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Re: Can I Have tips involving a pulled hamstring?
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Re: Can I Have tips involving a pulled hamstring? - May 2, 2006 9:38:00 AM
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VagusX
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From: Savannah, GA, USA
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To Jason and Randy
What I meant by increasing hamstring length is the same thing as what Jason phrased as "a more compliant muscle." A more compliant muscle that has a longer excursion.
I am familiar with how to increase the length of tissue. TERT, low load-long duration stretches have been been put into treatment options, but I still question them at times. For example, for my frozen shoulder patients, I tell them to do a double arm overhead reach to end range 10 reps, 10 times a day. MOst the time their GH flexion increases to a point where they can reach their cabinets in a week. Is this a case of neural relaxtion or tissue relaxation or a combination of the two? Why it works is in question, and it may hurt our professional integrity for not knowing "why," but my patient is sure happy.
Back to the compliant muscle.
I don't see how making a muscle more compliant to a passive stretch will affect active contractions. I would like to learn more about this if it is true. As far as I see it, a more compliant muscle to a passive stretch would be a more compliant to an active stretch or a PNF stretch and likely a nueral mob aka making the nervous system "happy" as Nari may explain it.
I can see this conversation really questioning my way of thinking. I like it.
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Re: Can I Have tips involving a pulled hamstring? - May 2, 2006 11:29:00 AM
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JLS_PT_OCS
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Vagus-
Au contraire, a passive stretch indeed affects the ability of a muscle to contract. In fact, passive stretching has been demonstrated to decrease subsequent power output of muscles! This sort of "anti-postactivation potentiation" is exactly what we don't want to provide.
To find out more, check these resources for a start:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15970955&query_hl=1&itool=pubmed_docsum
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10956367&query_hl=1&itool=pubmed_docsum
There are a lot more references available in the Journal of Strength and Conditioning Research, which you can search for free if you're an NSCA member. It's not indexed on MedLine.
On the frozen shoulder thing - I would hope you and your professional integrity care about your patient gaining motion and WHY. If the motion improved that quickly, we are obviously working with neural effects and not a true capsular contracture - but that's the whole "adhesive capsulitis" thing, it deserves it's own thread. Surely you are concerned with why- it's what differentiates a scientific professional from technician.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Can I Have tips involving a pulled hamstring? - May 2, 2006 12:27:00 PM
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nari
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Rob
It is pretty much how you described it; a slump is one way to go, but a variation on SLR can be safer - threatens the CNS less.
Supine, comfortable, with a small pillow under the head to keep the neck in neutral, flex the knee on the affected side to about 80-90 degrees, then invite the patient to extend the knee, slowly, and give some support to keep the hip flexed.
When the first 'bite' occurs, probably around the hams origin or "piriformis" area, back off; then go back to that 'bite' spot, and repeat.
Of course, ensure they understand that this pain cannot HARM them, nothing is tearing or prolapsing and that sort of thing.
Repetitions? Nobody knows. I never exceed 5 consecutive reps. Amplitude of movement is only about 10 degrees in and out of the 'bite' range.
They can do this at home, if there is someone who can help hold the hip in flexion. We don't want effort and heaps of muscles contracting - won't help at all. Failing that, on the floor, back to the wall, and leaning forward until the 'bite' is felt. Again - only a dew reps. They can do it as often as they want during the day, BUT only 3-5 reps. If they try ten, the pain will remain and they and you will be frustrated.
Simple Contact would work better without effort from PT or pt...keep it in mind.
Nari
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Re: Can I Have tips involving a pulled hamstring? - May 15, 2006 6:52:00 PM
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VagusX
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Thanks for the links J.
Makes sense. Now that I think about it I have experienced this phenomena in some instances being a pole vaulter in high school. running from event to event I had my best vaults in comparison to sitting around and stretching for 30 minutes before my trial. Could be something there.
But.....we're still talking about a muscle that is more "compliant" in the long run. The point of stretching is to relax muscle to take forces off of bony structures that could subsequently cause restrictions up or down the chain. Stretching on a daily basis will do this. According to those studies above, peak torque etc. was lost for some hours post stretch, but how about long term? Sorry to digress from the SPorts and Fitness section, but hOw does a decreased power output of a muscle affect my patient that is going to be sitting down for 3 hours straight?
Yes, I strive to know WHY as much as possible. I would love to know why ever last thing does or doesn't work. However, I don't have a problem giving an activity to my patient that has demonstrated its efficacy, yet has never hurt my patient. Why not, it can't hurt to try.
-D
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Re: Can I Have tips involving a pulled hamstring? - May 16, 2006 8:34:00 AM
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JLS_PT_OCS
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Does stretching relax muscle?
Any evidence for this?
I agree that stretching might be helpful for some problems, but let's examine our terminology a bit...
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Can I Have tips involving a pulled hamstring? - May 17, 2006 7:11:00 AM
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Shill
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Apparently, stretching does lead to increased joint ROM.
Does stretching induce lasting increases
in joint ROM? A systematic review
LISA HARVEY, ROBERT HERBERT and JACK CROSBIE School of Physiotherapy,
University of Sydney, Australia
ABSTRACT Background and Purpose. Stretching (that is, interventions that apply tension
to soft tissues) induces increases in the extensibility of soft tissues, and is therefore
widely administered to increase joint mobility and reverse contractures. However, it is not
clear whether the effects of stretching are lasting. A systematic review was conducted to
determine if stretching (either self-administered, administered manually by therapists or by some external device such as a splint) produces lasting increases in the mobility of joints not directly affected by surgery, trauma or disease processes. Method. In order to determine the lasting effects of stretching, only studies that measured joint range of motion
(ROM) at least one day after the cessation of stretching were included. MEDLINE (from
1966 to June 2000), EMBASE (from 1988 to June 2000), the Cochrane Controlled Trials
Register and PEDro databases were searched, and citation tracking was used to identify
randomized studies that met the inclusion criteria. Each study was rated by two independent
assessors on the PEDro scale, which rated trials according to criteria such as
concealed allocation, blinding and intention-to-treat analysis. Results. Thirteen studies
satisfied the inclusion criteria. All examined the effect of stretching (median number of
stretch sessions = eight) on joint ROM in healthy subjects without functionally significant
contractures. Four studies were of ‘moderate’ quality and the remaining nine were of
‘poor’ quality. The ‘moderate’ quality studies suggest that regular stretching increases
joint ROM (mean increase in ROM = 8°; 95% CI 6° to 9°) for more than one day after
cessation of stretching and possibly that the effects of stretching are greater in muscle
groups with limited extensibility. Conclusions. The results of four ‘moderate’ quality
studies show a convincing effect of stretching in people without functionally significant
contracture. These findings require verification with high-quality studies. Lasting effects of
intensive stretching programmes (for example, stretching applied for more than six weeks
or for more than 20 minutes a day) or of stretching on people with functionally significant
contracture have not yet been investigated with randomized studies.
So, the question was posed.... Does it change the actual length of the soft tissue? No one knows.
I think we can, as a group, say that joint ROM can be increased with stretching. Do we know why its increased? I say no. One would be as correct saying it is due to muscle lengthening, or capsular lengthening, as one would be correct saying it is neuromodulation. The point is that we dont know why. People will attribute the effect of the stretch to the tissue they feel is most likely allowing the change in ROM. I dont particularly care which tissue it is in most cases, as I am perfectly comfortable explaining to the patient what happens to various tissues involved in a movement, telling them what it might be, and then telling them that their guess is as good as mine. We all have our hypotheses, so lets just agree to disagree.
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Steve Hill PT
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Re: Can I Have tips involving a pulled hamstring? - May 17, 2006 8:06:00 AM
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VagusX
Posts: 215
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From: Savannah, GA, USA
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You are right Jason. Relaxation is too vauge of a word.
Replace Relaxation with sustained Nuerological Lengthening, sustained reduction in passive tension, sustained flexibility, or sustained increased joint ROM.
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Re: Can I Have tips involving a pulled hamstring? - May 17, 2006 7:02:00 PM
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ginger
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From: Melbourne Victoria
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After we've figured out if stretching causes increased length of muscle, we should really get down to looking at wether eating a hamburger causes loss of hunger pains, having a shower really gets you wet , and if when money is spent its no longer in your pocket. Yep really important stuff like that. or,,, maybe some things just don't really need that kind of study. Surely you all must know of at least one grant application for research where the premise was so obvious that research was merely a way for some enterprising physio or student to take up otherwise usefull space.
Id still like to know wether the moon is really green cheese. Let's get to it.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Can I Have tips involving a pulled hamstring? - May 18, 2006 6:18:00 AM
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Shill
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Ginger,
I thought it was cream cheese. (?) I gotta believe cream cheese is tastier.
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Steve Hill PT
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Re: Can I Have tips involving a pulled hamstring? - May 18, 2006 6:29:00 AM
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JLS_PT_OCS
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There is a big difference between improving the physical length of soft tissue and decreasing it's neurological resistance to stretch. This concept, while possibly unimportant in the hamstring example, becomes very important when we consider other parts of the body, and a "I dunno" unthoughtful approach to clinical concepts is not really appropriate for a professional. No one is arguing that the motion is not improving, but the way in which it improves has obvious implications for many, many other modes of care in physical therapy.
If we think we are changing the physical length of soft tissue with our hands in manual therapy, we are fooling ourselves, and this leads to many problems and poor care for patients. Over-aggressive treatment of adhesive capsulitis is just one example. Soft tissue length change with manual therapy has never been demonstrated. Splinting, casting, surgical resection/release, sure. Manual therapy, impossible. Impossible because it directly contradicts the body of research on this topic and what we know about human physiology. We do ourselves and our students and patients no justice when we continue to perpetuate therapy myths. The assumption that it isn't important is simply intellectual laziness. Some things work for reasons we don't fully understand. That's OK, but to stop looking for why or to not care is simply unacceptable in a scientific profession.
This concept changes "everything" about how to approach the body and how to deal with restricted movement in a patient. Especially for a profession which prides itself on being movement impairment specialists.
I would refer everyone to Threlkeld's excellent article The Effects of Manual Therapy on Connective Tissue, from the Journal of the APTA, 1992. APTA members have full text and PDF access online.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Can I Have tips involving a pulled hamstring? - May 18, 2006 9:24:00 AM
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Synergy
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Jason,
I went looking for that article you mentioned, but it appears that the PT Journal only goes back as far as 1995 for full text articles. Am I missing something? If not, and if you have it on your computer, could you send it to me?
Thanks!
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Chris Adams, PT, MPT
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Re: Can I Have tips involving a pulled hamstring? - May 18, 2006 11:57:00 AM
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JLS_PT_OCS
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Thanks, Chris.
I had thought the archives went further back. I'll try to dig it up, in the meantime, accessing it through a library might be helpful...
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Can I Have tips involving a pulled hamstring? - May 18, 2006 1:38:00 PM
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jma
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Here's the info on how far back the free text info goes from the PT Journal.
"Physical Therapy Journal Abstracts
by Volume/Year
Full text articles are available beginning with the January 1999 issue. Abstracts of articles are available beginning with the January 1995 issue. Physical Therapy is in the process of electronically archiving issues published prior to 1999. You can search indexes to Volumes 78 (1998) and 79 (1999) online and then come back to this page to link to abstracts "
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Re: Can I Have tips involving a pulled hamstring? - May 18, 2006 2:10:00 PM
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ginger
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From: Melbourne Victoria
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Jason . your erudite and careful responses to the questions posed by myself and others are always of value. I'm taken to a new level of thoughtfullness by your example. It remains however a concern that tokenism , in the manner of choices for study or research does exist. By this I mean a disposition for lengthy research and model exploration to take the emphasis .That emphsis being to discuss at length details that while interesting in the total understanding of physiology, don't contribute to improvements directly in methods.
Evaluation of alternative techniques, the construction of skill related dialogue, and the use of resourses to benefit patients in a more direct manner is more difficult and so becomes the less travelled road.
Your concern about extending the value of stretch related subjects is worthwile of course.
As to my own contribution , I've begun a series of proposals to victorian hospitals for a research facility to be made available to me . The responses so far are very exciting, an agreement should be only a few weeks away. Presuming I have the control I seek I'll be looking to begin RCT's this winter.
My first concerns will be to establish best protocals for examination and treatment of PFS. I look forward to keeping you all informed as time allows.
Cheers
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Can I Have tips involving a pulled hamstring? - May 19, 2006 3:36:00 AM
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Shill
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So,
"The assumption that it isn't important is simply intellectual laziness". Doesnt the research for manipulation show that it isnt necessarily even important that we manipulate a specific level? Seems to me that we dont know why this has the effect that it does either. Does anyone really think we will find out the why on this?
While it is true that "some things work for reasons we don't fully understand", instead of it being unacceptable to not care why it this is the case, I feel it is a healthy dose of reality, regarding the capabilities of research.
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Steve Hill PT
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Re: Can I Have tips involving a pulled hamstring? - May 19, 2006 7:06:00 AM
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JLS_PT_OCS
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Steve-
Good example with manipulation, however, I think the body of neurophysiological evidence does present the most likely mechanism. It's OK to not know, I submit that it's not OK to not care.
I think not "knowing" why is a dose of reality, and not "caring" why is intellectual laziness. Please note I am not aiming this at anyone in particular, least of all you.
I was expressing a general sentiment about some members of our profession, and I hope no one took it personally.
Ginger-
Thanks also to your thoughtful responses. However, I submit that this issue we are discussing here is not only about theory, but relates directly and immediately to our treatment of patients. Consider adhesive capsulitis for example. It seems most medical doctors will slap this label on any patient over 45 who has a painful shoulder that they are reluctant to move actively or allow to be moved passively. The assumption that such a finding always means a contracted/stiff/shortened capsule is incorrect on it's face. Also the idea that if it were such a capsular stiffness, that manual therapy could significantly alter the length of the tissue also is not only incorrect, but leads to the needless and painful treatment of many patients with this diagnosis. I'm sure you would agree, and we both have seen this in the clinic.
This is an example where the discussion has a direct relation to hands-on treatment, and where theory is used to guide treatment not only of hamstring problems, but many other areas as well.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Can I Have tips involving a pulled hamstring? - May 19, 2006 10:43:00 AM
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Jeffre
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Just dropping this in to see everyone's thoughts:
Phys Ther. 1986 Aug;66(8):1220-3. Related Articles, Links
Hamstring muscle strain treated by mobilizing the sacroiliac joint.
Cibulka MT, Rose SJ, Delitto A, Sinacore DR.
The purpose of this study was to compare the effectiveness of two types of treatment of hamstring muscle strains. Twenty patients with hamstring muscle strains were assigned randomly to an Experimental Group (n = 10) or a Control Group (n = 10). Peak torque production of the quadriceps femoris and hamstring muscles and hamstring muscle length were measured before and after treatment. The hamstring muscles of the Experimental and Control groups were treated with moist heat followed by passive stretching. The Experimental Group also received manipulation of the sacroiliac joint. The change in hamstring muscle peak torque was significantly greater for the Experimental Group than for the Control Group (p less than .005). No significant differences existed between the two groups in either quadriceps femoris muscle peak torque or hamstring muscle length. The results of this study suggest a relationship between sacroiliac joint dysfunction and hamstring muscle strain.
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Re: Can I Have tips involving a pulled hamstring? - May 19, 2006 4:32:00 PM
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jma
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Interesting, despite the low number of participants in the study. Wonder if it was ever followed up or not since then.
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Re: Can I Have tips involving a pulled hamstring? - May 20, 2006 8:08:00 AM
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Shill
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Jas,
Keep in mind that whether someone cares about the why, and does thousands of hours of research towards unearthing the mystery, or doesnt care, both people end up still not knowing. The not caring part can be related to hours of futile efforts already spent. Admitting defeat is an admirable quality, while toiling away endlessly is also admirable. To a point.....
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Steve Hill PT
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Re: Can I Have tips involving a pulled hamstring? - May 20, 2006 11:32:00 AM
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nari
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At least the person who looks for the 'whys' has a professional advantage over the person who does not care; there is always the opportunity that doing some decent hard slog will be extremely rewarding. And it often is, to the extent that one's entire clinical practice approach will change.
Nari
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