Persistent Low Back Pain: The Physical Therapist’s Role

Low back pain is the most common cause of disability and lost work time in industrialized countries.   Persistent low back pain is characterized by periods of high and low pain intensity which can persist for years.  Periodic “flare- ups” are common and often result in the seeking of medical treatment.  Medications and surgery are often ineffective and may be harmful in some situations.  Physical therapy is a non-invasive treatment approach which is often considered in those with persistent low back pain.  However, improvements are often short-term for those with longstanding pain.  Similar to surgery and medications, the long-term success of physical therapy treatments for chronic back pain is questionable.

Traditional approaches utilizing physical therapy involve a short, but intense course of treatment such as 12 visits over a 4 to 8 week period.  However, this type of treatment approach is likely insufficient to positively influence a person’s beliefs and behaviors about their pain.  Changing these beliefs and behaviors are crucial if an individual with persistent pain is to self-manage through physical activity and lifestyle changes.

Persistent Low Back Pain is Complex

When pain persists beyond expected time frames, changes occur within our nervous system.  These changes include abnormal pain processing pathways and poor execution of movement patterns.  Because the nervous system is so complex, individual “pain experiences” vary greatly among those with persistent low back pain.  Diagnostic tests and scans, including MRI, are of little help because the primary problem is in the nervous system, not the low back.

The low back muscles of those with persistent pain undergo substantial changes over time.  This is believed to be caused by changes in the central nervous system.  These changes include atrophy (loss of muscle) and deposits of fatty tissue in the place of the lost muscle.  In particular the lumbar multifidus muscle has been shown to be selectively atrophied in many, but not all, individuals with persistent back pain.  Not only does the structure of muscle change with long-standing pain, but so does the nervous system’s ability to activate certain muscles.  Some muscles may become underactive while others become overactive.  These patterns differ among individuals with back pain making symptoms highly variable.   A common strategy is when many muscles of the low back contract simultaneously resulting in an unhelpful stiffening or bracing of the trunk.

Persistent Low Back Pain & Exercise

Altered pain processing pathways in the nervous system and changes in the back muscles leads to difficulty learning low back exercises.  A long term stimulus is likely needed to overcome atrophy of spinal muscles and to regain proper muscle function.  Performing low back exercise several times per week for 1 to 2 months is not adequate dosage.  Therefore, those with persistent pain may require repeated practice for several months in order to master the most basic of exercises.

In order to restore normal movement patterns exercise prescription must be matched to the individual’s beliefs and functional problems.  Ongoing types of cognitive interventions, such as education about the science of pain are beneficial to facilitate participation in exercise and physical activity.  An emphasis on education and a gradual progression of physical activity then becomes the long-term treatment.

The Role of the Physical Therapist in Helping Those with Persistent Low Back Pain

A recent episode of low back pain often responds well to manual therapy treatments such as mobilization, manipulation, or massage.  Sometimes, ice or hot packs can be helpful in these situations. However, passive interventions are of little help for those with persistent pain.  Instead, treatments that effectively involve the patient in long-term performance of physical activity are likely to be most valuable. These approaches seek to empower the patient by emphasizing their own preferred types of physical activities which can be progressed and modified as needed over time by the physical therapist.

There is no one-size fits all approach to prescribing exercise for those with persistent low back pain.  Core stabilization exercise receives a great deal of attention but this form of treatment is only helpful in some.  The same goes for stretching, resistance exercise, and aerobic exercise.  All these forms of exercise can be helpful in some but not all.  Therefore, the physical therapist and the patient should collaborate to develop an exercise plan which the patient finds enjoyable or preferable.  This is the only way the program will be adhered to for the long-term.

Final Thoughts on Physical Therapy for Persistent Low Back Pain

The traditional approach of attending physical therapy sessions 2 to 3 times a week for 4 to 8 weeks is not optimal.  Instead, the physical therapist and patient should seek to develop a long-term working relationship over time.  Initially, physical therapy sessions may occur multiple times a week but only for a few weeks.  Sessions should then be spaced out over time.  The physical therapist can assist the patient in progressing or modifying their exercise program at each session.

The physical therapists primary role is as a coach or guide who empowers the individual to self-manage for the long-term.   The ultimate goal is for the individual to manage and be prepared for fluctuations in their back pain.  Those with persistent back pain are ideally suited to directly access the services of a physical therapist without a physician referral.  In these instances, sessions are best when spaced out every few months or as needed.

Medications for Low Back Pain: Helpful or Harmful?

It has been estimated that half of Americans will experience low back pain each year.  Approximately 80% will experience low back pain at some point in their lifetime.  Now the good news: It is estimated that about 90% of those who experience back pain will recover well within a few weeks or months.  The other 10% may go on to experience chronic disabling back pain that remains resistant to treatment.   Identifying factors which may lead to chronic pain is a complex matter.   Some believe that controlling the initial intensity of pain is the key.  However, the research does not strongly support this idea.  In fact, efforts to control pain with medication may actually be more harmful than helpful.

Opioids, Low Back Pain, and Depression

Recent practice guidelines published in the European Spine Journal recommend against the use of imaging (MRI or CT scans), injection, anti-inflammatory medications (ibuprofen, etc), and opioids. These same guidelines suggest using patient education, exercise, and manual therapy should be the first treatments used for those with low back pain or sciatica.  Contrary to popular belief, research does not support the use of opioids for short-term pain relief in those with back pain or sciatica.

In the United States, there is a strong association between depression, low back pain, and being prescribed opioid medication.  Individuals with low back pain and a history of depression are more likely to be prescribed opioid medication.  Not only are individuals with depression more likely to be prescribed opioids, but the dosage these individuals are prescribed is twice as high per year compared to those who have no history of depression.  It is then reasonable to theorize that individuals with a history of depression are more likely to develop a dependency or addiction to these powerful medications.   Given the proven benefits of exercise for depression and low back pain, exercise should be used as a first line treatment for these individuals before considering prescription medication.

Muscle Relaxants and Low Back Pain

Muscle relaxants may offer a safer pharmacological option to manage back pain compared to opioids.  Research does suggest a potential short-term benefit to using muscle relaxants when pain is severe.  However, evidence is lacking to support the use of these medications for patients with low back pain lasting greater than 3 months.  Adverse reactions to these medications are usually minimal and similar to those experienced with placebo.

Anti-Inflammatory Medications

The best available evidence suggests a very small and non-significant benefit to using non-steroidal inflammatory medications for back pain and sciatica.  The benefits to using these medications for a new episode of back pain is questionable and the side effects can be severe.  The most serious side effects include ulcers, cardiovascular events (heart attack or stroke), and kidney failure.  If these medications are used, short-term doses should be used in order to minimize risk.

Closing Thoughts

I am not a medical physician.  I cannot prescribe medication and I cannot counsel anyone who is currently taking prescription medication.  However, I do hope that anyone taking prescription medication for low back pain understands the risks, especially with using opioids.  Please carefully discuss these risks with your physician.  Living an active medication-free life, with little or no pain, is possible and always a reasonable goal.

References

  1. Smith JA, Fuino RL, Pesis-Katz I, et al. Differences in opioid prescribing in low back pain patients with and without depression: A cross- sectional study of a national sample from the United States. Pain Reports. 2017;2:1-7.
  2. Ransmussen-Barr E, Held U, Grooten W, et al. Non-steroidal anti-inflammatory drugs for sciatica (Review ). Cochrane Database Syst Rev. 2016;(10):1-53. doi:10.1002/14651858.CD012382.www.cochranelibrary.com.
  3. Shaheed CA, Maher CG, Williams KA, Mclachlan AJ. Efficacy and tolerability of muscle relaxants for low back pain: Systematic review and meta-analysis. Eur J Pain. 2017;21:228-237. doi:10.1002/ejp.907.
  4. Stochkendahl MJ, Kjaer P, Hartvigsen J. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27:60-75. doi:10.1007/s00586-017-5099-2.

 

Five Exercises to Train the Abdominal Muscles

Abdominal muscle weakness and poor control of the trunk (or “core”) can negatively influence athletic performance and activities of daily living.  Poor trunk muscle strength has been associated with injuries in baseball players and several other sports.  Also, exercises to improve trunk muscle strength have been shown to improve soccer and distance running performance.  Trunk muscle weakness has also been linked to falls in seniors and low back pain in adults and children.

Exercises to strengthen the abdominal muscles and improve coordination of the trunk should be integrated into a comprehensive total body strength training program.  Training should never focus on any single muscle or body part.  In general, abdominal exercises should start in supported positions, such as supine lying, and progress to more functional positions, such as standing.  Exercises are predominately training for muscular endurance with short sustained holds (8 to 10 seconds) and a progressive number of repetitions.  As exercises become less challenging, the number of repetitions should be increased or the exercise itself should be progressed to a more challenging position.  The five exercises which follow are ordered from the most basic to the most challenging.

Dead Bugs

Begin in a supine lying position with the arms held straight up and the feet off the floor.  The hips and knees should be bent to 90 degrees.  Gently flatten the low back into the floor and maintain this abdominal contraction throughout the exercise.  Simultaneously raise the right arm overhead and extend the left leg without touching down.  Hold this position for several seconds and maintain low back contact with the floor.  Reverse the movement back to the starting position. Then, perform the opposite diagonal pattern with the left arm and right leg.  You should alternate sides with each repetition.  Maintain low back contact with the floor throughout the exercise.

Stability Ball Roll-Outs

Begin in a tall-kneeling position with both hands on the ball.  Roll the hands along the ball until the elbows or upper arm contacts the ball.  The elbows should remain extended as the hands and hips move together.  Engaging the gluteus and abdominal muscles help maintain proper position during the exercise.  As you lower the body towards the floor, maintain a neutral spine position and avoid arching the low back.  Hold this position for several seconds before reversing the movement back to the starting position.

Side Plank with Rotation

Begin in a side-lying position resting on one elbow.  Raise the trunk and knee off the floor until you are fully supported by your elbow and feet.  While maintaining the side plank position, reach up and then under and behind the body with the top hand.  This will induce trunk rotation and challenge the oblique abdominal muscles.  Hold this position for several seconds before reversing the movement back to the starting position.

Half-Kneeling Cable Chop

Assume a half-kneeling position next to a cable column or anchored resistance band.  The kneeling position removes contributions from the lower body and increases the demands on the trunk, pelvis and hip musculature.  From a balanced and upright kneeling position, pull the cable or band diagonally across the body towards the opposite hip.  Maintain a neutral spine and trunk position throughout the exercise.  Avoid rotating the body as your arms pull across the body.  Resisting this movement is what activates the abdominal muscles.  Hold this position for several seconds before reversing the movement back to the starting position.

Lateral Lunge with Press and Reach

This advanced exercise starts from a standing position next to a cable column or anchored resistance band.   Holding the handle or band close to the body; initiate the exercise with a lateral lunge.  Once the lunge position is attained, slowly press the arms straight out in front of the body.  The band or weight will induce a rotational challenge to the trunk muscles.  Resisting this movement is what activates the abdominal muscles.  Next, slowly raise the arms straight overhead while maintaining the lunge position.  Maintain a neutral spine and trunk position throughout the exercise.  Hold this position for several seconds before reversing the movement sequentially back to the starting position.

Closing Thoughts on Abdominal Exercises

Abdominal exercises are one component of a comprehensive exercise program targeting total body muscular strength and physical performance.  Abdominal exercises performed in isolation are rarely successful for improving performance or decreasing pain.  When developing your program, consider these five trunk muscle exercises.   Performing each exercise in a controlled fashion, with a focus on proper technique and muscular endurance will elicit the best results for the long-term.

References

  1. Chaudhari AMW, Mckenzie CS, Pan X, Onate JA. Lumbopelvic control and days missed because of injury in professional baseball pitchers.  Am J Sports Med. 2014;42(11):2734-2740. doi:10.1177/0363546514545861.
  2. Granacher U, Gollhofer A, Hortoba T, Kressig RW, Muehlbauer T. The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: A systematic review. Sports Med. 2013;43:627-641. doi:10.1007/s40279-013-0041-1.
  3. Reed CA, Ford KR, Myer GD, Hewett TE. The Effects of isolated and integrated “core stability” training on athletic performance measures: A systematic review. Sports Med. 2012;42(8):697-706.

Understanding the Hip Hinge: The Basics

The hip hinge is an important movement pattern for everyday life and athletics.  This movement is similar to “bowing” or bending at the hips while maintaining a flat spine.  The movement occurs at the hips which loads the gluteus maximus and hamstring muscles.  The hip hinge is characteristic of picking up a bag of groceries from floor or performing a maximal dead lift with a barbell.  Mastering the hip hinge takes advantage of the large gluteal and hamstring muscles while minimizing compressive loads through the low back.

Muscle Activity during the Hip Hinge

The hip hinge movement is controlled by eccentric actions of the hamstrings and gluteus maximus muscles.  These muscles are actively lengthening to control the “bowing” movement of the hip hinge.   Research has shown slightly greater activation of the medial, or inner, hamstring muscles during the hinge in comparison to the lateral hamstrings.  Also, in comparison to the squat, the hip hinge requires greater hamstring than quadriceps muscle activation.

The hip hinge also requires activation of the core musculature to maintain a neutral spine position.  The rectus abdominis and oblique abdominal muscles are activated at relatively low levels compared to the low back musculature.  The erectors spinae is the primary muscle required to maintain a neutral lumbar spine during the hip hinge.  The demands placed on the hamstrings, gluteus maximus, and erector spinae makes the hip hinge a great movement pattern to train the posterior chain.  The posterior chain is important for athletic success and to counteract the postural changes which occur as a result or aging or a sedentary lifestyle.

Adding Load to the Hip Hinge

Once the hip hinge pattern has been mastered, a kettlebell or dumbbell can be used to add load and build strength.  Begin by placing a light kettlebell or dumbbell on its end on the floor.  Stand over top or slightly in front of the kettlebell.  Place your feet slightly wider than hip-width with your knees slightly bent.  Keep your chest up, shoulders back, and abdominals tight.  Without bending your knees any further, push your hips back and lower your chest toward the floor.  Reach for the kettlebell, keeping your back straight and bending your knees only slightly.   The movement occurs at the hips, not the knees.   Once you can grab the kettlebell, pick it up and reverse directions by pushing your hips forward and squeezing your glutes.  Return the kettlebbell to the floor by hinging at the hips.

Closing Thoughts

The hip hinge can be a challenging movement pattern to master.  Many are prone to flexing or rounding the low back instead of moving through the hips.  This commonly occurs in everyday life when bending to the floor to pick up light or heavy objects.  A low back-driven pattern will increase demands on the lumbar spine structures instead of the much larger and stronger lower body muscles of the posterior chain.  This article highlights some of the basics to performing the hinge.  In future articles, we will outline exercises to improve the hip hinge movement pattern.

References 

  1. Andersen V, Fimland M, Gunnarskog A, et al. Core muscle activation in one-armed and two-armed kettlebell swing. J Strength Cond Res. 2015;30(5):1196-1204.
  2. Del Monte M, Opar DA, Timmins RG, Ross J, Keough JW, Lorenzen C. Hamstring myoelectrical activity during three different kettlebell swing exercises. J Strength Cond Res. 2018;Ahead Prin:1-17. doi:10.1519/JSC.0000000000002254.

Abdominal Oblique Injuries in Rotational Sports

Abdominal oblique injuries, also known as side strains, are common in rotational sports such as baseball, tennis, golf, and track and field.  These injuries are characterized by a sudden, sharp onset of pain near or on the side of the rib cage.  The injury usually occurs during some type of rotational sports movement such as swinging a bat, club or racket; or throwing a ball.

Trunk rotation plays an important role in generating and transferring power during sport.  It is through the trunk or core, that forces are transferred from the lower body to the shoulder and arms. Activities such as throwing and swinging require the core muscles to both stabilize the trunk and create force in order to transfer power to the upper body.

Anatomy of the Abdominal Oblique Muscles

The core includes the thoracolumbar, abdominal, pelvic, and hip musculature.  These muscle groups provide trunk stability to allow integrated limb movements, such as throwing and swinging, to occur. The abdominal core muscles include the rectus abdominis, transversus abdominis, internal oblique and external oblique.  Most abdominal injuries occur in the internal and external oblique muscles.  Less commonly, injuries can occur to the intercostal muscles between the ribs themselves.

The Role of the Oblique Muscles in Sport

The internal and external oblique muscles are responsible for flexion and rotation of the trunk, as well as providing trunk stabilization during complex sports movements.    Poor mobility of the hips or thoracic spine can contribute to excessive stress and compensation through the trunk musculature during swinging or throwing.  Rehabilitation often addresses hip mobility with manual therapy techniques performed by the physical therapist.  An imbalance between right and left side oblique muscles are also common is in sports such as golf and baseball.  This may place excessive forces through the lead side oblique musculature.  Finally, the large forces generated by lower body muscles (quadriceps and hamstrings) may overpower the weaker core musculature leading to injury during explosive sports movements.

The incidence of Abdominal Oblique Injuries in Baseball

A 2010 study in the American Journal of Sports Medicine investigated the incidence and trends of abdominal injuries in professional baseball players.  From 1991 through 2010, abdominal strains accounted for approximately 5% of all injuries in Major League Baseball.   Nearly half of these injuries occurred in pitchers.   These injuries occurred most often during the early part of the season.

In both pitchers and position players, the majority of injuries occurred on the side opposite to their throwing arm.  Pitchers missed, on average 35 days on the disabled list, while position players missed 26 days on average.  Players who receive steroid or PRP injections have been shown to miss more time from injury.   More than 1 out of every 10 sustained a re-injury during their career.  Most of these re-injuries occurred during the same or the following season.   As a result of these injury trends, many MLB teams have increased their focus on preemptive core and trunk strengthening exercises for all players.

Closing Thoughts

The incidence of abdominal oblique injuries is on the rise in rotational sports such as baseball and golf.   These injuries can result in substantial loss of playing time.  Proper training can prevent abdominal oblique injuries from occurring.  In a few weeks, I will post an article describing exercises which can help reduce the risk of sustaining an injury.  These exercises can also be part of a comprehensive rehabilitation program to safely return an injured athlete back to sport.

References

  1. Camp CL, Conte S, Cohen SB, et al. Epidemiology and impact of abdominal oblique injuries in major and minor league baseball. Orthop J Sport Med. 2015;5(3):1-8. doi:10.1177/2325967117694025.
  2. Conte SA, Thompson MM, Marks MA, Dines JS. Abdominal muscle strains in professional baseball. Am J Sports Med. 2010;40(3):650-656. doi:10.1177/0363546511433030.
  3. Nealon AR, Kountouris A, Cook JL. Side strain in sport: A narrative review of pathomechanics, diagnosis, imaging and management for the clinician. J Sci Med Sport. 2017;20:261-266.

Exercise is Medicine for Depression

Depression can be a short-term state or a long-term clinical disorder.  Depression as a transient mood state is characterized by feeling sad, discouraged, or unhappy. These feelings generally resolve over the course of a few days or less.  Depression as a clinical condition is a psychiatric disorder where certain diagnostic criteria must be met.  The diagnosis of major depressive disorder requires psychiatric evaluation by a qualified professional. The diagnosis typically includes at least several of the following: weight loss, sleep disturbance, agitation, fatigue or loss of energy, feelings of worthlessness or guilt, diminished concentration, and possibly recurrent thoughts of death.  Major depressive disorder is distinguished from transient feelings of depression by both the severity and duration of symptoms.

It is estimated that one in five adults will suffer from major depressive disorder at some point in their life.  The incidence is higher in women.  One in four adolescents suffers from depression and this increases the risk of depression later in life.   Depression has also been linked to obesity, diabetes, and heart disease.  All of these disorders, including depression, are on the rise in the United States.   These disorders are also commonplace in outpatient physical therapy clinics where individuals are recovering from injuries.  Perhaps, the knowledge and positive habits learned in physical therapy can assist those with symptoms of depression and chronic disease.  Follow-through with a long-term exercise program can produce meaningful changes in mood, physical health, and quality of life.   All of these benefits can be achieved without the adverse effects associated with other forms of treatment.

Conventional Treatments for Depression

Antidepressant medication is the staple treatment for symptoms of depression.  Approximately half of individuals with depression will respond favorably to prescription medications without side effects.  The other half will either not respond to treatment or suffer side effects from the medications such as constipation, sleep loss, blurred vision, weight gain, fatigue, nausea, and sexual dysfunction.

Treatment may involve individual or group counseling lasting several months. Psychotherapy has been shown to be an effective long-term treatment for depression.  This form of treatment is often used in conjunction with antidepressant medication for individuals with more severe depression.   Cognitive behavioral therapy is one form of psychotherapy which aims to identify and change negative thoughts in those with depression.

Exercise as a Treatment for Depression

As a stand-alone treatment, exercise has been shown to result in moderate to large improvements in depressive symptoms.  Research has also shown no difference in outcomes when comparing exercise to cognitive behavioral therapy.  When combining the results from four studies, no differences were found between the effects of exercise and antidepressant medication.  This is not to suggest that medication and psychotherapy are ineffective.  Instead, exercise may enhance the effects of these conventional treatments for depression.  And perhaps, exercise may even be able to replace them over time.

Type and Dose of Exercise to Manage Depression

Most studies showing positive effects with exercise have included some form of aerobic exercise.  Walking, jogging, and cycling are the most commonly utilized forms of aerobic exercise.  The optimal frequency of exercise has not been determined but most studies have included exercising 3-5 times per week.  Programs with higher energy expenditures have been shown to produce greater results but positive effects can be achieved with lower intensity programs. A good starting point is to perform short walks 3 days per week.   As aerobic capacity and confidence improve, exercise should be progressed based on the American College of Sports Medicine recommendations of moderate intensity exercise performed for at least 30 minutes 5 days per week.  As aerobic capacity improves, exercise intensity and duration should be progressed in order to continue to make gains.

Tips to Increase Chances of Success

The first challenge with any exercise program is simply taking the first step.  Starting small and gradually building up the intensity, duration, and frequency is a wise approach.  Expect minor setbacks along the way and do not be discouraged when they occur.  The antidepressant effects of exercise takes time.  Be patient.   Once you begin to notice small progress in your exercise capacity and overall well-being, momentum will start to build.  The key to long-term adherence is to stay disciplined and develop habits for a lifetime.  Below are a few tips to help you on your journey.

  • Pick a form of exercise you enjoy and stick with it
  • Invest in a good pair of sneakers to exercise in
  • Pick a time of day to exercise which works best for you and make this part of your daily routine
  • Set your own goals and track your progress
  • Anticipate barriers (fatigue, work duties, bad weather, etc) and develop solutions ahead of time
  • Team up with a partner or partners and you will be more likely to stick with it
  • Do not be discouraged if you miss one session. If you fall off, get right back on the next day.
  • Take a minute and appreciate how you feel at the end of each exercise session

Let us know if you need help getting started and best of luck!

References

  1. Blumenthal JA, Smith PJ, Hoffman BM. Is exercise a viable treatment for depression? ACSMs Heal Fit J. 2012;16(4):14-21. doi:10.1249/01.FIT.0000416000.09526.eb.Is.
  2. Cooney G, Dwan K, Greig C, et al. Exercise for depression (Review). Cochrane Database Syst Rev. 2013;9:1-125. doi:10.1002/14651858.CD004366.pub6.www.cochranelibrary.com.

Early Sport Specialization and Long-Term Athletic Success

Sport specialization is defined as year-round (≥8 months per year) intensive training in a single sport at the exclusion of other sports.   Early sport specialization refers to those who focus on a single sport before entering high school.  Advocates for early specialization propose that athletic performance in that sport will be better than the performance of those who play multiple sports.  These beliefs became popularized after several recently published best-selling books proposed a “10,000 hour rule” of practice for developing expertise in any given skill or sport.

The effectiveness of increasing the amount of early exposure to a single sport on athletic performance is questionable.  In fact recent research suggests those youth athletes who participate in multiple sports and delay specialization are at an advantage over those who specialize.  The long-term athletic development (LTAD) model provides a structured framework where youth athletes participate in multiple sports in order to maximize their full athletic potential over the lifespan.  Emerging research supports multiple sports participation and the LTAD model as methods to reduce injury risk and maximize athletic potential through high school, college, and beyond.

Early Sport Specialization & High School Athletics

Present day athletes are specializing in a single sport earlier than previous generations.  One recent study showed current high school athletes specialize at an average age of 13 years old.  Current collegiate athletes specialized at an average age of 15 years old.  High school athletes who specialize in one sport for more than 8 months of the year are 2 to 3 times more likely to suffer a lower body overuse injury.  Athletes who engage in baseball for more than 8 months per year are more likely to develop overuse arm injuries.  The repetitive nature of engaging in a single sport predisposes youth athletes to chronic injuries which will likely impact their career beyond high school.  Also, there is currently no evidence which suggests athletes who specialize in a single high school sport are more successful performers than multisport athletes.

Early Sport Specialization & Collegiate Athletics

A survey of Division I college athletes showed 16% specialized in 9th grade and 41% specialized in 12th grade.  This suggests the majority of NCAA Division I athletes were late to specialize in their chosen sport.  Therefore, early specialization does not appear to be necessary in order to succeed at the collegiate level.   Other research found college basketball players who specialized late in their playing career developed their skills and performance to a greater level than those who specialized early.    Several Division I college coaches have gone on record to state their preference for recruiting multisport college athletes.  Athletes who participate in multiple sports possess superior fundamental movement skills and are generally more “coachable” than single sport athletes.

Early Sport Specialization & Professional Sports

Professional athletes are now advocating for multiple sport participation in today’s youth.  Sixty-three percent of surveyed professional baseball players believe early sport specialization is not required to play professionally.  Only twenty-two percent of professional athletes from multiple sports would want their own child to specialize in 1 sport during childhood

NBA players who played multiple sports in high school participate in more professional basketball games throughout their career compared to those who specialized early.  These same NBA players who played in more games were less likely to suffer an injury compared to those who specialized early.  Also, those NBA players who specialize late demonstrate greater longevity in the league.

Approximately half of present day MLB players specialized prior to high school.  Those who specialized early sustain more serious injuries during their professional career compared to those who specialize late.   Youth baseball players should be encouraged not to participate in a single sport given the increased incidence of serious injuries later in their careers. To date no research suggests that early specialization is needed to reach the professional level of any team sport.

Closing Thoughts

Parents and coaches should encourage youth athletes to delay sport specialization as late as possible.  Athletes who specialize late are at least as likely to compete at high levels (college and professionally) as those who specialize early.  Also, those  who delay specialization are less likely to sustain injuries and more likely to achieve long-term success at the professional level.   Most importantly, encouraging multiple sports participation promotes long-term enjoyment of sport which will build health and fitness habits for a lifetime.

References

  1. Bell DR, Post EG, Trigsted SM, Hetzel S, Mcguine TA, Brooks MA. Prevalence of sport specialization in high school athletics: A 1-year observational study. Am J Sports Med. 2016;44(6):1469-1474. doi:10.1177/0363546516629943.
  2. Buckley PS, Bishop M, Kane P, et al. Early single-sport specialization and professional athletes. Orthop J Sport Med. 2017;5(7):1-7. doi:10.1177/2325967117703944.
  3. Post EG, Thein-Nissenbaum JM, Stiffler MR, Brooks MA, Bell DR. High school sport specialization patterns of current division I athletes. Sport Heal A Multidiscip Approach. 2016;XX(x):1-6. doi:10.1177/1941738116675455.
  4. Santos S, Mateus N, Sampaio J, et al. Do previous sports experiences influence the effect of an enrichment programme in basketball skills? J Sports Sci. 2017;35(17):1759-1767. doi:10.1080/02640414.2016.1236206.
  5. Wilhelm A, Choi C, Deitch J. Early sport specialization effectiveness and risk of injury in professional baseball players. Orthop J Sport Med. 2017;9:1-5. doi:10.1177/2325967117728922.

 

Baseball Stretching Drill to Restore Range of Motion between Innings

Baseball players will lose range of motion in their throwing shoulder and elbow following a pitching session.  This loss of range of motion becomes cumulative over the course of a season.   Range of motion deficits have been shown to increase the risk of arm injury in baseball players.  Baseball stretching routines performed over the course of a season can help reduce this risk.  Also, stretching drills during baseball games, or between innings, is another method to combat muscle tightness and loss of range of motion in baseball pitchers.

The two-out drill has been developed by researchers from the California State University in Sacramento, and world-renowned orthopaedic surgeon Dr. James Andrews.   These seven baseball stretching exercises can be performed in approximately one minute between innings.  During game situations, the drill is initiated after two outs have been recorded and prior to the pitcher taking the mound each inning.   Performing this drill has been shown to restore professional baseball pitchers shoulder range of motion back to pre-pitching levels.   The seven baseball stretching exercises are described below with a video to follow.

Baseball Stretching: The Two-Out Drill

  1. Internal rotation stretch. Place the non-throwing hand on top of the throwing elbow with the non- throwing forearm resting on top of the throwing forearm. The non-throwing arm is then used to produce an internal rotation stretch in the throwing shoulder by rotating the forearms down towards the ground. This stretch is held for 3 seconds and is repeated twice with approximately 1 to 2 seconds of rest between stretches.  Be sure to stay tall during the stretch and avoid holding your breath.
  2. Elbow extension stretch. Extend the throwing elbow with the forearm tuned up. With the opposite hand, pull the throwing hand so that the wrist is extended back. This stretch is held for 3 seconds and is repeated twice with approximately 1 to 2 seconds of rest between stretches.  Be sure to stay tall during the stretch and avoid holding your breath.
  3. Big arm circles. Perform big arm circles clockwise and counterclockwise for 5 repetitions each way.  Make the circles as big and fast but comfortable, with an emphasis on increasing range of motion.  Be sure to stay tall during the exercise.
  4. Small arm circles. Perform small, tight arm circles clockwise and counterclockwise. Movement is fast but at a comfortable pace.  Perform 5 circles forward, and 5 circles in reverse.
  5. Forearm touch. With the arms up out to the side and elbows bent, move the elbows in so the elbows and forearms touch.  Next, move the arms in the opposite direction until a mild stretch is felt in the front of the shoulders or chest.  Repeat 5 times continuously.
  6. 90/90 IR and ER. Begin with the arms up out to the side and elbows bent. Internally and externally rotate the shoulders as far as possible at a fast but comfortable pace. Repeat 5 times continuously.  Be sure to stay tall and breathe during the exercise.
  7. Trunk Rotation. Begin with the arms fully extended and out to the side.  Rotate your arms and trunk from side to side, through a full range of motion, to the left and then back to the right. Movement is fast but at a comfortable pace.  Repeat 5 times continuously.

Closing Thoughts

Performing the two-out drill with two outs will allow adequate time to prepare the throwing shoulder for the subsequent inning.  This may be a practical and effective means to preserve shoulder range of motion throughout the course of a baseball game.  Rest and avoiding excessive throwing is undoubtedly the most important factor related to reducing risk for arm injuries in baseball players.  However, the two-out drill may help maintain shoulder flexibility during a game, and perhaps over the course of a season.  Maintaining shoulder range of motion is just one small piece to minimizing risk for injury in baseball players.

References

  1. Escamilla RF, Yamashiro K, Mikla T, Collins J, Lieppman K, Andrews JR. Effects of a short-duration stretching drill after pitching on elbow and shoulder range of motion in professional baseball pitchers. Am J Sports Med. 2016;45(3):692-700. doi:10.1177/0363546516671943.
  2. Reinold MM, Wilk KE, Macrina LC, et al. Changes in shoulder and elbow passive range of motion after pitching in professional baseball players. Am J Sports Med. 2008;36(3):523-527. doi:10.1177/0363546507308935.
  3. Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med. 2011;39(2):329-335. doi:10.1177/0363546510384223.
  4. Wilk KE, Macrina LC, Fleisig GS, et al. Deficits in glenohumeral passive range of motion increase risk of elbow injury in professional baseball pitchers: A prospective study. Am J Sports Med. 2014;42(9):2075-2081. doi:10.1177/0363546514538

 

 

5 Arm Care Stretching Exercises for Baseball Players

The unique demand of throwing a baseball places a great deal of stress on the bones, muscles, and soft tissues of the arm.  Therefore, shoulder and elbow injuries are common amongst baseball players of all ages.  Repetitive throwing leads to adaptations in the bony structure and muscles around the shoulder.  Some of these adaptations are believed to be necessary in order to perform at a high level.  Other changes, specifically those related to muscle tightness, can increase the risk of sustaining an elbow or shoulder injury.   Therefore, it is important for baseball players, coaches, and parents to understand the rationale and best methods for stretching the muscles of the arm in overhead athletes.

Range of Motion in the Baseball Pitcher

The amount of shoulder external and internal rotation range of motion receives a great deal of attention in overhead athletes.  Repetitive throwing during a youth athlete’s period of peak growth induces adaptive changes to the structure of the upper arm bone.  The middle portion of the arm bone actually rotates backward in relation to the upper end of the bone or head of the humerus.  This is termed retroversion and it is believed to be a necessary and beneficial adaptation.  Retroversion of the humerus allows the baseball player to achieve greater amounts of shoulder external rotation, or layback, during the arm cocking phase of throwing.

Retroversion of the humerus will cause an increase in the amount of shoulder external rotation but a decrease in the amount of available internal rotation.  Again, this is believed to be a necessary adaption to improve performance.  Research suggests that the total arc of internal and external rotation range of motion is what becomes important.  The total arc of motion between the throwing and non-throwing shoulder should be within 5 degrees of each other (shown in the illustration below).  When greater discrepancies in the total arc of motion are present, stretching exercises should be performed to improve symmetry between sides.

Image result for total arc motion

The Basics of Stretching for Baseball Players

Baseball players have been shown to lose range of motion throughout the course of a single game and over the course of a season.  This loss of range of motion and flexibility typically occurs in the shoulder and elbow musculature.  Common muscles prone to tightness in baseball players include the rotator cuff, lattisimus dorsi, pectoralis major and minor, biceps, and triceps.  A regular stretching routine, performed 3-5 times per week, can help restore lost range of motion.  Also, a basic 10-minute stretching routine may potentially improve performance and decrease risk for an arm injury.  The stretching exercises presented here are a few baseball players should be familiar with.

Five Arm Stretching Exercises for Baseball Players

  1.  Cross-Body Stretch: This stretch addresses the posterior shoulder muscles which are prone tightness in overhead athletes.  The infraspinatus, teres major, and teres minor muscles can become shortened from repetitive throwing.  This stretch is performed lying on the involved side with hips and knees bent.  The involved shoulder and elbow are positioned in 90 degrees of flexion.  The hand of the uninvolved arm grasps the elbow of the involved arm and gently pulls it across the body.  Once a mild stretch is felt on the outside or back of the shoulder, this position is held for approximately 30 seconds.  The stretch is typically performed 2-3 times each session.

  1. Sleeper Stretch: The cross-body stretch has been shown to be superior to the sleeper stretch for improving shoulder range of motion in young baseball players.  However, the sleeper stretch is probably the more popular of the two stretches.  For this stretch, the same starting position as the cross body stretch is assumed.  However, with the sleeper stretch, the wrist and forearm of the involved arm are gently moved down towards the table.  Once a mild stretch is felt on the outside or back of the shoulder, this position is held for approximately 30 seconds.  The stretch is typically performed 2-3 times each session.   For most athletes, both the sleeper and cross-body stretch do not need to be performed.  My personal experience, and the best available evidence, suggests the cross-body stretch is the most beneficial for improving range of motion.

  1. Bench T-Spine Mobilization: Extension of the upper back is necessary to achieve the arm cocking position needed for throwing.  Without adequate extension of the spine, unnecessary stress will be placed on the shoulder or elbow.  This stretch also provides a nice stretch to the lattisimus dorsi and triceps muscles which can also limit overhead mobility. The exercise begins by assuming a kneeling position facing a bench.  Place your elbows on the bench in front of you holding a PVC pipe or dowel with the palms facing up.  Sit back, pushing your buttocks towards your heels, keeping your spine relaxed, until you feel a stretch in your upper back.  Be sure to engage your abdominal muscles to prevent excessive arching of the low back.  (I could have done a better job of this in the video below).  For an added stretch you can bend your elbows further past your head.  Hold this position briefly, and exhale fully.  Reverse the motion to return to the start and repeat 6-8 repetitins.

  1. Thoracic Spine Windmill: This is a great dynamic mobility drill to restore thoracic spine rotation and improve the flexibility of the lattisimus and pectoral muscles.  Begin on your side with both arms outstretched in front of you.  Place a foam roll under your top leg with the knee and hip bent to 90 degrees.  The bottom knee and hip remain extended throughout the exercise.   Reach forward with your top hand and then complete a large circular windmill motion as you rotate your entire upper body.  Keep reaching as if you were attempting to lengthen your entire arm.  Follow your hand with your eyes to ensure proper thoracic spine and rib cage movement.  The top knee and leg should remain in contact with the foam roll throughout the exercise.  We generally perform 6-8 repetitions on each side.

  1. Side-Lying IR/ER: This is a more advanced dynamic mobility exercise targeting the thoracic spine, rib cage, lattisimus dorsi, and pectoral muscles.  Start in a side-lying position with the arm to be stretched on top.  Place a foam roll under your top leg with the knee and hip bent to 90 degrees.  The bottom knee and hip remain extended throughout the exercise.  Initiate the movement by reaching with the lower arm up towards the sky.  Hold this position, reaching upwards, throughout the drill.  The arm to be stretched is then placed overhead with the thumb pointing down towards the floor.  Exhale fully at the top and then reverse the movement by bringing the arm down to the side.  As the arm is lowered the thumb position changes so it is pointing down towards the back pocket.  It is important that both elbows remain fully straight during the drill.  We generally perform 6-8 repetitions on each side.

Closing Thoughts

These five stretching and mobility drills address typical muscle flexibility problems baseball players present with.  As always, an individualized approach is always superior to ready-made one-size fits all programs.  Building arm strength through resistance training is also important for improved performance and resiliency in the baseball player.   Before engaging in any exercise program, those with a history of arm problems or those currently experiencing pain should first be evaluated by a physician, physical therapist, or athletic trainer.  Some players may require additional arm care strategies such as passive stretching and soft tissue mobilization techniques.

 References

  1. Bailey LB, Thigpen CA, Hawkins RJ, Beattie PF, Shanley E. Effectiveness of manual therapy and stretching for baseball players with shoulder range of motion deficits. Sport Heal A Multidiscip Approach. 2017;9(3):230-237. doi:10.1177/1941738117702835.
  2. Hibberd EE, Oyama S, Myers JB. Increase in humeral retrotorsion accounts for age-related increase in glenohumeral internal rotation deficit in youth and adolescent baseball players. Am J Sports Med. 2014;42(4):851-858. doi:10.1177/0363546513519325.
  3. Keller RA, De Giacomo AF, Neumann JA, Limpisvasti O, Tibone JE. Glenohumeral internal rotation deficit and risk of upper extremity injury in overhead athletes: A meta-analysis and systematic review. Sport Heal A Multidiscip Approach. 2018;Online:1-8. doi:10.1177/1941738118756577.
  4. Mine K, Nakayama T, Milanese S, Grimmer K. Effectiveness of stretching on posterior shoulder tightness and glenohumeral internal-rotation deficit: A systematic review of randomized controlled trials. J Sport Rehabil. 2017;26:294-305.

Total Hip Arthroplasty (Replacement)

Total hip replacement is a surgical procedure that is most likely performed on people who have severe osteoarthritis of the hip. Other possible reasons for a hip replacement include, rheumatoid arthritis, osteonecrosis, fracture, and bone tumor. Since 2003, the number of hip replacement surgeries performed has increased by 33% in the United States. The most common age groups receiving hip replacements are people over 70 years of age.

Hip Replacement: Anterior vs. Posterior Approach?

There are 2 main surgical options for a total hip replacement; a posterior approach and an anterior approach. The type of surgical approach is typically determined based on physician preference. The anterior approach is a fairly new procedure which requires the surgeon to cut less muscle which some believe results in a faster recovery time. The posterolateral approach has been done for a longer period of time. One of the biggest risks following total hip replacement is dislocation. This complication has been noted to occur with 1% of surgeries with anterior approach and 1.3% with posterolateral approach.

The Role of Physical Therapy

The typical course of treatment after total hip replacement could involve a short stay in the hospital and in some cases a short stay at an inpatient rehab facility. Upon returning home, a large percentage of patients undergo a period of outpatient physical therapy, which usually lasts 1-2 months. Outpatient Physical Therapy consists of a combination of manual physical therapy, supervised exercise to improve range of motion, strength training of the muscles around the hip, and functional exercises that are geared towards returning the individual to prior functional activities.  At least one study shows that physical therapy had a positive effect on patients after a total hip replacement with faster recovery times and an increase in walking ability. Another study also found that physical therapy allows for an overall increase in functional status for patients who have received a total hip replacement.

Closing Thoughts

Physical therapy following hip replacement surgery requires a team approach between the patient, surgeon, and physical therapist.  If you are considering undergoing a hip replacement, or have recently undergone this procedure, please call one of our physical therapists to learn more about your recovery and return to function.

-Dr. Tom Michaels, PT, DPT, OCS, CSCS

References

  1. Freburger J. An analysis of the relationship between the utilization of physical therapy services and outcomes of care for patients after total hip arthroplasty. Journal of Physical Therapy. 2000;80(5):448-458.
  2. Kishida Y et al. Full weight-bearing after cementless total hip arthroplasty. International Orthopaedics. 2001;25:25-28.
  3. Jolles B, Bogoch E. Posterior versus lateral surgical approach for total hip arthroplasty in adults with osteoarthritis. Cochrane Database Systematic Review. 2006:3.