Wednesday, October 29, 2008

Plyometrics: An important exercise

Plyometrics is basically any exercise that involves a dynamic shift from the absorption of force to the expression of force. A typical example would be two consecutive bunny (two-footed) jumps. On landing from the first jump the muscles of the legs, calves and ankles would be put on stretch (this is technically known as an ‘eccentric contraction’). They then transfer power, by way of a shortening muscular contraction (technically known as a ‘concentric contraction’).

Because sports science research proves that muscles are able to exert much more force when they perform plyometrically. It’s a bit like pulling out a spring to its fullest length and then letting it go. Immense amounts of energy will be released in the split second the spring recoils. Significant improvements are achieved by (1) boosting muscle and tendon strength, and (2) improving the neuromuscular activation of the response (basically, our brain becomes better at co-ordinating what is required).

Although our body naturally performs the plyometric action when required, this does not mean that our response cannot be improved. In fact the right training programmes can significantly boost both our power and speed i.e. dynamic performance.

Dangers of Plyometrics:
Because plyometrics is often misunderstood – or performed incorrectly – if one don’t know exactly which exercises to perform, and how to integrate them into his existing training programme, then he unlikely to derive any benefit. Even worse – he could injure himself.

Choline & Our Brain

Brain may be starving. It may lack a vital nutrient one need to think and remember. This vital brain booster is choline. Our brain uses it to make acetylcholine, one of your key neurotransmitters – the chemicals our brain needs to transmit signals and messages.
Acetylcholine is the neurotransmitter of memory and muscle stimulation. It’s responsible for muscle control, sleep, arousal, attention, memory, intelligence and mood. Your brain needs a constant, rich supply of choline to keep all of these functions going strong.
Without acetylcholine one can’t string thoughts together or have full access to memory. So you can imagine not having enough can lead to real problems. Forgetting keys, can be an early symptom of choline deficiency. Research shows people with a variety of mental illnesses are severely lacking in choline. The brain scans of people suffering from both mild cognitive impairment and full-blown Alzheimer’s showed these diseases are directly related to low choline levels.
Several recent studies found choline can slow and even reverse the onset of dementia and improve memory and attention. We’ve known for years that if our brain is starved of choline, it starts to “steal” choline from other sources, like your cell membranes. This process is called “auto-cannibalism.” When this happens your brain starts “eating itself alive” to maintain daily functions. But over time, the problems just get worse. It’s one of the reasons why you see a rapid decline in brainpower among older folks—and this process is behind the onset of depression, poor sleep, Alzheimer’s, and worse.
How to stop this from happening?
The first thing is to make sure you get enough choline-rich foods in your diet. Here’s a list for easy reference:
COMMON FOOD
CHOLINE CONTENT (MG/100 G OF FOOD)
Egg Yolk (raw, fresh)- 682.4
Eggs (whole, cooked)-272.6
Chicken liver (all kinds, simmered)- 290.1
Turkey liver (cooked, simmered)- 220.2
Pork (cured, bacon, cooked, pan-fried)-130.8
Spices (mustard seed, yellow)-122.6
Almonds-52.0
Cauliflower (cooked, boiled, drained)-39.1
Artichokes (cooked, boiled, drained)-34.4
Green peas (frozen, cooked)-27.6
Spinach (whole leaf, frozen, microwaved)-27.5
Red Cabbage (cooked, boiled, drained)-21.5
Source: USDA Database for the Choline Content of Common Foods, March 2004
Dosage:
Men need more choline than women per day, about 550 mg compared to 425 mg for women. But with increase in age the need of choline is more. Many experienced physicians advice older patients as much as 1,500 mg per day to get the maximum brain-boosting benefit.

Tuesday, October 28, 2008

Physical activity in the prevention and treatment of cardiovascular diseases]

Mirat J (2007)
Abstract....

Cardiovascular diseases represent the leading health problem of the modern age. They are the first cause of mortality in developed as well as in transition countries. Physical activity has a beneficial impact on the cardiovascular system, both directly by improving endothelial function and indirectly by normalizing risk factors of atherosclerosis, such as dyslipidemia, high blood pressure, obesity and by positive effects on coagulation mechanism. The impact of physical activity on the cardiovascular system is manifested by immediate changes in hemodynamics, blood pressure and heart rate during physical training. After some time, consequences of continuous training are manifested as a decrease in the basal heart rate, blood pressure and heart rate responsiveness to physical activity stress, which indicates good conditioning i.e. increased physical capacity. Prospective epidemiological studies have shown that sedentary style of life has a twice-higher risk of sudden death and cardiovascular mortality. Physical activity should be permanent to have positive effects on the cardiovascular system; it means 4 to 5 times weekly depending on duration and intensity of exercises. In case of exercises 60-75% of the maximum, duration should be 30 to 45 minutes. Evidence based data show a 20-25 % lower mortality rate after myocardial infarction in the patients submitted to rehabilitation program of physical exercises. Physical activity in patients with coronary artery disease must be individualized, quantified and under control. In subjects with impaired function of the heart muscle, physical activity is limited with characteristic symptoms - dyspnea and stenocardia. These patients are classified into groups with mild, moderate and high risk, and based on this the allowed intensity of their physical activity is assessed, as well as the grade of its control. Physical exercises must be without range of tolerance and must not exceed this limit of symptoms. The aim of physical activity and training is increasing threshold of tolerance of symptoms. It has been shown that physical training in controlled quantities decrease relative risk of mortality by 35% and hospitalization by 28% in chronic heart failure. Physical training is beneficial for all forms of heart failure in terms of decreased mortality and improvements of the muscle mass and physical status.

Causes of joint pain and stiffness in exercising population

There are a large number of possible causes of joint pain and stiffness, and the diagnosis of a particular problem can be a very complex process – just ask any physiotherapist!

Exerciser's lists causal factors:

1. Acute injuries: come on suddenly and are usually associated with some kind of trauma. Common examples include: Ligaments torn or damaged by unusual or excessive movement of the joint; Impact injuries: where one or more of the joint structures is damaged by an external blow; Protruding/prolapsed intervertebral disc: where unusual intervertebral forces lead to the deformation of the disc, allowing it to come into close proximity with nerves

2. Chronic injuries tend to come on quite gradually, thus making them trickier to diagnose. Common examples include: Overuse injuries, where the long-term training volume exceeds the capacity of the joints involved to undergo adequate repair and recovery

a. Muscle imbalance injuries, where the joint fails to operate through its correct range of movement because of unequal or unbalanced muscular forces acting on the joint, or (particularly in the case of the spine) inadequate stabilisation of the joint(s) by the deep postural muscles

b. Degenerative conditions are associated with longer-term, less easily reversible functioning of the joints and are much more common in mature athletes. These conditions frequently include: Arthritic-type wear and tear, where the articular cartilage becomes worn, leading to narrowed joint spaces, sometimes referred to as osteoarthritis, Rheumatoid arthritis, an inflammatory condition of the joints caused by an auto-immune reaction, Low synovial fluid secretions, leading to reduced lubrication in the joint capsule.

Common to all these causal factors is the process of inflammation. Although part of the normal healing process, it can actually impede this process when it becomes chronic.

Monday, October 27, 2008

The effects of PNF training on the facial profile.

Namura M et al (2008)


Abstract…….


Although orthodontic treatment improves dentoalveolar problems, the facial profile seldom changes because the perioral muscles do not easily adapt to the new morphological circumstances.


We employed proprioceptive neuromuscular facilitation (PNF), which is training with added resisted movement to motions such as lifting the upper lip, lowering the lower lip, and sticking out the tongue, to adapt the perioral muscles to the new morphological circumstances. The subjects were 40 adults with an average age of 29.6 years. A series of PNF exercises was performed three times per day for 1 month. Lateral facial photographs were taken using a digital camera before training (T(0)), after training (T(1)), and 1 month after the end of training (T(2)). The nasolabial (NL), mentolabial (ML), and mentocervical (MC) angles were measured, and linear measurements were taken to verify the change of each measurement point. In the test group, the NL and ML angles significantly.

Although the training appeared to be effective for sharpening the mouth and submandibular region, continued training is necessary to avoid relapse.

Effect of proprioceptive neuromuscular facilitation stretching on the plantar flexor muscle-tendon tissue properties.

Mahieu NN et al (2008)

Abstract…..

Proprioceptive neuromuscular facilitation (PNF) stretching programs have been shown to be the most effective stretching technique to increase the range of motion (ROM).
The objective of this study was to examine the mechanism of effect of PNF stretching on changes in the ROM. Sixty-two healthy subjects were randomized into two groups: a PNF stretching group and a control group. The PNF group performed a 6-week stretching program for the calf muscles. Before and after this period, all subjects were evaluated for dorsiflexion ROM, passive resistive torque (PRT) of the plantar flexors and stiffness of the Achilles tendon. The results of the study revealed that the dorsiflexion ROM was significantly increased in the PNF group (DeltaROMext: 5.97+/-0.671 degrees ; DeltaROMflex: 5.697+/-0.788 degrees ). The PRT of the plantar flexors and the stiffness of the Achilles tendon did not change significantly after 6 weeks of PNF stretching.
These findings provide evidence that PNF stretching results in an increased ankle dorsiflexion. However, this increase in ROM could not be explained by a decrease of the PRT or by a change in stiffness of the Achilles tendon, and therefore can be explained by an increase in stretch tolerance.

Sunday, October 26, 2008

Treatment of cervical degenerative disc disease - current status and trends.

Review of Korianth MC (2008)......
Although less frequent than lumbar degenerative disc disease, cervical disc disease may be much more neurologically compromising due to anatomical particularities. Since its first description together with the typical signs and symptoms the operative therapy of cervical disc disease has undergone a changeful evolution over the years. The frequent shifts of paradigms in treatment are particularly noticeable compared to other neurosurgical diseases. Initially, the dorsal decompression of neural structures (laminectomy) with a more or less invasive posterior approach (posterior foraminotomy) was the primary aim of the operation. Because of anatomical limitations, a paradigm shift occurred in the middle of the last century, favouring an anterior approach and discectomy, without and with implantation of various spacers (arthrodesis). A large variety of different materials and designs for these implants as alternatives to autologous iliac crest bone were established, all with the aim of creating a solid fusion of the operated segment. Anterior cervical discectomy and fusion (ACDF), regarded worldwide as the "gold standard" for the treatment of cervical disc disease, was later complemented by modified, minimally invasive or endoscopic techniques using anterior and posterior approaches. The fear of adjacent level disease in the vicinity of a fused cervical segment led to another paradigm shift in the last few years, away from fusing procedures, towards new motion preserving technologies (arthroplasty) and back to minimally invasive dorsal techniques for the treatment of cervical disc disease. This article reviews the evolution of the operative treatment of cervical disc disease in the last 80 years, outlines the advantages and disadvantages of each approach and technique and focuses on the rationale of the paradigm shifts. Current established and alternative treatment concepts are illuminated and discussed together with the currently relevant literature.

Saturday, October 25, 2008

KNOW MORE ON FITNESS TESTINGS IN THE CONTEXT OF ENERGY SYSTEM TESTINGS

please read my forthcoming book on obesity for fitness tests specially focsing on testing of different energy systems.

9- Fitness tests employed in Indian cricket team during the period of Gregory King as the fitness trainer.

1. Skin fold test.
2. Bib test
3. Sprint repeat
4. Bench press
5. Pull ups
6. Push ups
7. Sit ups
8. Sit & reach
9. Vertical jumps

Tuesday, October 21, 2008

Biomechanics of running & mechanics of shoes: PART I

This is part I of my forthcoming article on shoe mechanics & running biomechanics (may be published in this site within 10 days). this part introduces how a properly designed may help in reducing injuries, also how mechanical considarations may revolutionize the running gait biomechnics and the sunning sports?

The Human Performance Laboratory in Calgary, Canada, concluded that shoe design:

1. Increases rotational ankle movement, notably plantar flexion and foot inversion (particularly in the first half of ground contact)
2. Decreases ankle joint impulses for the knee joint, which means that the knee has to withstand fewer repetitive rotational stresses (27%reduction)
3. Increases the user’s oxygen consumption by 2.5%
4. Increases movement of the ‘centre of pressure’ during standing, which allows force to be dissipated across a greater area of the foot. (High forces going through small cross-sectional areas of the foot are strongly linked to an increase in injury incidence with repetitive foot strikes over prolonged periods.)

Based on these findings, the researchers report that the shoe strengthens the intrinsic muscles of the foot and ankle complex, while reducing loading through the ankle joint.

Know your Shoulder joint complex – The 4 in 1 joint

The shoulder joint complex comprises of following 4 joints:

1. Sternoclavicular (SC) joint - this is actually the only bony connection that the shoulder has with the main skeleton
2. Acromioclavicular (AC) joint- between the collar bone and the point of the shoulder called the acromion, which is part of the scapula or shoulder blade
3. Glenohumeral (GH) joint- between the glenoid part of the scapula - the socket - and the head of the humerus (HOH) - the ball
4. Scapulothoracic (ST) joint- the ‘false joint’ between the scapula and the rib cage that it rides over.

Monday, October 20, 2008

Nutritional Engineering: THE CONCEPT ANTI-AGING


One can play an active role in his own future by turning on the genes i.e. “Good Genes,” that promote longevity and turning off the genes that let cells die. This is very exciting news seems like science fiction but scientists are looking forward to this latest medical breakthrough.
Twenty years ago “longevity gene” was discovered. It’s activated by caloric restriction. Researchers found that giving mice reduced calories increased their lifespan dramatically. Later studies revealed this effect wasn’t limited to mice: Calorie-restricted diets produced similar results across the board, from single celled organisms to mammals.
Recently a family of life-protecting genes called sirtuins (“silent information regulator proteins”) ware found. Sirtuins serves conditions of severe stress. They transmit signals to every cell in your body that literally cancel out the effects of aging. The process leads to cell death to slow to a crawl, buying your body more time to repair the DNA damage that brings life to an end. This sounds encouraging but keep it is important to remember that for Sirtuins to work caloric restriction must be imposed, the amount of caloric restriction brings the daily calorie intake down to near starvation levels. Not exactly the kind of diet one can stick to. Scientists are trying to answer how to “activate” sirtuin genes without caloric restriction? to change the course of life safely and naturally.
Research inputs on nutrient resveratrol.
It is claimed by many scientists that with nutrient resveratrol one don’t have to starve to switch on the longevity gene.
What nutrient resveratrol can do?
Some of the good anti-aging genes are “switched on” with resveratrol. These genes do following actions:
Suppress aberrant cellular proliferation (for example prevents cancerous cells from multiplying)
Induce DNA repair (for example fixes damaged chromosome)
Enable insulin to assist glucose uptake into cells (normalizes blood sugar)
Facilitate production of beneficial high-density lipoprotein or HDL. (Ramps up good cholesterol…)


Some of the bad genes are “switched off” with resveratrol. These genes do following actions:
Boost production of potentially harmful low-density lipoproteins or LDL (creates more of the bad cholesterol)
Override normal patterns regulating cell division (cuts off your body’s ability to regulate healthy cell production)
Promote excess production of insulin and inflammation (causing fat gain, swelling and joint pain)
Resveratrol increase insulin sensitivity, help body burn and release fat and protect against high blood pressure, obesity and heart problems. Hence it lower blood sugar, probably the more correct way to normalize blood glucose.
It also enhance mitochondrial energy production, improved motor function, including balance and coordination!!! This last benefit is worth repeating… Resveratrol actually improves quality of life, by boosting physical abilities.

Sunday, October 19, 2008

Proteins in sports performance: More queries & few answers; part I

In ‘sports nutrition’ the first word that comes to mind is carbohydrates. That’s understandable. We all know how essential carbohydrate is to sports performance. But there’s another essential component of sports nutrition that’s equally important and that’s PROTEIN. Because protein is so much more than just an essential nutrient – it’s the largest component in the body after water, typically representing about 15% of body weight. What’s more, most of this protein mass is found in muscle, which explains the importance of protein to athletes.

However, while the basic biochemistry and functional roles of protein in the body have long been understood, there’s still a huge amount of mythology and confusion surrounding protein nutrition – especially where performance athletes are concerned. This is partly because of general misconceptions about basic protein metabolism, and partly because new research continues to throw up surprises about exactly what constitutes optimum protein nutrition! New research work in this area revealed by sports scientists is that protein is essential in conditioning, training, recovery, injury prevention etc.

Dietary Protein & role it plays in the human diet, further how protein metabolism works, and the particular importance and relevance of protein for sporting performance are the most important queries. Protein metabolism is in a constant state of flux i.e. although muscle and other tissues contain a large amount of stored protein, this protein is not ‘locked away’. So when dietary amino acids (the building blocks of protein) are insufficient, tissue protein can rapidly be broken down back to amino acid building blocks, which are then used to replenish the ‘amino acid pool’, a reservoir of amino acids that can be drawn upon to support such vital functions as energy production or immune function. This explains why muscle mass is often lost during times of stress, disease and heavy training loads, or poor nutrition. Conversely, when dietary amino acids are in plentiful supply and other demands for protein are low, tissue protein synthesis can become the dominant process. So it’s essential that we athletes maintain optimum protein status so we have the muscle mass we need to perform at our very best, regardless of our sport or event.

There’s more to protein nutrition than just eating the optimum amount; the timing of consumption and the type of protein selected can both impact on nitrogen balance; and there are a number of nutritional ‘co-factors’ that are either essential or useful in promoting optimum protein metabolism within the body. This is especially true where carbohydrate is concerned, because building or even maintaining lean tissue mass is an ‘energy-intensive’ process. Increasing protein intake at the expense of carbohydrate can be a bad strategy for athletes engaged in heavy training, because without sufficient carbohydrate the body simply switches to other fuels for energy, and amino acids from protein (particularly the so-called branched chain amino acids) provide a ready source of energy!

The Role of Protein in Recovery: How to maximise both the speed and extent of your recovery from strenuous exercise? One of the problems with making definitive recommendations about the timing of meals and drinks to enhance post-exercise recovery is the multifaceted nature of the components required for recovery. In broad-brush terms, there are four major nutritional requirements during post-exercise recovery:

Water – to replace fluid lost as sweat and to aid the process of ‘glycogen fixation’
Electrolytes – to replenish minerals lost in sweat (eg sodium, chloride, calcium, magnesium)
Carbohydrate – to replenish muscle glycogen, the body’s premium grade fuel for strenuous exercise, and also to top up liver glycogen stores, which serve as a reserve to maintain correct blood sugar levels
Protein – to repair and regenerate muscle fibres damaged during exercise, to promote muscle growth and adaptation, and to replenish the amino acid pool within the body.

To date, most research into performance nutrition has focused on the first three of these factors. But new research suggests a crucial role for protein.

A chemical imaging technique called radio labelling has enabled scientists to probe the uptake of ingested protein amino acids into muscle cells. The amino acid is ‘labelled’ by removing a normal hydrogen atom from the molecule and replacing it with radioactive hydrogen. This means you can see what happens to this molecule using scanners when a subject consumes a protein drink or food containing it. If you take a sample of muscle tissue and detect the presence of radioactive hydrogen, you know that the body has incorporated the amino acid into muscle tissues – that protein synthesis has taken place. These studies shed new light on various aspects of post-exercise recovery, with respect to protein’s particular role. When to take protein? What kinds of protein give optimal results and how to mix protein with other foodstuffs for best results?

A fascinating finding; ‘fast’ and ‘slow’ proteins.
This refer to the speed with which these substances are ingested and synthesized, ‘fast’ is not always necessarily better. Sometimes ‘slow’ proteins are needed.

The sports nutrition world is filled with high-tech products designed to make recovery as quick and as efficient as possible but we need to know something about the body’s principal nutritional requirements – particularly with respect to the role played by protein & how to go about restoring the body to a position of nutritional balance and using protein as a key part of that strategy.

Endurance Strength: how to optimise your protein intake and muscle mass for endurance. Endurance athletes face an interesting paradox when it comes to muscle mass. Bigger, stronger muscles generate more forceful contractions, resulting in higher power and greater speed. However, the weight of bulky muscles imposes greater demands on our limited energy stores, especially in weight-bearing sports. But as we all know, maintaining adequate sport-specific muscle mass is critical for optimal performance in endurance athletes. The question is: how to go about doing so to best effect? First we examine the issue of how much muscle an endurance athlete actually needs; various dietary strategies for building and maintaining muscle mass – from the perspective of an endurance athlete is mportant.

Using a protein-centred nutritional strategy to build optimal levels of muscle, reduce markers of post-exercise muscle damage and soreness in endurance athletes, and to improve performance in subsequent exercise is of prime focus now a days.

Proteins in sports performance: More queries & few answers; Part II

Questions on utility of proteins in sports nutrition.

A) Which groups of athletes are known to be at risk of eating insufficient protein – and thus undermining their sports performance? What, if any, are the REAL health risks of a high-protein diet? Which forms of natural protein work best – and which are largely a waste of your time and effort? How does the average athlete’s Recommended Daily Allowance (RDA) of protein differ from that of a sedentary individual – and are the various national and international regulatory authorities correct in the advice they post on their web sites? What’s the most convenient way to get the optimal amount of protein into your diet – without having to eat absurd quantities of foodstuffs? How can protein ingestion be used to accelerate post-exercise recovery –even following a particularly strenuous work-out? What forms of protein have been proven to reduce the perception of fatigue in endurance athletes, while improving mood and cognitive performance, when administered in a certain way? Which protein supplements are worth taking – and which may be more hype than anything else.

B) How much protein do athletes really need to optimise and maintain performance? Should any extra protein be ingested at the expense of carbohydrate, the body’s preferred fuel for high-intensity training? Are there really implications for athletes’ health of following a high-protein diet? (Certainly health professionals often express such concerns.) What do we now know about the protein requirements of athletes, relative to sedentary people? How can larger athletes, or those engaged in high volumes of training, get the amount of protein they need in their diet without having to consume absurd quantities of eggs and the like, daily?Why quality is more important than quantity?

Saturday, October 18, 2008

4-major nutritional requirements during post-exercise recovery


Water – to replace fluid lost as sweat and to aid the process of ‘glycogen fixation’

Electrolytes – to replenish minerals lost in sweat (eg sodium, chloride, calcium, magnesium)

Carbohydrate – to replenish muscle glycogen, the body’s premium grade fuel for strenuous exercise, and also to top up liver glycogen stores, which serve as a reserve to maintain correct blood sugar levels

Protein – to repair and regenerate muscle fibres damaged during exercise, to promote muscle growth and adaptation, and to replenish the amino acid pool within the body.

WHAT SPORTS PHYSIO'S KIT MUST CONTAIN

i believe that following are essential for a sports physio attending team & matches played by them.
1 x Crepe Bandage 7.5x4.5cm
1 x Zinc Oxide 2.5x10cm
10 x Waterproof Dressings
2 x Sterile Dressing 12x12cm
1 x Finger Dressing
4 x Big Plasters 10x9cm
5 x Double Sided Non-Adherent Dressing 5x5cm
6 x Wound Cleansing Wipes (Alcohol Free)
2 x Vulkan Ice Pack
2 x Vinyl Gloves Powder Free (Medium)
10 x Cotton Buds
1 x Swabs Sterile 10x10cm
1 x Triangular Bandage
1 x Skin Closures 3x75mm
1 x EAB 5x4.5cm
1 x Pet Jelly
1 x Resuscitation Shield
many other are mising from the list such as vapocoolant anesthetic sprays (magic sprays).

Friday, October 17, 2008

Alien abduction: a medical hypothesis.

Essentially my blog site is not covering any discussions like this. But I myself from my childhood am fascinated by alien abduction stories. I personally believe in alien theories. Let us discuss the current medical hypothesis presented by Forrest DV, M.D., Clinical Professor of Psychiatry, Consultant to Neurology (Movement Disorders) and Faculty, Psychoanalytic Center, Columbia University College of Physicians & Surgeons.
Abstract…
In response to a new psychological study of persons who believe they have been abducted by space aliens that found that sleep paralysis, a history of being hypnotized, and preoccupation with the paranormal and extraterrestrial were predisposing experiences, I noted that many of the frequently reported particulars of the abduction experience bear more than a passing resemblance to medical-surgical procedures and propose that experience with these may also be contributory. There is the altered state of consciousness, uniformly colored figures with prominent eyes, in a high-tech room under a round bright saucerlike object; there is nakedness, pain and a loss of control while the body's boundaries are being probed; and yet the figures are thought benevolent. No medical-surgical history was apparently taken in the above mentioned study, but psychological laboratory work evaluated false memory formation. I discuss problems in assessing intraoperative awareness and ways in which the medical hypothesis could be elaborated and tested. If physicians are causing this syndrome in a percentage of patients, we should know about it; and persons who feel they have been abducted should be encouraged to inform their surgeons and anesthesiologists without challenging their beliefs.

Stress management techniques: are they all equivalent, or do they have specific effects?

Lehrer PM et al (1994) evaluateed the hypothesis that various stress management techniques have specific effects. Studies comparing various techniques are reviewed, as well as previous literature reviews evaluating the effects of individual techniques. There is evidence that cognitively oriented methods have specific cognitive effects, that specific autonomic effects result from autonomically oriented methods, and that specific muscular effects are produced by muscularly oriented methods. Muscle relaxation and/or EMG biofeedback have greater muscular effects and smaller autonomic effects than finger temperature biofeedback and/or autogenic training. EMG biofeedback produces greater effects on particular muscular groups than progressive relaxation, and thermal biofeedback has greater finger temperature effects than autogenic training. Disorders with a predominant muscular component (e.g., tension headaches) are treated more effectively by muscularly oriented methods, while disorders in which autonomic dysfunction predominates (e.g., hypertension, migraine headaches) are more effectively treated by techniques with a strong autonomic component. Anxiety and phobias tend to be most effectively treated by methods with both strong cognitive and behavioral components.

Thursday, October 16, 2008

A discussion on adult lateral meniscus.

Lateral meniscus induced antero-posterior translational during knee flexion is 12 mm & it contributes to the congruence of the knee joint. Meniscal lesion does not mean meniscectomy and this is particularly true for the lateral meniscus. Following are some facts from Beaufils P et al’s review:
1. The rate of joint space narrowing after lateral meniscectomy is of 40% at a follow-up of 13 years compared to 28% for the medial meniscus (symposium SFA 1996).
2. Lateral meniscectomy must be as partial as possible. Particularly, a discoid meniscus presenting a complete tear should be treated by a meniscoplasty in order to shape the meniscus in a more anatomic form than a total meniscectomy. Lateral meniscectomy is indicated in complex or horizontal cleavage, symptomatic, on stable knees. Meniscal repair is highly performed when the meniscal tear is associated to a rupture of the ACL (simultaneous reconstruction of the LCA). Postoperative outcome is different of that of a "simple" arthroscopic meniscectomy. The healing process being slow, it suits to protect the suture by a splint in the first month, and with an exclusion of sports with knee torsion during 6 months.
3. Functional results and anatomical results are good in 77% of cases (symposium of the French Society of Arthroscopy 2003) at a follow-up of 55 months.

Changed Biomechanics of Knee after meniscus injury & effect of meniscus repair on knee Mechanics.

1. Posterior root of Medial meniscus: A vital area for knee
Injuries to posterior root of the medial meniscus are becoming increasingly recognized as a factor that can cause rapidly progressive arthritis.
2. Biomechanical changes after partial or total meniscus removal
Shoemaker SC et al studied the role of the meniscus in the anterior-posterior stability of the loaded anterior cruciate-deficient knee and effects of partial versus total excision on cadaver knee in 1986. The effects of progressive removal of the menisci on the anterior-posterior force-versus-displacement response of the anterior cruciate-deficient knee were studied in fresh cadaver specimens at 20 degrees of flexion without and with tibial-femoral contact force (joint load).
The findings are as follows:
1. In the absence of joint load, removal of the medial meniscus increased total anterior-posterior laxity and subsequent lateral meniscectomy produced an additional 10 per cent increase.
2. When a bucket-handle tear of the medial meniscus was removed, the application of joint load caused the tibia to displace (subluxate) forward on the femur. Subsequent removal of the remainder of the medial meniscus and complete lateral meniscectomy both produced additional smaller anterior tibial subluxations.
3. Changes in total anterior-posterior laxity due to progressive meniscectomy in the loaded knee were dependent on both the amount of applied anterior-posterior force and the level of compressive force.
3. Changes of contact area i.e. load bearing area after meniscectomy
The role of the meniscus in load transmission across the knee has long been a subject of debate. Baratz ME et al examined the biomechanical consequences of the operative treatments for bucket-handle and peripheral meniscal tears.
Contact areas and instantaneous intraarticular pressure distributions were measured in two groups of human cadaver knees.
In Group I, consisting of 4 knees, Baratz ME et al created a bucket-handle tear involving the inner one-third of the meniscus, followed by partial, and then total meniscectomy.
In Group II, consisting of 3 knees, Baratz ME et al created a 2 cm peripheral tear of the posterior meniscal horn, followed by open repair, arthroscopic repair, segmental, and then total meniscectomy.
Knees were tested in an Instron testing machine after each procedure to peak local contact stresses (PLCS) at various knee angulations with calibrated amount of exerted force.
Findings:
1. After partial meniscectomy, contact areas decreased approximately 10% and PLCS increased approximately 65%. After total meniscectomy, contact areas decreased approximately 75%, and PLCS increased approximately 235%.
2. PLCSs and contact areas were found to be the same using either repair technique.
4. Effect of meniscus repair on knee biomechanics:
Injuries to posterior root of the medial meniscus are becoming increasingly recognized as a factor that can cause rapidly progressive arthritis. Allaire R et al reported Biomechanical consequences of a tear of the posterior root of the medial meniscus are similar to total meniscectomy. This study demonstrated significant changes in contact pressure and knee joint kinematics due to a posterior root tear of the medial meniscus. Yet root repair was successful in restoring joint biomechanics to within normal conditions.

Wednesday, October 15, 2008

Modern sports training 2: Part I

Example of Exclusive Dynamic Power circuit workout by elite training coaches

“Whatever one’s sport or event - whether he is a cyclist, race-walker, runner, rugby player, swimmer, or a participant in racket sports, he’ll improve his strength, mobility and stamina through this following training plan. As a result, he will move much more powerfully in his sport.” The following plan has been fully field-tested. The basic training circuit is combined with ‘dynamic mobility’ exercises to form a well-rounded training session. It includes warm-up, mobility training, circuit work and a 10-minute cool-down and can be completed in an hour or less. The main points of the program are as follows.

A. Increasing the general work capacity:

Increase in the general work capacity helps in

1. To improve ability to tolerate increasing levels of muscular fatigue (stamina improvement)
2. To elevate heart rates to upgrade cardiorespiratory capacity (stamina improvement).
3. To enhance overall body strength, including the strength and resiliency of muscles, tendons, and ligaments, the integrity of joints, and the strength and density of supporting bone structures (strength improvement).
4. To improve movement skill and body awareness. Perform exercises that utilize body weight as the primary form of resistance (skill improvement).
5. To increase lean muscle mass by a moderate amount and decrease body-fat levels through high levels of energy expenditure (body composition improvement)

B. Dynamic Mobility-plus-Circuit workout training program:

Part I: Circuit training for muscle power

During the past few years, endurance athletes in a number of sports have added resistance exercises to their training programs to boost their muscle power. Scientific studies have linked resistance training with a reduced rate of injury in athletes. It fortifies leg muscles and strengthens ‘weak links’ in athletes’ bodies, including the often-injured hamstrings and shin muscles, as well as abdominal and low-back muscles. Resistance work also improves tendon and ligament strength and increases bone density, which decreases the risk of injury. In addition, resistance workouts:

1. Heighten body awareness
2. Upgrade coordination
3. Reduce body-fat levels
4. Improve self esteem

All of these contribute to improved performance during competition.

For athletes, the general preparation period before the beginning of actual competitions is an ideal time to initiate a resistance training program. A four to eight-week period of sound resistance training helps to develop a nice foundation of suppleness (mobility), strength, and stamina (endurance), to which athletes can add speed and racing skill just before the competitive season begins.

Circuit training is an excellent way to simultaneously build strength and stamina.

The total number of circuits performed during training session will vary from two to six depending on training level (beginner, intermediate, or advanced), period of training (preparation or competition), and primary training objective (You may be developing total work capacity, boosting your power, or engaging in ‘active rest,’ for example.)

The 8 exercises in a circuit in a sequential format provided in this training plan for each circuit, with an analysis of how it helps the athlete:

Total-body exercise: Four-count squat thrusts
Upper-body exercise: Push-ups
Lower-body exercise: Scissor step-ups
Core/trunk exercise: Abdominal sit-backs
Total-body exercise: Squats to presses
Upper-body exercise: Body-weight rows
Lower-body exercise: One-leg squats
Core/trunk exercise: Low-back stabilisers


1. Develop strength and mobility in knee and hip joints – important for high-speed movement. Develops stability and strength in the upper trunk, abdominal, and pelvic regions, strength that is necessary to control torso movements during the running stride or when you strike a ball. Greatly increases your cardiac demand, hikes the power of leg muscles, and increases the impact forces (upon landing) as well, fortifying the bones in legs and feet.

2. Increase upper-body strength, developing abdominal and hip-flexor stability. Improves stability, helps to control hip, trunk, and shoulder movements as one move quickly. Also promotes balance between the upper and lower body.

3. Develop leg strength, power, and dynamic-balance control (coordination), without which one can’t move quickly, whether it’s from one end of the football pitch to the other, from the baseline to the net on a tennis court, or from the start to the finish of a 10k race. Cardiovascular benefits of this exercise can be increased by speeding up stepping cadence or by increasing the height of the step. Enhances leg-muscle power and improves mobility of the hip and knee joints.

4. Increase abdominal stability, which carries over to improved posture and better core stability in running. A strong pelvic girdle and trunk provide the anchor point for a strong pair of legs, allowing use of legs in a maximally powerful manner during quick sprints – or during sustained, vigorous running.

5. Increase strength and power in legs, hips, low back, abdominals, shoulders, and arms. Note that the whole-body involvement of this exercise increases cardiorespiratory requirements, compared to the more commonly used, isolated pressing exercises such as bench and shoulder presses.

6. Improve pulling strength of the upper-back, shoulder, and arm muscles, and does for the back side of the body what the push-up does for the front side. Also serves to increase stabilizing strength in the low back, gluteals, and hamstrings, all of which are critically important for quick movement whenever one participate in a sport. One will achieve a balance between lower and upper body strength by performing this exercise.

7. Develop muscle strength in the quads, hamstrings, and gluteals, the muscles which provide much of power while running. By strengthening hip and knee joints in a coordinated and integrated fashion, leg strength and running power should improve tremendously. It can also help improve vertical jumping ability.

8. Heighten low-back strength providing for proper posture while running and also provides excellent ‘motion control’ of the torso and hips throughout the running stride. As a result, one will move more quickly – whether it’s to return a serve on the tennis court or to reach the football in time to score a goal.

Improvements in body functions occur whenever overload principle is applied to body’s systems. The circuit program described provides an overload of cardiorespiratory system (especially the hard circuits), taxes muscular system by forcing it to work against increased resistance, and forces the key joints involved in moving body to go through a wider range of motion than they commonly encounter.
The result, when combined with the Dynamic Mobility workout below will be better, more powerful performances.

Modern sports training 2: Part II

Part II: Dynamic Mobility workout

This second part of training contains pre-workout exercises to give a valuable boost to competitive performances. So why is this neglected area so important?

Quote

“What you do just before your workout begins can have a big impact on what you are able to do during your workout.”

Many athletes prepare for a training session by carrying out some routine stretching exercises, but it's important to remember that although stretching helps to improve static (non-moving) flexibility, it does not do a good job at preparing body to move quickly and efficiently. That's why current recommends focuses much on Dynamic Mobility exercises before every workout. Here are the facts:

Dynamic Mobility exercises prepare body completely for the vigorous movements that make up the main part of workout. Most sports involve forceful, strenuous activity, and mobility exercises and drills stimulate your nervous system, muscles, tendons, and joints in a very dynamic manner, unlike stretching. Static stretching exercises simply elongate a particular muscle or group of muscles. Their value and proper usage are often misunderstood. It’s best to do them at the end of your workout as part of the cool-down, not at the beginning of a training session. This is because they bring body back toward a state of rest and recovery and allow focusing on relaxing and lengthening the muscles that have put under stress during workout. Placing static stretches at the beginning of a training session interrupts the natural flow of an optimal warm-up and fails to prepare fully for the dynamic movements that follow.

Making the transition to high-energy activity
Dynamic Mobility exercises are designed to warm up, stretch, and keep moving as one makes the transition from resting to high-energy activity. Following are examples of 2 mobility trainings that are recommended during pre-workout warm-ups. Warm up will raise body temperature, increase blood flow to muscles, activate nervous system, and prepare one fully for mobility exercises - and for a strenuous overall workout.

Here are the 4 stages of the dynamic mobility exercises are:

Upper body mobility
Neck mobility
Trunk and shoulder-girdle movements
Lower body mobility

These exercises allow muscular and nervous systems to progressively adapt to the movements. The final result will be significant, functional increases in mobility.

Why one should attempt to expand the mobility of his neck and shoulders?

Training focus has changed over the years from local muscular training to training of global muscular system of body. For example despite the leg muscles being the 'prime movers' during actual workouts one must remember that whole body functions as a unit - a 'chain' of interrelated parts. As a principle the movements should flow from stabilized proximal joints.

For example, if shoulders are stiff, it won't allow a quick, fluid arm swing while running further without a proper arm swing, legs will slow down and the workout quality will drop.

Mobility and flexibility training has a cumulative effect over an extended period of time. After about 4 weeks or so, appreciable gains in mobility, flexibility and ability to move smoothly during training sessions are noticed in workouts and further it is reflected in competitive efforts.

Tuesday, October 14, 2008

Factors for knee injury in habitual runners

Running is a popular form of exercise all over the world. Many do it for fitness all through out the year. According to a USA based statistics 36 million Americans participate in running each year, with 10.5 million running at least 100 days per year. Although running injuries are well understood medically, their potential risk factors are not.
All behavioral and physiological risk factors influences potential knee injury mechanisms, including knee joint forces and knee moments.
According to research carried out by
Messier SP et al the most important factors for running knee injuries are due to increased knee loads. Larger knee joint loads are due to poor hamstring flexibility, greater body weight, greater weekly mileage etc. Most of these risk factors could potentially be modified to reduce joint loads to lower the risk of injury.

Cuboid "pseudotumour"

Oedema with erosion of the cuboid bone, simulating a bone lesion (cuboid "pseudotumour"), may be caused by adjacent tendinopathy of peroneus longus. It is vital to be aware of this entity to avoid unnecessary biopsy of the cuboid. O'Donnell P et al reported Cuboid oedema due to peroneus longus tendinopathy in acase series of 4 cases. The tendon and/or paratendinous tissues were abnormal in all cases, but no tendon discontinuity was identified. This highlights focal bone abnormality in the cuboid due to tendinopathy of the adjacent peroneus longus.

Monday, October 13, 2008

Modern sports training 1:

Increasing passive stiffness
In our bodies, the biochemical elements of the muscle-spring system are the protein titin (in muscle tissue) and collagen (in tendon tissue). The stiffness of these proteins determines the passive stiffness of our muscles and tendons, respectively.
The long-term objectives of ‘spring training’, should be to create shorter titin molecules and more cross-linked collagen to increase the passive stiffness of the muscles and tendons that make up our springs. For athletes and coaches, the important question is ‘can training produce these changes?’ The answer to this question is ‘yes’.
For example, training basketball players for eight weeks results in approximately 10% improvement in two measures of passive stiffness, which in turn translates into better jumping performance. This tells us that our springs can be stiffened with the appropriate training.
Increasing active stiffness
Increasing the passive stiffness of muscles and tendons is all well and good, but to gain a performance advantage, you need to translate that passive stiffness into speed. Turning passive stiffness into speed involves activating the muscles within the spring at the right time (increasing active stiffness).

Updates on tendon disorders

Certain tendons are particularly more vulnerable to degenerative pathology; these include the Achilles, patella, elements of the rotator cuff, forearm extensors, biceps brachi and tibialis posterior tendons.
Often tendonitis in above said conditions becomes chronic and can be difficult to manage successfully in the long term. Additionally the presence of neovascularization is now well-recognized in long-standing tendinopathy.
Current histopathological & imaging technique evidences suggests: tendonitis seen in the above said tendons are degenerative rather than inflammatory in nature.
Strategies loosing support:
Traditional treatments of anti-inflammatory (NSAIDs) strategies, which are often inappropriate.
Strategies gaining support:
In particular the advent of 'eccentric loading' training programmes has revolutionized the treatment especially of Achilles tendinopathy. This concept is currently being extended to include other commonly injured tendons.

Sunday, October 12, 2008

Chromium polynicotinate is also an anti-obesity agent!!!

There’s another natural substance that works in much the same way as HCA. It’s a micronutrient called chromium polynicotinate works for glucose metabolism. Like HCA, chromium polynicotinate operates against weight gain by throwing a number of genetic “switches.” In a recent animal study, scientists Roy et al found that it had the power to activate four muscle-specific genes that tell “pre-adipocytes,” pre-cursors of fat cells, to turn into muscle instead of fat. It also turned off two genes that make brown fat, the hardest kind of fat to shed. Even more interesting, chromium polynicotinate powers down the gene that provides antioxidant support to your fat cells. This means it literally accelerates fat cell death while letting other types of cells thrive.
The problem is most doctors and nutritional experts don’t know about them—or where to get them. There are a few supplements on the market that offer HCA and chromium polynicotinate in varying amounts. But it’s hard to know for certain whether you’re getting them in their purest form.

HCA in Tamarind an anti-obesity agent!!!

Most weight loss specialists don’t know about following fact
For centuries people in Indonesia, Asia, and Africa have used the Malabar tamarind to make food more filling. It works with your body to reduce appetite and shed fat, safely and naturally. The latest research by Francis et al confirms its hunger suppressing power. These Geneticists discovered that its active ingredient, hydroxycitric acid (HCA), actually switches on the genes that accelerate the breakdown of fat. It also switches off the genes that make you fatter. Researchers Rink et al took fat tissue from obese women and exposed it to HCA for two weeks. What they found HCA activated genes within fat cells that secrete several key compounds, one that breaks down fat and another that “starves” your fat cells of oxygen.
HCA also activate “leptin” which signals one’s brain that he has eaten enough. This means that one is shedding the pounds and feeling full without harming his body or altering its nutritional balance.

TRAINING TIPS: HOW DO SOME ATHLETES SUDDENLY IMPROVE THEIR PERFORMANCE TO WORLD STANDARDS?

If you have ever wondered how some athletes, having competed for years, suddenly improve their performance to world class standards the answer is latest training procedures adopted by them is similar to used by the world’s top athletes.
Following are few points of focus:
1. Exercises to increase strength, stamina, fitness and speed
2. Stop out-of-date exercise routines & getting involved with new scientifically approved training methods
3. Being specific & categorical: Why selective training techniques produce better results?
4. Relying on long, tough workouts (Hard workouts) to attain peak performance may not produce the results.
5. Understanding the coupling of neurological, biomechanical & muscular systems in exercise. This helps further to increase strength and power by altering the way one’s muscles are controlled by the nervous system.
Improving fitness, including one’s speed, endurance and work capacity, while at the same time enjoying the schedule and introducing variety into one’s regular routine is very much elemental for success.

Saturday, October 11, 2008

Heel pain and calcaneal spurs


Plantar calcaneal spurs are common, however their pathophysiology is poorly understood. In a Chinese study in 1996
Lu H et al reviewed 137 X-ray films of the involved feet in order to find out the relationship between the length, shape and the direction of the spurs with the heel pain.
Lu H et al found:
(1) There are no clear relationship between heel pain and the length, shape and the direction of the calcaneal spur.
(2) The plantar soft tissue of the painful foot was thickened, indicating the heel pain was due to inflammation in the plantar soft tissue.
(3) Heel pain is related to the patient's age and sex.
(4) The spurs still exist and grow even bigger after the syndrome disappears.
However one will always find few things very tricky. If spurs are thought to be produced by pull of tight planter fascia then why it is reported in the above study that there is no relationship between heel pain & direction of the calcaneal spur?
Controversy in Pathogenesis:
Vertical loading response leading to out crop of calcanal spurs: an opinion gaining support
1. We will follow a recent study by
Menz HB et al in 2008. in a study Menz HB et al tried to find out whether longitudinal traction or vertical compression that is responsible for out crop of a heel spur? They found Calcaneal spurs are common in older men and women and are related to obesity, osteoarthritis and current or previous heel pain, but are unrelated to radiographic measurements of foot posture. These findings support the theory that plantar calcaneal spurs may be an adaptive response to vertical compression of the heel rather than longitudinal traction at the calcaneal enthesis.
The stimulating factor for the development of heel spur (calcaneal exostosis) is controversial.
Li J et al (2007) reported in a sample of elderly cadaveric specimens, using radiographic, gross morphological, and histological investigation, that heel spurs are generally not found in the trajectory of traction from the plantar aponeurosis enthesis or plantar muscles. Rather, they are variably associated with soft tissues including loose connective tissue, fibrocartilage, muscle, and aponeurosis. Furthermore, the bony trabeculae of the spur are not aligned in the direction of soft tissue traction, but rather in the direction of stress on the calcaneus during walking and standing. These results substantiate the view that the heel spur may be a skeletal response to stress and may serve to protect the bone against the development of microfractures.

Heal spur as a result of traction of planter fascia: an opinion loosing support
2.
Kumai T et al reported spurs develop on the deep surface of the plantar fascia but their formation is heralded by degenerative changes that occur within it. According to differences between small and large spurs, we propose that there are 3 stages in their development: (1) an initial formation of cartilage cell clusters and fissures at the plantar fascia enthesis; (2) thickening of the subchondral bone plate at the enthesis as small spurs form; (3) development of vertically oriented trabeculae buttressing the proximal end of larger spurs. The spurs grow by a combination of intramembranous and chondroidal ossification.
However
Kumai T et al’s belief is contrary to popular belief (“subcalcaneal heel spurs cannot be traction spurs as they do not develop within the plantar fascia itself”). According to them heel spurs differs fundamentally from spurs in the achilles tendon i.e. heel spurs develop as a consequence of degenerative changes that occur in the plantar fascia enthesis.
Complication of heel spur
Heel spur leading to abductor digiti minimi atrophy (ADMA)
MRI studies reveal there is an association of atrophy of the abductor digiti minimi muscle, an manifestation of chronic compression of the inferior calcaneal nerve suggesting the clinical diagnosis of Baxter's neuropathy. MRI markers of potential etiologies, includes calcaneal spur formation, plantar fasciitis, calcaneal edema, Achilles tendinosis and posterior tibial tendon dysfunction.
Chundru U et al reported advancing age, calcaneal spur, and plantar fasciitis are significantly associated with atrophy of the abductor digiti minimi muscle. They further suggested a possible etiologic role for calcaneal spur and plantar fasciitis in the progression to Baxter's neuropathy.

Currently taping techniques are becoming popular with many clinicians specially physiotherapists & sports medicine professionals. Let us discuss a paper on effect of taping for calcaneal spurs.
Hyland MR et al of department of Physical Therapy, Mercy College, USA. did a RCT comprising of calcaneal taping, sham taping, and plantar fascia stretching for the short-term management of plantar heel pain. They found Calcaneal taping was shown to be a more effective tool for the relief of plantar heel pain than stretching, sham taping, or no treatment.
See the following URLs:
1.
http://www.youtube.com/watch?v=jKGDhxcdtzE (comprehensive)
2.
http://www.youtube.com/watch?v=J7rk2YaJZbo (quick learning)
3.
http://www.youtube.com/watch?v=XxVA5xaP3CI (part 1)
4.
http://www.youtube.com/watch?v=SsUQQVb3iE4 (part 2)


New modalities for recovery after exercises

1. Our very own DR. AG Sinha (PHD, PT) have shown that faradic stimulation can be used as a recovery modality after exercise. Those attending the IAP conference at Kolcutta had a chance to hear his PHD thesis based on this concept.
2. According to a study by Broadbent S et al in British journal of sports medicine Vibration therapy reduces plasma IL-6 and muscle soreness after downhill running. Hence as Vibration therapy reduces muscle soreness and IL-6; It may stimulate lymphocyte and neutrophil responses, and be a useful modality in treating muscle inflammation.
3. Curcumin effects on inflammation and performance recovery following eccentric exercise-induced muscle damage.
Curcumin, a constituent of the Indian spice turmeric has been investigated for its anti-inflammatory activity. In an animal study Davis JM et al of Division of Applied Physiology, Department of Exercise Science, Arnold School of Public Health, University of South Carolina, USA. examined the effects of curcumin on inflammation and recovery of running performance following downhill running in mice.

The findings ware:
a. Downhill running was also associated with an increase in inflammatory cytokines (24 h and 48 h) and creatine kinase (24 h) that were blunted by curcumin feedings.
b. These results support that curcumin can reduce inflammation and offset some of the performance deficits associated with eccentric exercise-induced muscle damage. How far the results of this study can be extrapolated to human beings is questionable.

Friday, October 10, 2008

Unspecific features that might be venous insufficiency & medical compression stockings

The cause of occasional pain in the legs of apparently healthy people is unknown. Some features of the syndrome reflect an emotional disorder while others mirror venous insufficiency.
Occasional leg symptoms, like feelings of heaviness and tension, and occupational or evening oedema are considered typical features of a venous disorder but have shown low specificity in epidemiological and observational studies.
Bl├Ąttler W evaluated the prevalence and nature of such symptoms in subjects with no history or signs of venous disease and investigated the optimal strength that medical compression stockings (MCS) should exert in order to alleviate the symptoms and to prevent leg swelling. They found MCS of 15 mmHg effectively relieve the symptoms resembling venous insufficiency, prevent oedema and are well-tolerated.

Eccentric Exercises in patellar tendinopathy.

A comparison of decline eccentric squats to standard eccentric squats:
Kongsgaard M et al in a recent study have shown excellent clinical results using eccentric squat training on a 25 degrees decline board to treat patellar tendinopathy.
To explore why therapeutic management of patellar tendinopathy using decline eccentric squats offer superior clinical efficacy compared to standard horizontal eccentric squats, their study compared EMG activity, patellar tendon strain and joint angle kinematics during standard and decline eccentric squats. This study suggested the use of a 25 degrees decline board increases the load and the strain of the patellar tendon during unilateral eccentric squats.
See the following URL for single leg eccentric exercise of Quads on a declining plane:
http://www.youtube.com/watch?v=wY98htXP0O4. Now when you have seen watching the video we will go through current researches on the topic.

Single-limb squats on a decline angle have been suggested as a rehabilitative intervention to target the knee extensors especially the single-leg squat on a 25 degrees decline board has been described as a clinical assessment tool and as a rehabilitation exercise for patients with patellar tendinopathy. However, differences in mechanical loading of the patellar tendon have been suggested as a reason for varying effects in rehabilitation of patellar tendinopathy using different eccentric squat exercises and devices.
The key thing is that several assumptions have been made about eccentric exercise’s working mechanism on patellar load and patellofemoral forces, but these are not substantiated by biomechanical evaluations. Investigators have not presented with any empirical research in which they have documented the biomechanics of these exercises or have determined the optimum angle of decline used.
How ever the following may be helpful for your clear understanding:
1. Frohm A et working on patellar tendon load in different types of eccentric squats demonstrated clear differences in the biomechanical loading on the knee during different squat exercises. Quantification of such differences provides information that could be used to explain differences in rehabilitation effects as well as in designing more optimal rehabilitation exercises for patellar tendinopathy.
2.
Zwerver J et al investigating on biomechanical analysis of the single-leg decline squat found single-leg squats at decline angles more than 15 degrees result in 40% increase in maximum patellar tendon force. In knee flexions more than 60 degrees, patellofemoral forces increase more than patellar tendon forces. They further suggested higher tendon load can be achieved by the use of a backpack with extra weight.
3. In a biomechanical investigation of a single-limb squat on declining angle
Richards J et al found; as the decline angle increased, the knee extensor moment and EMG activity increased. As the decline angle increased, the ankle plantar-flexor moments decreased; however, an increase in the EMG activity was seen with the 24 degrees decline angle compared with the 16 degrees decline angle. This indicates that decline squats at an angle greater than 16 degrees may not reduce passive calf tension, as was suggested previously, and may provide no mechanical advantage for the knee.
Surgical treatment compared with eccentric training for patellar tendinopathy: Evidences from RCTs
There are reports of superior clinical efficacy of decline eccentric squats in the rehabilitative management of patellar tendinopathy. Although the surgical treatment of patellar tendinopathy (jumper's knee) is a common procedure, there have been no randomized, controlled trials comparing this treatment with forms of nonoperative treatment.

Bahr R et al compared the outcome of open patellar tenotomy with that of eccentric strength training in patients with patellar tendinopathy. 40 knees who had been referred for the treatment of grade-IIIB patellar tendinopathy were randomized to surgical treatment (twenty knees) or eccentric strength training (twenty knees).
The eccentric training group performed squats on a 25 degrees decline board as a home exercise program (with three sets of fifteen repetitions being performed twice daily) for a twelve-week intervention period.
In the surgical treatment group, the abnormal tissue was removed by means of a wedge-shaped full-thickness excision, followed by a structured rehabilitation program with gradual progression to eccentric training. The primary outcome measure was the VISA (Victorian Institute of Sport Assessment) score (possible range, 0 to 100), which was calculated on the basis of answers to a symptom-based questionnaire that was developed specifically for patellar tendinopathy. The patients were evaluated after three, six, and twelve months of follow-up.
No advantage was demonstrated for surgical treatment compared with eccentric strength training. Eccentric training should be tried for twelve weeks before open tenotomy is considered for the treatment of patellar tendinopathy.

Diagnosis of Intersection syndrome & Dequervain’ tenosynovitis may pose challenge.

According to Parellada AJ et al distal intersection tenosynovitis of the wrist is a lesser-known extensor tendinopathy. Intersection syndrome is a condition that should be differentiated from DeQuervain's stenosing tenosynovitis, as there are many subtle differences in treatment and prognosis. Hanlon DP et al discussed intersection syndrome, describing its characteristic clinical and anatomic features in journal of emergency medicine. They highlighted differences in the areas of diagnosis and treatment relative to the better known DeQuervain's tenosynovitis.
Parellada AJ et al presented the MRI imaging findings of extensor tenosynovitis at the distal intersection or crossover between the second (extensor carpi radialis longus (ECRL) and brevis (ECRB)) and third (extensor pollicis longus (EPL)) extensor compartment tendons, and the anatomical details that may play a role in the pathogenesis of this condition. They concluded that distal intersection tenosynovitis may be related to the biomechanical pulley effect exerted by Lister's tubercle on the EPL tendon as it leaves the third compartment and crosses over the extensor carpi radialis tendons, as well as the constraining effect of the extensor retinaculum.

Key to diagnosis:
1. Site of pain presentation: intersection site which is proximal and dorsal to dequervain’s site of pain occurance.
2. Cyriax soft tissue tension.
3. Palpation for tenderness.

See the following URL dequervain’s disease:
http://www.youtube.com/watch?v=wiqpJpeYP-E

See the following URL for intersection syndrome:
http://www.youtube.com/watch?v=SyM-HCVHSrM

Tuesday, October 7, 2008

Tension myositis syndrome: A new thing to ponder!!!, A research topic!!!


This article is taken from wikipedia for the knowledge of physiotherapists & physicians who refer this site for updating their skills.
Tension myositis syndrome (TMS) is a name given by Dr. John E. Sarno to a condition he describes as characterized by psychosomatic musculoskeletal and nerve symptoms, most notably back pain. Sarno, a Professor of Clinical Rehabilitation Medicine at New York University School of Medicine and Attending Physician at The Rusk Institute of Rehabilitation Medicine at New York University Medical Center, has described TMS in four books, and has stated that the condition may be involved in other pain disorders as well. The treatment protocol for TMS includes education, writing about emotional issues, resumption of a normal lifestyle and, for some patients, support meetings and/or psychotherapy. In 2007, Dr. David Schechter (Sarno's former medical student and research assistant) published a peer-reviewed study of TMS treatment showing a 54% success rate for chronic back pain. In terms of statistical significance and success rate, the study outperformed similar studies of other psychological interventions for chronic back pain.
The TMS diagnosis and treatment protocol are not accepted by the mainstream medical community. However, TMS and Sarno's treatment methods have received national attention, including a segment on ABC's
20/20; an episode of Larry King Live; an interview with Medscape; and articles in Newsweek, The Seattle Times, and The New York Times. Notable patients treated for tension myositis syndrome include John Stossel, Howard Stern and Anne Bancroft. Author Richard E. Sall, MD includes TMS in a list of conditions he considers to be possible causes of back pain resulting in missed work days that increase the costs of worker's compensation programs.
Symptoms:
Back pain is frequently mentioned as a TMS symptom. However, Sarno defines TMS symptoms much more broadly than just back pain:
Symptom type: TMS symptoms include pain, stiffness, weakness, tingling,
numbness and other negative sensations, according to Sarno.
Symptom location: In addition to the back, Sarno states that TMS symptoms can occur in the
neck, knee and other parts of the body. Schechter states that the symptoms have a tendency to move to other parts of the body. He considers symptom movement to be an important indicator that the pain is from TMS.
Diagnosis:
Below is a list of criteria for diagnosing TMS, according to Schechter and Sarno:
Lack of known physical cause: Schechter and Sarno state that a physical examination, tests and imaging studies may be needed to rule out serious conditions, such as tumors. Sarno considers
spinal disc herniations to generally be harmless, because he says the symptom location does not correlate to the herniation location.
Tender points: While medical doctors use eleven of eighteen tender points as a diagnostic criteria for
fibromyalgia, Sarno states that he uses six main tender points to diagnose TMS: two tender points in the upper trapezius muscles, two in the lumbar paraspinal muscles and two in the lateral upper buttocks. He states that these are found in 99% of TMS patients.
History of other psychosomatic disorders: Schechter and Sarno consider a prior history of other psychosomatic disorders to be an indication that the patient may have TMS. They list
irritable bowel syndrome and tension headache as examples of psychosomatic disorders.
Schechter and Sarno state that if a patient is unable to visit a medical doctor who is trained in TMS, then the patient should see a traditional medical doctor to rule out serious disorders, such as
fractures, tumors and infections.
Treatment:
Treatment protocol
The treatment protocol for TMS includes education, writing about emotional issues and resumption of a normal lifestyle. For patients who do not recover quickly, the protocol also includes support groups and/or psychotherapy.
Sarno's protocol for treatment of TMS is used by the Harvard RSI Action Group, a student volunteer organization, as part of their preventative education and support program for people with
repetitive strain injury, also referred to as "RSI".
1. Education:
Education may take the form of office visits, lectures and written and audio materials. The content of the education includes the psychological and physiological aspects of TMS. According to Schechter, the education allows the patients to "learn that their physical condition is actually benign and that any disability they have is a function of pain-related fear and deconditioning, not the actual risk of further 're-injury.'"
2. Writing about emotional issues:
Sarno states that each patient should set aside time daily to think and write about issues that could have led to the patient's repressed emotions. He recommends the following two writing tasks:
Writing a list of issues. Sarno states that each patient should try to list out all issues that might contribute to the patient's repressed emotions. He suggests looking in the following areas: (a) certain childhood experiences, such as
abuse or lack of love, (b) personality traits such as perfectionism, conscientiousness and a strong need to be liked by everyone, (c) current life pressures, (d) aging and mortality and (e) situations in which the patient experiences conscious but unexpressed anger.
Writing essays. Sarno recommends that the patient write an essay for each item on the above list. He prefers longer essays because they force the patient to examine the emotional issues in depth.
Schechter developed a 30-day daily journal called "The MindBody Workbook" to assist the patient in recording emotionally significant events and making correlations between those events and their physical symptoms. According to Sarno and Schechter, daily repetition of the psychological process over time defeats the repression through conscious awareness.
3. Resumption of a normal lifestyle:
To return to a normal lifestyle, patients are told to take the following actions:
Discontinuation of physical treatments - Sarno advises patients to stop using
spinal manipulation, physical therapy and other physical treatments because "they tend to reinforce erroneously a structural causation for the chronic pain."
Resumption of normal physical activity - Schechter states that patients are encouraged to "gradually be more active, and begin to resume a normal life." In addition, patients are encouraged "to discontinue the safety behaviours aimed at protecting their 'damaged' backs".
4. Support meetings:
Sarno uses support meetings for patients who do not make a prompt recovery. Sarno states that the support meetings (a) allow the patients to explore the emotional issues which may be causing their symptoms and (b) review concepts covered during the earlier education.

5. Psychotherapy
Sarno says that about 20% of his patients need
psychotherapy. He states that he uses "short-term, dynamic, analytically oriented psychotherapy." Schechter says that he uses psychotherapy for about 30% of his patients, and that six to ten sessions are needed per patient.
6. Effectiveness
A non-peer-reviewed 2005 study by Schechter at the Seligman Medical Institute (SMI), co-authored with institute director Arthur Smith, PhD, found that treatment of TMS achieved a 57% success rate among patients with chronic back pain.
A peer-reviewed 2007 study with Schechter, Smith and Stanley Azen, PhD, Professor and Co-Director of
Biostatistics in the Department of Preventative Medicine at the USC Keck School of Medicine, found a 54% success rate for treatment of TMS (P<.00001). The treatment consisted of office visits, at-home educational materials, writing about emotional issues and psychotherapy. The average pain duration for the study's patients was 9 years. Patients with less than 6 months of back pain were excluded to "control for the confounder that most back pain episodes typically resolve on their own in a few weeks." Schechter, Smith and Azen also compared their results to the results of three studies of other psychological treatments for chronic back pain. The three non-TMS studies were selected because of (a) their quality, as judged by the Cochrane Collaboration, and (b) the similarity of their pain measurements to those used in the TMS study. Of the three non-TMS studies, only one (the Turner study) showed a statistically significant improvement. Compared to the 2007 TMS study, the Turner study had a lower success rate (26%-35%, depending on the type of psychological treatment) and a lower level of statistical significance (P<.05).
Theory:
According to Sarno, TMS is a condition in which emotional
stress causes physical pain and other symptoms. His theory suggests that the autonomic nervous system decreases blood flow to muscles, nerves or tendons, resulting in oxygen deprivation, experienced as pain and tension in the affected tissues. Sarno theorizes that because patients often report that back pain seems to move around, up and down the spine, or from side to side, that this implies the pain may not be caused by a physical deformity or injury.
Sarno states that the underlying cause of the pain is the mind's defense mechanism against
unconscious mental stress and emotions such as anger, anxiety and narcissistic rage. The conscious mind is distracted by the physical pain, as the psychological repression process keeps the anger/rage contained in the unconscious and thereby prevented from entering conscious awareness. Sarno believes that when patients recognize that the symptoms are only a distraction, the symptoms then serve no purpose, and they go away. TMS can be considered a psychosomatic condition and has been referred to as a "distraction pain syndrome".
Sarno is a vocal critic of
conventional medicine with regard to diagnosis and treatment of back pain, which is often treated by rest, physical therapy, exercise and/or surgery.
Notable patients
Notable patients who have been treated for TMS include the following:
Radio personality
Howard Stern credited TMS treatment with the relief of his "excruciating back and shoulder pain", as well as his obsessive-compulsive disorder.
20/20 co-anchor John Stossel was treated by Sarno for his chronic debilitating back pain. In a 20/20 segment on his former doctor, Stossel stated his opinion that the TMS treatment "cured" his back pain, although he admitted that he continues to have relapses of pain.
Television writer and producer
Janette Barber said that for three years, she had been increasingly unable to walk, and eventually confined to a wheelchair, due to severe ankle pain originally diagnosed as tendinitis. She was later diagnosed and treated for TMS. According to Barber, she was "pain-free one week after [Sarno's] lecture" and able to walk and run within a few months, notwithstanding her "occasional" relapses of pain.
The late actress
Anne Bancroft said that she saw several doctors for back pain, but only Sarno's TMS treatment helped her.
Controversy
The TMS diagnosis and treatment protocol are not accepted by the mainstream medical community. Sarno himself stated in a 2004 interview with
Medscape Orthopaedics & Sports Medicine that "99.999% of the medical profession does not accept this diagnosis.”
Critics in mainstream medicine state that neither the theory of TMS nor the effectiveness of the treatment has been proven in a properly controlled
clinical trial, citing the placebo effect and regression to the mean as possible explanations for its success. Patients typically see their doctor when the pain is at its worst and pain chart scores statistically improve over time even if left untreated and most people recover from an episode of back pain within weeks without any mechanical intervention at all. The TMS theory has also been criticized as too simplistic to account for the complexity of pain syndromes.
My suggestions
1. There is rationality of this theory.
2. Much more has to be done in the term of research in this aspect.
3. Professionals especially rehabilitation professional should take this as a PHD thesis.