Monthly Archives: June 2014

Improving Pain While Running by Changing Step Rate

29 Sunday Jun 2014

Posted by in Running

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jogging

It has been shown that increasing step rate during running will change the runner’s biomechanics.  These changes in the biomechanics of the runner will improve loading of the joints of the lower extremities… But what is an appropriate step rate while running?

I came across an article that examined the biomechanics of running at a runner’s preferred step rate to increases of 5% and 10% of their preferred step rate.  They showed significant improvements with most biomechanical parameters at a 5% increase in step rate with an even greater improvement at all parameters at a 10% increase in step rate.  If an individual is having lower extremity pain from a repetitive use injury such as patellofemoral pain due to running, a recommendation can be made to increase the step rate of the runner by 10% or to about 190 steps/minute (which was the mean step rate of the subjects in the study plus 10%).  In order to accomplish this pace you may count the amount of times the right leg contacts the ground in 30 seconds while running and multiplying it by 4.  Then they may increase that amount by 10% and try to maintain that step rate while running for about 2 weeks to observe changes in lower extremity symptoms.

(Click here for access to the article)

Effects of Step Rate Manipulation on Joint Mechanics During Running

Purpose: To characterize the biomechanical effects of step rate modification during running on the hip, knee and ankle joints, so as to evaluate a potential strategy to reduce lower extremity loading and risk for injury.

The study assessed 45 healthy adult runners who ran at least 15 miles per week and had been running for at least 3 months.  The participants were unable to participate if they had an injury to the lower extremity, a part lower extremity surgery, or pain with running.

The participants were studied running at their preferred step rate, +5% and +10% of their preferred step rate.

The examiners found as step rate increased by 5% and 10% the step length and variability in center of mass vertical movement decreased significantly.  They observed heel strike became closer to the center of mass which reduced the forward braking motion during the gait cycle.  All other parameters showed significant improvements at the 10% increase in preferred step rate.  They also found 20% and 34% less energy was absorbed at the knee with step rate increases of 5% and 10%; respectively, and there were significant reductions at the hip at the 10% increase.  Finally, they found that there was a decrease in hip flexion and adduction during loading response with a reduction in peak hip abduction and internal rotation moments at +10%.

The limitations of the study according to the authors are that the study only assessed the short-term and not the long term, the step rate count was prone to measurement error, and that testing was done on the treadmill so they cannot make inferences to overground running.

Take this recommendation on running modification with a grain of salt.  It may not work for everyone but the concept is to change the forces placed on the lower extremities and to help improve mechanics, reduce discomfort, and hopefully prevent future injury.

Patient Case – Chest Pain

22 Sunday Jun 2014

Posted by in Case Studies, Trunk

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This was an interesting patient case study.  I was wondering if I missed any special questions and what the origin of this patient’s symptoms.

Subjective: The patient is a 61 year old female with a chief complaint of right chest pain of insidious onset a couple years ago.  Patient states that her pain encompasses her right ribcage; from her clavicle to 12th rib and sternum to the spinal cord.  The patient mentions that the pain is 6/10 and feels as though there is a lot of pressure on her chest and similar to the feeling of someone having punched her.  Pt states that at its worst her pain reaches 10/10 and has gone to the emergency room due to the pain.  She mentions that the pain has been worsening and fears a flare up of 10/10 which occurred a couple years ago.  The patient states that the pain worsens with physical activity such as walking, stair climbing, etc.  She states that she feels her breathing increase dramatically, increased perspiration, and a rapid heart rate.  She mentions that the symptoms may linger for a couple hours after the onset.  She reports right sided cervical pain and a history of migraines, a history of right sided lower back pain and sciatica that started in 1999, and a left sided meniscal repair.  She states that there may be a correlation between the chest pain and her cervical pain but does not see a correlation between the chest pain and the LBP/sciatica.  The patient had MRI’s completed on the chest, x-rays, and blood work.  All tests were negative on abnormal findings.  She was referred with the diagnosis of right chest wall pain by a physician and was told by another physician that she has myofascial syndrome by another physician.  She mentions that she is on several prescribed medications (about 5-6 types) for pain management, cholesterol, blood pressure, etc.  She mentions that she would like to be weaned off of her pain medication and was prescribed another less strong medication and reduced the dosage of the stronger medication.  She went through physical therapy in the past and stated that she recalls receiving ultrasound to her chest which reduced her symptoms to manageable levels.  She mentions that she had a recent flare up of discomfort around the time of her meniscal repair surgery.  The patient lives at home and her three grandchildren are always present (males ages 19, 20, and 21) to help care for her.  She works as an accountant and will not be working for the next month due to symptoms.

Objective: 

  • Observation: Posture – forward head, protracted shoulders, hyperkyphotic upper thoracic spine, and limited lumbar lordosis; Breathing – paradoxical breathing (chest breathing only)
  • Palpation: Tenderness at right chest wall (unable to reach R1 upon palpation), cervical paraspinals, right upper trap, thoracic paraspinals, psoas, quadratus lumborum, and diaphragm.
  • Joint mobility: Not assessed due to hypersensitivity
  • Manual Muscle Test: Not assessed due to hypersensitivity
  • Neuro Exam: Not assessed due to hypersensitivity
  • Special Tests: BP = 131/82; no audible sounds of pulse in the abdomen, no rebound tenderness

Treatment:

  • Soft Tissue Massage: Left side-lying – thoracic paraspinals and right ribcage to R1; Supine – abdomen; all of which caused increases in discomfort
  • Deep Breathing: reeducation on breathing with one hand on chest and one on stomach which also became her HEP.

It seems to me that the patient is expressing signs of chronic pain.  Her sympathetic is in overdrive and causing her to be hypersensitive.  The side-lying soft tissue massage caused tearing of the eyes which is not so much due to pain but more due to her sympathetic system.  I plan to calm down her sympathetic system with more breathing reeducation, visualization, abdominal STM, foot rolling on lacrosse ball, and slight stretching.  I am concerned that there may be more going on with the patient such as a systemic issue even though she has been to 3-4 physicians for the problem and all medical tests were negative.  Are there other areas I should assess or special questions to ask?  Or am I on the right path and she is suffering from chronic pain?

Categorize Patients With Low Back Pain Based on Hip Rotation Range of Motion

17 Tuesday Jun 2014

Posted by in Low Back Pain

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I came across this article that I thought might be beneficial to help with treating patients with low back pain.  The idea is that people who suffer from low back pain have range of motion abnormalities elsewhere.  These abnormalities place stress on the lumbar spine.  I plan to use this article to help me understand that more common hip rotation range of motion abnormalities in individuals with lower back pain and assessing patients that I work with to see if they have similar findings.  Then trying to improve upon these deficits to speed up the recovery process.

Hip Rotation Patterns:

Pattern I: Total medial hip rotation equals total lateral hip rotation of both lower extremities and is broken down into two subcategories.

  • Pattern Ia: Left medial, left lateral, right medial, and right lateral hip rotations were all equal
  • Pattern Ib: Total medial hip rotation equals total lateral hip rotation but one or more of the ranges were unequal (e.g. left lateral, left medial, right lateral, right medial hip rotations)

Pattern II: Total medial hip rotation is greater than total lateral hip rotation

Pattern III: Total lateral hip rotation is greater than total medial hip rotation

Ellison JB, Rose SJ, Sahrmann SA. Patterns of hip rotation range of motion: a comparison between healthy subjects and patients with low back pain. Phys Ther. 1990; 70:537-541.

Purpose: 1. to describe the amount of hip rotation range of motion in healthy subjects and in patients with low back pain; 2. to categorize these individuals based on different patterns of hip rotation range of motion; and to compare the distribution of healthy subjects and patients with low back dysfunction in the range of motion pattern categories.

The authors discus the fact that low back discomfort doesn’t just come from dysfunction of the back but also can translate from adjacent areas such as the hip.  They focus on the idea of limited or excessive hip range of motion.  These abnormalities at the hip can cause cumulative stress and strain on soft tissue and bone.

The researchers measured the hip rotation ranges of motion of a little over 20 subjects in prone with the knee flexed to 90 degrees and while seated with a goniometer and an inclinometer.  They found that there was not significant difference between testing position or the use of a measuring device.  The researchers decided to use the prone position with an inclinometer to measure the subjects for the study.

They measured 150 subjects (100 healthy and 50 patients with low back pain).  They decided that equal ranges in motion would measure within 10 degrees of each other.  The percentages of subjects for each pattern were presented.

Pattern Ia: 27% of healthy subjects and 14% of patients with low back pain

Pattern Ib: 5% of healthy subjects and 8% of patients with low back pain

Pattern II: 41% of healthy subjects and 30% of patients with low back pain (most prevalent pattern for healthy individuals)

Pattern III: 27% of healthy subjects and 48% of patients with low back pain (most prevalent pattern for patients with low back pain)

They also found that the total left hip rotation (medial + lateral hip rotation) and the total right hip rotation (medial + lateral hip rotation) was equal in 78% of patients with low back pain and 94% of healthy subjects.

This research article shows that there is a significantly greater proportion of individuals suffering from lower back pain with greater total lateral hip rotation when compared to medial hip rotation.  They also showed that healthy individuals had a greater prevalence of equal hip rotation ranges of motion than did individuals with low back pain.

My recommendation for future research is to differentiate between low back pain diagnoses (e.g. stenosis, disc herniations, etc.), reduce the range for equal hip range of motion to <5 degrees which is the standard error for goniometric measuring, and to differentiate between female and male patients with and without low back pain (due to gender differences in normal hip ranges of motion).  The researchers had difficulty understanding if the abnormalities in hip rotation range of motion was due to low back pain or predisposes an individual to low back pain.

 

Core Stabilization Assisted with Ankle Dorsiflexion

06 Friday Jun 2014

Posted by in Trunk

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I find it difficult to assist patients with activation and improving core muscles.  I came across this article thought it would be beneficial to aid in core muscle activation and integrate movement patterns with core stabilization exercises.  I plan to use this treatment technique as a precursor to integrating more advanced proprioceptive neuromuscular facilitation (PNF) patterns and eventually to their home exercise program (e.g. supine marching, dead bugs, etc.).  Hopefully you will find this article helpful to draw a connection between static to dynamic core stability exercises.

(Click the link for access to the article)

You JH, Kim SY, Oh DW, Chon SC. The effect of a novel core stabilization technique on managing patients with chronic low back pain: a randomized controlled, experimental blinded study. Clin Rehab. 2014; 28(5): 460-469.

The study compared individuals in the control group who completed a core stabilization exercise that consisted of drawing in the lower abdomen and holding for 20 seconds, completing 10 repetitions, for 3 sets with individuals from the experimental group.  The experimental group also completed the previously mentioned exercise as well as another exercise with the individual in supine while holding ankle dorsiflexion against 30% of maximal voluntary contraction for 20 seconds, completing 10 repetitions for 3 sets.  The treatment was completed for 8 weeks and then progressed to drawing in the lower abdomen while simultaneously maintaining ankle dorsiflexion for the 20 sec x 10 reps x 3 sets.  All subjects had to maintain a blood pressure cuff at 40 mmHg that was placed at the lumbar spine (L5 region) during stabilization exercises.

The purpose of this article was to identify the effect of a core stabilization exercise on physical function, pain, and core stability in patients with chronic low back pain.  They based their research on the premise that voluntary control of core muscles is difficult and pain can cause inhibition of neuromuscular motor patterns.  Lumbo-pelvic core instability has been consistently identified as an important factor in chronic lower back pain.  Core stability is essential for rehabilitation of patients with low back pain and core instability.  The primary principal that they wanted to study was the idea of irradiation.

Irradiation is the spread and increase of muscle strength in response to resistance, possibly resulting from a stimulus-induced summation in muscle fibers.  

This will help to increase the number of motor units activated in a neuromuscular response.  The muscles that cause dorsiflexion of the ankle irratiate to the deep core muscles via proprioception neuromuscular facilitation.  The PNF flexion patterns primarily involve dorsiflexion, knee flexion, hip flexion, and flexion of the trunk with deviations of internal/external rotation and adduction/abduction at the hip.

Also, there is fascia that links the ankle dorsiflexors to the thoraco-lumbar fascia, which is the primary site of attachment of the abdominal muscles (e.g. transverse abdominis, internal obliques, erector spinae, multifidus, gluteus maximus, latissimus dorsi, and quadratus lumborum).

I hope this article is helpful to you and your patients that have difficulty transitioning from a static exercise to eventually a dynamic core stability exercise.