INTRODUCTION
The gluteal muscles are arguably the most important muscles for runners in terms of strength and activation. The gluteal muscles consist of the gluteus maximus, gluteus medius, and gluteus minimus. These muscles work as a group to prevent femoral adduction and internal rotation, which have been linked to an increased risk of injury in the early stance phase of running. Weakness or dysfunction of the gluteal muscles in runners has been shown to contribute to many musculoskeletal disorders including low back pain, patellofemoral pain syndrome, and iliotibial band syndrome, to name a few.
The authors in a recent study, Comparative Analysis of Hip Muscle Activation During Closed-Chain Rehabilitation Exercises in Runners, looked at the effectiveness of three rehabilitation exercises (bilateral hip external rotation, forward lunge, and single leg squat) designed to stimulate the demands of the gluteals during running. The authors hypothesized there would be greater gluteal activation during the forward lunge compared to bilateral external rotation and single leg stand seeing as that exercise was the most similar to running.

METHODS
Twenty-two healthy runners performed three gluteal strengthening exercises while electrodes recorded peak amplitude of muscle activity. The researchers measured the peak amplitude of muscle activation during the concentric (muscle shortening) and eccentric (muscle lengthening) phases of the exercises and compared it to the runners’ peak muscle activation during the stance phase of running.

CONCLUSION
All three of the exercises showed the same peak amplitude during the eccentric phase. The bilateral external rotation elicited significantly reduced amplitude than the squat and lunge activity during the concentric phase of the exercise. The exercises investigated in this study were less than 70% of the peak activation levels obtained with running.

CLINICAL GUIDELINES
Because of the high prevalence of running-related injuries, and the potential of gluteal strengthening and activation in reducing these injuries, it is important to identify exercises which activate these muscles similarly to how they are used in runners. This was one of the first studies observing muscle activity during functional exercises. Although none of the exercises investigated in this study approached the peak activation levels obtained with running, the results indicate that the forward lunge with resistance band and single leg stand were superior to the bilateral external rotation exercise for concentric activation of the gluteus maximus and medius.
In theory, a progression of these exercises from clamshell to single leg rotational squat, to forward lunge could be beneficial in activating and strengthening gluteal muscles in a runner. More research is needed to identify different functional activities specific to runners.

PHYSICAL THERAPY FIRST IMPLICATIONS
Similar exercises as those measured in the study are common for physical therapists to give as part of an individualized home exercise program. Our team continues to stay up to date on the latest research in order to provide our clients with an evidence-based approach to therapy. The exercises measured in the study successfully activated the gluteals in an eccentric manner and thus performing these regularly could help to decrease a runner’s risk for developing a running-related injury.

FUNCTIONAL EXERCISE PROGRESSION FOR GLUTEAL STRENGTHENING IN RUNNERS
1. Bilateral Clamshell

2. Single-leg rotational squat

3. Lunge with Resistance Band

REFERENCE
Connelly, Chrostopher., Moran, Matthew., Grimes, Jason (2020). Comparative Analysis of Hip Muscle Activation During Closed-Chain Rehabilitation Exercises in Runners. International Journal of Sports Physical Therapy. Vol 15, Number 2: 229-237

INTRODUCTION
Patellofemoral pain syndrome (PFPS) is a common source of knee pain in the physically active population and one that we treat at Physical Therapy First regularly. PFPS occurs more in females than males with a ratio of 2:1. This syndrome presents as pain in the anterior part of the knee, around the kneecap, and can occur on one or both sides of the body. It is commonly an overuse injury and has been linked to impairments of the quadriceps muscle. In the study Hip Strengthening Prior to Functional Exercise Reduces Pain Sooner Than Quadriceps Strengthening in Females with Patellofemoral Pain Syndrome: A Randomized Clinical Trial, the authors address the hypothesis of early proximal hip strengthening versus quadriceps strengthening for the treatment of PFPS.

METHODS
Thirty-three women with unilateral or bilateral patellar pain were included in the study and given the visual analog scale (VAS) as a pain scale and the Lower Extremity Functional Scale (LEFS) as a measure of function. Objective measures including isometric hip abduction, hip external rotation, and knee extension were taken using a hand held dynamometer. Functional strength was also assessed using an anterior step-down test for the number of repetitions in a 30 second period of time.

Participants were divided into hip or quadriceps strengthening program and performed rehabilitation exercises three times a week for four weeks in addition to a common stretching program. Both groups then performed the same exercises for weeks four through eight which focused on functional weight-bearing and balance training.

After the eight weeks of training, participants were given the VAS and LEFS and their strength was re-measured.

RESULTS
The results showed significantly less pain in the hip strengthening group compared to the quadriceps group at four weeks as reported on the VAS. Pain scores at four and eight weeks were significantly lower than baseline scores in the hip group. Scores for the quadriceps group were significantly lower at the eight-week time point but not at the four-week point compared to baseline.

Both groups significantly improved on the forward step-down test. Hip abduction strength significantly increased in the hip group from weeks zero to eight but not in the quadriceps group. Hip external rotation strength increased over the 8-week period in both groups. Knee extensor strength did not improve in either group over time.

DISCUSSION
The purpose of this study was to compare initial hip strengthening to initial quadriceps strengthening in the treatment of females with PFPS. It was hypothesized that rehabilitation initially focusing on isolated hip strengthening would result in less pain, more strength and function, and better preparation for functional exercises than initial quadriceps strengthening. While both groups experienced similar overall increased strength and function, the hip group reported less pain than the quadriceps group after the first four weeks of rehabilitation.

The most significant finding of the study was the decreased pain reported at week four in the hip strengthening group, which decreased by 43%. Both hip and quadriceps strengthening led to increased function over time as measured by the forward step-down test.

The authors found it interesting that there were no improvements in quadriceps strength in this group. The authors proposed this finding could be due to pain preventing adequate muscle activation.

LIMITATIONS
One limitation in this study includes the varying amount of pain reported by the participants; some had minimal pain with activity and others had a higher degree which severely limited their function. Additionally, the study only looked at women and was only performed for an 8-week time period so it cannot be generalized to men with this syndrome or show long term effects

CONCLUSIONS AND PTF IMPLICATIONS
The main conclusion in this article shows that focusing on a proximal hip strengthening program is more efficient in decreasing pain and increasing hip strength than quadriceps strengthening program in the treatment of PFPS.

PFPS is a diagnosis that we commonly see at Physical Therapy First and our therapists are able to create an individualized treatment program which includes proximal hip strengthening for the treatment of patellar pain.

Dolak, K., Silkman, C., Medina McKeon, J., Hosey, R., Latterman, C., Uhl, Timothy (2011). Hip Strengthening Prior to Functional Exercises Reduces Pain Sooner Than Quadriceps Strengthening in Females With Patellofemoral Pain Syndrome: A Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy: Vol 41, 8: 561-570.

BACKGROUND:
A concussion is a type of traumatic brain injury caused by a bump, blow or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to move in the skull, creating chemical changes and sometimes stretching or damaging brain cells. Concussions are a common sports injury and most people recover in 7-10 days, but some continue to have persistent symptoms. Two of the most frequently reported symptoms are headache and dizziness, followed closely by nausea and neck pain. Cervical spine trauma may cause prolonged post-concussion headaches. Upper cervical spine dysfunction can cause cervicogenic headaches while dizziness and balance deficits may be due to dysfunction of the vestibular, proprioceptive or central system.

PARTICIPANTS:
29 participants total
-14 participants in the control group
-15 participants in the treatment group

METHODS:
The participants were randomly allocated to the control group or the treatment group. Participants attended physical therapy once per week for 8 weeks. Both groups performed non-provocative range of motion exercises, stretching and postural education by the same physical therapist. Then the intervention group was instructed by another physical therapist for a combination of cervical spine physical therapy and vestibular rehabilitation. The primary outcome measure was number of days from treatment initiation until medical clearance to return to sport.

RESULTS:
Eleven of the 15 participants in the treatment group were medically cleared to return to sport within 8 weeks of treatment. Only 1 of the 14 participants in the control group was medically cleared to return to sport within 8 weeks of treatment. Individuals in the treatment group were 10.27 times more likely to be medically cleared to return to sport as compared to the control group.

CLINICAL APPLICATION:
Here at PTF we will complete a thorough evaluation to determine the origin of the symptoms each patient is experiencing. We will then create a comprehensive treatment plan based on our findings and each patient’s goals. In patients with post-concussion symptoms, we will work to combine cervical spine treatment with vestibular rehabilitation which may facilitate recover and decrease time lost from sports.

ORIGINAL ARTICLE:
Schneider, K. J., Meeuwisse, W. H., Nettel-Aguirre, A., Barlow, K., Boyd, L., Kang, J., & Emery, C. A. (2014, September). Cervicovestibular rehabilitation in sport-related concussion: a randomized controlled trial. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24855132

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.