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The Effects of Running Cadence Manipulation on Plantar Loading

by | Dec 13, 2024 | Health Tips

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction:

Running is one of the most popular forms of physical activity. However, the popularity of running is accompanied by a high prevalence of overuse injuries. Most injuries occur in the lower extremities, with a substantial proportion affecting the foot. These injuries are often linked to biomechanical factors such as impact loading, plantar pressure, and repetitive stress, particularly on the metatarsals and soft tissues of the foot. To address these issues, research has explored biomechanical modifications, such as cadence manipulation, as a strategy to reduce injury risk. Increasing cadence has been shown to decrease step length and ground reaction forces, potentially mitigating the forces implicated in injury development. This study specifically evaluates the effects of cadence manipulation on plantar loading in healthy runners, focusing on how these changes could influence injury prevention and management.

Methods:

Thirty-eight healthy recreational runners participated in this study. Participants met inclusion criteria requiring a minimum running distance of 12.87 km per week and no musculoskeletal injuries in the prior six months. Plantar loading data were collected during treadmill running at participants’ preferred pace under three cadence conditions: preferred, 5% increased, and 5% decreased. Each trial was randomized to minimize fatigue effects, with data collected for 30 strides per condition.

Plantar loading variables analyzed included:

  • Contact Time (CT): The duration of foot contact with the ground.
  • Peak Force (PF): Maximum force exerted during a foot strike.
  • Force Time Integral (FTI): Total force exerted over the contact period.
  • Peak Pressure (PP): Maximum pressure exerted on the plantar surface.
  • Pressure Time Integral (PTI): Total pressure applied over time.

These variables were measured for the total foot and four specific regions: heel, medial metatarsal, central metatarsal, and lateral metatarsal.

Results:

The study found that cadence manipulation significantly influenced plantar loading patterns:

  1. Increased Cadence (+5%):
    • Decreased CT, PF, and PTI for the total foot and all foot regions.
    • Reduced heel loading, including lower pressure and force variables.
    • Lower metatarsal loading across medial, central, and lateral regions.
  2. Decreased Cadence (-5%):
    • Increased CT and higher PF and PTI values in the heel and metatarsal regions.
    • Elevated total foot loading, with more pronounced force and pressure variables.

Discussion:

The results underscore the biomechanical benefits of increasing cadence during running. A faster cadence reduces plantar loading by decreasing contact time and ground reaction forces. Notably, this study refuted the hypothesis that increased cadence would elevate metatarsal loads; instead, all regions of the foot experienced reduced loading. These effects may be attributed to reduced vertical oscillation of the body’s center of mass and a decreased foot inclination angle at initial contact.

From a clinical perspective, cadence manipulation presents a promising strategy for reducing the risk of overuse injuries, such as plantar fasciitis, Achilles tendinopathy, and metatarsal stress fractures. By lowering repetitive loads on vulnerable foot structures, a 5% increase in cadence can mitigate the cumulative stress associated with long-distance running.

Conclusion:

This study highlights the potential of cadence manipulation as an effective tool for injury prevention and rehabilitation in runners. A modest 5% increase in cadence reduces plantar loading across all foot regions, suggesting that cadence training could be integrated into physical therapy protocols for managing running-related injuries. Given the small but meaningful biomechanical changes observed, cadence adjustments should be considered alongside other therapeutic interventions, such as strength training and gait retraining, to optimize treatment outcomes.

Implications for Physical Therapy:

The findings of this study have direct applications in physical therapy practice. For patients recovering from lower extremity injuries or seeking to prevent future injuries, cadence training offers an evidence-based intervention to reduce plantar stress and improve running mechanics. Physical therapists can use tools like metronomes or wearable devices to guide patients in cadence adjustments, ensuring gradual and sustainable changes in running form. Furthermore, cadence manipulation can complement traditional rehabilitation approaches, such as strengthening exercises for the intrinsic foot muscles and addressing biomechanical deficits in the kinetic chain. By incorporating cadence training into a comprehensive rehabilitation program, therapists can enhance patient outcomes, reduce injury recurrence, and promote safe, efficient running mechanics. This approach aligns with the growing emphasis on personalized and biomechanically informed physical therapy interventions.

  1. Wellenkotter J, Kernozek T, Meardon S, Suchomel T. The Effects of Running Cadence Manipulation on Plantar Loading in Healthy Runners. International journal of sports medicine. 2014;35. doi:10.1055/s-0033-1363236

Exercise and Non-Pharmacological Treatment of POTS

by | Nov 7, 2024 | Health Tips

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Article: 

Exercise and Non-Pharmacological Treatment of Positional orthostatic tachycardia syndrome (POTS)

Introduction: 

Positional orthostatic tachycardia syndrome (POTS) is a condition where the heart rate increases to a tachycardic rate following positional changes.  Previous studies have demonstrated that patients suffering from POTS tend to have smaller hearts as well as lower blood volume.  These factors contribute to a large decrease in stroke volume during orthostasis which in turn leads to an increase in heart rate via the baroreflex.  Patients with POTS often have low exercise tolerance and poor cardiovascular conditioning.  Patients with POTS are commonly treated with exercise training along with volume repletion therapy.  This article proposes a structured, non-pharmacological treatment approach designed to treat patients with POTS.

Methods: 

The article divides its treatment approach into exercise, volume expansion, reduction in venous pooling and physical countermeasures.  The article draws on many other studies to pull its advice from but it is not an organized meta-analysis or systematic review. 

Results: 

The article gives the following advice regarding the treatment of POTS:

              A combination of endurance training and lower body strength training are the primary components in the treatment of POTS.  A structured exercise program is known to correlate with increased cardiac size, peak oxygen uptake, blood volume and improvement in functional capacity and patient mood. 

              In the early stages of treatment for POTS, patients should begin endurance training at about 75% of their predicted max heart rate or at an RPE of 13-15 which may be described as somewhat hard.  Sessions should take place for 25-30 minutes 3 times per week using a recumbent bike.  The use of the recumbent bike is critical in the early stages of treatment because it allows the patient to exercise without experiencing POTS symptoms.  Patients with POTS and Ehlers-Danlos Syndrome (EDS) are recommended to exercise either by swimming or by using a rowing machine at moderate intensity to avoid putting excess stress on ligaments that are inherently less stable than average.  These patients may also benefit from wearing knee or elbow sleeves depending on the severity of their condition. 

              As treatment continues, the goal is to gradually progress the patient over a 3-month period to doing more upright exercise such as an upright bike or elliptical.  Once the patient is confident with upright endurance training, they may progress to jogging or stair climbing if they want to and are encouraged to continue exercising for endurance 3 times per week. 

              Resistance training is also recommended for this patient population with an emphasis on lower body muscles since these muscles act as pumps to encourage more efficient venous return.  The author suggests that seated, machine-based lifts are preferable to free weight lifts at least in the early stages of treatment.  This is to lower the risk of injury and to allow the patient to exercise in a seated or recumbent position to avoid increasing POTS symptoms.  The routine suggested includes leg press, knee extension, hamstring curls, seated calf raises, chest press, seated rows and some form of floor-based core exercises such as planks and abdominal crunches.  The author suggests that weight training begin once a week for 15 to 20 minutes and gradually progress to twice a week for 30-40 minutes as the patient’s tolerance improves. 

              Since many patients with POTS are known to have low blood volume which may contribute to their symptoms, the author recommends a diet that includes high levels of salt as well as increased water intake.  Patients may also try to sleep in a head-up position to encourage an increase in blood plasma volume.  The author cautions that although effective anecdotally, there have not been large clinical controlled trials to assess the efficacy of this treatment approach. 

              Patients with POTS have been shown to have increased venous pooling while in upright positions.  To counteract this, the author recommends compression garments.  Compression of all lower body compartments is ideal so the author suggests using compression garments that cover the entire lower extremity even into the lower abdomen.  The author cautions that compliance with this treatment is often low because the garments are difficult to don and doff, even with assistance.  Custom compression garments have been developed by NASA that may be easier for patients to use. 

              The author also provides several physical countermeasures that patients can utilize while experiencing POTS symptoms acutely.  Rhythmically squeezing a rubber ball with the hands while engaging the core and lower body muscles has been shown to increase mean arterial pressure.  Crossing the legs and squeezing the glute and quadricep muscles has been shown to quickly return blood from the venous system to the heart, this is mainly mechanical effect but there is some evidence that it may also reflexively cause an increase in cardiac output.  Engaging the leg muscles in rhythmic contractions has been shown to effectively pump blood centrally from the lower legs. 

              Squatting, sitting and lying down have all been shown to reduce the symptoms of POTS acutely. Forceful coughing can increase intrabdominal pressure which increases cardiac output and mean arterial pressure, assisting the heart.  Using a device to increase inspiratory resistance is effective in increasing cardiac output.  Cooling the surface of the skin can also be effective in increasing orthostatic tolerance by encouraging blood flow toward the center of the body. 

Discussion and clinical utility: 

This paper does an excellent job not only of putting forth a structured, evidence-based approach for non-pharmacological treatment of POTS, it also explains the rationale behind each recommendation.  The suggested treatment approach may not be practical to use on all patients with POTS, but it gives a useful framework from which to draw, so clinicians can modify treatment to better suit their patient’s specific needs. 

References:

Fu Q, Levine BD. Exercise and non-pharmacological treatment of POTS. Auton Neurosci. 2018 Dec;215:20-27. doi: 10.1016/j.autneu.2018.07.001. Epub 2018 Jul 4. PMID: 30001836; PMCID: PMC6289756.

Patellofemoral Pain Clinical Practice Guidelines

by | Oct 30, 2024 | Health Tips

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Article:

Patellofemoral Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association

Introduction:

The orthopaedic section of the American Physical Therapy Association (APTA) published these clinical practice guidelines in 2019 to give recommendations to clinicians in the differential diagnosis, assessment and treatment of patellofemoral pain.

These recommendations are designed to fit into the International Classification of Functioning, Disability, and Health (ICF model) that was introduced by the World Health Organization (WHO) to improve clinician’s ability to appropriately treat and communicate with patients by including pathoanatomical, psychosocial and societal factors when assessing a patient’s wants and needs.

Methods: 

Content experts were appointed by the orthopedic section of the APTA to search the current literature for articles relating to the treatment, assessment and diagnosis of patellofemoral pain.  Articles included were taken from MEDLINE, Scopus, CINHAL, SPORTDiscus, and the Cochrane Library with dates ranging from 1960 to 2018.

The chosen articles were then categorized based on level of evidence where I represented the highest quality evidence and V represented expert opinion.  After the evidence was reviewed and ranked, the experts developed and ranked recommendations utilizing the information.  A ranked recommendations were based on strong evidence while F ranked recommendations were based on expert opinion.  These recommendations were further categorized into the following content areas; diagnosis, classification, examination, and interventions.

Results: 

After reviewing the available literature, the authors made the following recommendations:

Clinicians should use the reproduction of pain behind or around the patella during squatting or other motions that load the patellofemoral joint in a flexed position to help diagnose patellofemoral pain.

The following factors can be used to diagnose patellofemoral pain:  pain behind or around the patella, reproduction of pain when the patellofemoral joint is loaded in a flexed position, exclusion of all other conditions that can cause anterior knee pain including tibiofemoral pathologies.

Clinicians can use the patellar tilt test with the presence of hypomobility to support the diagnosis of patellofemoral pain.

Since there are no previously established classifications of patellofemoral pain, the authors propose the following 4 classifications:  overuse/overload without other impairments, muscle performance deficits, movement coordination deficits, and mobility impairments.

Clinicians should use the following patient reported outcome measures when assessing patients with suspected patellofemoral pain:  the Anterior Knee Pain Scale, the patellofemoral pain and osteoarthritis sub-scale of the Knee Injury and Osteoarthritis Outcome Score, the Visual Analog Scale, the Eng and Pierrynowski Questionnaire, the Numeric Pain Rating Scale.

Clinicians should use functional tests such as squats, or step downs that reproduce patellofemoral pain to assess a patient’s progress throughout an episode of care.

Clinicians may use body structure and function impairments such as joint hypomobility, muscle weakness and lack of muscle extensibility to assess progress throughout an episode of care.

Clinicians should employ an exercise approach that targets both hip and knee musculature.  During the early stages of therapy, exercises targeting the posterolateral hip musculature is preferred but as the plan of care continues, targeting knee musculature as well is essential.

Clinicians may use patellar taping in the early stages of rehabilitation with the goal of reducing pain to enhance exercise performance.  Evidence shows that this can be helpful early on but generally has no lasting impact on prognosis or symptoms.  Clinicians should not prescribe knee orthoses such as knee sleeves or braces for the treatment of patellofemoral pain.

Clinicians may prescribe prefabricated foot orthoses for patients with greater than normal foot pronation during the early stages of rehabilitation in concert with an exercise program.  There is limited evidence suggesting that custom foot orthoses are more effective than prefabricated foot orthoses.

Clinicians should not use electromyography-based biofeedback on medial vastii activity to augment quadriceps exercise therapy for the treatment of patellofemoral pain.  Clinicians should also not use visual biofeedback on lower extremity alignment during hip and knee targeted exercise during the treatment of patients with patellofemoral pain.

Clinicians may use gait retraining during running for multiple sessions to adopt gait changes during running for patients with patellofemoral pain.

Clinicians may use blood flow restriction plus high-repetition knee exercises for those with limited or painful resisted knee extension.

Clinicians should not use dry needling for the treatment of patellofemoral pain, however acupuncture may be used to reduce pain.  There is limited evidence that acupuncture is more effective than placebo so caution should be exercised with this recommendation.

Clinicians should not use joint mobilizations or manipulations as a stand-alone treatment for patellofemoral pain.  Clinicians should not use biophysical agents including ultrasound, cryotherapy, phonophoresis, iontophoresis, electrical stimulation, or therapeutic laser therapy to treat patellofemoral pain.

Evidence suggests that patient education regarding plan of care, patellofemoral joint loading and Kinesio phobia helps to improve exercise program compliance to a rehabilitation exercise program.  The evidence suggests that a multimodal approach is ideal in the treatment of patellofemoral pain but that exercise is the primary factor in successful treatment.

Discussion and clinical utility:

This CPG is helpful because it provides new classifications of patellofemoral pain to help clinicians guide their plans of care.  It is also useful to see that exercise is the biggest factor in the effective treatment of patellofemoral pain.  This helps clinicians empower patients to be active and help treat their own symptoms.

References:

Willy RW, Hoglund LT, Barton CJ, Bolgla LA, Scalzitti DA, Logerstedt DS, Lynch AD, Snyder-Mackler L, McDonough CM. Patellofemoral Pain. J Orthop Sports Phys Ther. 2019 Sep;49(9):CPG1-CPG95. doi: 10.2519/jospt.2019.0302. PMID: 31475628.

The Effects of Thera Band Exercises on Rounded Shoulder Posture and Breathing Capacity

by | Oct 9, 2024 | Health Tips

Reviewed by Maggie McPherson, SPT

Article:

Effect of TheraBand Exercises on Rounded Shoulders Associated with Pulmonary Capacity in Young Adults: A Pre-Post Intervention Study published in Indian Journal of Physiotherapy & Occupational Therapy DOI: 10.37506/cbecx947

Introduction

Rounded shoulder posture is increasingly common in today’s sedentary world. Rounded shoulder posture can lead to upper extremity pain and dysfunction. What some people may not know is that the posture can also lead to changes in breathing capacity by changing certain postural and respiratory muscles’ ability to fully expand the rib cage.

Methods

This study is a pre-post intervention design that looked at the effects of Thera Band exercises on improving rounded shoulder posture and breathing capacity. Twenty-three young adults between the ages of 18-23 years, both male and female, were recruited for the study. The intervention program consisted of a TheraBand training program and pectoralis minor and pectoralis major stretching. The Thera Band resistance increased one level each week. The program frequency was 4 days a week for 3 weeks. Rounded shoulder posture was measured in supine with a measuring tape (distance from highest point of shoulder to table in cm). Pulmonary capacity was measured by spirometry, including Forced Expiratory Volume (FEV-1) and Functional Vital Capacity (FVC).

Results

After 3 weeks of the Thera Band exercise program, there were statistically significant improvements in rounded shoulder posture (p<0.001) and non-statistically significant improvements in both FEV-1 and FVC (p>0.001).

Discussion

These results demonstrate that a simple Theraband exercise and stretching program could demonstrate improvements in rounded shoulder posture in just 3 weeks. This could be useful to improve and prevent upper extremity pain and dysfunction. It is unclear from these results whether these exercises can improve breathing capacity. A larger, broader sample size and a randomized control group would be needed. As there was no control group or randomization in this study, no causation can be determined from these results. However, these results lay a promising foundation for future studies.

Reference

Anitha M, Tamatta S, bhosle S. Effect of TheraBand Exercises on Rounded Shoulders Associated with Pulmonary Capacity in Young Adults: A Pre-Post Intervention Study. Indian Journal of Physiotherapy & Occupational Therapy. 2024;18(3):46-50. doi:10.37506/cbecx947

Metronome Augmentation Increases Cadence in Novice and Recreational Runners

by | Sep 26, 2024 | Health Tips

Reviewed by Maggie McPherson, SPT

Article:

A One Session Gait Retraining Protocol with Metronome Augmentation Increases Cadence in Novice and Recreational Runners published in International Journal of Sports Physical Therapy DOI: 10.26603/001c.90909

Introduction:

Inexperienced runners are more likely to sustain running injuries, potentially due to poor form and training strategies. Research shows that some of the highest performing running athletes have a higher cadence than the average runner. This study explores the effects of a training protocol that includes a one-time training session followed by metronome augmentation practice. The aim of the study was to see if the protocol resulted in increased running cadence, as increased cadence is widely believed to improve running biomechanics and decrease sub-optimal force distribution through the lower extremities.

Methods:

This is a randomized controlled trial that looked at the effects of a training protocol on 33 novice or recreational runners over the age of 18. Each participant completed a 12 Minute Cooper Run at baseline and again after 2 weeks of training. Outcome measures included rate of perceived exertion (RPE), heart rate, cadence and distance covered. They additionally measure biomechanics via inertial measurement units, tracking stance duration, vertical excursion, knee flexion, and lumbar flexion.

The protocol included a training session for how to use the metronome while running. Each runner’s cadence was set at a 5-10% increase from their baseline cadence. Each participant then ran 2-3 times per week for up to 30 minutes for two weeks, with their set cadence playing via metronome. The researchers used a Mann-Whitney U test to analyze significant differences between the control and intervention groups.

Results:

Cadence at one minute (p=0.037) and overall cadence (p=0.002) both demonstrated significant, meaningful improvement versus the control group at the follow-up 12 Minute Cooper Run. There was no significant difference for any other outcome measures, including biomechanics.

Discussion:

Improving cadence has been largely supported in the research to improve running form, as over-striding is the number one biomechanical running error for recreational runners. Over-striding may cause increased stress on the lower extremity during gait, as the knee cannot properly respond to the high ground reaction forces as the foot hits the ground. These results offer a standardized, practical tool for clinicians to implement in their practice. External augmentation via metronome is a feasible way to improve novice runners’ cadence.

Reference:

Huber A, Verhoff D. A One Session Gait Retraining Protocol with Metronome Augmentation Increases Cadence in Novice and Recreational Runners. International Journal of Sports Physical Therapy. 2024;19(1):1494-1502. Accessed August 15, 2024. https://research.ebsco.com/linkprocessor/plink?id=5898c2c8-8a54-3f8b-b4e7-bdb5239c4026