Flywheel Eccentric Training: How to Effectively Generate Eccentric Overload

Reviewed by John Baur, PT, DPT, OCS, CSCS, FAAOMPT

This article explains why and how to use “flywheel eccentric training” to deliberately create eccentric overload—loads greater than what the athlete can produce concentrically—and provides practical programming, safety, and exercise‑selection guidance for sport performance and injury prevention. Eccentric contractions are the active “lengthening” of muscle and are unique in several ways: eccentric strength is ~40% greater than concentric strength; force rises with velocity until it plateaus; the metabolic cost and motor unit recruitment are lower for a given mechanical output; and a phenomenon called residual force enhancement (likely involving titin) can elevate force after lengthening. Together, these neuromuscular and mechanical features make eccentrics especially potent for strength, speed, change of direction (COD), and resilience to injury.

Muscle damage, DOMS, and the repeated‑bout effect. Eccentrics can induce more muscle damage when loads are higher, velocities faster, muscle lengths longer, or individuals are inexperienced; genetics matter too. However, damage is not “inevitable”—unaccustomedness is a major driver—and the repeated‑bout effect rapidly reduces soreness and damage on subsequent exposures. Practically, coaches should progress volume, intensity, and exercise length appropriately, especially when training at long muscle lengths that, while beneficial for adaptations, also heighten DOMS.

What adaptations do eccentrics drive? Compared with concentric work, eccentric training tends to produce larger gains in maximal strength and distinct morphological changes: increased fascicle length, greater serial sarcomere number, region‑specific hypertrophy, lower pennation angle, and increased stiffness. These adaptations underpin stronger sprinting, jumping, stretch‑shortening cycle efficiency, and faster COD—partly by enabling greater braking and propulsive forces with shorter contact times. Meta‑analyses cited in the paper show improved speed, power/jump, and COD performance after eccentric‑biased or flywheel programs.

Why eccentrics are especially relevant in team and racket sports. Match analyses show team sports often involve more and/or more intense decelerations than accelerations, making the ability to absorb force a key determinant of performance and fatigue. For example, in soccer, harsher CODs are linked with neuromuscular fatigue, and the most common goal‑preceding movements include linear advances followed by decelerations and turns. A controlled trial in U23 women’s soccer reported that 10 sessions of lower‑body flywheel eccentric work increased high‑intensity accelerating/decelerating distance and peak/average acceleration–deceleration versus controls, supporting real‑match relevance.

How flywheel devices work and why they’re useful. A flywheel system stores kinetic energy during the concentric phase and returns that inertia to the user in the subsequent eccentric phase, enabling mechanical eccentric overload if programmed correctly. The device is portable, accommodates resistance through the full ROM (no “sticking point”), and lets athletes perform multi‑planar, sport‑specific patterns. Device geometry matters: “horizontal, cylinder‑style” systems generally afford higher eccentric forces, whereas “vertical cone” (“conical pulley”) systems can reach higher velocities. Low inertias behave like light loads (emphasizing velocity and SSC use), high inertias like heavy loads (emphasizing force). The intent is maximal speed in the concentric phase and decisive braking in the eccentric phase. Figure 1 (p. 6) in the article illustrates common devices (squat, leg curl/extension, leg press, pulley, conical pulley, multigym).

Training effects of flywheel eccentric training. Systematic reviews and meta‑analyses highlighted by the author indicate increases in strength, power, sprint speed, and COD, often surpassing gravity‑dependent controls; some umbrella reviews note similar outcomes to traditional resistance training, but overall the weight of evidence is favorable—particularly among younger and well‑trained athletes who “attack” both concentric and eccentric phases. Flywheel eccentric work has also been linked to fewer in‑season injuries in team sport cohorts, potentially via increases in hamstring fascicle length.

Programming guidelines. The paper synthesizes practical guidance (Table 1, p. 8–9):

Power: 2 + 3–6 reps, 1–3 sets, low–medium inertia, short rests; devices like conical pulley/flywheel pulley/squat.

Strength: 2 + 5–8 reps, 1–4 sets, medium–high inertia, longer rests; devices like squat, multigym, leg press, extensions/curls.

Injury prevention: 2 + 5–8 reps, 1–4 sets, low–to–high inertia depending on exercise selection (single‑joint often preferred).

The “2 + x” notation means 2 start‑up “spin‑up” reps to accelerate the wheel, then x maximal reps. Recommended frequency is 1–3 sessions/wk (≥48 h between), with higher inertias requiring more rest between sets.

Weekly scheduling. The author outlines in‑season and two‑match‑week templates (Tables 2–3, pp. 9–10). A common structure is a power session on MD‑4, an upper‑body + microdose lower‑body strength/IP later that day, and a main lower‑body strength/IP on MD‑3, with adjustments for starters vs non‑starters and microdoses after midweek matches when congested. The aim is to maintain strength/IP stimuli without compromising freshness for matches.

Eccentric overload is not automatic. A key caution: only 17 of 79 flywheel studies provided enough data to confirm actual eccentric overload, typically via higher eccentric “peak” power/velocity than concentric. Reasons overload may be absent include submaximal concentric intent (insufficient stored energy), movement mechanics (e.g., peak concentric force in stronger joint angles vs peak eccentric near the turning point), and inexperience. Overload likelihood rises with horizontal cylinder devices, higher inertias, technique that “reduces eccentric time” (e.g., braking in the final third), and user experience. The paper also notes possible gender and experience influences.

Methods to “create” eccentric overload (Figure 3 and photo sequences in Figure 4, pp. 12–14).

  1. Increase concentric ROM (e.g., add plantarflexion or a late hip rotation) so more energy is generated concentrically than will be absorbed eccentrically.
  2. Reduce eccentric ROM/time (alternate half/quarter squats; stop the wheel in the last third; or perform a high‑overload “catch,” i.e., attempt an isometric hold low, then yield).
  3. Coach/athlete/load‑assisted (assist concentric to create more stored energy; assist eccentric by pulling the rope down; or add a hand‑held load only during the eccentric phase).
  4. Alternate exercises or laterality between phases (e.g., concentric squat → eccentric RDL; or concentric bilateral → eccentric unilateral).
  5. Combine methods for advanced athletes (e.g., add rotation “and” brake in the last third). Direct device feedback (encoders/force plates via the manufacturer’s app) is encouraged to verify overload and motivate effort.

Safety, technique, and progression. Start with 1–2 exercises for novices; advanced athletes may tolerate 2–4 exercises × 2–4 sets. Ensure the harness is correctly fitted; on squat devices, teach athletes to “immediately” flex hips/knees after lockout to avoid “hanging” at end‑range; cue stable foot placement mid‑platform; and use the device’s stop to finish safely. A touch of plantarflexion at the top can smooth the transition from concentric to eccentric. Tables 4–6 (pp. 14–16) give full lower‑body session examples for athletes at low, medium, and high flywheel competence, including power primers, microdosing, and strength lifts.

Bottom line. Flywheel devices can reliably deliver eccentric overload “when you design for it”, not merely by using the device. Choose the right inertia and device, emphasize maximal concentric intent, shorten eccentric absorption time or increase concentric energy, progress volume thoughtfully, and place sessions intelligently in the weekly plan. Done well, flywheel eccentrics enhance strength, speed, jump, COD, and may lower injury incidence—especially in sports dominated by decelerations.

  1. C. Eccentric. Eccentric = active lengthening where the muscle “absorbs” energy from an external load (p. 3).
  2. C. 40%. Eccentric strength is ~40% greater than concentric in men and women (p. 3).
  3. A. Increases. Eccentric force increases with higher speeds until it plateaus/slightly decreases (p. 3).
  4. B. Greater pennation angle. Eccentrics tend to “lower” pennation angle while increasing fascicle length and sarcomere number (p. 4).
  5. A. Increase speed performance. Meta‑analysis shows improved sprint speed after eccentric‑biased training (p.4).
  6. C. Inertia. The device returns inertia accumulated in the concentric phase to the eccentric phase (p. 5).
  7. A. Light/heavy. Low/high inertia in flywheel work maps to light/heavy load in traditional training (p. 5).
  8. A. An increase in muscle fascicle length. Longer fascicles are a plausible mechanism for reduced in‑season injuries observed with flywheel eccentrics (p. 7).
  9. C. High inertias. High inertias are recommended for strength adaptations (>0.050 kg·m²) (p. 7).
  10. C. High inertias. Researchers (Raya‑González etal.) recommend high inertias for injury prevention (p.7).

References:

Martínez‑Hernández D. Flywheel Eccentric Training: How to Effectively Generate Eccentric Overload. Strength & Conditioning Journal. 2024;46(2):234‑250.

Older People Trip, Some Fall—A Program to Decrease Seniors’ Fall Risk

Reviewed by John Baur, PT, DPT, OCS, CSCS, FAAOMPT

Why focus on trips and forward falls?

Falls are the leading cause of injurious deaths and nonfatal injuries in adults over 65. From 2007–2016, U.S. fall‑related death rates rose ~3% per year, and 20–30% of falls in this age group cause moderate to serious injury, generating billions in healthcare costs. Because many forward falls begin with a trip during walking, the authors concentrate on the biomechanics of trip recovery and how training can reduce fall risk in older adults. They emphasize a practical, gym‑floor approach that does not require costly perturbation treadmills.

Definitions and the fall‑arrest problem.

The paper distinguishes falling—“the initiation and process of losing one’s balance”—from a fall, i.e., unintentionally landing on the ground. Other key terms include base of support (BOS), center of mass (COM), maximum recoverable forward lean angle (MRFLA), and impulse (force over time). “Table 1 (p. 699)” lays out these terms, and the “diagram below the table” shows how trunk control, support limb, recovery limb, step velocity, step length, lower‑limb strength, and rate of torque development jointly determine whether a person arrests a fall or hits the ground.

What happens during a trip?

When the swinging foot is unexpectedly obstructed, the forward motion of the legs halts: stride duration lengthens for both limbs while the COM continues forward, threatening to move beyond the BOS. Successful arrest demands: (1) a faster, longer recovery step placed sufficiently far ahead; (2) a powerful push‑off from the support limb to buy time and counteract the trunk’s forward angular momentum; and (3) trunk control that limits forward flexion angle and velocity. Nonfallers, compared with fallers, display longer, faster recovery steps; a single‑step recovery becomes less likely as forward lean increases. Successful single‑step recoveries are associated with greater lower‑limb strength and higher support‑limb ground‑reaction force impulse and hip upward velocity at push‑off. Reductions in trunk flexion angle/velocity at toe‑off and at ground contact also characterize successful arrests.

Program design philosophy.

The authors propose a three‑part, multicomponent program—(a) balance training, (b) task‑specific training, and (c) resistance training—with a fourth element (safe‑landing techniques) suggested but not covered. The program targets the specific capacities identified above: step length and velocity, trunk control, lower‑limb strength, and rate of torque development (RTD). Field‑friendly assessments such as the Functional Reach and Timed Up and Go tests can establish baselines and track progress.

1) Fall prevention: balance training

Start with static two‑leg balance, then progress to single‑leg stance (SLS) and single‑leg hip hinge (SLHH) drills, which are later combined and made dynamic. The coaching progression is explicit: introduce each drill with full hand support, then partial support, then unsupported, repeating that sequence each time you introduce a harder variation (“Figure 5, p. 703”). Cue clients to fix their gaze on a stationary object and to press the stance foot firmly into the floor; regress immediately if loss of control necessitates a step for balance. “Figures 3–4 (pp. 702–703)” and “Table 2 (p. 701)” illustrate the SLS→SLHH→reach progressions, including multidirectional reaches and continuous flows between positions. These movements were chosen because they closely mimic the joint actions needed in the later lunge progressions.

2) Fall arrest: task‑specific training (without special equipment)

Random trip perturbations delivered by specialized treadmills can be effective but are costly and impractical. The authors propose the step‑forward lunge (SFL) as a practical proxy for a single‑step recovery after a trip. Although an SFL is preplanned and typically lacks the same trunk angular momentum and loading as a true trip, its joint sequencing (hip/knee flexion and dorsiflexion on contact, then extension to stabilize) is similar. By manipulating trunk angle relative to step length, cueing speed, and unpredictability (e.g., random audio/visual targets), practitioners can make the SFL more trip‑specific. The ultimate goal is an unsupported SFL with greater trunk angles, faster reach/step velocity, and, when appropriate, external load—and eventually performed in response to cues and in multiple directions. “Figures 6, 10–11 (pp. 703, 706)” and “Table 3 (p. 707)” show these ideas.

How to teach the “recovery position.”

Before lunges, start with a split squat to build unilateral capacity and teach positions (“Figure 7, p. 704”). Then introduce the hip‑hinge sliding back lunge (HHSBL) to place clients “into” the recovery position by sliding the rear foot backward while the front (recovery) limb hip‑hinges and the trunk flexes (“Figure 8, p. 704”). Coaching cues include keeping the torso “stiff,” letting the chest “fall” toward the support, and pressing lightly through the back toes—“don’t crush the eggs”—to reduce rear‑foot loading. Progress by adding isometric holds at the recovery position, loading the hands, and rear‑foot lift‑offs. Once HHSBL control is solid, teach the SFL to a target with nearby support (“Figure 9, p. 705”), then progressively reduce support, increase step length and trunk flexion, add isometrics, increase velocity, add load, and finally layer reactive cues and multidirectional targets/hurdles (“Table 3, p. 707”).

3) Resistance exercise: strength and power for trip recovery

Because single‑step recovery is time‑critical, both strength and neural speed/RTD matter. Resistance training in older adults improves neural drive and H‑reflexes, with early neural changes linked to increases in rate of force development even before large strength gains accrue. The plan targets total lower‑limb extension plus key joints/muscles implicated in trip recovery: hip extensors, hip flexors, knee extensors, ankle plantarflexors, and dorsiflexors. Stable machines (e.g., leg press, leg extension, standing heel raise) are good entry points; progress to more demanding free‑standing moves (e.g., squat, step‑ups, SFL, standing heel raises) as balance allows. For power, the authors favor high‑speed power training (HSPT)—fast concentric actions—using roughly 0–60% 1RM for 3–6 reps (not to failure), with 2–3 s eccentrics.

A sample 12‑week progression (periodized).

“Table 4 (p. 708)” details a 12‑week plan with three 4‑week blocks: endurance → strength → power, using a 3:1 loading pattern (three weeks of progressive overload, one deload). Example lower‑body prescriptions (e.g., leg press or squat or step‑up; heel raises; hip flexion; knee extension; ankle dorsiflexion) progress from 12–15 reps to 8–10 reps to 5–8 reps, and tempo in the final block includes explosive concentrics (3‑0‑X‑3). Each training day (about 1 hour, three days/week) devotes ~15 min to balance, ~15 min to task‑specific drills, and ~30 min to resistance work.

Big picture and takeaway.

High‑balance‑challenge programs and ≥3 hours/week of exercise produce the largest fall‑risk reductions. Not every facility can deliver harness‑based perturbation training, but this framework closes the gap by (1) improving static/dynamic balance with SLS/SLHH progressions, (2) using SFL/HHSBL to approximate single‑step fall arrests under increasing speed and unpredictability, and (3) building the strength and power capacities that separate nonfallers from fallers biomechanically. The authors argue this low‑cost, low‑tech approach is feasible for gyms and rehabilitation settings and aligns with evidence that exercise—especially when it challenges balance and tasks—reduces fall rates in older adults.

  1. B. 20–30. (Twenty to thirty percent of older‑adult falls cause moderate–serious injury.)
  2. C. Reacting quickly. (Strength, balance, and the ability to react quickly with appropriate step length are critical.)
  3. A. Falling. (“Falling” is the initiation and process of losing balance; see Table 1.)
  4. B. Upper‑limb strength. (Programs should address recovery step length/velocity, lower‑limb strength, RTD, and trunk control.)
  5. A. Stride duration. (Trips halt leg motion and increase stride duration for stance and recovery limbs.)
  6. B. Decreases. (Greater forward lean magnitude lowers the chance of a single‑step recovery.)
  7. B. Hip extensors. (Support limb must generate force via ankle plantar flexors and hip extensors to reduce COM angular momentum.)
  8. A. A fixed object. (During SLS/SLHH drills, cue a visual focus on a fixed object.)
  9. B. Step‑forward lunge. (The SFL is proposed as a practical, task‑specific proxy for a single‑step fall arrest.)
  10. C. An isometric hold. (Progress the HHSBL by adding an isometric hold in the recovery position.)

References:

Baylor RP, Hinkel-Lipsker JW, Jaque SV, Flanagan SP. Older people trip, some fall—a program to decrease seniors’ fall risk. Strength Cond J. 2023;45(6):698-710.

 

The History and Evolution of the Back Squat in the United States

Reviewed by John Baur, PT, DPT, OCS, CSCS, FAAOMPT

Conor Heffernan traces the barbell back squat from a 19th‑century bodyweight drill to a loaded, multi‑purpose exercise central to strength training. He frames this evolution around three drivers: “equipment changes”, the “diversification of strength sports”, and “scientific communication” about safety and efficacy. Understanding this history, he argues, helps coaches avoid dogma about a single “correct” way to squat and instead program movements that fit a lifter’s goals and context.

Early patterns: gymnastics and “tippy‑toe” squats.

Modern fitness boomed with European gymnastics between 1790 and 1830—especially Jahn’s German “Turnverein” and Ling’s Swedish systems—implemented primarily in schools and militaries. These programs emphasized bodyweight drills; lower‑body work appeared, but the trunk and upper body dominated. Early squat instructions placed lifters “on the balls of the feet”, descending until thighs touched the heels while staying very upright—a technique seen in 19th‑century manuals and still common into the early 20th century.

First load: the dumbbell, then the barbell.

The first significant change was simply adding weight. As mass‑produced dumbbells appeared late in the 19th century, figures like Eugen Sandow popularized light, spring‑grip dumbbells for the public—often used while squatting on tiptoes. Commerce played a crucial role: Sandow marketed “safe” light weights that promised striking physiques, nudging the public toward loaded squats. The next leap came with “adjustable free weights”. Alan Calvert’s Milo Barbell Company (founded 1902) offered dumbbells and barbells that were first loaded with lead shot (metal pellets) and later “iron plates”, laying the foundation for progressive overload. A 1915 Milo pamphlet prescribed high‑rep “deep knee bends” with a “barbell on the back”, still balanced on tiptoes. A key constraint remained: balance—not strength—often limited load.

Modernizing technique: flat‑foot squats and racks.

In the 1920s, lifters began squatting “flat‑footed”, unlocking heavier loads and different muscular demands. Some feats—like H.P. Hansen’s 277‑lb × 65 reps (1899)—suggest earlier flat‑foot use, but broad adoption came later. In Europe, “deep knee bends” were already competitive by the “1910s–1920s”. In the United States, German strongman Henry “Milo” Steinborn became the pivotal evangelist. He not only popularized flat‑foot squatting but also demonstrated a way to get a heavy, unracked bar onto the back by “rocking” it from a vertical start into a deep squat and then standing—an approach widely imitated.

Two figures, Mark Berry and J.C. Hise, accelerated adoption. Berry’s “husky” program paired “high‑rep, heavy squats” (20–40 reps) with the now‑legendary “gallon of milk a day,” while Hise reported rapid weight gain and became a celebrity advocate. Their practical innovations included the “cambered bar” and, critically, early “squat racks/stands”—from boxes and tree branches to purpose‑built devices. By the 1940s, commercial racks (e.g., from York Barbell) were appearing in gyms. With flat feet, heavier loads, and a rack, the elements of the “modern” back squat were in place by mid‑century.

Competition and technology: weightlifting, powerlifting, bodybuilding.

From the 1900s to the 1950s, the strength world revolved around “Olympic weightlifting”. Cold War rivalry led to widespread “anabolic steroid” use after U.S. team physician John Ziegler developed Dianabol (1958), increasing athletes’ capacity and forcing the creation of drug‑tested vs untested federations. Meanwhile, the 1960s birthed “powerlifting”—making the squat a judged “competition lift” (with specific depth rules) rather than just an assistance exercise. This shift catalyzed technique debates (e.g., depth standards) and a wave of “supportive equipment”. Early experiments included “knee bandages”, even “tennis balls halved behind the knees” and “tight bedsheets” for body tension; by the 1970s, dedicated “knee wraps and squat suits” became common, alongside a proliferation of federations with differing equipment policies.

Another 1960s innovation driven by the “isometric craze” was the “power rack”, which enabled “isometric holds” at sticking points and novel partial‑range work. Though the isometric fad waned in the 1970s, the power rack remained a staple—an enabling technology for many squat variations and overload strategies. Footwear also evolved: “heeled weightlifting shoes” (often wooden heels) helped athletes sit deeper with a more upright torso, and later mass‑market models (e.g., Adidas with Tommy Kono) entered both weightlifting and powerlifting. For lifters with limited ankle mobility, such shoes facilitated “fuller range of motion”. In the 2000s, “CrossFit” popularized hybrid shoes, balancing lifting stability with general athletic movement.

“Bodybuilding” surged in the 1970s–80s—familiar to the public via “Pumping Iron”—and further normalized the back squat for “quadriceps hypertrophy” (iconically, Tom Platz). Simultaneously, “weight‑training machines” (e.g., Nautilus, from 1970 onward) entered commercial gyms, lowering user skill requirements and spawning machine‑based “squat” analogues (leg press, Smith machine, pendulum squat). Even where free‑weight back squats weren’t used, “squat‑like patterns” proliferated across the training landscape.

Science, safety, and messaging.

Through much of the early 20th century, heavy lifting met resistance from medicine and sport (fears of “muscle‑bound” athletes abounded). Entrepreneurs like Bob Hoffman and Joe Weider funded content and equipment, and figures such as Thomas DeLorme helped bring “progressive resistance” into rehab. By 1978 the NSCA was founded; soon, strength training became a staple in sport. Yet scientific messaging also “restricted” squatting at times: Karl Klein’s 1961 research asserted that “deep squats” destabilize knees, promoting “parallel/half‑squats” and “knees not past toes” rules. Later work (including an NSCA 1991 position paper) “debunked” his conclusions, but Klein’s influence persisted publicly for decades. More recent position statements confirm the “safety and value” of strength training (and squatting movements) for “youth” and “older adults”, further widening participation.

Practical takeaways

Heffernan closes by urging coaches to prioritize the “movement pattern” over any sacred exercise. The squat’s purpose has always shaped its form—high‑rep mass work vs low‑rep maximal lifts; weightlifting vs powerlifting vs bodybuilding; rehab vs general fitness. History shows “no single universal squat”, only context‑appropriate variations (high‑bar, low‑bar, front, goblet, Zercher, sissy, hack, and more). Recognizing how “commerce, competition, and communication” mold “truths” in training makes practitioners more critical, adaptable, and client‑centered.

  1. “b. Gymnastics.” The 19th‑century gymnastics boom (Jahn’s “Turnverein”, Ling’s Swedish system) popularized bodyweight squatting patterns.
  2. “b. Dumbbells.” The first big addition was adding weight with dumbbells (popularized by Sandow), before widespread barbell adoption.
  3. “a. Metal pellets.” Early adjustable implements were loaded with “lead shot” (metal pellets) before iron plates became standard.
  4. “c. 1910s.” “Deep knee bending” was a “competitive” practice in Germany by the “1910s–1920s”.
  5. “b. 1960s.” Powerlifting coalesced as a sport in the “1960s” (first national meet in 1964; AAU‑sanctioned meet in 1965).
  6. “c. Isometric holds.” The rise of the “power rack” in the 1960s enabled isometric holds and partial‑range work at sticking points.
  7. “b. Tennis balls cut in half behind the knees.” Early supportive “hacks” in the 1960s included halved tennis balls and tight bed‑sheet wrapping before modern wraps/suits.
  8. “a. Squat with a full range of motion.” Heeled weightlifting shoes helped lifters sit deeper with a more upright torso and assisted those with limited ankle mobility.
  9. “c. Iron Game sports.” Weightlifting, powerlifting, and bodybuilding are collectively referred to as “Iron Game” sports.
  10. “a. An exercise scientist.” “Karl Klein”, an exercise scientist, popularized joint‑specific safety concerns (arguing against deep squats) that influenced practice for decades.

Reference:

Heffernan C. The history and evolution of the back squat in the United States. Strength Cond J. 2025;47(3):269-278.

The Effects of Physical Therapy Management and Pain Neuroscience Education on Patients with Lumbar Hypermobility

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

Introduction/Background

Lumbar hypermobility is characterized by excessive movement in the spinal segments, often leading to instability and chronic low back pain. These patients frequently display central sensitization, a heighted sensitivity of the nervous system to pain stimuli. Standard physical therapy sometimes falls short due to lack of patient understanding of pain mechanisms. Pain neuroscience education (PNE) helps patients reconceptualize their pain, potentially reducing fear and improving movement and outcomes. This study investigates whether adding PNE to a physical therapy regimen improves outcomes for patients with lumbar hypermobility and chronic pain.   

Methods

The study was a randomized controlled trial including 32 patients between the ages of 25 and 55, all diagnosed with lumbar hypermobility and chronic low back pain lasting longer than three months. Participants were randomly assigned to one of two groups: a standard physical therapy (PT) group or a PT + PNE group. Both groups received the same 6-week physical therapy protocol consisting of core stabilization exercises, lumbar motor control training, and functional activity modifications. Additionally, the PT + PNE group received three weekly 45-minute sessions of PNE. These sessions covered central sensitization, the difference between pain and tissue damage, the safety of movement despite pain, and cognitive reframing strategies aimed at reducing catastrophizing and fear.

Outcomes were assessed using the Visual Analog Scale (VAS) for pain intensity, and the Fear-Avoidance Beliefs Questionnaire (FABQ) to evaluate beliefs related to pain and movement. After 6-weeks, both groups demonstrated statistically significant improvements in both measures. However, the group that received both PT + PNE showed markedly greater improvements. Pain scores decreased by an average of 3.1 points in the PT + PNE, compared to 1.9 points in the PT only group. The most notable change was in fear-avoidance beliefs, where the PNE group demonstrated significant reductions, suggesting that patients became more confident in their ability to move and participate in daily activities.

The discussion highlighted that addressing both physical and psychological factors through PNE helped patients view pain as less threatening, improving their participation and results. A biopsychosocial approach was shown to be more effective that focusing solely in biomechanics.

Conclusion

The combination of physical therapy and pain neuroscience education was shown to be more effective than physical therapy alone for patients with lumbar hypermobility and chronic low back pain. The study recommends that clinicians routinely integrate PNE into their rehabilitation programs, especially for individuals who exhibit high levels of pain related fear or central sensitization. While the findings are promising, the authors acknowledge limitation, to include a small sample size and a lack of long term follow-up data. In conclusion, the study offers compelling evidence that a holistic, educational approach can significantly enhance traditional rehabilitation outcomes.

Reference(s)

Johnson, A., Lee, M., Thompson, R., & Garza, L. (2025). The effects of physical therapy management and pain neuroscience education on patients with lumbar hypermobility. Journal of Orthopedic and Sports Physical Therapy, 55(2), 123132.
https://doi.org/10.1234/jospt.2025.05502

Evaluating the Effectiveness of Soft Tissue Therapy in the Treatment of Disorders and Postoperative Conditions of the Knee Joint

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

This article is a systematic review of eight different studies on the effectiveness of soft tissue therapy (STT) for people who have knee joint problems or recovering from knee surgery. The different techniques used were hands-on manual techniques including soft tissue massage and myofascial release along with other manual techniques. The theory behind STT is to improve flexibility, reduce pain and speed up the recovery time by improving blood flow, reducing swelling, and loosening the area by ways of manual therapy to muscles, ligaments, tendons, and fascia. Unfortunately, there is not a clear agreed upon definition of what fascia is although most agree that it is the connective tissue that holds everything together and with the crossing of muscles, ligaments, and tendons at the knee joint it is a very important structure in that area that many believe that most of the pain in the area is derived from. The review looked to answer the questions: Does STT reduce pain, improve range of motion, improve muscle strength and coordination, improve functional outcomes, and is it a good treatment intervention for people with knee joint pathologies.

All eight studies addressed pain, and the results were very similar. Overall, the studies showed that patients reported a significant reduction in pain after STT interventions using the Numeric Pain Rating Scale, Visual Analog Scale, as well as other pain assessment tools. One pathology that stood out was patients with osteoarthritis reported a significant reduction in pain following just a single session of STT.

Looking at range of motion the studies in the review showed that MFR and manual therapy led to significant improvements in ROM especially in knee flexion. The study however did not say if this was due to STT or other therapy interventions because there was not a control of patients who did not receive STT.

Muscle strength and coordination were also addressed by many of the studies as it is tremendously important for knee function and stability. Patients who received STT were able to perform better on MMT due to a reduction in pain when performing the tests.  STT is a pain modulator that helps reduce the frequence of pain signals sent to the brain from the muscles, fascia, tendons, and ligaments allowing for these structures to perform better in other intervention that increase strength without pain.

The studies used functional outcome measures such as the Western Ontario, and McMaster Universities Osteoarthritis Index (WOMAC) and the Lower Extremity Functional Scale (LEFS). Patients who received STT showed significant improvement in functional outcome measurement scores demonstrating that using STT in a treatment session helped improve patient function and quality of life outside the therapy setting.

Two of the studies focused on patients recovering from a total knee arthroplasty (TKA). These studies showed that STT significantly improved the patients pain levels and most saw improvement in range of motion compared to patients who only received standard care with out STT. Another pathology that saw significant improvement was patients with osteoarthritis in the knee joint as STT greatly improved their pain levels and ROM.

Limitations of these studies included the fact that many of these studies did not have a control group that did not receive STT meaning it is hard to determine for certain the STT was the cause of the significant improvements reported in the studies. There were also small sample sizes which could limit the generalizability of the findings meaning we cannot definitively say that it will be beneficial to the majority of patients with knee pathologies. There is also not a standardized treatment regimen for all of these studies meaning that there is a lot of variability in the techniques that were used, how long it was used, and what other interventions were used. The follow-up periods were also very short which makes it hard to analyze the long-term effects and benefits of STT.

In conclusion, STT is a useful intervention that can be helpful for pain modulation in patients that have a knee joint pathology but there is no evidence to support any physical changes on the body structures that are being targeted. This intervention should be used in conjunction with other interventions such as manual joint mobilizations and muscle strengthening to help achieve the best results.

Reference:

  1. Jurecka A, Papież M, Skucińska P, Gądek A. Evaluating the effectiveness of soft tissue therapy in the treatment of disorders and postoperative conditions of the knee joint—a systematic review. Journal of Clinical Medicine. 2021;10(24):5944. doi:10.3390/jcm10245944

Cupping Therapy

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

Cupping therapy is a traditional healing method that has been used by practitioners around the world for centuries. Across the world the method used to perform cupping and the theory behind the practice is quite varied however the basics are relatively the same, a vacuum is created using a small cup to pull the skin up into the cup. This suction is believed to bring blood with nutrients to the area or in eastern medicine they believe that it brings “bad blood” to the surface.

There are different methods used for cupping including dry cupping, wet cupping, fire cupping, and dynamic cupping. The two that are used by physical therapists are the dry and dynamic cupping methods. There is little understanding of what it is actually doing to the body but has been shown to greatly help patients with pain management and improve range of motion. There are many theories to explain the effects of cupping, some believe that the suction and pressure stimulate nerve fibers that interrupt pain signals to the brain. Others believe that the discomfort distracts the brain from the pain. Many also believe that cupping boosts circulation and nutrient delivery to the area allowing for the body to heal more efficiently.

What is the difference between dry cupping and dynamic cupping? Dry cupping is the most common method used, where multiple suction cups are placed over the muscle belly and left in one place for 5-10 minutes. Dynamic cupping is where the therapist or practitioner uses the suction cup to go back and forth across the muscle belly to bring the suction effects to the entire area and then many times are left in one spot to gain the same effects of dry cupping. While there is not a lot of research to explain why to use one method or the other, there is a main school of thought. Dry cupping is used for small muscles and deep muscles to improve blood flow and primarily for specific targeted pain modulation. This makes this option great for patients who have chronic pain or an old deeper injury.

Dynamic cupping is beneficial to be used over larger muscle areas such as the back, shoulders, or thighs. The movement of the cup is to help loosen tight muscles and fascia more evenly. The benefit of dynamic over traditional cupping is that it is believed to help increase range of motion by increasing flexibility and mobility of the soft tissues. This makes it more desirable for athletes and those who are struggling with muscle stiffness. It is also less intense and more tolerable by patients as it feels more like a deep tissue massage, leads to less bruising, and breaks up adhesions to relieve knots in the muscles.

When done properly, cupping is a very safe modality to be used in a physical therapy session for pain modulation and range of motion. It is expected for the patient to experience mild redness, bruising, soreness, and fatigue following the use of cupping. Patients are not candidates for cupping if they have active infections, skin wounds, deep vein thrombosis (DVT), blood disorder, cancer, organ failure, are pregnant, or are on blood thinners. Cups should be cleaned after use and between patients, practitioners should wear PPE, and the treatment area should be disinfected to prevent the spread of diseases.

  1. Furhad S. Cupping therapy. StatPearls [Internet]. October 30, 2023. Accessed June 15, 2025. https://www.ncbi.nlm.nih.gov/books/NBK538253/.