Keep it Simple – Knee Mechanics and TNTI (The Need to Impress)

Quadriceps - Colin Badali  I have once again crossed a bit of Paul Ingraham’s work that resonates with thoughts I’ve had for many years.  You can’t isolate the vastus medialis obliquus (the medial head of the quadriceps group – the quads being the big group of muscles at the front of your upper leg).  Hold on, there’s a greater overarching theme for my readers who might not care about such a specific topic.

Therapists of all sorts, especially physiotherapists, RMTs, fitness trainers, just love to prescribe exercises designed to isolate the vastus medialis obliquus (VMO) portion of the quadriceps group, for things like PFS or patellofemoral syndrome. The theory is that the VMO is oftentimes weaker than the vastus lateralis (the outside head of the quad group), and this causes tracking issues or issues with the position of your patella/kneecap.  For my therapist-readers, as mentioned in Ingraham’s e-book on the topic, Peeler et al. found “no significant correlation between any of VM insertion length, VM fiber angle, limb alignment, and patellofemoral joint dysfunction location and severity [of pain]”  Truth be told, these exercises (which would include squeezing a ball between your legs while you are extending/straightening your legs while sitting on the edge of a table), don’t actually isolate the VMO.  They still might help you improve, via strengthening the knee as a whole!  But the point is, you’re better off simply performing exercises designed to strengthen the knee.  No need to be fancy.

Greater themes here:

  1. Keep it simple – it is easy to impress clients by saying you’re going to strengthen the VMO in order to fix a tracking issue of the patella which should help mediate knee pain (when really, general strengthening is all that is required). Well, on second thought, I guess you can do that, and perhaps the client will be impressed.  However, one must be prepared to face the music when criticism/doubts surface (either from the client him(her)self, or from some other health professional they are seeing).
  2. Don’t be afraid to question (as a client or a therapist): I remember being taught these exercises in 2009, by physiotherapists at a clinic, while working as a kinesiologist.  I had my doubts of course, but as a recent uni-grad, you’re expected to simply do as you’re told.  You should question things, within reason though!  Don’t get yourself fired, and absolutely do not provide your client with a “nocebo” effect i.e. making them think that what they are doing is going to hurt them.  Keep such conversations between professionals only.

Full PainScience article – here

Colin Badali, RMT, CSCS


Knee Surgery – Placebo?

New England Journal of Medicine - Colin Badali   PubMed - Colin Badali   Cochrane - Colin Badali

Perhaps one of the most astounding examples of the placebo effect was demonstrated in a relatively famous study – “Moseley JB, O’Malley K, Petersen NJ.  A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002″.  In this remarkable study, patients with osteoarthritis in the knee improved the same amount regardless of whether they received fake surgery, or real surgery.  “In this controlled trial involving patients with osteoarthritis in the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure”.  Not only was this study published in a prestigious journal, but the results have been fully supported by a Cochrane Collaboration review (a gold standard in research review – if you’re ever seeking to fact-check a particular treatment/modality, just Google it, for ex. “cochrane review ultrasound for low-back pain” or “cochrane review acupuncture for depression”.  This might be a better way to find out about the legitimacy of a modality, rather than peruse through hundreds of studies on PubMed, which are of varying quality and relevance.

The placebo effect is an incredibly important concept in medicine.  It may be hard to believe, but it involves real and proven neurobiological mechanisms of action, when it comes to pain relief, immunosuppression, Parkinson’s disease and depression.  Brain imaging techniques have shown that placebo can have a measurable effect on physiological changes in the brain.  Changes like heart rate, blood pressure, chemical activity in the brain – in cases involving pain, depression, anxiety, fatigue, and certain Parkinson’s symptoms.

The placebo effect is part of the response to any active medical intervention or therapy.

The placebo effect indicates the enormous importance of perception and the brain’s role in physical health.  The use of placebos, however, is very controversial in medicine, as it involves the issue of practitioner-patient deception.  The placebo response may be partly due to an alteration of hormones, endocannabinoids, endogenous opioids, expectancy effects, amongst other factors.

The placebo relates very much to a patient’s expectations.  Much like the “nocebo” effect, which can lead to negative effects if a patients expects a harmful outcome, the placebo can lead to positive results if the patients expects them.

In other words, placebo effects, it is hypothesized, are produced by the self-fulfilling effects of response expectancies, in which thinking that one will feel different will lead to a patient feeling different.  According to this theory, the belief that one has received treatment can produce the effects of a real treatment.  Placebo can mimic classical conditioning, in which a placebo and an actual stimulus are used at the same time, until the placebo is associated with the effect of the actual stimulus.  Both conditioning and expectations play a role in the placebo effect – clients who think a treatment will work display a stronger placebo effect than those that don’t, as seen in certain acupuncture studies.  The mechanism behind many other therapies could be similar.

Of interest: Studies have been done demonstrating that people given sham ergogenic aids (fake sport-enhancing drugs), display improved endurance, speed, and strength.

Colin Badali, RMT, CSCS

Aristotle and Exercise – S.A.I.D.

Aristotle - Colin Badali   Wayne Gretzky - Colin Badali   Outliers - Colin Badali

As Aristotle said, “We are what we repeatedly do”.  This proverb is heavily related to the exercise physiology principle, known as S.A.I.D. (Specific Adaptations to Imposed Demands).  The SAID principle states that the body is incredibly adept at making particular alterations to its structure and function in direct response to the type of stress that is placed upon it.  It does this, in order to able to better withstand this stress in the future.  The body makes adaptations in all eight of its systems (skeletal, muscular, cardiovascular, digestive, endocrine (hormones), nervous, lymphatic, and respiratory).

In short, the body gets better at whatever you practice.  Malcolm Gladwell popularized the 10,000-hour-rule in “Outliers”, using Wayne Gretzky, Bill Gates (programming practice), and The Beatles  as examples.  He emphasized that it is those who achieve this number of hours of practice who ultimately become experts in their respective fields, and it is often important how quickly one is able to achieve said number of hours.  Gretzky didn’t accumulate 5,000 hours of hockey practice, and 5,000 hours of dry-land training by the time he was 12.  He accumulated 10,000 hours of hockey practice.

A few notes from Todd Hargrove’s article on the matter: (link Todd Hargrove – SAID article)

  • adaptation is specific.  Mechanical stress on bones leads to thickening and hardening of bones in the area being stressed (+osteoblasts).  Dominant arm of tennis player = larger bones.  Tendon + ligaments thicken and strengthen with resistance training.  Muscular stress leads to bigger muscles, etc.
  • SAID also includes motor-skill learning (throwing, playing the piano).  With piano practice, the neurons responsible for coordinating finger actions will develop faster lines of communication between themselves.  In addition, the memory of such skills are stored in the brain such that they can accessed and executed in a more automated way without any conscious effort or thought
  • If training for a sport, your training stress must be sufficiently specific to ensure “transfer” or “carryover”
  • Failure to improve could be due to a lack of sufficient stress, or too much stress i.e. not allowing the body sufficient time to recover (progresses into a chronic injury)
  • Basic rule with regards to getting better at anything, is to progress in difficulty without getting hurt
  • How much does your training program in the gym carryover to the sport you are training for?  The suggestion is, perhaps not very much.
  • “Righting reflex vs. Titling reflex” – those who train balance on a swiss ball are no better than anyone else at balancing with one foot on the ground.  Different mechanisms at play.
  • Passive stretching as a means to improve your flexibility + prevent hamstring pull?  Studies show no improvement in injury prevention – in fact, makes you slower and less explosive (specificity of movement!).  Stretching is not a specific preparation for soccer.  Much better warmup for injury prevention: soccer-specific movements (cutting, running, etc.) This is the SAID principle at its finest.
  • Cross Training – can we enhance VO2 (oxygen consumption capacity) capacity for cycling by running and vice versa?  Studies show that there is a small carryover.
  • Carryover of cycling to running is week – running is a complex activity.  Example: Lance Armstrong (perhaps greatest biker of all time and co-owner of highest V02 max in history, despite his incredible moral shortcomings), completed a marathon (running) in ~3 hours.  It is a great time for an amateur runner, but nowhere near the time we would expect if aerobic capacity from cycling had a strong carryover to running.

Eccentric Exercise

No, not “eccentric” like your odd sister-in-law or Donald Trump.  Eccentric as in the movement of muscle while it is LENGTHENING under load, as opposed to shortening under load (which would be considered “concentric” exercise).  It was hard to believe that eccentric exercise could actually help with chronic breakdown-type conditions like tendinosis when I first learning about it at McGill 8 years ago or so, but I’ve now seen some good quality research and experienced its effects with clients.

When resting or optimizing movement patterns does NOT help, then repetitive stress injuries i.e. tendinosis (chronic tendinitis in the elbows for example), or plantar fasciitis, might be due to a dysregulation of the healing and repair process in the areas of those injuries.  These conditions could be looked upon as having an alteration in the quality of the tissue, brought on by stress that the body simply was not capable of adapting to.

Aside from rest, the best treatment option might be eccentric exercise.  LILT (low-intensity laser therapy) would most likely be the other best option.  The eccentric exercise causes small amounts of damage that might initiate the healing process, breaking an otherwise “positive feedback loop”, in which pain simply perpetuates.

Colin Badali, RMT, CSCS

Sitting is NOT the “new smoking”!

I have had my doubts about the popular claim that sitting is the “new smoking” for a while now.  The idea seemed to gain exponential growth and support in the media over the past few years.  It is an effect I will refer to as PSM (Popular-Science Momentum).  We’ve seen this sort of thing throughout history, i.e. unjustified yet perpetuating beliefs (ex. fat consumption or eating eggs are bad for you).  I am glad that PainScience has brought a new study to light, with results contradicting the idea that sitting is as dangerous as smoking.  It doesn’t mean we don’t need to exercise; simply, that we can compensate for sitting by exercising.

I have personally worked with a client with CP (cerebral palsy), who despite being very active and exercise-conscious, MUST sit virtually all day.  In light of research, we now know that those with paraplegia have almost no discrepancy in life expectancy, as compared with “able-bodied” folk.  And, to offer another example which may assist us in concluding that sitting is perhaps not as dangerous as once thought: cultures including Chan Buddhist monks, sit or remain inactive much of the day (and of course, are famous for their good health).  Contextualizing is absolutely necessary.

Here is what PainScience had to say: (full PainScience Sitting not = smoking article)

“This study is a nice FUD-fighter: its results directly contradict the overhyped notion that a lot of sitting is just as dangerous as smoking, an idea that’s been around for a few years now and it reeks of premature, fear-mongering speculation. There was never any good evidence that “sitting is the new smoking,” but this is good evidence that “sitting time was not associated with all-cause mortality risk” in over 5,000 subjects.

This doesn’t remotely get us off the exercise hook. It doesn’t mean that a sedentary lifestyle is safe or healthy, but it does strongly suggest that we aren’t doomed by it (that is, you likely can compensate for a lot of time in a chair by being as active as possible otherwise).

And it’s still possible that sedentariness is unhealthy independently of other exercise, and I’m sure we’re going to see more research about it. Regardless, the scary headlines over the last few years were not defensible, and this new evidence is definitely reassuring.”

Colin Badali, RMT, CSCS

The War on Science

ASAP Science Colin Badali

I have to hand it to the fellows at AsapSCIENCE; they really knocked it out of the park with this latest video of theirs.  It explores themes that I am deeply interested in, namely: science, scientific thinking, and preconceived notions/bias.  Here are some of the ideas they presented, and here is the link to the video (it already has ~1.5 million views): AsapSCIENCE War on Science

-Science asks, “how can me make things better?”.  Scientific thinking does not accept the status quo, especially if things are not already perfect.  And as we can all attest to, we do not live in a perfect world.

-Despite all of its achievements, science is often at odds with society.  “We live in a society exquisitely dependent on science and technology, in which hardly anyone knows anythings about science and technology” – Carl Sagan

-When we look to history, ignoring science has led to the crumbling of societies.

-Science is much more than a body of applications and knowledge.  Science is a way of thinking, a way of unraveling the world’s mysteries, to see it’s beauty; looking at all the facts to make informed decisions, instead of relying on preconceived notions and biases. 

-“Science is a way of not fooling ourselves” – Richard Feynman

Muscle Cramps, Monkeys, and Blue Jays

To introduce this topic, we have Kawasaki, a Toronto Blue Jays player: Kawasaki video – Monkeys + Bananas

Colin Badali Monkey Colin Badali Toronto Blue Jays

Everyone experiences muscle cramping at some point, unless you are a monkey, of course.  There are different types of cramping, and the causes can be numerous.  Muscle cramping is defined as an involuntarily and forcibly contracted muscle that will not relax.  Cramps can last seconds or hours.  Skeletal muscle cramps can be categorized into four major types. These include “true” cramps, tetany, contractures, and dystonic cramps. Cramps are categorized according to their different causes and the muscle groups they affect.

“True cramps” are caused by hyperexcitability of nerves responsible for the muscles in question.  These can result from acute injury, or vigorous activity.  “Rest cramps” are those you might get during your sleep, especially within the calf/gastrocnemius muscle.

Dehydration and/or sodium depletion are factors involved. Low magnesium, calcium, potassium are also factors.  Deficiencies in vitamins B1, B5, B6 also potential factors involved.

Another way that cramping might occur is via poor circulation (and, oxygen deprivation as a result of this), which is complicated topic that I will not delve into here.

Not all cramps can be easily categorized however – some cramps are merely a relatively minor portion of more serious conditions such as ALS (amyotrophic lateral sclerosis or Lou Gehrig’s disease), certain radiculopathies, or diabetic neuropathy.

*Although the cause of night cramps (i.e. in the calves) is not easy to determine, I have heard that a good preventative approach might be to stretch regularly, have adequate fluid intake, appropriate calcium and vitamin D intake, perhaps vitamin E supplementation, and perhaps, with physician consultation, magnesium supplementation.

Does ultrasound work?

The proposed biophysical effects of therapeutic ultrasound have fallen largely out of favour with people that research the modality.  So why is ultrasound still a multi-billion-dollar industry?  It’s an imperfect world I guess, and it takes a long time for a previously well-intentioned therapy/modality/belief to fall out of favor with those that use it.  Therapeutic ultrasound is quite possibly no better than placebo.  There is a shocking (pun intended) lack of evidence for shockwave therapy as well (a more “intense” version of ultrasound).  I don’t enjoy being negative, but there must be critics in healthcare, if positive change is going to occur.

There might be a reader or two thinking, “well, I’ve had ultrasound and it seemed to work”.  I hear this all the time.  The purpose of the research studies (on Ultrasound, or any modality), is to weed out confirmation bias, belief perseverance, and illusory correlation.  So, for example, if a patient had ultrasound on a painful shoulder three times per week over the course of 1 month, and experienced a significant dissipation in pain, they might assume that it was the ultrasound that lead to these results, when it may have simply been the passage of time, or due to any other mix of confounding variables.

Here is Paul Ingraham, talking about this very subject, a little more eloquently (link to his full article: PainScience Ultrasound article)

“It’s not rocket science. Ultrasound is not a difficult therapy to test,10 and if it works reasonably well, then the results should be pretty clear: simply compare results in patients who received real ultrasound to patients who get a fake instead. To a shocking degree, these simple tests have simply not been done adequately. There should be hundreds of them in the archives. Instead there are just a few dozen.

Between 1995 and 2008, the science that has been done was reviewed in only ten papers that seem worthwhile (11,12,13,14,15,16,17,18,19,20,21). Nine were unambiguously negative about US, and some of them strongly so. Their authors had almost nothing good to say about ultrasound. Conclusions like this one from Windt et al are typical:

As yet, there seems to be little evidence to support the use of ultrasound therapy in the treatment of musculoskeletal disorders. The large majority of 13 randomized placebo-controlled trials with adequate methods did not support the existence of clinically important or statistically significant differences in favour of ultrasound therapy.

Windt et al, “Ultrasound therapy for musculoskeletal disorders: a systematic review,” Pain, 1999″

Heat Vs. Ice! What is better?

It is a hotly debated topic is the sport science world.  The answer is, of course, it depends.  Typically, we use ice for acute injuries where inflammation and pain are present.  In such cases, the cold/ice can offer a reduction in inflammation+swelling, as well as pain relief.  And heat for the more chronic and non-inflammatory conditions, which might benefit from an increase in vascularity/blood flow, like pesky “trigger points”, or tendosis (when the tendon has actually broken down, as opposed to tendinitis in which the tendon is merely painful due to inflammation).

What you most likely would not want to do, is apply heat to an acute injury, which will only increase pain+inflammation.  Nor would it be sensible to apply heat to back pain or a “trigger point” if they are not inflammatory in nature.

Seems sensible enough, right?  But what about icing an injury that is inflamed for more than a day or two?  Don’t you want your body’s inflammatory processes to run their natural course? Perhaps.  Or perhaps you want to create what has been referred to as “circulatory gymnastics”, in which 20min-ice-on/20min-ice-off is used, which temporarily suppresses blood flow for 20min, followed by a compensatory increase in blood flow for the next 20min, which can be therapeutic for reasons that are unclear (but could be attributed to a net change in vascularity to an area which is striving to repair itself.  As we know, the only way repair can take place is from nutrients derived from blood).

Bottom line: heat vs. ice depends on the nature of the injury.  Effects should be constantly ax’d/re-ax’d

Once again, PainScience has more on this topic: