It’s the holy grail of healthcare. How to turn back the effects of time on your body so that it doesn’t wear out and / or “groan” from the cumulative strain of a lifetime of life forces.
Imagine ageing without any associated physical pain. To contemplate such a possibility is almost absurd.
And yet, in theory and proven in real life, this possibility can become reality.
An Amazing Story About an Amazing Person
Let me explain.
May presented for treatment of her lower back pain at the age of 98. From her assessment, it was clear that May experienced back pain when she was sitting. Consequently, I recommended that May place a lumbar roll (back cushion) in the small of her back while she was sitting.
May then informed me that none of her chairs had a back on them as she only sat on stools. In other words, the cause of May’s lower back pain was the fact that she sat on stools with a slouched posture. Once corrected, her pain resolved within a couple of weeks.
It was then that I asked May “How would you like never to have to go into hospital or into a nursing home for the rest of your life?” to which May replied “Yes please”.
So we set about implementing a treatment program that would address and counter all the physical effects of ageing – the stooped posture, the specific muscle imbalance, joint stiffness, loss of balance and the faulty performance of everyday activities.
And you know what? We achieved it! Who would have thought that I would be treating May on and off for another 10 years. In that time, she never went to hospital (except for unrelated non-physical conditions) and never went to a nursing home (except for occasional respite).
Even more amazing was that May never had a hip replacement, nor a knee replacement and up until the last month of her life, she was still going out and playing bingo three times a week and catching up with her grand-children and their friends every Saturday for lunch.
What’s more, May lived at home independently at home until she passed-away surrounded by her family and friends.
It’s an incredible story about an incredible person. For me it was an absolute privilege and a great learning lesson.
Now, you might say that May had great genes and that might be the case. But, I like to think that the treatment program that we implemented also positively impacted May’s physical health so that she could stay mobile, independent and be able to perform her every day activities without limitation or pain.
Her story changed my perspective that getting old didn’t have to mean becoming disabled and dependent.
How could it be possible though to live to 108 and not need a joint replacement, let alone remain active and independent?
The Secret to Preventing, Reversing or At Least Slowing Ageing
The answer has to do with your body’s ability to heal and adapt to physical forces.
You see, your body is constantly changing with the forces being applied to it. Apply force that is within your body’s physiological limits and it will adapt positively by getting stronger, more resilient and / or more flexible. Apply forces that are outside its physiological ability to cope, it will cause breakdown of tissue. Apply no force and your body will waste away.
Your body actually lays down tissue wherever and whenever stress is applied and removes tissue whenever stress is taken away. Stress muscles, they get bigger. Remove stress from muscles, they get smaller. That is why it is often said “use it or lose it”.
The key to preventing, reversing or at least slowing osteoarthritis and the “ageing” of joints has to do with a concept called “The Path of Instantaneous Centre of Rotation”.
Many of the joints in your body are “ball and socket joints”. One end of the bone is like a ball that fits inside the hollow socket of the adjacent bone. And what “The Path of Instantaneous Centre of Rotation” means is that the axis around which the ball moves is perfectly located in the centre of the socket at any and every instant, no matter what position the joint is in or what movement your body is performing.
In this scenario, your prime mover muscles act like guidewires, pulling on your bones to move your body whilst your stabilizing muscles constant, precise tension keeps your joints in optimal alignment.
If one muscle is used more often as with performing a routine movement, it is likely to get stronger and pull earlier than the surrounding muscles. Likewise, if you stretch soft tissue for 20 minutes such as if you adopt a slouched posture, it will take at least 40 minutes for that tissue to regain its normal, pre-stretch characteristics.
Both these “adaptive” processes lead to muscle in-coordination, faulty bony alignment, joint stiffness or instability, inflammation and tissue breakdown. Once this process has begun, it is perpetuated and reinforced as these postures and movements become habits.
On the other hand, a variety of stresses such as what occurs with different postures and movement patterns, leads to ideal joint alignment and muscle balance.
Think about it this way. Imagine that your spine is the rim on a bicycle wheel and the spokes are your muscles. Pull too hard on one of the spokes and the rim is pulled out of shape. To pull the rim back into alignment, you need to tighten the loose spokes and loosen the tight ones.
How to “Reverse” Ageing
The same is true for your body. To “pull” your body back into ideal alignment, you need to tighten (strengthen) the loose muscles and loosen (stretch) the tight ones.
Likewise, your stiff joints need to be “freed up” with hands on techniques and your unstable or hypermobile (excessively mobile joints) need to be stiffened through the use of taping, bracing or by improving the control of your stabilising muscles.
Therefore, if you know the degrading effects of ageing (just have a look at the elderly people around you), then it becomes obvious what joints you need to free up (e.g. back, hips, knees and ankles), what muscles you need to strengthen (e.g. mid and lower back, gluteal and calf muscles) and what postures and movements (e.g. sitting, standing, squatting, walking) that you need to correct to reverse this process.
To reverse the ageing means to reverse this process of becoming stooped, stiff and dysfunctional. To achieve this isn’t necessarily difficult, but it does take a disciplined and graduated program of “hands on” techniques, specific muscle training and posture and functional movement correction.
No one technique or facet of treatment or training will achieve this end result by itself. It must involve a sustained, coordinated approach for at least 4 to 6 weeks.
Why? Because it takes at least 4 weeks for muscles to strengthen and for new posture and movement habits to form.
Do You Have a Software or Hardware Problem?
Having said all of this, you might be unable to achieve ideal forces on your body, simply because of the way that your body is.
You may have been born with one of many physical variations such as a long leg, a twisted spine, a bent back, a flat back, a Pidgeon chest, curved shin bones, high arched or flat feet.
In this case, you have a hardware or structural problem and no amount of treatment or training is going to absolutely correct this. Treatment and training may help bring your body back within normal limits, but it will never “perfect” your body’s\ alignment or mechanics.
For a structural problem, you need a structural solution such as an orthotic, a brace and sometimes even surgery. Although, in most cases, it is safer, cheaper, safer and more effective to start with the least invasive approach first. Surgery should be the last option when all else fails.
These structural variations may be genetic and therefore may be something that you can’t do much about.
However, in many cases, you may have a software problem. By this I mean that it may be a your core stability, body co-ordination, posture and movement habits as well as your diet, self-identity, perception and / or your way of thinking that lead to physical pain and ageing.
Left untreated for long enough and these software problems can become hardware problems as your body adapts to life forces and these adaptations become fixed.
This is why it is always better to be seen earlier rather than later and to have a complete and professional physical and functional examination to determine causes and identify sources of your pain and / or dysfunction.
How you age to a large extent is up to you. What will you choose? To stay active, independent, involved and connected or to become disabled, dependent and dysfunctional.
The choice is yours.
I hope that this helps.
If you have any questions or would like any advice, instruction or perhaps a complimentary, no obligation physical or injury assessment, please call 1 300 BODYWISE (263 994).
In the meantime, I wish you the best of health and life.
Rebates are available through your private insurance extras cover;
For complex or chronic conditions, you may qualify for the CDM (Chronic Disease Management) allowing you to receive 5 allied health services each calendar year with a referral from your GP. For more information, please call Bodywise Health now on 1 300 BODYWISE (263 994).
References Available on Request
When treating physical pain, there is one question that is rarely asked and even more rarely answered. Why? Why have I got back pain? Why have got neck pain? Why have I got knee pain? Even if a diagnosis is made and it is known to be the source of pain, no one ever asks “Why is my disc painful?” Why is my tendon painful? Why do I have arthritis?
Every day people tell me that they have been told that they have an injured tissue or structure and that they need to have medication, a cortisone injection, denervation, surgery or other passive technique in the hope that these interventions will solve your problem.
But unless you know why these tissues and structures have become painful, then your chances on getting permanent pain relief are at best remote. It is like putting a band-aide over a cut and then you keep cutting the area. You have simply “masked” the pain for a short time. Once the “effects” of the intervention have worn off, the structures will become painful again as you keep aggravating the damage or irritated tissue.
This point was born out in a research article titled “Effects of manual therapy and exercises targeting the hips in patients with low back pain” that was published in the Journal of Evaluation in Clinical Practice, January 2017.
This article indicates that low back pain and hip pain are becoming increasing associated and that together they cause greater pain at each site than if the back pain or hip pain existed in isolation. As yet, it hasn’t been determined which causes which. In other words, does low back pain cause hip pain or hip pain cause lower back pain.
But perhaps more importantly, what has been found is that treating and freeing up the hip has resulted in reduced lower back pain.
The bigger issue that this raises is the concept of regional interdependence. This means that even seemingly unrelated parts of your body can cause pain and injury in other parts of your body.
As physios, we know that stiffness of your ankles, knees and hips as well as tightness and weakness of your leg muscles can cause back injuries such as disc bulges, arthritis and stenosis. Why? Because stiffness in your leg joints will cause you to twist in your back every time you squat, get out into/out of the car or on/off a low chair.
Likewise, weakness in your leg muscles will mean that instead of squatting, you will bend at your back every time you need to reach low or pick something off the floor. This is not to say that you shouldn’t bend at you back. It is to say that you shouldn’t bend so much and that bending at your back hundreds if not thousands of times a day because you can’t squat will eventually lead to a back problem.
The more that these incorrect movement patterns become practiced, the more that they become habits leading to muscle imbalances, joint mal-alignment, joint irritation, stiffness and eventually more pain.
A quick scan test to see if your legs might be contributing to your back pain is a Squat Test. Stand with your feet pointing directly forwards, hip width apart. You should be able to squat all the way down to your heels and not allow your feet to turn outwards. If you can’t then this test is indicating that your leg joints are either stiff or your leg muscles are weak. This means that every time you get in / out of a car, or on / off a seat, you are likely to be compensating at your back.
Other commonly associated areas of your body that can cause pain include excessive turning in of your hips causing knee and foot pain, a stiff mid-back and weakness in your leg muscles can causing elbow and shoulder pain or poor hearing and vision leading to neck pain.
This is because one area of your body will try and compensate for other areas of your body that may not be doing their job optimally and it is these areas of compensation which so often become painful as they are trying to perform functions that they are not designed to do.
Another way of beginning to understand what the cause of your pain is, is to identify what you are doing or what have you just done when your pain comes on.
Are you sitting, getting out of the car, gardening or putting on shoes and socks, in which case it maybe bending and / or the way that you are performing these activities which are likely to be the cause of your pain. Or are you walking, in which case it may be arching your back or something to do with placing weight on your legs that may be the cause of your pain.
Then we get to be detective. What is it about these activities and the interactions of your body which is causing your pain? Are your calves so tight that they pull you backwards as you stand, causing you to bend slightly forwards to compensate and it is this constant slight bend forwards that then causes a disc bulge which leads to your lower back pain?
What’s even more frustrating is that these faulty ways of “being” have become such ingrained habits that you may have no idea that they are doing you harm until it’s too late and you are injured and in pain.
Many people will say that their parents had the same problem or that they were born this way. And it is true that you may have unique physical structural characteristics that may cause problems. One long leg, excessively arched or flat feet, twisted, bowed or knock kneed knees, turned in or out legs, an excessively curved or flat back, tall pelvis, a wide pelvis and / or wide shoulders, pigeon chest and so on, all have particular physical effects that can lead to pain and loss of function. Some might need a structural solution such as orthotics, bracing or worse-case scenario, surgery.
The way that you then perform your daily activities will often make the effect of these “variations” worse. This is because it takes awareness, discipline and perseverance to correct the detrimental effects of these physical forces on your body.
As your body follows the path of least resistance, it is so much easier to “go with” these forces than to oppose them. This means that not only will any negative effects be perpetuated, they will worsen over time making a chance of complete recovery more and more remote.
However many times, even these physical variations and incorrect movement patterns can be adequately addressed with “hands on” treatment, movement correction and physical training.
“Hands on” treatment by itself however, is not intense enough to create any sort of lasting improvement as it causes just a short term change in soft tissue tension levels and joint mobility.
In addition, exercise training by itself is also inadequate, because it is not specific enough to create change or increased mobility at the specific areas which have become stiff.
And finally, posture and movement retraining by itself is also inadequate because joints may be too stiff or unstable and muscles may lack the strength, endurance, co-ordination and control for ideal postures and movement patterns to be adopted in the first place.
To achieve permanent pain relief and sustained improvement in your ability to live pain-free and without limitation, requires a program of “hands on” techniques, corrective rehabilitative exercise and optimal posture / movement pattern retraining.
And yet, this program will also be adequate, if it is not intense enough to change the excessive or abnormal mechanics and the postural movement habits that have created them, permanently.
Treatment / training once a week is simply not going to be intense enough. There are at least 167 other hours during the week, when all the benefits from treatment can be undone.
It takes at least 4 weeks for your muscles to get stronger and at least 3 to 6 weeks for you to develop new, correct posture and movement habits. treatment / training must therefore be at least 2 to 3 times a week for at least 4 to 6 weeks to get a result. But the beauty of this approach, is that once you have achieved an improvement, it is more likely to be permanent.
Not only does this mean that you will prevent further flare-ups and the possibility of re-injury, you will actually perform every day movements better, with more freedom, strength, control and confidence as well as with less fatigue.
Even better, you will have increased your capacity for living, giving you a reserve capacity that will enable you to perform unfamiliar activities or to keep going safely when physically challenged.
Whilst this approach does take more effort, time and work than passive approaches, the benefits of being set free to live without limitation and without the need for medications, injections or surgery are worth it.
Until next time, Stay Bodywise,
Director Bodywise Health
Bade M, Cobo-Estevez M, Neeley D et al. Effects of Manual Therapy and Exercise Targeting the Hips in Patients with Low-Back Pain – A Randomized Controlled Trial; Journal of Evaluation in Clinical Practice 2017; 23(4): 734-740. doi: 10.1111/jep.12705. Epub 2017 Jan 27.
Ah yes, January 3 and probably most people have already failed in their New Year's Resolutions. If your one of them, don't be disheartened. You are working against the forces of neuro-anatomy, neuro-physiology, neuro-psychology, physical forces and both overt and covert social pressure.
There is no doubt that as we start the New Year, many of you have the best intentions to make this year better than the last. To lose weight, get fitter, become more organised, be more effective and enrichen your relationships, might be just some of your hopes for this year.
And yet, even with the best of intentions, you need to know is that will-power by itself often won't work. Why? Because for however many years that you have been alive, you have been reinforcing nerve pathways in your brain, physical and physiological adaptations in your body as well as social and environmental constructs that will all work to maintain the status quo. Even your self-perception holds you back. The exponential growth in lap-band surgery is a testament to this.
You see, your brain and your body don't have delete buttons. You can't simply just erase memories and start again. Your thoughts, words, actions, experiences and perceptions, all leave a trace "memory". As I so often say in the workshops that I present, you are a reflection of the way that you live. You reflect not just what you do but how you do it. In many ways, we are manifestations of our habits. So to change a habit we essentially have to change ourselves. Not easy to do.
As a physio, I know that many aches, pains and physical problems that people suffer is a result of incorrect postures and faulty movements habits that people have been doing all their lives. These lead to excessive or abnormal forces on body tissues and structures, creating micro-trauma which leads to tissue irritation, inflammation and tissue breakdown or degeneration.
I know that if I ask someone to stand differently or move differently, I have "Buckley's" chance of them doing what I have asked. They can may be do it for a day or two but not forever. And yet, if I am to help someone achieve a permanent pain relief or a permanent improvement of their health status, this is what needs to happen.
One of my key learnings is that pain is the potent driver of human activity. You see it all the time. What do you do if you have hurt your leg? You limp. And if you limp for long enough, even if your leg gets better, you will continue to limp. Essentially, limping has become the way that you walk. So how do I stop you from limping? I teach you how to walk correctly with crutches so that you never learn to limp in the first place.
This principle of pain to drive change can also be used to your advantage. To help correct posture and movement, I tape people. This not only supports the injured tissue, hastening healing, but also makes it uncomfortable to stand or move incorrectly. The new correct posture and movement then creates new behaviours which begin to forge new neural pathways in your brain. If the new, correct behaviours can then be reinforced over the next four to six weeks they can become lifelong habits, enabling you to experience less pain, better performance and greater energy, for the rest of your life!
So the question is, as you begin the year full of hope of keeping your New Year's resolution, what is your "tape"? What is your pain and how do you use that to your advantage? Is it the threat of the loss of your health, the loss of relationships, the loss of time, the loss of your ...? Is it that you will be held to account by your accountability partner, whether that be a family member or friend?
Whatever your "tape" is, it always pays to take stock of where you are at, so that you can measure and track your improvement over time. Your improvement then becomes your reward and serves to motivate you, creating a groundswell of momentum propelling you towards your goal.
To help you determine your baseline physical health status, we are offering FREE Physical Examination for the month of January.
If injury or pain is holding you back from beginning your quest for better health, then we will throw in an injury assessment for FREE. So what do you have to lose except another year of your life not living to your full potential?
Call 1 300 BODYWISE (263 994) to book your FREE Injury and Physical Assessment today. It might just be the best New Year's Resolution that you could make.
We look forward to helping you get your life back.
Until next time, Stay Bodywise,
* Yes, Bodywise Health is open throughout the holiday period;
* Rebates are available through your private insurance extras cover;
* For complex or chronic conditions, you may qualify for the CDP (Chronic Disease Program) allowing you to receive 5 allied health services each calendar year with a referral from your GP. For more information, please call Bodywise Health now on 1 300 BODYWISE (263 994).
In this age of blogs, podcasts, TV shows, radio programs, magazine articles and Dr Google, it is amazing just how many people perform strength exercises which are at best doing little to enhance their strength and at worst, making them more injury prone. So here are 10 principles that you can use to enhance your strengthening exercise program so that you can "Get Better, Stay Better and Live Better".
Principle 1 - No Pain No Gain Is a Myth - Train But Not Into Pain
Understand that pain means danger and to change how you are doing something or you will cause injury. To train into pain is not only foolhardy but it doesn't work. Why? Because your brain will inhibit and / or impede your muscles from contracting so that you don't injure yourself. This is called "pain inhibition". A great example of this is watching an arm wrestle. Often there will be a great struggle between opponents until one person's arm suddenly gives way.
High intensity strength (load) training should only be used by people who have been training for more than one year or with people who have trained up to this intensity during rehabilitation from injury (e.g. eccentric training for tendinopathies). It should never be used people in the acute stage of injury, beginners and / or with children (until well into adolescence).
Respecting pain is especially important when treating injuries. Use pain as your guide and remember if you always work short of pain, you will be unlikely to flare-up your injury. Having said that, there is no doubt that a progressive strengthening (loading) program is one of the key stimulants to tissue remodelling and maturation. This means that strengthening and placing tension on a repair becomes important towards the end of the proliferation phase of healing (about the 10 - 14 day mark) to align and strengthen healing fibres along lines of force.
Principle 2 - Stabilise First
"You can't shoot a canon from a canoe." In other words, you can't perform strong, dynamic movements off a flimsy and unstable base. And there are many reasons why supportive, stabilising muscles stop working as well as they should.
Remember, these are the small muscles that attach closely around each joint to hold the joint surfaces in optimum contact so that they form a strong, stable platform. The more stable your platform, the more resistance or weight that you can lift and the stronger you will get.
Pain, swelling, inactivity, poor postures, repetitive movements can all reduce the activation of these muscles leading to joint instability and potentially injury. Research has shown that these muscles do not begin working again without specific training. They must be specifically targeted and activated.
To stabilise, "pre-tension" or contract all the muscles around your joints to what is maximally comfortable. Even better, position yourself correctly by having your knees slightly bent, feet apart and on a slight diagonal. Then, stabilise your whole body by drawing your stomach in, your pelvic floor up and slightly tuck in your chin.
Principle 3 - Isolate
As mentioned above, pain, swelling and general deconditioning, can all act to stop muscles from being effectively activated. And just because you perform a movement, doesn't mean that these muscles start working again. They need to be "woken up". Research has shown that not only do these muscles need to be trained specifically to begin working normally again, but that if they're not, people will begin to substitute other muscles and use incorrect strategies for movement which may eventually lead to injury.
To isolate a specific muscle for strengthening, you need to know what the muscles attachments are as well as the precise movement that the muscle performs. For example to best strengthen your biceps, muscle on the front of your upper arm), you need to start with you hand turned with the palm facing backward and then turn to bring the palm forwards to the front of the shoulder as you bend your elbow only.
Almost all muscles have a rotation component as well as an angle and direction at which they are best activated. Know these and you will better target that muscle for strengthening.
Principle 4 - Activate
The more nervous impulses that enter a muscle and the more effectively and efficiently muscle fibres are activated, the faster your muscles will adapt and get stronger.
Here are a 5 of tips to engaging your muscles better.
1. "Tension" or contract your muscle first to what is maximally comfortable.
2. Hold the muscle at this maximum tension throughout the movement and do not allow it to be turned on during shortening of the muscle and off during the lengthening of the muscle.
3. Perform the movement slowly engaging the muscle with maximum tension and use holds at different parts of the movement.
4. Understand patterning. In other words, position your body to better activate the muscle. For example, if you hold your hand open and backwards whilst trying to perform a bicep curl, you will be less effective at activating the muscle than if you tension your fist and hold your wrist slightly forwards.
5. Know how to use your breathing to assist with stabilising your body but not so much as to increase the pressure within your body to dangerous levels. Some authors have suggested that better results from strengthening may be achieved by breathing in during bending or closing down movements and by breathing out during straightening or opening up movements.
Furthermore, if you hold your breath just to a catch point (most difficult point of the contraction) the increased abdominal pressure will assist in stabilising your spine. However, to prevent possible adverse effects of this pressure, you must breathe out just after this point to release this pressure.
Principle 5 - Use Feedback
Mirrors are not just there to show you how good you look! Visual feedback along with the voice and touch actually play a crucial role in ensuring the correct technique, maximum activation and optimal performance that is needed for the best results.
This feedback can be gained from mirrors, a coach or partner and even your own fingers placed on then muscles that you want to contract. It is especially vital early on when learning an activity, as generally the more the better feedback, the better and faster you will learn.
It has been said that to learn a new skill requires about 300 to 500 repetitions and can take about a month. However, to correct a poorly performed skill with a better technique can take about 3,000 to 5,000 repetitions. Learn how to perform exercises and activities correctly the first time. It can save you weeks and months of poor results as well as the possibility of injury.
Principle 6 - Integrate
For better transfer of strengthening over to everyday life, isolated strengthening exercises must be followed strengthening exercises that use these muscles in functional activities. Muscles must work in co-ordination to perform an activity to achieve a result and the only way to improve at these functional activities is to practise and progress them.
There are seven types of movements that are the basis for most of the activities that we do. They are bending, twisting, pulling, pushing, squatting, lunging and ambulation (walking / jogging / sprinting). I call them Primary Movements as they are the movement patterns that you need to be able to live and function optimally.
To get better results, follow an isolated strengthening exercise with the functional strengthening of the muscle in a related everyday activity in which it is used. This will enable you not just to look better but to live better as you will have greater strength and co-ordination in the activities that you do every day. Examples of this might be to follow a knee extension strengthening exercise with a double or single leg squat.
Principle 7 - Automate
You can't live by thinking about activating every single muscle during every single movement. To live effectively, correct muscle activation and movement have to occur automatically and without thinking. This means that you must train your brain as much you train your muscles through performing these exercises with varying speeds, directions, amplitudes and on varying surfaces, progressing from very stable to unstable.
You must keep your brain guessing by progressively reducing feedback to the point that your brain is literally anticipating and automating muscle co-ordination and movement without the need to think about contracting muscles consciously.
Break the seven Primary Movements into their component parts and then combine them again and progress them with ever increasing levels of co-ordination, speed and agility demands. Activities such as learning to balance standing on one leg. Then progress this by standing on your toes, then squatting, hopping first up and down and then at different angles and speeds whilst catching a ball. You are only limited by your imagination.
Principle 8 - Think Anti-Gravity
There's one thing for sure as you get older and that is that it will get more difficult for you to be up straight. Take note of the posture of our senior citizens and you will get an idea of where you are heading.
There are many reasons why people might be bent forward; genetics, habits, occupations, poor balance, may all play a role. And sometimes inadvertently you can make things worse through your strengthening program. As you only see and focus on the front of your body (chest, abdominals), this means that you are more likely to strengthen the muscles that by actually pull your body further downward and inward.
It then doesn't become too difficult to know what muscles you need to strengthen; the front of your neck, your upper and lower back, your buttocks, quads and calves. If you biased your strengthening towards these areas, you will enhance your ability to be up straight as well as perform anti-gravity activities such as standing from sitting, walking up stairs and climbing.
Principle 9 - Measure, Adjust and Progress Strength Your Training
There is an old saying, “You can only manage what you measure”. Unless you take initial and ongoing measurements, you won’t have any criteria to know if what you are doing is helping or not. You won’t really have any idea as to what is working and what isn’t and therefore you won’t have any guidelines as to how to refine your strength training to give you the best results.
And yet, only if the effect of your strength training is monitored and measured, can it be appropriately adjusted and progressed.
It has been said that the definition of insanity is doing the same thing over and over again and expecting a different result. And yet, this is exactly what people do. It doesn’t make sense to waste your time and money on doing the same thing over and over again for no change.
If you have a strength and / or health outcome that you want to achieve, you must first define what the result that you want to achieve is, set a path for achieving your goal (Recovery Action Plan), test frequently to ensure that you are on track and make training adjustments as circumstances change to ensure that your training is maximally effective.
Principle 10 - Have Fun
Whilst exercise takes effort and energy, it doesn't have to be and shouldn't be boring. Find activities that you love to do and add some resistance and holds to them. Get outside and enjoy the great outdoors. Rock climbing, stair / ramp climbing (1,000 steps) and walking / jogging with strength interval stations can all be great fun. Mix it up. Explore different locations and different surfaces. Ever tried to walk or jog in soft sand? Go trail walking or running. Find a friend to share your training with and you might just double the fun. Not only is variety optimally beneficial for your body, it is healthy for your mind as well.
If there is one thing that we are all short on these days its time. Don't waste your time by doing ineffective, inefficient strengthening exercises. Use these techniques and strategies to enhance your program and you will enjoy the benefits of looking younger, feeling stronger and performing better in all areas of life.
If you want to overcome injury, if you want to eliminate pain, if you want to get your health and your life so that you can begin enjoying your life more, call Bodywise Health on 1 300 BODYWISE (263 994) for a complimentary*, no obligation assessment and Recovery Action Plan from one of our expert physiotherapists.
We look forward to helping you get your life back.
Until next time, Stay Bodywise,
* Rebates are available through your private insurance extras cover;
* For complex or chronic conditions, you may qualify for the CDM (Chronic Disease Management) allowing you to receive 5 allied health services each calendar year with a referral from your GP. For more information, please call Bodywise Health now on 1 300 BODYWISE (263 994).
How to turn back your body clock,
become pain-free and,
regain your strength and agility,
in as little as 6 weeks
Does This Sound Like You?
You’ve had a nagging pain in your back, neck, shoulder, knee or some other part of your body for at least a couple of weeks if not months. You either can’t remember how it came on or it came on with the most minor of movements like getting out of the car, gardening or reaching forward to pick up something. It’s not getting better. You check out Dr Google. There seems like it could lots of possibilities. Perhaps it’s this problem or that. You don’t what to get it wrong or do the wrong thing.
You go and see your doctor who doesn’t even look at where you hurt but says to take these medications and that your pain will get better in time. You take the medications. They help take away your pain – for a short time. But in the process they bind you up and make you feel awful.
You go back to see your doctor who sends you for an x-ray, ultrasound, CT or MRI scan. The scan costs a couple of hundred dollars but at least you will find out what the cause of your pain is right. Wrong! The scan findings are grim. You have arthritis, degeneration, a bulging disc, a torn tendon or “bone on bone”. Then you find out that often at least 40% of people who have no pain have these same findings. What’s going on?
You return to your doctor who wants to send you to an orthopaedic surgeon. Hang on. Who said anything about surgery? You don’t want surgery. It involves going to hospital, being put under a general anaesthetic, pain, medications and weeks if not months of recovery, all with the high possibility of staph infections and complications.
You ask your doctor is there something else you can do. Your doctor tells you that you could try a cortisone or PRP injection. What you’re not told is that there is little or no evidence for these injections and that at best they offer short term relief and at worse can make your condition worse as without your pain, you continue to re-injure your problem. It seems like a quick and easy fix, so you think that you will give it a go. You rock up and have the injection perhaps under the guidance of ultrasound. It’s painful, but not as painful as the thousand or so dollars that it costs. Thank goodness, after a few days you finally begin to feel some relief. Pity it lasts just a few weeks, before your pain returns.
You begin to feel a pang of desperation. Time is marching on. Perhaps you won’t get better. You’ve spent hundreds, if not thousands of dollars, seen a number of doctors and medical specialists and still no result. In fact, your pain is the same and / or worsening.
You speak to your partner or friends and they tell you that they know a chiropractor, osteo, physio or massage therapist who can help you. But you’re not sure about chiropractors. You’ve heard stories about getting cracked and people getting hurt. Then someone else says to go and see their osteo and another says to go a see their physio. What’s the difference? Who do you trust? You’re worried that you might end up on some never ending cycle of treatment and you don’t have the time or money for that. You just want to get better and get back to normal without having to take medication or see a therapist for the rest of your life. It all seems so confusing, so hopeless.
Why You Haven’t Got Better and What You Need To Do About It!
Let’s face it, we all want a quick fix. There is nothing better than the miracle cure where you get up off the bed and say “I’m better!” And it does happen - occasionally. It takes no work, it takes no effort, it is great value for money and it’s quick. But as opposed to what modern medicine might have you believe, it is the exception rather than the rule.Why? Because it takes time for body tissues to heal, for treatment /training effects to occur and for new correct physical habits to become engrained. In other words, it takes work, discipline and perseverance. But on the plus side, the benefits can include a lifetime of being pain-free, stronger, more agile and with an increased capacity to perform everyday tasks. Worth it don’t you think? So why don’t people get better? The mistakes includes:
Not reducing bleedingNot many people recognise this, but “bleeding” is the first phase of healing. Following bleeding, a number of substances are left which later become the platform for the adhesion of cells. The problem with bleeding, is that if left unchecked, it can reduce blood flow and prevent oxygen, nutrient exchange as well as limit waste removal.
Also, the more blood that seeps into the tissue, the more blood that has to be broken down by the immune system (more on this next) and therefore the longer that this takes, thus slowing down the whole process.
Not controlling inflammation (Demolition Company)“Inflammation”, it gets so much bad press. Anyone would think that it was evil and that we should get rid of it. And yet, inflammation is an immune response that is essential for healing. You see, your immune system has two purposes.
The first purpose is to defend the body against infection or anything that may do damage. The white blood cells do this by eating and ingesting the substance.
The second purpose is to act like a demolition company. When the tissues of the body have been injured and damaged, the white blood cells use this same process to remove the damaged cells. It is a breaking down process where the white blood cells of your body “ingest” the damaged cells. Ask anyone. Is it easier to build a new house on a cleared block of land, than it is to renovate a broken down house and they will always say that it is easier to build on cleared land. It’s the same for your body. It is much easier to lay down new tissue with all the debris removed than to try a build on top of fragmented remains. As such, inflammation is critical for healing to take place.
So why do we take ant-inflammatory medication? Because inflammation is a process which is prone to overshoot and in so doing begin to “break down” healing and healthy tissue. It therefore needs to be controlled, otherwise it can delay and even prevent healing.
Not creating a healing environment (Construction Company)Repairing and regenerating your body is akin to building a house. You need the right conditions, the right workers and the right materials. Trying to building on shifting sand, during a cyclone, with unskilled people and without concrete, wood and steel is prone to failure.
Similarly, expecting the body to heal when you have raging inflammation (breaking down cells), a flood of swelling, re-injury occurring, poor nutrition (inadequate protein, vitamin C and continuing to take ant-inflammatory medication), and while you are feeling stressed, depressed (cortisol), tired (not sleeping) and sick, is just not realistic.
To heal optimally, your body needs the right environment. This means controlling inflammation, minimising swelling, reducing tissue tension, preventing re-injury, optimising load, priming blood flow, enriching nutrition and enhancing your stress levels is critical. And these processes must be continually monitored and adjusted for so that your healing environment remains optimal for facilitating the best, fastest repair possible.
Continuing to re-injure your injury (Picking the scab)Think about it. Your body’s natural default is to heal. Cut yourself and it heals. So why is your back, neck, shoulder, hip, knee injury or any other injury any different? If you continue to pick a scab, does a wound heal? No. Then why do we expect an injury to heal if we keep hurting it? It doesn’t make sense and yet this is exactly what often happens every day.
In fact, we aid and abet re-injury by taking pain medication and removing this one indicator that alerts us that we are re-injuring our bodies. Pain is good (at least initially) in that it tells us to change our behaviour so that we stop hurting ourselves. Without it, we would injure our bodies and not even know it (this is what happens with leprosy).
We don’t want to experience pain, because it is doesn’t feel good. But this is exactly the point. It is doesn’t feel good so that we change what we are doing. However, instead of altering our behaviour (which takes work and may be inconvenient), we stop listening to what our brain is telling us, try to ignore it and in the process continue to hurt ourselves.
Getting only passive treatmentBy passive treatment, I mean treatment where you don’t have to do anything. It is treatment which is done to you. Whether you get just hands on treatment from a physio, chiro, osteo, remedial massage therapist, will likely achieve just temporary improvement (days). Likewise medication, injections, dry needling, acupuncture and even surgery may achieve short term results (days to weeks). Why? Because you haven’t dealt with the cause of your pain.
We know that the cause of 97% of back pain is mechanical. This means that it is due to excessive or abnormal physical forces acting on your back which are beyond your body’s capacity to adapt in a healthy way. This leads to cellular irritation, inflammation, tissue break down, swelling, stiffness and pain.
If your back pain is caused by the fact you have a stiff ankle, knee or hip and that you twist awkwardly every time you get out of the car, using passive treatment is not going to fix the cause. Passive treatment will alter your internal body forces (and biomechanics) for a short time only before you aggravate your back again as you get out of the car.
The same goes for anytime where one part of your body is not moving optimally. In these instances, another part of your body has to move differently from which it was designed to do to compensate for the not ideal movement elsewhere. This will always lead to excessive or abnormal forces on your body. It then becomes not a question of if you will develop a pain syndrome, but when you will develop a pain syndrome. The variables of the intensity, volume (number of times) and duration of the abnormal or excessive forces as well as the adequacy of recovery your own personal characteristics (age, health, nutritional status, weight etc.), will simply determine how quickly you begin to feel pain. But you will feel pain. It is guaranteed.
There are times however, when you may have a structural and an anatomical problem like having one leg longer than the other, excessively flat or arched feet or a disc herniation which is pressing on a nerve. These do require structural as well as behavioural solutions like orthotics, surgery and behaviour modification.
Don’t get me wrong. Passive treatment is important for helping to create a healing environment. It helps to reduce swelling, control inflammation, unstiffen stiff joints, loosen tight tissues and relax you both locally (where the injury is) and more holistically. And when you think about it, you tend to feel best and healthiest when you feel relaxed. Passive treatment lays the foundations. You still however, need to build your framework.
Only doing exercisesNone of us doubt the benefits of exercise. It has been stated, that if exercise were a drug, it would be the greatest drug ever developed, with more far reaching, positive effects on the body that any other medication ever developed.
However exercise can also be damaging. Performing the wrong exercise, in the wrong way, at the wrong intensity and at the wrong time, can worsen an injury. Getting back to the cut analogy, a sprain is simply a tear of a ligament or joint capsule (tissue holding a joint together), whilst a sprain is a tear of muscle or tendon. If you have a cut or tear, what would happen if you pulled it apart? It would re-tear again wouldn’t it? So why do we stretch muscle strains? Yes, following stretching you do feel good for a short time, as the lengthened tissue has reduced tissue tension. However, if you follow the long term history of people who just stretch, you will find that they never tend to get better.
Stretching lengthens tissue and any lengthened tissue has a tendency to be weak and to lead to poor dynamic control (alignment) of joint surfaces and instability, thereby setting you up for more problems.
Similarly, attempting to over-ride your brain and strengthen inhibited muscles (muscles which the brain is trying to shut down to protect you) and go too hard, too early can also aggravate an injury.
Additionally, strengthening the wrong muscles such as prime mover muscles (big, powerful muscles which attach a long way away from the joints that they move) as what Keiser training tends to do without first developing the platform upon which these muscles pull, is like “shooting a canon off a canoe”. The movement produced will be weak, ineffective and potentially injurious.
Finally, strengthening the wrong muscles can lead to further muscle imbalances and worsen faulty postures and movement patterns, thus perpetuating the causes of an injury or creating other problems.
Yet, the evidence indicates that exercise is an essential part of recovery. As passive treatment is likely to lead to short term improvement, exercise is likely to medium term improvement (weeks to months). And so, if exercise is to be optimally employed as a treatment modality, there must be some strategy or guideline behind what, how and when it is employed. Doing exercise for exercise sake is not going to give you permanent results. Sustained results will only be achieved when exercise is fused with function to correct what are often the causes of posture / movement based problems in the first place and that are the faulty postures / movements themselves.
Only doing movement / posture trainingIf the cause of most physical pain syndromes are excessive or abnormal forces due to faulty postures or movement patterns, then it makes sense that if you concentrate on correcting your posture and movement patterns then you will fix the cause of the problem. And truly that is the end goal.
However, if you don’t have the passive treatment first to facilitate healing and restore joint mobility and then do exercise work to re-establish muscle control, strength and endurance, then no amount of wanting to correct your posture and movement will work because:
1. Your injury is unlikely to have healed optimally;2. You won’t have the joint mobility or muscle control to adopt new correct postures and movement patterns;3. You won’t have the muscle strength and endurance to maintain new correct, postures and movement patterns;4. You won’t have something preventing you from adopting faulty habits and reminding you to perform them correctly.
And if don’t perform the correct postures and movements for at least 3,000 to 5,000 times or at least for 3 to 6 weeks, they won’t become engrained enough to become habits that you do without thinking. Over time, you are likely to revert back to your old incorrect habits and thereby causing your problem to re-occur.
Not sleepingIf you are anyone who is in chronic pain if they sleep, their answer is generally no or poorly. Sleep is critical for the body to heal, renew and refresh. Without it, all functions of the body begin to be adversely affected. The nervous system becomes more hypersensitive. You don’t digest food as well. Your immune system becomes activated causing inflammation. A “Fight or Flight” response is triggered. All these reactions are the opposite of what should be happening when you are asleep and that is growth and repair. In this environment, healing becomes almost impossible.
Over stressedClosely related with not sleeping is being “over stressed”. Stress causes the release of the hormone cortisol. Cortisol and adrenalin both activate to stimulate the body to be ready for action in the Fight or Flight response. Blood is shunted away from the digestive system to the muscles. You breathe quicker. Your pulse races. You become more alert. You may perspire. Again, all these responses are the opposite of what is needed (at least initially) for growth and repair.
Not eating correctlyThis is one of the most over-looked aspects of healing, despite eating and food being a national past time. And yet, ensuring that you are having the correct nutrients may have have a profound effect on the rate and quality of your healing. The opposite is also true. Eating foods that increase inflammation or which provide no building blocks for tissue repair, may prevent, slow or at least impair healing.
Taking advice from too many people It’s a common problem. If you are injured or in pain then it seems everyone you come into contact with will offer you advice whether you have asked for it or not. Comments such as, “Oh, I have had your problem and this is what worked for me”; or, “I know this therapist and they are a guru”; or, “I read recently that this is the best way to treat your condition”.
If you go to 5 different health professionals and it is likely that you will get 5 different diagnoses and treatment plans. And if all else fails and you are not completely confused, you’ve always got Dr Google.
So how do you know who and what to believe? First and foremost, you need to understand that you are unique and therefore you need to have you and your unique circumstances taken into account. Dr Google can never do this! It can only be adequately accomplished by having a comprehensive professional assessment and examination.
Forget all the do-gooders. Whilst their intentions may admirable, their advice may do you more harm than good. In the end, they don’t have the experience nor the knowledge to adequately advise you. Seek advice from someone who has is qualified, has stood the test of time and has a proven track record in getting results.
Getting the wrong investigations at the wrong timeX-rays, ultrasound, CT and MRI scans are important, but they must be taken in context or they can be more confusing than helpful.
With lower back pain, it is well established that most imaging findings, particularly degenerative changes, correlate poorly with clinical presentation.
For example, MRI studies of healthy adults with no history of upper or low back pain found that 47% had disc degeneration, 53% had disc bulges and 58% had disc tears in their thoracic spine.
For shoulder pain, MRI studies of adults who have no shoulder pain show that 20% have a partial rotator cuff tear and 15% have a full thickness tear. In those 60 and older with no shoulder pain or injury, studies have shown that 50% (half) of people have a rotator cuff tears on their MRI’s that they didn’t know about.
With hip scans it has been established that there is only a weak association between joint space narrowing as seen on x-rays and actual symptoms.
It is a similar story for knees, with studies showing that up to 85% of adults with no actual knee pain have x-rays that show knee arthritis. Another study showed that 48% of professional basketballers without knee pain had meniscal (cartilage) “damage” on their knee MRI’s.
There are times however, when it is critical to have further investigations. These times include:
1. If there has been a history of trauma or external force causing an injury, investigations are needed to shed light on the full extent of the injury;2. If your assessment points to a more sinister cause of your problem (e.g. cancer; inflammatory diseases; visceral issues; frank pressure on a nerve);3. If you are not getting better or there has been no improvement in your condition within 3 weeks of treatment.
These research findings indicate that x-rays and scans must be taken in context and be interpreted in the light of your circumstances, your history and your physical examination.
Only then can x-rays, scans and further investigations bring the full truth on source and cause of you problem as well as a potential treatment solution.
Getting treatment from too many different health professionalsLike getting advice from too many people, getting treatment from too many health professionals can waste your time and money as one treatment might against another treatment.
This is particularly the case when these health professionals are from similar backgrounds. For example, let’s say you are seeing a physiotherapist who is providing you with stabilisation exercises because they believe that it is uncontrolled movement which is causing your problem. Improvement is slow, so you begin to see a chiropractor who believes that your back is “out” and so begins to perform spinal adjustments. These two treatment techniques provide outcomes which are the direct opposite of each other; stabilisation exercises provide stability and adjustments promote mobility. So who’s right? You will never know because the effects of one treatment might cancel out the effects of the other treatment therefore providing you with no result. What’s more, you won’t be able to determine what’s working and what isn’t.
The one time that it might be better to get treatment from more than one health professional is if the health professionals involved are working together as a team and with a treatment strategy to deliver you complementary techniques so that you achieve a faster result. For example, a physiotherapist might deliver a physical strategy, a dietician a nutritional strategy and a psychologist a mental strategy. Together, they may be to deliver you a better, faster result than if they worked alone.
Generally though, it is better to follow through treatment with one health professional before switching to another. How long should you wait before you switch? Ask the health professional. Only then can you hold them to account and know if you are wasting your time and your money. For me, I generally tell my patients that I expect to experience significant improvement within three weeks for moderate conditions and six weeks for severe conditions. If they haven’t, I refer them to someone else who I believe might be able to assist them further.
Having no strategic treatment plan for achieving the results that you wantIt was Winston Churchill who said that “He who fails to plan, is planning to fail”.
But let me ask you this question? When was the last time that you were provided with a written treatment plan detailing the source and cause of your problem and a road map to getting better complete with milestones, a timeline and an achievement date? My guess is never or rarely. And yet, if you don’t have any strategic plan to get better, treatment may then become a hotch potch of treatment techniques, delivered with a scatter gun approach.
If there is no written strategic treatment plan, there is no forethought about how to achieve both short term (this session) and long term (completely better) goals in the best, fastest way. With no written plan, how can any consideration be given to what treatment techniques, in what combination and with what timing that may be applied synergistically to magnify the individual effects of each technique to achieve a better result in two thirds or perhaps half the time? How can you understand and know the big picture of how you can help with your own recovery, if you are not sure where you are going? The simple answer is you can’t.
The more common scenario is for a treatment technique to be applied in the hope that it helps and if it doesn’t, something else will be tried. And this approach is repeated until hopefully something works. There are so many specialists all dealing with the own area of specialty but oblivious to the possibility that other parts of the body may be causing pain or dysfunction in their specialised area. Is it no wonder that often problem returns after a short time?
The body is made up of many systems all working together to produce a result, that is enabling you to live, survive and thrive in a changing and unpredictable world. Treating the body as separate compartments at best will provide you with short term improvement and at worst no improvement at all. To achieve the best outcome possible, you need a written strategic treatment this question plan, period.
Not measuring the effect of your treatment programAnother reason why people don’t get better, is they have no idea what is working and what isn’t. There is another old saying, “You can only manage what you measure”. Unless initial and ongoing measurements are taken, you won’t have any criteria to know if intervention is helping or not. You won’t really have any idea as to what is working and what isn’t and therefore you won’t have any guidelines as to how to refine your treatment to give the best results. You may have a vague idea that something might be helping, but you won’t be able to identify accurately what it is. You may be in fact wasting your time focusing on treatment techniques that have little or no positive benefit and you won’t know it.
Not adjusting and progressing your treatment programFollowing closely behind not measuring your treatment program is not adjusting or progressing your treatment program. And yet, only if the effect of treatment is monitored and measured, can it be appropriately adjusted and progressed.
Worse still, many people attend for the same treatment over what can sometimes be many years for little or result. If you have a health outcome that you want to achieve, you must first define what the result that you want to achieve is, then set a path for achieving your goal (Recovery Action Plan), measure frequently to ensure that you are on target and make treatment adjustments as circumstances change.
As the saying goes, the definition of insanity is doing the same thing over and over again and expecting a different result. And yet, this is exactly what people do. It doesn’t make sense to waste your time and money on doing the same thing over and over again for no change.
It's one of the more challenging judgement calls to make. When to return to sport or pre-injury activities. Unfortunately, like so many things in healthcare, it is not an exact science.
There are so many things that need to be considered; so many variables. Some of these include:
1. The structure or tissues injured;
2. The severity of your injury;
3. The type of activities that you might be returning to;
4. Your work, living and or playing environment;
5. Your physiological, physical, psychological and social circumstances.
It is estimated that 12-34% of hamstring injuries 1 and 3-49% of anterior cruciate ligament injuries 2 re-occur as a result of incomplete rehabilitation and premature return to sport and their pre-injury activities.
People often severely underestimate the time needed to be able to return to their pre-injury level of performance. Lack of knowledge, lack of experience and lack of perseverance, all play a role.
For example, when a group of runners and dancers were asked to estimate how long it would take for them to return to their activities, the runners replied four weeks and the dancers replied one week. The actual average return was 16 weeks for the runners and 50 weeks for the dancers 3.
For physiotherapists it is a challenge as well. Even if injured tissues should theoretically be healed, trying to determine when they are able to withstand the unpredictable stresses of life and sporting activities is difficult if not impossible.
The Science behind Recovery
The starting point for staging when you can return to pre-injury activities and sport is having an accurate knowledge of the theoretical time-frame that it takes for various tissues to heal. For example, your blood cells turnover every 120 days, your bone building cells every 3 months and your skin cells every 2-4 weeks 4.
The healing time will vary for different tissues and structures but is primarily determined by the blood supply to the area; your age; genes; your general health and nutritional status (e.g. abundance of protein, Vitamin C) and even medication (e.g. Anti-inflammatory medication such as Ibuprofen is known to delay healing).
Soft Tissue Healing as a Guide to Your Treatment
Following trauma and injury, your body will always go through the same phases of healing, the length of each varies depending on the type of tissue damaged, the severity of the injury and the intervening treatment. Healing can be divided into four broad phases which overlap considerably. These phases include:
1. The Bleeding Phase
2. The Inflammatory Phase
3. The Proliferation Phase
4. The Remodelling Phase
The Bleeding Phase
This phase occurs immediately following injury and can last anywhere from 6 to 24 hours depending on the type of tissue injured. In the bleeding phase substances are released which enable the adhesion of various cells. The complication of this phase is excessive bleeding and swelling. This excessive "clot" along with the damaged tissue needs to be removed, thus delaying the laying down of new tissue.
Excessive swelling also delays healing as excessive fluid pressure effectively prevents oxygen from being delivered to the injured cells, leading to increased cellular death and even more debris which has to be removed.
Consequently, it is critical that IMMEDIATELY following trauma or injury, treatment is begun to prevent excessive bleeding and swelling. Treatment such as compression, immobilization, lymphodema massage (massage that removes swelling) and unloading damaged tissue (e.g. crutches), if implemented in the first 24 hours by a competent physiotherapist, CAN SAVE YOU WEEKS IF NOT MONTHS OF TREATMENT.
The Inflammatory Phase
Likewise, the Inflammatory Phase is critical for healing. Inflammation has the classic characteristics of heat, redness, swelling, and pain (which is often constant, throbbing and can wake you at night).
Inflammation escalates rapidly a couple of hours following injury, increases to a maximal reaction at 1-3 days before gradually resolving over the next couple of weeks. Essentially during the Inflammatory Phase, the role of the body's immune system is to act like a demolition company, clearing the 'construction site' of debris and damaged tissue.
The complication of this phase, is that the inflammatory process gets out of control leading to an acidic environment, excessive protein breakdown and further cellular death. Consequently, treatment should include all the same modalities as in the Bleeding Phase with more emphasis on cold packs (15 minutes at least 6 times a day with emphasis on hourly cold packs at the end of the day), compression as well as optimal loading reduce swelling and decrease the activity of the inflammatory cells.
The Proliferation Phase
The Proliferation Phase involves the formation of repair material, which in the case of musculoskeletal injuries is mostly scar (collagen) material. At about day 5, the collagen is weak and easily broken with any chemical and physical stress. From day 6 to day 14, this scar tissue gradually becomes more durable to the point that the fibres have knitted and the defect has been bridged.
Consequently, treatment must be geared towards increasing and optimizing the activity of the cells laying down the repair. Warmth and electromagnetic stimulation (which increases cellular activity) along with hands on techniques and easy pain-free movements that optimizes tissue tension to enhance the repair.
The proliferation phase peaks at about 2-3 weeks, (less time for more vascular tissues) before winding down over the next 4-6 months.
The Remodeling Phase
The Remodeling Phase results in a quality, organized, functional scar that can behave like the parent tissue that it replacing. New evidence indicates that the Remodeling Phase begins as early as the first week. Initially, collagen fibres are laid down randomly. However, with the expert application of specific tension, these fibres become aligned along the lines of force.
Collagen molecules also have an electric charge and stress on collagen fibres produces a piezo-electric effect which may also help to re-orientate fibres.
Whilst it is unclear however how much tension is necessary or optimal, it seems that working to the point of discomfort but not into pain, may be a good guide as to what might be the most optimal tension for ideal adaptation.
From this point, gradual, controlled, progressive, specific loading has been found to accelerate early return to sport4. For optimal rehabilitation, this specific loading must be integrated into graduated functional strengthening, beginning with low level, safe, static and progressing to more physically demanding, dynamic, reflexive sport or functional specific activities.
These dynamic, reflexive, functional or sport specific activities can then become the tests which help to determine if you are ready to return to sport or your pre-injury activities.
Special Tests for Return to Pre-Injury Activity
For Shoulder Injuries - Throw and Catch
The throw and catch test consists of the throwing of varying weighted balls at different speeds and angles and durations until the action replicates as best as possible the intensity of the sport.
For all leg injuries - Balance standing on injured leg to progressing to hopping and then to running
These tests involve being able to maintain alignment of your hip bone, middle of your knee cap and 2nd toe with progressively more demanding, dynamic activities.
This alignment is consistent with ideal biomechanical forces being placed on our body tissues and structures and requires adequate core and leg muscle strength and control as well as sufficient hip, knee and ankle mobility.
All of these activities can be progressed in various ways for example by increasing the instability of the surface (e.g. duradiscs), increasing the depth of squat; height of the step as well as the distance, angle and speed of hopping and running.
Other special tests include:
1. Single leg hop
2. 6 Metre timed loop
3. Triple hop for distance
4. Cross over hops for distance
5. Running Drills
The Importance of Ongoing Rehab
Even once you have returned to pre-injury activities, you need to continue with an ongoing conditioning exercise program to ensure that your body is able to cope with the daily demands that you place upon it.
This conditioning exercise program must consist of strengthening exercises for the injured area and associated areas as well as balance and core stability activities. This needs to be completed at least twice weekly for at least four weeks following return to full activities.
A Final Word
There is no doubt that most people have large misconceptions about when they think that they are better and able to return to their full pre-injury activities. Understanding the process and timeline for healing is a starting point for staging the healing of tissues. This however must be supplemented by specific, injury related, objective testing and compared with the non-injured side and valid data.
Finally, it is important that you stay positive and remain engaged and connected with others and that you celebrate the milestones on your journey back to full health.
If you are injured or if you know of someone else who has a physical injury, seek or encourage them to seek treatment as soon as possible. It may just save you weeks if not months of pain, frustration and isolation.
If you are injured or in pain and want to get back to doing the things that you love to do, please call Bodywise Health on 1 300 BODYWISE (263 994) for a complimentary*, no obligation assessment and Recovery Action Plan from one of our expert physiotherapists.
We look forward to helping you get your life back.
Until next time, Stay Bodywise,
* Rebates are available through your private insurance extras cover;
* For complex or chronic conditions, you may qualify for the EPC (Enhanced Primary Care Program) allowing you to receive 5 allied health services each calendar year with a referral from your GP. For more information, please call Bodywise Health now on 1 300 BODYWISE (263 994).
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3. Br J Sports Med.2006 June;40:40-44.
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OK, you have just been injured, what are you going to do, rest, stay active or seek treatment? It can be somewhat confusing to know what to do. There is so much misinformation and so many mixed messages. Natural instinct might be to rest as that is what you do when you are "sick". But you are not sick, you are injured. The purpose of this article is to draw on both the latest evidence and clinical experience to give you some guidelines on what is best practice management following an injury.
The Traditional Model of Treatment
The acronym R.I.C.E. (Rest, Ice, Compression and Elevation) was for a long time the benchmark for acute clinical care following injury. This was expanded to PRICER to include Protection and Referral to better address the essential need not to re-aggravate your injury as well as to encourage you to seek professional assistance so that you can minimise any possible complications and optimise your recovery.
But now the term 'rest' is being widely criticised as it can be interpreted to mean 'being inactive' and doesn't reflect the possibility of needing to load or move injured tissues and structures to facilitate the healing process.1,2
Consequences of the Term 'Rest'
Bed rest, initially thought to be the safest approach in the treatment of acute musculo-skeletal injury (especially for acute low back pain4), has been found to cause further complications and disablement3 physically and psychologically.
Not only may 'rest' result in increased swelling, poor circulation, slow, delayed and inferior tissue repair, but it may also lead social isolation, catastraphization and a sense of hopelessness.
A New Acronym and Treatment Approach
Recently, the British Journal of Sports Medicine published a new acronym, POLICE, (where Rest is replaced by Optimal Loading) as a treatment guideline. The POLICEacronym, still recognises the importance of Protection through the use of crutches, braces or taping for at least the first 3-6 days to prevent further bleeding, inflammation, damage and pain.
Likewise, Ice, Compression and Elevation are still considered essential in the initial stages of treatment.
How much loading that is optimal depends upon a number of factors including the degree of damage, the stage of healing, the irritability of the tissue (how much stimulus, causing how much pain for how long it lasts) as well as the expertise of a health professional.
More severe, acute and sensitive injuries may require immobilisation for a time, to protect against re-injury and to allow for repair. However, the research is increasingly advocating early movement to reduce swelling, enhance circulation, maintain joint movement stimulate the formation of collagen fibre networks and facilitate their alignment along lines of force.
Scientists from the University of Tampere, Finland, stated that following a muscle tear, the limb should be immobilised initially for a scar to form before activity is commenced within the limits of pain7. Extended periods of restricting movement however, lead to the random laying down of fibres predisposing the tissue to again being injured and damaged when stress is re-applied3.
Optimal Physical Stimulation - The Key to Accelerated Recovery and Optimal Repair
Physical loading is not just critical for the stimulation, regulation and turnover of healthy, adaptable and strong tissues and structures. Physical loading also can accelerate healing. This is what researchers from the University of Queensland discovered when they applied controlled loading during fracture healing.
Another study at the University of Ulster, Ireland, found that exercises started in the first week following grade 1 and 2 ankle sprains "significantly accelerated tissue healing9.
For joint injuries and post-surgical cartilage repairs, early easy movement with low level optimal loading had been shown to reduce complications, accelerate healing and improve tissue repair5,10.
For Achilles tendinopathy, researchers from the University of Emea, Sweden, found that specific loading of the Achilles tendon lead to decreased pain as well as improved Achilles tendon strength and function, 3.8 years after the training finished12.
Finally in another study, early quadriceps activation and progression in strength training was shown to reduce pain following knee injury13,14.
Consequently, if you want to accelerate healing, if you want to optimise repair and if you want to achieve the best most complete recovery possible, early, precise movement and loading under the expert supervision of a skilled health professional is critical.
Why it is Better to Be Seen Sooner than Later
The sooner you see a qualified health professional skilled in the art of rehabilitation following your injury, the sooner you can begin optimising each stage of healing. Ultimately, this means faster healing, a better repair and a more complete recovery.
A skilled physiotherapist is able to ascertain the source and cause of your injury as well as grade its severity, irritability and the stage of healing. These are critical factors that uniquely influence the intensity and guide progression of your treatment.
If you are injured or if you know of someone else who has a physical injury, seek or encourage them to seek treatment as soon as possible. It may just save you and them weeks if not months of pain, lack of function and frustration.
To overcome your injury or pain and reclaim your health, please call Bodywise Health on 1 300 BODYWISE (263 994).for a complimentary*, no obligation assessment and Recovery Action Plan from one of our expert physiotherapists.
We look forward to helping you get your life back.
Until next time, Stay Bodywise,
* Rebates are available through your private insurance extras cover;
* For complex or chronic conditions, you may qualify for the EPC (Enhanced Primary Care Program) allowing you to receive 5 allied health services each calendar year with a referral from your GP. For more information, please call Bodywise Health now on 1 300 BODYWISE (263 994).
1. B J Sports Med.2012,6 (4), 220-221.
2. Br J Sports Med. 2009, 43,247-251.
3. The Iowa Ortho J, 1995,15,29-42.
4. West J Med, 2000, 172 (2).
5. The Science and Practice of Manual Therapy, 2005. Elsevier Churchill Livingston London.
6. Rehabilitation Techniques, 2011, McCraw Hill, Singapore.
7. Aust J Phsyiortherapy, 2007, 53, 247-252.
8. Best Practice Res Clin Rheumatol, 2007, 231 (2), 317-331.
9. BMJ, 2010,340, cl1964.
10. The American Journal of Knee Surgery, 1994, 7 (3), 109-114.
11. Knee Surg Sports Traumatol Arthrosc 1999, 7: 378-81.
12. Br J Sports Med, 2004, 38, 8-11.
13. J Multidiscip Healthc, 2011, 4 383-392.
14. Med Sci Sports & Exerc, 2010, 42 (5) 856-864.
Are you worried about seeing your child's toes point inward as they stand or walk? Whether you should be depends upon the cause of toe in postioning as well as the age of your child.
Pigeon toe or toe in walking is a common and often painless condition for children. Very often, it occurs in one or both feet in children under the age of 2. The condition usually corrects itself with no intervention. This type of pigeon toe often develops in the womb or is due to genetic birth defects, so little can be done to prevent it. Contrary to popular belief, there are no known shoes or orthotics that help prevent pigeon toe and no evidence to suggest that learning to walk in bare feet has any effect on the condition.
The Causes of Pigeon Toe
Pigeon toe may develop in the womb and often corrects itself.
There are three potential causes of pigeon toe:
1. Metatarsus varus or metatarsus adductus
With metatarsus varus or metatarsus adductus, the front of the foot is angled inward giving the foot a curved, half-moon appearance. This type of pigeon toe is common in babies who were breech in utero or whose mothers had less amniotic fluid. Occasionally, there is a family history of the condition.
Normally, the foot is abled to be straightened out by a doctor or healthcare professional once the child is born with no further treatment generally being required. Although its not imperative, a parent can also gently stretch the baby's feet a few times a day to help correct the shape.
2. Internal tibial torsion
Internal tibial torsion refers to the inward twisting of the shin bone or the tibia. This twisting of the shin bone often becomes noticeable as a child first begins to walk. It is generally not painful, but parents of children with internal tibial torsion tend to report that their child falls frequently. Like metatarsus adductus, the condition often resolves without the need for therapy, bracing or casting.
Sometimes however, in more severe cases and / or the shin does not straighten out by the time a child reaches 9 or 10 years of age, internal tibial torsion may require surgery to fix it. The procedure involves cutting through the twisted bone and reattaching it to make the foot straighter.
3. Femoral anteversion
This type of toe in positioning is very common affecting up 10 percent of children. Here, the thigh bone (femur) is excessively rotated inward in the hip joint. It is thought that this may be due to stress to the hips before birth. Normally this type of in-toeing resolves by the age of 8 years. If it continues after this age, an examination by a physiotherapist, doctor or other paedicatric health care professional is recommended to assess what might be the best course of action to correct the toe in positioning. Occasionally the neck of the thigh bone is angled in such a way as to increase the turning inward of the leg. At other times, this type of toe in standing and walking may be purely a habit that can be corrected with making the child aware of the fact that their feet are turned inward.
When to see a physiotherapist or doctor
Generally there is no urgent need to see a physiotherapist or doctor. However, if the toe in position is still apparent by the time your child reaches 8 years, or if it causes your child to fall more often than normal, a physiotherapist or doctor should be consulted.
Diagnosis for pigeon toe can often be determined by a comprehensive physical examination. Occasionally, X-rays and other imaging may be necessary.
For metatarsus varus or metatarsus adductus, diagnosis is generally made very early, often during the newborn's post-birth examination. A skilled physical examination will identify that the positioning of the foot bones are cause whilst ruling out out other possible causes such as mal-alignment of the hip joints.
Internal tibial torsion generally apprears only as a child begins to walk and so the earliest diagnosis may be slightly before 1 year of age during a physical examination of the infant's legs. If diagnosed, the physiotherapist or doctor will take measurements of the legs.
Femoral anteversion is most often diagnosed when the child is between the ages of 4-6 years. This will normally start with a physical examination and a review of the medical history of the child and family.
Treating pigeon toe
Toe in positioning may be treated with time, normal growth and reassurance. If more therapy intervention is required treatment may include:
To fix these issues does require a comprehensive, co-ordinated approach. It is essential to assess whether there are any structural limitations or deficits preventing these children from walking correctly. Do they have an arched or flat back? Are their hips stiff? Are they knock kneed or bow legged? Do they have flat or highly arched feet?
Already these children's bodies have begun to adapt to this way of walking. This means that they are likely to have poor core stability, their outside hip muscles are likely to be stretched and weak, whilst their hamstrings and the muscles on the inside and outside of their thighs are likely to be tight and dominant. Their ankle joints are also likely to be stiff, their calf muscles tight and their foot muscles and plantar fascia weak and overstretched.
These children are also likely to have poor balance which requires that they walk with their feet wide apart making ambulation inefficient and tiring.
Correcting these kids walking pattern is easier said than done. Ultimately, it means loosening stiff joints, strengthening weak muscles and stretching tight soft tissues. It often requires balance retraining and learning to walk with feet less wide apart and a correct heel - toe contact. Taping, bracing and orthotics may all be useful in assisting and accelerating the rate of improvement.
Whilst all these interventions and techniques may sound over-whelming, they can be integrated into a concise, targeted program that usually delivers results within four weeks. It is worth it. Incorrect walking can cause a multitude of problems over your child's life culminating in multiple joint replacements.
It can cause children to be less active, less engaged and less connected. It can lead to a decrease in sports achievements. However, most devastatingly it can take away opportunities and limit your child's potential.
If you do have any concerns regarding your child's posture or movement including the way that they walk, please call Bodywise Health on 1 300 BODYWISE (263 994) for a free examination and advice. It may save them a life time of physical and social problems.
Hamstring, Hammies, Hams, or if you're feeling fancy you can use their latin names. Keep in mind there are three muscles that make up the group of muscles called the hamstrings, they are biceps femoris, semimembranosus and semitendinosus.
This group of muscles is a notorious repeat offender for injuries, across numerous sports. AFL, soccer, rugby, cricket and baseball players are all frequently falling victim to the sharp pain in the back of the thigh that can mean anything from missing a few games to ending a career.
There have been a number of superstars with their futures in doubt due to the injury, just to name a few; Michael Clarke (cricket), Chris Judd (AFL), Jamie Lyon (NRL). And more recently Cale Hooker (AFL) was in doubt to play against Geelong in the last preseason game.
What puts someone at risk of a Hamstring Injury?
When all of the studies looking into risk of injury are combined we get a good overall picture of the elements that increase the risk that someone's hamstring will be injured.
As we noted with the ACL injuries (ACL injuries in females), there are a number of factors that contribute to an injury. Some of these we can influence and others are out of our hands.
The two big factors we cannot change that influence your risk of injury are age and previous history of hamstring injury (or previous ACL/knee injury)1.
Though if you haven't had a hamstring injury before, perhaps now is the best time to see a Bodywise Health Physiotherapist for a personalised preventative program.
The good news is there are a number of risk factors that we can improve on. These include muscle strength ratios, strength characteristics of the hamstrings and player endurance1.
Are there different types of Hamstring injuries?
The location of the tear can have a significant impact on the recovery process, especially the time and rehabilitation required to get back on the field.
When considering the location of a muscle tear it is important to appreciate the whole unit. The whole unit includes the bony attachments (both ends), the tendons (a flexible cord on either end of the muscle that transmits the force of the muscle contraction to the bones) and the muscle belly - the power generator. There is also an important transition of muscle to tendon towards either end. These different locations all heal at different rates and sometimes require different rehabilitation strategies.
The extent of the tear arguably will have an impact on the recovery process. Studies looking at imaging results have not consistently shown a clear correlation between the findings on scans like an MRI and the time to return to sport (RTS). Having said that, one can respect that a more substantial sized tear would require longer to repair the damaged tissue, but there are a number of factors that weigh in when considering returning to sport.
If you have been injured, a physiotherapist at Bodywise Health will be able to assess your hamstring and determine what type of injury you have or if further investigations are required.
What can be done to prevent an injury?
This is the most important section. If you have never had a hamstring injury before you want to be proactive in reducing your risk. If you have been unfortunate enough to have sustained an injury previously, you should be working hard to reduce your other risk factors.
There have been many studies looking at reducing the risk of injury. And the great news is there are many things that can be done to reduce your risk.
Your training program should include anaerobic interval training, sports specific training drills and lengthening exercises. Stretching especially while the muscle is fatigued, has also been shown to reduce injury risk. So a proper cool down is important2!
There are also specific exercises that have been shown to reduce the risk of a hamstring injury.
What can be done if I am injured?
Just as was seen in the preventative efforts, lengthening exercises have been shown to have a faster RTS time3. Additionally, agility and trunk strengthening offered slightly quicker RTS and lower re-injury rates, when compared to just strengthening/stretching3.
It was noted that more frequent stretching can still improve the range of movement faster, as well as allowing a faster RTS, suggesting that a home exercise program conducted frequently will be helpful. NSAIDs were not found to be helpful for recovery, PRP injections were also found not to offer benefit in RTS times3.
Sports focused exercises were also found to reduce the number of hamstring injuries sustained by AFL players4.
Unfortunately many of even the elite clubs are failing to adopt the 'evidence based' hamstring injury prevention measures. One study looking at elite soccer clubs in Europe had as many as 83.3% of clubs not following guidelines5.
So if you play a sport that involves running or kicking, get ahead of the competition and see a Bodywise Health Physiotherapist for an assessment and a preventative program. If you've sustained a hamstring injury either recently or a while ago, reduce the risk of re-injury by getting a preventive program.
For a complimentary injury assessment and advice, please call Bodywise Health on 1 300 BODYWISE (263 994).
Until next time stay Bodywise,
Director Bodywise Health
1. T. Pizzari, Risk factors for hamstring injury: An updated systematic review and meta-analysis, Journal of Science and Medicine in Sport, Volume 19, Supplement, December 2015, Page e9, ISSN 1440-2440, http://dx.doi.org/10.1016/j.jsams.2015.12.401
2. Verrall GM, Slavotinek JP, Barnes PG The effect of sports specific training on reducing the incidence of hamstring injuries in professional Australian Rules football players British Journal of Sports Medicine 2005;39:363-368.
3. Pas HI, Reurink G, Tol JL, et al Efficacy of rehabilitation (lengthening) exercises, platelet-rich plasma injections, and other conservative interventions in acute hamstring injuries: an updated systematic review and meta-analysis Br J Sports Med 2015;49:1197-1205.
4. Proske, U., Morgan, D., Brockett, C. and Percival, P. (2004), IDENTIFYING ATHLETES AT RISK OF HAMSTRING STRAINS AND HOW TO PROTECT THEM. Clinical and Experimental Pharmacology and Physiology, 31: 546-550. doi:10.1111/j.1440-1681.2004.04028.x
5. Bahr R, Thorborg K, Ekstrand J Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey Br J Sports Med Published Online First: 20 May 2015. doi: 10.1136/bjsports-2015-094826
With children returning to school in the next couple of weeks, helping them make the right start to the year is critical. It can help them avoid all the negative effects that go hand in hand with pain; loss fitness, decreased confidence and social withdrawal.
And with the incidence of back pain in adolescence approaching that of adults1, the muscle and bone problems associated with backpack use have become an increasing concern with school children2.
A study by Simmons College (Boston) professor Dr. Shelly Goodgold, has found that more than half of children in the study regularly carried more than the recommended 15 % of their body weight in their school pack packs.
The U.S. Consumer Product Safety Commission estimated that more than 3,300 children aged 5-14 years, were treated in emergency rooms for injuries related to backpacks in 1998; these numbers do not include students who went to their family doctor or health professional.
A study by Auburn University researchers (Anniston, Alabama, Pascoe et al.) stated that the most common symptom reported from backpack use is “rucksack palsy”. This condition results when pressure put on the nerve as it passes into the shoulder causes numbness in the hands, muscle wasting and in extreme cases nerve damage (Journal Ergonomics Vol. 40 Pg. 6 1997).
58% of orthopaedic health professionals polled in the USA reported treating children with back pain attributable to carrying backpacks. So if your child is complaining of neck, back, shoulder or arm pain, the cause might be an ill-fitting backpack. And despite the advent of tablets, notebooks and smart phones, it seems that if anything, school bags have become heavier, not lighter.
Children are especially at risk of injury from backpacks as carrying too much weight in a backpack or an improper fit, can put undue strain in young muscles and bones that have not full developed.Here’s what can happen. As an overloaded backpack pulls the body backwards, your child may try to re-balance the body by bending forwards at the waist.
How much is too much?
Recent university studies indicate that if a backpack weighs more than 15% of a person’s body weight, it causes adverse effects on the neck as well as upper, middle and lower back which over time will lead to pain and physical problems. In other words, it is recommended that the weight of the backpack should be no more than 15% of a person’s body weight.3 For a 50 kilogram child, that’s 7.5 kilograms.
Your child’s still developing muscle and bone systems can handle 15% without much chance of injury or permanent structural change. This weight can be carried without major postural changes occurring.
However an overloaded or incorrectly fitted backpack can cause the wearer to lean forward in an effort to compensate for the additional weight on their back.
Why you should be concerned
As these muscles are developing, the risk is that they develop abnormally, setting up an abnormal posture for life. The top straps of the backpack which can compress the sensitive nerves and blood vessels as they pass from the neck through the shoulder area and into the arm.
This compression can lead to pain, tingling, numbness and even weakness in the arms and is called “rucksack palsy”.
What you can do
There are 3 things that you can do to ensure that your child is not at risk of injury from an unsafe back pack.
1. Select the correct backpack
2. Load the backpack properly
3. Adjust and wear the backpack correctly
Selecting a Backpack
1. The backpack should be no wider than the torso and not much longer than shoulder to hip.
2. Well-padded straps will distribute the load over a greater area, protecting the sensitive nerves and blood vessels as they pass beneath.
Some bag straps have adjustable air bladders and wait straps for a true custom fit.
Loading a Backpack
The guiding rule is that your child’s backpack should not weigh more than 15% of their body weight. Pack only what is needed for that day and stack the heaviest items closest to the back.
Wearing a Backpack
1. Adjust the straps for a snug fit.
2. Fit the backpack to the upper part of the back as a loose, low bag is more likely to compress the nerves and blood vessels of the neck and arm as well as strain the middle and lower back.
3. Never wear a backpack slung over one shoulder; not only can it compress nerves and blood vessels, but can also cause leaning to one side which may lead to twisting of the spine (scoliosis).
How to detect if there is a problem
Research has indicated that the use of computer photography is a valid and effect tool in detecting adverse postural changes that may occur with the wearing of a backpack.3
Bodywise Health has now acquired this technology so that you can identify quickly and easily if you or your child has a postural problem.
Once identified, simple techniques, exercises and strategies can then be implemented to correct joint stiffness, muscle imbalances and faulty postures and movement habits so that physical and health related postural problems can be avoided.
Prevention as the best cure
As with all health problems, the best cure is prevention or at least correction of a problem at the earliest possible instance.Getting a quick posture and / or backpack fitting check is an ideal way to stop problems before they start.
If you are concerned about your child’s posture; if you do worry about the weight of their backpack and you would like to correct the stresses on their body so that they don’t cause physical problems for the rest of their lives, the physiotherapists at Bodywise Health have the technology, knowledge, experience and skill to be able enable your child not only to make a great start to the year, but to enjoy life long better posture, better health and greater happiness.
If you would like further information or an appointment, please call 1 300 Bodywise (263 994).
Wishing you and your family the best of health,
P.S. For the next 2 weeks, Bodywise Health is offering FREE Posture and Backpack checks to you or your children. To get you FREE Posture and Backpack check, just mention this blog at the time of booking your appointment.
1. Skagg, D, Early S, D’Ambra P et al. (2006) Journal of Orthopaedics: 26: 3: 358-363.
2. Troussier B et al. (1994): Back pain in school children: A study among 1178 pupils. Scandinavian Journal of Rehabilitation Medicine 26: 143-145
3. Chansirinukor W. et al. (2001): Effects of backpacks on students: Measurement of cervical and shoulder posture. Australian Journal of Physiotherapy 47: 110-116.
4. Siambanes D et al. (2004): Influence of School Back Packs on Adolescent Back Pain. Journal of Pediatric Orthopaedics 24:2:211-217.
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