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Cycling and Physiotherapy

Injury prevention, education, and performance through the analysis of cycling technique

by Martin Krause

Muscle coordination patterns for efficient cycling is achieved through coordination of muscles at the same joint, across several joints through sequential peak activation patterns from knee to hip to ankle, and reliance on multiple muscles for large joint torques. Variation of activation patterns at top and bottom dead center are also suggestive of important coordination patterns between left and right legs (Blake et al 2012, Med Sc Ex Sp, 44, 5, 926-938). At Back in Business Physiotherapy we specialize in cycling optimisation and comfort. Whether you uncomfortable on your bike, or have a specific injury, and/or would just like to improve your performance, we will do a thorough examination. This examination would look at posture, bony alignment, muscle length, strength and synergistic timing, as well as aberrations of movement. Our approach uses releases of myofascial trains, joint mobilisations and manipulations, muscle energy techniques, acupuncture dry needling, taping as well specific exercise regimes. This multidimensional and multimodal approach has been developed since my involvement with cycling since the 1970's and my association with The Rennbahn Klinik and Magglingen in the 1980's where we treated and screened professional Tour de France Cyclists, and Elite Amateur Swiss national team cyclists in preparation for the Barcelona Olympics in 1992 as well as the Sydney Olympics in 2000. Furthermore, cycling has been shown to have potent effects in the treatment of chronic low back pain.

Index

Introduction

Cycling Kinematics

Optimisation of cycling technique

Muscle activity during pedal stroke

Literature Review

Pedal Impulse

Pedal Effective Force

Pedal Torque

Kinematic Analysis

Discussion

Effectiveness of performance

Features of positive performance

Improvements to performance

Beneficial features

Conclusions

Chronic Low Back Pain

FAQ's

Uphill Training

Fatigue during cycling

Intralimb muscle coordination

Core stability in cyclists

Kinematic comparative analysis of pedaling in seated versus standing cycling

by Martin Krause 2004

Task Demand

Cycling requires efficient pedaling action to maintain adequate power output to win a race. Importantly, an endurance sport such as cycling requires a pedaling action, which provide sufficient cadence to maintain a steady state of efficiency. In particular race advantage over competitors can be achieved through efficient hill climbing. Anecdotal evidence suggests that cyclists prefer to stay seated as long as is possible before rising out of the saddle. However, acceleration during hill climbing is frequently achieved through standing off the saddle. This acceleration appears to be achieved through the use of body weight and arm moments as well as increased use of shank and thigh movements. Therefore, increased plantar flexion and hip-knee extension may be expected.

When considering moments of inertia it is probable that efficient cycling technique involves the ability to maintain saddle contact even during hill climbing. Additionally, when considering the sliding filament model of muscle action, it is likely that due to specificity of muscle contractile action it will be the cyclist who can maintain a pedaling action which does not vary considerably from sitting to standing who will be most efficient in hill climbing action. However, power may be a greater consideration than efficiency when standing out of the saddle. Therefore, effective pedal force may also be the result of arm action. Finally, when comparing body position from the seated to standing position, the cyclists center of gravity moves further forward and therefore more likely to be over the center of crank rotation in the standing position.

At the bottom of the pedal cycle, during the transition period between the downstroke and upstroke, the ankle plantar flexors and the knee flexors (Semitendonosis and Biceps) showed the greatest EMG activity. Tibialis Anterior (TA) and Rectus Femoris (RF) have demonstrate large EMG activity at TDC, whereas Vastus Lateralis (VL), Vastus Medialis (VM) and Medial Gastroc (MG) have increased EMG activity during the downstroke. Therefore progression of muscular activity during the downstroke are TA and RF at TDC, VM, VL and GM acting synchronously in the downstroke, and followed by GM, then Soleus, and then LG, MG, ST and BF synchronously (Blake et al 2012). Peak muscle activity occuring sequentially from the knee to hip to ankle with multiple muscles producing large joint torques.

Introduction

Efficient pedaling requires the effective transfer of energy from the lower limbs into the pedal. Consequently, this energy is transferred into the crankshaft, which drives the chain that accelerates the bike. Importantly, the effective use of force, through the pedal at the correct point in time of the crank cycle, is required. Anecdotally, this force is thought to be applied perpendicular to the pedal crankshaft during the down stroke. However, the foot is seldom perpendicular to the pedal crankshaft (Cavanagh et al 1986). Additionally, as the cyclist moves from the seated to the standing position, logic would dictate that the pedal – crankshaft angle will change and the range of the down stroke where maximum force is applied will also change. Finally, since the pedaling action is a cyclic activity then the recovery phase (upstroke) of cycling requires efficient use of energy through the inertial forces of the pedaling action (Cavanagh et al 1986). However, in standing these inertial forces change as the joint torque changes. Therefore, energy can be lost through incorrect pedaling angle resulting in reduced effective force.

Literature Review

Investigations examining the kinematic parameters of seated versus standing cycling are sparse. Most studies have focused on cycling in level terrain (Caldwell et al 1999). Why cyclists adopt the standing position remains unresolved (Davison et al 2000, Ryschon et al 1991). However, the inertial properties of cadence and quasi static forces of lower cadence may be the deciding factor as to whether a cyclist determines the need to stand. Lower cadences would appear to be less efficient and therefore would require greater force to be applied through the pedal (since Power = Force x velocity). Indeed, peak resultant pedal force and peak crank torque increased by 200% and 130% respectively in the uphill standing position (Caldwell et al 1999). Stone and Hull (1993) suggested these forces to represent greater than 60% body weight in the standing position. Furthermore, these peak forces occurred later in the crank cycle for the standing position (at 155 degrees for force and at 130 degrees for torque) than in the sitting position (100 degrees for force and 85 degrees for torque) (Caldwell et al 1999) (see Figure 1). Interestingly, the higher peak kinetic values were linked to kinematic changes in pedal orientation and therefore changes to force vector direction throughout the crank cycle (Caldwell et al 1999).

Investigation into kinematic parameter variations between various seat heights suggest that the peak knee extension increases from 65 to 125 degrees in the low seat to 25 to 105 degrees in the high seat configuration. Additionally, ankle angle varied from 5 dorsiflexion (DF) to 25PF degrees in the low seat condition to 12 plantar flexion (PF) to 20PF degrees in the high seat condition. Peak knee extension and flexion occurred at 170 degrees and 350 degrees of the crank cycle respectively (Gregor et al 1996). This suggests that at least in the varied seated position the muscles length tension relationships would change, thereby affecting force capabilities of the muscle by placing them in a different area of their length-tension and force-velocity curves (Gregor et al 1996). Extrapolation of these results to the standing position, suggest similar implications for the length-tension and force-velocity relationship for the production of power during uphill climbing. However, hip and knee angular kinematics have opposing effects and therefore result in minimal muscle length change in the hamstring muscle (Rugg et al 1987). A similar pattern was seen in the gastrocnemius muscle. In contrast, changes in the length-tension relationships of the mono-articular muscle such as soleus may be expected as it does not cross both the knee and ankle. The magnitude of initial lengthening was about the same in the various seated positions, however the magnitude of shortening increased dramatically from about 1cm to approximately 2.5cm (Rugg et al 1987). Therefore, an expected kinematic outcome for the standing position is increased plantar flexion. This should result in an increased rate of shortening of the soleus muscle from it's initially lengthened position.

Impulse occurs earlier in the crank cycle than does the development of the effective pedal force (figures 1 and 2). Therefore, an increased rate of muscle shortening to accommodate the application of muscle force over an increased range of motion may be seen through altered velocity and acceleration at the ankle joint. Paradoxically, the soleus muscle is considered to be an endurance muscle with slow twitch properties suggesting lesser abilities to shorten quickly (Soderberg 1992). Furthermore, muscles with a large proportion of it's myofilaments in series are considered to have a greater propensity to shorten with greater velocity over a greater range of motion. However, the soleus muscle has a large proportion of it's myobrils in parallel (Jones et al 1990). Additionally, the soleus muscle has some of the largest angles of pennation (up to 60 degrees) seen in the human body (Soderberg 1992). Large angles of pennation reduce effective force transmission (Lieber 1992). Consequently, the implications of altered loading of such an essentially slow twitch endurance muscle are either changes in the myofibril architecture with training, a reduction in cadence in the standing position, altered timing in the application of torque or synergistic muscle load sharing (Caldwell & Li 1998).

In order to examine changes in joint kinematic parameters we maintained a constant pedaling frequency. Additionally, the effect of load sharing between the soleus and gastrocnemius muscle were examined by looking at the kinematic parameters at the knee and ankle to see if they would result in little change in the length of the gastrocnemius muscle, as is suggested by the literature (Gregor et al 1996). Finally, examination of the ankle joint angle (see figures 3 and 4) during the crank cycle should determine variations to the timing in the application of effective force and therefore torque during the crank cycle, described by Cavanagh et al (1986).

Fig 1: pedal impulse: Since Impulse = force x time, it can be seen from the light shaded area that 50% of the propulsive impulse is delivered between 60° and 120° after TDC (top dead center)

 

Fig 2: pedal effective force: the light shaded area represents 'unused force' whereas the dark shaded area represents negative effective forces. The objective of the rider is to reduce the size of the unused force and eliminate the negative effective forces without decreasing the size of the propulsive impulse

 

Fig 3: pedal angle and timing of torque: The orientation of the pedal and the resultant force vector are shown at 20 positions of the crank cycle. It is interesting to note the orientation of the force vector during the first half of the revolution and the absence of pull up forces in the second half.

 

Fig 4: pedal angle: A shows the angle conventions used for the calculation of force. B and C show the resultant force. Fe is called the effective force because it represents that component of force that is effective in generating a force at the rear wheel.

(Figures 1-4 from Cavanagh et al 1986, pp103-109)

Methods

The subject was a healthy 37 years old male amateur cyclist. He was asked to cycle at 60 revolutions per minute in the sitting and standing positions using a bike ergonometer. He had markers placed on the lateral aspect of the shoe at the region of the 5th metatarsal, at the lateral maleolus, at the superior head of the fibula, and at the greater trochanter. A digital video camcorder (Canon Pal MV530i) recording at 50 frames per second was used to record the cycling action. Recordings were made during steady state 60 revs per minute cycling.

The digital video was then captured on the computer using the Ariel Performance Analysis System (APAS) system of kinematic analysis. The captured film sequence was trimmed to remove unwanted sequences, digitized, transformed using the calibration points, and filtered cut off frequency to smooth out errors in digitizing. Once the results were displayed, the data was cut n' pasted into an excel spreadsheet and then graphed for comparative qualitative analysis.

Presentation of results from kinematic analysis

Graph 1: Ankle angular displacement: ankle displacement in standing demonstrated considerably larger (approx 8 degrees) plantar flexion.

Graph 2: Ankle angular velocity: ankle velocity into plantar flexion during standing was somewhat higher, however the change of direction into dorsiflexion was more pronounced in the standing position

Graph 3: Ankle angular acceleration: ankle acceleration into dorsiflexion (top of graph) appears on average higher than the acceleration in plantarflexion (bottom of graph) during the standing position. This result may be expected as the total displacement of the ankle has increased for the same revolutions per minute. Therefore greater ankle displacement must occur in the same amount of time. Additionally, greater acceleration may be synonymous with greater impulse generation (I=F.t=m.a.t=m.v) and therefore greater momentum. However, the momentum generated will be influenced not by velocity alone but by the greater mass of body weight in the standing position.

Graph 4: Knee angular displacement: The total range of knee motion did not change significantly from the sitting to standing positions. However, the displacement occurred in a more extended position (bottom of graph) of knee extension in the standing position. Yet the results in the standing position are within the expected range of motion if the seat height is correctly fitted for the rider (see below).

Graph 5: Knee angular velocity: Knee velocity did not vary greatly between sitting and standing as the displacement between the two positions were similar.

Graph 6: Knee angular acceleration: Knee acceleration did not vary greatly between the sitting and standing positions suggesting that the Impulse generation and momentum were similar at the knee joint in the 2 conditions. These results suggest that a greater impact may be expected on the internal mechanics of the actin-myosin sliding filament in the quadriceps and hamstrings muscle due to their working in a different range of motion. Importantly, since mass is increased through the application of body weight in the standing position, then the velocity of shortening may be expected to decrease.

Discussion of results

Our results suggest that ankle displacement is strongly influenced by changes in body position. The results demonstrate an average range of ankle displacement of 25° (range = 80-104° ) for the standing position and 17° (range = 80-97° ) in the sitting position. Similarly, Caldwell et al (1999) demonstrated 17° of ankle displacement in standing. This compares with 40° 58'+6.01 and 25° 7'+14.12 in sitting and standing respectively found by Shemmell & Neal (1998) and Too (1996). These authors provided normative data suggesting that the range of angular displacement at the ankle in standing was 137° 40'+9.53 to 96° 82'+11.07, with the pattern of angular displacement showing a trend to reach maximum plantar flexion earlier in the pedal cycle in the non-elite group (Shemmel & Neal 1998). This suggests that the optimal pedaling angle during standing is always in some plantarflexion thereby providing an effective force angled downwards and backwards. Therefore, during the recovery phase of the pedal cycle little or no upward pull can occur on the pedal. When considering Figures 1 and 2, this technique should then minimize negative effective forces described by Cavanagh & Sanderson (1986) on the upstroke of the pedal cycle. However, prolonged plantarflexion does suggest an increase of 'unused force' at the bottom of the pedal cycle. Our results vary significantly as our subject demonstrated the same amount of dorsiflexion whether in sitting or in standing. Additionally, this dorsiflexion occurred below the 90° angle suggesting a large amount of eccentric calf muscle activity prior to plantarflexion. In contrast, data from Caldwell et al (1999) demonstrated that regardless of the condition, ankle moment profiles demonstrate exclusively plantarflexor torque throughout the crank cycle, with the highest values after 90° , i.e. in the latter part of the downstroke. Shemmel & Neal (1998) concluded that ankle angles were found to be the best discriminative tool as the ankle plantarflexors contribute more to force production in the standing versus seated position.

Our knee displacement results in standing of 72° and 62° in sitting contrasts significantly with 28° 69'+8.80 and 73° +6.41 (Shemmell & Neal 1998). Caldwell et al (1999) demonstrated knee displacement of 82° 39', with a range from 17° 6' knee extension to 99° 45' knee flexion in the standing condition. Shemmel & Neal (1998) attributed their dramatic change to the forward shift of the cyclist over the pedals during standing. The significant difference between our results and their results may be due to the outdoor 10.5% incline condition, which they used for their analysis. Additionally, they factored the bicycle tilt in the frontal and saggital planes into their calculations. Stone & Hull (1993) suggested a 5° phase lag due to the 8% incline used in their investigation. Finally, Caldwell et al (1999) had their subjects use their own bicycles and were asked them to complete the task as closely as possible to real racing conditions. These latter factors are in contrast with our protocol as we maintained the same incline and cadence; whereas in racing conditions the incline increases and cadence frequently decreases during the uphill phase of the race (82rpm to 65rpm {Caldwell et al 1999}). A notably exception to this rule was an increase in Lance Armstrong's cadence during the 2001 Tour de France on Col Du Madelaine.

Effectiveness of performance

The demonstrated kinematic changes suggest kinetic consequences to work and power production. Caldwell et al (1999) demonstrated an increase in the peak magnitude of the ankle plantarflexor and knee extensor moments during uphill cycling. They suggested that these changes were likely related to the total work done per crank revolution as a consequence of holding power output constant while cadence is decreased.

Our kinematic results tended to suggest that peak plantar flexion occurred earlier in the crank cycle. Yet the results obtained by Caldwell et al (1999) suggest distinct kinetic modifications at the knee and ankle later in the crank cycle in the uphill standing position. Ankle plantarflexion moment increased by 160% and shifted by roughly 45° in the crank cycle. The knee extensor profile also showed a shift towards the late downstroke period, with a bimodal extensor pattern that exhibited a second peak at about 135° crank angle (Caldwell et al 1999). In the uphill standing posture the cyclists body moves forward and upward. The knee extensor phase persists into the first portion of the upstroke, as does the ankle (Caldwell et al 1999). These kinematic changes result in altered pedal orientation to a more toe downward position throughout the crank cycle and modification of the applied pedal vector (Caldwell et al 1998).

Features which contribute positively to performance

In the standing position, the line of action of the force vector is closer to the ankle joint center, but the pedal force is much larger resulting in an ankle joint moment which is increased in the later part of the downstroke. Similarly, in the standing position the force line of action is posterior to the knee in the earlier part of the crank cycle (140° ), but moves in front of the knee later in the downstroke (near 160° ) (Caldwell et al 1999). Unfortunately, we were not able to establish this point because we did not use a body marker in our analysis.

In standing the removal of saddle support results in the greater contribution of gravitational forces. In the later part of the downstroke, the rider can make greater use of the effective force by angling the pedal downwards thus increasing the backward horizontal component of the force. In contrast, in the seated position, the backward horizontal component can only be generated by pulling back on the pedal with a flexor moment (Caldwell et al 1999).

Stone & Hull (1993) demonstrated additional positive power moments through the action of the arms during standing. The arms pulled up and back during the power stroke of the corresponding leg and pushed down and forward during the upstroke. This represents a reversal in direction when compared to the sitting condition. Importantly, the maximum lean of the bicycle corresponds with the maximum power output at about 140° of the crank cycle (i.e. downstroke phase). Because the arms pull up and back at this instant, the normal force would be affected. Therefore, achieving forces greater than body weight is a result of the action of the arms.

Improvements, which could be made to performance

Based on inverse dynamics analysis assumptions have been made that mono-articular muscles contract in the absence of antagonist contraction. However, several authors suggest that mono-articular and bi-articular muscles play different roles in the production of multi-segmental actions such as cycling. In particular, the uphill standing position, which frees the hips from the constraint of the saddle, may play an important role in the development of efficient propulsive forces when cycling uphill. Therefore, conclusions based on inverse dynamics may be less accurate when examining the standing condition.

Changes in the effective pedal force direction due to alterations in body position and therefore joint position suggest alterations in the functioning of bi-articular muscles. The gastrocnemius, rectus femoris and hamstring muscles have been shown to be active during cycling (Li & Caldwell 1998). In particular, the later muscle has been attributed to providing a hip extensor moment through a backward pull on the femur through it's insertion into the pelvis (Lombards paradox). Based on kinematic and kinetic analysis, Fregly & Zajac (1996) concluded that the net ankle and hip extensor joint torques function synergistically to deliver energy (38 joules = 50-82% of energy generated to the limb) to the crank during the downstroke. However, they attributed these net moments to the mono-articular soleus and gluteus muscles. Mono-articular muscle may indeed provide the majority of muscular work at each joint, yet the bi-articualr muscles probably redistribute the energy across adjacent joints (Caldwell et al 1999).

During the upstroke, contrary to popular opinion an ankle-hip flexor synergy is not used. Rather, the ankle extensor torque transfers energy from the crank to the limb in the upstroke (Fregly & Zajac 1996). Suggestions were made that in the presence of increased force through application of body weight in the standing condition that the two energy sources (gravity and ankle extensor torque) could restore the potential energy of the limb in the upstroke (Fregly & Zajac 1996). Therefore, the standing position may provide a more effective lower extremity joint angle that increases effective force production (Too & Landwer 2000). However, it would appear more likely that the effective pedal forces are enhanced by positive torques developed by the arms during uphill standing through the pull upwards on the handlebars during the downstroke and the push forward on the handlebars during the subsequent upstroke (Stone & Hull 1993). The maximum upward pull on the handlebars corresponded with maximum power production at 140° of the crank cycle (Stone & Hull 1993).

Minimizing the joint moment cost function would minimize leg stress and fatigue, thus maximizing propulsive power and cycling performance. However, based on the muscle force-velocity relationship, maximal power is not achieved through high velocities and low loads, nor low velocities and high loads, but rather a moderate load and velocity (Winter et al 1996). The standing condition does not suggest optimization of performance due to the high load and low velocity often employed by cyclists. Suggestions that the bi-articular muscles may be optimizing their length tension relationship in the standing condition don't appear to be supported by the literature. Instead, the bi-articular muscles are thought to act as 'energy straps' transferring energy from one limb segment to another (van Ingen Schauer 1989). Furthermore, the biarticular muscles are considered to control the direction of applied external forces by balancing the relative moments of the adjacent joints they cross (van Ingen Schauer et al 1992). Importantly, bicycle lean and effective force production by the arms (as demonstrated by Stone & Hull 1993) have important implications for the transfer of energy through the body to the pedal.

Why particular features of the task may or may not be beneficial

Anthropometrical differences between cyclists, suggests that the taller cyclist with longer leg lengths (and greater inertial properties) would minimize their kinematic moments through reduced pedaling cadence. Conversely, the shorter cyclist (with shorter leg lengths and lower inertial properties) would minimize their quasi-static moments with a higher pedaling cadence (Too & Landwer 2000). Regardless, a cyclist is more likely to stand up out of the saddle to maintain their inertial properties of cadence through a change in joint moments as well as the addition of body weight to the limbs inertial forces. Additionally, the arms provide considerable positive moments during the power phase of the crank cycle. These moments allow the pedaling force to exceed body weight (Stone & Hull 1993). However, unless there is sufficient neurophysiological control and co-ordination, these increased forces may not contribute to effective pedal force. The bi-articular muscles are thought to not only transfer energy but also control the direction of force production. As stated early the standing position results in a body position almost vertically over the center of rotation of the crank, which may be a means to control the perpendicular distance from the point of force application to the axis of rotation. Hereby, the cyclist may attain greater effective force through the pedal. However, due to the use of the arms greater energy is expended which suggests reduced efficiency as less amount of time can be spent in the standing position due to finite amounts of energy (ATP). Therefore, ideally the cyclists should adjust their seat height in order to obtain minimum kinematic joint moment cost function (Gonzalez & Hull 1989). Tri-athletes tend to have bicycles built whereby their seated position is more forward. They also have the additional benefit of being able to slide the seat forward on the seat post thereby bringing their body closer to the center of the cranks (Price & Done 1997) without the need to stand up out of the saddle. However, in contrast to cyclists, triathletes need to maximize their efficiency in swimming and running as well. The forward seating position may more resemble to kinematics of running thereby opitimising the specificity of training the myo-filaments. Additionally, reduced need to use the arms after the swimming leg may represent better cost efficiency in already fatigued muscles.

Conclusions

Our data demonstrated greatest change in the kinematic parameters at the ankle joint in the sitting versus standing condition. During standing the ankle was in larger and more prolonged plantarflexion. This suggests that the crank-pedal angle and the position in the crank cycle where most of the effective force is applied, varies significantly from the sitting to the standing condition. Although, the knee angle during the crank cycle varies significantly from sitting to standing, the overall displacement was the same in the two conditions.

According to the literature, the standing position is likely to produce greater effective force production through peak moments involving the use of body weight as well as the pull and push of the arms through the handlebars during the downstroke and upstroke respectively. Furthermore, the cyclist tends to bring their body upward and forward over the axis of crank rotation in the standing condition thereby altering joint kinematics. The bi-articular muscles are thought to be involved in the transfer of energy from the upper limbs to the lower limbs. Additionally, the bi-articular muscles are thought to control the direction of effective force application in the standing condition.

It is likely, that the cyclist takes up the standing position to minimize the quasi-static moments which could arise if the power generating capacity of the muscles is being compromised through reduced cadence (P=F.v.). The addition of body weight and arm moments should allow the greater use of impulse (I=F.t.) and therefore momentum (M=m.v.). However, the amount of time that work (W=P.t) can be generated in the standing position is likely to be less due to greater energy expenditure. Therefore, the standing position represents a good compromise by enhancing kinematic parameters to produce greater effective pedal forces, although for a short period of time. When compared with sitting (where peak force is around 90 degrees), most authors agree that the development of peak effective force and power occur later and in the region of 135-140° of the crank cycle during standing. According to the literature, this phase lag is a result of alterations in body position, as well as surface gradient incline and bicycle sideways tilt.

Interestingly, in the seated position, at a cadence of 90rpm, relative hip extension power doesn't increase with increasing power (250W ->800W) requirements. What does increase is the time spent in knee extension and the relative knee flexor power contribution (Elmer et al 2011). Conventional wisdom dictates that the hamstrings, together with the hip extensors and vastus lateralis act as synergistic knee extensors in the seated position. Coyle (1995) suggested that more experienced cyclists distribute the work across more muscular actions to reduce the localized stress. Further considerations of efficiency must include the transfer of power generation between the left and right legs. Indeed, Blake et al (2012) have shown muscle activity variablity between the top and bottom of the cycle at approx 60% VO2Max. As cadence decreases, the time lag between legs has greater potential of increasing. Ideally, cyclists should have a cadence of between 90 and 120 rpm when developing full power. Furthermore, as cadence does increase (90->120rpm) the power contribution of the hip extensors does increase (Elmer et al 2011).

Cycling versus Pilates specific exercise for chronic low back pain

Sixty-four patients with low back pain were randomly assigned to 8 weeks of specific trunk exercise group (SEG), or stationary cycling group (CEG). Self-rated pain, disability, catastrophizing and FAB scores were collected before, immediately after (8 wk), and 6 months after the training program. Clinically meaningful improvements were defined as greater than a 30% reduction from baseline in pain and disability scores. At 8 weeks, disability was significantly lower in the SEG compared with the CEG (d = 0.62, P = 0.018). Pain was reduced from baseline in both the groups after training (P < 0.05), but was lower for the SEG (P < 0.05). FAB scores were reduced in the SEG at 8 weeks, and in the CEG at 6 months. No between-group differences in Fear Avoidance Beliefs (FAB) scores were observed. Similar reductions in catastrophizing in each group were observed at each time point. At 6 months, the overall data pattern suggested no long-term difference between groups. Hence, long term bicycle riding can play a significent role in the reduction of the severe behavioural affects of chronic low back pain. (Marshall PW, Kennedy S, Brooks C, Lonsdale C. (2013) Pilates exercise or stationary cycling for chronic nonspecific low back pain: does it matter? a randomized controlled trial with 6-month follow-up.Spine;38(15):E952-9)

Frequently asked questions

Pulling up?

Mr. Krause,

This is a question about working and strengthening the muscle(s) used during the recovery phase, 180 – 360 deg (approx). Last season I began slowly working on "pulling up" during the up stroke of the pedal, with the thinking that (being 56 years old) I need everything I can get to stay with the pack during a ride. At the end of the season there was tremendous improvement, and I found general use for this little bit extra during seated climbs and sprints.

Recently, I attended a 3 day bike fitting seminar, know as SICI, during which our leader who is a PhD said it wasn't necessarily a good idea to work these muscles so much, and I could possibly cause problems if I continued. I did not argue with his position.

I've never had any problems with pain in any part of my leg(s) last cycling season. This winter (I'm in New England) I did leg presses at the gym and hit 500 lbs, leg extensions at 150lbs, and leg curls at 110lbs, which is not winning me any prizes, but I'm not embarrassed at the end of a sprint. Also, I'm not a maniac when it comes to workouts, and I generally don't mind some pain, but if I'm not getting paid to experience it, then I'd prefer not.

Could I please get your thoughts on this? My concern is not to cause a problem now, or later.

Sincerely,

G

Answer

Hi G,

The general wisdom is that you shouldn't pull up as you over-activate your hip flexor which can reduce blood flow into and out of the legs, alter lumbo-pelvic kinematics and create low back pain. As pedal force increases, the 'negative effective force' increases during the 'upstroke' phase (Blake et al 2012). In fact, Korff et al (2007) demonstrated reductions in gross efficiency when subjects were asked to 'pull up'. Furthermore, as power requirements increase, the time the knee spends in extension also increases (Elmer et al 2011) which would mitigate against pulling up. However, it sounds like you are using your hamstring muscles for the task. Elmer et al (2011) demonstrated increased knee flexor power as power requirements increased, effectively making the hamstrings a knee extensor.

Hence, the pulling up is fraut with danger if you have weak hamstrings or tight hip flexors (iliopsoas). Your hamies certainly don't sound weak with the leg curls and judging by your leg press you aren't lacking power in the quads either. Hence I don't think that the loading relative to your overall strength would lead to injury, except after a period of illness or inactivity that has led to deconditioning.

You also state you feel more power. The pulling up is important for uphill peddling and sprinting. However, the hamstring is particularly important in the downward extension phase where it is contracting and lengthening at the same time. Hence the elasticity and pliability of your hamies and their contractile recovery are important. Since you are going uphill I assume your cadence is a little slower and hence the transition phase (lengthening -> shortening) takes longer.  Importantly, you should remain seated as much as possible. There is a form of strength training where athletes deliberately use high gears and even fixed gears to develop power. This differs to sprinting where power (P=Force x Velocity) is developed through the speed of muscle contraction and high cadence pedalling. Hence you may need to stretch and/or massage your hamies. But don't overstrech them and always stretch with a slightly bent knee (20 -30 degrees - bending forward at the hip) whereby you should feel the muscle pull in the middle of the hamie bulk and not at the tendons. Moreover, by bending the knee, you reduce the risk of over-stretching you sciatic nerve.

When you aren't powering uphill or sprinting you should focus on continuing to spin the Pedals as evenly as possible, even if this means on occasions using the hip flexors in the 'dead' upward phase of pedalling.

More importantly, as we age, strength training becomes very important for the prevention of sarcopenia (loss of muscle mass)

I hope that this helps
cheers
Martin

Uphill Training

  • my personal preference for time poor cyclists is to do quality hill training, whereby strength and endurnace can be trained simultaneously with efficient pedalling technique
  • as gradients increase to over 8% gross efficiency is lower as cadence decreases. This is compensated for by more efficient distribution of muscular force across the downward pedal cycle (Arkesteijn et al 2013, Med Sc Ex Sp, 45, 5,  920 - 926)
  • slow sustained climbs involve using low gears (eg 12/13 to 53) on moderate (8%) to steep (14%) incline at a very low cadence (30rpm) for a period between 5 and 7 minutes. Total time should be in the vincinity of 21minutes (eg 3 x 7 minutes) with only a short time (4-5 minutes) for recovery.
  • These slow rpms should result in some 'burning' in the leg muscles, the recognition of left - right strength deficits as well as appreciation of the upper body and core abdominal - back muscles to the overall development of synergistic strength. Hence, the cyclist should remain seated for these repeats.
  • Remaining seated should mean that you are engaging the hamstring muscles to work in a synergy with the gluteal muscles and more obvious quadriceps. Importantly, if the the hamstrings are engaged correctly, there should be no sense of strain behind the knee cap (patella) or knee joint, but rather it should be felt purely within the muscle.
  • Ideally, these repeates are accompanied by core stability exercises (eg 'the plank') and upper body exercises (eg japanese push-ups). Whilst doing these exercises, visualise yourself going uphill, for transference of learning to take place at a cognitive subconscious level.
  • Naturally, this isn't for the faint-hearted nor should these be done in the racing season. 48-72 hours recovery between sessions is recommended. This recovery may take the form of cycling but with low gears and preferably flat.
  • The program should last 4 weeks and should be done after a 6-12 week preparatory phase of endurance/base conditioning cycling.
  • After these slow sustained efforts and the basic preparatory phase, a 4 week period of pre-competition hill climbing should be undertaken 2 times per week. a rest day should preceed the first session. These efforts involve finding a hill and dividing it into halves. Where the first half is at a moderate cadence of 60-70rpm and/or 70-75% HRmax, the next half involves changing down 2 gears engaging a high cadence and high power output not exceeding 85% HRmax on 1 day per week - always stay seated if possible. 48 - 72 hours later find the same hill and divide it into thirds. First third at 75% HRmax seated, the mid third at 85% HRmax out of the saddle, and the final third 90% HRmax in week 1, 95% HRmax in week 2-3 all out effort by week 4. Generally 4- 7repeats with sessions lasting between 20 and 40minutes in total. Initially, fewer repeats to accustom oneself to the intensity and later fewer repeats due to the higher intensity i.e. weeks 2 and 3 having higher repeats. Rest day should follow the higher intensity sessions whereas the first efforts should be followed by a day of 2hours of rolling hills. This trains power.
  • Depending on where you live, it would be a great idea to find a hill which lasts 45-60minutes and break it up into thirds and gradually increase the intensity each third (75% HRmax, 85% HRmax, 90% HRmax). Ideally, the incline is steady and around 8-14%. This trains strength-endurance.
  • At least 1 day a week should be a long ride of 3-4hours for endurance - here some high cadence (80 - 100rpm) should probably also be employed even if it is only on the flat or downhill..
  • Alternate, hill training can include changes in the variables 'incline', 'cadence', 'gear ratios', 'seated vs standing' using a fartlek methodolgy whereby recovery rate is trained through 60secs on: 60secs off for a period of 20-40minutes
  • If training at altitude, there are 2 philosophies - train high : sleep low and the reverese. The concept of sleeping low is based on better hormonal recovery at night after intense training. The methodology of sleeping high and training low, is that it is easier to develop more strength during training due to less strain from lack of oxygen. Then by sleeping high, the body adapts and increases it's haemoglobin carrying capacity for oxygen, which then improves endurance. With a good endurance base, strength can be developed without risking over training and injury.

Central and Peripheral Fatigue and Central Motor Drive (CMD) as it relates to altitude training

Peripheral fatigue comprises changes in the metabolic milieu of the working muscles whereas central fatigue comprises of  a failure by the central nervous system (CNS) to 'drive' the motor neurons, commonly referred to as a reduction in central motor drive (CMD).  It is thought that the feedback from type III and type IV nerve receptors in muscles, about the peripheral metabolic milieu, is critical to CMD. However, in an interesting review, Markus Amann (2011, Med Sc Sp Ex, 43, 11, 2039-2045) argues that, when there is a direct threat to the CNS, as a result of adverse physiological circumstances, such as hypoglycaemia, mental stress/fatigue, or in the presence of extreme environmental influences, such as heat or severe hypoxia, these factors play a much greater influence than peripheral metabolic milieu. In the case of hypoxia, the exercising terminating threshold can be up to 30% less, when exhaustion becomes exercising limiting. Hence, when training at altitude, factors such as hypoxia and the other 'threats to the CNS' should be taken into consideration, epsecially when it comes to team training camps, where many influences out of the athletes control come into play.

Muscle coordination within and between limbs

Blake et al (2012) demonstrated the importance of intra-limb coordination for the development of peak sequential power from knee to hip to ankle, and the relience on multiple muscles to produce torque. Furthermore, variations in power output at TDC and BDC are suggestive of the influence of each limb on each other. The video at the beginning of this page demonstrates the amount of 'play' which can occur across the pelvis, leading to inefficient and and potentially injurious actions. At back in Business Physiotherapy, we use a very comprehensive approach to treating the spine and pelvis, whereby, even improvements in areas of the body not traditionally associated with leg dynamics, such as ribcage biomechanics, will improve power output. Treatment of pelvic asymmetries and low back conditions can frequently relieve recalcitrant chronic knee pain. These issues have been addressed elsewhere on this website.

link to pins and needles, numbness in cyclists feet

Link to Pelvic - Neck dysfunction

Core Stability for cyclists

Pilates Reformer for Core Stability and Peripheral Mobility

Core Stability Training using the Swiss Ball

References

Blake OM, Champoux Y, Wakeling JM (2012). Muscle coordination patterns for efficient cycling. Med Sci Sp Exerc, 44, 5, 926 to 938.

Caldwell GE, Li L, McCole SD, Hagberg JM (1998). Pedal and crank kinetics in uphill cycling. Journal of Applied Biomechanics, 14, 245 to 259.

Caldwell GE, Hagberg JM, McCole SD, Li L (1999). Lower extremity joint moments during uphill cycling. Journal of Applied Biomechanics, 15, 166 to 181.

Cavanagh PR, Sanderson DJ (1986). The biomechanics of cycling: Studies of the pedaling mechanics of elite pursuit riders. In : Science of Cycling, Human Kinetics Books, Champaign, ch5.

Coyle EF (1995). Integration of the physiological factors determining endurance performance ability. Exerc Sports Sci Rev, 23, 25-63

Davison RCR, Swan D, Coleman D, Bird S (2000). Correlates of simulated hill climb cycling performance. Journal of Sports Sciences, 18, 105 to 110

Elmer SJ, Barratt PR, Korff T, Martin JC (2011). Joint specific power production during submaximal and maximal cycling. Med & Sc in Sp & Ex, 43, 10, 1940-1947

Fregly BJ, Zajac FE (1996) A state-space analysis of mechanical energy generation, absorption, and transfer during pedaling. Journal of Biomechanics, 29, 1, 81 to 90

Gregor RJ Fowler E (1996). Biomechanics of Cycling. In : Zachazewski JE, Magee DJ, Quillen WS. Athletic Injuries and Rehabilitation, WB Saunders Co, Philadelphia, Ch19

Jones DA, Round JM (1990). Skeletal muscle in health and disease. Manchester, Manchester University Press pp24 to 25.

Korff T, Romer LM, Mayhem I, Martin JC (2007). Effect of pedaling technique on mechanical effectiveness and efficiency in cyclists. Med Sci Sports Exerc, 39, 6, 991-995

Li l, Caldwell GE (1998) Muscle co-ordination in cycling: effect of surface incline and posture. Journal Applied Physiology, 85, 3, 927 to 934.

Lieber RL (1992). Skeletal muscle structure and function. Williams & Wilkins, Baltimore, pp41 to 42

Price D, Donne B (1997) Effect of variation in seat tube angle at different seat heights on submaximal cycling performance in man. Journal of Sports Science, 15, 395 to 402.

Rugg SG, Gregor RJ (1987) The effect of seat height on muscle lengths, velocities and moment arm lengths during cycling. Journal of Biomechanics, 20, 899

Ryschon TW, Stray-Gundersen, J (1991). The effect of body position on the energy cost of cycling. Medicine and Science in Sports and Exercise, 23, 949 to 953.

Shemmell JB, Neal RJ (1998) The kinematics of uphill, out of the saddle cycling. The North American Congress on Biomechanics, August 14 to 18, University of Waterloo, Ontario, Canada

Soderberg GL (1992). Skeletal muscle function. In : Currier DP, Nelson RM (1992) Dynamics of Human Biological Tissue, FA Davis Company, Philadelphia, Ch 3.

Stone C, Hull ML (1993). Rider/bicycle interaction loads during standing treadmill cycling. Journal of Applied Biomechanics, 9, 202 to 218.

Too D (1996) The kinematics of uphill cycling. Proceedings 9th CSB biennial conference, 184 to 185.

Too D, Lndwer GE (2000) The effect of pedal crank arm length on joint angle and power production in upright cycle ergometry. Journal of Sports Sciences, 18, 153 to 161

Van Ingen Schenau GJ (1989). From rotation to translation: constraints on multi-joint movements and the unique action of biarticular muscles. Human movement sciences, 8, 301 to 337.

Van Ingen Schenau GJ, Boots PJM, de Groot G, Snackers RJ, van Woensel WWLM (1992). The constrained control of force and position in multi-joint movements. Neuroscience, 46, 197 to 207.

Winter EM, Brown D, Roberts NKA, Brookes FBC, Swaine IL (1996). Optimized and corrected peak power output during friction-braked cycle ergometry. Journal of Sports Sciences, 14, 513 to 521.

"If everyone who lives within 5 miles of their workplace were to cycle to work just one day a week and left the car at home, nearly 5 million tons of global warming pollution would be saved every year, the equivalent of taking about a million cars off the road. "

link to cycling advocacy

Link to injuries relating to Pelvic Asymmetry

external non-sponsored link to Steve Hogg and his business in setting up cyclists at http://www.cyclefitcentre.com/

and see non-sponsored link to

local MTB club http://nobmob.com/

http://www.cyclingnews.com for all sorts of advice

Last update : 7 October 2013


 

Trending @ Back in B Physio

  • Sun 15 Oct 2017

    Neuroplasticity in Tendon Dysfunction

    Neuroplasticity in Tendinopathy by Martin Krause A multitude of contributing factors to altered motor control must be addressed when treating tendon dysfunction. What we have failed to consider in the past when dealing with chronic or recurrent tendon issues are motor control problems encompassing corticospinal control of excitation and inhibition as well as belief systems about pain and contextual factors related to imaging.  Research by Ebonie Rio et al (2015) (BJSM Sept 25, 10.1136/bjsports-2015-095215) suggest that the pain state sets up an adaptive pathway whereby the ipsilateral kinetic chain is directly inhibited by reflexogenic pathways, as well as being inhibited by contralateral hemispheric activity. Simultaneously excitation is enhanced in the opposite limb as well as in antagonists...at least in the case of enhanced excitation of the hamstrings in quadricep tendinopathy. If this is true, then so much for training the contralateral limb for 'cross training' purposes! This may also explain why a lot of people seem to have "all their injuries on the same side" (of the body). Furthermore, they recommend enhancing corticospinal drive through the use of 30-60 second isometric holds at 70-80% MVC to load the muscle whilst using isokinetics to load the tendon. Moreover, they recommend the use of a metronome at 60bpm (stages 1 and 2) with a count of 3 up, 2 down for quads, and 2 up, 3 down for calf isokinetics to optimally engage corticospinal drive through the visual and auditory stimuli (also shown by Kohei et al 2012 for motor imagery and M1 stimulation) .....read more Cortical mapping of infraspinatus muscle in chronic shoulder pain demonstrating higher motor thresholds (aMT= activation MT) and hence reduced excitability on the affected side (39 vs 35) (Ngomo et al 2015 Clinical Neurophysiol, 126, 2, 365-371) Cortical mapping of pain and fear. Lots of overlap suggesting that taking away the fear from the pain with clear clinical explanations and a focused goal directed program using specific functional outcomes is important.  ndividuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036, https://doi.org/10.1093/pm/pnx036)  Uploaded : 18 October 2017 Read More
  • Mon 09 Oct 2017

    Imaging

    Do I need a scan? "a picture tells a thousand words" - not really! by Martin Krause A scan, in it's self, will not improve anyone's condition. The purpose of a scan is to gain more information about the pathology. Sometimes this information may be irrelevant to the management of a patient's condition. For example, if you knocked your elbow on a door frame and suffered a bruise, which was already beginning to resolve, an ultrasound scan may show some minor soft tissue damage, but that was already obvious by the fact of the bruise, and the information gained from the scan has not helped nor changed the management of the bruise. Therefore, the main reason for getting a scan would be because there is concern that the presence of certain pathologies may lead to a change in the medical management. For example, sometimes a rolled ankle can be more than sprained ligaments, and may require surgey or immobilisation in a boot. If the therapists suspects this might be the case, then they will recommend or refer for a scan (probably an X-Ray) to check the integrity of the bones (especially the fibular and talar dome), because if there is no bony damage then the patient can be managed conservatively with taping, exercises, ultrasound, massage, joint mobilisations etc. However, if there is boney damage, for example, then it might be necessary for the ankle to be immobilised in a boot for three - six weeks, for example. This dramatically different medical management depends on the results of a scan, and it is therefore worth doing. However, scans have no predictive value to the presence or severity of pain. Thirty-three articles reporting imaging findings, in the low back, for 3110 asymptomatic individuals were investigated for pathology. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age. (Brinjikji, W et al Spine Published November 27, 2014 as 10.3174/ajnr.A4173). Hence, the results of imaging need to be assessed within the context of the entire clinical picture. Frequently too much emphasis is placed on the imaging not only by the clinician but also by the patient. Some people react to pathology seen on scanning as an affirmation of their problem and can either use it to gain clarity and become better or conversely become worse. Moreover, some people find imaging with inconclusive results as a 'panic moment' - "no one knows what is wrong". Similarly, ultrasound imaging of the tendond has good predictive diagnostic and aids in clinical reasoning when it comes to full tears. However, with partial tears it is a totally different 'ball game'. Ultrasound is highly user dependent, with specifically trained musculoskeletal radiologists able to produce high-quality images that may provide more clinically relevant information than those produced by clinicians with less experience in imaging. Sean Docking, a leading tendon researcher at Monash University, cited 7 authors who found pathological tendon chnages in 59% of asymptomatic individuals, whereas he found that 52% of asymptomatic elite AFL sportsmen had tendon pathology on imaging! Furthermore, symptomatic individuals who improved clinically to the point of resuming play, weren't shown to have improvements on imaging. Again, the clinical context and the clinical reasoning can in many instances prove to be the 'gold standard' not the imaging itself, when considering management options. Shoulder supraspintatus tendon pathology, in the abscence of trauma, is known, in many instances, to be a disorder of immune-metabolic compromise of the tendon and bursa. Imaging may show some changes in signal intensity but, unless it's a complete tear, it can reveal neither the intensity nor the severity of pain when taken outside of the clinical context. A thorough physical and subjective examination integrating all the clinical dimensions of the problem will have far greater value than any one single imaging modality. Yet, imaging still should be used in instances of progressive rapid deterioration and suspected serious pathology which may require surgery and/or immediate medical intervention. In summary, sometimes it is worthwhile getting a scan, because the information gained from that scan will determined the type of medical management that is employed. However, at other times, the scan may be unneccessary, because the information may be irrelevant or lead to an incorrect change in medical management, due to over-reporting of 'false positives'. You will be able to make this decision on the advice of your health care professional. On occasions it can actually be detrimental to have a scan, because some patients can become overly obsessed with the medical terms used to describe their scan results, which then can become the major focus for the clinician and the patient, rather than the more prefereable focus on their symptoms and functional abilities. For example, many people have lumbar buldging discs yet have no symptoms, yet sometimes when these patients have an MRI or CT scan, they can develop symptoms because they think they should have pain if the scan says so! Conversely, for some people the results of imaging can have a positive and reassuring affect. Therefore, it is very important to assess a clients attitude to scans before prescibing them so that the patient's expectations are managed appropriately, and not burdened by the additional, sometimes confusing, information supplied by a scan. Uploaded : 10 October 2017 Read More
  • Thu 14 Sep 2017

    Cervical Spine implications in concussion

    Neck aetiology, autonomic and immune implications, exercise and diet in the musculoskeletal physiotherapy management of Post Concussion Syndrome (PCS) by Martin Krause, MAPA, Titled member Musculoskeletal Physiotherapy Association of Australia  A 14 year old boy presented to A&E, in August 2016, after receiving an impact to the head during AFL (Australian Rules Football). Although his SCAT3 scores were relatively mild, he went on to suffer severe lethergy, resulting in a lengthy abscence from school, culminating in a return to school for exams in the first week of December 2016. Even by December, even a 30 minute walk was extremely fatiguing. To place this into perspective, he had been playing elite academy grade AFL for several seasons and was an extremely fit outdoor adventurer. Confounding Variables : end of season injury and hence no follow up from the academy suffers from Hypermobile Joint Syndrome (HJS) and possibly Ehlers Danlos Syndrome (EDS), however Beighton score 4/9. suffers from food intolerances, particularly to Glutin and diary, but also some other foods. Potential IBS and autoimmune issues. had just gone through a growth spurt (190cm) Imaging : Brain MRI normal Medical Examination : Balance remained impaired to tandem walking and single leg stance. The vestibular occular motor scale showed significant accomodation deficit of 15cm and there was a mild exacerbation of symptoms. ImPACT testing revealed adequate scores and reaction time of 0.65 which is within acceptable range. History : School holidays December - January. Return to school and was placed in the lower classes. Prior to his concussion he was a top 10 student at an academically selective high school. Took up basketball and rowing as summer sports. Academic results tanked. Several Basketball injuries (Feb - April 17') as a result of what apppeared to be muscular imbalances from the relatively recent growth spurt, as well as taking on a new sport. Showed little interest in returning to AFL as no-one had followed him up during the previous year.  Current History : September 2017 showed a continued decline in academic levels. School teachers noted an inability to concentrate. Academic results still well below pre-concussion levels. Fatigue continuing to be problematic.  Literature Review : Post Concussion Syndrom (PCS) is defined as "cognitive deficits in attention or memory and at least three or more of the following symptoms: fatigue, sleep disturbances, headache, dizziness, irritability, affective disturbance, apathy, or personality change"  Further complications of PCS also appear to be an increased risk of musculoskeletal injury Nordstrom et al (2014, BMJ Sports Med, 48, 19, http://bjsm.bmj.com/content/48/19/1447) Predictors of PCS are uncertain. However, the following clinical variables are considered factors at increasing risk. These include prior history of concussion, sex (females more prominant), younger age, history of cognitive dysfunction, and affective disorders such as anxiety and depression (Leddy et al 2012, Sports Health, 4, 2, 147-154). Unlike the 'old days' which recommended a dark room and rest for several weeks post concussion, the consensus appears to be a graded return to exercise in order to restore metabolic homeostasis. Incredibly, highly trained young individuals can find even exercises in bed extremely demanding. Kozlowski et al (2013, J Ath Train, 48, 5, 627-635) used 34 people 226 days post injury to conclude significant physiological annomalies in response to exercise which may be the result of 'diffuse cerebral swelling'. Researchers have noted lower systolic and higher diastolic blood pressure in PCS (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Due to autonomic dysfunction manifested in altered cardiovascular and pulmonary responses (Mossberg et 2007, Arch Phys Med Rehab, 88, 3, 15-320) some clinicians have recommended the use of the exercise program for POTS (Postural Orthostatic Tachycardia Syndrome). This is a 5 month program which recommends mainly exercise in the horizontal and sitting positions for 1-4 months, including recumbent bike, rowing ergometer and swimming laps or kicking laps with a kick board. Month 4 upright bike and Month 5 upright training such as a elliptical trainer or treadmill.  http://www.dysautonomiainternational.org/pdf/CHOP_Modified_Dallas_POTS_Exercise_Program.pdf Other progressive exercise therapies have also included 20 minutes per day, 6 days per week, for 12 weeks of either treadmill or home gym exercises at 80% of the heart rate at which their concussion symtoms are exacerbated. Their programs were individually modified as the heart rate provoking symptoms increased. When compared to the 'control group', this intervention was shown to improve cerebral perfusion on fMRI, increase exercise tolerance at a higher heart rate, less fatigue and were showing activation patterns in areas of the brain on performing math processing test which were now normalised (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Graded exercises could also have included 'motor imagery' as espouse by the NOI group and the work of Lorrimer Moseley (University South Australia) when dealing with chronic pain. Ongoing Symptoms : The literature review by Leddy et al (2012) found that ongoing symptoms are either a prolonged version of concussion pathophysiology or a manifestation of other processes, such as cervical injury, migraine headaches, depression, chronic pain, vestibular dysfunction, visual disturbance, or some combination of conditions. Physiotherapy Assessment : One year PCS, fatigue continued to persist. Cognitive deficits with school work were reported to becoming more apparent. Assessment using various one leg standing tests employing oscillatory movement aroud the hips and knees for kinetic limb stability and lumbopelvic stability, which had been employed 6 months previously for his Basketball injuries were exhibiting deficits, despite these being 'somewhat good' previously. Physical Examination : cervical and thoracic spine Due to the Joint Hypermobility Syndrome (JHS) it was difficult to ascertain neck dysfunction based on range of movement testing. ROM were unremarkable except for lateral flexion which demonstrated altered intervertebral motion in both directions. Palpation using Australian and New Zealand manual therapy techniques such as passive accessory glides (upslopes and downslopes and traction) exhibited muscles spasms in the upper right cervical spine. Eye - Neck proprioceptive assessment using blind folds and laser pointer also  revealed marked variance from the normal. Repositioning error using the laser pointer with rotation demonstrated marked inability to reposition accurately from the left, tending to be short and at times completely missing the bullseye. Gaze stability with body rotation was NAD. Gaze stability whilst walking displayed some difficulty. Laser pointer tracing of the alphabet was wildly inaccurate. Thoracic ring relocation testing also revealed several annomalies, which may have also accounted for some autonomic dysfunction.  Occulomotor assessment and training Headache : Commonly referred to as cervicogenic headaches, one in five headaches in the general population are thought to be due to the cervical spine. The Upper Cervical Spine is particularly vulnerable to trauma because it is the most mobile part of the vertebral column, with a complex proprioceptive system connecting the vestibular apparatus and visual systems. It also coincides with the lower region of the brainstem and fourth ventricle. The brainstem houses many neurones associated with autonomic responses to pain and balance. Imaging of the fourth ventricle for swelling of the 'tonsils' and Arnold Chiari malformations are recommended when symptoms persist. In particular, children and adolescents are more vulnerable to neck contusions due to the proportionately larger head and less developed musculature. Cervical vertigo and dizziness after whiplash can mimic symptoms of PCS.. Mechanoreceptor dysfunction and vertebrobasilar artery insufficiency should be part of the differential diagnosis. Mechanical instability of the Upper Cervical Spine should also not be missed. Cervicogenic Headaches Further Interventions : Neurocognitive rehabilitation of attention processes. Psychological intervention using cognitive behavioural therapy (CBT). Neuro-opthalmologist to assess and treat smooth pursuit eye tracking. Naturopath for food intolerances and dietician for the optimisation of diet. Diet :  In cases with chronic fatiguing factors, nutrition can be become a vital aspect into the reparative process. This may include energy and mineral rich foods such as bananas, green leafy vegetables for iron and magnesium (200-300mg), oranges for vitamin C (anit-oxidant and helps with the absorption of iron), anti-oxidant rich foods such as EPA/DHA (1000mg) fish oil, curcumin (tumeric), Cats Claw, Devils Claw, Chia seeds, fruits of the forest (berries), and CoQ10 with Vitamin B. Folate and Ferritin levels should also be checked. Calorific energy intake should balance with energy exependiture. However, as we are often dealing with young individuals, as in this case, some form of comfort food may be appropriate such as, nuts, legumes, homus and sushi. Protein intake prior to carbohydrate intake may help ameliorate any blood suger fluctuations due to Glycemic Index factors, however simple carbohydrates (high GI) should be avoided wherever practical. Even oats need to be soaked overnight and cooked briefly, otherwise they become a high GI food and may even affect the absorption of iron. The type of rice used can also influence GI, hence the addition of protein such as fish. Protein supplementations are generally over-used. Daily protein intake should not exceed 1.2g per kg of body weight per day. Dosage for children is less than that for adults. See Nutritional Section of this Site Conclusion  Investigations, into people with persisting PCS, demonstrated that they applied more force over time to control balance. Helmich et al (2016, Med Sc Ex Sp, 48,  12, 2362-2368) proposed that in regard to cognitive processes, the increase of cerebral activation indicates an increase of attention demanding processes during postural control in altered environments. This is relevant in so far as individuals with post concussive symptomatology have a variety of symptoms including headache, dizziness, and cognitive difficulties that usually resolve over a few days to weeks. However, a subgroup of patients can have persistent symptoms which last months and even years. Complications in differential diagnosis, can arise clinically, when neck dysfunction and altered motor control occur concurrently due to both neck and cerebral pathology. For example, Whiplash and other traumatic head and neck injuries can result in pathology to both regions, whereas, more discreet altered cognitive processing from concussion can result in altered neck motor control. Musculoskelatal Physiotherapy can play a vital part in the treatment of neck dysfunction including the re-establishment of occulomotor proprioception and managing localized strength and cardiovascular exercise regimes. A total body, multi-disciplinary approach which is well co-ordinated amongst practitioners is vital to an optimal outcome.    Uploaded : 17 October 2017 Read More
  • Thu 24 Aug 2017

    Pain in the Brain - neural plasticity

    Pain in the Brain and Neural Plasticity by Martin Krause There are several mechanisms that can create a sensation of pain, which has been described as 'an unpleasent sensory and emotional experience in response to perceived or potential tissue damage'. Pain can be the result of peripheral sensitisation from peripheral inflammation, vascular compromise, necrosis, swelling, etc. Importantly, higher centres of the central nervous system not only perceive such sensitization of the peripheral nerve receptors, they can also modulate and control the intensity and tolerability of the perceived sensation through descending modulation at the peripheral receptor and in the spinal cord and through transcortical mechanisms depending on the 'meaning' and 'context given to the pain. Moreoever, the higher centres can create a 'state' of perceived 'threat' to the body through emotions such as fear and anxiety. Rather than the brain acting as a filter of unwanted sensation, in the higher centre induced pain state, rumination and magnification of sensations occur to create a pathological state.  Paradoxically, representation of body parts such as limbs and individual muscles can reduce in perceived size. In such instances the pain doesn't represent the sensation of pathology but rather pain has become the pathology. Hence, the brain generates pain in the brain, where the pain is perceived to be some sort of non-existant inflammatory or pathological sensation in the periphery. Evidence for this neural plasticity comes from imaging studies, where brain white matter structural properties have been shown to predict transition to chronic pain (Mansour et al 2013, Pain, 154, 10, 2160-2168). Specifically, differential structural connectivity to medial vs lateral prefrontal cortex and connectivity between medial prefrontal cortex and nucleus accumbens has been shown in people with persistent low back pain. In this case the back pain becomes the inciting event and given the persons' structural propensity, establishes specific functional coonectivity strength.  further reading Peripheral input is a powerful driver to neuroplasticity. Information gathered by touch, movement and vision, in the context of pain can lead to mal-adaptive plasticity, including the reorganisation of the somatosensory, and motor cortices, altered cortical excitability and central sensitisation. Examples of somatosensory reorganisation come from the work of Abrahao Baptista when investigating chronic anterior knee pain, who not only demonstrated reduced volume of Vastus Medialis but also is cortical translocation to another part of the cortex. ndividuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036, https://doi.org/10.1093/pm/pnx036)   AKP = anterior knee pain The same researcher (Abrahao Baptista) has shown that maximal tolerable electrical stimulation (eg TENS) of muscles can induce normalisation of the cortical changes through a process called 'smudging'. Transcortical stumilation has also been applied as a cortical 'primer' prior to the application of more traditional therapy such as motor re-training, exercise, and manipulation. Body illusions are another novel way to promote the normalisation of cortical function through adaptive neuroplasticity. Examples come from people with hand athritis, whose perception of their hand size is underestimated (Gilpin et al 2015 Rheumatology, 54, 4, 678-682). Using a curved mirror, similar to that in theme parks, the visual input can be increased to perceive the body part as larger (Preston et al 2011 DOI: 10.1093/rheumatology/ker104 · Source:PubMed ) . Irrespective of size, watching a reflection of the hand while performing synchronised movements enhances the embodiment of the reflection of the hand (Whitkopf et al 2017, Exp Brain res, 23, 5, 1933-1944). These visual inputs are thought to affect the altered functional connectivity between areas of the brain thereby affecting the 'pain matrix'. Another, novel way of looking at movement and pain perception is the concept of the motor engram. This has been defined as motor skill acquisition through the modification and organisation of muscle synergies into effective movement sequences. The learning process is thought to be acquired as a child through experientially based play activity. The specific neural mechanisms involved are unknown, however they are thought to include motor map topography reflecting the capacity for skilled movement reorganisation of motor maps in a manner that reflects the kinematics of aquired skilled movement map plasticity is supported by a reorganisation of cortical microcircuitry involving changes in synaptic efficacy motor map integrity and topography are influenced by various neurochemical signals that coordinate changes in cortical circuitry to encode motor experience (Monfils 2005 Neuroscientist, 11, 5, 471-483). Interestingly, it is an intriguing notion that accessing motor engrams from patterns aquired prior to the pain experience might lead a normalisation of brain activity. My personal experience of severe sciatica with leg pain, sleepness nights and a SLR of less than 30 degrees, happened to coincide with training my 9 year old sons soccer training. I was noticing that the nights after i trained the children, I slept much better and my range of movement improved. I commenced a daily program of soccer ball tricks which i had been showing the kids, including 'juggling', 'rainbows' and 'around the worlds'. Eventually, I even took up playing soccer again after a 30 year abscence from the sport. Other than new activity related pain issues (DOMS), four years on, the sciatica hasn't returned. I can only conclude that this activity activated dormant childhood motor engram, worked on global balance, mobilised my nerve, encouraged cross cortical activity and turned my focus into finctional improvement. Further explainations for my expereience comes from evidence suggesting that a peripheral adaptive pain state is initiated, whereby transcortical inhibiton occurs by the contralaleral hemisphere to the one which controls the affected limb. Additionally, excitation cortical (M1) drive of the muscles of the contralateral limb to the one which is in pain also occurs. In such cases re-establishement of motor drive to the affected side is important. In terms of tendon rehabilitation, external audtory and visual cues using a metronome have been employed and are showing promising results (Ebonie Rio et al 2017 Personal communication). In terms of my experience with the soccer ball tricks, the external visual cues and the cross talk from using left and right feet, head, shoulders, and chest during ball juggling manouvers, whilst calling the rhythm to the kids may have been the crucial factor to overcome the dysfunctional brain induced pain - muscle inco-ordination cycle, which I was in. Additionally, I was cycling which allowed me to focus on motor drive into the affected.limb. However, work by Lorrimer Moseley on CRPS has established that 'brain laterality' must be established before commencing trans-cortical rehabilitation techniques. Lorrimer's clinical interventions use 'mirror imaging' techniques which are only effective once the patient is able to discriminate the left and right sides of the affected body parts, presented visually, in various twists and angles.   Alternatively, the altered pain state can result in a hostage like situation, whereby the pain takes control. Similar to the 'Stockholm Syndrome' where the hostage begins to sympathise with their captors, so do some peoples brain states, where it begin to sympathise with the pain, creating an intractable bondage and dysfunctional state. One screening question which may reflect commitment to the process of rehabilitatation is to question whether they were able to resist the cookie jar when they were a child? Or were they committed to any sporting endeavours as a child? This may give some indication for the presence of motor engrams which can be used to overcome dysfunctional pain induced muscle synergies (neurotags), but also indicate an ability to be self disciplined, as well as being able to reconcile and identify goal oriented objectives, in spite of the cognitive pain processes? Remember that neurons that fire together, wire together. Uploaded : 18 October 2017 Read More
  • Thu 03 Aug 2017

    Sickle Cell Trait and Acute Low Back Pain

    Researchers believe that lumbar paraspinal myonecrosis (LPSMN) may contribute to the uncommon paraspinal compartment syndrome and that sickle cell trait (SCT) may play a role. Sustained, intense exertion of these lumbar paraspinal muscles can acutely increase muscle size and compartment pressure and so decrease arterial perfusion pressure. This same exertion can evoke diverse metabolic forces that in concert can lead to sickling in SCT that can compromise perfusion in the microvasculature of working muscles. In this manner, they believe that SCT may represent an additional risk factor for LPSMN. Accordingly, they presented six cases of LPSMN in elite African American football players with SCT. See link below http://journals.lww.com/acsm-msse/Fulltext/2017/04000/Acute_Lumbar_Paraspinal_Myonecrosis_in_Football.1.aspx Read More
  • Thu 03 Aug 2017

    Ibuprofen, Resistance Training, Bone Density

    Taking Ibuprofen immediately after resistance training has a deleterious effect on bone mineral content at the distal radius, whereas taking Ibuprofen or undertaking resistance training individually prevented bone mineral loss. http://journals.lww.com/acsm-msse/Fulltext/2017/04000/Effects_of_Ibuprofen_and_Resistance_Training_on.2.aspx Read More
  • Tue 11 Jul 2017

    Mitochondrial Health and Sarcopenia

    The aging process (AKA 30 years of age onwards), in the presence of high ROS (reactive oxygen species) and/or damaged mitochondrial DNA, can induce widespred mitochondrial dysfunction. In the healthy cell, mitophagy results in the removal of dysfunctional mitochondria and related material. In the abscence of functional removal of unwanted mitochondrial material, a retrograde and anterograde signalling process is potentially instigated, which results in both motor neuronal and muscle fibre apoptosis (death) (Alway, Mohamed, Myers 2017, Ex Sp Sc Rev, 45, 2, 58-69). This process is irreversible. Investigations in healthy populations, have shown that regular exercise improves the ability to cope with regular oxidative stress by the buffering and 'mopping up' of ROS agents which are induced as a result of exercise. It is plausible and highly probable that regular exercise throughout life can mitigate against muscle fibre death (Sarcopenia). Importantly, this process of muscle fibre death can commence in the 4th decade of life. and be as much as 1% per year. Reduction of muscle mass can result in immune and metabolic compromise, including subclinical inflammation, type II diabetes as well as the obvious reduction in functional capacity for activities of daily living. Published 11 July 2017 Read More
  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) by Martin Krause When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups.  https://youtu.be/4rj-4TWogFU In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. An interesting case of EDS and it's affect on post concussion syndrome can be read elsewhere on this site. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 17 October 2017  Read More
  • Fri 09 Dec 2016

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More

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Updated : 10 May 2014

No responsibility is assumed by Back in Business Physiotherapy for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material in this and it's related websites. Because of rapid advances in the medical sciences, the author recommends that there should be independent verification of diagnoses and exercise prescription. The information provided on Back in Business Physiotherapy is designed to support, not replace, the relationship that exists between a patient/site visitor and their treating health professional.

Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected