Onsite Blog

Core strength, abdominal training and the need to move efficiently (by David Nolan MSc).

I know this blog can seem to give core stability a hard time, but I think it’s a really important issue in long term pain problems, not just in back pain but sporting injuries from the elite to the weekend warrior!

In western society we have a certain view of how the abdominals should work and, more importantly, look. Much of this is driven by the fitness industry which tells us we need “killer abs” not only to prevent back pain, but to be attractive to the opposite sex! This drives beliefs that for any sporting injury or back pain we must have weak abdominals, and that these need to be trained in order to turn us into Olympic athletes............... is this really the case?

One problem with training the abdominals inappropriately and even cognitively contracting them (‘sucking in’ the abdominal muscles) is we then prevent any movement coming from our trunk. When we walk to generate momentum and make us efficiently our pelvis rotates, so when our left leg advances in walking and running our hip follows it slightly and the upper body rotates in the opposite direction. This movement around our pelvis creates kinetic energy by the ‘sling’ action that that helps the other leg move forward and this mechanism is the key to efficient movement. When the abdominals are overactive this movement is blocked so we can not rotate out pelvis. This lack of rotation compounded by our increasingly sedentary life styles as we spend longer at desks and in cars.

This creates a problem: the body has to generate is power from somewhere else and the legs have to overwork to create forward momentum. This can cause Achilles tendon, knee or hip pain due to inappropriately use. So if this describes you and pain is a long term problem and it is not resolving, you may need to look at how you move.

So next time you watch an running race, look at the runners at the front of the field and look at those towards the back, who is working harder with more muscle activity?......... it’s the ones at the back, the ones at the front are efficient and actually putting very little effort into running. Learn to rotate correctly and you will move more efficiently and even begin to develop your ‘six pack’ as rotation of the trunk is the key to activating abdominal muscles.

What's new in Parkinson's and rehabilitation? (Bhanu Ramaswamy)

The latest buzz around the management of Parkinson's is the availability of a cheap, new drug 'exercise'. Combined with strategies to help movement, there is some evidence emerging of the ability to physical activity, if performed at an appropriately high intensity to modify or slow the deterioration of the condition.

Parkinson's disease is thought to result from a combination of multiple genetic, environmental, and behavioural factors. Exercise / physical activity is just one potential method of positively impacting on one of these factors. The evidence about exercise being beneficial is still in its infancy, and most of it has been taken from the information from testing animal models which are experimented on to cause them to develop symptoms of the condition. As this is rarely how humans develop Parkinson's, some of the claims need to be taken with a pinch of salt. The evidence though is not to be dismissed, and is compelling.

Physical activity is often divided into light-intensity and moderate to vigorous activities. Examples of light-intensity activity (averaging 3.5 metabolic equivalents [METs]), includes walking and dancing; moderate to vigorous activities (averaging 4 to 7 METs), includes jogging or running, lap swimming, tennis or racquetball, bicycling (or using a stationary bike), and aerobics.
Not only is the uptake of sufficient intensity exercise (at least moderate, but better if vigorous) being shown to slow the condition over the period exercise is performed (no long term trials have as yet been undertaken), but there is also evidence of a reduction in the risk of developing Parkinson's if moderate to vigorous activity is engaged in early life. In the populations followed, such as Thacker's 2007 trial results looking to forecast cancer predictors in 63,348 men and 79,977 women in the Cancer Prevention Study II Nutrition Cohort from 1992 to 2001, and Chen et al in 2005 whose research team prospectively followed 48,574 men and 77,254women providing information on physical activity in 1986or in early adulthood, a 40% - 60% less risk of Parkinson's was found respectively in people who participated at the highest level of physical activity.

So basically, get exercising, as not only is it good for the heart and lungs, but appears to be of benefit in preventing the onset of other neurological degenerative conditions, or at least able to slow the progress if performed at a strong enough intensity and duration.

Watch two key note lectures about the benefits of exercise and Parkinson's from a Conference looking at both human and animal models at:

http://spring.parkinsons.org.uk/content/blogcategory/90/349/ (or directly from http://spring.parkinsons.org.uk/springdocs/NieuwboerPage.html for the therapy one and http://spring.parkinsons.org.uk/springdocs/ZigmondPage.html) for the animal model one.

Dentists, pain, physio and rehabilitation (Steve Hodgson PhD).

It may sound like divine retribution for inflicting pain on the general publics’ teeth, but dentists do experience high levels of musculoskeletal pain themselves performing this service. The figures vary but Rundcrantz in 1991 (http://bit.ly/bL33KU) reported that 83% of dentists stated some form of musculoskeletal pain with 72% reporting headaches. Another study conducted in Greece http://bit.ly/agZQKU by Alexopoulos (2004) found that 62% of dentists had one or more areas of musculoskeletal pain and 30% said that these were chronic. The latest review http://bit.ly/a2c91y by Hayes et al. (2009) reported even higher figures with a range of 64 to 93% of all dentists reporting some musculoskeletal pain. Back and neck pain were the most commonly reported problems with 36 to 60% and 20 to 85% respectively.

These statistics concur with my clinical experiences in the clinic as many dentists, and more ominously; dental students, seek help with chronic problems. Why are these professionals at risk? The main problem is the length of time they sit and the poor positions they gradually assume. Work by Ratzon et al. 2000 (http://bit.ly/a6XZIr) linked the prevalence of low back pain to time spent sitting. Those dentists that worked between sitting and standing reported less back pain. I agree that moving is a key to preventing low back pain in dentists, and everyone else, and they need to move between patients and exercise outside of work to increase their total movement quotient. There is no ‘perfect’ posture, but aim to keep moving frequently.

The other factor that is key to understanding the problems dentists face is the gradual asymmetrical positions they adopt in practising their highly skilled techniques. Their posture is dictated by the hand position and once this has been rehearsed and repeated thousands of times, the brains ‘neural signature’ is so well formed that the dentist often doesn’t know how to move from this posture even if they tried. This problem is compounded by the asymmetrical postures adopted, as most dentists have a dominant side. The repeated loading of the neck and back is towards one side and this further stresses the body.

In an ideal world dentists should be ambidextrous, so minimizing stress on the body by maintaining variability of movement, but most are unable to achieve this without losing considerable skill on their non-dominant hand. So what can you practically do? Learn to move differently when you are not working as a dentist. Don’t stay permanently flexed (often looking at the floor) when you leave the practice and don’t keep the right/left shoulder fixed in that unusual, but highly comfortable, position. You might work for 40 hours per week plus, but move differently when you are not at work and if you sit twisted predominantly to the right, rotate in the opposite direction frequently and encourage your body to do something different.

Why did David Beckham’s Achilles tendon rupture? (Steve Hodgson PhD).

Mr Beckham’s Achilles tendon, as with many professional footballers, probably started the long process of breaking down whilst practising on the school playing fields as a young man.
Research on the structure of Achilles tendons shows that it begins to demonstrate signs of degenerative changes from a young age in footballers. Most Achilles tendonitis is not "tendonitis" or inflammation of the tendon but degenerative changes within the tendon fibers. Additional trauma and even injections into the tendon would further accelerate the damage and this would leave the tendon weakened and vulnerable to rupture.
The final injury in a non contact situation was caused as the calf muscle contracted strongly and it snapped or ruptured. The catalyst to the injury was probably increasing training in anticipation of a final world cup competition.

‘Talking therapy’ and Low Back Pain: CBT and Research (Steve Hodgson PhD).
This was a large study conducted by Professor Lamb from the Universities of Warwick and Oxford . Patients were recruited to the study if they had low back pain for longer than six weeks and received either one session of advice or six sessions of cognitive behavioural therapy (CBT). Patients were assessed up to 12 months after starting the study and the conclusions were that CBT had a great improvement in disability and also patients in the CBT group were also more satisfied with the treatment they received.

This is an interesting study, but many national papers made the mistake of
reporting that back pain is ‘all in the mind’ ( http://bit.ly/b0TUqd). Back pain, like all pain, is perceived in the brain and psychological techniques such as CBT will modify behavior and, if this study is to believed, will provide long-term benefits to people with back pain.

However, from reading the brief abstract of the study, it has several potential problems regarding the methodology. First, the control group received one advice session compared with the six treatment sessions of the CBT group. This represents an unequal treatment allocation between the two groups and this is important as we know the more therapy people receive, the more likely they are to improve. This could be improved by giving the control six treatment of anything other than CBT and measuring the results at 12 months. Second, 37% of those patients allocated to the CBT group did not complete sufficient sessions to be included in the research analysis. This is important as it demonstrates people were probably not convinced of the benefits of CBT and therefore were unlikely to complete treatment. Also, most research studies aim to have a dropout rate of less than 20%; this study had a dropout rate of nearly double this (37%).

The improvement at 12 months of the control group’s disability was 1.1 points compared with the CBT groups, 2.4 points improvement. This represents a 1.3 .improvement in disability at 12 months on the Roland Morris score. This is a marginal improvement in level of disability which is probably of not clinical significant. More patients in the CBT group were satisfied with the treatment they received, but then again they did get more contact with the health professional than those in the control group. But when 37% drop out of the CBT group you have to wonder how satisfied were they with the treatment?

Overall, I do believe that a CBT approach should be incorporated into the rehabilitation of patients with low back pain, but I do not think this study provides sufficient evidence for firm conclusions to be made about the benefits the CBT. Combining CBT with a physiotherapy programmme aimed at the restoration of normal movement will, I suspect, reduce disability by clinically significant levels.

Trochanteric (Hip) Bursitis, Steroid injections and rehabilitation (Steve Hodgson PhD).
It's common for people to report pain around the hip following trauma, total hip replacement or for no specific reason at all. This is often diagnosed as ‘trochanteric bursitis’ which means that one or more of the small sacs around the hip joint has become inflamed and is painful. This has recently being challenged as scans and ultrasound have shown no specific lesion and the term Greater Trochanteric Pain Syndrome (GTPS) is probably a better description of the problem.

However, it is undeniable that people do experience hip pain and one of the common treatments is injection of a corticosteroid into the painful area. A recent paper published in the American Journal of Sports Medicine (http://bit.ly/85bVjn) demonstrated that people who had their hip injected with steroids had short-term improvement (one month), but at long-term follow-up (15 months), patients receiving a home exercise program or shock therapy had a significantly better results. The exercise group were 80% better at long-term follow-up compared with those that had the injection (48% better).

The author of the paper Dr. Jan Rompe, concluded that ‘the role of corticosteroid injections into the hip for trochanteric pain needs to be reconsidered’. I would agree with his comments as from my clinic experience injection does give short-term improvement, but over the long-term patients are often worse. The key to the problem with people who experience hip pain (or any other problem) is to find the source of the problem. The lumbar spine and hip joint will both produce pain over the bursa and health professionals often misdiagnose this as ‘bursitis’. I rarely see bursitis around the hip and as discussed in a previous blog, the problem is often misdiagnosed.

If you do experience pain around the hip find a physiotherapist will look at the cause as to why your experience pain and this may include how you run, walk, or sit. The hip is an incredibly repost joint and generally responds well to correction of faulty movement patterns and return to full activity.

Chronic elbow pain in climbers: is the problem really in the elbow? (Steve Hodgson PhD).
Elbow pain in climbers is a common problem, but one that remains recalcitrant to many forms of rehabilitation. From my experience many climbers have had their elbows massage, stretched, strengthened and finally rubbed with ultrasound and yet many symptoms remain. Why?

It may seem strange, and even radical, but the cause of many painful elbows has its origin not in the elbow, but the neck. There are two main reasons why you may have pain in the elbow, but the source of the problem is the cervical spine. First, the nerves from the lower cervical spine pass around your elbow and if you strain your neck these nerves may become sensitized and produce pain which you experience around your elbow. These are relatively easy to spot as the pain is often associated with pins and needles, loss of skin sensation and even muscle weakness (but not always). The neck problem could be a result of a specific trauma such as a whiplash injury, but the most common cause is climbers who spend most of their working days sitting at a computer. Holding poor postures for long periods of time will stress the lower cervical nerves and the symptoms may be experienced around the elbow.

Second, if the lower cervical spine joints stiff or stressed they can refer pain into the elbow, but without causing any noticeable neck pain. This cause is often missed during examination either because the neck is not examined thoroughly or it has not been considered as a possible cause of the symptoms in the elbow. You will still experience local elbow soreness and this is often over the tendons, but in reality the local pain is only referred pain from the neck.

Try this simple test at home and see if your elbow pain has its origin in your neck. Provoke your elbow symptoms by gripping or lifting an object (do anything that provokes your elbow pain) and then try changing your neck position (rotate either way or try looking up) while still provoking the symptoms. If the symptoms in your elbow change then consider that you may have a neck problem which is referring pain into your elbow. If this is the case, find a competent physiotherapist who has experience treating climbers and you may finally get rid of your elbow symptoms.

Finger Arthritis and Climbers: Is there a link? (Steve Hodgson PhD).
There is a general misconception that the more we use out joints, the more we are likely to damage them. Wrong! A paper published in 2006 by researchers of whom two were climbers, (http://bit.ly/FRH7d) helps to dispel this belief, as it compared arthritic changes in the hands of climbers (35 subjects) with those of a non-climbing cohort.
The hand x-rays were assessed by a Radiologist and they were unaware of which group the x-rays belonged. They assessed the hand joints for any changes that would suggest the early stages of arthritis and the climbers showed no significant joint damage compared with those of the non-climbers.
Interestingly, the climbers did show that the bones in the hand had a greater bone density, greater due to the normal adaptations of any tissue to increased load. Therefore form follows function. Progressively loading any joint will cause changes that reflect the normal use of that limb and providing the time taken to adapt to a new activity is not too short, then the joint will function well under the new task. The most harmful time for a joint is when the normal loads are removed or greatly diminished such as our increasingly sedentary life style. Keep climbing.

Stroke Rehabilitation – What is the answer? (Karen Hodgson MSc).
Currently within Physiotherapy there is a huge debate about rehabilitation following stroke and other neurological conditions. Should we be using approaches such as the ‘Bobath Concept’ (Meadows et al. 2009) or instead do what the Physiotherapists in the Netherlands now do, adopt a new evidence based guideline approach (Kollen B et al. 2009). Apparently medical science demands we seek the best approach (Damiano 2007) ....my question would be ‘ has anyone asked the patients?’ People with stroke and other neurological conditions place their care into our hands and it is extremely important that we offer them the best treatment possible, but do the patients want evidence based guidelines or a Bobath therapist? No. What they require is a thinking therapist who can relate to them and provide them with a rehabilitation programme that is realistic and appropriate to their needs. For each patient is an individual and we should not forget this: one so called best approach will not be suitable for every patient. Furthermore, there is a general lack of evidence regarding the best stroke rehabilitation and some of the research, so far, is not suitable for many patients (constraint induced therapy) or involves expensive equipment (treadmill training).
Our job as therapists is surely to recognise these differences and adapt our treatments appropriately. I agree wholeheartedly that using evidence is highly important in our decision making processes but we also need to exercise clinical judgement otherwise why do we have the training we do. As a physiotherapist I will continue to treat each patient as an individual and use a variety of methods to meet the goals of the patient as I do not believe there is now, or will be, one best approach to rehabilitation. I will review the evidence and adapt to my practice, but my clinical experience will remain central to this process.
References
Damiano D ‘Pass the torch, please’ Development Medicine and Child Neurology (2007) 49:723
Kollen B et al ‘The effectiveness of the Bobath concept in stroke rehabilitation. What is the evidence?’ Stroke (2009) 40:e89
Meadow L et al (editor) Bobath concept: theory and clinical practice in neurological rehabilitation. Wiley Blackwell, October 2009

Low back pain and clearing snow: the dangers! ( Steve Hodgson PhD)
Like many people for three weeks I have been clearing snow from both the drive outside the house and clinic car park. Any romantic notions you may have had about snow are soon dispelled after the first few tons of snow are shifted. Additionally, this is time that people come to the clinic complaining of back and shoulder pain resulting from clearing snow. For this reason I have posted a few notes about how to prevent hurting yourself during these winter months.

Fitness
If your idea of exercises is mainly confined to watching sports on TV or squeezing the toothpaste in the morning I would seriously avoid clearing snow. A cardiovascular workout is one that should be taken seriously, so if in doubt avoid it and throw yourself at the mercy of your neighbors.

Equipment
The fastest way of hurting yourself is by trying to clear snow using a garden spade. Lifting and twisting repeatedly from a low position is bound to cause some problem. Purchase a snow shovel preferable one with a long handle.

Technique
Repeatedly lifting snow will only cause you to strain your back as the cumulative effect will over load the spine from a flexed position. Try pushing using a long snow shovel and keep lifting to a bear minimum. If you do have to lift then avoid twisting the same way as this only produces point stresses on your body. Consider reversing a posture every ten minutes and if you spend a lot of time flexing, reverse this position by bending backwards. Remember it's always easy to move snow that has freshly fallen before it has been compressed into ice.

Stretching
We're constantly told that stretching is good for injury prevention, however there is really very little evidence to suggest that stretching reduces injuries. A gentle warm-up is best before taking any form of exercise and only stretch if you want to achieve a specific function such as ballet or kickboxing.

If you follow these few basic ideas you should remain reasonably fit during the winter months and if all else fails leave the snow where it is and stay inside and come out in spring!

Whiplash & Physiotherapy: Prognosis and Long-term Problems (Steve Hodgson PhD)
Evidence would suggest that 50% of people are symptom-free one year after a whiplash injury (http://www.pubmedcentral.nih.gov). This rate will vary for many reasons and even cultural beliefs about whiplash seem to influence recovery, for example, in Greece 90% of people are symptom-free within one month of their whiplash (http://www.ncbi.nlm.nih.gov/pubmed/10728446).

One factor in the long-term prognosis (or predicted outcome) is the presence of multiple symptoms and degree of pain post accident. If you experience significant amounts of pain following the injury and/or signs of nerve involvement (pins and needles, weakness or sensory loss in the upper limb) you are more likely to have ongoing problems at one year. Nerve damage is notoriously slow to recover, but can improve with the correct rehabilitation. Psychological factors also play a key role in the long-term prognosis of whiplash injury (http://www.pubmedcentral.nih.gov).

High levels of anxiety or depression will modify how you recover from any accident as people often become frightened to move (see Hallamshire Physiotherapy blog on ‘fear avoidance’ at http://blog.hallamshirephysiotherapy.com/) and this has a general effect on mood, behaviour and activity levels. If people adopt a passive coping strategy that involves prolonged periods of rest, avoiding general activity, time off work and over-reliance on pain medication, then rehabilitation will take longer. This is why it is crucial post whiplash injury to give clear instructions so as to reduce any anxieties that may exist and to begin an early activation program. In extreme cases some people have post traumatic stress disorders as they continually relive the accident and these people may need to see a Clinical Psychologist or a Cognitive Behavioural Therapist (see http://en.wikipedia.org/wiki/Cognitive_behavioral_therapy).

Compensation will complicate the picture as a system that provides payment based on level of disability and stress caused by the accident, discourages people to recover.

From my experience, most people just want to get better and I see many people who still have symptoms from a whiplash injury many years after their compensation claim has been settled. We may not be helping people recover by encouraging them to take out lengthy compensation claims as this may just continue to focus them on the problems.

Whiplash: Early Rehabilitation (Steve Hodgson PhD)
The next day you wake with a painful (and stiff) neck and possibly pain radiating into both shoulders. Additionally you may experience pain in your thoracic spine (between your shoulder blades and above your waist), lumbar spine and even into your head.

The key to the early phase of rehabilitation is to remain active and put controlled movements through your neck and upper body. Do not spend long periods resting and try to exercise your neck at least once every hour. Try to remain at work, but modify this according to the level of pain. If you have not already been prescribed medication by your Doctor, consider taking simple painkillers to allow you to move with some degree of comfort (see this site for further information on rehabilitation http://www.oxfordradcliffe.nhs.uk/forpatients).

Start by rotating your neck from side to side in a sitting position. If this proves too painful lie on the floor or bed so that the head is supported on the pillow when rotating to either side. Additionally, try to lift both arms above your head until a stretching sensation is felt in both shoulders. From sitting, try rotating your upper body to either side until you feel a gentle stretch across your ribs and upper spine.

Maintain your general activity by walking and try to swing your arms so as to gently stretch your body and maintain your cardiovascular status. Avoid any vigorous sporting activities until your range of movement has improved or seek advice from your Doctor/Physiotherapist (see this site for more details regarding treatment http://www.nhs.uk/Conditions/Whiplash/Pages/Treatment.aspx).

Progress this routine for the next few days and most people will be able to self manage the problem. If after two weeks you continue to experience symptoms see a physiotherapist who has experience in this field. If at any time you experience a flare up in your pain, reduce the exercises and consult a health professional.

If you have experienced a simple neck sprain avoid wearing a neck brace or other immobilization aid as this has been shown to delay recovery. Soft tissues and joints, even when damaged, respond to controlled movements as this stimulates tissue repair and healing. From all my years of treating people with whiplash injury the people that really struggled to recover usually have some degree of prolonged immobilisation, be that from a neck collar or from a fear of moving (see Hallamshire Physiotherapy blog on fear avoidance at http://www.blogware.com/admin/index.cgi).

Womens Health Physiotherapy at Hallamshire Physiotherapy
From the 1 October 2008 Alison Bourne MA BSc MSCP is providing the new service of Women’s Health at the Hallamshire Physiotherapy clinic. Alison is an experienced clinician with many years working both in the NHS and privately. She works closely with Mr Steve Radley, Consultant Obstetrician &. Gynaecologist at Sheffield Teaching Hospitals, who developed the e-PAQ (electronic Personal Assessment Questionnaire system) and Alison uses this in her initial assessment. This system allows the clinician to assess the patient and to evaluate the outcome of any intervention.

Alison is another dynamic addition to the expert team at Hallamshire physiotherapy and is also an expert panelist for the on-line ‘Babycentre’ web site that gives advice to women on a range of issues regarding pregnancy and giving birth (www.babycentre.co.uk/). She is committed to giving the best treatment to women about a range of conditions relating to Women’s health such as back pain during and after pregnancy, incontinence and antenatal advice (see web site/services for full listing of conditions treated).

As in common with all staff at Hallamshire Physiotherapy, Alison has a keen interest in developing and evaluating new treatments in her particular field, and next year starts a PhD at Sheffield Hallam University investigating the effects of low back pain during pregnancy.

Hip pain following Total Hip Replacement and Rehabilitation (Steve Hodgson PhD)
We see many people following a total hip replacement (THR) each year and they often ask why (see this site for an explanation and video about the surgery: http://www.nhs.uk/conditions/Hip-replacement/) they have pain in their 'new' hip. They have had pain for many years before the operation and walked with a poor gait pattern to try and maximise function. This is very common as we ‘limp’ to reduce stress on damaged tissue and this is a normal adaptation to a pain. After the operation they often feel much better and most people do not experience pain in their hip as soon as the effects of the surgery have reduced. However, some people experience considerable pain and this is first checked by the surgeon to rule out any possible post-operative complications (e.g. infection, fracture, loosening, dislocation).

Once serious pathology is excluded, patients are discharged once they have mastered the stairs and learned to function at home without excessively stressing their new hip. A large survey investigating 1231 patients who had a THR 12 to 18 months ago, 28.1% reported pain in the hip and 12.1% stated that pain had a moderate (www.ncbi.nlm.nih.gov/pubmed/) or severe effect on their ability to perform normal activities.

If you have compensated for the pre-operative pain by limping, you will continue to walk in the same way and this will stress the new hip joint and surrounding tissues. Hospital physiotherapy usually consists of getting you out of bed and practising the stairs and they often don't have time (too many patients in a short period of time) to re-educate your walking pattern. Physiotherapy aimed at restoring a normal gait pattern and teaching you how to activate muscles that have probably not worked for many years, quickly reduces the stress on the new hip, improves your balance and abolishes pain. Don't limp following your operation and seek professional help to maximise your new hip.

Stretching: does it prevent injury? (Steve Hodgson PhD)
The mantra that we must always stretch before exercise has been around for years. Is there any evidence stretching before exercise helps to limit injuries? In a word, no. In a systematic review by Small (2008) they concluded that there was “moderate to strong evidence that routine application of static stretching does not reduce overall injury rates.” The review included many research papers, but the most reliable randomized controlled trials showed no benefit to static stretching (www.library.nhs.uk/trauma_orthopaedics/).

By stretching before exercising we might actually be traumatizing cold muscles and produce more injuries. Additionally, from my experience many people are often too flexible and by further increasing muscle length, it might make them more vulnerable to injury. Another problem with stretching is relative flexibility. For example, if you try to stretch tight hamstring muscles, but your lower back is already very flexible you often find the stretch goes via the low back, thus further increasing its range of movement without addressing the tight hamstrings.

If after a long run or prolonged exercise you feel your muscles tightening up, maybe a gentle stretching programme could be useful after exercise. However, if you have a particular problem muscle group that always feels tight and sore then try to find a reason for the ongoing problem. For example, if you habitually run on your toes your calf muscles will tighten up in response to this stress. Don't stretch your calves but change how you run (run ‘heel-toe’ and roll over your foot) and the soreness will go and you will also run faster. Don't waste time stretching before exercise, but gradually increase the blood flow to muscles by doing your particular sport slowly for 10 to 15 minutes. Only after this time should you increase the intensity of the exercise and make allowances for how you are feeling, environmental temperature and age.

Maybe it’s about time we addressed this belief that stretching should be performed before exercise and begin to tackle the actual cause of the problem.

The brain that forgot how to move its shoulder (Dave Nolan)
I had a fascinating patient in the other day which really got me thinking, so I thought I would share this experience with you. A chap came to see me who had a fall whilst out walking in the hills. Soon after the fall his shoulder started to hurt and he lost all his movement in it. So, naturally being concerned he had damaged it, he went to his GP who arranged an x-ray, which came back all clear so arranged for him to see a Physio. However, his movement failed to return so the tests escalated and he was sent for a scan of his shoulder which again showed nothing.

One year later and still unable to move his shoulder he now presents himself at Hallamshire Physiotherapy. The interesting thing was that when you lay him down flat he has full range of motion in his shoulder, good strength and little problem......... So what was going on when he stood up?

Well, when you ask him to lift his arm he could barely move it from his side, why? When you looked at him trying to move his arm he took all his weight on his opposite leg and kept his elbow straight and he really looked like he was trying to move his shoulder. That's not how the brain or shoulder works. We are task oriented beings; hence the only function of the shoulder is to allow the hand to function. After a little thought, I placed a cup at shoulder height and taught him to first stand correctly and then move his arm whilst I guided his hand to the cup. Very quickly he was able to pick the cup up at shoulder height and within another ten minutes he had full range of shoulder movement. This chap had no serious problem with his shoulder, but his brain had forgotten how to use it.

This is a ‘learned disuse’ (read the work by Dr Edward Taub for more details http://bit.ly/6aRSpU) and is a common problem with many conditions. Repeated examinations and tests fail to reveal pathology, but your brain can learn immobility as much as can movement, especially after an injury.

Foot pronation and problems (Dave Nolan MSc)
What is pronation? When the foot hits the ground to absorb the shock, it rolls in. This is natural and really important to distribute the forces that act upon the leg. If you excessively pronate this can cause problems with the alignment of the leg.

The theory goes that if you put a big wedge in your shoe, under the arch then the excessive pronation can’t take place....... Indeed modern running shoes seem to be obsessed with putting something under the arch to support the foot. But, block pronation at your peril. When you block the natural movement of the foot you will compensate by gaining that movement somewhere else, be it the knee, hip or back potentially causing pain. The problem is not pronation, the problem is in what position the foot hits the ground and how well controlled pronation is. NOT pronation itself.

Pain, pain and more pain (Steve Hodgson PhD)
The eminent epidemiologist, Peter Croft,wrote an excellent article in the BMJ (www.pubmedcentral.nih.gov ) entitled: The epidemiology of pain: the more you have, the more you get. He clearly identified from current research the nature of pain and how with repeated exposure we learn pain and, unfortunately, experience more.

Some people are more vulnerable to the experience of pain and develop chronic pain both in the initial painful area, but also in places remote from the initial site. Others have better pain control mechanisms and are able to reduce their susceptibility to the formation of chronic pain. Additionally, the experience of pain does not match the degree of tissue damage and this is probably the reason why there is poor correlation between x-rays and the symptoms reported.

A new research paper has worryingly identified a correlation between how much pain a (http://www.ncbi.nlm.nih.gov/pubmed/19056799?dopt=Citation) person experiences and mortality. The research followed 4515 subjects in a large cohort study and recorded death rates against previously reported levels of pain and showed that people with widespread pain had a 30% increase risk of dying compared to those without pain.

The paper did not explain why this occurred, however we know that people with chronic pain also have high levels of disability and this will influence lifestyle and activity levels. The mortality rates were higher due to increased levels of cancer and cardiovascular disease. When somebody reports pain in the back, but also complains of pain in other sites, every effort must be made to ensure that the person receives optimal rehabilitation to limit disability and mortality.

Reflections on work and the problems with sitting (Dave Nolan MSc)
I have recently started working at a large company as the in house physiotherapist. The company has a large workforce with many manual workers and hence they see it as economic sense to employ a physiotherapist to ensure their staff remain fit and healthy.

The company has several thousand staff with about 70% of them in active jobs. The other 30% work in administration and are relatively sedentary. Since working there 80% of my time has been spent treating the office staff as many have neck and shoulder problems. These two areas are intimately related and affect each other strongly, so if you have had a stiff shoulder and it’s not improved by treating your shoulder then the problem might lay elsewhere. One of the down sides of increasingly deskbound work is the lack of the single most important factor that keeps our joints healthy: movement!

Lack of movement over a prolonged period of time leads to stiffness and it could be that your ‘shoulder’ problem actually originates in the neck and this is causing your problem. The moral to the story: try to stay as active as you can if you have to sit all day. Stretch your back and neck, move your arms above your head regularly and take breaks. And if you’re sedentary at work, try to move after work, even if it’s just a brisk walk home or even better get in the gym, go for a run, have a cycle or go to the pool.

Can we make individual muscles work? (Steve Hodgson PhD)
During a recent lecture given to a group of post graduate physiotherapists I happened to mention my general concerns about Pilates. One of the physiotherapists who practised Pilates, told me that the modern approach was to look at individual patients and match the prescribed exercises to their given problem. This is all well and good, but this is not generally my experiences with treating people with low back pain who are given exercises that require them to ‘suck in’ their stomachs and ‘squeeze’ their buttocks. This often results in patients who have a rigid trunk that are unable to move thus increasing the pain. Furthermore, their inability to perform these specific tasks only adds to their ‘fear avoidance’ and further compromises movement and reduces function.

Recruitment of specific muscles (motor control) for low back pain has been investigated recently by two authors and their results suggest that activating individual muscles is not superior to a general exercise programme (Ferreira, Ferreira and Latimer et al. 2007

http://bit.ly/DePDh, Akbaria & Khrashadizadeha (2008) http://bit.ly/4dOzOH). It is a very attractive proposition that individual muscle groups stop working when you have low back pain and you only need to learn to activate muscles again and hey presto: pain vanishes – wrong!

The brain works by movement and the best approach, like learning any new task, is to repeatedly perform a task and the brain selects the most appropriate group of muscles for the specific function. I am continually surprised by physiotherapists who attend courses in which they are required to activate muscles in the shoulder, hip or back and the vast majority complained they are unable to work specific muscles. If physiotherapists are unable to activate individual muscles, then how can we expect patients (with pain) to perform this unnatural task?

If you want an example of how complicated movement is and the range of factors that influence performance read this piece by Richard Schmidt on hitting a baseball (http://bit.ly/2f7Tro).

Knee Surgery versus physiotherapy (Steve Hodgson PhD)
The Daily Telegraph paper published on 12 September 2008 the results of a clinical trial that had compared arthroscopic surgery to physiotherapy in the treatment of the osteoarthritic knee, The conclusions were that “knee surgery to treat osteoarthritis maybe a waste of time and money”. The paper published in the New England Journal of Medicine randomly allocated patients with moderate to severe osteoarthritis of the knee into one of two groups. The first group received arthroscopic surgery, which included lavage and debridement (wash out of the knee and removal of any loose cartilage). The physiotherapy consisted of one session per week for twelve weeks and a home exercise programme that included gait re-education, the use of stairs and they were given an educational booklet on arthritis. The arthroscopic surgery group also received the same physiotherapy protocol and the treatment was assessed over two years.

The outcome measures indicated that the group undergoing arthroscopic surgery received no additional benefit than those undergoing active physiotherapy. These findings were corroborated by the 2008 Cochrane review that includes three other randomised control trials and they concluded that there is good evidence that arthroscopic debridement has no benefit for indiscriminate osteoarthritis.

Knee arthroscopy for the osteoarthritic knee is a common procedure and probably only delays recovery from on-going knee pain. There is clear evidence that physical treatments aimed at restoring normal gait patterns, strengthening the leg and re-educating the patient about how they use of a specific joint gives great benefits (www.wrw.interscience.wiley.com/cochrane/clsysrev/articles). Too many people leave their arthritic joint and are told there is nothing that can be done about it and in ten years time they will require a joint replacement. With an ageing population we cannot keep replacing joints, especially if these joints are amenable to simple rehabilitation strategies that work.

My experience from working at the Hallamshire Physiotherapy clinic suggests that at least 80% of those patients who present with osteo-arthritic knees make significant improvements and often return to their previous levels of function or status. The pain from the osteoarthritic knee is often not because the joint is wearing away, but that the joint has been abnormally stressed caused by altered movement patterns, fear of movement and a belief that nothing else can be done. Paradoxically, resting the joint only accelerates the joint damage as movement is essential for normal joint health.

Addressing these issues can make significant improvements and now we have research to support it. The next series of blogs will discuss management of osteoarthritic knees and what people can do to improve their particular problem.

Just tight hamstrings? (Dave Nolan MSc)
I’ve seen a number of chronic hamstring strains in the clinic recently, this being one of the most common muscles pulled in sport. If you have pulled your hamstring then a simple programme of R.I.C.E, stretching and a graded exposure to activity should see you back in action within 3 to 4 weeks.

However the hamstrings I tend to see are the repeated minor strains or chronic feeling of tightness. Deep tissue massage, sticking needles in them and stretching tend not to get these better, or only give short term relief at best, you need to look at why the hamstring is tight in the first place, if indeed it is tight at all. You do not need long hamstrings to run well.

When you look at the anatomy of the muscle it is easy to understand why it can complain from time to time. It attaches from the pelvis to below the knee and is active with the movement of the legs when running. But if that hamstring is also trying to stabilise an unstable pelvis it is asking too much of it and will be prone to strain. The muscle won’t relax until the pelvis is more stable. This doesn’t mean months of Pilates! But, normally a few sessions of looking at the position you use the pelvis in is enough to provide symptom relief.

There is also a nerve that runs through the muscle, and the hamstring will contract around the nerve in a protective response, wrongly giving the person the belief the muscle is the problem. This is normally dues to some stiffness in the spine or holding the back in the wrong position when you run, this can normally be changed quite rapidly.

Flintoff’s injuries and retirement (unlucky or predictable).
Last night I wrote on twitter that I thought Andrew Flintoff would not play for England again this season and following this mornings news that he is to retire from international test match cricket at the end of the season came as no surprise.

If you look at the list of injuries he has sustained over the last few years you end up asking is (www.timesonline.co.uk/tol/sport/cricket/article6713854.ece) he vulnerable to repeated injury or just unlucky? Clearly he is not weak and I suspect he has excellent tissue quality (I always tell people it’s important to choose your parents carefully!). So why does he suffer so many problems as many cricketers subject their bodies to this type of stress without missing matches?

After an injury you compensate, or adapt to the pain and this is often seen as an abnormal gait pattern or reluctance to fully weight bear through the affected limb (the same compensation occurs in the upper limb but I will only use the lower limb as an example). This is entirely normal, but if you continue to compensate you never fully recover and you are vulnerable to another injury. The problem may not be in the original area, but somewhere else, for example, if you damage your left knee there is a tendency to overload the right one which eventually becomes painful.

Addressing these faulty movement patterns is often not considered during rehabilitation and only leads to people thinking it's time to retire so as to maintain some function in later life. This situation does not benefit the sportsperson or the spectator.

The secret to a flat stomach (Steve Hodgson PhD)
If you spend any time on the Internet you will not fail to see adverts that promise to give you toned abdominal muscles with very little effort. This is plainly ridiculous and from my experience of working with people with lower back pain, the position they hold their pelvis is the main reason why they can not activate their lower abdominal muscles (this loss of control in their lower abdominal muscles might also contribute to why they have lower back pain) . Additionally, the person ends up with a small sagging stomach that no amount of sit-ups and purchasing of expensive equipment seems to resolve.

It is not possible to strengthen the lower abdominal muscles unless you can first learn to actively recruit the muscle. For example, if you stand with an anteriorly tilted pelvis (bottom sticking out) the lower abdominal muscles (fig.1) do not need to work to keep you against gravity as you compress your low back into extension and this, incorrectly, supports the lower trunk.

This position often causes low back pain as the lower vertebrae are repeatedly compressed and symptoms are often worse in standing or walking. To activate the lower abdomen muscles that person must learn to move the pelvis backwards (posterior tilt), but please note this is not part of the ‘core stability’ fallacy (the concept of ‘core stability’ is very fashionable and like many fashionable things incorrect). To learn how to posteriorly tilt your pelvis lie on the bed with both knees flexed and feet flat. Slowly begin rotating the pelvis backwards, but do not suck muscles in or perform a sits up and try to think ‘movement’ .

Once you have mastered this manoeuvre lying down, perform the same exercise against a wall until the pelvis moves backwards to a more neutral position. The lower abdominal muscles will become active as you perform this movement and within a few days you will notice that previously flaccid muscles will finally begin working. Do not be surprised if you experience muscle soreness in your lower abdomen after performing this exercise. You never know this might abolish it low pain and give you new abdominal muscles.

Why some people don’t recover following an injury (Steve Hodgson PhD)
Most soft tissue injuries recover and the ones that do are characterised by rapid improvement over the first 48 hours. Some injuries do go on to develop longstanding problems and these are the ones that I will discuss today.

For example, one year after a simple ankle sprain 5 to 33% of people still experience pain (see www.ncbi.nlm.nih.gov/pubmed/18374692 for details of a large systematic review of ankle sprains). Interestingly, up to 34% have another repeat sprain within three years of the original injury. Some of this can be explained by different degree of ankle damage, but many compensate for the injury and avoid using the ankle and changing the normal walking action. This leads to disuse and the control around the ankle is lost and further injury is highly likely. If the ankle is painful and the person thinks that walking will only cause further damage even after many months of an injury, then the normal stresses that injured tissue requires for recovery are removed.

This is why a person’s beliefs about their injury are so significant. The fear to move, and more importantly, the anticipation of pain even before movement occurs, is one of the main barriers to recovery (see the review article by Steven Linton for further information on this topic www.springerlink.com/content/374150v7n15x1138/). This fear is often a reasonable response, but even damaged tissues will respond to movement and recovery in many cases will occur with the restoration of normal function. This is seen daily at the clinic even with problems that have lasted for years. We have an amazing ability to recover, but we need the stimulus of movement for tissue repair and the goal must be return to function.

High levels of exercise and the arthritis myth (Steve Hodgson PhD)
A recent research paper by Dr Stehling and colleagues featured on the BBC health web site (http://bit.ly/4pOlWZ) suggested that “People with higher physical activity levels may be at greater risk for developing knee abnormalities.”

Should we believe these findings? This is a relatively small study and a better longitudinal study carried out over 18 years found that older runners (http://bit.ly/2pjknW) showed no signs of accelerated arthritis compared with a control group. It is always dangerous to scan ‘normal’ people who do not have symptoms as many changes are seen on a range of imaging modalities that do not correlate to symptoms.

If Dr Stehling had measured levels of pain in the cohort, I suspect the ones taking less exercise would report more pain. Why? Well joints need exercise and movement is beneficial and what you are seeing on the knee scans of the people taking high levels of exercise is tissue adapting to increased loads. Yes, some would argue this is damage and arthritis will ensue, but research has repeatedly shown we ‘rust out and not wear out’. The most dangerous thing you do with your knees is rest them under your computer or chain them to your car seat. A report on the BBC health website earlier this year (http://bit.ly/HwdYE) suggested that ‘running can slow the ageing process’ and that is probably a better take home message.

Core stability and low back pain: Does it work? (Steve Hodgson PhD)
After many years working as a physiotherapist you see many trends in the management of low back pain and the recent fad of strengthening the ‘core’ to prevent problems is a classic. The belief that a weak ‘core’ causes problems and that by strengthening specific muscles will abolish back pain is attractive as it is a simple explanation and is easily remedied. Wrong. Most people with low back pain have rigid trunks and are afraid to move. Educating them to ‘suck’ muscles in only compounds their stiffness and, more importantly, heightens anxiety levels and contributes to the pain experience.

I see many people who have had years of exercises aimed at strengthening their ‘core’ and they are often told to think ‘concrete’ when visualising their trunk. This does not help the back as over contraction of back muscles only loads the spinal joints further and gives more pain. The latest research evidence in the form of a systematic review (http://www.ptjournal.org/cgi/content/abstract/89/1/9) on motor control exercise versus spinal manipulation or general exercise, concluded that “Motor control exercise is not more effective than manual therapy or other forms of exercise.” A previous randomised controlled trial by Ferreira et al. (2007) http://search.pedro.org.au/pedro/browserecord.php?record_id=2853 only found improvement in the motor control group (‘core’ strengthening exercises) at eight weeks, but no difference at 6 or 12 months.

In summary, don’t waste your time or money sucking in trunk muscles, but concentrate on moving correctly. General exercises are great and remember to get as much variety as possible into your activities. If you can’t exercise because of back pain, find a physiotherapist who doesn’t ask you to activate individual muscles (we learn through movement: move correctly and the brain will work out which muscles are needed), but works out why you are still experiencing pain and gives you a plan of how you can return to full activity and normal function. Rapid improvements with the right physiotherapist are made within four to five sessions even with people who have had low back pain for over twenty years.

Mr and Mrs Core stability (by Dave Nolan MSc)
We seem to be in a revolution of “core stability” and “abdominal tone”. Indeed Transversus abdominis and the pelvic floor are commonly used buzz words in all gyms, with people looking at recruiting the “inner core”. Good, that’s back pain sorted, no more problems then.............. err no........ back pain is now a bigger problem than ever.

Long term back pain can be complex and multifactorial in nature. There are a group of patients that adopt positions and postures that do mean they are weak in Transversus abdominis and pelvic floor, but the way of turning these muscles on is not to consciously “pull your stomach in” ,but to adopt better positions and postures that allow these muscles to be activated. They do not need conscious recruitment.

Recently I have been seen a number of patients that fit in the opposite end of the spectrum. It is totally possible to be too “core stable” and over recruit all your muscles around your middle. When you do this you compress all the structures around your back and this can easily cause problems. Pain sensitive structures don’t like to be compressed! These people often sit upright, think they are “weak”, quite anxious about bending, done years of “core stability”..... is this you? You may well be too core stable.

How to prevent back pain when sitting (Steve Hodgson PhD).
A few weeks ago a patient who had been suffering from low back pain told me that his company had bought him a new chair at a cost of over £1000. The manufacturers claimed that the chair would prevent his backache and this company felt pleased that they were doing something positive for the employee. Unfortunately, the chair did not help his back pain and he resorted to getting his old chair from the skip and the new chair was pushed to the back of the office and from where it's probably gathering dust now.

The best way to prevent back pain when sitting, is to minimize time spent sitting; and when you do need to sit, the key is movement. Research by a colleague at Leeds Metropolitan University, Dr. Jamie Bell, measured the time people working in an office sat. Some people sat for many hours without standing or walking and these people were more prone to low back pain.

Despite the claims of chair manufacturers, the chair is not the most important factor when trying to prevent back pain when sitting. There is no evidence that the more you spend on a chair the less back pain you will experience so save your money and consider these more effective solutions:

• When you go home try increasing your exercise levels as this will balance the sedentary nature of your work.

Remember there is no ideal posture, but you should have an ability to move from a ‘neutral’ pelvic position (the mid way position between fully upright and slumped). If you sit perched on the edge of the chair with your back extended then try sitting at the back of the chair for some of the time. Conversely, if you sit ‘slumped’ in the chair try sitting upright for some of the time. Ensure your sitting posture has variability and movement.

Try these simple methods before you ask your company to buy you a fancy new chair and everyone will benefit.

Barriers to Rehabilitation (by Steve Hodgson PhD)
At the ancient Olympics the javelin competitors had to throw with both arms and the winner was the person who threw the best accumulative distance with both arms. Recently after talking to a badminton coach, the advantage that Asian badminton players have over Europeans, is their ability to push off equally with either leg. European players are more often one side dominant and this causes them to tire in the final games and this contributes to them losing.

The ancient and modern athletes recognised the importance of using all the body and this improved both performance and reduced injury. Many people have to use their body in stereotypical ways that repeatedly stress certain structures. For example: golf, climbing, running, using a computer or working in a flexed position over a machine. If we stress our body in certain directions repeatedly, then some people will develop problems. Variety of movement is crucial in preventing injury and that is why I ask patients to try reversing their golf swing or strengthen muscles that they don’t often engage (e.g. climbers strengthening the muscles that push their arms backwards).

If you are experiencing problems or just want to improve your performance in a sport or activity, consider the muscles you don’t routinely use and embrace greater variety.

Why some ankle sprains don’t recover (Steve Hodgson PhD)
A sprained ankle is a very common injury and approximately 18 to 30% people who sustain this type of injury will have chronic problems. The ligaments in the ankle are usually damaged when the ankle is inverted (the sole of the foot faces towards the middle of the body) and the soft tissues around ankle stretch beyond the normal elastic limits. After a few days limping and reduced function the ankle usually starts to improve within 48 hours and normal function is usually regained within 4 to 6 weeks.

Why do some people fail to improve after this time? There are many reasons for this and in the next few blogs I will begin to discuss each of the barriers to recovery with this common type of injury. The first observation from clinical practice is that when the ankle is damaged it is not just localized to the lower leg, but the hip on the damaged side is often involved. Work by Friel et al. in 2006, identified significant hip weakness http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1421486) in the leg that had sustained the sprained ankle. This hip weakness could be a consequence of spraining the ankle, however it could be a predisposing factor in explaining the ankle sprain. Whatever the cause, the resulting hip weakness reduces the person's ability to control the leg and subsequent re-injury may occur.

The best way to test if you have weakness or poor control around the hip is to try kneeling first on your injured leg and then try kneeling on the uninjured side (kneel on the floor on a pillow with your arms resting on the chair in front of you and slowly transfer your weight from one side to the other and compare your balance on either side). If you feel unsteady on the side you injured, you may have weakness around the hip and this may contribute to ongoing problems resulting in further ankle damage and the vicious circle continues. Practise balancing on your hip in a kneeling position twice a day for three weeks and I suspect your ankle will improve as the hip strength returns and the feeling of instability reduces. If not, see a physiotherapist who is recommended to you.

Ankle instability and rehabilitation: Potential pitfalls (Steve Hodgson PhD)
A few weeks ago I saw a young man who had repeatedly sprained his ankle (if you want more information on what to do if you sprain your ankle please refer to ‘Get back on your feet’ at www.squidoo.com/anklesprain) and suffered repeat sprains to his ankle on a weekly basis for over two years. He had seen several ‘experts’ and been given a rigid ankle support and a ‘wobble board’ (a large circular board with a small central cone that is designed to improve balance and therefore prevent further ankle sprains). Despite this treatment he still continued to sprain his ankle as the ligaments on the outer part of his ankle were damaged (grade 2 injury).

This is a common scenario and research evidence would suggest that exercise and treatment aimed at restoring balance and control of the muscles that act across the ankle are effective (see the recent review by Bleakley et al. at www.physiotherapy.asn.au). Surgery may be necessary (see the Cochrane reviw on treatment for ankle strains at http://fmweb01.ucc.usyd.edu.au/pedro/FMPro and Loudon et al. 2008 at www.ncbi.nlm.nih.gov/pubmed/18557658), but conservative management should be the treatment of choice and surgery should only be considered when this has failed.

So why did this person fail to respond to previous treatment? It failed because it did not understand that he had stopped walking correctly and compensated by looking at his ankle and the floor to maintain the correct foot alignment. If we damage an area of the body repeatedly, we don’t stop functioning we compensate and sometimes this allows us to continue to function normally, but it can ‘trap’ us into repeatedly injuring an area. Physiotherapy is more than giving a series of meaningless exercises to someone, but it’s the detailed analysis and its restoring movement that stops us damaging ourselves. People are not aware of how they have compensated for a particular problem as they learn this now faulty movement pattern and are always surprised as make them move correctly.

Use it: or lose it, but try to use it correctly and don’t perpetuate your pain and suffering.

The research by a Radiologist examined the knees of 236 people between the ages of 45 and 55 years and measured their level of physical activity and scanned their knees (MRI). They found a correlation between those people who participated in high levels of activity and the changes seen on the MRI of the ligaments, cartilage and other soft tissues. They concluded that these people would be at a greater risk of developing arthritis and should think about changing to swimming or other less stressful activities.

Should we believe these findings? This is a relatively small study and a better longitudinal study carried out over 18 years found that older runners (http://bit.ly/2pjknW) showed no signs of accelerated arthritis compared with a control group. It is always dangerous to scan ‘normal’ people who do not have symptoms as many changes are seen on a range of imaging modalities that do not correlate to symptoms.