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Managing Recovery and Fatigue

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Recovery and Fatigue

There is plenty being spoken about the health benefits of getting a good night sleep and we agree that if you sleep well it has a multitude of positive flow on effects on how we feel. Exercise is sometimes a means to providing an improvement to the quality of our sleep but excessive exercise can lead to general fatigue which can erode the desired overall health benefit. This article is a follow-on to our last blog on exercise addiction.

In this article we will refer to fatigue as a level of exhaustion or tiredness. One definition of fatigue is extreme tiredness resulting from mental or physical exertion illness. Whether you should continue to exercise when you feel fatigued depends on the severity and cause.

Some of the negative effects of exercising when fatigued are:

  • Lack of recovery time can increase risk of injury and becoming unwell
  • Doing too much when you aren’t medically well can prolong recovery from illness
  • Specific muscle fatigue in a certain muscle area from repetitive exercise increases the likelihood of musculoskeletal injury due to lack of variation in exercise program

Simple advice for when you feel fatigued is to consider your exercise routine as a cause relative to recent illness or an endurance exercise event. If you determine that your fatigue is not caused by anything but your regular exercise program then a reduction in exercise load is advised. If there is no obvious physical cause, consider whether stress or mental well-being might be a contributor and similarly consider the amount of quality sleep. Inadequate nutrition and energy intake can also lead to symptoms of excessive fatigue. Once you identify a cause then you are in a better position to work out what to do with your exercise routine.

Excessive amounts of exercise without adequate rest / recovery time is not recommended for healthy living nor for athletic or sports performance. Its worth a few minutes of thought.

Click the links to read our last two blogs in the series on the benefits of exercise on depression and when exercising can become a problem.

When is too much exercise a problem?

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exercise problemExercise plays an important role in assisting in the management of mental well-being. Research exists that agrees with the idea that if we are regularly active the symptoms of depression may improve (Click here to read our previous blog on exercise and depression). If we then exercise harder, it sometimes makes us feel even better and this good feeling can both mentally and physically become addictive.

A recent practice article from Heather Hausenblas and James Smoliga in the British medical journal discusses ‘addiction to exercise’, where exercise is an essential element to every day. The discussion surrounding the difference between healthy regular exercise and an addiction to exercise is important especially when injury occurs, as a reliance on exercise is difficult to overcome.

Having a physio practice in a gym based environment means we have seen clients with a reliance on exercise to the point of it being an addiction. As a general observation it is more common now than 10 years ago, but a greater number of people have a level of awareness of their need to exercise. The greatest time of concern with exercise addiction relates to when injury occurs and the ability to exercise has decreased.

Managing an unhealthy reliance on exercise involves starting with reflecting on the motivation or reasons for needing to exercise. What are your goals for exercising? If an exercise addiction is present, then we do not need to stop exercising, but rather understand the reasons and work towards a healthy exercise routine with less risk of injury and improved health benefits. Hausenblas refers to it as reducing the rigidity of an exercise routine. If you are over-reliant on running, then we may try to change the exercise routine initially and replace a run with a swim. Gradually work towards a healthy volume of exercise is the goal.

If you are reliant on exercise and don’t feel you can stop then discuss it with your GP or a psychologist. Alternatively give us a call and we can discuss your exercise routine. We will not ask you to stop but can assist with strategies to start moving towards a healthy exercise routine.

Housenblas H, Shreiber K, Smoliga J. (2017): Addiction to exercise. The British Medical Journal. http://www.bmj.com/content/357/bmj.j1745

Depression and the Benefits of Exercise

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Exercising for depressionExercise is a useful method of managing depression but is not a stand-alone treatment. There is research based reviews that support that exercise can reduce the symptoms of depression, and now a recent article by Harvey et. al in the American Journal of Psychiatry has found exercise / activity can prevent future cases of depression.

There are several features of the researcher’s interpretations that are useful. They concluded that exercise intensity was not relevant to the prevented cases of depression. This means that any exercise is better than no exercise. Just going for a walk is one of the simplest and easiest forms of exercise to start with. If you can’t walk due to pain or injury then we would encourage water based exercise or an exercise bike. Even a short walk will release endorphins to begin to make you feel better.

The findings of an 11 year prospective study were that as little as 1 hour of physical activity per week prevented 12% of future cases of depression. So if you are not currently exercising then just being active for 1 hour a week can help with depression. The recommended 30 minutes per day remains an ideal amount of exercise for healthy living (combining physical, cardiovascular and metabolic health) and if you achieve this you are way above the 1 hour per week required for assisting with depression.

The researchers did not find that exercise was not helpful in preventing future cases of anxiety. If you have anxiety or depression use the resources such as websites such as beyond blue and black dog institute and discuss it with your GP.

Click here to read the black dog institute’s fact sheet on exercise and depression.

Harvey et.al (2017). Exercise and the Prevention of Depression: Results of the HUNT Cohort Study: AJP in advance. doi: 10.1176/appi.ajp.2017.16111223,

Strength exercise – more evidence that it is worth doing

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Strength Training

The reason for doing the recommended 2 strength based exercise sessions per week has been given another boost from a recently published study. Stamatakis et al analysed adults over 30 in the United Kingdom that were selected from a pool of 80,000 people completing an annual survey then further assessed via interview and questionnaires over a 9 year period.

Strength based exercise on its own has been shown to reduce diabetes risk and when combined with cardio exercise gave even greater benefits. This study looked at reductions in mortality that could be attributed to different types of exercise that is recommended by the world health organisation. Namely 150-300 minutes of cardiovascular exercise and 2 strength exercise sessions per week.

They found 36.2% of the sample group met only the aerobic exercise guidelines. 3.4% met only the strength exercise guidelines and 5.5% met both aerobic and strength exercises recommendations.

Participation in any form of strength exercise led to a 23% reduction in mortality from all causes and a 31% reduction in mortality from cancer. Combining the strength and aerobic exercise guidelines further reduced the rate of mortality than aerobic physical activity alone.
The definition of strength exercise included both gym and body weight exercises but they analysed whether one was better than the other. The study found bodyweight exercises gave the same benefit to gym-based activity. Previous studies have indicated that increasing muscle strength has been associated with reduced cancer mortality independent of aerobic fitness. Also higher muscle strength, as opposed to just participating in strength exercise led to reductions in mortality.

Meeting the strength exercise recommendations of twice per week was found to be as important as achieving the weekly aerobic exercise recommendations for health benefits and reducing the risk of mortality.

Summary:

  • Get into strength exercises even if it’s just body weight exercise
  • Make it challenging enough to increase your strength
  • If you are just starting out, don’t go too hard too fast or you may increase your risk of injury
  • If you are not sure what strength exercise program is suitable for you, let us know and we can help you get started on a program that is safe and effective to achieve your health goals

Stamatakis et al 2017, Does strength promoting exercise confer unique health benefits? A pooled analysis of eleven population cohorts with all-cause, cancer, and cardiovascular mortality endpoints. Am J of Epidemiology.

Lifting and stooping- the latest in lifting related research

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lifting

Should we avoid stoop lifting? There has been plenty of lifting related research in the past but none of it is conclusive. We rely on expert opinion that says the squat lift is safer than stoop lifting but recent discussion amongst clinical experts and researchers surrounds other factors being more important than the classic type of described lift when it comes to avoiding injury. The original review of van Dieen at el in 1999 highlights the very little amount of good quality research existing in the area and recent research from Dreischarf et al 2016 has provided data that challenge existing beliefs on lifting.

A summary on our recent masterclass session on the topic of lifting and avoiding injury concluded the following 5 factors were valuable:

  1. Keeping the load close to the body reduces the forces on the lower back more when compared with the type of lift (stoop vs squat).
  2. Strength and conditioning to the chosen method of lifting is important. I.e. if you never stoop lift and then have to because of where the object is then you are more likely to have an injury than if you stoop lifted more often.
  3. The timing of the movement is important. This is a difficult concept to simplify but refers to when the knees and hips straighten during a lift and what the back is doing at the same time. A common observation in the clinic is that over-arching the back during a lift often leads to pain.
  4. Cumulative loading is important. If you sit and slouch through the pelvis for long periods then it will increase your risk when lifting but if you get up regularly and change posture from sitting to standing or walking then the effect of cumulative loading is reduced.
  5. Semi squat lifting places less stress on the knees than the full squat which is important if you have knee pathology. If the timing is correct and you are conditioned to lift this way it remains the optimal choice of lifting.

For those who are interested, the references referred to in this blog are:

Dreischarf et al, 2016. In vivo loads on a vertebral body replacement during different lifting techniques; Journal of Biomechanics. 49(2016):890-895

Van Dieen et al, 1999. Stoop or squat: a review of biomechanical studies on lifting technique; Clinical Biomechanics. 14(1999):685-696

 

The effect of static stretching on performance and preventing injury

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Stretching

Historically many people have used static stretching – a long hold and the end of available muscle length – as a part of a “warm up” routine before sport or exercise. But the research doesn’t back it up, and it may be detrimental.

Let’s talk about performance first. Static stretching actually decreases muscle power for a period of time – the period is debatable, but at least 5 minutes and up to 3 hours – after stretching is performed1,2. This also applies for contract-relax or proprioceptive neuromuscular facilitation (PNF) stretching. This could easily impair athletic performance, especially in sports where high force generation is required. Dynamic exercise/facilitation exercises do not seem to have this power loss effect.

What about injury prevention? Nope, no help there either. A very large study by Lauersen et al. (2014) which synthesises the best quality research surrounding injury prevention to date reported no reduction (or increase) in injury risk for people who performed static stretching3. What they did find was that proprioceptive training, strength training and a dynamic warmup did reduce the risk of acute and overuse type injuries4,5,6.

It’s hard to break old habits, but if static stretching can impair your performance and doesn’t make any difference to injury risk, it may be time to change it up. Athletes can derive a greater benefit by spending that time on a dynamic proprioceptive, agility, strength and balance training program warmup.

If you aren’t about to perform a physically demanding athletic activity and you enjoy stretching, go for it. There is no harm in stretching and if you haven’t got the mobility to perform a sport or task then both static and dynamic stretches are options to achieve this.

To read more about avoiding running injuries, click here and to read up on how to prevent injuries during pre- season click here.

  1. Marek, S. M., Cramer, J. T., Fincher, A. L., & Massey, L. L. (2005). Acute effects of static and proprioceptive neuromuscular facilitation stretching on muscle strength and power output. Journal of Athletic Training, 40(2), 94.
  2. Behm, D. G., Bambury, A., Cahill, F., & Power, K. (2004). Effect of acute static stretching on force, balance, reaction time, and movement time.Medicine and science in sports and exercise, 36, 1397-1402.
  3. Lauersen JB(1), Bertelsen DM, Andersen LB. Br J Sports Med. 2014 Jun;48(11):871-7. doi: 10.1136/bjsports-2013-092538. Epub 2013 Oct 7. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials.
  4. Soligard, T., Nilstad, A., Steffen, K., Myklebust, G., Holme, I., Dvorak, J., … & Andersen, T. E. (2010). Compliance with a comprehensive  warm-up programme to prevent injuries in youth football. British journal of sports medicine, 44(11), 787-793.
  5. Soligard, T., Myklebust, G., Steffen, K., Holme, I., Silvers, H., Bizzini, M., … & Andersen, T. E. (2008). Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. Bmj,337, a2469.
  6. Herman, K., Barton, C., Malliaras, P., & Morrissey, D. (2012). The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC medicine, 10(1), 1.

Hamstring injury management – A breakdown of the latest research

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Sliding exercise

Athletes rejoice! For decades our understanding of hamstring (HS) injuries has been improving and evolving, yet the frequency of HS injury rates in sport have not declined. Finally, a new paradigm has been developed which consolidates our knowledge of the anatomy and the physiology of this highly prevalent injury, applies effective rehabilitation strategies, accurate return to sport testing and re-injury prevention.

We can broadly define the typical hamstring strain into a sprinting type strain which occurs at high speed running versus a stretch type strain which occurs with high kicking or other stretching movements. Each of these will typically cause an injury to a different muscle in the hamstrings group. They can generally be diagnosed in the clinic without the need for any imaging. The most common type is the sprinting type, frequently seen in football codes, soccer, hockey, athletics and other running sports. The stretch type is more common in dancers, jumpers and hurdlers, although either type can occur in any sport. Knowing the type of injury gives us a chance to apply the right exercise rehab as well as gives a guideline for the return to sport time, which varies enormously between the type, location and grade of strain.

We know that most HS injuries occur when the muscle is working hard in its lengthening phase, therefore it is essential that the rehabilitation program targets this movement at high load. A comprehensive program is undertaken, which incorporates hamstring strength, but also hip, pelvis, trunk and general lower limb strength and stability. This addresses all the factors which will lead to re-injury – that’s not new. What is new is a set of 3 specific exercises, that when applied correctly in soccer players led to a re-injury rate of only 1 in 75 players over 12 months! That’s way down from the average 1 in 4 players with conventional rehab in professional soccer.

The protocol is based on 3 specific lengthening (eccentric) strength exercises and the technique, timing and progressions of these are of critical importance, they need to be integrated and complemented with other exercises and, as a rule, should be pain free. So what can you expect to gain from completing a modern rehab program like the one we provide at NU Moves? A research study by Askling and colleagues found that their protocol of exercises led to an average return to play time of 28 days, compared with 51 days for the conventional group. Combining this with the low reinjury rate means it was proven to be a much better approach to HS rehab. The research also provided an additional return to play testing procedure (H test), which we integrate into our comprehensive existing return to play algorithm in the clinic. It assesses apprehension or feeling of insecurity as well as pain when performing a high load eccentric braking action on the leg, similar to what happens during an injury but in a safe way.

So to put it all together, we have a rehab protocol that fits well with our current understanding of hamstring strains and their risk factors. It is easy and inexpensive to perform once taught. It also reduces the time to return to play and gives better long-term outcomes. If you are ever unlucky enough to be in this position, then things are looking better now than they ever have!

NU Moves physio provides sports physio services to clubs around newcastle. For more information contact us online or give us a call and to view our current sports teams or what services we provide, click here.

Feel better through movement

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Manual physio newcastle

The Uni Physio Clinic on Callaghan campus is located within The Forum Sports Centre. NU Moves has been helping staff and students for more than a decade now, specialising in manual therapy, exercise prescription, and rehabilitation. Our goal is to help you feel better in the short term and increase movement / exercise in the long term.

Are you currently:

  • Sitting most of the day?
  • Not exercising daily?
  • Stressed (workload, interactional, emotional)?
  • Have any neck / shoulder or back / hip pain?

If you answer yes to 3 or 4 of these questions then it’s time to reflect and make some changes to your daily habits now.

If you answer yes to the first 2 questions then consider how you can start to fit a walk or another exercise you enjoy into your day. The goal for long term health and feeling better now is 30 mins of activity per day. It can also help prevent muscular pain associated with excess sitting.

If you have neck & shoulder or back / hip pain, that is when we can help you the most. Physiotherapy has a range of treatment options from massage, spinal manual therapy or dry needling to reduce pain. There should always be advice on activity / exercise or we can design a full exercise program suited to your goals. Assessment of your computer ergonomic setup is essential and advice on simple changes often helps. Occasionally we utilise orthotic prescription but only if it helps you get active with less pain.

To book an appointment with NU Moves call 4921 6879 or email admin@numovesphysiotherapy.com.au

Complex ankle injuries

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Ankle Injuries

It is commonly thought that ankle sprains are a minor injury, which usually resolve fully and quickly. While this is sometimes the case, research shows that 64% of people who sprain their ankle report ongoing problems 12 months later! The main complaints we see for a “problem” ankle are swelling after activity, loss of normal range of movement, recurrent sprains, tendon pain, inability to participate in high level sport and feelings of instability.

Why? The list of possible injuries that can come from rolling an ankle is rather long, both for acute injuries and persistent ankle pain … tears of the 3 outside ankle ligaments (ATFL, CFL, PTFL) or the inside ankle deltoid ligament; osteochondral lesion (bony / cartilage bruising) of the talus; high ankle sprain (syndesmosis injury); fractures of the ankle malleoli, navicular or base of the 5th metatarsal;  tendon strains or rupture/dislocation of tibialis posterior or peroneal tendons; chronic instability; subtalar joint sprain; joint synovitis; tenosynovitis; sinus tarsi syndrome; anterior/posterior impingement.

Most people don’t get the right diagnosis (or any diagnosis) or just get an incomplete one on the sideline immediately after the injury. Fortunately, with the correct diagnosis and treatment the majority of ankle injuries can be treated non-surgically by physiotherapy. Early intervention is the best management. Unfortunately a lot of poorly managed or misdiagnosed ankle injuries present to our clinic, often months or years after the initial injury. These people have ongoing symptoms and limitations, which leads to frustrated and uncertainty about why it isn’t getting better. The main problem is difficulty competing in sport or doing regular exercise.

There is hope! We can help you accurately diagnose the problem and design a specific intervention. Many of our problem ankle cases have had a full resolution and are now symptom free. So if it’s you, a team mate, friend or family who are struggling with a non-resolving ankle injury get it assessed – get it treated – get back to sport and exercise!

To read more about foot and ankle pain click here.

ACL Reconstruction – When is best?

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ACL reconstruction

The NU Moves team recently did a masterclass session into the research associated with ACL tears and reconstructions. The questions we raised were based on a randomised trial published in BMJ in 2013 and several papers this year from Assoc Prof Richard Frobell and collaborates*.

Do you always need to have an ACL reconstruction?

Surgical repair of the ACL depends on the presence of instability and your specific goals. If you want to play sport involving change of direction (football, netball, basketball, etc) then surgery is recommended. However, having surgery in all cases is not as clear as it was 10 years ago. If you only want to walk and cycle then in some cases it’s possible to rehab the knee to an adequate level of stability. Persistent feelings of instability or giving way after rehab would warrant consideration of surgical intervention in any case, even if you don’t want to play sport.

When is the best time to have an ACL reconstruction post injury?

Current evidence clearly shows better outcomes are achieved if the patient undergoes an initial period of rehab prior to surgical intervention, deciding when and whether to have ACL surgery can be made once you have completed your rehab. A 12-week rehab period should be used to reduce swelling and regain strength and stability.

What should you do before ACL reconstructive surgery?

You must have a physiotherapy assessment and intervention. When we refer to rehabilitation following an ACL injury it involves strategies directed at reducing pain and swelling from the initial injury; regaining mobility and muscle length; and mostly importantly strengthening all the muscles of the legs to provide stability at the knee. These factors are the most relevant factors influencing your functional outcome, should you undergo ACL reconstruction.

Do you need to have an MRI?

Yes. If you have a suspected ACL tear then you should have an MRI to investigate, your doctor or physiotherapist can arrange this. The extent of ACL injury and other cartilage damage that can occur with ACL injuries are best identified via MRI. If there is significant meniscal or other cartilage damage then it needs to be considered relative to the rehab management and sometimes earlier surgery.

Do you always need to see an orthopaedic specialist?

Yes. They are the specialists of ACL surgery. Alternatively you could see a sports physician for a non-surgical opinion. There is now debate around the prevention of arthritic changes in the knee by undergoing ACL reconstruction surgery, evidence of its effectiveness is still valid but not as clear cut as it was 10 years ago. Studies over longer periods of time are still required to fully answer the question of whether surgery is better than conservative rehabilitation to delay or avoid arthritic change in the ACL injured knee. Getting a good orthopaedic opinion relative to your injury and goals is advised. For isolated ACL injuries it is now clear that better outcomes are achieved after a 3 month pre operative rehab period. So get the rehab started and then organise an orthopaedic referral at a time that suits you.

If you have any questions or have injured your ACL contact us to organise a time to start your rehab. Read more about knee rehab here.

* Articles reviewed:

  1. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Frobell et al. BMJ Jan 2013.
  2. Lower extremity performance following ACL rehabilitation in the KANON trial. Ericsson et al. Br J Sp Med 2013.
  3. Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5 year outcome. Filbay et al. Br J Sp Med 2017.
  4. Surgical reconstruction of ruptured ACL prolongs trauma induced increase of inflammatory cytokines in synovial fluid. Larsson et al. Osteoarthritis and cartilage 2017