Tips to stay ‘injury free’

As we roll into the summer, we start to become very aware of how our new years resolution to get fit is drifting away. At TA Physio we see many clients who started fitness programs in the first few months, stop, then try again with injury or alarming pains. There are a few ways to help remove these undesired results and still get fit for the summer.

There are many reasons for injury, especially in sports with contact which result in direct trauma, but there are many internal reasons for injury too. These are things that you may not be aware of when you start your sport or activity, such as weak muscles, reduced range of movement and level of fitness (1).

Here are some tips to help reduce the risk of injury:

  • Start small and build – Up to 40% of injuries in athletes are due to a rapid change in training(2). Even the fittest need time to adapt. People often decide to start a sport or activity from doing very little, to upwards of 3 to 4 times a week. This can be too much too soon for your body, it may not be able to deal with the new stresses and load. Getting fit is also about patience!

  • The importance of a warm-up and cool-down – We all know the rush when you’ve only a short amount of time to do your workout and skip the warm-up/cool-down. Neglecting this can leave you prone to easily avoidable injuries (3). On the other side, stretching hasn’t been found to be effective in reducing the risk of injury(4) – but we know it feels good so no need to stop!

  • Resistance Training – It is important to add strength and conditioning into your program to reduce the risk of injury. Resistance training once or twice a week is effective in reducing the risk of sports injuries by up to 1/3 and overuse injuries by 1/2 in active individuals(4).

  • Rest – Probably one of the most important is making sure you have rest days, enough sleep and look after yourself. Sleep has been shown to improve memory, performance and reduce risk of injury (5). It is recommended that adults get at least 7 hours of sleep to get the full benefits(6). Recovery is just as important as the work itself.

Injury prevention is specific to each individual – with age, sex, fitness, general health, mobility, strength and previous injury all being risk factors (1).

Hopefully this has helped you think about what you might be neglecting, and given you a few ideas of what you can do to help keep yourself pain free.

Thanks for reading.


Aran Pemberton

Aran qualified as a Physiotherapist graduating from the University of Worcester in 2017. He has since been working within the NHS, rotating into different specialities such as the Emergency Department, Critical Care, Orthopaedics and MSK.  He has worked with people of all ages and different levels of health and fitness, encouraging exercise as an essential part of health and wellbeing and providing the best care for his patients.

Aran has a keen interest in soft tissue mobilisation and movement re-education as part of the rehabilitation process. He has an interest in sports injuries and has experience treating players and working with the strength and conditioning coaches under the physio in Worcester County Cricket Club.

References

  1. Murphy DF, Connolly DAJ, Beynnon BD Risk factors for lower extremity injury: a review of the literature British Journal of Sports Medicine 2003;37:13-29.
  2. Gabbett TJ, The training—injury prevention paradox: should athletes be training smarter and harder?British Journal of Sports Medicine 2016;50:273-280.
  3. Herman K, Barton C, Malliaras P, et al, The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC Med 2012;10:75.
  4. Lauersen JB, Bertelsen DM, Andersen LB The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials British Journal of Sports Medicine 2014;48:871-877.
  5. Roberts SSH, Teo W, Warmington SA Effects of training and competition on the sleep of elite athletes: a systematic review and meta-analysis British Journal of Sports Medicine 2019;53:513-522.
  6. Ohayon M ,Wickwire EM , Hirshkowitz M, et al, National sleep foundation’s sleep quality recommendations: first report. Sleep Health 2017;3:6–19.

Patellofemoral Pain in Runners

Patellofemoral pain (PFP) is pain associated around or behind the kneecap; it is the one of the most prevalent running injuries, with 9 – 15% of the active population reporting PFP at one time or another. This pain in runners is debilitating, often varied in how it presents, and the true source of pain is very difficult to narrow down (Stefanyshyn et al. 2006; Barton et al. 2012).

“THAT’S A FACT: RUNNERS TEND TO OVERDO AND PUSH THROUGH PAIN”

Jean-Francois Esculier – The Running Clinic

Should I stop running?

When you get PFP it’s not to say you should stop running completely, but perhaps you can modify your training for the moment? Can you reduce the distance, or slow your pace down and see if this helps?

According to Esculier et al. (2017) you should experience no more pain than 2/10 (in a 0-10 model for pain with 0 being nothing and 10 being the worst possible pain) whilst running; have no pain after an hour stopping the run and have no pain the next day. They found that this simple guidance, then building this activity up gently, was found to be effective in treating PFP.

There is an agreement that the position and glide of the patella is influenced by the soft tissue and biomechanics of the general lower limb and the joints. This means that muscle imbalances can put certain stresses on the patella and can be a reason for your pain (Neal 2019).

The role of strengthening the glutes has shown to be important in runners with PFP– they need to manage 4 x your body weight whilst running (Lenhart et al. 2014).

There’s a good glute’s circuit by Tom Goom (running physio) to help get people started – this isn’t appropriate for everyone and always best to be assessed first, or consult your healthcare professional if you’re unsure.

What this all means?

The take home message is to adjust your running regime to a more manageable pain level and gradually build from there. Maybe you’ve increased your pace, distance or number of sessions recently and your body isn’t ready just yet and needs to build up slowly?

Evidence suggests that effective treatment is about modifying activity, strengthening and education tailored to the individual (Lack et al. 2015; Barton et al. 2015). Everyone is different and in injuries there’s rarely, if at all, a “one size fits all” approach.

At TA Physiotherapy we aim to incorporate this into our assessment and treatment. If you have concerns or feel you need a thorough assessment book with one of our physiotherapists or our running coach.

Aran Pemberton

Aran qualified as a Physiotherapist graduating from the University of Worcester in 2017. He has since been working within the NHS, rotating into different specialities such as the Emergency Department, Critical Care, Orthopaedics and MSK.  He has worked with people of all ages and different levels of health and fitness, encouraging exercise as an essential part of health and wellbeing and providing the best care for his patients.

Aran has a keen interest in soft tissue mobilisation and movement re-education as part of the rehabilitation process. He has an interest in sports injuries and has experience treating players and working with the strength and conditioning coaches under the physio in Worcester County Cricket Club.

References

Barton CJ, Lack S, Hemmings S, et al. The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning Br J Sports Med 2015;49:923-934.

Barton CJ, Lack S, Malliaras P, et al. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review Br J Sports Med 2013;47:207-214.

Lack S, Barton C, Sohan O, et al. Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis Br J Sports Med 2015;49:1365-1376.

Lenhart R, Thelen D, Heiderscheit B. Hip muscle loads during running at various step rates. J Orthop Sports Phys Ther. 2014;44(10):766–A4. doi:10.2519/jospt.2014.5575

Neal BS, Lack SD, Lankhorst NE, et al. Risk factors for patellofemoral pain: a systematic review and meta-analysis Br J Sports Med 2019;53:270-281.

Stefanyshyn DJ, Stergiou P, et al.  Knee Angular Impulse as a Predictor of Patellofemoral Pain in Runners. The American Journal of Sports Medicine 2006, 34(11), 1844–1851.

Sensorimotor System – What does it mean & What’s the implication for rehab? Bec van De Scheur

IMG_2527After hitting heavy traffic, turning what should have been a swift two hour car trip into an eventful six hour journey to Birmingham, we finally reached the Therapy Expo 2017!

 

Fuelled with coffee, we sat in on a number of interesting presentations. Although there was diversity amongst the guest speakers a common theme seemed to present itself, the role of the sensorimotor system in injury rehabilitation.

 

Steven Hawking said it perfectly when he stated:

 

“Intelligence is the ability to adapt to change”

 

The human body is of no exception. Our desire to move after injury sees that we will go to great lengths to keep our bodies mobile. Often completely subconscious, we find ways to move around pain, stiffness, or imbalances. Thus, compensatory movement patterns or “muscle patterns” are born.

 

Jo Gibson [Twitter: @shouldergeek1], well renowned shoulder rehabilitation specialist, whose lecture we were lucky enough to attend at the Expo, has been quoted to explain it like this in relation to the shoulder:Jo Gibson januar 2016 (2)_edited1

 

“Muscle Patterning refers to inappropriate recruitment, commonly of the torque producing muscles of the glenohumeral joint e.g. Latissimus Dorsi, Pectoralis Major, Anterior /Posterior Deltoid. This unbalanced muscle action is involuntary and ingrained. Patients with muscle patterning essentially have a muscle recruitment sequencing problem that results in abnormal force couples, destabilising the joint.”

It is an important topic, as failure to correctly diagnose a structural instability versus a functional instability is a common factor in patients failing conventional rehabilitation or surgery.

‘Rehabilitation in this situation should be aimed at ‘normalising’ muscle recruitment patterns around the shoulder girdle and this involves appropriate facilitation throughout the kinetic chain. Balance, coordination and core control are all factors that must be addressed to optimise neuromuscular control mechanisms.’(1)

 

Our ability to adapt to change is both the human body’s greatest strength and its biggest weakness.

As a short term strategy compensation is a great tool. It is protective against further injury and it enables us to get on with our daily function. However, when these newfound motor patterns become long term and supersede our normal programming we will at some stage hit a point of failure, which usually manifests as injury or failed rehab.

 

It can be explained like this…..

 

Your weekend football team is down a player and you have no choice but to replace your star striker with the goalkeeper. Chances are he will manage to get the job done for a period of time, but because his training has not been specific to the role of striker and he is not conditioned or well rehearsed to the demands of this position, at some point in the game he will fatigue, his reaction time will diminish and his ability to generate power and keep up with the pace of the game will become apparent, leaving him vulnerable to injury.

 

Similarly, if you delegate a task to a muscle that it is not designed for, it can deal for a time, but ultimately it will not be able to withstand the extra demands that have been placed upon it.

 

For therapists this is very important to recognise as it will guide how we structure our rehabilitation. When patterns become maladaptive and cemented centrally, rehabilitation takes on a different level of complexity. We are no longer treating an isolated system.

 

It is easier to learn than to unlearn a skill. My father always says, “Practice does not make perfect, perfect practice makes perfect”. As performing something in a sub optimal way over and over again only leads you further away from skill mastery.

 

So lets break it down….

 

What does sensorimotor mean?

 

The term sensorimotor system describes, ‘the sensory, motor, and central integration and processing components involved in maintaining functional joint stability’. This encompasses neuromuscular control and proprioception. (2)

 

Sensorimotor Diagram
Neural Basis of sensorimotor learning: modifying internal [Lalazar & Vaadia, 2008] https://www.sciencedirect.com/science/article/pii/S0959438808001578
 

Lets look at this in relation to a common injury such as an inversion injury of the ankle….

 

It is generally known that the primary risk factor for an ankle sprain remains a history of a previous sprain (5). It is thought that the initial damage to the lateral ankle ligaments alters the function of mechanoreceptors of these ligaments disrupting the ability to sense motion at the joint (4) and can lead to functional instability of the ankle. It is often described as frequent episodes of “giving way” or feelings of instability at the ankle joint.

 

A number of authors support the idea that some patients with functional ankle instability have deficits in neuromuscular preparatory or anticipatory control, which increases the risk of injury to the ankle, as it is less protected in an inadequate ankle joint position. Add to this a sub optimal rehabilitation program and paving the way towards a chronic ankle issue.

 

So what does this mean in terms of exercise prescription?

 

Benoy Mathew [Twitter: @function2fitnes] from Harley Street Physiotherapy during his talk regarding “the problem ankle” discussed the benefits of dynamic exercises such as sport specific plyometrics, which utilises sensorimotor training to promote anticipatory postural adjustments as well as optimise agility, landing technique and reaction time.

 

When it comes to overall running efficiency Mike Antoniades [Twitter: @runningschool], Performance & Rehabilitation Director of The Running School agrees:

 

“To change running technique, theoretical information and tips will not do the trick. The body needs to learn movement through movement – mostly while running but also through other re-patterning exercises”

(1)

 

During his workshop at the Therapy Expo, Mike gave us great examples during a live running assessment of particular movement dysfunctions that result from motor patterning, which often lead to muscle imbalances, poor technique and may be a factor in the recurrence of injury.

 

A common example is poor gluteal activation, which leads to compensatory hamstring dominance. Recognising this as the main offender of a patients running pain is a great start but strength training alone will only get you so far if it is a neuromuscular issue and ‘sensory motor amnesia’ is the primary reason why certain muscles fail to activate during movement.

 

There is a lot to think about during clinical diagnosis to ensure we are not ‘band-aiding’ a sensorimotor issue with strength exercises and manual therapy.

 

It is our responsibility as physiotherapists to ensure that we are continuously looking for opportunities to enhance our clinical skills. By optimising our assessments we are giving each person that seeks our advice the best opportunity to reach their full potential.

 

  1. Antoniades, M (2016), Mikes view on therapy expo 2016. Retrieved December 10, 2017, from http://runningschool.co.uk/blogs/mikes-view-on-therapy-expo-2016/
  2. Foundation of Sports Medicine Education and Research (1997). The role of proprioception and neuromuscular control in the management of knee and shoulder conditions.; August 22–24; Pittsburgh, PA.
  3. Gibson, J (n.d), Advances in rehabilitation of the shoulder. Retrieved December 10 2017, from http://www.physioroom.com/experts/expertupdate/interview_gibson_20041031_1.php
  4. Hertel J. (2002). Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of Athletic Training. 37(4) 364–75.
  5. Milgrom C, et al. (1991). Risk factors for lateral ankle sprain: a pro- 
spective study among military recruits. Foot Ankle. 12(1), 
26–30.
  6. Lalazar & Vaadia, (2008). Neural Basis of sensorimotor learning: modifying internal models.  https://www.sciencedirect.com/science/article/pii/S0959438808001578

 

Bec van De Scheurcropped-logo-resize-21.png

Sticks & Stones – Bec Van de Scheur

STICKS AND STONES…

 

Best selling author Don Miguel Ruiz in his book The Four Agreements reveals what he believes to be the primary sources of self-limiting beliefs. The first and most important of these principles is to be impeccable with your word.

 

It sounds easy enough, as a professional we are under the agreement to ‘do no harm’. As a colleague, friend, family member or acquaintance we aim to be courteous, thoughtful, and kind. The problem is not so much our intention but our awareness of the words that we use to convey meaning. Some of which may, without our knowing, pass through the filter and hold more weight than what we give them merit.

Because the fact is, words do ‘hurt’ and not just emotionally.

 

This-is-a-cartoon-image-of-brain-coupling-during-communicationThere have been a number of studies detailing placebo and nocebo patient responses to explanations regarding interventions by a professional within their field of expertise.  An example of this is a study by Varelmann et, al. (2010), where one hundred and forty healthy women at term gestation requesting analgesia were randomized to either a placebo (“We are going to give you a local anesthetic that will numb the area and you will be comfortable during the procedure”) or nocebo group (“You are going to feel a big bee sting; this is the worst part of the procedure”). Pain was assessed immediately after the local anaesthetic skin injection using visual analog scale scores of 0 to 10. Median pain scores were significantly lower when reassuring words were used compared with the more intense nocebo words. This study and many others are beginning to show a pattern suggesting that more reassuring words may improve the subjective experience.

 

Lorimer Moseley has stated that:

 

‘100% of the time, pain is a construct of the brain’.

 

 

Now this is not to say we lie to our patients. We also have an ethical obligation to be truthful and transparent when gaining consent, giving a diagnosis, a prognosis or offering advice. However it is important to recognise that therapists are in a powerful position in their ability to influence a patient’s perception regarding pain and recovery. It is our responsibility to have an awareness of words that we use and whether or not they have a connection to negative suggestions and connotations, as this may feed into a fear generated belief system and adversely affect recovery.

 

 

“The human mind is a fertile ground where seeds are continually being planted, the seeds are opinions, ideas and concepts. You plant a seed, a thought, and it grows. The word is like a seed and the human mind is so fertile. The only problem is that too often it is too fertile for the seeds of fear” (Ruiz, 1997).

 

IPainf a patient comes to you with concerns about an injury, anxieties about returning to sport or a fear of whether their pain will ever resolve it is important for us to recognize the power of the words we use and the long-term impact they may have on a persons wellbeing.

 

…We do not want to be unconsciously watering the seeds of doubt, fear or despair.

 

It sounds relatively simple to strip down and remove some of these negative connotations. However, some of these words are more subtle than we realise. They are words we use often without acknowledgement. For example;

 

  • Words such as ‘try’ suggest anticipated failure.

 

  • A statement like ‘don’t worry’ is associated with there being something to worry about (Allen, et al, 2011).

 

Terms such as ‘chronic’, ‘disc’ ‘damage’ or  ‘osteoarthritis’ may be enough to set off a flag for danger and generate a fear or anxiety driven response.

 

 

So where to from here?

I invite you to be impeccable with your word.

 

Below is a list of resources to assist in better understanding this concept, strategies for intervention and some great tools that can be shared with patients. Knowledge is power.

 

 

Resources

 

 

 

 

 

 

 

References:

  1. Cyna, A.M, Marion, A.I, Tan, S.G.M, & Smith, A.F. (2011).Handbook of

  Communication in Anaesthesia & Critical Care: A Practical Guide to   

  exploring the art. New York, United States: Oxford university press.

 

  1. Ingraham, Paul (updated Nov 18, 2016, first published 2010)

  Pain is Weird. Retrieved April 26, 2017, from

https://www.painscience.com/articles/pain-is-weird.php

 

  1. Ruiz, D.M & Mills, J. (1997). The Four Agreements: A Practical Guide to

  Personal Freedom (A Toltec Wisdom Book). California, USA: Amber-

  Allen Publishing

 

  1. Varelmann, D, Pancaro, C, Cappiello, Eric C & Camann, W. R. (2010)

Nocebo-Induced Hyperalgesia During Local Anesthetic Injection

Anesthesia & Analgesia: 

March 2010, Volume 110, Issue 3, pp 868-870.

Retrieved from http://journals.lww.com/anesthesia- analgesia/Fulltext/2010/03000/Nocebo_Induced_Hyperalgesia_During_Local.42.aspx

 


 

Becs Van de Scheur – Physiotherapist & Pilates Trained [Mat Work Level I]

From the East Coast of Australia, Bec graduated with a Degree in Human Movement Science before going on to complete her studies as a Physiotherapist in which she graduated in 2012 from the University of Newcastle, Australia.

With a background in private practice and aged care Bec enjoys working with individuals of all ages and all sporting backgrounds placing a large emphasis on education, with an aim to empower individuals by providing them with the skills they require to take ownership over their own health.

With a keen interest in holistic management and pain science Bec believes in offering a combination of hands on therapy and individualised exercise prescription.  Bec has completed her Level 1 Mat work pilates training and also offers Dry needling and Western acupuncture techniques when indicated.

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Post-Pregnancy: When and How To Return To Exercise

As a physiotherapist, I regularly see patients who are unsure how and when to get back into exercise after giving birth, so I’ve written this article to help.  As you’ll see, there are plenty of benefits of getting back into a safe workout routine.  We’ll discuss what to do and how much, as well as looking at some of the complications that may occur and how to know if you’re overdoing it.  I’ve also included some pilates-based exercises for you to try at home, based on your ability and desired challenge!

 

 

Benefits of exercise post partum

 

It’s great if you are motivated to get back to exercise after giving birth!  It has many benefits, including:

  • Promoting weight loss;
  • Restoring muscle strength;
  • Raising energy levels;
  • Improving cardiovacular fitness;
  • Reducing risk of urinary incontinence;
  • Stress relief
  • Improving your mood;
  • And it gives you opportunity for increased social interaction.

 

However, after giving birth, the important questions are:

  • How much is safe?
  • And how soon should you return?

 

Everyone is different, so make sure you are following the individualised advice from your midwife.  Your return to exercise will depend on several factors including:

  • The strength of your pelvic floor muscles;
  • The number of pregnancies you have had;
  • The type of delivery (recovery following a caesarian will always be longer than a natural birth so you will therefore take longer to return to exercise);
  • The level of exercise you were completing ante natally;
  • And whether you have any pelvic girdle pain (PGP) or diastasis recti (keep reading to find out more about these conditions).

 

If you had a normal birth, you should be able to start easing back into gentle exercise as soon as you feel ready.  You should not start any high level or impact exercise until at least 6 weeks post partum, as long as your midwife clears you to do so at you 6-week check up (according to the NHS guidelines).  However, 12-16 weeks post partum is probably a more realistic time frame because the weakness of your pelvic floor muscles following pregnancy will take time to retrain and strengthen.  Doing too much exercise too soon can result in a prolapse which can be both uncomfortable and painful.

 

 

What is a prolapse?

 

A prolapse is when the organs in your pelvis drop down into the vagina, rather than being held in their normal position.  This can result in a heaviness sensation, there may be bulging present, and it can result in pains or aching in the lower back and stomach.

 

 

Why do prolapses happen?

 

A  number of factors associated with pregnancy can cause weakening of the pelvic floor muscles and surrounding ligaments.  Your pelvic floor muscles are often left weak and stretched, and this will put you at increased risk of having a prolapse.  This can happen for several reasons including:

  • The weight of the growing baby;
  • The pelvic floor muscles and ligaments may have been overstretched if you had a vaginal birth;
  • You may not have completed your pelvic floor muscle exercises as often as you recommended during your pregnancy;
  • Or you may have increased your exercise too quickly after childbirth (returning to high impact exercise too early will put you at particular risk).

 

 

PGP & Diastasis Recti

 

Along with risk of prolapse due to weakened pelvic floor muscles, pelvic girdle pain (PGP) and diastasis recti will also play a part in how quickly you can return to exercise.

 

Pelvic girdle pain includes pain in one, or several areas around the pelvis:

  • Pain over the pubic bone;
  • Pain in you perineum (area between your vagina and anus);
  • Pain across your lower back.

It is often aggravated by activities such as walking, going up stairs, standing on one leg, or turning over in bed.

 

Diastasis recti is separation of the 2 muscles that run down the middle of your stomach. You can check for diastasis recti yourself:

  • Lie on your back with your legs bent and your feet flat on the floor;
  • Raise your shoulder blades off the floor and look down towards you belly button;
  • Use the tips of your fingers to feel between the edges of the stomach mucles, where they should join in the middle, both above and below the belly button;
  • See how many fingers you can fit into the gap between your muscles;

If a gap of 2cm or more is present this is classed as diastasis recti.  You should notice this gap gradually decreasing over the first 8 weeks after the birth of your child.

 

If you think you may have either of these conditions, it will contraindicate you from completing the intermediate or advanced exercises suggested in this article.  It is advisable to see a physiotherapist or healthcare professional to help to improve or resolve these symptoms as soon as possible.

 

 

How do I know if I am overdoing it?

 

If you experience any of the following symptoms, you should reduce the level of exercise you are completing, or rest completely until they resolve:

  • Fatigue;
  • Slow recovery from exercise;
  • Disproportionate muscle aches and pains for the level of exercise you have completed;
  • Increase in flow of lochia (vaginal discharge after giving birth containing blood, mucus, and uterine tissue);
  • Change of colour of lochia to pink or red;
  • Lochia restarts flowing after it has stopped.

 

 

Which types of exercise are safe to help you get back into sport post pregnancy?

 

Low impact exercises such as: swimming (once lochia has stopped); walking; yoga; and pilates are all great ways of easing you back into sport after pregnancy.  Try the following exercises for an introduction to pilates!

 

 

***

 

 

Getting back into exercise:  A pilates-based programme you can try at home!

 

All of the following exercises should be pain free to complete.  If you experience any pain whilst completing them, or disproportionate aches or pains for the level of exercise you have completed following your pilates home session, stop and seek assessment and advice from a healthcare professional.  Please closely follow the advice on exercise progression, and only progress to the next difficulty if you meet the criteria stated.

 

 

Basic

 

These exercises should be safe to be completed by any new mum:

 

 

  • Deep neck flexor exercise:
    • This will help improve your upper body posture and reduce neck pain
    • Lie on your back with your head supported by a pillow
    • Lengthen through the back of your neck, and push the back of your head down into the pillow (a bit like you are making a double chin)
    • Hold for 10 seconds, then relax
    • Repeat 10 times

 

  • Transversus abdominus & pelvic floor activation:
    • This is the action of drawing your belly button in towards your spine, and drawing up through your pelvic floor muscles as if you are stopping yourself from going to the toilet
    • This muscle activation exercise should be practiced in sitting, lying, standing, high kneeling, side lying & 4pt kneeling
    • Hold the muscle contraction for 10 seconds, then relax
    • Repeat 10 times

 

Pelvic tilt

  • Pelvic tilts:
    • Lie on your back with your knees bent (crook lying)
    • Gently tilt your pelvis forwards and backwards
    • You should feel your lower back arching and flattening on and off the floor
    • Repeat this 10 times in each direction

 

 

Intermediate

 

If you have mastered the basic exercises, are not experiencing any pelvic girdle pain, and do not have diastasis recti, you should be safe to progress to completing these exercises:

 

  • Dumb waiter in standing:
    • Stand tall, with your pelvis in a neutral position, engage your deep stomach muscles and pelvic floor muscles, and have your arms by your sides with your elbows bent
    • Rotate your arms outwards, and stretch out to the side
    • Then bring your elbows back into your sides and rotate your arms inwards to return to the starting position
    • Repeat 10 times

 

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  • Spinal twist in high kneeling:
    • Kneeling up, with your pelvis in a neutral position, engage your deep stomach muscles and pelvic floor muscles, squeeze your bottom muscles (glutes), and cross your arms in front of you
    • Keeping your pelvis pointing forwards, rotate through your middle back round to the left, then slowly back to the centre
    • Repeat to the right
    • Repeat 10 times in each direction

 

 

  • One leg stretch in 4 point kneeling:
    • On your hands and knees (knees under hips, & hands under shoulders), with your pelvis in a neutral position, engage your deep stomach muscles and pelvic floor muscles
    • Slowly slide one foot back behind you, trying to keep your back and pelvis still
    • Slowly slide your leg back in towards you, and repeat with the other leg
    • Repeat 10 times with each leg

 

 

  • Breastroke preps:
    • Lie on your stomach with your hands by your sides, with your pelvis in a neutral position, engage your deep stomach muscles and pelvic floor muscles, and make sure you are aiming your tail bone down towards the opposite wall so your back isn’t arching
    • Squeeze your shoulder blades back and down, lift your hands an inch from the floor, stretch them down towards your feet, and lift your head and chest an inch off the floor
    • Slowly lower
    • Repeat 10 times

 

 

  • One leg stretch:
    • Crook lying, with your pelvis in a neutral position, engage your deep stomach muscles and pelvic floor muscles
    • Slide one heel away from you, trying to keep your back and pelvis still
    • Slowly draw your heel back into towards you
    • Repeat on the other side – alternate legs
    • Repeat 10 times on each leg

 

 

  • Clams:
    • Side lying, with your pelvis in a neutral position, engage your deep stomach muscles and pelvic floor muscles
    • Keeping your pelvis still and your ankles together, lift your top knee, then lower it slowly
    • Repeat 10 times
    • Turn over and complete on the other side

 

 

Advanced

 

If you have mastered the basic & intermediate exercises, if you are not experiencing any pelvic girdle pain, and do not have diastasis recti, you should be safe to progress to completing these exercises:

 

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  • Lunges with spinal twist:
    • Standing tall, with your pelvis in a neutral position, engage your deep stomach muscles and pelvic floor muscles
    • Step one foot forwards, and lunge down, making sure you are keeping up tall through your spine
    • Reach your arms out in front of you
    • Open one arm out to the side, then bring it back to the centre, then repeat on the other side
    • Step your front leg back, so you are back in the neutral standing position
    • Repeat with the other side – alternate legs
    • Repeat 10 times on each leg

 

 

  • Swimming (advanced level):
    • On your hands and knees (knees under hips, & hands under shoulders), with your pelvis in a neutral position, engage your deep stomach muscles and pelvic floor muscles
    • Slowly slide one foot back behind you, and lift it up, whilst simultaneously lifting and reaching the opposite arm, whilst trying to keep your back and pelvis still
    • Slowly bring your leg and arm back in towards you, and repeat with the other leg
    • Repeat 10 times on each side, alternating sides

 

 

  • Scissors level (advanced level):
    • Crook lying, with your pelvis in a neutral position, engage your deep stomach muscles and pelvic floor muscles
    • Bring your legs up one at a time into double table top (90 degree bend at the hip, 90 degree bend at the knee) and hold them there
    • Tap one foot down to the floor, then return it to double table top
    • Repeat with the other leg
    • Repeat 10 times on each side, alternating legs

 

 

  • One leg stretch (advanced level):
    • Crook lying, with your pelvis in a neutral position, engage your deep stomach muscles and pelvic floor muscles
    • Bring your legs into double table top as you did with Scissors
    • Stretch one leg away, making sure you keep your lower back still on the floor (don’t let it arch or twist), then bring your leg back into double table top
    • Repeat with the other leg
    • Repeat 10 times on each side, alternating legs

 

 

This article has been provided to give only general advice to new mums regarding graded return to exercise post partum.  It does not replace individualised assessment and advice provided by healthcare professionals.  When following advice from the article, if you experience pain or discomfort, please stop and seek advice and assessment from a healthcare professional.  If you are not sure whether you have pelvic girdle pain or diastasis recti, please ask your healthcare professional.

 

Anna Meggitt of Tom Astley Physiotherapy provides 1:1 pilates assessments and small group sessions at Project: Me, 84 Park Road, Crouch End, N8 8JQ.  Bookings available by phone (0203 659 3545), or email (info@taphysio.co.uk).

Cycling Technique and Muscles

Cycling Technique & Muscle Activation:

Thanks all for taking the time to read my blog about cycling. I’m only a physiotherapist and by no means a coach or bike fitter so these are just my observations and understanding from reading around the topic.

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Cycling Muscle Co-ordination

The diagram to the left demonstrates the muscular sequence of events in the correct cycling pedal turn.

Right at the top phase of the pedal strike the power should come straight on via the glutes, the muscles of the bottom, and power down to a point where the large quadriceps muscles share the power and gradually become the dominant mover in the sequence.

During the lower section of this movement the calf muscles join the quadriceps to push the pedal through the lowest section of the pedal turn. It is then the turn of the muscles of the shin to pull the toes back up to level the foot out and the hamstring muscles to bring in a powerful pull back up. The final stage of the movement is the muscles of the hip flexors pulling the knee back up to the start phase.

When a cyclist cycles with this sharing of power there is much greater ability to create higher wattage, power, on the bike by not having any dead spots of power during the cycle rotation. It also means that there is greater use of all muscles and no overuse of one muscle group which helps prevent injury and muscle overuse issues.

Common Faults and Corrections

The most common problems that we see with cyclists of all levels are:

  • Overuse of the quadriceps – most people who cycle tend to rely too much on the big muscles of the quadriceps and this can result in reduced power due to inhibition
  • Lack of power on the lift phase – The current advice from British Cycling is that amateurs need to not be concerned regarding the upstroke of pedalling. The risk is an increased overload of the hip flexors. Training the hamstrings and the hip flexors to be able to perform this task is essential if you are to maximise all phases of movement. So an incremental increase in focusing on the pulling on the up stroke should be gradually introduced. However, this comes with a warning: DO NOT TAKE PRESSURE OFF THE OPPOSITE DOWN STROKE. Its easy when learning to ride smoothly to focus on too many things. The skill in using clip in pedals & shoes is timing, up stroke pulling whilst maintaining downward pressure on the opposite down stroke.
  • Tight muscles across hips and hip flexor strain– Its easy, in the beginning to overload the hip flexors due to the flexed nature of cycling. Like all sports, exposure should be gradual and incremental over a number of weeks. The hip is key in cycling and needs to work in an optimal range. The muscles around the hip, as we can see on the diagram above, are important for generating power (hip extensors) but also for moving the foot into the power phase (hip flexor). It’s important not to overwork the hip flexors and not to have too much hip flexion resulting in the anterior hip compression. If the hip has a lack of ability to efficiently bring the knee to the top phase of movement the body usually compensates through the upper body, resulting in swaying at the lumbar spine. This is commonly seen when you watch a cyclist from behind and see their back swaying from side to side with every pedal lift. This happens as the body makes room for the knee to be lifted through and puts a great deal of stress on the spine and the muscles of the lower back. Good range of movement and wiggins_2270877bstrength through the hips allows for good knee lift through the top end of pedal phase and power to go straight on, with the body holding tight and allowing maximum power transfer through the pedals. Lack of adequate range here also tends to result in repeated lower back tightness and pain.
  • Toes pointing down or toes pointing up? The current trend is neither, British cycling advocates a neutral foot position so that the power of the calf complex can be optimised.  If you watch cyclists you will see a vast number who cycle with the toes lower than the heels at all phases of movement. This style of rising will often be partnered with the body being positioned too far forward so that the knee can get over the pedal. This toe pointing style of riding makes it very difficult to use the glutes effectively in the first phase of movement and also makes it much harder to bring the knee back over the top phase of movement at the end of the pedal movement and be ready for starting the next phase. Equally, toes pointing up can result in a loss of power generation from the large calf complex which is particularly utilised in the down phase of the pedal stroke. Ultimately you should find your own style, don’t copy others, find what’s comfortable for you & riding styles can depend on your sport: For example, a triathlete might not be encouraged to ride with toes up because they might utilise their calf complex which in turn might inhibit the initial stages of their running. Yet on the other hand, should a world champion triathlete ask if they should change they’re cycling foot position, probably not: ‘if it ain’t broke, don’t try to fix it’
  • Knee alignment over toes. During all phases of cycle movement, when you watch from the front, the knee alignment should be almost directly above the line of the toes at all times. This is particularly important at the top and power phase of movement. This alignment during power phase allows all power that the cyclist generates to be transferred down through the leg and into the pedal. If this alignment is out the power will not be directed down into the pedal, therefore losing power. The added lateral movement through the body will add strain into the joints of the knee, ankles and pressure across the foot.

 

Thank you for reading and I hope this has given you some insight into cycling technique and mechanics of muscle use when partaking in all levels of the sport.

 

Always remember to enjoy cycling and Lycra is cool, whatever anyone else says. We offer physiotherapy, pilates, & sports massage in Crouch End & Finsbury Park. Please book online here

 

Regards

Team TAP

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Saddle Issues for Female Cyclist by Bianca Broadbent

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As I am a female bike fitter, we tend to get a lot of female cyclists come in for a bike fit, with their primary complaint being saddle comfort (with numbness and soreness being the top issues within this). It is unfortunately normal for cyclists to think that saddle discomfort is something that needs to be tolerated, but this is simply not the case. In extreme cases cyclists report pain or difficulty urinating for several days post ride! Of course the exception being long distance cyclists or cyclists whom may not have “acclimatised” to spending periods of time in the saddle.

The saddle is the one of the most fundamental things to get right on the bike, and without this all other adjustments will be less than optimal.

You might ask yourself, what signs and symptoms should I look out for which tell me that my current saddle choice or set up isn’t right for me? Some of these might be:

  • Numbness
  • Lack of sensation when passing urine during the ride or after the ride
  • Soreness, whether this is in the genitals themselves, the perineum or the tops of the thighs
  • Saddle sores
  • Sexual dysfunction
  • Deformity to soft tissues

As a result, we have compiled a brief list of things to look out for and consider changing in order to make your cycling more comfortable and alleviate those unwanted pelvic symptoms.

 

 

Saddle

 

As we mentioned, some of the most common problems arise from the saddle itself. A decent saddle is worth its weight in gold. We have found that there are many factors that dictate which saddle will suit you best.

  • Saddle height – too high and you will rock on the saddle which will lead to possible chafing and friction
  • Saddle tilt – some saddles are actually designed to have a slight nose down tilt i.e. ISM. Others are supposed to be set up according to the middle third. As a result a lot of the saddles we see are often far too nose up!
  • Saddle fore/aft – too far forwards and too much anterior tilt can place a lot of pressure on soft tissues and thus shoulders. Consider moving the saddle further back to allow a neutral pelvic position and optimal load transfer through upper limbs
  • Riding style – if you adopt a more upright riding style you may want something slightly wider to support the contact points of your pelvis. Conversely, those who ride in a more aggressive position will need something that maximises pressure distribution otherwise soft tissues will take most of the weight
  • Sit bone width – this is more relevant for the recreational and upright riders, but women often have wider ischial tiberosities which may mean a wider saddle will help load bony prominences rather than soft tissue
  • Saddle “cutout” – many clients find relief from a small channel cut out which reduces pressure through the neural and soft tissues within the pelvis
  • Soft tissue anatomy – Cobb cycling have a very good article on “innies” or “outties”. It’s true that if you have more soft tissue exposed this will dictate what kind of saddle you will prefer.
  • Brands that we tend to find alleviate these problems are Cobb, Selle SMP, Specialized. It’s not that we don’t like other saddles, but when client’s have problems these tend to be the ones that resolve the issues

 

 

Pedals/cleats

If you have asymmetries in your pelvis (functional, leg length or you over pronate or supinate), this can lead to changes in how your hips and knees track. As a result this could cause chafing on one leg, or make you sit to one side. There are a variety of ways you can resolve these issues:

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  • Cleat wedges – these are small angular pieces of plastic which will change the angle of your foot. They can be stacked or layered to stop the foot over pronating or supinating, or to address small leg length discrepancies
  • Cleat shims – these are thicker pieces of plastic that can be stacked to reduce the severity of the leg length. Bikefit.com produce very good products
  • Insoles – to help the knee track and thus reduce compensatory strategies at the hip
  • Combination of in the shoe adaptations e.g. heel wedges and forefoot wedges – however these are space occupying so can be an issue
  • Cleats too far forward may also change your tipping point and cause you to come further forward on the saddle

 

 

Cranks

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Now the cranks are a widely overlooked aspect of bike fitting. It would be difficult to discuss them in great detail during this article, but what we do know is that the standard cranks that come on a bike aren’t always suitable for the rider on the bike. For example, we had a triathlete in recently who was approx 5ft 5 but running 175mm cranks! There are many reasons to pick cranks;

  • Leg length – it is suitable to pick cranks that roughly match the leg length of the rider NOT the height
  • Hip/knee flexibility –If this is lacking (or albeit even if it is not!) it is best to look for shorter cranks which allow you to pedal in a smooth motion, otherwise this movement often tracks back to the pelvis, where excessive rocking can cause shearing forces through soft tissue and thus pain!
  • Closed hip flexion positions lead to strains through pelvic floor musculature which can also impact on negative sensations and experiences

 

 

Handlebars

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The handlebar position can have a HUGE impact on symptoms at the pelvis.  If the reach is too short you may round your pelvis and put yourself in an suboptimal position, too long and you may put too much pressure through soft tissues. Too low and you will end up with the same problem, it might not be an issue for 30-60 minutes but over the course of a long ride this is when problems can manifest. You might also want to consider shallow drop handlebars to reduce the pressure when riding on the drops.

 

 

Other

  • Seatpost – Believe it or not, changing the seatpost can be a VERY good way to help reduce pressures through the saddle. If you are especially sensitive consider a carbon seatpost or something with shock absorption to help dissipate the energy that would otherwise end up in your pelvis

 

Specialized CG-R
Specialized CG-R. Cyclocross Magazine
  • Chamois cream – anecdotally clients whom have had pelvic pains report that chamois cream helps immensely, particularly when their mileage has significantly increased or they have started doing longer riders

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  • Decent chamois – do not underestimate the benefits of a decent pair of shorts! A well designed chamois will help reduce friction and pressure through sensitive areas. Personally I find something with a little extra padding more comfortable, but less padding suits others. It’s worth spending the extra money, believe me! (Just made sure you put them on the right way round!!!!)

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As this is just a basic outline on bike issues, we will be publishing articles that address each bike component separately.

If you have any questions for us feel free to email info@fityourbike.co.uk or contact us on Facebook http://www.facebook.com/fityourbikeuk

If you are interested in booking a bike fit, we operate clinics in Birmingham and Essex, and our fitter is female so perfectly placed to empathise with any pelvic issues you may be having!

Pregnancy: To exercise or not to exercise?

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Advocate for fun and accessible fitness for all. Get in touch @rachael_PT

Rachael Field Roddis – Personal Trainer, pre & post-natal qualified trainer and mom of one has taken the time to write a piece for Tom Astley Physiotherapy blog. So sit back and relax with a cup of brew before making those plans for returning to exercise:

 

The mentality of eating for two and giving up exercise during pregnancy has thankfully waned in recent years. If a pregnancy is without complications and the mum-to-be is clear of injury and/or medical conditions there should be no reason to prevent safe, appropriate and modified exercise all the way to full-term. Like any fitness programme it should be prescribed to suit the woman’s own health, lifestyle and fitness levels, we are unique and so is each pregnancy. Using my own pregnancy as an example, you can see from the first to the third trimester different physiological and biochemical changes just require exercise adaptations to workout safely.

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In the first trimester (0-12 weeks) training was hampered by sickness. Being sick on the gym floor was not going to make me any friends and so I trained less frequently due to the nausea and fatigue. One of the first valuable lessons I learnt about pre-natal exercise: “Listen to your body and don’t exercise to exhaustion.”

 

Changes in hormone levels require more care and attention to be taken when exercising. Asking the mum-to-be to look out for the signs and verbally screening before you start each training session is crucial. The hormone relaxin softens ligaments and connective tissues throughout the whole body, but is meant to primarily prepare the pelvis for delivery and cervix dilation. When I reached the second trimester (13-26 weeks) my joints started to feel unstable when running on a treadmill. To prevent injury I lowered the impact and used a cross-trainer. My flexibility increased and I had to be mindful of this when stretching and not taking exercises past the usual range of motion. Each woman will be different and some don’t feel these major changes but err on the side of caution at all times.

 

aerobics.jpgOn the homestretch, the third trimester (27-40 weeks) and more than anything the size of a woman’s bump will now probably dictate what exercise can and cannot be performed. For me it wasn’t the size of my bump but a change to my centre of gravity that forced me to adapt exercises. A lack of balance made it more difficult to perform exercises I’d usually find easy. To continue executing them I made modifications, for example by working unilaterally and using an inclined bench or wall for support.

 

Resuming exercise after the birth depends on the type of delivery and what happens during labour. At present it is suggested that after a vaginal delivery it should be at least six weeks and for a caesarean section it’s twelve weeks, to allow for post-operative healing. A medical professional must give the post-natal client the ‘all-clear’ before she starts exercising. I was grateful to receive an exercise sheet from a physiotherapist after the birth, which had safe gentle abdominal and pelvic floor exercises that I could do straight away. After the ‘all-clear’ from the GP it was a case of me creating time for fitness while adapting to motherhood and breastfeeding too.

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Pre and post-natal exercise has so many psychological and physiological benefits, why would we not promote it? As fitness professionals we have the ability to support, encourage and provide knowledge for risk-free enjoyable exercise during this remarkable period.

At Tom Astley Physiotherapy we advocate exercise participation through pregnancy and post-pregnancy, we can offer you pre & post natal Pilates classes in small groups lead by a qualified Physiotherapist – Anna Meggitt at Project: Me (N8 8JQ).

Contact us on 0203 659 3545 or info@taphysio.co.uk

 

The author and contributor to the blog, Rachael, also works in North London and is available for private personal training.

Contact Rachael on rachael_pt@yahoo.co.uk

 

Commonwealth Day #10 – Refection #5

Well the end is in sight for Glasgow 2014 Commonwealth Games and I’ve had a blast so much so I might go to Rio.

Working in the poly clinic as a physio to the athletes has been a once in a lifetime experience and taught me so much about the world of elite multi-sport events.

I have had the opportunity to work under a great physiotherapy in Lynne Booth and a fantastic team of physio’s from across the UK.

The next goal for me is to get My Physio in sport bronze award and then continue multi-sport event physiotherapy through UK Athletics and BUCS pathways.

Thanks for reading my previous blogs.

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Commonwealth Day #9 – Reflection 4

XX Commonwealth Games
XX Commonwealth Games

 

The 2014 commonwealth games is coming to a close within the next few days. The Glasgow platform has provided some amazing sporting outcomes and a great experience for athletes, team officials, and Clydesiders alike. As part of the medical services, working in the polyclinic has given me a taste of the multi-sport elite level competition, and whilst it is hard work, it’s certainly something I have thoroughly enjoyed.

 

The What?

I have learnt a lot from being in the polyclinic environment and working alongside some fantastic physiotherapists over the past two weeks. When an athlete is injured, they usually transferred to the polyclinic, from the field of play, to receive world-class treatment. However, what happens when the athletes doesn’t listen?

 

So What?

A netball player presented to the polyclinic with an acute ankle sprain, 2 days previously, she sprained her ankle competing. Treatment was provided to aid recovery but as part of my assessment, I enquired as to when she was competing next, the reply I received was ‘5pm today’.

As physiotherapists, we naturally want to promote activity and sports participation, but sometimes the body needs time to heal. The athlete always wants to play and the coach always wants their best players fit for action. The difficulty comes when the coach is present to hear your opinion about an injury or doesn’t choose to hear it.

I advised the netball player that should not play on her ankle in its current state, despite the fact that she had a game that afternoon, and this is why.

The ‘envelope of function’ (according to Dye, 2005): increase in activities (both frequency and intensity) leads to tissue loading outside the zone of physiological homeostasis
The ‘envelope of function’ (according to Dye, 2005): increase in activities (both frequency and intensity) leads to tissue loading outside the zone of physiological homeostasis

The tissues within the body are maintained in homeostasis through training and competing. The tissues and structures in the body are pushed into ‘supraphysiological overload zone’ when competing, which means that are optimised within the ‘Envelope of Function’. When these tissues are overloaded beyond the ‘Envelope of Function’, i.e an injury occurs, then tissues fail and break or rupture. due to injury, the envelope of function is reduced and tissue homeostasis is disrupted.

 

What this means in the context of the athlete competing, is that they have a reduced physiological ability to perform to their highest level, which would be needed at an international event like the Commonwealth Games. If the athletes does compete with a reduced ‘Envelope of Function’, then they risk further injury as the tissues get overloaded beyond the envelope sooner. The cycle of boom and bust can re-occur until the tissue is given sufficient time to heal and repair to restore tissue homeostasis.

 

Now What?

1) Communicating the importance of tissue healing to athletes is difficult but needs to be emphasised to avoid boom and bust cycle of injury.

2) Communicating the outcomes of clinical assessments to the athletes medical team should be done immediately to discuss return to competition but athletes want to play and coaches want their best players available for selection, so getting this message through can be difficult.

3) Treatment of injuries should be looked at in the short-term and long-term outcomes with the athlete at the centre of the treatment goals

 

Reference

1) Dye SF. The pathophysiology of patellofemoral pain: a tissue homeostasis perspective. Clin Orthop Relat Res 2005; 436:100-110.