On Saturday January 20, 2007, Pilates instructors from around the Bay Area met at Los Gatos Pilates to attend the Physical Therapy of Los Gatos Train-the-Trainer seminar: “Assessment for Pilates Instructors.” The purpose of the seminar was to present key physical assessment tools that Pilates instructors can use to customize exercise programs to meet the specific  needs of individual clients.

“Given the many similarities between Physical Therapy and Pilates, the move to more prescriptive exercise provides greater long term results for clients,” said Rob Naber, founder of Physical Therapy of Los Gatos.   The seminar included an instructional lecture and hands-on practice to assess client’s posture, spinal lumbopelvic range of motion and rhythm, flexibility and core strength.  At the conclusion, case studies were presented with “home work” for the attendees.  Answers to the assignment are provided at the end of the presentation.

Physical Therapy of Los Gatos thanks Nancy Chin and Marcie Ryken at Los Gatos Pilates for hosting the seminar.

Download “Physical Assessment for the Pilates Professional” (7.5 MB pdf)

Therapeutic exercise is a hallmark of physical therapy. Among many benefits, therapeutic exercise can restore correct strength ratios between muscles, increase functional capacity, and improve coordination.

When prescribing therapeutic exercise, the physical therapist must consider the entire sequence of neuromuscular events that allows the patient to perform their daily activities and sports. This sequence can be thought of as a chain composed of three elements: proximal (closest to the spine) stability, distal (away from the spine) motion, and finally, the desired fine motor skill.

While this sequence of neuromuscular events accompanies all deliberate human motion, it is perhaps most readily illustrated by the action of throwing a dart. The motion requires a firm basis of proximal support and slight rotation around the spine, distal motion performed by muscles of the chest, shoulder, and upper and lower arm, and fine motor skill as the fingers take control of the dart’s release. The controlled, simultaneous engagement of all three elements is what enables the competitor to hit the target’s triple ring.

In Pilates-speak, the deep muscles of the trunk that provide proximal stability are called the “core,” and the ability to move one’s limbs and carry out skilled tasks while holding the trunk steady is called “dissociation.” Strength and control over these deep muscles of your trunk provide the stable base required to perform tasks such as kicking a soccer ball or swinging a golf club.

Here at Physical Therapy of Los Gatos we draw from a wide a variety of exercises to help our patients coordinate, strengthen, and engage this three-part chain. Visitors to our clinic might recognize our use of movements from yoga, Swiss ball exercises, elastic band resistance exercises — even pull ups and hands stands. They might also recognize mat-based and equipment-based Pilates exercises. As a form of exercise, Pilates expands the clinical repertoire of physical therapy with a diverse range of exercises, performed in multiple planes and positions.

Pilates for Neuromuscular Retraining
Full recovery from injury proceeds through overlapping stages. Therapy to bring about full recovery must be coordinated with these stages. Initially, a patient may need to unlearn inefficient movement patterns that allowed the injury to occur in the first place. The Pilates Reformer offers an effective exercise platform where this unlearning can occur, and old patterns of movement can be replaced by ones that properly engage the proximal to distal to fine motor skill sequence. The Reformer enforces correct exercise motion and helps the therapist and patient isolate and train the deep muscles of the trunk required for proximal stability.

On the Pilates Reformer, neuromuscular re-training exercises can be performed in kneeling, supine, prone, or side-lying positions. This allows the therapist to prescribe some unusual exercises, such as supine “jumping” and rowing while kneeling. Patients and therapists have found that neuromuscular retraining to correct injury-causing patterns of movement proceeds more rapidly in these unfamiliar exercise positions, where gravity pulls the body along different axes and the usual proprioceptive cues are absent. As training proceeds, the therapist can progress the patient to exercise postures needed for his or her sports and activities to fully restore endurance, power and agility.

Pilates for Correct and Calibrated Strengthening
At Physical Therapy of Los Gatos we design individualized treatment programs that coordinate the timing and intensity of therapeutic exercise with each patient’s condition and functional capabilities. Injured tissues such as bones and ligaments must be allowed to heal, but incremental loading (progressive resistance training to increase strength) along correct axes is required to bring about full maturation of healing tissue. If exercise is delayed or inadequate, the muscles around the injured site become weaker and atrophy, slowing down the recovery process. Pilates helps close the gap between bed rest and full recovery by providing a variety of exercises that can be performed over a wide range of functional abilities.

In the case of a basketball player recovering from knee arthroscopy, the mechanics of jumping can be practiced in a supine position on the horizontal carriage of the Pilates Reformer. In addition to providing the neuromuscular training benefits described above, the Reformer in this case allows the therapist to initiate incremental loading of the affected knee without subjecting injured tissues to the full forces of gravity. In this type of therapeutic exercise, the Reformer is unlike a traditional leg-press apparatus because the patient’s position during the Reformer exercise simulates the relative head, torso, and leg alignment of regular upright jumping. With Pilates, the physical therapist can prescribe low-intensity jumping exercise in early treatment, and increase the intensity as recovery progresses. This enables the patient to recover upright jump capability and return to competition sooner.

Pilates for Full Recoveries
To us, “full recovery” does not simply mean returning the patient to his or her previous activities in order to be injured again. We are unique in our analytical approach into the causes of each patient’s susceptibility to injury. Our definition of full recovery includes identifying and strengthening weak muscles that allowed the injury to occur in the first place, and achieving neuromuscular control consistent with injury prevention. Ideas such as “dissociation” and “core” in Pilates helps isolate and train muscles responsible for preventing injury.

The Spring 2006 West Valley College Sports Medicine Symposium was held May 5th. The symposium was organized by John Kao MD for an audience consisting of physical therapists, athletic trainers, and physicians. The purpose of the Sports Medicine Symposia series is to continue improving the standard of orthopedic medicine here in the Bay Area by providing orthopedic professionals an opportunity to share their knowledge with one another and with other medical practitioners. This year’s spring symposium focused on current challenges of treating the lower extremities.

The following local professionals gave presentations:

• John T. Kao, M.D.

• Grady L. Jeter, M.D.

• Robert S. Nishime, M.D.

• Thomas Elardo, D.P.M.

• Paul Christensen, DPT, OCS, ATC

• Rob Naber PT, OCS, ATC

• Ross Nakaji PT, OCS, ATC, CSCS

• Fabrice Rockich, DPT, OCS, CSCS

• Paul Starks, MA, ATC, PTA, CSCS

Physical Therapy of Los Gatos principal Rob Naber spoke about the evaluation and treatment of problems affecting the knee. Rob began by noting the value of recent knee research and the bearing of research findings on the practitioner’s approach to knee conditions and injuries:

“The knee is often the weakest link that defines and limits an athlete’s total competitive capacity. The knee is needed for speed, power and strength, but is also vulnerable to injury. A knee injury not only means missing practice or competition but may also lead to the loss of scholarship support and potential professional opportunities. Extensive research of the knee, and improved diagnostic, rehabilitation, and surgical methods have brought new hope to athletes and clinicians dealing with the challenges of the injured knee.”

– from Current Issues in Sports Medicine: The Knee presented by Rob Naber PT, OCS, ATC

One of the key takeaway messages from Rob’s presentation was the importance of quantifying the capability and condition of the knee while the joint is in motion. In the evaluation and treatment of anterior knee pain, for instance, measuring the concentric vs. eccentric torque capacities of the knee is critically important as a diagnostic aid and as a reliable indicator of treatment progress. In rehabilitation following surgical reconstruction of the anterior cruciate ligament, videographic analysis of lower extremity angles during landing and jumping provides data the therapist needs to design and carry out a course of treatment that brings about rapid restoration of function and corrects neuromuscular control deficiencies that would otherwise invite re-injury.

Using the links below, interested individuals can view visuals and handouts from Rob Naber’s presentation to the Spring 2006 West Valley College Sports Medicine Symposium. For more information about Physical Therapy of Los Gatos’ approach to the evaluation and treatment of knee problems, please call the clinic at (408) 358-6505.

Current Issues in Sports Medicine: The Knee (view presentation visuals)
Current Issues In Sports Medicine: The Knee (download text)

Jump Strength Training Program (download program description)

Jump Strength Training Glossary (download glossary)

You know the feeling. You’ve put in the miles, the hills, the interval training. Now it’s race day and you’re having a good one. You feel balanced, light, and fast. You press the pace one more click and leave another pack of runners behind.

Then it happens. Your foot comes down on a rock and rolls painfully inward. You hear a sickening “pop,” you go down, and the runners you just passed thunder past you. Nauseating pain overwhelms your interest in the torn skin on your hands and stays with you throughout the long limp back to town.

Here in Los Gatos we’re fortunate to have miles of unpaved recreational trails and utility roads, such as the Los Gatos Creek Trail, the Flume Trail, the Jones Trail, and the Limekiln Trail, offering a variety of terrain through our open space preserves. The race described above could well be our own late-summer annual event, the Dammit Run. If you suffer an ankle sprain while running in competition or in training, here’s what you need to know to get back on the trail and back up to speed.

A Few Definitions
A ligament is a band of fibrous tissue in a joint connecting bone to bone. Each joint has several ligaments. Ligaments are distinct from tendons, which connect muscle to bone. Ligaments support and strengthen joints and make joints stable by limiting joint motion from movements in unwanted directions.

A sprain occurs when a ligament is stretched beyond its normal limits. Sprains are classified according to degrees of severity. A Grade I sprain involves damaging a ligament but not compromising its function of restraining unwanted motion. In a Grade II sprain, the ligament is partially torn and allows some unwanted motion. In a Grade III sprain, the ligament is completely torn and cannot stop unwanted motion, and joint stability and function are lost. Grade III sprains cause diffuse swelling and bruising around the affected joint.

A sprain is more than a simple mechanical injury. Sprains affect proprioception, the neural feedback mechanism that enables us to know the angles of our joints, and the positions of our limbs and extremities, without looking. Good proprioception is what enables us to run in the dark without thinking about where to put our feet, or land a jump shot when focusing on the hoop.

First Aid for Sprains
First Aid for sprains can be remembered by the acronym  “RICE,” (Rest, Ice, Compression, Elevation). For Grade I sprains, First Aid treatment alone is often adequate. Grade II and III sprains require rapid administration of First Aid, plus medical evaluation and treatment including some external support, such as a McDavid ankle brace , to protect the ligament while healing. Complete recovery from a Grade II or Grade III sprain is unlikely to occur without medical attention.

Recovery from Sprain
Recovery from a sprain involves promoting the healing of the ligament, elimination of swelling and bruising, increasing strength, and restoring proprioception. At Physical Therapy of Los Gatos the goal of treatment is returning the individual to their pre-injury level of activities and sports, without elevated risk of re-injury. If our runner returns to training on the Los Gatos Creek Trail without fully restored proprioception, he or she will find intense concentration is needed on the exact placement of each foot-fall to prevent the injured ankle from rolling inward again. Longer term, residual changes in joint forces and mechanics, due to incomplete recovery, can accelerate degenerative changes and conditions, such as arthritis.

Restoring Proprioception
Proprioception is based on neural feedback loops that carry and compare information from the eyes and middle ear, and from the stretch receptors of muscles and connective tissues. Following a sprain injury, proprioception is restored by thoroughly rehabilitating neuromuscular control over the affected joint with facilitory techniques such as compression, vibration, and biofeedback. This must be accomplished in a way that promotes, rather than impairs, healing of the injured ligament, and trains the surrounding muscles to assist the injured ligament in supporting the joint while it heals.

Elements of Therapy for Sprain
Therapy begins with a thorough evaluation of the sprain injury. If a Grade III sprain is suspected, the injury should be evaluated by an orthopedic specialist, who will order and evaluate X-ray or MRI images to detect any damage to the underlying bone structure of the affected joint and to obtain a clear picture of soft tissue injuries. Evaluation of a sprain performed by a physical therapist or a physician will also include stress tests to measure the extent of abnormal joint motion caused by the injury, and the progressive tightening of the joint as the injured ligament heals, as compared to the stress-bearing characteristics of the opposite joint and normative values.

In addition to specific, individualized strengthening exercises aimed at re-establishing neuromuscular control and joint strength, physical therapy for sprain should also include evaluation and training of muscles affecting the entire limb of the injured joint. For instance, when ankle pain, weakness, or injury compromise proprioceptive cues, the hips and low back muscles will compensate by altering the injured individuals’ walking and running patterns. Because the goal of therapy is complete recovery, including normal or improved function, specific, progressive exercises are prescribed over the course of rehabilitation to restore motion, strength, and control throughout the entire limb.

If you suspect you have a joint injury involving ligament sprain, please contact us for expert advice by calling (408) 358-6505. For additional information about ankle sprain, see the related article “Foot and Ankle Injuries of Ballet Dancers.”

At the September 2005 Western Occupational Health Conference, Physical Therapy of Los Gatos principal Rob Naber delivered presentations on anterior knee pain and lumbar active range of motion. At the same conference, Rob also gave a somewhat more technical presentation for physicians on the topic of lumbar spine stability. This web site article was adapted from his presentation notes and materials.

Lumbar spine stability is an important concept in orthopedic medicine because its absence is often identified as the cause of lower back pain. When the lumbar spine is insufficiently stable, the motion between the joints of the lower back is exaggerated and abnormal. A patient with lumbar spine instability will experience lower back pain when the joints of the lumbar spine “wobble” in use rather than transferring forces with the smooth, synchronous movements of a healthy spine.

If lumbar spine instability is identified as the cause in a case of lower back pain, lumbar spine stabilization must be the cure. Too often this simplistic view of the relationship between lumbar spine stability and lower back pain is used as the basis for handing out “core strengthening” exercise instructions as a treatment for lower back pain. Few cases of lower back pain caused by lumbar spine instability are relieved by pre-printed handouts of abdominal and paraspinal, or “core,” strengthening exercises.

While we encourage our patients toward any healthy form of exercise, including those forms that address core strength, we are critical of physical therapists and other health care providers who prescribe pre-printed, generic strengthening exercises to patients suffering from lower back pain. In most cases, these exercises will fail to provide any relief. And unfortunately, the most motivated patients receiving these instructions will succeed in strengthening their abdominal and paraspinal muscles. Greater strength will cause untreated lumbar spine joint wobbling to occur with greater force and velocity, and the patient will feel much worse.

In the maintenance of healthy lumbar spine stability, muscle endurance is more important than muscle strength. Furthermore, muscle endurance, the condition of ligaments, and motor control of the structures supporting the spine must be in balance if lumbar spine stability is to be achieved. Generic muscle strengthening regimes that disregard initial measures of paraspinal and abdominal wall muscle endurance, and do not aim to restore correct, specific, balanced, and sustainable force vector ratios around the lumbar spine will fail to produce measurable improvements and will likely increase the patient’s pain and disability.

At Physical Therapy of Los Gatos, our physical therapists are trained to evaluate lumbar spine instability using effective methods and clinical precision. Measurements taken during the evaluation phase of therapy and at key intervals over the course of treatment include timed isometric holding exercises in right and left “side plank” positions, a sixty degree sit-up position, and the Biering-Sorensen position (pictured). The results of these tests are compared with normative time values determined in research studies and are used to design individualized treatment protocols to restore correct force vector ratios around the lumbar spine. These individualized treatment protocols produce complete and rapid recoveries from lower back pain caused by lumbar instability.

Lumbar Spine Stabilization presentation by Rob Naber to the 2005 Western Occupational Health Conference (765 KB .pdf

Conference Program Abstract (76 KB .pdf download)

Low back pain is a vexing medical and personal problem. Almost everyone has to deal with it sooner or later. Low back pain can interfere with almost every aspect of daily living and causes more days lost from work than any other malady except the common cold. Low back pain can make finding a comfortable sleeping or sitting position impossible, and due to the central position of the lower back and its key mechanical role in supporting and enabling movement, resting the painful spine during waking hours is very difficult.

A clear physical evaluation and focused goals are imperative when solving enigmatic health problems such as low back pain. At Physical Therapy of Los Gatos, evaluation for low back pain includes objective measurement of the patient’s function, mobility of the spine, neurological assessment, dynamic strength, flexibility, and gait analysis. In our experience, the outcome of physical therapy that begins with a comprehensive evaluation is more likely to be successful than one that passes over the opportunity to use up-to-date diagnostic instrumentation and methods for precise patient evaluation.

One of many tools and methods we use to evaluate low back pain is the Oswestry Low Back Pain Disability Questionnaire. Originally published in 1980, the Oswestry questionnaire measures how one’s low back pain affects a variety of daily activities. Patients usually complete the questionnaire in less than five minutes. The answers patients select from the multiple-choice questionnaire provide useful information about the behavior, mechanical cause, and severity of the patient’s low back pain. This information, combined with other responses and measures used in our evaluation, help us to design a personalized, effective course of treatment, and prognosticate the duration of treatment.

If you’d like to take the Oswestry Low Back Pain Disability Questionnaire, you can pick up a copy at Physical Therapy of Los Gatos, or call to have us fax or mail it to you, or download the questionnaire. You can find our location and contact information near the top right-hand corner of this web page. Afterwards, we’ll be happy to discuss the results with you and, depending on your score, discuss our recommendations for more precise evaluation of your low back pain.

Osteoarthritis is a degenerative joint disease marked by joint inflammation and deterioration. Osteoarthritis is common: according to the Arthritis Foundation, nearly 21 million Americans, or 7% of the US population, are affected by osteoarthritis. The incidence of osteoarthritis goes up sharply with age.

Considering its prevalence, you probably already know someone who has been diagnosed with osteoarthritis. If that person is a competitive or recreational runner, one might expect to hear others say, “All that running. It’s no wonder he’s got arthritis.”

The fact is, there are plenty of non-runners with osteoarthritis, too, and there is a lack of evidence to support the notion that running causes arthritis.

In his excellent book, “Lore of Running,” Dr. Timothy Noakes cites a variety of research studies designed to examine the relationship between running and arthritis. Studies published in 1994 and 1997 determined that recreational joggers are not at any increased risk of developing osteoarthritis. A study published in 1985 found that the incidence of osteoarthritis in a group of runners who competed between 1930 and 1960 was lower than a matched group of swimmers who competed at the same time. A Danish study published in 1990 found that a group of athletes that ran 20 to 40 km per week for 30 years had an incidence of osteoarthritis that was no different from that of a comparison group. And a 1986 study found that runners with an average age of 60 who had run an average of three hours per week for 12 years did not have a greater prevalence of osteoarthritis than a comparison group.

Though at no greater risk of developing osteoarthritis than others, runners can and do experience pain from soft tissue injuries, such as hip bursitis, iliotibial band (ITB) friction, and tendonitis. Pain resulting from these other causes can be serious enough to interrupt training and recreational running. The runner with poor mechanics may never train long enough to develop osteoarthritis from running. And clearly an athlete who has jogged for 30 years has the correct biomechanics to run without breaking down.

Excluding injuries resulting from falls, runners’ injuries are almost always due to progressing their training too quickly or overloading the muscle support around the affected joint. A runner’s muscular strength around his or her load-bearing joints must be considerably stronger than that of non-athletic individuals of the same age and sex. Furthermore, different types of running such as sprinting, long-distance, cross-country, and asphalt training have different muscle support requirements.

The running program at Physical Therapy of Los Gatos is a goal-directed training program designed to prevent running injuries, get runners who have been injured or recovering from orthopedic surgery back into training, and increase running speed. The evaluation for the running program includes a comprehensive interview process where we measure baseline parameters of running fitness, uncover specific deficiencies, analyze your running form, and help you clarify your goals. For additional information on preventing running injuries, rehabilitation of running injuries, and increasing running speed, please contact Physical Therapy of Los Gatos by calling (408) 358-6505.

An unintended consequence of the increase in sports participation by girls and young women over the past thirty years has been an extraordinary rise in the incidence of anterior cruciate ligament (ACL) injuries in young female athletes. At the college level, one in ten young female athletes participating in sports such as soccer, volleyball, and basketball will suffer an ACL tear injury. These girls are typically unable to practice or compete for one or more seasons and face potential loss of scholarship funding and significant psychological trauma. A widely cited 1985 study found that at the high school level, the knee injury rate among female athletes is one per 100 participants, and noted the need for preventative measures.

In 1983, sports medicine researchers determined that four-fifths of ACL injuries are non-contact injuries, that is, they are caused by the athlete’s own motions rather than collisions with other players. To the researchers, this finding meant that the high incidence of ACL tear injuries in young female athletes might be greatly reduced if those motions could be identified and avoided.

The ACL is one of four major ligaments that connect the upper and lower leg at the knee. The ACL provides joint stability and supports cutting and pivoting motions. Oftentimes, the ACL will tear with a “pop” that can be heard by spectators and other players. Pain and immediate swelling follow. ACL tears require surgical reconstruction using tendon grafts from other areas of the knee or from cadavers, followed by a long period of rehabilitation.

The frequency and seriousness of ACL tears in young female athletes has led to research studies aimed at understanding the problem. These studies are now yielding valuable data. Three major hypotheses to account for the higher number of ACL tears in female athletes versus male athletes have been examined: hormonal differences causing laxity of the female athlete’s ACL, a smaller and more narrow space within the knee for the female athlete’s ACL, and sex-based differences in lower extremity strength and coordination. The last of these three hypotheses is receiving the most scientific support from study data.

Certain aspects of lower extremity strength and coordination can be captured and measured by videotaping athletes while they perform athletic movements in the research lab. While video recordings do not capture complex three-dimensional movements and the rotational stresses that these movements place upon the knees, the recordings do enable researchers to make close measurements of joint and limb positions in a single plane. These measurements were found to have predictive value.

In one well-designed study of 205 young female athletes, researchers found that athletes with a specific way of posturing their lower extremities, known as “valgus” (or “knock-kneed”) alignment, during certain athletic movements were more likely to suffer ACL injury than athletes with more “neutral” or straighter lower extremity alignment. This valgus alignment can be seen by analyzing the angles formed between the ankles, knees, and hips when the athlete lands from a jump off a small box and when she jumps vertically from a crouched position. A separate study that included videographic analysis of 325 young female athletes showed that a six-week neuromuscular training program corrected the lower limb valgus alignment associated with injury during jump landing and takeoff.

It is already well-known to physical therapists that muscular strength stabilizes the knee by helping to maintain the correct relative positions of knee structures during sports movements and by allowing muscles in the legs to absorb forces that would otherwise subject the joint to potential injury. But physical therapists treating young female athletes must now consider the implications of the new studies. Physical therapists familiar with these studies infer that rehabilitation from ACL injury should, in addition to conventional strength training treatment methods, include specific neuromuscular training aimed at improving the athlete’s ability to avoid valgus alignment of the lower extremities during high-risk sports.

It is no longer acceptable to reconstruct the ACL but leave neuromuscular control deficient.

The jump strength training program at Physical Therapy of Los Gatos is an element of rehabilitation from surgical reconstruction of the ACL as well as a standalone performance improvement module. The program includes jump analysis, strength conditioning, and neuromuscular training designed to improve power and acceleration. The neuromuscular training methods employed include visual, auditory and proprioceptive cues to train athletes to use muscular strength to absorb jump impacts in a controlled fashion, and, if necessary, to correct jumping, landing, and pivoting techniques in order to avoid forces associated with injury. For additional information about prevention of ACL injury, rehabilitation from surgical ACL repair, and jump strength performance training for athletes, please call Physical Therapy of Los Gatos at (408) 358-6505.