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The Lowdown on Myofascial Release, aka Cupping

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Do you remember the red circles on Michael Phelps’ back during the 2016 Summer Olympics? Athletes are among the most popular groups of people to use Cupping, also known as Myofascial Decompression (MFD), to treat soft tissue injuries in order to reduce soreness and speed up the healing of overworked muscles, but it’s also safe for patients of all ages and activity levels.  Myofascial Decompression is a negative pressure technique used in conjunction with active movements which make biomechanical structural changes in order to improve muscle flexibility, tissue tension, joint mobility, strength, and pain.  Common myofascial treatments, such as stretching, soft tissue massage, and myofascial/trigger point are all common “compressive” techniques, while MFD is the only “decompressive,” negative-pressure technique.  The origin of myofascial decompression has ancient roots. Traditional Chinese Medicine cupping uses heat and glass cups to provide the decompression of the restricted area to treat pain, headaches and immune disorders. Traditional Cupping is passive, as patients are generally seated or lying down and the cups are left on for up to 20 minutes.  MFD, on the other hand, uses plastic cups with a handheld pneumatic pump instead, in order to create a negative-pressure vacuum inside.  While the cups are positioned strategically on the patient’s body for a shorter duration, the patient then takes the affected joint or joints through active and active-assisted ranges of motion, guided by the physical therapist, in order to further the effects on the myofascial tissue. Once the cups are taken off the patient’s body, soft tissue massage and muscle activations are implored in order for the patient to maintain their new range of motion, mobility, strength, or decreased pain. Myofascial decompression can be done to the same area no more than once per week.  In response to the negative pressure, the tissue underneath the cup(s) becomes ischemic (there is restricted blood supply). Once the cup is released, there is an increase in blood flow and microcirculation within the local area.  Blood re-enters the tissues, which produce endorphins and enkephalins that help regulate pain. The result is an overall increase in temperature within the tissue, leading to a reduction of hyaluronic acid viscosity. This allows for improved tissue and fascial gliding and mobility.  MFD can target both superficial and deep fascial tissue and research has shown that it can increase both a muscle’s length and its strength in elite athletes.  MFD therapy also relieves pain by acting as a counterirritant and a decompressor of any type of nerve entrapment or compression.  

Concussions Part 4: Concussion Treatment

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Following the diagnosis of concussion, patient and symptom-specific treatment is utilized to address the presenting impairments of each patient. It is a typical recommendation to implement activity modifications or restrictions during early management following a concussion. This period, which may last between 0-3 days, commonly involves recommendations for rest; altering school, work, and daily activities; limiting reading, television, video games, and computer use; and avoiding exertion, but decisions regarding these recommendations are based on symptom response. After this period of activity modification, presentation-specific treatment is typically implemented based on the patient’s symptoms and examination findings. Although treatments related to neck pain, vestibular-ocular dysfunction, and physiologic conditioning are commonly implemented in physical therapy, patient education, such as sleep and stress management strategies, and physician referrals are common in the management of patients with concussion. The video demonstrates various management strategies for several types of concussion seen in the physical therapy setting. Each treatment is specifically tailored to each patient to maximize their outcomes!

Concussions Part 3: Concussion Examination

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Patient and symptom-specific testing is crucial for identifying the subtypes of concussion presentations that may be present and determining the best treatment strategies. Here are some tests that are commonly used to categorize concussion. Symptom Assessment Examination begins with patient-reported symptoms utilizing a standardized, self-report symptom scale (pictured), which is vital for understanding and tracking symptoms following a concussion!   Neuro-cognitive testing Neuro-cognitive testing using tests, such as the King Devick Test (pictured), are vital for assessing visual performance, concentration, and memory. Physiologic testing Physiologic testing using the Buffalo Treadmill Test protocol, which is a standardized and progressive treadmill walking test is implemented for concussions to determine the impact of physical exertion on symptoms. Cervical spine testing Cervical spine testing that assesses posture, range of motion, muscle flexibility, joint mobility, and palpation for tenderness is used to determine if the neck is contributing to concussion symptoms that may include neck pain, dizziness, visual disturbances, and headache. Vestibular-ocular testing Vestibular and visual testing assess the status of the vestibular (inner ear) and the visual systems that are vital for visual tracking and focus and maintaining balance, which are often impacted after a concussion, resulting in difficulty reading, blurry vision, dizziness, and loss of balance.

How Technology Can Make You a Better Runner

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This ultra runner came to Elevate with knee pain that had him fully side-lined, plus hamstring pain he’d had for years.  He had BIG goals of fixing it all in time to run the world famous 100 mile Leadville Ultra. He worked with Co-Founder Dr. Meredith Soelberg PT, DPT, MBA, in our Running and Movement Lab .  High-speed cameras, research-grade Simi Aktysis software, and an in-depth knowledge of running biomechanics allowed her to critically analyze his running and re-train his movement.  She was able to dissect his running one frame at a time, uncover the flawed mechanics, provide the visual feedback and movement education (and the critical strength and mobility training too). He’s now back to 60+ miles / week,  20+ mile trail runs, and going strong!  LOOK OUT LEADVILLE!  HE’S COMIN’ FOR YOU! “Without the technology and analysis,” Dr. Soelberg points out, “we’re really in the dark about what’s faulty and contributing to the pain from a movement perspective.  The therapist’s naked eye cannot see the flaws.  And the runner cannot see what changes to make, or if they’re successfully making a recommended change.  Employing video gait analysis plus strength and range of motion assessments gives us the complete picture of the root cause(s) of the pain, and what, very specifically, to do about it.” The secret is out.  People come from hours away to do this in-depth analysis at Elevate!

Gait Analysis: The Serious Runner’s Salvation

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A Tool to Precisely Spot Stride Problems and Stop Joint Pain and Injury People who lace up their running shoes and pound the pavement have a roughly 50% chance of sustaining an injury that interrupts their training. Among marathon runners, studies have placed the injury incidence rate significantly higher, in some cases as high as 90%. It isn’t running itself that’s doing the damage, a growing number of physicians, physical therapists and exercise scientists say. It’s the way people run. Too many runners stride too far out in front of their bodies, or land with their legs at awkward angles. Anne-Michelle Barrett, a personal trainer and triathlon coach who lives in Sausalito, Calif., suffered a stress fracture in her left shin in 2010, then one in her right shin at the beginning of 2013. She says she wasn’t overtraining. She rested and wore an orthopedic boot for six weeks in 2010 and four weeks in 2013. “I coach running, personal training and triathlon, and even I was still struggling,” says Ms. Barrett, 37. Desperate to figure out what was causing the injuries, she signed up for a gait analysis at New York City’s Hospital for Special Surgery with Michael Silverman, a physical therapist and the coordinator at the hospital’s Tisch Performance Center. Mr. Silverman’s initial examination revealed Ms. Barrett had hyper-mobile hips, which can produce an unstable stride. Then Mr. Silverman had Ms. Barrett perform a series of leg squats. He also watched as she stepped slowly off a platform. During each motion her knees bent inward as her legs moved forward. Next, Mr. Silverman filmed Ms. Barrett running on a treadmill from several angles. When he slowed down the video and measured the angles of her legs during her stride, the likely source of the pain became obvious—big strides and landing on the inside half of her feet. This article originally appeared on the Wall Street Journal: September 22, 2014 https://www.wsj.com/articles/gait-analysis-the-serious-runners-salvation-1411428069

Concussions 101: Part 2 – Types of Concussions

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Concussion Types Not all concussions are alike! If someone sustains a concussion, what symptoms might we expect? Headaches, difficulty concentrating, fatigue, drowsiness, and dizziness are among the most common symptoms that may occur. However, not everyone will experience these symptoms at the same intensity, for the same amount of time, or even at all! The more we learn about concussions, the more we have identified that each person (and presentation!) is different and should be treated as such. Even though each case may have similar signs and symptoms, each person may respond differently to a concussion and the cause of those symptoms can vary between people. For instance, a headache is the most common symptom experienced after a concussion, but a headache can be caused by altered metabolic activity within the brain, impaired visual function, injury to the muscles and joints of the neck, fatigue, anxiety, etc. Luckily, due to increased research investigating concussions, we are more versed in concussions now than we have ever been before.   It is now clear that concussions are not a “one size fits all” diagnosis. Clinical research has identified multiple subtypes of concussions with different causes, presentations, and treatment options.   Concussion Subtypes The most common concussion subtypes managed in an outpatient physical therapy clinic include physiologic, vestibular, ocular, and cervical concussions. Physiologic concussion symptoms are the result of altered metabolic activity and energy demands on the brain and worsen with physical exertion Vestibular concussion symptoms originate from vestibular (inner ear) dysfunction and can cause dizziness and impaired balance Ocular concussion symptoms result in visual dysfunction that can cause blurry vision, double vision, and difficulty tracking objects Cervical concussion symptoms originate from structures of the neck including the muscles, joints, and ligaments and can cause neck pain and headaches Other concussion subtypes include post-traumatic migraine, cognitive/fatigue, and anxiety/mood, each of which is best managed with the help of other medical professionals. Post-traumatic migraine concussion symptoms include headaches, nausea, and sensitivity to light and sound Cognitive/fatigue concussion symptoms include fatigue, headache with cognitive demands, and difficulty sleeping Anxiety/mood concussion symptoms include anxiety, difficulty sleeping, and depressed feelings However, it is common that multiple subtypes present at the same time for a given individual, which is called a mixed concussion presentation. Therefore, it is recommended that a thorough clinical examination is performed to develop an individualized treatment program for the specific presenting conditions. Remember, every person is different, and every concussion is different!

Concussions 101: What You Should Know – A Four-Part Series

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Concussions have become a highly discussed and debated topic. Because of our increased awareness, the diagnosis of concussion has increased dramatically at all levels of athletics and in the general population. However, many athletes, parents, and even clinicians lack a good understanding of the underlying condition, the several types of concussion, and the appropriate ways to properly evaluate and manage the condition. WHAT IS A CONCUSSION? A concussion is a functional injury of the brain that results in altered metabolic activity within the brain. This alteration involves changes in chemical activity, increased energy demand, and decreased blood flow within the brain. Simply put, the combination of increased energy demand and decreased blood flow results in an “energy crisis” that impairs optimal function and leads to the symptoms of a concussion. Many of these changes occur within the first 24 hours of the injury, but some of these changes can persist for multiple weeks! Contrary to widespread belief, a concussion does not involve any structural damage to the brain or surrounding structures of the head and neck. Other injuries to the head and neck may occur in conjunction with a concussion but are not required to be diagnosed with a concussion, which is diagnosed based on the individual’s signs and symptoms. Therefore, if a concussion is suspected it is imperative to be evaluated by a medical professional that can guide appropriate care and rule out the possibility of a structural injury that may require diagnostic imaging. However, if a head or neck injury is not suspected, then diagnostic imaging is not indicated, and diagnosis is based on a thorough clinical examination. WHAT CAUSES A CONCUSSION? Concussions can occur through a variety of mechanisms. Although most common in impact sports, they can also occur in non-impact sports and in incidents such as motor vehicle accidents. Typically, a concussion occurs when an impact is made with the head, or the head and neck undergo a violent acceleration or deceleration motion. These motions can place stresses on the structures within the brain that result in injury and responds with altered metabolic activity. It is important to remember that a concussion does not always require a violent motion or loss of consciousness. Even seemingly innocent injuries can lead to a concussion! Furthermore, signs and symptoms do not always present immediately, so it is important to be aware of and monitor for the signs and symptoms and seek medical care if suspected. WHAT ARE THE SIGNS AND SYMPTOMS OF A CONCUSSION? Typical signs and symptoms of a concussion can vary between individuals. The most common symptom of a concussion is a headache, but other common symptoms may include: Additionally, symptom presentation and recovery can vary drastically between individuals and may be based on age, gender, activity level, and history of prior injury, among other factors. For instance, symptoms may be exaggerated in younger individuals due to an immature neurologic system. On average, professional athletes become asymptomatic in 1-2 days, collegiate athletes in 2-7 days, and high school athletes in 1-2 weeks! And, while most people recover in less than 2 weeks, approximately 20% of individuals take more than 3 weeks to recover! This is referred to as post-concussion syndrome and can lead to persistent symptoms that not only impact return to athletic activities but can impair mental performance and cause persistent pain. In these scenarios it is especially important to seek medical advice from a qualified medical provider that can accurately identify the type of concussion, contributing factors, and appropriate management options. WHAT TO DO… Now that you are more informed about the potential causative factors and signs and symptoms related to concussion, it is important to recognize when a concussion might be present and be evaluated by a medical professional if it is suspected. If sustained at a school-related sporting event this may be performed by the Athletic Trainer, but, if one is not present, a physician that specializes in concussion is a great option. They can decide if further testing is warranted and refer to Physical Therapy! As we will soon see in the next segment in this four-part series, a concussion is not as simple as we once thought, and Physical Therapy can be a fantastic treatment option to promote return to function.

Fruit: Nature’s Answer to Your Snack Cravings

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By Kyle Blix, CPT, Cert. Ace Fitness Nutrition Specialist Are you working hard in the gym but not seeing the changes you’re going for with your weight or body composition? It may very well be your diet–and more specifically, your snacks. Perhaps the greatest contributor to seeing results in with any exercise program is the diet. A week of hard lifting and strenuous cardio can be seriously undercut by poor food decisions. This is because food plays such a critical role in rebuilding the cells of the human body. As a personal trainer and nutrition counselor, I stress the importance of eating real, whole, unprocessed foods as much as possible, because they’re proven to be the most nutritionally dense and thus keep the body healthy and lean.(1) When strategizing for proper nutrition, one of the most helpful questions to ask first is:  What are the foods that you know, without a doubt, are holding you back? And more specifically, what are the snack foods that you’re eating in-between and after your meals? Often times people will get into a whole food diet only to go off the rails when it comes to their snack habits, which in turn can sabotage their progress of sculpting a lean physique. Here,  we turn to nature for the solution–fruit.  When used as a snack replacement, fruit is one of the easiest ways to keep your body healthy and lean without sacrificing flavor and satisfaction. Fruits are nature’s ultimate snack hack. To better understand just how fruit interacts with our bodies, we must address fructose. Simply put, fructose is fruit sugar. It’s a monosaccharide, the simplest form of carbohydrate, and thus it digests very easily.(²)  Fructose is also found in processed foods as well, more commonly under the name high fructose corn syrup (HFCS). It’s a cheap way to sweeten processed foods and is found in a variety of products. However, there’s a big difference between HFCS and natural fructose from fruit.  The negative effects of high fructose in the diet are known to cause metabolic issues, such as obesity, high blood pressure and type 2 diabetes. But the naturally occurring fructose in fruit is completely different. Unlike HFCS, fructose does not cause a rapid rise and subsequent drop in blood glucose levels, giving it a fairly low glycemic load. Glycemic load is the measure of how a carbohydrate impacts your blood glucose levels.(³)  Fruit has a fairly low glycemic load and contains a good amount fiber and water, which, when consumed together, help to mitigate the effects of fructose on blood sugar. For this reason, most fruits take a while to digest and hit the liver-insulin system slowly.(4)  This is beneficial because consuming foods with a low glycemic load reduce the chance of health problems like diabetes, hypertension, obesity and heart disease. Compare eating two apples, with a total of 38g of fructose sugar, to a can of Coke containing 39g of HFCS or cane sugar. One is going to keep you satisfied and fuller, and the other is going to cause a huge spike and crash. They both have completely different effects on the body. The nutrient density of fruits cannot be ignored. They’re rich in fiber, vitamins, minerals, as well as a plethora of phytonutrients and antioxidants. Plus they’re incredibly filling, and delicious. Fruits have been shown in multiple studies to reduce the risk for type 2 diabetes, heart-disease and as well as different types of cancer. In one particular study, research found that the risk of heart disease is reduced by 7% for each daily portion of fruit.(5) Fiber especially has many benefits. The soluble fiber found in fruits has been shown in several studies to reduce cholesterol levels as well as slow down the absorption of carbohydrates.(6)  This benefit carries over into weight loss as well, as fiber plays a critical role in increasing satiety, which in turn leads to consuming fewer calories. On the caloric front, fruits come with more good news! They’re relatively low in calories, which means you can consume a variety of fruits before coming anywhere close to what the average bag of chips would cost you, for example. The average apple comes in at 95 calories, a banana 100 calories, an orange 45 calories and a carton of strawberries at 145 calories. When you habitually eat fruit, you’ll be less inclined to turn to snacks that are devoid of nutritional value. To drive it home, the most useful way to work fruits into your diet is to use them as a complete snack replacement.  Fruits are nature’s ultimate snack-hack. Take any and all sweet snacks that you would normally eat after a lunch or dinner and simply replace them with a variety of fruits. For example, you could pack two bananas and a Tupperware of berries to take with you to work. Or toss them in a smoothie along with a plant-based protein powder for a meal replacement. They’re portable, tasty, and most importantly, incredibly nutrient-dense. You could even start with eating only fruit for breakfast and you would already be on your way to a much healthier day than if you picked a sugary cereal or a bagel. Armed with this knowledge, try incorporating more fruit into your diet combined with your exercise program to see those results you’re hoping for and realize the multitude of health benefits from fruit!   References: 1: Slavin, Joanne L., and Beate Lloyd. “Health Benefits of Fruits and Vegetables.” Advances in Nutrition 3.4 (2012): 506–516. PMC. Web. 16 Mar. 2018. 2: The Britannica – https://www.britannica.com/science/monosaccharide 3:Eleazu, Chinedum Ogbonnaya. “The Concept of Low Glycemic Index and Glycemic Load Foods as Panacea for Type 2 Diabetes Mellitus; Prospects, Challenges and Solutions.” African Health Sciences 16.2 (2016): 468–479. PMC. Web. 16 Mar. 2018. 4:Tappy L, Lê KA. Metabolic effects of fructose and the worldwide increase in obesity. Physiol Rev. 2010 Jan;90(1):23-46. doi: 10.1152/physrev.00019.2009. Review. PubMed PMID: 20086073. 5: Luc Dauchet, Philippe Amouyel, Serge Hercberg, Jean Dallongeville; Fruit and Vegetable Consumption and Risk of Coronary

Get Strong to Run!

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This week, we are sharing our favorite exercises for Getting Strong to Run! Inspired by our Elevate PT’s preparation for the LA Marathon this month, she is going to show some necessary strengthening exercises that are crucial to running injury-free. PHASE 1: Glute Activation Prior to a run, activating your glutes is so important in order to help stabilize the pelvis during your jog, and to reduce the load on your knees and lower legs. Isometric holds are important to allow higher focus on recruiting the correct muscles, and improving neuromuscular activation at the brain. Here are our 4 favorite glute exercises: 1. Side plank with Clam Hold 2. Single Leg Bridge Holds 3. Banded Squat Holds 4. Standing fire hydrants holds PHASE 2: Core Strength Having a strong core, especially with rotational strength, is so important for runners because it helps power and propel your run while also protecting your spine. A stable trunk is the starting point for *safe and efficient movement* and will also help protect your lower extremity kinetic chain while you run! Here are 3 of our favorites: 1. Banded Dying Bugs 2. Isometric Lunge with Diagonal Chop 3. Plank on medicine ball with Diagonal Mountain Climbers   PHASE 3: Leg Strength “Is strength training really necessary?” Research shows that adding strength training twice a week for 12 weeks improves speed by 8% and VO2max by 10% on average for endurance runners! Since running is a “single leg ballistic activity,” we really focus on single limb support strengthening. The split squat progression you see in the video works the calf as it’s progressed to the toe and then into a hop. Aside from glutes, calf strengthening is often a missed strength exercise, and an area of weakness that leads to injury in runners. Our top 4 exercises for Leg Day? 1. Banded Hex Bar Dead Lifts 2. Split squat, progressed to toe, progressed to ballistic hop 3. SL squat with a row 4. Crab Walks and Monster Walks

What is Achilles Tendinopathy?

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Achilles Tendinopathy is a common injury in runners and other athletes. It is generally classified as localized pain in the tendon and/or heel that is worse with increased loads through the tendon (a heel raise hurts more than standing, hopping feels worse than heel raises). People also usually report their symptoms are worse in the morning during the first few steps right after getting out of bed. Although this condition has historically been known as a “tendinitis”, it is now being referred to as “tendinopathy”. The suffix “itis” means “inflammation” and in this condition, there are generally no inflammatory cells present and causing the symptoms. Rather, it is more of a reactive process to overload. Tendinopathy refers to any problem within the tendon and its cells, and is therefore a more fitting name than tendinitis. Insertional vs Mid-Portion Achilles Tendinopathy There are two different forms of Achilles Tendinopathy and it is important to know the difference between the two of them because some of the exercises vary slightly for each. In Insertional Achilles Tendinopathy, there is generally pain where the Achilles Tendon inserts on the calcaneus (the heel bone). Performing a calf stretch, walking barefoot, squatting, and uphill walking may all be aggravating factors. In Mid-Portion Achilles Tendinopathy, the pain is generally located 2-6 cm above the heel. Aggravating factors may include running, heel raises, and hopping. If you think you may have Achilles Tendinopathy, it is important to have a thorough evaluation by a Physical Therapist so that they can rule out other potential causes of your pain, and help design an individualized rehabilitation program for you based on the Stage of Tendinopathy you are currently presenting in, what your personal goals are, what type of Achilles Tendinopathy you have, and any other biomechanical or movement issues that need to be addressed. What causes Achilles Tendinopathy? The single greatest cause Achilles Tendinopathy is training errors. Sudden increases in activity, mileage, speed, incline running, changing stride or cadence can all lead to tendinopathy. Remember, your body is always in a balancing act of load/wear and rest/repair. Increasing training load or activity too much without enough rest can tip your tendons too far towards the load/wear side of the spectrum and can cause tendinopathy. A good, general rule of thumb to follow is to not exceed increases in training load by more than 10% each week. That means that if you have been able to comfortably run 20 miles per week for the past month, then you can increase your next week’s mileage to 22 miles without increasing your risk of injury. Of course, each person is different and it is therefore advisable to track your training load with the help of a Doctor of Physical Therapy or Personal Trainer to make sure you are progressing in a safe and gradual manner. Some other risk factors for Achilles Tendinopathy include a previous history of Achilles Tendinopathy, recent injury, age, gender, muscle power/strength, poor dorsiflexion, excessive pronation, and weight gain. Another risk factor that often goes unmentioned is taking antibiotics from the Fluoroquinolone family. These medications are used to treat a range of illnesses including respiratory infections and urinary tract infections. Some of these medications commonly prescribed are Ciprofloxacin (Cipro), Gemifloxacin (Factive), Ofloxacin (Floxin), Moxifloxacin (Avelox), Levofloxacin (Levaquin), and Norfloxacin (Noroxin). This risk increases with higher dosages of the medication. When compared to other classes of antibiotics, fluoroquinolones demonstrate a 3.8-fold greater risk of developing Achilles tendinopathy/rupture. Patients treated with fluoroquinolones have a 1.3-fold increased risk of tendon rupture compared to those not taking them, and that risk increases to a 46-fold greater predisposition if patients are also exposed to corticosteroids simultaneously. Age greater than 60 also seems to increase the risk of tendon rupture with fluoroquinolone use. If you have recently taken, or are currently taking any of these medications, ask your Physician or Pharmacist for information about the increased risk of tendon ruptures while on these medications. It is also important that you tell your Physical Therapist and Personal Trainer if you are on (or have recently been on) any of these medications so that the necessary load modifications can be made. The body is constantly in an equilibrium between load (or use)/wear and rest/repair. Whenever you perform a bicep curl, for example, you are applying load to the bicep muscle and tendon. Throughout the performance of the curls, the bicep is subjected to loads which cause micro tears within the muscle belly. When you are done working out, and give your bicep time to recover, those micro tears begin to repair and then become adapted to the loads you have just subjected them to. The key here is that you must give your body ample time to recover between bouts of loading. The same is true in all bodily tissues. When you apply a given load, there is a period of wear and then the tissue needs time to recover and repair during which time it becomes adapted to handle the loads you applied to it. When the scale begins to tip too heavily towards the load/wear side without enough rest/repair, the tissues you loaded are at an increased risk of injury. In tendinopathy, when tendon loading exceeds the tendon’s capacity (you ask it to do more than it is able to at that particular point in time), without sufficient rest, it develops into a tendinopathic tendon which then becomes less capable of handling load. The Stages of Tendinopathy: Before delving into how to treat Achilles Tendinopathy, it is important to understand the different stages of tendinopathy. These stages are classified differently, but they are really more of a continuum with load being the main driver along the spectrum. The Reactive Stage: The Reactive Stage of Tendinopathy is the tendon’s immediate response to overload. It can be painful and irritable in this phase. This is something that many people have experienced. If you have ever spent a day walking around Disney Land and then noticed by the end of