Run the ING NYC Marathon in 3.5 Minutes. . .

Awsome time-lapse video of the NYC Marathon course on the NY Times website.



Adam Banks

Getting Old Isn's an Excuse to Give Up

Tales of “the older athlete” — Part 1

80 yr old completes 21st iron man. Defying laws of aging? Or does he just has the right attitude?

This weekend I witnessed 80 yr old scientist, Lew Hollander, from Bend Oregon, power through the finish line to complete his 16th ironman at Kona Hawaii, in a time of 15hrs 48mins, beating his time from last year by 34 minutes. Interestingly he completed his first ironman 25 years ago, at the ripe old age of 55 in a time of 15hrs 47 mins, only 1 minute faster. Hasn’t slowed down too much. What’s his secret…

“while you do lose some quickness, agility and range of motion, you NEVER lose your competitive spirit”

While most 55+ yr olds I treat couldn’t imagine doing even a part of an Ironman, when it comes to active goal setting, they’re often capable of setting the bar a little higher than they think. It’s our job as PT’s to facilitate and motivate them. When they suffer an injury, they become discouraged that “they’re getting older and slowing down”, and they will not be able to do the things they enjoy doing. The body is more than capable of building muscle and maintaining a good level of cardiovascular fitness as we get older.
Interestingly on the plane coming home, I was talking with the girl next to me and asked her how she did in the Ironman. She replied that she was here to watch her 60 yr mother complete her third Ironman. According to her daughter, she was never much of an athlete but picked up triathlons at age 50, joining a triathlon group in California. Over the past 10 years she has trained her way to be in “the best shape of her life”.
Why are triathlons good for “the mature athlete”?

Triathlons offer a good form of cross training, and often if training for a specific event, require athletes to train 6 times/week. It may sound intense, however 1-2 hrs of exercise a day can really help improve cardiovascular fitness (improving blood flow to the brain), joint nutrition and flexibility, and help slow the diminutive effects of aging. Training with a group or team provides structure, discipline and help bring out their competitive spirit, driving them to speed up and not slow down as they get older. Also the older athlete becomes more aware of their overall health, including diet and learning how to use their bodies more efficiently (part of our role is an educative one when working with them). Also structured exercise has been shown to help alleviate the symptoms of depression.

Lew Hollander demonstrates that the right attitude, focus and commitment to a goal, helps the body and mind keep going. Our role is to facilitate our patients to achieve these goals!

Check out his website:  http://www.lewhollander.com/pages/athlete.html
Luke Bongiorno

Pilates - A Patient's Perspective

A patient wrote in describing her experience during physical therapy:

As I crescendoed to the E string on my violin and turned my body to the right for emphasise, I knew that was it. A slight pinch in my lower left side and I dropped on the floor in agony. I knew the inevitable had come. It was the proverbial straw that broke the camels back. I’d been in denial about my increasing muscle stiffness and aches in my lower back and neck, which had been niggling away for the past 18months. I never thought that at 25 years of age and with my level of fitness, I might end up bedridden for 6 weeks on my back, with shooting pain down my legs and arms, debilitated. I was wrong. I had be superficially trying to fix my lower back and neck pain by attending the Physical Therapist (PT) occasionally, but wasn’t committed enough to actually learn the exercises the therapist taught me. I had been going to the PT every time I experienced discomfort: a little manipulation that always gave me some relief, however this was temporary. I thought that combining this occasional treatment with running 3 times a week was good for my body. Little did I know that every jolt was compounding the stiffness in my joints due to prolonged sitting at a desk and that visits to the PT once every 6 weeks was no panacea. The first lesson of my back pain experience was never to be arrogant about your body, no matter the level of fitness or your age. Crippling pain can strike anyone. A mixture of poor posture, bad genes and lack of core strength led to my predicament.

Unable to work or study I was forced into a life of appointments, trying every treatment to rid myself of the pain. I saw all sorts of practitioners trying to understand the cause of my back pain and more importantly learn what I could do to relieve it. I went to physicians, osteopaths, PTs and Chinese doctors. The relief these practitioners provided was often good but temporary. I decided that soon I could not afford to be making appointments 2-3 times a week in order to get a few hours of relief.

I had heard of pilates but thought it sounded pretentious and useless. I needed some relief from the stiffness and pain so I was willing to try anything. At first I was fearful of the equipment used for pilates (or neuromuscular re-education) and was worried the exercises would set me back into weeks of agonising pain again. My body had gone into protective mode and I had to work hard to fight the fear of pain so I could move again. To my relief, pilates was the only thing that gave me movement back and forced me to get over my fear. All of this was a marvellous breakthrough and left me wondering why it hadn’t been suggested by a therapist earlier. The PT I used to see had mentioned exercises that would help my condition but it was usually in a rushed manner about 5-10 minutes after the consultation.

I had never visited a PT who was into a holistic approach and whose motivation was to help me solve my problems permanently until I came to see Luke Bongiorno at NY Sports Med. I needed a therapist who was patient and willing to teach me these exercises properly, in supervised sessions, so that I could learn a whole new way to move. After a few sessions with Luke, I was relieved to see that pilates and PT (manual therapy) were so heavily integrated. I wondered why all therapists weren’t using this treatment because as I see it, you are only getting half the care you need to fully recover if you are only receiving manual treatment.

I agree that manual therapy definitely has its place but unless the patient takes responsibility for their own rehabilitation and learns proper exercises that strengthen the core muscles, recovering from back pain will usually be a prolonged process. Not only is it expensive, but it also prevents full recovery from your musculoskeletal problems and leaves you relying on medication to relieve your pain. I do not have a background in health and knew very little about how the body worked before I had my back injury. After learning pilates I have a much better understanding of movement and posture and I know how vital it is to incorporate these principles into my everyday routine.

The unfortunate thing about it all was that it took an injury that set me back for 6-12 months to realize it. I just wish more physical therapy clinics and therapists themselves encouraged pilates because this is not only a real solution to prolonged pain but a fantastic way to prevent it.

- Josephine Cincotta
* Patient’s name was changed to protect her identity

Tennis Elbow - What's the Best Approach?

Tennis elbow, lateral epicondylitis, lateral epicondylalgia or whatever you wish to call that pain on the outside of the forearm, is not easy to treat. Assuming that “tennis elbow” is not referred pain from the cervical spine, there are many treatment techniques I have encountered that aim to reduce the pain of the condition, and increase the hand and elbow function of those afflicted by it.

Some of the techniques commonly used include, but are not limited to: prolotherapy, steroid shots, lidocaine shots, Platelet Rich Plasma (PRP) shots, oral NSAIDs, oral analgesics, oral steroids, topical NSAIDS (Voltaren, Penssaid), elbow braces, immobilization of the elbow, compression bandages, ultrasound, phonophoresis, electrophoresis, trigger point release of forearm muscles, trigger point injections, cold-laser therapy, stretching, transverse frictions, joint mobilization, mobilizations with movement, mill’s manipulations, rest, postural re-education, eccentric forearm exercises, tendon transfer surgery….etc. No management strategy has had exceptional results with treating tennis elbow, even though numerous randomized trials have been performed

Bisset et al (2006) investigated whether Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow[1] had the best short and long-term results. The results of this study were not surprising, but rather, give further credence to the field of physical therapy.

The authors found that cortisone injections had the best effect at 6 weeks, even over physical therapy (except on the global improvement outcome scale), and significantly better than “wait and see.” At 6 weeks, mobilisation with movement (MWM) and exercise had a clear advantage over “wait and see.” The NNT (number needed to treat) in this example was 3, ie for every 3 patients treated with MWM and exercise, the PT would have had one more successful outcome than if they “waited to see.” At 52 weeks, physical therapy was superior to both corticosteroid shot and “wait and see.” Interestingly, those subjects that had injections had the highest reoccurrence rates of tennis elbow.

Numerous studies have shown the absence of inflammatory cells[2] histologically in tennis elbow, so why use anti-inflammatories or cortisone shots at all? I can see the benefit in the first 6 weeks of injury when inflammatory markers may be present, but I see no additional benefit for chronic cases of tennis elbow. This brings up another interesting question. Why do anti-inflammatories or NSAIDs work at all (albeit short term) in chronic cases of tennis elbow? Perhaps they work on inhibiting the pain element of the cyclooxygenase pathway (COX pathway), rather than the inflammatory element? I welcome responses regarding this phenomenon.

Some evidence suggests that tennis elbow may be related to changes in the common extensor origin, more specifically:

•neurogenic chemical mediators of pain (substance P and calcitonin gene-related peptide).[3]
•Increased level of glutamate (an amino acid)[4]
•neovascularization[5]
•muscle fiber morphology changes (ie fiber necrosis, higher percentage of fast twitch oxidative fibers, and moth eaten fibers)[6]
•Changes to sympathetic nervous system (no vasomotor response)[7]
•Presence of mechanical, but not thermal hyperalgesia[8]

With regard to manual therapy, there have been numerous studies purporting its benefit to treating tennis elbow, and proposing varied reasons why it works. In reality, there are probably many varied reasons (explained and unexplained) as to why manual therapy works on various different systems. Interestingly, Abbot et al (2001) proved that a MWM performed on the elbow in patients with tennis elbow resulted in improved external rotation ROM immediately after the procedure.[9] This certainly baffles me!

Vicenzino et al (2009) are following in the footsteps of the Childs and Cleland (2006) clinical prediction rule for treating lower back pain, in that they provided a Level IV evidence of a clinical prediction rule to treat tennis elbow[10]. Their analyses looked at age, and pain-free grip strength on the affected and unaffected sides. I will reserve judgement on this article until a further validation study has been performed.

Coombes et al (2009) in an exciting and prospective trial are following on from the work of Bisset et al (2006). In this trial, they have gathered 132 tennis elbow patients. They intend to randomize the subjects into one of four treatment groups:[11]
1) Corticosteroid injection
2) Saline injection
3) Corticosteroid injection with physiotherapy
4) Saline injection with physiotherapy.
PT will comprise 8 sessions (like in the Bisset et al trial), with follow –up assessments at 4, 8, 12, 26, 52 weeks.
I look forward to the results of this trial, especially since the authors are including cost effectiveness and cost-benefit analyses. After all, treatments must be cost-effective and have therapeutic value to be considered for use in the wider community.
--------------------------------------------------------------------------------

[1] Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939
[2] Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow): Clinical features and findings of histological. immunohistochemical, and electron microscopy studies.Bone Joint Surg Am. 1999; 81:259-278.
[3] Ljung BO, Alfredson H, Forsgren S. Neurokinin 1-receptors and sensory neuropeptides in tendon insertions at the medial and lateral epicondyies of the humerus: Studies on tennis elbow and medial epicondylalgia. J Orthop Res 2004;22:321-327.
[4] Alfredson H. Ljung BO, Thorsen K, Lorentzon R. In vivo investigation of ECRB tendons with microdialysis technique: No signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop. 2000;71:475-479.
[5] Zeisig E, Ohberg L, Alfredson H. Extensor origin vascularity related to pain in patients with tennis elbow. Knee Surg Sports Traumatol Arthroscopy. 2006;14:659-663.
[6] Ljung BO. Lieber RL, Friden J. Wrist extensor muscle pathology in lateral epicondylitis. J Hand Surg. 1999;24:177-183.
[7] Smith RW, Papadopolous E. Mani R, Cawley ML Abnormal microvascular responses in a lateral epicondylitis. Br J Rheumatol. 1994;33:1161-1168.
[8] Wright A, Thurnwaid P, Smith J. An evaluation of mechanical and thermal hyperalgesia in patients with lateral epicondylalgia. Pain Clinic. 1992;5:221-227.
[9] Abbott JH. Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia. Manual Therapy. 2001;6:170-177.
[10] Vicenzino B, Smith D, Cleland J, Bisset L. Development of a clinical prediction rule to identify initial responders to mobilisation with movement and exercise for lateral epicondylalgia. Manual Therapy. 2009;14(5):550-554.
[11] Coombes B, Bisset L, Connelly L. et al. Optimising corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: A protocol for a randomised control trial with placebo comparison. BMC Musculoskeletal Disorders. 2009; 10:76.

How Much Does That Shoe Weigh?

When helping customers at The Runner’s High, I get all kinds of questions about shoes. One of the most common being, “How much does the shoe weigh?” I could easily weigh or check the specs however, I always tell the customer that the weight should not be a major factor in running shoe selection. Here are the most important factors to remember when choosing a running shoe:


1. The purpose and function of the shoe based on the runner’s individual needs
2. The proper fit for the runner’s foot type
3. The level of protection provided by the shoe
4. The runner’s ability to run properly in the shoe selected

I almost never advise a customer to choose a shoe solely based on its weight. Understanding more about when running injuries occur can help you understand why I focus on the above factors.

Running injuries happen during the weightbearing phase (when your foot is on the ground). This weightbearing phase is where inherent weaknesses will appear, but the weight of the shoe is relatively inconsequential. In the non-weightbearing phase of running (when your leg is in the air, swinging forward) we almost never see running injuries. This is the only time where the weight of the shoe really may make a difference. The weight doesn’t truly help strengthen a running-related weakness. Instead, the runner should focus on what protective support their shoe offers so they don’t aggravate an existing deficit or cause a new injury.

Training shoes, which are generally heavier than racing flats or minimalist shoes, may assist in offering the foot resistance during the non-weightbearing or swing phase (and thereby assist in strengthening). The heavier shoes often offer more protection for the runner’s foot during the weightbearing or stance phase of running due to their greater level of protection in the shoe’s construction. On day race people often “shoe down” with a lighter racing flat which offers less resistance during the race (there will also be less protection offered to the runner’s foot). Racing flats are designed to enhance performance, but are not intended to be used throughout training. Training predominately in lighter shoes limits the benefits gained by the runner when they attempt to “shoe down” for performance on race day. Choosing the correct level of shoe protection for your foot can make your training more effective with deacreased probability of aggravating an inherent weakness.

Ultimately, your choice of proper running shoe depends on the factors I listed at the beginning of this article. I try to suggest the lightest shoe that still provides the best protection when selecting training and running shoes. Gaining a better understanding of the reasons behind why these choices make a difference can mean a more successful and enjoyable running experience for you!

Bruce Wilk

Ergonomics Part I

This is the first of a three part series of articles on ergonomics. Ergonomics is a multi-disciplined science that includes biomechanics, engineering, psychology, sociology, and economics, combined with human factors/error. It investigates all aspects of the mind, body, and soul connections, and analyzes/compares their functions to the tools, equipment, and methods used in the workplace. To put it simply, ergonomics looks at human ability versus the demands of one’s work, play, and daily activities.

ErgoWorks teaches three basic steps for performing an ergonomic analysis:

1) Identify ergonomic hazards.
2) Quantify the hazards and eliminate/reduce them through engineering, administrative, or work practice controls.
3) Demonstrate cost-effectiveness and implement solutions.

The first step is the easiest to teach and everyone can learn it. There are only six ergonomic hazards that cause injury. ErgoWorks has developed an acronym F.R.E.D. V.P. © as a way of remembering these causes of aches and pains:

FORCE – Lift, carry, push, pull, grasp, pinch, swing, strike, jerky/sudden movement, contact stress.
REPETITION – How many?
ENVIRONMENT – Hot, cold, wet, dry, humid, noise, bright, dark, slippery, outdoors, indoors, confined, hazardous, heights, dust, fumes, mist, negotiate irregular terrain.
DURATION – How long? How much recovery?
VIBRATION – Whole body or segmental.
POSTURE – Twisting, static, restricted movement, bending, reaching, poor seating, inadequate tool, squat, kneel, crawl, manipulates: slippery, bulky, sharp, awkward objects.

When the demands of these hazards are greater than human ability, they can cause fatigue; the beginning of the injury cycle. The one hazard that causes fatigue quickly is. . . Posture!

1) Carpal tunnel – stems from deviated wrist postures.
2) Rotator cuff injuries – elbow at, or higher than your shoulder.
3) Lateral and medial epicondylitis – wrist deviations of flexion and extension respectively combined with grasp force.
4) Postural back injuries – not maintaining lumbar lordosis posture and forward bending > 30 degrees.
5) Neck injuries – forward head posture.
6) Knee injuries – bending the knee > 90 degrees.

Posture is the one hazard that your patients usually have the greatest control over. Learn to identify these hazards and teach them to your patients for better compliance and reduce risk for re-injury.
Part II will discuss how to quantify these hazards and eliminate/reduce them through engineering, administrative, or work practice controls.

Glenn Orser - CEO of ErgoWorks

The New Soldier: Physical Therapy Treatment for Veterans Returning from Iraq and Afghanistan

Physical Therapy started as a profession in the United States in the early 1900’s. It formed its roots at the beginning of World War II with advent of polio and the return of injured soldiers from Europe. As a profession, physical therapy has always been closely associated with the treatment and continued care of soldiers, helping them to return to their stateside lives or back to the battlefield.

As time has passed, both war and physical therapy methods have changed. With the enhancements in body armor, improvement in battlefield surgical care, and refinement in hospital care after primary on-site surgical interventions, soldiers are now surviving injuries that were previously fatal. This, along with the preciseness of new weapons, creates new physical and mental obstacles for both the soldiers and physical therapists to overcome. Among some of the most common is an increasing number of troops returning with traumatic brain injuries.

According to many studies, between 10 and 25 percent of all soldiers deployed to Afghanistan and Iraq are coming back with mild traumatic brain injuries. Symptoms include but aren’t limited to:

•Headaches or neck pain that do not go away;
•Difficulty remembering, concentrating, or making decisions;
•Slowness in thinking, speaking, acting, or reading;
•Getting lost or easily confused;
•Feeling tired all of the time, having no energy or motivation;
•Mood changes (feeling sad or angry for no reason);
•Changes in sleep patterns (sleeping a lot more or having a hard time sleeping);
•Light-headedness, dizziness, or loss of balance;
•Urge to vomit (nausea);
•Increased sensitivity to lights, sounds, or distractions;
•Blurred vision or eyes that tire easily;
•Loss of sense of smell or taste; and
•Ringing in the ears. (Centers for Disease Control and Prevention)
With the litany of common symptoms, physical therapists and injured soldiers alike are faced with the daily challenges of figuring out how to overcome their injuries and what methods of treatments would be most beneficial. According to an article published by the APTA, US Army Captain and APTA member Matthew R. Scherer, PT, MPT, NCS states that, ”there is limited scientific and medical literature available about the management of orthopedic, integumentary, neurocognitive, and neurobehavioral effects in survivors of blast, there is even less research addressing the vestibular symptoms of these injuries.” Because there is not significant research on “best practice” for these patients, we must tailor the therapy to address the specific need of each soldier. Using such techniques as word association (to increase retention), balance rehabilitation, and careful planning with the soldiers’ medical team is imperative to create a successful and amicable environment that promotes the best rehabilitation possible.

For more information about traumatic brain injuries in soldiers returning from the battlefield visit the Defense and Veterans Brain Injury Center’s website.

Picture from the Huffington Post.


Ryan Orser