INTRODUCTION
Vitamin D is an important nutrient for athletes, specifically runners. Vitamin D comes from food, supplements, and sun exposure and is converted by the liver and kidneys into its active form which helps regulate calcium and promote bone mineralization. In addition, it plays a role in cell growth and neuromuscular and immune function. Deficiency is linked to muscle myopathy, muscle weakness, and muscle fatigue. Athletes are recommended to have blood levels of vitamin D above 50 ng/mL.

Continuous eccentric exercise (eg. downhill running) is known to cause muscle damage. A previous study shows the prevalence of vitamin D deficiency in extreme endurance athletes has a delayed physical performance. Optimal Vitamin D dosage for athletic performance and recovery is controversial.

The authors in the article, The Effect of Vitamin D Supplementation on Serum Total 25 (OH) Levels and Biochemical Markers of Skeletal Muscles in Runners, created a double-blind placebo-controlled clinical trial to observe the effects of a daily vitamin D supplement on blood levels of 25 (OH)D and biomarkers for muscle damage following an eccentric run. Vitamin D is transported by way of 25 (OH)D in the blood, making it a good indicator for levels of this vitamin present at a given time. They also looked at skeletal muscle biomarkers, proinflammatory cytokines, and tumor necrosis factor alpha levels which all cause inflammation and are linked to muscular pain in the process of muscle recovery.

MATERIALS AND METHODS
Twenty-four male ultramarathon runners with seven years-experience were randomly assigned to either a three-week placebo (control group) or a 2000 IU vitamin D supplementation protocol (the experimental group). The subjects followed controlled diets void of caffeine, supplements, or alcohol for three weeks prior to the start of the study and three weeks during the study.

The runners participated in an eccentric downhill treadmill running test at 70% of their VO2 Max before and after the vitamin D or placebo intervention. Venous blood draws were taken at rest, immediately after the exercise, and at one hour and 24 hours post-exercise.

RESULTS
There was a significant effect of vitamin D supplementation on blood concentrations at baseline between pre and post intervention in the experimental group. There was a higher post intervention vitamin D serum levels in the experimental group. There were decreased skeletal muscle biomarkers including troponin, creatine kinase, and TNF-alpha level at one-hour post-exercise in the supplement group. At the 24-hour mark, there was significantly lower creatine kinase activity in the supplemental group. There was a negative correlation between post exercise vitamin D levels and skeletal muscle biomarker levels in the supplemental group.

DISCUSSION
The goal of the study was to see if there was a relationship between vitamin D supplementation, blood serum 25(OH)D levels, and skeletal muscle biomarkers to amplify recovery in marathon runners. The results show that vitamin D supplementation did, in fact, decrease the amount of muscle inflammatory cells at 1 hour and 24 hours post running. Strenuous exercise with eccentric muscle contractions may be attributed to muscle fatigue due to muscle membrane damage. With less muscle damage, there is a decreased recovery time.

CONCLUSIONS
Three weeks of vitamin D supplementation had a positive effect on serum 25(OH)D levels in endurance trained runners and a marked decrease in post-exercise biomarker levels. Vitamin D supplementation might play an important role in the improvement of muscle function and prevention of skeletal muscle injuries following exercise with eccentric muscle contraction in athletes.

PHYSICAL THERAPY FIRST RECOMMENDATIONS
We treat many runners at Physical Therapy First. This study shows that Vitamin D is important in decreasing pain and improving the recovery time after long distance running. In addition to a proper physical therapy training program to decrease your risk of sustaining a running-related injury, we recommend talking with your physician about vitamin D levels and possibly supplementing at a recommended dosage in order to promote improved muscle recovery after your next training run or race.

REFERENCE:
Zebrowska, A., Sadowska-Krepa, E., Stanula, A., Waskiewicz, Z., Takomy, O., Bezuglov, E., Nikolaidia, P… Knechtle, B (2020). The Effect of Vitamin D Supplementation on Serum Total 25 (OH) Levels and Biochemical Markers of Skeletal Muscles in Runners. Journal of International Society of Sports Nutrition. 17:18

ARTICLE REVIEW: Regional Manual Therapy and Motor Control exercise for Chronic low back pain: A Randomized Clinical Trial

INTRO:
Chronic low back pain is a common complaint among many individuals and can negatively impact their routine activities. The most up to date evidence suggests treatment for chronic low back pain should consist of a combination of manual therapy, motor control exercises, and a general exercise program. Recent questions have developed on the benefits of performing manual therapy techniques to other areas of the body which may contribute to low back pain (such as the hips or the thoracic spine). This concept is termed regional interdependence, which means impairments in a remote anatomical region can cause primary pain complaints in a different region. There is limited evidence to support or refute this idea when it comes to treatment of low back pain. This study looks at the additive effects of manual therapy to the thoracic, pelvic, and hip regions when combined with standard physical therapy (PT) to the lumbar spine.

METHODS:
Participants: Forty (40) participants were used for this study that were between 18-65 years old, had active low back pain for at least the past 3 months, had at least one hypomobile thoracic or lumbar segment (back stiffness), demonstrated hip mobility deficits, and had at least one hypermobile lumbar segment or weak pelvic/ trunk muscle strength. Also, these participants did not have any red flags, systemic inflammatory conditions, nerve related signs/ symptoms, no spinal injections within past 2 weeks, and would be safe to tolerate manual therapy. Each participant underwent a 2-week, 4-week, and 12-week follow up.

Outcome Measures: The main outcome measure was disability level of each patient measured by the Modified Oswestry Low Back Disability Questionnaire (ODQ). This is a patient reported questionnaire that has shown to be reliable, valid, and responsive to measure disability. Other outcome measures include pain intensity, pain catastrophizing, fear avoidance beliefs, and perceived effect of treatment. Each of these were measured using different patient reported questionnaires as well.

TREATMENT RECEIVED:
Regional Manual Therapy group : 10 minutes of manual therapy consisting of non-thrust and thrust manipulation to the lumbar spine, thoracic spine, pelvis or hips; or soft tissue gliding over these areas. 20 minutes of motor control exercises that were progressively advanced.
Standard Lumbar PT: 10 minutes of manual therapy consisting of non-thrust mobilizations to the lumbar spine or soft tissue gliding between L1-L5 vertebrae. 20 minutes of motor control exercises that were progressively advanced.
Each group received 30 minutes of treatment 2x/ week for 4 weeks. Both groups were given a home exercise program to work on motor control and self-mobilizations. After the 4 weeks of treatment, they were to perform their HEP 3x/ week for the next 8 weeks without coming to PT sessions.

RESULTS:
Significant differences were found for both groups for improvements in disability level, pain levels, pain catastrophizing scales, and fear avoidance beliefs across time. At the 2-week and 4-week follow up, the regional manual therapy group was more likely to report a >50% improvement in their disability level and had a higher rating of perceived effect; but neither showed a significant difference at the 12-week mark.

DISCUSSION:
Both groups had significant improvements across multiple domains over the 12-week period indicating the combination of manual therapy with exercise is beneficial for the treatment of chronic low back pain. The group receiving regional manual therapy in addition to exercises had a greater decrease in reported disability during the 4 weeks of receiving treatment suggesting interventions to areas other than the lumbar spine may improve patient outcomes in a quicker manner. This improves efficiency of physical therapists and may allow the patient to return their prior functional levels in a shorter amount of time.

LIMITATIONS:
Some limitations of this study include: small sample size, different forms of manipulation were used based on therapist discretion (however, other studies suggest no difference in thrust vs non-thrust manipulations for outcomes of chronic low back pain), patients allowed to use pain medications. Also, results of this study should only be applied to patients with chronic low back pain and associated hip stiffness with spinal hyper or hypomobility.

CONCLUDING THOUGHTS:
Manual therapy with a progressive motor control exercise program is beneficial for chronic low back pain. Assessing associated joints at the thoracic spine, pelvis, and hips should be performed by therapists as deficits at these joints can contribute to pain in the low back. For these other deficits found, performing manual therapy techniques in addition to standard physical therapy treatment may provide additional short-term benefits and allow patients to more quickly return to their routine activities with less pain.

It is standard practice for us at Physical Therapy First to assess adjacent joints and determine any other anatomical factors that can be contributing to someone’s pain. We provide thorough examinations and will utilize manual therapy techniques accordingly to treat all parts of the body. In addition, we understand the benefits of proper exercise programs to make them progressive and functional so our patients can meet their individualized goals. Back pain can be debilitating and the PTs at Physical Therapy First are here to help!

REFERENCE:
Jason Zafereo, Sharon Wang-Price, Toni Roddey & Kelli Brizzolara (2018) Regional manual therapy and motor control exercise for chronic low back pain: a randomized clinical trial, Journal of Manual & Manipulative Therapy, 26:4, 193-202, DOI: 10.1080/10669817.2018.1433283

Piriformis syndrome is a commonly overlooked diagnosis for hip and buttock pain. In the article, Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach, the researchers reviewed the literature to present a summary of this diagnosis as well as a variety of treatment options.

This diagnosis is a neuromuscular condition which is caused by peripheral neuritis of the sciatic nerve due to an abnormal condition of the piriformis muscle. It is characterized by hip and buttock pain, parasthesia, hyperasthesia, and muscle weakness. This syndrome occurs most frequently in women ages 40-60. Incidence ranges widely from an estimated 5% to 36% among patients with low back pain.

The sciatic nerve exits inferior to the piriformis in the majority of the population. It is estimated that in 22% of the population, the sciatic nerve pierces the muscle, splits the muscle, or both as it travels posteriorly down the leg. When this anatomical variation is present, it is known as primary piriformis syndrome.

Secondary piriformis syndrome occurs as the result of a micro or microtrauma, local ischemia, or mass ischemia. The most common cause is a direct trauma to the buttocks region, leading to inflammation of soft tissue and/or muscle spasm which results in nerve compression. Microtrauma may result from overuse of the muscle such as in long distance walking or running.

The most common symptoms patients present with include increased pain while sitting longer than 20 minutes and tenderness over the piriformis muscle. Patients might also complain of difficulty walking and pain while sitting cross-legged. The symptoms may appear gradually or suddenly and are associated with spasm of the muscle or compression of the sciatic nerve.

As clinicians, we also look for certain objective measures to support the diagnosis including tenderness to palpation of the piriformis, palpable mass in the muscle belly, weakness, limited hip internal rotation of affected side, and a shorter leg on the affected side. A spasming piriformis muscle causes ipsilateral hip external rotation, anterior sacral torsion toward ipsilateral side, and compensatory lumbar rotation in the direction of the spasming side. Additional osteopathic tests include the Pace sign, Lasegue sign, Freidberg sign, Beatty test, and FAIR test (flexion, adduction, internal rotation). Differential diagnoses include lumbosacral radiculopathy, degenerative disc disease, compression fractures, and spinal stenosis. The obturator internus muscle has also been suggested as a contributing source of sciatic neuritis in patients with piriformis syndrome.

Physical therapy is a great option to treat patients with piriformis syndrome. A trained physical therapist will focus on treatment techniques specific to this diagnosis which focus on decreasing and eliminating the spasm in the piriformis by way of strain-counterstrain and facilitated positional release. Spinal, pelvic, and hip manipulations might also be warranted to address associated lumbo-pelvic dysfunctions. Strengthening of the hip adductor muscles has been shown to be beneficial for this syndrome as well as a stretching sequence which is tailored to each patients’ needs. The staff at Physical Therapy First are board-certified manual trained therapists with experience providing these techniques. Further diagnostic tests and imaging include EMG studies, and MRI or CT scan to rule out lumbar disc pathologies. Other treatment includes pharmacologic treatment (NSAIDs, muscle relaxers, local steroid injection, and prolotherapy), and in severe cases, surgery.

Reference

Boyajian-O’Neil, L., McClain, R., Coleman, M., Thomas, P (2008). Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach. Journal of the American Osteopathic Association: Volume 8, No 11.

INTRODUCTION
Spinal Manipulative Therapy (SMT) is known to help decrease pain and improve spinal mobility. The authors of this article, Effect of Spinal Manipulative Therapy with Stretching Alone on Full-Swing Performance of Golf Players, propose that this treatment also coincides with maintenance and improvement of joint function, muscle balance and speed of neuromuscular reflexes, thus optimizing an athlete’s performance in their sport.
A golfer’s swing is a complex full-body motion which requires spinal mobility and limb flexibility. The shoulders are required to rotate up to 90 degrees and the hips by 45 degrees. This rotation places higher compressive loads in the low back (8x body weight) than rowing (7x) or running (3x). Because of this increased force on the spine, muscle strains are a common injury amongst golfers.
The researchers in this article evaluated the effect of SMT on the performance of golf players with a handicap between 0-15 during their full swing using a driver club.

METHODS
Men between the ages of 18 and 55 with a handicap from 0 to 15 and who practiced golf at least once a week for four hours were recruited from two golf clubs in Brazil. They were randomly selected to be in one of two groups: Group I was a stretch-only program and Group II was a stretch and SMT program.
The stretches performed by both groups included those for the forearm flexors, deltoids, brachioradialii, biceps, forearm extensors, levator scapulae, gastrocnemii, solei, quadriceps, hamstrings, and gluteal muscles which were performed bilaterally for 20 seconds. Each golfer was also evaluated for joint dysfunction in the cervical, thoracic, and lumbar spine. SMT was performed on the dysfunctional segments in participants in Group II only.
Prior to each treatment, the participants performed three full-swing shots and the average distance of the shots was recorded. Participants then participated in the intervention (stretching or stretching + SMT) and performed three more full-swing shots on the driving range. This process was repeated once weekly, for a total of four weeks.

RESULTS
Group II showed a gradual improvement in the pre to post intervention shot distances across the four days, as seen in Figure 1 below. The fourth and final day showed a statistically significant change between pre and post intervention. When looking at Group I’s pre to post intervention distances, the results were inconsistent, as seen in Figure 3 below. There was a statistically significant decrease in average pre to post shot distance on day two.

Figures 2 and 4 below compare the shot averages between the first and last days of the experiments in Groups II and I, respectively. There were improvements in both groups, but neither was of statistical significance.

LIMITATIONS
This study has a small sample size (43 men) and is not representative of all golfers, including the estimated 80 million female golfers worldwide, according to the National Golf Foundation.

CONCLUSIONS
The authors concluded that stretching and SMT seemed to be associated with an improvement in golfer’s swing performance. Therefore, spinal manipulative therapy could be a treatment option for patients who enjoy golfing.
Clinical Significance
Our clinicians have extensive training in manual therapy and efficiently evaluate and assess our patients to ensure they are appropriate candidates for safe manipulation techniques. Assessment of spinal mobility in the cervical, thoracic and lumbar spine, extremity joint mobility, soft tissue flexibility and strength are considered and evaluated as all are important for a successful golf swing. Come see us for an initial evaluation and treatment session to get ready for your upcoming golf season!

REFERENCE:
Costa, S., Chibana, Y., Giavarotti, L., Compagnoni, D., Shiono, A., Satie, J.: Bracher, E (2009). Effect of spinal manipulative therapy with stretching compared with stretching alone on full-swing performance of golf players: a randomized pilot trial. Journal of Chiropractic Medicine 8: 165-170.

A COMPARISON OF TWO NON-THRUST MOBILIZATION TECHNIQUES APPLIED TO THE C7 SEGMENT IN PATIENTS WITH RESTRICTED AND PAINFUL CERVICAL ROTATION
Mobilizations and manipulations to joints in the cervical spine is a common intervention performed by physical therapists to improve neck range of motion. There is controversy about using rotary thrust manipulations in the lower cervical spine and has potential to cause adverse reactions, therefore it may be more appropriate to use non-thrust mobilization techniques instead. A study looked at the effectiveness of two different types of non-thrust mobilization techniques. These 2 techniques are:

Non-thrust C7 facet joint gliding mobilization: (for restricted right rotation): “The T1 segment is manually stabilized in left rotation by pressing the left shoulder girdle in a posterior direction. Bilateral translatory movements are applied to the lamina and inferior facets of the C7 segment in the direction of right rotation.” (Left image below)
Non-thrust facet joint distraction mobilization: (for restricted right rotation): “The clinician uses his left hand to separate (distract) the right inferior facet of C7 away from the superior facet of T1. The clinician uses his right hand to maintain a ventral and medial pressure against the lamina and inferior facet of C7. This compresses the inferior facet of C7 against the superior facet of T1. This will shift the axis of movement to the left, which will facilitate greater motion (facet distraction) on the right side of the C7 segment. Manual stabilization of the T1 segment occurs by using the right lower extremity to passively press the left shoulder girdle and clavicle in a posterior direction, which rotates the T1 segment in the opposite direction of the intended mobilization.” (Right image below)
**In this study, one intervention = three consecutive, 7-second, grade III, non-thrust facet glide or facet distraction mobilizations**

Creighton, D., Gruca, M., Marsh, D. and Murphy, N., 2014. A comparison of two non-thrust mobilization techniques applied to the C7 segment in patients with restricted and painful cervical rotation. Journal of Manual & Manipulative Therapy, 22(4), pp.206-212.

This study had 30 participants who had cervical pain rated as 2/10 or higher, pain with both left and right active cervical rotation, and limited active cervical rotation in both directions when measured with a CROM. The participants were split in half in which one group received the facet joint glide technique and the other received the facet joint distraction technique.

Outcomes measured for this study were degrees of active right and left rotation, pain rating at end range right and left cervical rotation, and the number of adverse reactions produced. These measures were taken before and after the mobilization technique was performed.

The results display that both groups of participants had a statistically significant increase in both right and left active cervical rotation range of motion: about 5 degrees increase in both directions. There was also a statistically significant decrease in pain levels for both right and left active cervical rotation. No adverse reactions were reported by any subject. One technique did not produce significantly better results compared to the other technique.

Limitations of this study include: the researcher was not blinded, challenging study reproducibility since training is likely required to perform the same techniques, possible placebo affect may have occurred, small sample size, possibility for measurement error, and does not look at long term outcomes.

Despite the limitations, these 2 techniques show that they can be a safe, low risk, and effective addition to a treatment session for patients with limited and painful cervical rotation range of motion. However, these techniques do not prove to be a stand alone way to improve cervical pain and range of motion. It is recommended that therapeutic exercise and other manual therapy interventions should be performed in addition to these techniques to have the best outcomes.

Reference:

Creighton, D., Gruca, M., Marsh, D. and Murphy, N., 2014. A comparison of two non-thrust mobilization techniques applied to the C7 segment in patients with restricted and painful cervical rotation. Journal of Manual & Manipulative Therapy, 22(4), pp.206-212.