually ramping up training:  Has the climbing, or other related activity, increased significantly from normal frequency or difficulty?

3. Maintaining good flexibility by stretching the muscles that are being used:  Static stretching after climbing (or repetitive gripping motions) is the best time.  Hold the stretch for 30 seconds for 2-3 repetitions, 2-3 times throughout the day.

wrist flexor stretch
wrist/finger extensor stretch

4. Trigger Points/Myofascial restrictions:  Check for any trigger points (spots that feel tight or tender) at the end of the climbing day or after any activities requiring repetitive gripping/grasping motions.   Hold direct pressure on those spots for 2-3+ minutes.  Below are some options but feel for other spots in the surrounding area.

extensor carpi radialis brevis trigger point
extensor digitorum trigger point

5. Body awareness:  Is there any pain on the outside of the elbow during or after climbing or after any activities requiring repetitive gripping/grasping motions?  If so, consider modifying your activities so as not to continue to aggravate the injury.

 

Treatment

Much time and frustration will be saved, not to mention pain, by addressing the above symptoms as soon as possible.  A challenging aspect of tendon injuries is that they typically take longer to heal than muscle injuries.19  Due to the decreased blood supply to tendons in comparison to muscle and bone, tendons receive less “contractors and workers” to repair the damaged area.  This is a reason to not let this get out of hand and to cultivate awareness of any activities throughout your day that may be contributing to the symptoms.  A massage therapist once told me that switching from a squeeze bottle to a pump for her massage lotion/oils almost immediately cleared up a long bout of her tennis elbow symptoms.  Its amazing how seemingly minuscule activities can produce huge effects when they’re repeated a hundred times or more per day.

There have been 40 or so treatments studied for this injury!8,14,15  A few of the treatments that have shown the best results, are the most common, and can be performed at home will be discussed and described.  In the initial phase of healing, it is important to avoid making the injury worse.  This means listening to the signals the body is sending (pain) and allowing the natural inflammatory process to do its job of removing dead tissue, repairing damaged tissue, and laying down new tissue.  Crosier, Foidart-Dessalle, et al state that creating increased pain has been noted to slow healing progress with this injury.  They further note, “Our position is that pain must be interpreted as an alarm signal and that if the injurious effects of the repetitive motion continue, tendinous suffering may persist or even worsen.”20  On the other end of the spectrum, not using the arm at all, or immobilization, has been shown to decrease the healing progress as well, because it slows new tissue formation.20  Listening to the body and using pain as a guide will increase the ability to find the balance.  The first goal is to maintain range of motion in the elbow and wrist.

Some of the treatments that have been successful with this injury are:
1. Static stretching of the wrist extensors: 1,8,21  This stretching helps the new tissue being laid down during the healing process to line up in the proper way to allow the elbow joint to move without restrictions.  Hold the stretch for 30 seconds for 2-3 repetitions, 2-3 times throughout the day.

wrist/finger extensor stretch

2. Myofascial release: 4  (see “trigger points/myofascial restrictions” section above) Although the common extensor tendon and muscles coming from those tendons were specifically targeted in the research, it may help to also check for trigger points of the muscles of the common extensor tendon, extensor carpi radialis longus, triceps brachii, brachioradialis, supinator, and supraspinatus. Trigger points in these muscles can refer pain to the outer elbow.  The goal is to find any area that feels tight or tender and to hold direct pressure on those spots for 2-3+ minutes.

3. Eccentric strengthening of the wrist extensors:  It is suggested to start this after the acute phase (10 to 14 days) when the damaged tissue has been removed and the new tissue has been laid down. 1,8,15,20,22   With eccentric strengthening, as opposed to concentric strengthening, the muscle is actively contracting while it is lengthening. This type of strengthening is thought to increase tendon strength and, due to the muscle lengthening aspect, help the new tissue fibers that are being laid down during the healing process to line up properly.  Furthermore, the type of collagen found in healthy tendon (Type 1 collagen) has been found to increase and excessive tendon thickness found to decrease with eccentric strengthening.3,8,10,23,24

eccentric wrist extensor strengthening start
eccentric wrist extensor strengthening end

 

Concentric strengthening of a muscle is actively contracting the muscle while it is shortening.  This type of strengthening has been shown to be beneficial as well 3,7,8 however, the lengthening or stretching aspect does not occur as with eccentric strengthening.  Furthermore, eccentric contractions have been found to produce more force while requiring less oxygen and energy than concentric contractions and therefore will produce increased strength of the tendon with less waste products as opposed to concentric strengthening.11,25

4.  Other:  Various types of joint mobilizations/manipulations and taping have been suggested, some of which may be performed at home:9,16,26  Healthcare practitioners such as physical therapists, chiropractors, and osteopaths can evaluate the injury and provide instruction for these services, if appropriate.  Furthermore, other areas (shoulder, neck, etc) can contribute to elbow symptoms, which can be evaluated by a physical therapist or other practitioner familiar with optimal alignment and movement strategy evaluations.

An interesting note with this injury is that it typically resolves on its own within one year’s time.  Furthermore, although corticosteroid injections significantly decrease symptoms initially (the first 6 weeks or so), symptoms have been found to actually worsen and recurrence rates are higher compared to no treatment at all from 12 to 52 weeks.26,27

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

References:

  1. Wen DY, Schultz BJ, Schaal B, Graham ST, Kim BS. Eccentric strengthening for chronic lateral epicondylosis: a prospective randomized study. Sports Health. 2011 Nov;3(6):500-3.
  2. Nagrale AV, Herd CR, Ganvir S, Ramteke G. Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial. J Man Manip Ther. 2009;17(3):171-8.
  3. Raman J, MacDermid JC, Grewal R. Effectiveness of different methods of resistance exercises in lateral epicondylosis–a systematic review. J Hand Ther. 2012 Jan-Mar;25(1):5-25.
  4. Ajimsha MS, Chithra S, Thulasyammal RP. Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals. Arch Phys Med Rehabil. 2012 Apr;93(4):604-9. doi: 10.1016/j.apmr.2011.10.012. Epub 2012 Jan 10.
  5. Rooks MD. Rock climbing injuries. Sports Med. 1997 Apr;23(4):261-70.
  6. Moore K, Dalley A. Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, 1999. p. 746.
  7. Peterson M, Butler S, Eriksson M, Svärdsudd K. A randomized controlled trial of exercise versus wait-list in chronic tennis elbow (lateral epicondylosis). Ups J Med Sci. 2011 Nov;116(4):269-79. doi: 10.3109/03009734.2011.600476.
  8. Waseem M, Nuhmani S, Ram CS, Sachin Y. Lateral epicondylitis: A review of the literature. J Back Musculoskelet Rehabil. 2012;25(2):131-42.
  9. Shamsoddini A1, Hollisaz MT. Effects of taping on pain, grip strength and wrist extension force in patients with tennis elbow. Trauma Mon. 2013 Sep;18(2):71-4. doi: 10.5812/traumamon.12450. Epub 2013 Aug 13.
  10. Murtaugh B, Ihm JM. Eccentric training for the treatment of tendinopathies. Curr Sports Med Rep. 2013 May-Jun;12(3):175-82. doi: 10.1249/JSR.0b013e3182933761.
  11. Skjong CC1, Meininger AK, Ho SS. Tendinopathy treatment: where is the evidence? Clin Sports Med. 2012 Apr;31(2):329-50. doi: 10.1016/j.csm.2011.11.003.
  12. Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J. Bone Joint Surg. 2005; 87:187Y202.
  13. Bass, E. Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters. Int J Ther Massage Bodywork. 2012; 5(1): 14–17. Published online 2012 March 31.
  14. Stasinopoulos D, Johnson MI. Cyriax physiotherapy for tennis elbow/lateral epicondylitis. Br J Sports Med. 2004 Dec;38(6):675-7. Review.
  15. Viswas R, Ramachandran R, Korde Anantkumar P. Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial. ScientificWorldJournal. 2012;2012:939645. doi: 10.1100/2012/939645. Epub 2012 May 2.
  16. Vicenzino B. Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Man Ther 2003;8:66-79.
  17. Schweizer A. Sport climbing from a medical point of view. Swiss Med Wkly. 2012;142:w13688.
  18. Hockhoelzer T, Schoeffl. One Move Too Many… Druckerei Sonnenschein, Ebenhausen, 2003. p. 109.
  19. Holtzhausen LM, Noakes TD. Elbow, forearm, wrist, and hand injuries among sport rock climbers. Clin J Sport Med. 1996 Jul;6(3):196-203.
  20. Croisier JL, Foidart-Dessalle M, Tinant F, Crielaard JM, Forthomme B. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med. 2007 Apr;41(4):269-75. Epub 2007 Jan 15.
  21. Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med. 2013 Nov;47(17):1112-9.
  22. Tyler TF, Thomas GC, Nicholas SJ, McHugh MP. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. J. Shoulder Elbow Surg. 2010; 19:917Y22.
  23. Woodley BL1, Newsham-West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med. 2007 Apr;41(4):188-98; discussion 199. Epub 2006 Oct 24.
  24. Alfredson H1, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998 May-Jun;26(3):360-6.
  25. Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin Orthop Rel Res 1986;208:65–8.
  26. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: r andomised trial. BMJ. 2006 Nov 4;333(7575):939. Epub 2006 Sep 29.
  27. Smidt N, Van Der Windt DA, Assendelft WJ, Deville WL, Korthals-De Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002; 359:657–62.