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It's natural for your hamstrings to feel a bit tight and stiff after training, and using a foam roller or doing hamstring stretches can really help to ease the discomfort. But you need to be mindful of the fact that rolling or stretching them out may not be enough. If your hamstrings continue to feel tight, sore, or uncomfortable during or after training, they may be telling you that they need a rest or that your lower back isn’t happy. If that’s the case, foam rolling your hamstrings won’t really make any difference. In this article: Video: How to foam roll your hamstrings When to foam roll your hamstrings When NOT to use a foam roller on your hamstrings When foam rolling your hamstrings won’t work Video: How to foam roll your hamstrings When to foam roll your hamstrings Before training: Research suggests that foam rolling before training can improve your flexibility. Researchers are a bit divided on whether or not it actually improves performance, but it has not been shown to have any negative effects on performance. You can read more about the benefits of foam rolling here. After training: It may be useful to foam roll your hamstrings after training as it has been shown to improve flexibility and there is some evidence to suggest that it can reduce the amount of soreness that you feel after exercise. When not to use a foam roller on your hamstrings Do not use a foam roller if you suspect that you may have pulled or torn your hamstring. You’ve likely torn your hamstring if you developed a sudden pain or pull while you were exercising or if you have swelling or bruising. Using a foam roller within the first 5 days can worsen the injury. It will also not help you heal any quicker. Be careful when you roll over the bony points where the hamstrings attach at your sit-bone (ischial tuberosity) or at the knee. Compressing the hamstring tendons onto those bony points can make injuries worse or cause compression injuries if you are too aggressive.. Note: Commission may be earned on the links above When foam rolling your hamstrings won’t work If your hamstrings have been over-worked and you are not giving them enough time to recover between bouts of exercise, they will remain tight and sore and foam rolling will have no lasting effect. In this case they need relative rest. Do activities that are low impact and low intensity. If your hamstring tightness is caused by neural tension. Stiffness in your glutes and lower back or injury to the lower back can sometimes stop your sciatic nerve from sliding freely. Your brain then causes the hamstrings to tighten up in order to protect the sciatic nerve. If this is the case your hamstrings will remain tight until the cause of the neural tension has been addressed. A physiotherapist can help you with this and this is something that one of our team can diagnose and treat via an online physio consultation via video call. If your hamstring discomfort is due to referred pain from your lower back or sciatica, then foam rolling the hamstrings may bring transient relief. But as with the increased neural tension mentioned above, you will have to sort out the injury higher up if you want to permanently improve it. Foam rolling can often also cause sciatic pain to increase if the sciatic nerve is very sensitive. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate. References: Capote Lavandero G, Rendón Morales PA, Analuiza A, et al. Effects of myofascial self-release. Systematic review. Revista Cubana de Investigaciones Biomédicas 2017;36(2):271-83. Macgregor LJ, Fairweather MM, Bennett RM, et al. The Effect of Foam Rolling for Three Consecutive Days on Muscular Efficiency and Range of Motion. Sports medicine-open 2018;4(1):26. Morales‐Artacho A, Lacourpaille L, Guilhem G. Effects of warm‐up on hamstring muscles stiffness: Cycling vs foam rolling. Scandinavian Journal of Medicine & Science in Sports 2017;27(12):1959-69. Mueller-Wohlfahrt H-W, Haensel L, Mithoefer K, et al. Terminology and classification of muscle injuries in sport: a consensus statement. Br J Sports Med 2012:bjsports-2012-091448. Schroeder AN, Best TM. Is self myofascial release an effective preexercise and recovery strategy? A literature review. Current Sports Medicine Reports 2015;14(3):200-08. Zazac A. Literature Review: Effects of Myofascial Release on Range of Motion and Athletic Performance. 2015

Foam rolling can be great to loosen off your calves when they’re tight from training. But there are times when foam rolling can actually make your calf pain worse. Other times, you may find that it doesn't really have a lasting effect. In this article, I'll explain why this may be and I've also included a video where I demonstrate my favourite calf rolling technique. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. In this article: When to foam roll your calves When NOT to use a foam roller on your calves When foam rolling your calves won’t work How to foam roll your calves I also discuss all of the dos and don'ts of foam rolling in this video and demonstrate my favourite method. When to foam roll your calves Before training There is some evidence to suggest that you can “wake muscles up” through foam rolling and that it may improve performance, but the research is not quite clear on it yet. It may also help to improve your flexibility. The most important thing is that none of the studies have reported any negative effects from foam rolling under these circumstances, so it is perfectly safe to do as part of your warm-up. I’ve previously discussed the benefits of foam rolling here. After training It may be useful to foam roll your calves after training, as it has been shown to improve flexibility, and there is some evidence to suggest that it can reduce the amount of soreness that you feel after exercise. When NOT to foam roll your calves Calf strains Do not use a foam roller on your calves if you suspect that you may have torn or strained it – especially if you have bruising or swelling. If you felt your calf muscle pop or you felt a sudden sharp pain while running, then you've likely torn it. The muscle fibres need time to recover, and you can worsen your injury if you do strong massage on a recently strained calf. Foam rolling does not make injuries heal faster. Muscle strains require a combination of rest and strengthening exercises to heal. You can read more about the treatment of calf muscles strains in this article. Blood clots If your calf pain started for no apparent reason, and it just suddenly became painful, red, and swollen, you should not foam roll or massage it. Rather consult your doctor immediately or go to the accident and emergency room, because you may actually have a blood clot, and it has to be treated immediately. When foam rolling your calves will not work Overuse If you’ve worked your calves very hard and haven’t given them enough time to recover between training sessions, they may remain tight and sore even after using a foam roller. In this case, you need to give them relative rest through reducing your running intensity and/or volume and rather doing low impact activities, e.g. gentle cycling or swimming. Neural tension Your sciatic nerve originates in your back, passes through your gluteal muscles, and runs down the back of your leg. If your lower back or gluteal muscles are tight, they will prevent your sciatic nerve from sliding freely when you use your legs to run, walk, cycle, etc. I often find this to be the case in patients who complain of chronically tight calves. Including mobility exercises for your lower back and hips in your routine can make a massive difference if your calf tightness is due to neural tension.  A physiotherapist can help you with this, and it is something that our team can diagnose and treat via an online physio consultation via video call. How to foam roll your calves Technique There is currently no gold standard for foam rolling calves, but the methods most frequently used in the research are: Broad or longitudinal strokes along the length of the calf muscle (ankle to knee). They usually spend about two minutes per leg. Point pressure or sustained pressure. This is where they sustain the pressure for between 30 and 60 seconds on a painful spot (until the sensitivity decreases) and then move on to the next. Using a massage ball for this usually works a better than a foam roller. I demonstrate my favourite technique in the video at the start of this article. Type of roller A firm roller is better than a soft one; it should have a bit of give in it but not dent in excessively when you press on it. If you get one with knobbles on it, it may be better for applying point pressure. For massage balls, I prefer the smooth lacrosse ball type made of rubber, as they don't slip around on your exercise mat. A massage stick can also be useful if you don't want to be rolling around on the floor, and it allows you to control the amount of pressure better. Note: Commission may be earned on the links above. Amount of pressure The pressure you apply should be 'comfortably uncomfortable'. One of the reasons why foam rolling helps to relax your calf muscles, is that it desensitizes the nervous system, which in turn reduces the muscle tone. If you are too aggressive and cause too much pain, the opposite happens - the nerve endings become more sensitive and the muscles increase their tone. How we can help Need more help with an injury or perhaps just advice on injury prevention? You’re welcome to consult one of the team at SIP online via video call for an assessment and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate. References: Capote Lavandero G, Rendón Morales PA, Analuiza A, et al. Effects of myofascial self-release. Systematic review. Revista Cubana de Investigaciones Biomédicas 2017;36(2):271-83. Macgregor LJ, Fairweather MM, Bennett RM, et al. The Effect of Foam Rolling for Three Consecutive Days on Muscular Efficiency and Range of Motion. Sports Medicine-Open 2018;4(1):26. Morales‐Artacho A, Lacourpaille L, Guilhem G. Effects of warm‐up on hamstring muscles stiffness: Cycling vs foam rolling. Scandinavian Journal of Medicine & Science in Sports 2017;27(12):1959-69. Mueller-Wohlfahrt H-W, Haensel L, Mithoefer K, et al. Terminology and classification of muscle injuries in sport: a consensus statement. Br J Sports Med 2012:bjsports-2012-091448. Schroeder AN, Best TM. Is self myofascial release an effective preexercise and recovery strategy? A literature review. Current Sports Medicine Reports 2015;14(3):200-08. Zazac A. Literature Review: Effects of Myofascial Release on Range of Motion and Athletic Performance. 2015

Poor hip control and pelvic stability has been indicated as a possible cause of several running and sports injuries, including runner's knee, iliotibial band syndrome, and ACL tears. In this article, we explain how to test your hip control. In this article: Quick test for hip control Hip stability: The glute med is only half the story Summary - what exercises to focus on Glute med exercise Glute max exercise Quick test for hip control Stand in front of a mirror and balance on one leg. Now bend your knee to do a single leg squat. Look at the angle between your hip and where your knee moves. Your knee should stay in line with your second toe and your pelvis should stay level. If your knee moves in past your big toe or your pelvis drops, it may mean that you have weak hip stabiliser muscles. Doing hip strengthening exercises may decrease your risk of injury. Hip stability: The glute med is only half the story Most people these days will tell you that you have to strengthen your Gluteus Medius (Glute Med) muscle to improve your hip stability. We fully agree with that, but the Glute Med is not the only muscle in charge of stabilising the hip and pelvis. Fetto et al. argues that the Glute Med alone is not able to prevent the pelvis from dropping during walking. The hip has to absorb the biggest force during the mid-stance phase of gait, so you would expect the glute med to be the most active during this phase. EMG studies (where they test muscle activity) have shown that the glute med is actually most active just before mid-stance which indicates that another structure or muscle must also play a role. They also go into details about how much energy it would cost etc. etc. but you can read their full article here if you are interested. They point out that a person, whose leg is amputated above the knee, always walk with increased hip adduction or a Trendelenburg sign, while a person whose leg is amputated below the knee does not. The difference between the two procedures is that the iliotibial band is cut during the above knee procedure but not the below knee one. The iliotibial band is thus an important passive stabiliser of the hip and pelvis. No one really ever talks about strengthening the Gluteus Maximus muscle (Glute Max) to improve frontal plane hip and pelvic stability (to stop the thigh moving in and the pelvis dropping). Fetto el al., however, points out that 75% of the Glute Max attaches onto the iliotibial band and they therefore argue that the Glute Max has an important role to play in tensioning the iliotibial band and stabilising the pelvis. Summary - what exercises to focus on: You should do hip strengthening exercises that will strengthen the Gluteus Medius as well as the Gluteus Maximus muscles to improve your pelvic and hip stability during running and walking. Gluteus medius exercise The Clam exercise is a good place to start. They should be done very slowly to teach yourself to isolate the muscles and control the movement. Once you can manage 3 sets of 15 slow repetitions of this exercise, you should move on to more challenging exercises in standing. Starting position: Lie on your side with your hips bent to about 60 degrees and your knees at a 90 degree angle. Movement: Tighten your stomach muscles to help stabilise your trunk during the movement. Keep your feet touching but lift your top knee up and back, so that your legs separate and open like a clam. Hold the position for 3 seconds and then SLOWLY take your leg back down. Check that: Your pelvis or hips do not roll back as you lift your leg. Gluteus maximus exercise A good exercise to start with to activate and strengthen the Glute Max is the bridge with your feet on a chair or step. Starting position: Lie on your back with your hips and knees bent to 90 degrees and your feet on a chair. Movement: Tighten up your stomach muscles and lift your bottom off the floor until your trunk and pelvis form a straight line. Squeeze your buttocks and hold the position for 10 seconds. Repeat 10 times. Check that: You do not put too much pressure on your neck and that you do not over-extend your back by trying to lift your hips too high. It may be an indication that you are forcing the movement too much if your back hurts afterwards. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate. Reference: Fetto, J., Leali, A., & Moroz, A. (2002). Evolution of the Koch model of the biomechanics of the hip: clinical perspective. Journal of Orthopaedic Science, 7 (6), 724-730.

Some sports injuries have very obvious causes - you step in a ditch and sprain your ankle or you forget your feet are clipped in and fall off your bike. But what about those aches that suddenly appear halfway through a run? Or the Achilles that stiffens up 2 hours after training? To understand why we suffer these sports injuries with their "mysterious" causes, one has to first understand how the body reacts to exercise. The body has an immediate response to exercise as well as a long-term response. Immediate response to exercise: This is the cells' short term reaction (up to approximately 48 hours) to exercise. Hormones are secreted, energy stores are used up and have to be restored, etc. Long-term response to exercise: This involves structural and functional changes to the tissue. For example, muscle fibres get bigger during long-term strength training and your heart and lungs get fitter during prolonged endurance training. The body’s immediate response to exercise can be explained at the hand of the supercompensation cycle which is divided into three stages: Fatigue (your cells run out of energy, develop micro-damage, etc.) Recovery (the cells start to repair and replenish energy stores) Adaptation (your cells "super" compensate in case you expect them to do more exercise). Fatigue phase (Your cells are tired out) When you exercise, the body uses energy stores at higher rates than at rest. Your body starts to fatigue and your performance starts to decline as the energy stores are depleted. By-products accumulate and the cells suffer micro-damage. The micro-damage can increase to the point where it causes an injury if you ask your muscles, tendons, ligaments or bones to cope with a load that is above their physical ability (you haven't trained it for it). For example if you pick up a weight that is too heavy, run too far or too fast. You are also at more risk of being injured when you become fatigued. Fatigue may cause your muscles to lose their ability to absorb the shock during exercise and can lead to your ligaments or joints taking more strain. Nutrition also plays an important role during this phase. You will fatigue much faster if your energy stores are not at optimal levels to start with. You can further delay fatigue by taking on food and drink while exercising. Recovery phase (Your cells have to recover from training) The name is pretty much self-explanatory. Once you finish your exercise session, the energy stores have to be refilled, by-products removed and micro-damage repaired to prevent more serious damage. You increase your risk of injury if you train while your body is still in the recovery phase. If you do this too often, it may even lead to overtraining syndrome, a condition that can take months to recover from. Different activities of varying intensities require different recovery times. Muscle can take between 24 and 36 hours to normalise after resistance training, while between 10 and 48 hours are required to replenish glycogen stores after aerobic exercise. Certain hormones, e.g. testosterone, can enhance recovery, which is why men generally recover quicker than women. Athletes younger than 18 years and older than 25 years also require longer rest periods to reach the adaptation phase. Trained athletes usually require less time to recover since their bodies have adapted to high training loads and have become more efficient over time. Novice runners, for instance, should really not run more than 3 times a week, while professional triathletes can cope with having just one rest day in 10! Getting your nutrition strategies right during this phase is as important as rest. Recent research suggests that you benefit most from consuming a combination of protein and carbohydrates within 30 minutes of completing exercise. Restricting your energy intake (not eating enough) between training sessions means that the body cannot repair the damaged cells. In extreme cases it may have to break down muscle and bone just to survive. Stress actures are a good example of an injury that can develop due to athletes not eating enough. The environment, travelling and sleep can also influence your recovery from exercise. There is no one size fits all when it comes to recovery and it is worth consulting an experienced coach or sports physiotherapist if you think you may be overtraining. Adaptation phase ( Your cells are ready to train and stronger than before) This phase is the most important phase for training. During this phase the body rebuilds itself and replenishes its energy stores to a higher level than before your previous exercise bout. You will see the best training results if you can time your next exercise bout to fall in this phase. Summary: What causes sports injuries? Sports injuries are caused by: Trauma Doing more exercise than what you have prepared your body for e.g. lifting a weight that is too heavy, running too far or suddenly doing a very hilly run. If you do not give your body enough time to recover between training sessions. The result is that different tissues in the body (bone, muscle, tendons) become weaker rather than stronger. This is usually the case when you suddenly develop an injury during an exercise session that normally does not cause you trouble. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate. References: MacLaren, D., Spurway, N., & Whyte, G. (2006). The Physiology of Training: Churchill Livingstone.

I find in practice that my patients often think that only yoga and Pilates type exercises can help lower back pain. If the thought of you being told to breathe in deep while contracting this and moving that fills you with dread, you’ll be happy to know that these are not the only forms of exercise that can relieve lower back pain! In this series of three blog posts, I have so far looked at: Part 1: Does Pilates benefit people with lower back pain? Part 2: Does yoga hold any benefits for lower back pain sufferers? My third and final post in this series looks at other forms of exercise that have been shown to help people with lower back pain. So, do you have to do yoga or Pilates if you have lower back pain? You may have guessed the answer to this by now. No, there are plenty of other forms of exercise that you can do that can also help lower back pain. The most effective exercise for lower back pain Hayden et al. looked at all the different exercise strategies employed in studies that investigated exercise for lower back pain. They identified that the most effective strategies: Were individually designed exercise programmes, delivered in a supervised format (for example, home exercises with regular therapist follow-up), done often. Adding other conservative treatment, such as advice to stay active, NSAIDs, or manual therapy, also resulted in improved pain and function outcomes when compared to exercise only. What type of exercises should be included for lower back pain? Researchers have found that stretching exercises appear to be the best type of exercise to decrease pain while strengthening exercises are the most effective at helping people function better. A recent study has even shown that free weight training can be an effective treatment for lower back pain. Other types of exercise that has been found to be useful include aerobic exercise, mobilising and coordination exercises. My ideal exercise programme for lower back pain I usually prescribe a combination of stretching, mobility and strengthening exercises that should be done daily and cardiovascular exercise that should be done at least 3 times a week. My patients usually consult me on a weekly basis for 2 or 3 weeks, during which we adapt their exercise programme to make sure it works for them. I usually also include self-massage techniques that help with their pain. Once their pain starts to settle and they are confident with their exercises, I send them away to continue their exercises and only see them every few weeks to progress their programmes. 1. Stretches These should be very gentle to start with and what I choose will depend heavily on the cause of my patient’s lower back pain. Someone with acute nerve pain down the leg will for instance make their symptoms worse if they try to stretch their hamstring, since this stretch will also stretch the irritated nerve. I have included some examples of my favourite stretches for lower back pain in the next section. 2. Gentle mobility exercises People who have had severe pain or have been in pain for a long time can be very fearful of movement. Prolonged lower back pain can also cause the subconscious brain to be over-protective and cause it to shout “Pain!” for things that is not supposed to be painful. You can switch this over-protective system off by doing gentle movements in positions that the “brain” feels safe in and then slowly move on to more challenging positions. A good example of this is the spine curl exercise (see below) that you do while lying on your back. I use it often for patients with lower back pain who cannot bend forward in standing or who try to avoid flexing their spine when I tell them to touch their toes. 3. Strengthening exercises These can take many forms and can include: bridges, squats, abdominal exercises, back extension exercises etc. The main point to remember is that you should be able to do very simple stable exercises first, before you can progress to more dynamic things e.g. kettle bell swings. You can find an example of a strength training programme for lower back pain here. Your exercise selection will once again be dictated by the cause of your lower back pain. 4. Cardiovascular exercise This is a very important component of any exercise programme for lower back pain and one that I feel is often neglected. It helps to improve the whole body’s health status, but can also act as a potent pain killer due to the "happy hormone" released during cardiovascular exercise. My weapon of choice is usually cycling on a stationary bike. I prefer this exercise due to its low impact and your ability to play with your position on the bike. I find it especially useful for people who spend a lot of time sitting during the day. In my experience, the gluteal muscles (your bum muscles) can often contribute to my patient’s lower back pain and cycling seems to have a positive effect on them, which is likely due to increasing their blood supply. Other useful choices can include walking, using a cross-trainer and swimming. Your choice should be influenced by your personal preference and how your back reacts to it. I usually ask people to avoid breast stroke, because the rotation movement of the legs can sometimes stir things up a bit. Choose something you enjoy! Otherwise you will not stick to it. Try to do it at least 3 times a week. Example exercise programme for someone with acute lower back pain: You should feel either better or the same after you have done these exercises – not worse. These exercises will not suite everyone. 1. Be as active as your back allows you to be. Do any activity that does not cause an increase in your pain. Swim, cycle or walk. You may have to decrease the time you do these activities for e.g. swim for 30 minutes rather than your normal hour. 2. Piriformis and gluteal stretches You should only feel a gentle stretch – not pain. DO NOT PULL TOO HARD. Lie on your back with your knees bent. Place the outside of your right ankle on your left thigh. Place your right hand on your right knee and your left hand on your right lower leg. Now pull your leg up to your chest so that your right knee moves towards your right shoulder. Hold the position for 30 seconds. Repeat with your other leg. Do 3 repetitions on each leg. Then repeat the exercise, but pull your leg diagonally across your chest so that your right knee approaches your left shoulder. Hold the position for 30 seconds. Repeat with the other leg. Do 3 repetitions on each leg. You should feel a stretch in your buttock and/or back of your thigh. You can sometimes feel a stretch in your back if you are really tight. 3. Lumbar rotation stretch You should only feel a gentle stretch – not pain. DO NOT PULL TOO HARD. Lie on your back with your legs straight. Place your left foot on your right thigh just above the knee. Now use your right hand to pull your left knee over to the right so that your lower body rotate to the right. You should feel a stretch in your left buttock or lower back. Your buttock and lower back are allowed to lift off the bed, but your upper back should stay flat. Hold the position for 30 seconds and repeat it 3 times to both sides. 4. Spine curls This exercise is great for regaining some mobility, but it is also a gentle strengthening exercise for the back, gluteal and thigh muscles. Lie on your back with your knees bent. Pull in your lower tummy muscles so that your pelvis tilts backwards and your lower back flattens into the bed. Slowly lift your bottom off the bed and then imagine lifting one vertebrae at a time until your trunk forms a straight line. If you find that it causes you pain to lift your back up, only lift to before you feel the pain (this may sometimes mean that you only do the pelvic tilt and do not even lift up). The more you do it to just short of pain, the better you will get. Eventually you will be able to do the full movement. Once you reach the end position, maintain the position for 10 seconds before slowly rolling down to the bed. Make sure that your bottom is the last thing to touch the bed. So you roll up in a wave and then come down in a wave. Repeat this 10 times. Be careful not to try and lift too high. It can cause you pain if you try and over-extend your back. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate. References: Hayden, J. A., van Tulder, M. W., & Tomlinson, G. (2005). Systematic Review: Strategies for Using Exercise Therapy To Improve Outcomes in Chronic Low Back Pain. Annals of Internal Medicine, 142(9), 776-785. Mostagi, F. Q. R. C., Dias, J. M., Pereira, L. M., Obara, K., Mazuquin, B. F., Silva, M. F., et al. (2014). Pilates versus general exercise effectiveness on pain and functionality in non-specific chronic low back pain subjects. Journal of Bodywork and Movement Therapies. Patti, A., Bianco, A., Paoli, A., Messina, G., Montalto, M. A., Bellafiore, M., et al. (2015). Effects of Pilates Exercise Programs in People With Chronic Low Back Pain: A Systematic Review. Medicine, 94(4), e383.

Lower back pain affects 85% of us at least once in our lifetime. Most of us are lucky enough to recover within a few months, but around 10% of people continue to suffer. The most commonly prescribed forms of exercise for lower back pain are yoga and Pilates, but this type of exercise does not necessarily suit everyone's personality or schedule. In this series of three blog posts, I take a closer look at the evidence behind these forms of exercise and hope to answer the following questions: Part 1: Does Pilates benefit people with lower back pain? Part 2: Yoga for lower back pain - does it actually work? Part 3: Is there any other form of exercise that can help your recovery from lower back pain? In Part 1, I looked at the evidence behind the use of Pilates to treat lower back pain. Part 2 will now take a closer look at what yoga is and whether there is any evidence that it may be useful in the treatment of lower back injuries. What is Yoga? Yoga is an ancient form of exercise that consists of a combination of meditation and yoga poses. People tend to think of yoga as mainly consisting of stretching exercises, but the poses develop strength, endurance and flexibility depending on how you perform them. I highly recommend that you read the section on “What is Yoga” on about.com for a deeper understanding of how this ancient exercise form works. Yoga for lower back pain - does it actually work? Yes, two literature reviews of the most current research agree that Yoga can reduce pain and disability associated with lower back pain. I can unfortunately not make any recommendations as to what type of Yoga is best for lower back pain, since the included studies used several different types. The sessions were all led by experienced teachers which may have attributed to the positive results. "But why does Yoga hurt my back?" There may be several reasons why yoga can make your pain worse, but the main two are: 1. Your teacher does not understand your condition and is not giving you appropriate exercises. Not all movements and poses are appropriate for everyone. The yoga classes used in the research studies were all tailored to the specific needs of the patients. 2. You are trying too hard – stop competing with the guy in the corner who can hook his leg behind his ear! I always advise my patients to: Book 1 to 1 sessions with an experienced yoga teacher (preferably one with a physio background) for 6 weeks. Make sure that your teacher provides you with an exercise sheet and do the exercises EVERY DAY. Only join a class once you understand the movements and know your limitations. Make sure that you join a class that suits your skill/activity level. DO NOT PUSH THROUGH PAIN. While it may be normal to have a slight increase in your pain after a class, you should not experience a big flare in pain or other symptoms. “But I really don’t like yoga!” Don’t worry. The research has found that yoga is no more effective than other mind-body exercises like Thai Chi and Pilates. Next week I’ll discuss what exercise regimes other than Pilates and yoga have been shown to be beneficial for decreasing lower back pain. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate. References: Cramer, H., Lauche, R., Haller, H., & Dobos, G. (2013). A Systematic Review and Meta-analysis of Yoga for Low Back Pain. The Clinical Journal of Pain, 29(5), 450-460. Saragiotto, B. T., Yamato, T. P., & Maher, C. (2015). Yoga for low back pain: PEDro systematic review update. British Journal of Sports Medicine, 49(20), 1351.

I am often asked by my patients what is the best type of exercise to relieve or prevent lower back pain, or rather the questions usually sound something like this: “Should I do Yoga or Pilates for lower back pain?” “I know I should be doing Pilates, but I find it sooo boring and the breathing confuses me. Should I go back to it?” “I tried Yoga and Pilates for a while but I found that it hurt my back.” I’ll try and answer these questions in a series of three blog posts: Part 1: Pilates for lower back pain - does it really help? Part 2: Does Yoga help for lower back pain? Part 3: Do I have to do Yoga or Pilates if I have lower back pain, or can I try something else? Part 1: Pilates for lower back pain - does it really help? What is Pilates? Pilates is an exercise method where you focus on developing your body control, strength and flexibility. Yes, Pilates increases your core strength, but more importantly it also teaches you how to move your body in a coordinated way. If, for instance, you have poor control and strength in your back and trunk and move you back every time you use your arms or legs, you are more likely to injure it. If, however, you are able to control your back’s position while you are using your arms and legs, you are less likely to strain it. By control, I do not mean brace your body as hard as you can so that your back does not move at all. What I mean is that you are actually aware of the position of your joints and control the movement of the back as you move rather than just allowing it to go wherever it wants to go. Having a well-controlled and strong trunk will also improve your accuracy and performance during sport and is one of the main reasons why different sports teams (including our tough rugby boys) have integrated Pilates classes into their training regimes. I attended The Young Athlete Conference held by the ACPSEM over the weekend and the physiotherapist from Southampton football club presented data that showed how they have decreased the incidence of groin injuries in their footballers through Pilates exercises that were aimed at the lower back, pelvis and hip. Pilates is named after its founder, a German by the name Joseph Hubertus Pilates. He developed the exercise regime for himself and incorporated several elements from other exercise forms e.g. Yoga into it. “In 1912 Joe went to England, where he worked as a self-defence instructor for detectives at Scotland Yard. At the outbreak of World War I, Joe was interned as an “enemy alien” with other German nationals. During his internment, Joe refined his ideas and trained other internees in his system of exercise. He rigged springs to hospital beds, enabling bedridden patients to exercise against resistance, an innovation that led to his later equipment designs. An influenza epidemic struck England in 1918, killing thousands of people, but not a single one of Joe’s trainees died. This, he claimed, testified to the effectiveness of his system.” From http://www.pilates.com It was only after his release when he moved back to Germany that the method gained popularity under the dancing community due to its ability to improve body strength and control. It is only in recent years that it has been advocated as a cure for lower back pain. Does Pilates exercise actually help for lower back pain? Yes, a recent review of the literature has found that Pilates based exercises are effective in decreasing pain as well as improving flexibility and function in people with chronic lower back pain. “So, why did Pilates hurt my back?” Pilates exercises can come in various forms and intensities and your experience can be heavily dependent on you instructor’s skill to understand your condition and adapt the exercises for you. It has also been shown that exercise programmes that are specifically designed for a specific person is more effective in decreasing lower back pain and increasing function. Not all exercises and positions are appropriate for all people. I always steer my patients towards classes taught by experienced physiotherapists. They have a much better understanding of the different health issues and are better placed to provide exercise in the beginning stages. They may even conclude that Pilates is not the appropriate form of exercise for you and prescribe something totally different! But I find Pilates sooooo boring! My answer to this is: “You are attending the wrong class.” While it is important to get the basics right at the beginning, you should progress on to more challenging and complex exercises as you get stronger. There is, however, no getting past it – you have to master the simple, low level breathing combined with move-this and move-that exercises first, before you can get to do the more exciting stuff. You will not work up a sweat in the first 2 months. You may very well leave your first class feeling a bit confused and overwhelmed by trying to activate muscle groups you never knew existed! I usually advise my patients to do the following: Attend 1 to 1 classes with an experienced Pilates instructor (preferably with a physio background) for 6 weeks. Make sure that the instructor provide you with an exercise sheet and things to do at home. Doing these exercises once is week is not enough! Do these exercises EVERY DAY. Then join a class. Choose the intensity of the class according to your ability and pain. There is no use in attending a high intensity class just because you like to sweat, if you are unable to control your body under those circumstances. Use the key concepts that you learn during the Pilates classes in everything you do, from work to sport. Still bored of Pilates? Go and try something else, but apply the Pilates principles that you have learned. It has been shown that while Pilates is effective in decreasing chronic lower back pain, it is no more effective than other types of exercise e.g. cycling. (3) Word of caution: The type of exercise has to be appropriate for your injury, so please consult your physiotherapist before embarking on a new exercise plan. Let’s face it, if you do not enjoy the exercise you are doing, you are not going to stick to it. SO CHOOSE SOMETHING YOU ENJOY! Next week we will look at whether Yoga is effective in treating lower back pain. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate. References: Patti, A., Bianco, A., Paoli, A., Messina, G., Montalto, M. A., Bellafiore, M., et al. (2015). Effects of Pilates Exercise Programs in People With Chronic Low Back Pain: A Systematic Review. Medicine, 94(4), e383. Hayden, J. A., van Tulder, M. W., & Tomlinson, G. (2005). Systematic Review: Strategies for Using Exercise Therapy To Improve Outcomes in Chronic Low Back Pain. Annals of Internal Medicine, 142(9), 776-785. Mostagi, F. Q. R. C., Dias, J. M., Pereira, L. M., Obara, K., Mazuquin, B. F., Silva, M. F., et al. (2014). Pilates versus general exercise effectiveness on pain and functionality in non-specific chronic low back pain subjects. Journal of Bodywork and Movement Therapies.

This article discusses the benefits and risks of strength training for children. It also outlines how to compile a safe and effective resistance programme for children and adolescents. The UK's Strength and Conditioning Association recently published a position statement on resistance training for young people that dispels many of the surrounding the negative impact it may have on the immature skeleton. Part 1 of this article discusses the benefits and risks as well as what effects it can have on performance. Part 2 (below) explains the principles of compiling a safe and effective resistance programme for children and adolescents. Strength Training For Children Part 1: Benefits, Risks and Performance You can find a summary of the key facts at the end of part 1. Health benefits The media in the UK has been full of alarming reports regarding rising obesity and decreasing levels of fitness in our children over the past few years.  Lloyd et al. adds to this by pointing out that recent evidence also shows a decrease in muscular strength levels of school-age children. Resistance training has been shown to have a positive effect on musculoskeletal health, body composition and cardiovascular risk factors. Fears that resistance training would harm the growing skeleton of children and adolescents have thus far not been supported by clinical observations. In fact, research has indicated that childhood may be the opportune time to build bone mass by participating in weight-bearing physical activity. Resistance training may further be of specific benefit to overweight children. Endurance exercise is normally prescribed to help with weight loss but the researchers argue that excess body weight may be an obstacle to performing activities such as jogging. It has also been found that overweight children seem to have decreased motor control and an increased injury risk compared to their peers, which may make strength training a safer option initially. Their view is that the inclusion of a structured strength training programme into a weight loss programme, can help children improve their motor skills and muscle strength while gaining confidence in their physical abilities. It will also help increase muscle mass which adds to a healthier body composition. Injury prevention benefits There is a growing body of evidence that appears to show that participation in regular resistance training by young athletes lead to a reduction in acute and overuse injuries over the competitive season as well as a shortened rehabilitation period if injured. Qualified supervision and appropriate training loads are however essential to prevent young athletes from sustaining injuries through resistance training. Researchers investigating acute injuries related to resistance training found that 77.2 % were accidental and that most could have been avoided with appropriate supervision and a focus on technical competency. Multifaceted programs that increase muscle strength, enhance movement mechanics and improve functional abilities may be the most effective strategy for reducing sports related injuries in young athletes. These programs further seem to be more effective if implemented in younger age groups – before the onset of neuromuscular deficits and biomechanical alignment issues. The researchers recommend that children should build a good basic strength, motor control and fitness base before they start taking part in competitive training. Incorporating basic jumping activities into free play can for instance strengthen their muscles and tendons and prepare them for sport in later life. The problem is that all the evidence these days suggest that kids are less active and do not spend enough time playing outside, which may mean that the musculoskeletal system of aspiring young athletes are ill prepared for their sport. The focus with strength training in children and adolescents should thus be to first produce an individual with balanced muscle strength and good muscular control, before they specialise in a specific sport. A well supervised programme may also help children overcome the loss of coordination and muscular control that they typically experience when they go through a sudden growth spurt. Young females In general injury records show that female athletes of all ages may be predisposed to certain injuries (e.g. anterior cruciate ligament rupture (ACL)) compared to their male counterparts. This is thought to be in part due to differences in biomechanics displayed between female and male athletes. Researchers have found that young female athletes who participated in strength training as they matured demonstrated fewer of the injury risk factors e.g. increased knee angles with landing. A recent meta-analysis of all the available literature revealed that an age related association between resistance training and a reduction of ACL injuries may exist in that strength training only reduced ACL injury incidence when it was implemented between the ages of 14-18. Performance enhancement There is evidence that various forms of resistance training are capable of improving young athletes’ performance in: Muscular strength Power production Running velocity Change of direction speed General motor performance (jumping etc.) Psychological benefits The research on this topic is still open for debate. It does seem to suggest that multi-faceted programs inclusive of resistance training may have psychological benefits as long as self-improvement and enjoyment remain central to the training programme. Excessive volumes of physical training could however lead to negative psychological effects and if the recovery time between training sessions are inadequate it can cause overtraining syndrome. Overtraining syndrome leads to changes in the biological (injury), neurochemical (depression) and hormonal systems (sleep disturbances) and a child can take a very long time to recover from this. See my post on overtraining syndrome for details on how to manage and prevent this condition. Summary Part 1 Resistance training is safe and beneficial for children as well as adolescents. Attention to postural alignment and technical competency during all exercises is essential to prevent injury. It can help increase bone mass and muscle mass and help with weight loss in overweight youths. It can effectively reduce the injury risk over a competitive season and aids recovery from injury. It has specific benefits for injury prevention in young females with best results gained when implemented between the ages of 14 to 18 years. Resistance training can enhance performance in various activities (running, jumping, etc.) It may also have a positive psychological effect as long as enjoyment stays central to a programme. Excessive volumes of any sport can lead to overtraining and have negative psychological effects. Part 2: Developing a strength training programme for children How does muscle strength develop in childhood and adolescence? As children reach the onset of puberty they experience rapid growth along with non-linear gains in muscular strength. Strength gains during childhood are thought to be mainly due to the maturation of the central nervous system (how well the brain and nerves control the muscles) for instance improvements in nerve firing frequency and synchronisation. Strength gains during adolescence are mostly driven by structural changes to the muscle tissue due to hormonal changes but also include some neural development. Interestingly the number of muscle fibres that one possess is already determined before birth, so any increases in muscle cross-sectional area is largely due to increases in muscle fibre size. The focus of resistance training in children should thus be based on goals related to enhancement of muscle strength, function and control as opposed to trying to make substantial increases in muscle size which will only happen during puberty. It is important to remember that children mature at varying rates and that young athletes of the same chronological age can vary with up to 5 years in their biological status. A young athlete should thus be trained according to his biological status. The athlete’s training age should however also be taken into consideration. A technically proficient athlete should not be restricted to introductory training just because of their age. Evidence further indicate that the most effective training programmes lasts more than 8 weeks, involve multiple sets and are executed more than once a week. Detraining can occur quickly once training is stopped and it is therefore advised that they partake in some form of strength training all year round. Weightlifting for young athletes The research, according to Lloyd et al., suggests that the performance of weightlifting movements as part of a strength and conditioning programme can be safe, effective and enjoyable, provided qualified supervision and instruction are available and progression is based on the technical performance of each lift. Conditions for safe training: The child should be mature enough to follow directions It should be done under the supervision of a qualified professional who is knowledgeable of youth resistance training protocols Correct technique and posture should be acquired first Exercises using body weight should be mastered first Free weights should then be introduced since they appear to stimulate more muscle activation than machine based exercises Once the youth is technically competent multi-joint, velocity specific activities can be introduced e.g. plyometrics and weightlifting. Once again technique should first be developed using modified equipment and light loads. High training intensities (heavy weights) at the expense of correct technique will likely lead to acute injuries High training volumes at any load in turn may lead to overuse injuries For individuals without prior experience of resistance training: Low volume (1-2 sets) and low to moderate training intensities (≤ 60% 1 RM) for a range of movement patterns should be used. Also note that when children are initially introduced to multi-joint exercises (e.g. squatting) their motor control development benefits more from fewer repetitions (1-3) and real time feedback after each repetition. Constructive feedback is essential to learn good technique Once technically competent the prescription should be progressed for example 2-4 sets of 6-12 reps at low to moderate intensity (≤ 80% 1 RM). As training age and athletic competency progress, periodic phases of low repetitions (<6) at high external loads (>80% 1RM) can be used. Monitor for accumulated fatigue during a training session to minimise the risk of fatigue –induced technical decrements which could lead to injury. Rest intervals: Children recover more quickly from fatigue-induced resistance training and are less likely to suffer muscle damage. One minute rest should be enough between sets but this should be increased (2-3min) as the intensity of training increases or if a high level of skill is required. Training frequency: 2-3 sessions per week on non-consecutive days are advocated to be the most appropriate for children and adolescents. The competitive season should however also be taken into consideration as training volumes may already be high. Depending on the competitive demands of the sport, anywhere between 1 and 3 strength training sessions should be completed every week to enhance or at least maintain previously acquired muscle strength. Repetition velocity: It basically boils down to technical competence and training age. A youth with limited training experience should perform exercises at a moderate speed to ensure control and good technique. A youth with several months of training experience should be exposed to greater movement velocities in order to develop motor unit recruitment patterns and firing frequencies within the neuromuscular system. Or in normal language, to enable him to produce power quickly as is needed in most sports. When high weights are used, the intention to move it as explosively as possible (even if the movement occurs relatively slowly) is enough to maximise the training effect. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate. References Lloyd, R. S., Faigenbaum, A. D., Stone, M. H., Oliver, J. L., Jeffreys, I., Moody, J. A., et al. (2014). Position statement on youth resistance training: the 2014 International Consensus. Br J Sports Med, 48(7), 498-505.

What causes muscle loss as you age, and can anything be done about it? A common complaint from my more competitive patients, who find themselves at the less desirable side of 50, is that they have to train double as hard to perform at their previous levels. They usually dread taking even a few days off training, as they feel that their fitness levels decline much faster than in their younger days. (If you like facts and details please continue to read. If, however, you would like a quick summary and succinct advice, skip to the end of the post) A recent review by Dickinson et al. (2013) looked at the causes of muscle loss in seniors and offers some insight into the processes that may partly be to blame for this decline in performance. What follows is essentially a summary of their article with some of my own thoughts interspersed. It is important to note that all of this research was conducted using older adults (above the age of 50), who are mobile but not following a regular exercise regime. How these findings relate to physically fit older adults, who train on a regular basis, is unknown. I was unable to find any research that specifically compared older adults who trained regularly with young adults who trained regularly. There are also other factors than muscle strength that could influence performance in older adults namely a decreased aerobic capacity. It has long been known that aging is characterised by the gradual loss of skeletal muscle. I use the word ‘aging’ very loosely here since it has been shown that muscle mass may start decreasing as early as the ages of 25 to 30. Interestingly it appears that the contractile properties of muscles remains unchanged and that it is thus the gradual loss of muscle size that is to blame for the decreases in strength and function. In their review, Dickinson and colleagues, focused on the role exercise and nutrition can play in reversing or slowing down the process of muscle loss. Background: Skeletal muscle The body continuously breaks down and rebuilds skeletal muscle. The process of rebuilding muscle is called muscle synthesis. Changes in muscle size occur when one of these two processes (breakdown vs. synthesis) dominates the other. Nutrition and exercise have previously been shown to be strong stimuli for muscle synthesis. One of the main factors thought to contribute to muscle loss in older age is an impaired ability of the muscle tissue to respond to the stimuli that cause muscle protein synthesis. Building new muscle: Effects of nutrition and aging It has been established that the balance between skeletal muscle breakdown and synthesis (building new muscle) is strongly influenced by the levels of amino acids (the building blocks of protein) circulating in the blood. The exact science involved in the process is still unclear but results thus far suggest that there is an intricate relationship between amino acid availability, skeletal muscle synthesis and aging. Ingesting small quantities (7-10g) of essential amino acids (protein) is capable of stimulating skeletal muscle synthesis in young individuals but not in older adults. However, ingesting large quantities (20-40g) of amino acids stimulates muscle protein synthesis to the same degree in both age groups. The authors conclude that the data indicates that the ‘threshold’ at which amino acids stimulates muscle synthesis is increased with age and that it could be overcome by ingesting adequate quantities. A specific type of amino acid has been identified to be the most important for muscle synthesis, namely leucine. Leucine has previously been shown to be a potent stimulator for muscle growth and in studies where they increased the leucine concentrate in the protein consumed by subjects, they found that young (28/30yrs) and old (66/70years) subjects showed the same level of muscle synthesis despite the small dose of protein (7g but more than 2g leucine) ingested. Thus increasing the amount of leucine in a meal may promote muscle synthesis in older adults. NB: As with all processes in the body there is not just one factor involved in the synthesis of skeletal muscle and this is demonstrated by the conflicting results reported in the literature. As an example of this, see our post regarding Vitamin D and Athletic Performance for the influence Vitamin D can have on muscle synthesis. Pennings et al. (2010) stand in contrast with the above findings in that they found no difference in muscle synthesis in response to 20g amino acid ingestion between age groups. This may be due to cultural differences(1). (Could the subjects in the Netherlands' study have a different lifestyle which impacts on their ability to maintain muscle mass in later life?) Verhoeven et al. (2009) does not seem to agree with the above recommendations either. They found no increases in muscle strength or mass in healthy elderly men after taking a 2.5g leucine supplement for 3 months. Possible differences in study design that could have contributed to these results are: The subjects may have already been taking above threshold levels of protein in their normal meals and therefore showed no further increase in muscle synthesis. Also, in contrast with the subjects in the previous studies, the subjects in this Verhoeven’s study consumed mixed meals which may have influenced how their muscles responded to the leucine(see section on insulin). A recent randomised control trial conducted over 3 weeks looked at the effect of 20g protein supplement on muscle mass post total knee replacement surgery. They found that the control group showed attenuated muscle atrophy in all the muscles of the operated as well as un-operated leg. Dickinson and colleagues warn that it is important to remember that exercise has been shown to play an important role in muscle synthesis and that physical activity or base level fitness may be an important reason for differences in results. I fully agree with this statement since the subjects in Dreyer’s study were asked to administer their supplements an hour after physical therapy, while Verhoeven and colleagues did not report on the activity levels of their subjects. See the section on exercise below for an explanation of why the timing of food intake may be important. The role of insulin There is evidence that the physiological response elicited by ingesting a mixed meal (carbohydrates and 40g protein) interferes with the ability of amino acids to elicit a protein synthesis response in older adults. This puzzled researches since a meal containing carbohydrates causes an increase in circulating insulin and insulin is known to stimulate muscle growth. Further investigation suggested that this effect may be due to the inability of insulin to stimulate an increase in muscle blood flow in older adults, since artificially increasing the blood flow in the muscles of older adults caused the difference in muscle synthesis between age groups to disappear. These results are supported by those of Fujita et al. (2007) who found that a bout of aerobic exercise performed before eating a mixed meal could restore the normal muscle protein synthesis reaction to insulin. Building new muscle: Effects of exercise and aging Resistance exercise Protein synthesis in older adults has an impaired response to resistance exercise. It can increase muscle size and strength in older individuals but just not to the same level as in younger individuals. There is evidence that more protein is incorporated into muscle if exercise is performed before the meal. Drummond et al. (2008) also found a similar response to ingesting 20g of essential amino acids after a bout of resistance exercise in young and old. Aerobic exercise There is not a lot of research available that look at the ability of aerobic exercise to stimulate skeletal muscle synthesis in older individuals. Traditionally it has been thought to rather bring about metabolic changes in muscles than increase muscle size. Recently it has been shown that a 12 week cycling programme was effective in increasing muscle mass in young and old individuals. The researchers think that the secret may lie in aerobic exercise’s ability to overcome age related insulin resistance. It is once again important to note that we are talking about untrained individuals, so it may have been a case of these individuals showed improvement because of their low baseline muscle mass. Summary: Why do older adults lose muscle strength Our bodies build new muscle when it receives a message telling it to do so. The two main events that sends this message to the body is when you eat protein and when you exercise a muscle. Researches have found that one of the reasons that older adults' bodies does not build new muscles as readily is because it does not respond in the same way to the food they eat as when they were young. These guidelines can help you optimise your muscle strength in older age Ingesting 20 to 30 grams of quality protein or 2 grams of leucine per meal is recommended to maintain muscle mass in older age. Ingesting more than this will likely not have any beneficial effect and excessive leucine intake may have a very negative effect. A table containing natural sources of leucine can be found on Wikipedia. The timing as well as the content of protein rich meals may be important, but the relevance of this is not yet fully understood for the older athletic population. Protein ingestion combined with resistance exercise could overcome age related impairments in muscle growth. Ingesting a mixed meal (carbohydrates and protein) may impair the ability of amino acids to stimulate muscle growth in older adults due to insulin resistance. Insulin resistance in older adults can be overcome by a bout of moderate aerobic exercise before a meal. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn, ResearchGate, Facebook, Twitter or Instagram. References Dickinson, J. M., Volpi, E., & Rasmussen, B. B. (2013). Exercise and Nutrition to Target Protein Synthesis Impairments in Aging Skeletal Muscle. Exercise and Sport Sciences Reviews, 41(4), 216-223. Dreyer, H. C., Strycker, L. A., Senesac, H. A., Hocker, A. D., Smolkowski, K., Shah, S. N., et al. (2013). Essential amino acid supplementation in patients following total knee arthroplasty. Journal of Clinical Investigation, 123(11), 4654-4666. Drummond, M. J., Dreyer, H. C., Pennings, B., Fry, C. S., Dhanani, S., Dillon, E. L., et al. (2008). Skeletal muscle protein anabolic response to resistance exercise and essential amino acids is delayed with aging. Journal of Applied Physiology, 104(5), 1452-1461. Fry, C.S., Drummond, M.J., Glynn, E.L., Dickinson, J.M., Gundermann, D.M., Timmerman, K.L., et al. (2011). Aging impairs contraction-induced human skeletal muscle mTORC1 signaling and protein synthesis. Skeletal Muscle, 1, 11. Fujita, S., Rasmussen, B. B., Cadenas, J. G., Drummond, M. J., Glynn, E. L., Sattler, F. R., et al. (2007). Aerobic exercise overcomes the age-related insulin resistance of muscle protein metabolism by improving endothelial function and Akt/mammalian target of rapamycin signaling. Diabetes, 56(6), 1615-1622. Harber,P.M., Konopka, A.R., Undem, M.K., Hinkley, J.M., Minchev, K., Kaminsky, L.A., et al. (2012). Aerobic exercise training induces skeletal muscle hypertrophy and age-dependent adaptations in myofiber function in young and older men. Journal of Applied Physiology, 113(9) 1495-1504. Katsanos, C. S., Kobayashi, H., Sheffield-Moore, M., Aarsland, A., & Wolfe, R. R. (2006). A high proportion of leucine is required for optimal stimulation of the rate of muscle protein synthesis by essential amino acids in the elderly. American Journal of Physiology, Endocrinology andMetabolism, 291(2), 28. Kumar, V., Selby, A., Rankin, D., Patel, R., Atherton, P., Hildebrandt, W., et al. (2009). Age-related differences in the dose–response relationship of muscle protein synthesis to resistance exercise in young and old men. The Journal of Physiology, 587(1), 211-217. Paddon-Jones, D., & Rasmussen, B. B. (2009). Dietary protein recommendations and the prevention of sarcopenia. Current Opinion in Clinical Nutrition and Metabolic Care, 12(1), 86-90. Pennings, B., Koopman, R., Beelen, M., Senden, J. M., Saris, W. H., & van Loon, L. J. (2010). Exercising before protein intake allows for greater use of dietary protein–derived amino acids for de novo muscle protein synthesis in both young and elderly men. The American Journal of Clinical Nutrition, 93(2):322-31. Peterson, M. D., Sen, A., & Gordon, P. M. (2011). Influence of resistance exercise on lean body mass in aging adults: a meta-analysis. Medical and Science in Sports and Exercise, 43(2), 249-258. Verhoeven, S., Vanschoonbeek, K., Verdijk, L. B., Koopman, R., Wodzig, W. K., Dendale, P., et al. (2009). Long-term leucine supplementation does not increase muscle mass or strength in healthy elderly men. The American Journal of Clinical Nutrition, 89(5), 1468-1475. Volpi, E., Mittendorfer, B., Wolf, S. E., & Wolfe, R. R. (1999). Oral amino acids stimulate muscle protein anabolism in the elderly despite higher first-pass splanchnic extraction. American Journal of Physiology - Endocrinology and Metabolism, 277(3), E513-E520.

One of the most common myths in exercise science is that muscle cramps during exercise are caused by dehydration and/or electrolyte depletion. Don’t get me wrong, these two factors can cause muscle cramps (think severe vomiting etc. when you have a stomach bug), but research has found that these are mostly not to blame for the cramps we get during or after exercise. Buskard (2014) recently published an article in the Strength and Conditioning Journal in which he reviewed all the available research on this topic. Muscle cramp causes: What we used to think Factors that we traditionally blamed for muscle cramps during exercise include: Accumulation of waste products that interfere with the muscle contraction Electrolyte depletion (loss of salts or electrolytes) Loss of fluid volume (dehydration) Extreme environmental conditions e.g. extreme heat or cold The research has, however, shown that most of the above factors are likely NOT the cause of muscle cramps in healthy individuals. There's an easy way to test to see if you're dehydrated so if you don't quite believe me check out this article. Two large studies that tested athletes after an Ironman triathlon and an ultra-marathon found no difference in hydration status or blood electrolyte levels between athletes who cramped up and those who did not. Heat and cold also do not induce cramps in muscles, but researchers do agree that the extreme weather conditions may lead to greater fatigue, which is currently seen as the main cause for cramping. What we currently think causes muscle cramps during exercise Muscle fatigue is the one factor that nearly all studies in this area has identified as a cause for exercise induced muscle cramps. The exact mechanism involved in this process is however still unclear. The altered neuromuscular control theory is the one that currently has the most scientific evidence in support of it. ‘Neuromuscular control’ can be defined as ‘how the nervous system (brain, spinal cord, nerves) controls the muscle’. This theory is based on the belief that fatigue causes changes in the firing patterns of the nervous system which in turn leads to muscle cramps. A muscle’s tone (how tense or relaxed it is) is controlled via the spinal reflex, where a receptor in the muscle sends a message to the spinal cord which in turn triggers a message to be sent back to the muscle. There are receptors in the muscle itself that can either increase the nerve’s activity (muscle spindles) via the spinal reflex and thus increase the muscle tone/contraction or decrease the nerve’s activity (Golgi tendon organs) and thus decrease the muscle tone/contraction when stimulated. These receptors have the ability to influence each other’s output e.g. increased firing of the Golgi tendon organs will lead to a decrease in the muscle spindle activity and cause the muscle tone to decrease (muscle relaxes). What the researchers are suggesting is that muscle fatigue causes the neural control of these receptors to become unbalanced so that the muscle spindles’ activity increases and causes a strong unregulated contraction. Researches view the fact that stretching a muscle helps to alleviate cramps as support for this hypothesis. When you stretch a muscle, you activate the Golgi tendon organs, which in turn decrease the muscle spindle activity. This hypothesis is further supported by the findings that cramps more frequently occur in shortened muscles and in ones that cross 2 joints since the Golgi tendon organs will be less active under these conditions. The research currently suggest that the following factors appear to predispose a person to exercise induced cramps: Having a history of cramping Individuals who cramp regularly have been shown to have a lower threshold frequency for cramps. This means that, during testing, it took less electricity to annoy the nerve and cause a muscle cramp in people who often cramp vs. ones that don’t. (Who volunteers for these studies?!) This may point to a genetic predisposition to cramping. Competing at a faster race pace than training pace (putting in a greater effort = greater fatigue). It was also suggested, but not yet investigated, that sub-clinical muscle damage due to insufficient tapering can cause cramp during a race. What can you do to prevent muscle cramps while exercising? Race nutrition. A group of researchers found that using a sports drink consisting of a mixture of carbohydrates, electrolytes and water significantly delayed the onset of muscle cramps during exercise. Their participants still experienced muscle cramps while drinking this mixture, but it allowed them to exercise for about 150% longer before cramping up. This study can unfortunately not tell us which of these 3 ingredients worked the magic, but my guess would be that the water and carbohydrates were the most important. It has previously been shown that adequate water and carbohydrate intake during exercise can prolong the onset of fatigue. Your body should have enough electrolytes unless you are following a very restricted diet. Train at race pace. Make sure that you complete some of your training at race pace. This will limit fatigue on race day. Dress appropriately. Overheating can lead to increased fatigue which may increase your chances of cramping. Taper your training in time to allow your muscles to recover. Racing on tired muscles will once again lead to early fatigue. What to do if you cramp up during exercise Stretch. Hold the stretch for a loooong time. As explained above, this will activate the Golgi tendon organs and relax the muscle. Slow down and walk or free wheel if cycling. This will give the muscle time to recover. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn, ResearchGate. References: Buskard, A. N. L. (2014). Cramping in Sports: Beyond Dehydration. Strength & Conditioning Journal, 36(5), 44-52

This article will help you to identify the signs of overtraining and provides some practical advice on how to treat as well as avoid overtraining syndrome. “Stress and adaptation” – My boyfriend’s favourite mantra when he parks himself on the couch (beer in hand) after a Saturday morning training session. Granted, his main aim is to get out of doing the household tasks and beer may not be the best recovery drink, but he makes a very important point. To take full advantage of a training session one has to allow an adequate period of time for the body to recover and rebuild stronger. In fact, you should view rest or recovery days as an extension of your training days, since the positive gains from training are only realised during these periods. It is so easy to get carried away when training for a big event and I see the following scenario so often, especially with novice athletes. They download a training programme or even find themselves a coach. They complete every training session to the minute, they can feel themselves getting stronger and fitter and they feel EPIC... This is when they enter the danger zone. The training high they are experiencing often make them push too hard during easy days and they ignore niggles and other signs that their bodies are struggling with the load. Inevitably this leads to injury or decreased performance and overtraining. Part of the problem is that no one can predict how your body will cope with training demands. The number of years you have been training, your own genetics and your normal lifestyle can all impact on how your body copes with training. That is why a beginner’s programme that works for one person may lead to injury and overtraining for the next. Inexperience may be the most common driver for overtraining that I see in my practice, but this may just be due to the population I work with. It has been reported that 60% of elite female and 64% of elite male athletes experience at least one episode of overtraining syndrome during their careers. The most likely cause in their case may be the constant pressure to perform at their best. The literature makes a distinction between overreaching and overtraining. Both conditions occur due to an accumulation of training and/or non-training stress, which results in a long-term decrement in performance. In the case of overreaching this can last a few days or weeks but if you have ignored the signs you may find yourself with full blown overtraining syndrome, which can take months to recover from. It is generally accepted in the literature that the main cause for overtraining syndrome is excessive training stress (volume, intensity, competition, inadequate recovery, environment e.g. heat), but it has been shown that other sources of stress can also play a significant role e.g. work or school demands, money hassles, pressure from parents or coaches and loss of sleep. This is because, when you exercise, the body produces some of the same hormones that you produce in reaction to normal life stresses. In the short term these hormones help to bring about the positive effects of training e.g. strength and speed gains, but if their levels remain too high over a long period of time they wear the body out. This is also the reason why some of the signs and symptoms experienced by people suffering from psychological burnout also manifests in athletes suffering from overtraining syndrome. Perfectionism is a personally trait that may further predispose an athlete to this condition due to the high standards they set themselves. Signs of overtraining The most obvious sign that you may be overreaching or overtraining is if you consistently underperform in training sessions and races. More subtle signs include constant physical exhaustion, mental exhaustion, mood disturbances and sleep disturbances. There are a myriad of other conditions that can cause the same symptoms and the diagnosis of overtraining syndrome should only be made once all other possible causes have been excluded e.g. anaemia, glandular fever, diabetes, thyroid dysfunctions, viral infections or inadequate energy intake (not eating enough). Several researchers have tried to develop psychological scales to monitor and identify athletes that may be over trained. The most widely researched are the Training-Distress-Scale (see picture below) and Recovery Stress Questionnaire for Athletes. A relative new tool that measures psychomotor speed is showing some potential in the early detection of overreaching and may therefore be able to prevent overtraining. The test measures reaction and attention, since it has been shown that central fatigue is an early manifestation of overreaching. Overtraining syndrome treatment Consult your GP and have some blood tests done to rule out any other diseases or deficiencies. Rest. If you have just temporarily overreached, you may be able to recover through just reducing the training load. If, however, you have ignored the signs for too long you will have to have complete rest in order to recover. Do sport for fun for a while and cross train. Check your nutrition. Make sure you are getting enough nutrients and energy in through your diet. Inadequate energy intake has been shown to affect mood negatively and a recent review of the literature has found that athletes tend to have sub-optimal levels of Vitamin D which can lead to a drop in performance. Sleep. This is the time the body uses to rebuild itself and you should be getting between 7 and 9 hours of sleep a night. Resumption of training should be individualised on the basis of signs and symptoms as there is no definitive indicator of recovery. How to avoid overtraining syndrome Keep accurate records of training and race performances. Be willing to take rest days and decrease training intensity if your performance declines or you experience excessive fatigue. It may help to use the Borg Scale of perceived exertion (picture below) to gauge the intensity of a session. Honour rest days. Avoid monotony of training. Ensure adequate hydration, nutrition and sleep. Identify other stressors in your life e.g. work or relationships and try to gauge its effect on your overall state. I use a very simple Stress Assessment Tool (see above), used for performance profiling, to assess the magnitude of different stressors. It may help to regularly complete some form of psychological evaluation e.g. the Training-Distress-Scale (see below) to identify changes in mood. Also, take note if your partner complains that you are turning into a grumpy old git. I find that partners are very good at detecting mood swing. :) Allow yourself time to recover after illness or injury. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. You can read more about her here. Follow her on LinkedIn or ReasearchGate References: Gustafsson, H., Kenttä, G., & Hassmén, P. (2011). Athlete burnout: an integrated model and future research directions. International Review of Sport and Exercise Psychology, 4(1), 3-24. Meeusen, R., Duclos, M., Foster, C., Fry, A., Gleeson, M., Nieman, D., et al. (2012). Prevention, diagnosis and treatment of the overtraining syndrome: Joint consensus statement of the European College of Sport Science (ECSS) and the American College of Sports Medicine (ACSM). European Journal of Sport Science, 13(1), 1-24.

A Harvard study compared the accuracy of 23 online symtom checkers and found that, on average, they were correct only 34% of the time. We explain why this might be. So, you develop an ache in your neck and take yourself off to the GP or physio. They ask you a few questions and readily provide you with a diagnosis. You feel quite chuffed until you see the notice behind them: “My diagnosis is usually correct in 34% of cases.” Hmmm, starting to lose your confidence in your diagnosis a bit? A recent study from Harvard suggests that this is the “best case scenario” when you use a symptom checker for an online diagnosis. In this article: Online symptom checker accuracy What is a symptom checker? Why are symptom checkers so inaccurate? Accurate online diagnosis is possible Online symptom checker accuracy The researchers from Harvard checked the performance of 23 symptom checkers found on the internet and the results were alarming. They found that the correct diagnosis was listed first in only 34% of cases. It gets even worse - performance varied by urgency of condition. For conditions that required emergency care, the correct diagnosis was only listed first in 24% of cases! Some of the symptom checkers did not offer a diagnosis, but provided triage advice only. Triage advice is when someone tells you if you should visit a GP or Emergency Department or whether you can manage your condition/injury yourself at home. The symptom checkers performed slightly better in this department with the correct triage advice being given in 57% of cases (still not going to let me sleep easy). There was of course a big variation in accuracy across the 23 symptom checkers. The most accurate at providing the correct online diagnosis was DocResponse. They had a 50% success rate while MEDoctor only managed it in 5% of the cases. HMS Family Health Guide gave the correct triage advice in 78% of cases (that’s looking better) while ITriage only manage it in 33% (I think they should reconsider their name!). The following Symptom Checkers were included in the study: AskMD (USA), BetterMedicine (USA), DocResponse (USA), Doctor Diagnose (USA), Drugs.com (USA), EarlyDoc (Netherlands), Esagil (USA), Family Doctor (USA), FreeMD (USA), Harvard Medical School Family Health Guide (USA), Healthline (USA), Healthwise (USA), Healthy Children (USA), Isabel (UK), iTriage (USA), Mayo Clinic (USA), MEDoctor (USA), NHS Symptom Checkers (UK), Steps2Care (USA), Symcat (USA), Symptify (USA), Symptomate (Poland), WebMD (USA). What is a symptom checker? Symptom checkers are designed to provide you with an online diagnosis of your injury or ailment and/or advise you about whether or not you have to visit your GP or Emergency Department. Symptoms are subjective signs of your injury or disease that you experience, e.g. pain, numbness or nausea, to name a few. These online diagnosis tools usually ask you to input the part of the body that you are experiencing trouble with and then ask you a few questions about this. They feed your answers into an algorithm and there you have it…your diagnosis! I tried a few symptom checkers this morning and was told my pain in my left thigh could be anything from a blood clot to fibromyalgia. The real cause wasn’t even listed: Irritation of my lower back brought on by my terrible posture while working on my laptop (#dontjudgeme). Why are symptom checkers so inaccurate? The short answer is that the “symptoms” of an injury or condition is only one piece of the puzzle. The symptom checker tools simply do not ask enough questions to provide an accurate online diagnosis. Pain in my thigh for instance can be caused by a muscle tear, a bruise, varicose veins or a parasite from the Amazon river, to name but a few. To narrow a diagnosis down, clinicians will listen to your symptoms and then ask more questions in reaction to these. E.g. have you visited any foreign country in the last 3 months? No? Then we can take exotic parasite off the list. How these symptoms behave, adds another important clue. Understanding the mechanism of injury, under what circumstances you experience your symptoms, how severe they are, what alleviates them etc. all helps to fine tune your diagnosis, since different injuries/conditions behave differently under the same circumstances. The medical signs associated with your condition also tells the clinician a lot. A knee that swells up severely immediately after injury usually indicates that your injury will require a scan. On the other hand, a joint that gradually swells up over time has usually sustained a mild strain only. Accurate online diagnosis is possible At Sports Injury Physio we first conduct a detailed interview over video call. We then get you to perform the same movements that we would use if we examined you in a regular clinic. This allows us to form a diagnosis and provide you with a treatment plan tailored to your specific needs. We will also communicate with your GP (with your consent) if we feel that you should have some further investigation done. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate.