Dear all, 

Welcome! A quick mention to check out dates for all the Mastering Lower Limb Tendinopathy Courses 2017.

And places are filling fast for Erik Meira’s fabulous Hip and Knee course in Melbourne in August.

This week we tackle the conundrum of isometric exercise for tendinopathy. This includes a sneak peak, or at least mention of an unpublished paper we are about to submit. This foray into isometrics is sparked by the recent study by Dimitris Stasinopoulos, a prolific tendinopathy researcher from Greece who works in Cyprus. A lovely guy too. I had the pleasure of visiting him in Cyprus a couple years ago. Hopefully you will come away with a better understanding of isometrics and how they can be used.

See you next time

Peter via Tendinopathy Rehab

Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy

Background: Stasinopoulos and his group have conducted a randomized controlled trial investigating exercise interventions for tennis elbow or lateral elbow tendinopathy (LET). Most people would agree exercise is useful in treating tendinopathy. The best exercise methods are debated and there is not great evidence suggesting we should be doing it one way and not another (e.g. eccentric vs concentric-eccentric). Recently, there is lots of buzz about isometric exercise for treating tendon pain. Stasinopoulos and his coworkers argue that LET is related to forceful grip activities requiring isometric contraction of the wrist flexors and extensors, so using isometrics in rehab makes sense. They evaluated the effect of eccentric versus eccentric-concentric versus eccentric-concentric + isometrics in managing LET.

What they did: LET diagnosis was based on localized pain and pain with resisted or stretching tests, and they excluded people with neck referral, arthritis, neurological signs, and prior surgery. Patients were asked to modified activities such as gripping tasks if provocative.

They randomized people with LET into the three exercise groups. All groups performed 3x15 and continued even if they had mild pain (defined <4/10). Load was increased with free weights when patients could perform the exercise without any discomfort. The groups performed slow (counting to 30 for a repetition) eccentric isolated (group A), eccentric-concentric (Groups B and C). The only difference between group B and C was the addition of a 45 second hold in between each of the 15 repetitions of the concentric-eccentric exercise. Wow, lot’s of loading! All groups also performed static stretching at the beginning and end of each session. 34 patients were randomized into eccentric (11), concentric-eccentric (12), and concentric-eccentric+isometric (11) groups.

The outcomes were VAS pain and function as well as grip strength at baseline, 4 and 8 weeks. They minimized positive feedback/interaction between the therapist and patient but outcome assessors were not blind to the group allocation.

What they found: The headline finding was the concentric-eccentric + isometric group was the clear winner. All outcomes (vas pain, function and grip strength) improved more for this group at both 4 and 8 weeks.

Clinical interpretation: Let’s consider a few questions in relation to this finding.

1.     Do we believe the findings? I would say yes, as the trial is well conducted. People were randomized into groups. The numbers could have been larger and blinded outcome assessment would have helped to increase our confidence. As well as longer follow-up times – that is probably the main weakness.

2.     Is this a clinically important finding?  It is important to note that there were improvements in all groups, and the greater improvement in the eccentric-concentric+isometric group was modest – eg extra 1 point on VAS for pain on average. So we could have a debate about the clinical significance of that. This is why longer follow up times may have been helpful.

3.     Why did the isometric group improve more? One potential answer is bias of the outcome assessors, but this is covered in point 1 above. Let’s assume there was a real effect, then we can ask, why? Is it because the isometrics was added and this is magically much better than the other interventions. Possibly, but a big factor may have simply been that they did more. Ie the dosage and in particular time under tension was far greater in this group. So we are unable to make firm conclusions about the contraction type.

One more question to complete this blog off. Where are we at then with the current evidence supporting isometric exercise for tendinopathy? Here are some slides that cover and include some key clinical messages. 

POINT 1 = isometrics have been shown to have a dramatic effect in patellar tendinopathy

POINT 2 = more variable response in Achilles tendinopathy (note this is from an abstract so differences between the studies are not absolutely clear to me)

 

POINT 3 = in tennis elbow there was no change in grip pain, but an INCREASE in reported resting pain post isometrics BUT ONLY for the group that exercises into pain (supra-threshold). Note that there were differences in the isometric protocol used compared with previous studies.

POINT 4 = in a 4-week study among in-season athletes, isometrics and concentric-eccentric interventions had a similar effect on pain outcomes

POINT 5 = we can argue until we are blue in the face about differences in protocols, populations, etc. The fact remains the evidence for isometric superiority for pain at the moment is, at very best, very limited. That is not the same as saying they are not useful. Here are some practical indications for isometrics…

POINT 6 = We need to understand the mechanisms by which isometrics influence pain. For example, Coombes found kinesiophobia or fear of movement strongly predicted pain with loading.

 

POINT 7 = Further to this, Vaegter found that exercise induced hyperalgesia was impaired in people with lower pressure pain thresholds (the high pain sensitivity group).

POINT 8 = probably the best thing to do is experiment with load (regardless of contraction type) and find the ‘entry point’ to achieve a positive response from an individual. Some patients need a softly softly approach, others you can escalate load sharply, others need lots of reassurance/education. Be prepared to play and try things! For example, some of my patellar tendon patients may spend 15-20 minutes gently developing load intensity to allow a positive response from load.

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

Hi all,

The first Mastering Lower Limb Tendinopathy Course for the year is in Sydney the end of March. Physios and non-physios very welcome. 

This week we have another very interesting blog from Erik Meira. The last guest blog was incredebly popular so it is my pleasure to have him on again. This time Erik touches on the potential mechanisms of exercise, moving beyond neuromuscular effects to psychological mechanisms and how they may play out. You can catch Erik deliver his Hip and Knee course in Melbourne this August - early bird rate ends soon!

See you next time

Peter

Just Load It

BY ERIK MEIRA

It has been quite a while since I created my “LOAD IT!!!” flowchart. The chart was just something that I slapped together one day without much thought, as an expression of frustration with physical therapists making things more complicated than they needed to be. I was sick and tired of hearing about all the tapes, massages, stretches, and “functional” training being prescribed to patients in the absence of any significant load application. So I made this:

My handy flow chart. Click to embigginate.
Since I released that flowchart, there have been several incidences whereupon meeting someone for the first time they remark, “Hey! Aren’t you the ‘Load It’ guy?!”

I guess so…

What does it mean to “Load It”?

As with damn near everything I’ve created, there have been some misunderstandings regarding the point of “Load It”. The most common thing that I hear is that the view is too narrow-minded – “It’s not just about load.” This misunderstanding seems to come from confusion regarding the effects of load.

First, when I say “load it” I am generally referring to applying stress to the organism. As physical therapists, the tool that we have in order to apply that stress is load in the form of external weight. Now the application of load requires a thoughtful approach which is why I like to say that we are in the business of load management.

One misconception about load application is a belief that it is about nothing more than building muscle. The thought here is that, since the application is in the form of resistive exercise, the effects being pursued must be strictly “in the tissue”. Although strength development is a good reason to apply load, that is not the only thing that happens.

The application of load has many effects on the organism as a whole. In this post I’m going to discuss three main categories: Structural, Neuromotor, and Psychological. That is not to say load doesn’t have other effects such as hormonal and cardiovascular as well. Keep in mind, all of these effects are layered and continuously interacting. Because of this, simplified explanations of effects (such as this post) will always be imperfect.

Structural

These are the effects people typically think of first when they think of what load does to the body. The most obvious are the muscle effects which can, in its simplest definition, be described as “strength”. But strength is a funny thing. The physical effects to the muscle refer to the absolute tissue strength and force production the muscle fibers could achieve in isolation (denervated). The capacity of that muscle to generate force.

In other words, if you took that muscle out of the human and wired it up on a machine for full contraction, how much force would it put out?

The ability of a human to generate force is a complicated thing dependent on more than muscle capacity. That said, the ability of a human to generate force is constrained by peak force that can be produced by a full contraction in isolation. You can’t will yourself beyond the physical limits.

But there is more than just muscle adaptations. All the other structural tissues respond to load as well including tendons, ligaments, bones, etc. As a complete physical organism, the human body is designed to manipulate loads and adapt to interactions with load in an active way. This collectively falls under the umbrella of “tissue change”. These changes, however, do require a considerable amount of load. Way beyond what you can apply with your hands.

The problem is that many people get the misconception that these physical effects are all that happens to the human body when loaded. I find that this is true of both the supporters and detractors of “Load It”. Now here is the key point of this post:

Saying that it’s all about load is not the same as saying it’s all about structure.

So let’s explore further…

Neuromotor

Structural components are not the only things that adapt to load. The nervous system also goes through changes when the organism is being physically loaded. Through a complex process of trial and error, the nervous system begins to learn how to interact and manipulate loads in the way it directs all of those structural components.

The key phrase here is “complex process”. Many people think I’m talking about what is going on through high level “neuromuscular re-education” and “functional training”. I’m not. I have said before that I don’t believe these interventions achieve what people think they are achieving: Correction of movement.

What I am talking about is the coordinated recruitment of muscle against simple load to the system. This complex process is occurring even with the simplest of movements. For example the neural complexity required to perform a basic leg extension is almost beyond comprehension. I feel that this critical component of load adaptation is often overlooked and underestimated.

Psychological

For some reason, the psychological effects of interacting against load seem to be rarely considered. I think that these are likely the largest effects that can be achieved by applying load to a patient. Let’s try to understand this through some examples…

If I have a current history of back pain, when I look at a heavy weight I will likely feel scared and fragile regardless of my strength. There is an equation in my head that says:

"Load = Danger"

Consciously AND unconsciously I believe that there is a good chance that the application of load will cause injury to my perceived fragile structure. In other words, I have an expectation of harm. Pain, a protective device, stops me from engaging in this perceived threat.

When I work against load I don’t just become stronger, I feel stronger. As I feel stronger, I perceive the risk of injury to be lower. If my perception of risk is lower, the perceived need for my protective device (pain) is also lower. I am not only becoming physically stronger, I am becoming psychologically stronger.

But there is more than this going on. Now let’s say that I have symptoms consistent with patellar tendinopathy. Sure there are some structural changes going on there but what about my mental state? Similar to the previous example, there can be an expectation of harm.

I sit down on a leg extension machine that is loaded with the full weight stack – immovable for my weak-ass knee. This gives me an opportunity to perform some isometrics. Isometrics are really popular nowadays…

I start kicking into the pad and immediately there is pain. My automatic reaction is to obey that pain response and stop kicking immediately. The system believes that harm was imminent and by aborting the exertion, it believes the tendon was saved. Hooray! All expectations are preserved.

But now let’s throw caution to the wind and push through the pain. I begin pushing against the pad and immediately feel the pain again. Instead of obeying the pain response, I override it and keep kicking into the pad, pushing that line of tolerable pain. As I continue to push longer and harder my protective process ramps up:

"DANGER! DANGER! CONTINUED LOADING WILL RESULT IN DAMAGE TO THE TENDON! CONTINUED LOADING WILL RESULT IN DAM-

Wait. Hold on. Nothing is happening. The tendon is NOT tearing. The tendon is NOT fragile. This pain appears to be a false alarm and can be ignored."

Weirdly, I now have less pain. But was that due to structural change in the tendon? No. Not that quickly. So what else could be going on?

Expectancy violation

I had an expectation that damage would occur when the tissue was loaded – Load is dangerous. I tested that expectation. The expectation was wrong. It was violated. I begin to develop a new expectation, the expectation that load is safe.

This phenomenon is known as “expectancy violation” and is a technique promoted for the treatment of phobias. Weirdly, it is most effective when the subject feels the least safe.

They have to really expect that their worst fear MUST happen when tested. So that means no preliminary education that would alter their expectation. It also means that you would NOT want to open a “window of opportunity” first. As a matter of fact, you would want to slam all windows shut before the exposure to raise the expectation as high as possible. That exposure should then be as heavy as tolerable.

Load is simple but the effects are not

I get frustrated when supporters of load application disregard the psychological effects that could explain their results. But I get equally as frustrated when the detractors forget that load application is an opportunity for systemic effects that are more than structural. And that is not even considering other effects such as hormonal and cardiovascular.

When someone simply moves against a weight, there is a lot of complex stuff going on.

Let me be crystal clear – I do believe that our patients likely have deconditioned structures (muscles, tendons, etc) that need increased load tolerance, but I also believe there is much more going on. When load is applied to a patient all three types of effects are occurring at all times. Sometimes the effects are more structural. Sometimes they are more psychological. Sometimes it is something else. A skilled physical therapist considers all of these things when they “LOAD IT!!!!”

In summary…

• Damn near everything I say is misunderstood
• Loading an individual has structural, neurological, and psychological effects
• Saying that it’s all about load is not the same as saying it’s all about structure
• When someone works against load they don’t just become stronger, they feel stronger
• Use higher loads to enhance violation of harmful expectations of damage
• Load is simple but the effects are not

BY ERIK MEIRA via Tendinopathy Rehab

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...