Stretching the marionette

Many of us, myself included, were raised in a sporting environment that emphasized stretching.  As a distance runner, I was routinely advised to stretch for 1/2 hour or more prior to running every day.  Unfortunately, many continue to repeat what they were taught and never question the status quo. There is a wealth of evidence that suggests static stretching can rob us of performance, although I do acknowledge some degree of tissue extensibility/mobility is necessary.

Liars! Changing the length of my strings makes things harder.

Those who treat runners know motor control (stability) is often an issue, particularly in the frontal and transverse planes.  Recently I saw the most under-controlled runner I’ve seen in a long time.  After an evaluation, corrective strategy, and conversation we reassessed and saw a nice improvement in symptoms and movement quality.  We discussed the future course of care and home exercise prescription and were about to part ways when…. the patient asked me what stretches he should add to the 2 exercises I just taught him.  Maybe I did the world’s worst job communicating what I thought the problem and potential solution were, but I suspect I was just up against an insurmountable preconceived notion.  Stretching is not a panacea solution.  It is also not a necessity for all activities, in particular running.  See NY Times Article: Reasons Not to Stretch.

There is also abundant evidence questioning the value and timing of static stretching.  A random selection, in no particular order:

I understand that handing out copies of the NY Times article or giving patients research citations, abstracts, or even full text articles isn’t a solution to the problem.  Further, in the current healthcare setting time and efficiency is often a key factor in clinical treatment.  So how do we effectively communicate this idea that stretching may impede performance as clearly and succinctly as possible?

Here’s one way I’ve had success.  I recommend you judge your successful communication by the change in facial expression (shocked), demeanor (surprised and curious), and the light bulb appearing above your patient/clients head.   

The way you move is coordinated in the subconscious portion of your brain.  This is done based on feedback regarding length and tension.  Changing your length and tension by stretching just before you run is like changing the length of the strings on a marionette just before the puppeteer takes the stage.  The performance will suffer.

I’m not sure why this analogy works better than all others I’ve tried, but it seems to.  Perhaps it’s the image of the clumsy puppeteer?  Maybe it’s the non-threatening nature of the analogy as it doesn’t directly compete with what so many ‘experts’ have told the athlete before?  Either way, it seems to be a way for people to grasp a complex concept that is often in opposition of their existing beliefs.

 

This conversation often continues into why they feel ‘tight’.  Here’s a nice recap of Professor Janda’s thoughts by Craig Liebenson, DC.

Concussion Conference

Being a strong proponent of active care I encourage many people to become more active, to move with better quality, and to then move more frequently.  For the majority, I think this is quality advice, but as with all clinical interventions a key component lies in knowing when not to apply that strategy.  Active care may be contraindicated in a few different conditions, but one is in those experiencing concussion symptoms.

Recently I had the opportunity to attend the 9th Annual Sports-Related Conference on Concussion and Spine Injury (May 18, 2012). While I must admit that my background in concussion management is not as strong as I would like it to be, I felt compelled to attend to strengthen my understanding so I would better be able to discuss this hot button topic with my patients and community.  Ultimately I see my role as a chiropractor in recognition of symptoms, prescription of sparing advice, reassurance, and referral for appropriate monitoring.  To do this effectively I needed to know more.  I found this conference to be a top notch assembly of exceptional health care professionals, former elite athletes, and researchers.  I left with an appreciation for all that goes into studying and managing concussions and appreciating that there is still a lot to learn.  Some points of interest, reviewed concepts, and things that peaked my curiosity below.

From William Meehan III, MD, the history of concussion was discussed.  It was known from the slaughterhouse that rotational acceleration was necessary to stun the animal and that blunt head trauma alone (head stabilized during the trauma) did not produce the dazed reaction they were looking for.  {Upcoming post on how often we know things before science catches up…. Soon.}  The role of second impact syndrome or repeated concussion is a hot topic these days, but was first described by Gronwall in 1975 who noted in his research that the 2nd concussion commonly took longer for recovery of symptoms.  Why are we sometimes so far behind ourselves?

(Overview) Management of a concussion:

  1. Rule out other injury (on the field ABCs, then consider fracture, intracranial hemorrhage, and other life threatening conditions)
  2. Physical rest (avoid working out so ATP & glucose is not stolen from the brain where it is needed for recovery efforts.)
  3. Cognitive rest (avoid mental activity using precious ATP & glucose that’s needed for healing.)
  4. Emotional rest (same rationale as above)
  5. Follow up and reassess for patient to be symptom free.
    1. Evaluate with PCSS- Post Concussive Symptom Scale
    2. BESS Balance Error System Score:  Double leg stance, Single leg stance, Tandem Stance (20s)
    3. Neurocognitive (ImPACT and similar tools):  Verbal memory, visual memory, processing speed, & reaction time
  6. When symptom free return to participation (RTP) stages
    1. Rest (physical, emotion, cognitive; as described above)
    2. Light aerobic
    3. Sport specific (low intensity) training
    4. Non-contact training drills
    5. Full contact
    6. Game play

 

Neuropsychologist Alex Taylor, PsyD reminded us that concussion is a silent disease.  Those suffering with it often appear healthy and normal.  Considering that 90% of concussions do not involve a loss of consciousness, MRI and/or CT are likely to be negative, and there are no dramatic outward signs (seizures, emesis, blood, bruise, cast, splint, etc), these injuries can often go under appreciated.  Particularly in students this can include parents, teachers, coaches, and friends.

He also noted significant role of computer based testing.  His explanation was that this testing was more sensitive than symptom reports only, but he emphasized the greatest sensitivity when combining the two:

–       64% accuracy with symptom reporting
–       83% accuracy with neuropsychologic (computer) testing
–       93% accuracy when combining both (the comprehensive approach is best).
–       As each individual recovers differently, evaluation and reevaluation is essential.

From Robert Cantu, MD – Ways to prevent concussions:

–       avoid taking unnecessary hits (non-contact practice)

  • CTE is more about repetition that significance of trauma; observe the most frequent positions in football – linebackers & lineman; mores than receiver.
  • Consider ‘hit’ count for kids, similar to pitch count in baseball.  Considering that pitching produces surgically repairable injuries and head trauma causes irreparable damage this should be given strong consideration.

–       proper technique (don’t lead with the head)
–       adequate hydration
–       having the right genetics  (good luck modifying this risk factor)
–       rules changes
–       strengthen your neck   *** see discussion below***

My side comment: (Note: I have no strong evidence to support this, just my thoughts.) 
Dr. Cantu was not the first or last to note ‘neck strength’ as a primary factor in concussion prevention during the conference.  As this was discussed my mind immediately jumped to the role of ‘core strength’ in prevention of back pain.  Core strength is/was commonly discussed as being preventative for back pain.  Research on this tends to be less decisive than the commonly accepted statement that a ‘strong’ core is protective for the back.  I wonder if this statement on ‘neck strength’ is equally well liked for it’s plausibility, but will also result in marginal or less than perfect correlation during research.  I suspect that the role of ‘timing’ of neck muscle activation plays a more significant role that ‘strength’. 

This was demonstrated well in Cholewicki’s work. [Here or even more clearly here.] To look at this in more common terms, let’s compare it to a car accident. I don’t think the ‘strength’ of the brake is the best determinant of injury during a motor vehicle accident, it is much more likely that the ‘speed’ or ‘timing’ of applying the brake has a more significant correlation on how well injury can be avoided.  Particularly when considering the role of external perturbation in Cholewicki’s study and the fact that some of the concussion-causing trauma is unanticipated.  The natural timing and response of the cervicocranial stabilizers appears to have the best chance of being protective by mitigated rotational forces.  (Again, this is just my speculation.)  During a brief conversation with Dr. Cantu he noted that he was unaware of any research done on concussions and cervical timing.

Childhood concussions with Dr. Gerard Gioia – a wealth of info, but this one resonated with me as it sounds much like what we (should) do to properly manage so many NMS conditions.  Have them do activities they can tolerate, help them learn what they can and can’t do, and “Teach them the sweet spot”. This results in active rest and active management which is then gradually increased.

Clinical Pearls:

-Younger brains need to be managed more conservatively.

-For unknown reasons, concussed females show a greater decrease in neuropsychological scores than males.

 

Ted Johnson (former NFL All-pro middle linebacker (paraphrased):

 

This is an exciting time for medical providers and scientists with all the new research.  It’s a terrifying time for patients as there is much attention, but so little is known.

Most of my concussions came in practice, not in games.

Players don’t know the long term effects of concussions.  I didn’t know & don’t tell me I did!

Before meeting my current concussion specialist, I was recommended for electroconvulsive therapy (ECT) because they didn’t know what else to do with me.

 

Links of interest:

Ted Johnson @ Harvard Concussion Conference NESN story & video

Ben Utecht:  Tell me if his story makes you wonder about the significance of these injuries.  Not only did he not recall being at his friends wedding, he didn’t recall that he sang at the wedding.  Doesn’t seem like an occasion you should need photographic evidence to refresh your memory.  http://espn.go.com/nfl/story/_/id/7966792/concussions-affect-now-singer-ben-utecht-life

CDC Concussion info (with good video for the lay public)

Mass Dept of Health Concussion resources

Sports Legacy Institute

 ImPACT testing

Medical News Misinformation

No man really becomes a fool until he stops asking questions. –Charles Steinmetz

How often do we see the evening news, a newspaper, or a web article touting the new, revolutionary, risk-free, most-effective, miraculous solution to condition X.  All too often.  If you’re anything like me you either cringe or shut down at these claims.  It just can’t be as good as they make it sound, and it almost never is.  After years of hearing, reading, ignoring, and disregarding these claims…. there really haven’t been too many revolutions in the way we treat some common health problems.  Just lots of empty promises, money making gimmicks, and profitable new drugs or procedures that are marginally different than the old.  So why do we continue to see these same over-hyped, flawed, and misleading news stories….

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We need to stop tolerating misleading journalism and instead start asking informed questions and demanding the whole story.

For a practical solution to many common health problems, try this.

FMS Study???

For those that wish to review the study, look here.

I first had this conversation with a colleague and then saw this post on Jeff Cubos’s Blog.
This study is well performed, but poorly designed.  The premise, as Jeff points out, has significant flaws.  They are taking a “screening test” for injury risk assessment and claiming to use it to measure athletic performance.  To compare how odd this is let’s think about drawing blood and measuring lipid profiles to determine the fastest runner.

A comment left on Jeff’s blog notes that improvement in the FMS screen may be implied to lead to improved athletic performance.  While not the intended goal of the screen (it is designed to test for risk of future injury), I can see that this would make sense.  For example, an athlete who scores a 13 (out of 21) and then participates in a corrective exercise program and a few weeks later able to score a 16 (with no asymmetries); I would assume that some translation to on the field performance may exist.  (Although again, this is not the goal of the FMS test.)

Parchmann & McBride not only begin their study with a flawed concept but seem to bias the test results as well.  In comparing a movement literacy test (FMS) to a power-based movement (1RM back squat) the researchers chose to use the following as benchmarks: sprint times (10m, 20m), vertical jump, T-test, and golf club head speed.

Exceptional workout power; limited performance

Suffice it to say that these are all power based movements.  The most powerful athlete will likely get the highest marks on each of these tests and therefore it is expected that a 1RM test correlates better than the FMS test.  However, this does not correlate well into determination of the best athlete.  [Think Brian Bosworth vs. Brian Urlacher].

Great workout; exceptional performance

To put this another way, I can swing a golf club really fast… however the score at the end of my round is nothing I care to brag about.  Swing velocity is not a good indicator of the best athlete, it’s indicative of the most powerful.

To recap:

  • I applaud Parchmann & McBride‘s effort to test the FMS screen.  We should challenge all concepts and make sure that we’re using what works best and not holding onto sacred cows or simply doing what “should work”.
  • This study has significant logical flaws as the FMS test is misinterpreted from the beginning and the authors base their conclusions on the flawed premise that the most powerful athlete is the best athlete.
  • As I suspect there is a mild degree of correlation from the FMS score to ‘coordinated movements’, I would be curious to see this compared to putting or chipping accuracy, or perhaps driving closest to a center line.  These non-power skills likely have little correlation to 1RM and may have some correlation to FMS scores. However we must remember that this was never the stated (or intended) purpose of the FMS test.