March 13, 2015

Rehabilitating Adductor Magnus Strain

In a prior post, I mentioned that I developed an overuse injury while training for a half marathon. Specifically, the adductor muscles of the inner thigh, which act to stabilize the lower extremity during walking or running, got overworked and inflamed.

Luckily, researching to pinpoint exactly where the problem lay, I came across a wonderful resource that every runner should have in their arsenal of care. The Running Injury Oracle was able to identify the type of injury, and basic self care of the injury, such as rest, ice, stretching and massage (which just reinforced information and skills I already have at hand.)

Most importantly, they also give advise about safe return your sport, including exercises to prepare in order to avoid re-injury. And for a newbie to any sport, these same exercises, specifically core stabilization, should be mastered before the feet even hit the pavement. Thankfully, I did not have any trouble accomplishing this exercise. As a physical therapist, I teach this concept to my patients all the time, especially the low functioning ones. The theory is, that if your armature (yes, that's an artists term) is not firm or stable, basic movement is difficult or impossible. Our bodies are designed to stabilize through the torso before we attempt to move our arms and legs. Once you have awareness of core stabilization, you'll be able to feel it happening, even if you're simply reaching into the cabinet for a coffee cup.

The other test and exercise that is so important for runners, is pelvic stabilization. And here is where I was in for a shock. Upon performing the test, I could not manage it without either a handhold or putting my foot down. My supporting knee wobbles all over the place on both sides. It is no surprise, I was able to accomplish this test easier on the left side than the right. Given my history of compromise through the right SI joint, it makes sense that I don't have good pelvic stabilization. Without mastering those pelvic exercises (which basically is the pelvic stabilization test repeated) I have no business running or else I'll just re-injure myself. So even though I didn't plan to run the half-marathon, my training for it is over and a new training program has taken its place.

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March 12, 2015

Marathon Training and Overuse Injury

When I started training for a half marathon, I expected pain. And I've been proud of myself that I've been able to accomplish as much of the training as I have without too much difficulty. However, now I've been temporarily side-lined from training due to an inflamed adductor syndrome called Gilmore's Groin. I've never heard of Gilmore's Groin but I am familiar with overuse injuries which did no abate with continued activity. Luckily, there seems to be no rupture, so with rest, ice, stretching, and massage, I can rehab this injury myself.

While I'm disappointed to not be able to continue training, the silver lining on this event is the opportunity to research and review the biomechanics of lower extremity function and rehabilitation. I've always used this blog, not only as a resource to my massage therapy clients, but also a way to educated myself about a variety of conditions that massage therapy and now physical therapy can address. You might be thinking, "but you're a physical therapist, you should know all of this already." The bulk of my physical therapy experience is hospital-based, where I assist patients out of bed following a surgery or stroke. Out-patient physical therapists work more with ambulatory patients and those who are injured due to sports.

So, this is a good review of some education that is already 5 years old!! Not only that, it is one thing to know information didactically, and completely another to know it when applied. Experiencing a sport, and having pain inside your own body, is a different kind of learning yet again. Movement, and how it aggravates pain, and how you must compensate to avoid that pain, is information I can use to make me a better therapist.

One thing I will admit that I should have known, and I didn't listen, is to start slow. By pushing myself too quickly in order to adhere to a truncated training schedule, I could have predicted this. However, there were other things at play here. Remember, in a prior post on this topic, I gave a run-down of muscle soreness? It turns out that long-standing SI joint instability set me up for this kind of strain. And this is where the real learning about lower body biomechanics is useful for me as a therapist.

If the SI joint acts as a shock absorber for the forces that are transmitted between the upper and lower body, than it is crucial that joint be healthy. Having an adhesion where the psoas is stuck down on the iliacus, means that the pelvic stabilization needed in order to have optimal biomechanics for running, is compromised. The body has to compensate somewhere and that area of compensation occurred for me in the antagonist muscles to the gluteus medius and gluteus minimus. Those two muscles are responsible for balance in standing and hip extension that occurs in the lengthened position of running when the foot is out behind. Remember, too that gluteus maximus is a big strong muscle driving the body forward. The adductors work against all of those muscles, especially the adductor magnus, to act as stabilizers against hip extension and external rotation. Instability in that system logically indicates weakness somewhere, meaning muscles within that dynamic complex will be asked to work overtime or engage in activity they were not primarily intended to do, and an overuse injury occurs.

PT peers, please feel free to chime in here and enhance my education if there is a piece of the biomechanical puzzle I've missed. Knowing how muscles are supposed to act in one or two planes is a different than when we begin to examine how they work dynamically within a complex during weight-bearing and movement.

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March 11, 2015

Half Marathon Training: How Do You Feel?

Day 4 of my half marathon training is my first rest day. Thank goodness. I've been looking forward to my day of rest because everything is sore!

Right off the bat, about 1/3 of the way into my first run, I felt my right SI joint and then my right psoas muscle begin a back and forth conversation. I have a long history of SI joint instability, since before I started massage therapy school. Fixing the SI joint became an area of expertise while I was a massage therapist, but I've never been able to fix my own and keep it fixed. Healer, heal thyself! So when I got home, I went to work on myself, freeing a small lesion where my right psoas was stuck down onto the underlying iliacus muscle. Once the muscles, which act together for pelvic stabilization, could slide smoothly across each other, I had no more SI joint discomfort during my runs.

Running down hills (which was easiest for me on day 1 of training) is known to be hard on the knees. Thankfully, my knees feel fine. But my quadriceps, those big muscles on the front of the thigh, are sending me hate mail. Going down stairs lately requires a handrail for safety. And sitting down ... well, lets just say that investing in highboy toilets may be a good idea in future house renovation.

Tensor fascia latae, the muscle on the outside of the hips that give tautness and support to the iliotibial band of the legs, are complaining too. Lots of stretching and range of motion exercise helped to calm them down. Following the second run, they did not complain nearly as much.

The adductor muscles run all the way down the inner thigh of the leg. Because of the pattern of discomfort, I thought my sartorious was complaining, but sartorious is a weak muscle and plays little role in pelvic stabilization during activity. The adductor muscles line up perpendicularly right underneath sartorious. So, once I took my third run (another 5 miler) I realized it was ALL the inner thigh muscles that were complaining. Unlike tensor fascia latae above, they did not calm down with additional running, which means there is a problem Houston!

My next post: Investigating why my inner thigh muscles hurt so much and what I should do about that.

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March 10, 2015

Half Marathon Training: What to Eat Before You Run

Okay, I woke up sore today. Basically everything from the waist up is sore. And that's okay, it feels like I've done something. And the good news is that the 7 minute cross training workout is not too much for my legs. So, I'm ready to run.

I begin with a warm-up of walking: up hill. That gets the blood pumping a little. Then I alternate running and walking so I can actually get through 3 miles of "easy running." Ha! The only easy running for me is down hills. My endurance stinks. It's not so much the breathlessness and elevated heart rate, it's that I'm literally running out of energy.

What did I do run. I ran on empty. It didn't take much distance actually running before my knees started to knock. Live and learn. So what do the experts recommend that we eat before running and how far in advance so that there is no cramping?

I'm surprised by the answer. No high fiber food, which is my usual breakfast of nuts and seeds. Instead they suggest a banana and greek yogurt, followed by a half hour break to let the food get down into the digestive tract. So the next day when I went on my run, I ate a banana. I didn't have any greek yogurt yet, so I made the supermarket my destination (and my rest break). My intent was to run 4 miles despite the training guide's suggested 6, because I didn't believe I was ready to go that far. By going the long route to the store, I ran a total of 5 miles! And this run was much easier than the first one because I had adequate nutrition!! Lesson learned.

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March 9, 2015

Training for a Half Marathon

As I mentioned in my earlier post, I'm training for a half marathon. Day 1 of the training regimen suggests cross training for 45-60 minutes of moderate intensity exercise. Now I have a confession to make here. I'm lazy, and I don't think I'm alone. I come from a long line of couch potatoes, so motivating myself to get off the sofa has never been easy.

So to start my cross-training, I decided to perform the New York Times 7 minute workout. I did really well with this workout until I hit exercise #7, the triceps dip on chair. It kicked my butt! And here's why: The muscles of the lower body around the hips, the glutes and quadriceps, are huge compared to other muscles in the body. So activities such as walking, and even running, and cycling, do not drive the cardiovascular system to work as hard as if you were propelling your body weight with your arms.

If you look at our quadruped friends in the animal kingdom, their upper and lower body musculature is relatively similar, and their butt development is relatively underdeveloped compared to us humans. We are uniquely designed to walk upright on well developed legs and glutes with wimpy arms. It goes along with our genetic endowment of over-sized brains and language development and the ability to reason. Though I would argue that other animals have developed language systems that are more subtle and complex than we can imagine, they don't have libraries full of literature and poetry. Who knows, maybe they have an oral story-telling history similar to what humans had before the bible was written. After all, even racoons can train their young to break into a trash can with a bungee cord holding the lid down. But I digress down a line of thinking that drives me toward vegetarianism.

So, back to those wimpy arms. From a physical therapy standpoint, the way to quickly drive the cardiovascular rate up for people who are debilitated or confined to a wheelchair is with arm exercises, specifically upper body ergometry. This is basically upper body cycling and the reason it drives the heart rate up (great for cardiac rehab too), is that it uses the small muscles of the arms to drive the cranks. The small muscles can't do as the same amount work as efficiently as the large muscles of the lower body. So using your arms to help cross train is a great way to give your legs a rest and still get a great cardiovascular endurance workout.

And that's what happened to me. Exercise #7 targeted the weakest part of my body and drove my heart rate up. And the rest of the routine felt like I was at 80% of my exercise max. I was just proud that this couch potato was able to get all the way through the routine.

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March 8, 2015

4 Week Training Schedule for Half Marathon

After a winter of working 10 hour days where I get up in the dark, come home in the dark, and have little desire to exercise in the cold and the wet, I feel horribly out of shape. So I decided to start training, in spirit, with my sister for a half marathon. I'm not running that dog, just training for it.

This is a mission of love, because, frankly, I hate to run. But she needs to train and she needs a cheerleader and I need to get back into shape. So here is the training schedule:

Monday: Complete rest or cross training (45 to 60 minutes at an easy to moderate effort)
Tuesday: 3 to 4 miles easy running
Wednesday: 6 to 7 miles easy running*
Thursday: Off day or 3 to 4 miles easy running
Friday: Cross training (45 to 60 minutes at an easy to moderate effort)
Saturday: 3 to 4 miles easy running**
Sunday: Long run! (Starting at 7 to 8 miles, increasing by one mile each week, up to 10 to 11 miles the Sunday before the race)

*5 to 6 miles during week one, and 3 to 4 during week four. Andrew suggested dropping this if I was feeling intimidated or overwhelmed by the mileage.
**2 miles easy running during week four (aka the day before the race).

Yep. That's a 4 week training schedule because SOMEBODY procrastinated!

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August 2, 2014

Slow Gait Predictor of Cognitive Decline?

Motoric cognitive risk syndrome (MCR) is a newly developed diagnosis that incorporates cognitive symptoms without dementia and slow gait or impaired mobility. Analysis of data from 26,802 older adults indicates that decreased scores on standardized cognitive tests and a walking speed 1 deviation below norm for a persons age and sex, may be predictive of cognitive decline, such as Alzheimer's Disease.

Along with simple cognitive tests, analysis of gait speed using a stopwatch to time an individual walking over a fixed distance, has the potential to predict risk for cognitive impairment more than 3 years out.

Gait speed has a common metric, high reliability between different protocols, and excellent validity in predicting health outcomes, he noted. And, unlike neuropsychological, laboratory, and imaging tests that can detect predementia syndromes, gait speed testing is readily available and practical in most settings.

This means simple screening tests could be performed in third world countries and first world country poverty settings where resources are limited. It's simple and does not have to be administered by a doctor and be done in wide variety of settings, further keeping costs down. This would allow clinicians to identify high risk individuals and flag them for further investigation.

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July 6, 2014

Fitness an Indicator of Cardiovascular Risk

Fitness can be used to indicate cardiovascular risk in the long term, according to new research. The Cooper Center Longitudinal study used treadmill testing along with cholesterol, triglycerides, glucose level, personal history and smoking habits during a physical exam to determine an individuals risk for cardiovascular disease in 30 years.

As expected, traditional risk factors including age, systolic blood pressure, body-mass index (BMI), diabetes, total cholesterol, and smoking were associated with increased risk of CVD death.

But when data took into account the level of fitness, the importance of HDL associated with long-term cardiovascular risk fell away.

Take home message: We're designed to walk, and it doesn't take much to improve fitness. Just three 10 minute walks daily at a brisk pace can add years to your life.

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June 29, 2014

A Thorough Chart Review

A thorough chart review is a must before seeing patients.

A 95-year-old woman with a diagnosis of Transient Ischemic Attack was recently admitted to our acute in-patient rehabilitation ward. She was on my list for an initial evaluation. I collected a quick history, reviewed her lab values, and checked her imaging studies, such as radiographs (x-rays), CT scan, MRI. Her imaging study revealed that, indeed, she had a recent CVA (cerebral vascular accident or stroke) in the right parietal lobe of her brain. Other information was included in the imaging report, so I scanned it quickly and came up short. Included in the report was "a C1 subluxation relative to the dens."

C1 subluxation on dens is a red flag. What is means is that the very top vertebra in the neck has slid forward on the second vertebra indicating an instability in the top part of the neck. This is very dangerous situation because the spinal canal is narrowed, the supporting structure is unstable, and a wrong move could either paralyze the patient from the neck down requiring life support or instantly kill them.

I searched in the clinical notes for the MD response to this problem. It was not addressed in the problem list, nor was the imaging study flagged by the reading radiology department as critical. I checked with the nurse to see if the patient had a neck brace; she did not. I sounded the alarm to my colleagues, my bosses, the nurse manager, the on-duty physician's assistant. The patient was immediately put on hold, then transferred to medicine.

As a clinician, I always worry that I'm going to miss something important. With this patient, I caught something important. Later consultations with the neurology department found that the subluxation was extremely small and that the patient was stable enough for treatment.

Those of us in the medical field are said to "practice" medicine. Practice, practice, practice. Eventually, with experience, we become good at what we do.

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May 13, 2014

Schroth Method For Scoliosis

I was intrigued when I saw this article concerning scoliosis and treatment that would correct spinal curvature, even in some patients whose scoliosis has matured and stabilized. Not only did I have several adult massage clients with scoliosis, but I have a (very) small scoliotic curve in my thoracic spine. Each client required a different massage protocol to address their unique curvature pattern.

In a quest to help them, I researched websites, one of which even recommended nutritional support for scoliosis. I believe I have an old blog post outlining my efforts. In PT school, most of the focus on scoliosis was in treatment of children. So when I found the Schroth Method, something looked familiar from a resource I found in PT school. I remember wondering "what existing equipment available in a pediatric rehab gym would simulate the wall bars, and immediately thought of the True Stretch cage.

In my own case, my small thoracic curvature creates a rotation through my thorax toward my left side. This causes my right scapula to "wing" slightly. Functionally, I'm not really affected by my curvature, however, I do have some chronic neck pain. My right shoulder sits higher than my left, and I usually get neck pain on my right side. I've finally figured out a series of exercises to manage my neck pain, involving scapular retraction, anterior neck strengthening, and sternal lifts for postural improvement.

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May 1, 2014

Spinal Cord Stimulator Helps 4 Paralyzed Men Move

On vacation a couple of weeks ago, a free copy of USA Today had a headline that jumped out at me (proving that just because you're on vacation doesn't mean you really stop working): Spinal Cord Stimulator Helps 4 Paralyzed Men Move Again.

Most spinal cord injuries (SCIs) these days are partial, thanks to advances in early intervention following trauma that reduces swelling around tender nerves. This allows some electrical signals to travel up and down the nerves of the spine. But many older injuries resulted in total paralysis of the lower limbs which prevents any movement much less walking.

But new research has revealed that with stimulation, nerve signals can be dialed up to "loud" enough levels that the brain can communicate with the lower limbs. Don't break out your sneakers yet. The four men who have been participants in the research have achieved miraculous things such as voluntary movement, standing, and with body weight support, walking on a treadmill.

But the most exciting finding is in one patient who had total lack of movement and sensation:

Other impairments caused by Summers’ injury also began to improve over time, in the absence of stimulation, such as blood pressure control, body temperature regulation, bladder control, and sexual function.

The reason this is so exciting is that it a side-effect of paralysis is a phenomenon called autonomic dysreflexia that can be life threatening. What happens: an noxious stimulation below the site of injury such as a full bladder, undetected injury, uncomfortable position genitalia, will send signals via the autonomic nervous system pathways up to the brain. The brain will respond with fight or flight signals in an effort to correct the situation, but the signal never gets below the site of injury and a correction of the problem is not achieved. Distress signals continue to be sent up the system and overload can result in respiratory distress, shock, and even death.

As physical therapists, we are trained to recognize these signals of distress and train the paraplegic to recognize them too. Then we systematically search for a cause and try to correct the situation. For this reason, scheduled bladder emptying is crucial for SCI patients. The results of this research are profound for SCI and paralysis recovery.

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April 30, 2014

3-D "Osteoid" Cast

The future of broken bones is looking cooler, and, well, less itchy and smelly! Industrial designer Deniz Karasahin has developed a 3-D printed cast, which has holes that allow for ventilation and includes a low-intensity ultrasound generator to help bones heal more quickly.

Still in the development stages, Michael Hausman MD at Mount Sinai Hospital, thinks the cast has promise. Pulsed ultrasound, research shows, is found to reduce healing time by 38% and is especially useful to aid healing of non-union fractures by 80%. How cool is that?

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