Friday, April 23, 2010
90 Seconds or less to Bond: skills of social engagement
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A bit ago i wrote about how Robert Sapolsky's Why Zebras Don't Get Ulcers
describes a rich variety
of animal case studies of coping with stress in these creatures natural habitats. A biggie of stress seen among our non-human kindred is the effect on longevity and quality of life. A key factor in bringing down stress and increasing longevity? Good socialization. After looking at Sapolsky's work it became clear that the research i do on well-being which had been focusing on nutrition, movement and rest/recovery needed to add in socialisation. But how?
In nutrition, movement and recovery, i've been keenly aware that there are skills for each of these practices, and i've spent some time researching, practicing and writing about some of them. Socialization has been a bit of a mystery, though. What skills would one even look for? We're not talking about etiquette, but about how to connect and play nice with others. Thumbing through the material for the various management and leadership courses i'd been on didn't percolate up anything about basic human engagement. In coaching, the closest thing seemed to be motivational interviewing, but that's not developing peer-to-peer encounter skills.
And then, it - or at least a partial it - happened. I came across this fabulously concise (audio) book: how to make people like you in 90 seconds or less by Nicholas Boothman (uk cd | uk book|| us book
| us cd
).
In this wee book, Boothman presents a suite of skills to help us connect with people. These skills start before the first hello, such that the work of those 90 initial seconds (or less) in someone's company are richly prepared for optimal success.
The title sounds rather flakey, but in actual fact the skills are well founded in concepts like neural linguistic programming. That practice too sounds a little daunting as a controversial area of psychotherapy from the same era as TM. But whether one accepts the entire NLP package or not, the very pragmatic and specific application of it to human close encounters is both easy to grasp and to test with this simple question: do these techniques enable me to engage with other people more of the time and more successfully in more situations? For an introvert like myself, trying to add this Fourth Front of WellBeing to my skill set, believe me, this stuff has to be pretty robust if it's going to work. And it does seem to be helping.
Boothman sets up a handful of concepts, from introduction approaches, to paying attention to the kind of language another uses (visual, auditory, kinesthetic) in order to successfully and quickly get on to that other person's wavelength.
Some of the techniques in the book will likely sound like simple politeness: be aware of cues from one person's conversation of where they want to go rather than pushing our own agenda/interests first. Other skills are more subtle: learn what to watch in body language cues for openness and engagement and where the body language matches words spoken - or does not.
And that's really it seems what these skills are mainly about: how attend with intent to an other in order to enable that person to feel comfortable. This comfort is achieved by having so modulating oneself to be on that other person's wavelenght that they feel safe, at home, we're sufficiently the same to share this exchange.
I'm looking forward to finding other books that map out more skills in the socializing space, but it seems remarkably appropriate that the first source that seems to fall into my hands (or ipod) is about these first steps to Making Contact.
If you too might like to improve the quality of your contact with Others, then i'd recommend this wee tome or cd set. Tweet Follow @begin2dig
A bit ago i wrote about how Robert Sapolsky's Why Zebras Don't Get Ulcers describes a rich variety of animal case studies of coping with stress in these creatures natural habitats. A biggie of stress seen among our non-human kindred is the effect on longevity and quality of life. A key factor in bringing down stress and increasing longevity? Good socialization. After looking at Sapolsky's work it became clear that the research i do on well-being which had been focusing on nutrition, movement and rest/recovery needed to add in socialisation. But how?In nutrition, movement and recovery, i've been keenly aware that there are skills for each of these practices, and i've spent some time researching, practicing and writing about some of them. Socialization has been a bit of a mystery, though. What skills would one even look for? We're not talking about etiquette, but about how to connect and play nice with others. Thumbing through the material for the various management and leadership courses i'd been on didn't percolate up anything about basic human engagement. In coaching, the closest thing seemed to be motivational interviewing, but that's not developing peer-to-peer encounter skills.
And then, it - or at least a partial it - happened. I came across this fabulously concise (audio) book: how to make people like you in 90 seconds or less by Nicholas Boothman (uk cd | uk book|| us book | us cd).In this wee book, Boothman presents a suite of skills to help us connect with people. These skills start before the first hello, such that the work of those 90 initial seconds (or less) in someone's company are richly prepared for optimal success.
The title sounds rather flakey, but in actual fact the skills are well founded in concepts like neural linguistic programming. That practice too sounds a little daunting as a controversial area of psychotherapy from the same era as TM. But whether one accepts the entire NLP package or not, the very pragmatic and specific application of it to human close encounters is both easy to grasp and to test with this simple question: do these techniques enable me to engage with other people more of the time and more successfully in more situations? For an introvert like myself, trying to add this Fourth Front of WellBeing to my skill set, believe me, this stuff has to be pretty robust if it's going to work. And it does seem to be helping.
Boothman sets up a handful of concepts, from introduction approaches, to paying attention to the kind of language another uses (visual, auditory, kinesthetic) in order to successfully and quickly get on to that other person's wavelength.
Some of the techniques in the book will likely sound like simple politeness: be aware of cues from one person's conversation of where they want to go rather than pushing our own agenda/interests first. Other skills are more subtle: learn what to watch in body language cues for openness and engagement and where the body language matches words spoken - or does not.
And that's really it seems what these skills are mainly about: how attend with intent to an other in order to enable that person to feel comfortable. This comfort is achieved by having so modulating oneself to be on that other person's wavelenght that they feel safe, at home, we're sufficiently the same to share this exchange.
I'm looking forward to finding other books that map out more skills in the socializing space, but it seems remarkably appropriate that the first source that seems to fall into my hands (or ipod) is about these first steps to Making Contact.
If you too might like to improve the quality of your contact with Others, then i'd recommend this wee tome or cd set. Tweet Follow @begin2dig
PDF
Thursday, April 22, 2010
Eccentric Exercise - some cool ideas as to why it seems to heal certain tendinopathies (ps, ditch -itis and -osis)
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Have you been suffering with some kind of sore tendon/jointy pain? Rotator cuff area, achiles, elbow, forearm, rsi etc etc? Guess what? First we're not alone, but second, just about anything that's been tried to address it has no real evidence to support it working, especially over time. Indeed, as the authors of a 2009 review study put it, "Tendinopathy is common although pathology of this condition is poorly understood." In other words, we don't really know how this dis-ease works. The point of this article is to consider why, as these authors see it, Eccentric Exercise (EE) which has seemed to have some good, some neutral results in research, may actually be successfully addressing the effects of that pathology. So much so, that it gets rated as a good "conservative" therapy for these kinds of common, awful and sometimes career ending, painful problems.
By way of context, in 2008, the year before these authors proposed why EE might be useful, another group reviewed pretty much everything under the sun applied to tendinopathies, from NSAIDS to shock wave therapy (and anything else one's GP may recommend). THe paper has the remarkably useful title "Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon"
They write of these therapies:
It's almost as bad as the common cold: ubiquitous and no idea how to cure it.
By 2009, however, the UK group of scientists seems ready to say that EE is a good "conservative" treatment for tendinopathy. What's quite remarkable is why they're making this claim, and that's at the heart of this article.
Tendinopathy?
But first things first, just to be sure we're all on the same page, what is tendinopathy? Tendinopathy is the umbrella term that includes, among other considerations, tendinosis and tendinitis. As for the differences between these two, on a functional level, Mike Nelson puts it nicely:
Hence we circle back to the term tendinopathy to cover this not unusually mixed condition of perhaps some inflammation but in particular, "degeneration, weakness, tearing, and pain" Hence both osis (tears) and itis (inflammation) may neither be particularly pathologically accurate or diagnostically helpful. And so, tendinopathy is the new and more robust term for these conditions.
With that note in mind, let me also add that the following discussion is not meant to be a prescription of any course of action. Get yourself checked with your doctor before starting anything. In my own case i have been disappointed by the fact that the thing that has actually helped the most immediately has been taking NSAIDS - some inflammation, or -itis maybe?
After a month of other non-drug interventions, day one after finally breaking down and seeing the doc: bam - immediate reduction in the pain that was making putting on a jacket a painful experience. bugger. But ah ha, it ain't all better that's for sure. What to do next? My hope is that the following research may offer some insight into WHAT to do if not exactly how and when to do it.
Eccentric Exercise and Tendinopathy
The authors of "Eccentric exercises; why do they work, what are the problems and how can we improve them?" J D Rees, R L Wolman, A Wilson write in the abstract:
The body of the article focuses on Achilles tendinopathy (mid back of the leg - base of the calf muscles), Insertional Achilles tendinopathy (where the tendon inserts away from the calf muscles, down by the ankle where it attaches to the bone) , Patellar tendon (either side of the knee cap) in particular.
The authors' insight has been to look at where in the tendon the lesion is occuring. Is it where the tendon attaches to the bone or where it attaches to the muscle? The effects of EE in the small number of studies are all over the map, so it's hard to draw any conclusion except, it seems, that where the lesion is on the tendon seems to have a correlation between the degree to which EE will be successful. For insertional achilles, as opposed to "the main body" of the tendon, EE's not showing up as so great. With the paterllar tendons, while some studies have shown benefit, especially over CE or concentric, whether there's a difference around proximal or insertional hasn't been the focus of research in such a way as it's possible to make a distinction.
With respect to other tendinopathies - like forearms (RSI kinda stuff) and elbows, the authors write:
What are Eccentrics Doing?
Despite this rather promising but still arid, partial research landscape for EE and tendinopathy, the authors have some ideas about the mechanisms that may be at play in eccentric efforts
Another factor the authors consider is blood flow. When we see tendons illustrated in anatomy texts, they're usually white-ish. That's the lack of a whole lot of blood going through them. This limit is in no small part why tendons can take longer than just about anything else to heal. So improving blood flow to tendons - blood being a nutrient carrier - could seemingly be a big plus. The authors write
Where using the Force Mayn't Matter. All this is cool, but it doesn't explain WHY these effects are occuring from EE. In particular, something the scientists can conclude rather strongly from the work that's been carried out is that the magnitude of the force has nothing to do with it. So lifting a big weight, or lifting a lighter weight faster (F=M*A) isn't what's getting the job done.
The key question the authors ask is:
Frequency rather than Force. This is so cool - it sounds great too: that the sort of cycling on and off of the muscle (the sinusoidal loading and unloading) during the eccentric may be the biggie in stimulating that good collagen rebuilding in particular associated with EE and maybe the blood flow too. The other interesting part is that there is a possible parallel to bone remodelling here (and Woolf's law).
That is, as force is applied to a bone it will get bigger (the outer shell gets pushed out it seems, as the inner lace work architecture increases) and so stronger to respond to that demand. Davis's law on tissue seems a wee bit similar: "If soft tissue is placed under unremitting tension, the tissue will elongate by adding more material. "
Bottom line: the particular type of muscular demands to maintain control of a load in extension (force fluctuations not force magnitude) may play a particular role in remodeling tendons in these various opathies.
Whither, Voyager for Futuer EE / Tendinopathy Research?
The authors are now happy to say EE seems to have sufficient basis to be considered viable. Time to figure out how to optimize it. THey write in the Future Work section:
As an example of eccentric exercises that have been tried out among at least a small population of elbow-opathies, Mike T Nelson's developed some nice eccentrics work with a kettlebell. Well worth a look and a go.
What i've been working lately for my shoulder/painful arc thing:
Concludium
Perhaps the main take away from this summary of recent research reviews and primary work is that tendinitis vs osis is largely a non-starter; tendinopathy is where it's at. And saying that, the pathology or dis-ease of tendinopathy is not well understood, which may also explain why treatements - in particular long term ones - don't have much evidence to support their efficacy. There are some prospective treatements on the horizon, however, with eccentric exercise amongthem. This latest study on EE and tendinopathy seems to propose the best hypothesis so far as to why eccentric exercises is showing up as particularly effective for at least main body tendinopathy.
Citations:
Related Resources
Have you been suffering with some kind of sore tendon/jointy pain? Rotator cuff area, achiles, elbow, forearm, rsi etc etc? Guess what? First we're not alone, but second, just about anything that's been tried to address it has no real evidence to support it working, especially over time. Indeed, as the authors of a 2009 review study put it, "Tendinopathy is common although pathology of this condition is poorly understood." In other words, we don't really know how this dis-ease works. The point of this article is to consider why, as these authors see it, Eccentric Exercise (EE) which has seemed to have some good, some neutral results in research, may actually be successfully addressing the effects of that pathology. So much so, that it gets rated as a good "conservative" therapy for these kinds of common, awful and sometimes career ending, painful problems. By way of context, in 2008, the year before these authors proposed why EE might be useful, another group reviewed pretty much everything under the sun applied to tendinopathies, from NSAIDS to shock wave therapy (and anything else one's GP may recommend). THe paper has the remarkably useful title "Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon"
They write of these therapies:
Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear.
It's almost as bad as the common cold: ubiquitous and no idea how to cure it.
It's interesting that from that mix of "current data" strategies that look promising in the 2008 survey quoted above, the authors of the 2009 BJMS article are interested in eccentric exercises. In 2007, another group of researchers concluded a literature survey about Eccentric Exercise and chronic tendinopathy with the sad claim thatAside: And if you have a type of rotator cuff tendinopathy, and your doctor is suggesting a steroid shot? I'm motivated here as this is me. You may want to point that caregiver to this 2007 review of the lack of proven efficacy of this approach.
This systematic review of the available literature indicates that there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease.
the dearth of high‐quality research in support of the clinical effectiveness of EE over other treatments in the management of tendinopathies.In other words, good quality studies that would be taken as being say clinically significant are thin on the ground. They're not as rigerous as these scientists would like to see in the presciption of a protocol to treat something.
By 2009, however, the UK group of scientists seems ready to say that EE is a good "conservative" treatment for tendinopathy. What's quite remarkable is why they're making this claim, and that's at the heart of this article.
Tendinopathy?
But first things first, just to be sure we're all on the same page, what is tendinopathy? Tendinopathy is the umbrella term that includes, among other considerations, tendinosis and tendinitis. As for the differences between these two, on a functional level, Mike Nelson puts it nicely:
TendonITIS is normally from inflammation (itis). TendonOSIS is normally from messed up connective tissue.To get into a bit more detail, the intro to the 2008 survey is very helpful
Traditionally, pain in and around tendons associated with activity has been termed tendonitis. This terminology implies the pain associated with these conditions results from an inflammatory process. Not surprisingly, treatment modalities have mainly been aimed at controlling this inflammation. The mainstays of treatment have included rest, nonsteroidal antiinflammatory medications (NSAIDs), and periodic local corticosteroid injections.So for practitioners in the know, it seems the once-frequent diagnosis of "tendinitis" has gone down quite a bit - because inflammation may or may not be present, and when it is, may or may not be the main cause of pain. Also, there is an "imbalance" of protective/regenerative responses to overuse and pathological (diseease) responses. This is Mike's "messed up connective tissue."
There are two problems with this approach. First, several studies demonstrate little or no inflammation is actually present in tendons exposed to overuse [83, 96, 163]. Second, traditional treatment modalities aimed at modulating inflammation have had limited success in treating chronic, painful conditions arising from overuse of tendons. More recently, the term tendinopathy has been advocated to describe the variety of painful conditions that develop in and around tendons in response to overuse. Histopathologic changes associated with tendinopathy include degeneration and disorganization of collagen fibers, increased cellularity, and minimal inflammation [83, 163]. Macroscopic changes include tendon thickening, loss of mechanical properties, and pain [163]. Recent work demonstrates several changes occur in response to overuse including the production of matrix metalloproteinases (MMPs), tendon cell apoptosis, chondroid metaplasia of the tendon, and expression of protective factors such as insulin-like growth factor 1 (IGF-1) and nitric oxide synthetase (NOS) [10, 76, 93, 99, 154, 155, 174, 199]. Although many of these biochemical changes are pathologic and result in tendon degeneration, others appear beneficial or protective. Tendinopathy appears to result from an imbalance between the protective/regenerative changes and the pathologic responses that result from tendon overuse. The net result is tendon degeneration, weakness, tearing, and pain.
Hence we circle back to the term tendinopathy to cover this not unusually mixed condition of perhaps some inflammation but in particular, "degeneration, weakness, tearing, and pain" Hence both osis (tears) and itis (inflammation) may neither be particularly pathologically accurate or diagnostically helpful. And so, tendinopathy is the new and more robust term for these conditions.
With that note in mind, let me also add that the following discussion is not meant to be a prescription of any course of action. Get yourself checked with your doctor before starting anything. In my own case i have been disappointed by the fact that the thing that has actually helped the most immediately has been taking NSAIDS - some inflammation, or -itis maybe?
After a month of other non-drug interventions, day one after finally breaking down and seeing the doc: bam - immediate reduction in the pain that was making putting on a jacket a painful experience. bugger. But ah ha, it ain't all better that's for sure. What to do next? My hope is that the following research may offer some insight into WHAT to do if not exactly how and when to do it.
Eccentric Exercise and Tendinopathy
The authors of "Eccentric exercises; why do they work, what are the problems and how can we improve them?" J D Rees, R L Wolman, A Wilson write in the abstract:
Eccentric exercises (EE) have proved successful in the management of chronic tendinopathy, particularly of the Achilles and patellar tendons, where they have been shown to be effective in controlled trials. However, numerous questions regarding EE remain. The standard protocols are time-consuming and require very motivated patients. EE are effective in some tendinopathies but not others. Furthermore, the location of the lesion can have a profound effect on efficacy; for example, standard EE in insertional lesions of the Achilles are ineffective.So, the researchers are sitting with the 2007 surveyview that while there's some hints of promising evidence in the past about EE, it hasn't been super. They think that now, however, they have a better sense of what might be making it effective.
Until recently little was known of the effect of EE on tendinopathic tendons, although a greater understanding of this process is emerging. Additionally, recent in vivo evidence directly comparing eccentric and concentric exercises provides a possible explanation for the therapeutic benefit of EE. The challenge now is to make EE more effective. Suggestions on areas of future research are made.
The body of the article focuses on Achilles tendinopathy (mid back of the leg - base of the calf muscles), Insertional Achilles tendinopathy (where the tendon inserts away from the calf muscles, down by the ankle where it attaches to the bone) , Patellar tendon (either side of the knee cap) in particular. The authors' insight has been to look at where in the tendon the lesion is occuring. Is it where the tendon attaches to the bone or where it attaches to the muscle? The effects of EE in the small number of studies are all over the map, so it's hard to draw any conclusion except, it seems, that where the lesion is on the tendon seems to have a correlation between the degree to which EE will be successful. For insertional achilles, as opposed to "the main body" of the tendon, EE's not showing up as so great. With the paterllar tendons, while some studies have shown benefit, especially over CE or concentric, whether there's a difference around proximal or insertional hasn't been the focus of research in such a way as it's possible to make a distinction.
With respect to other tendinopathies - like forearms (RSI kinda stuff) and elbows, the authors write:
A small number of studies have examined the use of eccentric exercises in the management of tendinopathy of the lateral extensors of the forearms.26–28 There is some evidence suggestive of an increase in function using EE compared with ultrasound in the treatment of lateral extensor tendons,29 and a recent study adopted an isokinetic eccentric protocol in the management of lateral elbow tendinosis and reported promising results.30 No randomised study on the effectiveness of EE on the rotator cuff has been published, although a small uncontrolled pilot study of nine patients did suggest a significant benefit of EE (patients with arthritis of the acromioclavicular joint or significant calcification were, however, excluded).31 Further trials on both tendinopathy of the rotator cuff and lateral extensor forearm tendons are required in order to evaluate EE more fully.Just my luck: shoulders with EE haven't been evaluated. Time to become an experiment of one.
What are Eccentrics Doing?
Despite this rather promising but still arid, partial research landscape for EE and tendinopathy, the authors have some ideas about the mechanisms that may be at play in eccentric efforts
The pathophysiology of tendon injury and healing is incompletely understood. It does appear, however, that in established tendinosis the tendon often does not progress into an active (or at least successful) healing cycle. EE may work by providing a mechanical stimulus to the quiescent tendon cellsThe authors propose several interesting ways in which this "mechanical stimulus" may work. The first is on that all important building block for tissue, collagen
Physical training in general has been shown to increase both the synthesis and degradation of collagen,39 and in the longer term this may lead to a net increase in collagen. Recently it has been recently elegantly demonstrated by Langberg and coworkers, by use of the microdialysis technique, that a chronically injured Achilles tendon responds to a 12 week EE programme by increasing the rate of collagen synthesis.40 In this study 12 patients (six with Achilles tendinosis and six normal controls) performed EE over a 12 week period. The EE group had increased collagen synthesis (peritendinous type I collagen) without a corresponding increase in collagen degradation. There was also a corresponding drop in pain levels (in line with other studies).That collagen production - to repair tendon degredation - is a huge and good deal. Especially that the exercise is not causing breakdown, but actual rebuilding.
Another factor the authors consider is blood flow. When we see tendons illustrated in anatomy texts, they're usually white-ish. That's the lack of a whole lot of blood going through them. This limit is in no small part why tendons can take longer than just about anything else to heal. So improving blood flow to tendons - blood being a nutrient carrier - could seemingly be a big plus. The authors write
The effect of EE on Achilles tendon microcirculation has also been studied. Achilles tendon oxygenation was not impaired by an EE programme but was accompanied by a decrease in postcapillary venous filling pressures, the authors suggesting that this reflects improved blood flow. Again this study looked only at eccentric exercise so it is not possible to determine whether this is a specific effect of EE.In other words, concentric exercise may have the same benefit on blood flow as eccentric exercise - we don't know - but what we do seem to know is that exercise (in the studied case, eccentric) keeps the blood moving, circulating rather than sitting somewhere. The anti pump? in a good way?
Where using the Force Mayn't Matter. All this is cool, but it doesn't explain WHY these effects are occuring from EE. In particular, something the scientists can conclude rather strongly from the work that's been carried out is that the magnitude of the force has nothing to do with it. So lifting a big weight, or lifting a lighter weight faster (F=M*A) isn't what's getting the job done.
The key question the authors ask is:
If the efficacy of EE cannot be explained by the magnitude of force, then what is responsible?Great Question. They have one very intersting finding about eccentric exercise - the shape of control of the muscle when it's lengthening and contracting at the same time:
Intriguingly, we observed a pattern of sinusoidal loading and unloading in EE which was not demonstrated in CE. The fluctuations in force probably reflect the difficulty in controlling a dynamic movement with a lengthening muscle; similar to the experience that it is easier to lift a heavy weight under precise control than to lower the same weight. We propose that these fluctuations in force may provide an important stimulus for the remodelling of tendon. Certainly in the remodelling of bone it is known that bone responds to high-frequency loading and appropriate mechanical signals can lead to a dramatic increase in bone density.
Frequency rather than Force. This is so cool - it sounds great too: that the sort of cycling on and off of the muscle (the sinusoidal loading and unloading) during the eccentric may be the biggie in stimulating that good collagen rebuilding in particular associated with EE and maybe the blood flow too. The other interesting part is that there is a possible parallel to bone remodelling here (and Woolf's law).
That is, as force is applied to a bone it will get bigger (the outer shell gets pushed out it seems, as the inner lace work architecture increases) and so stronger to respond to that demand. Davis's law on tissue seems a wee bit similar: "If soft tissue is placed under unremitting tension, the tissue will elongate by adding more material. "
Bottom line: the particular type of muscular demands to maintain control of a load in extension (force fluctuations not force magnitude) may play a particular role in remodeling tendons in these various opathies.
Whither, Voyager for Futuer EE / Tendinopathy Research?
The authors are now happy to say EE seems to have sufficient basis to be considered viable. Time to figure out how to optimize it. THey write in the Future Work section:
Little is known of the optimal protocol for EE. Indeed, fundamental questions remain unanswered, such as how fast the exercises should be performed and progressed. This is certainly an area worthy of future research. The specific location of the pathology within a tendon has increasingly been shown to have an effect on the efficacy of EE, and further study in this area is also suggested. Other potential areas of research include studying the effect of periodisation of training, a technique currently perhaps more familiar to athletes and their coaches than to sports medicine physicians.Goodness, that's interesting. Periodization combined with frequency may be the sweet spot for rehab. Why not? It's excellent for anti-fatigue strength building; why not repair?
As an example of eccentric exercises that have been tried out among at least a small population of elbow-opathies, Mike T Nelson's developed some nice eccentrics work with a kettlebell. Well worth a look and a go.
What i've been working lately for my shoulder/painful arc thing:
put a wee kettelbell or light db in the hand of the sore side. bring hand up to chest (with weight in it), then lift elbow so it's parallel or close to shoulder height WITH NO PAIN - only go as high as you can with no pain
- slowly abduct the hand away from the chest, and potentially rotate wrist down (like pouring a jug) - if the load feels too heavy - brings on pain - bring hand in a bit; reduce turn in wrist; then lower the whole arm (not just the elbow but this L shape you're holding) so you're working the shoulder.
that lets one do the concentric pretty much unloaded and focus on a safe eccentric.
if you give that a go for a while let me know how that feels - just don't move into pain.
Concludium
Perhaps the main take away from this summary of recent research reviews and primary work is that tendinitis vs osis is largely a non-starter; tendinopathy is where it's at. And saying that, the pathology or dis-ease of tendinopathy is not well understood, which may also explain why treatements - in particular long term ones - don't have much evidence to support their efficacy. There are some prospective treatements on the horizon, however, with eccentric exercise amongthem. This latest study on EE and tendinopathy seems to propose the best hypothesis so far as to why eccentric exercises is showing up as particularly effective for at least main body tendinopathy.
Citations:
Rees, J., Wolman, R., & Wilson, A. (2009). Eccentric exercises; why do they work, what are the problems and how can we improve them? British Journal of Sports Medicine, 43 (4), 242-246 DOI: 10.1136/bjsm.2008.052910
Andres, B., & Murrell, G. (2008). Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon Clinical Orthopaedics and Related Research, 466 (7), 1539-1554 DOI: 10.1007/s11999-008-0260-1
Woodley, B., Newsham-West, R., Baxter, G., Kjaer, M., & Koehle, M. (2007). Chronic tendinopathy: effectiveness of eccentric exercise * COMMENTARY 1 * COMMENTARY 2 British Journal of Sports Medicine, 41 (4), 188-198 DOI: 10.1136/bjsm.2006.029769
Koester MC, Dunn WR, Kuhn JE, & Spindler KP (2007). The efficacy of subacromial corticosteroid injection in the treatment of rotator cuff disease: A systematic review. The Journal of the American Academy of Orthopaedic Surgeons, 15 (1), 3-11 PMID: 17213378
Related Resources
- b2d movement index
- why not train through pain?
- chronic low back pain - possible strategies
- What do omega 3's have to do with anti-inflammation?
- free your feet index - you might feel better.
Wednesday, April 21, 2010
Ankle Sprains: Tape, Bracing - doesn't matter finds research - but how'd we get so busted up in the first place?
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A recent paper has presented the results of a bunch of trials looking at interventions for ankle sprains. Main result? if someone's had an ankle injury - like a sprain - then tape or brace doesn't seem to show a difference: both seem to cut down reinjury. What's troublesome on a metalevel, is first how sort of accepted the notion of this level of injury seems to be, and second how nascent in the approach described here is the model that for folks who haven't been injured - as a preventitive - they maybe should be immobilised too. Aren't there other questions to ask - perhaps especially about the injury free staying injury free - rather than whether incapacitating natural function is a Good Idea? But perhaps more fundamentally, how did we get to this point where someone is so beaten up their joints are written off as so dysfunctional they must be immobilized to perform?
Here's the abstract:
So what's going on here that this is even considered a useful strategy?
Apparently, there's a lot of functional instability, mechanical and proprioceptive factors are also considered in some of the studies to be impaired. Mechanical instability (lax joint) can be a cause of functional instability. These effects build up from - you guessed it - repeated ankle injuries. Where reflexes get slower, joints can get hypermobile, funtional loss of static and dynamic support of the joint has gone way down. Effectively, the ankle for a potential variety of reasons, is so beaten up and abused, it can no long function as an ankle, so, a greater degree of immobility is preferable to too much.
Um. what happened that a person gets to this point of so MANY repeated injuries they're beyond the pale of recovering normal function? Ah right: this is sport, not health.
Intriguingly, there's a claim that some bracing helps proprioception:
There are alternatives approaches: perhaps we should ask, as indicated, what's causing these injuries in the first place? Is it a skills-on-the-field problem? turning skills? cognitive processing for field awareness skills? Is it lack of ankle flexion or hip/pelvis restrictions? Is it a sensory-motor disconnect with shoes or other gear killing proprioceptive awareness of foot placement?
Folks like Gray Cook working with NFL football teams have been looking at athletic mobility/stability. Eric Cobb has been looking more at sensory-motor approaches, and cognitive stress for field performance that's more effective and injury free.
Any solution assumes a model for which that solution is appropriate. The solutions proposed by these authors seems to presuppose a model where (a) the amount of reinjury that leads to such horrible dysfunction is taken as a given and seems to be ok such that (b) further bodily immobilization seems like a good idea to enable athletic movement seems problematic to me on a number of levels.
Strategies to understand why the injuries are so high in the first place - never mind acceptable - seems to be a more humane way to begin strategizing about enabling athltetes to play ball, no?
Related Posts
Citation
Dizon, J., & Reyes, J. (2010). A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players Journal of Science and Medicine in Sport, 13 (3), 309-317 DOI: 10.1016/j.jsams.2009.05.002 Tweet Follow @begin2dig
A recent paper has presented the results of a bunch of trials looking at interventions for ankle sprains. Main result? if someone's had an ankle injury - like a sprain - then tape or brace doesn't seem to show a difference: both seem to cut down reinjury. What's troublesome on a metalevel, is first how sort of accepted the notion of this level of injury seems to be, and second how nascent in the approach described here is the model that for folks who haven't been injured - as a preventitive - they maybe should be immobilised too. Aren't there other questions to ask - perhaps especially about the injury free staying injury free - rather than whether incapacitating natural function is a Good Idea? But perhaps more fundamentally, how did we get to this point where someone is so beaten up their joints are written off as so dysfunctional they must be immobilized to perform?Here's the abstract:
Epidemiological studies have shown that 10–28% of all sports injuries are ankle sprains, leading to the longest absence from athletic activity compared to other types of injuries. This study was conducted to evaluate the effectiveness of external ankle supports in the prevention of inversion ankle sprains and identify which type of ankle support was superior to the other. A search strategy was developed, using the keywords, ankle supports, ankle brace, ankle tapes, ankle sprains and athletes, to identify available literature in the databases (MEDLINE, PubMed, CINAHL, EMBASE, etc.), libraries and unpublished papers. Trials which consider adolescents and adults, elite and recreational players as participants were the study of choice. External ankle supports comprise ankle tape, brace or orthosis applied to the ankle to prevent ankle sprains. The main outcome measures were frequency of ankle sprains. Two reviewers assessed the quality of the studies included using the Joanna Briggs Institute (JBI Appraisal tool). Whenever possible, results were statistically pooled and interpreted. A total of seven trials were finally included in this study. The studies included were of moderate quality, with blinding as the hardest criteria to fulfill. The main significant finding was the reduction of ankle sprain by 69% (OR 0.31, 95% CI 0.18–0.51) with the use of ankle brace and reduction of ankle sprain by 71% (OR 0.29, 95% CI 0.14–0.57) with the use of ankle tape among previously injured athletes. No type of ankle support was found to be superior than the other.This is when it's nice to have the whole article, because you'd think it just stops there, right? For previously injured, folks who were taped didn't seem to get reinjured. How does one predict the future like that? Well that's the toughie: only one study had a control group - so did they just get reinjured that many more times than the athletes who braced? No, it's of the populations taped or braced, how many did NOT have a recurrence in a given period.
So what's going on here that this is even considered a useful strategy?
Apparently, there's a lot of functional instability, mechanical and proprioceptive factors are also considered in some of the studies to be impaired. Mechanical instability (lax joint) can be a cause of functional instability. These effects build up from - you guessed it - repeated ankle injuries. Where reflexes get slower, joints can get hypermobile, funtional loss of static and dynamic support of the joint has gone way down. Effectively, the ankle for a potential variety of reasons, is so beaten up and abused, it can no long function as an ankle, so, a greater degree of immobility is preferable to too much.
Um. what happened that a person gets to this point of so MANY repeated injuries they're beyond the pale of recovering normal function? Ah right: this is sport, not health.
Intriguingly, there's a claim that some bracing helps proprioception:
"they restrict range of motion to a certain degree and enhance proprioception of the injured ankle making them more useful in the prevention of possible re-injury."Wow, that's wild. How does that work? And can that awareness be re-trained rather than delivered only through a device? Where's it coming from? But there's not a lot of interest in the article in looking at say other strategies like rehab, movement assessment. Why not? There's a model here that says once injured, you're toasted:
As mentioned earlier in the discussion, after a sprain, structural damage occurs to the ligamentous tissues, nervous and musculo- tendinous units in the ankle joint. Functional and mechanical instability arise. For these reasons, the risk of injury to a pre- viously injured ankle is increased. his is the point where external ankle supports play an important role.And that may have informed the authors' decision simply to look at what type of bracing is better to reduce re-injury, rather than to wonder if
- training that can find movement or other sensory-motor issues that may be related to WHY a person roles their ankles
- investigation of the stupid shoes that may be killing proprioception necessary to reduce ankle sprains
- anything else that may help the athlete perform with less likelihood of injury, better performance
This review provides good evidence for the use either ankle taping or ankle braces to prevent lateral ankle sprains among previously injured players. However, for those with- out previous ankle injuries this still needs to be proven. There is no evidence on which external ankle support is better than the other. Each has its own advantages and disadvantages.You see it? These folks with this model of the weakness of the ankle - where "10-28%" of all athletic injuries occur - are already thinking MAYBE - we don't know yet - but maybe if we just brace the ankle up from the get go, we'll keep more ankles from being sprained.
There are alternatives approaches: perhaps we should ask, as indicated, what's causing these injuries in the first place? Is it a skills-on-the-field problem? turning skills? cognitive processing for field awareness skills? Is it lack of ankle flexion or hip/pelvis restrictions? Is it a sensory-motor disconnect with shoes or other gear killing proprioceptive awareness of foot placement?
Folks like Gray Cook working with NFL football teams have been looking at athletic mobility/stability. Eric Cobb has been looking more at sensory-motor approaches, and cognitive stress for field performance that's more effective and injury free.
Any solution assumes a model for which that solution is appropriate. The solutions proposed by these authors seems to presuppose a model where (a) the amount of reinjury that leads to such horrible dysfunction is taken as a given and seems to be ok such that (b) further bodily immobilization seems like a good idea to enable athletic movement seems problematic to me on a number of levels.
Strategies to understand why the injuries are so high in the first place - never mind acceptable - seems to be a more humane way to begin strategizing about enabling athltetes to play ball, no?
Related Posts
Citation
Dizon, J., & Reyes, J. (2010). A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players Journal of Science and Medicine in Sport, 13 (3), 309-317 DOI: 10.1016/j.jsams.2009.05.002 Tweet Follow @begin2dig
Monday, April 19, 2010
Some differences between Active vs Passive (Only) Work to Enhance Performance
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Active? Manual/Passive? What's the difference when we hurt or hit a performance hurdle? If we get a movement-oriented pain (low back, sore shoulder, hinky knee), our traditional, initial response after seeing a doc to make sure an alien is not about to pop out of our chest, is usually to seek out a manual therapist - a chiropractor, active release person, a massage therapist, an accupressurist/puncturist - to get us "fixed." If we're in acute pain in particular, these can be great approaches to get out of that immediate pain place. Super. Likewise, if we sense we have a movement limitation, we might do the same thing: if stretching doesn't get it done, we go get it "worked on" by a manual therapist to help "open it up." While there can be benefit to these approaches in these cases, there may also be richer, sometimes faster paths to performance improvements that are active rather than passive.What does that mean though, to "go active" rather than passive/manual?
Manual therapies all have that one trait in common. They are the act of something being done to us, while we remain primarily the passive recipient of these ministrations. In some contexts this can be fabulous. Various kinds of massage enact a relaxation reflex that can help us - and our bodies - calm down - at least while we're on the table. And that may be sufficient for us to move past whatever effect it is we're experiencing to get to the other side.
Active approaches, in contrast, are when we do the work for ourselves. Active approaches have certain neurological benefits: they seem to require significantly great neurological engagement to be carried out. Models of motor learning that i've talked about before get engaged.
The differences between active and passive work might be expressed in the example of someone learning to swing a tennis racket. If a coach stands behind us, and does the swing for us, we get a sense of the feel of where the arc should be in our body - where our joints should move - but until we practice it for ourselves, we're not firing up all the muscle fibers in the correct sequences to hold the racket, and move the racket ourselves, through that arc. We certainly haven't coordinated the feel of that action while running one way and potentially looking another (blending in balance and visual acuity). So, pretty obviously, carrying out a movement actively engages a lot more of our systems than passively being lead through the same motion. And that active engagement is a Good Thing for our well being.
As i've written about before (here's a list), a lot of performance limitations (stalling out in a lift, or a swing or whatever) and a lot of pain seems to come from issues in movement - poor mobility (control over one's movement) in one area requires compensations in movement (that may be uncomfortable after awhile) in others.
These kinds of movement/performance challenges are so well understood, Gray Cook and Brett Jones's entire "Secrets of ..." series deals with what they frame as mobility/stability issues. In their dvd on the Turkish Get Up, Kalos Sthenos, for instance, Cook and Jones talk at length about the effects of say restricted upper spine mobility and the negative consequences this has for upper body movement in general and strength work like pressing in particular. Their functional movement approach to addressing these restrictions is not to get a person on a massage table, but to get the person active with what they term corrective drills that work with the thoracic spine and shoulders.
Threat or No Threat In Z-Health, Eric Cobb looks at this kind of mobility (control of one's movement) as the fastest path to the nervous system that is the governor of the entire muscular-skeletal/sensory-motor system. I've written before how in this model, the only thing the nervous system cares about is threat or no threat. That a perceived threat (like jammed or less independently mobile joints) causes a reduction in outputs like force production. Help address the quality of movement, threat goes down as quality of information to the nervous system goes up; performance goes up.
Recently i've talked about a wee hypothesis i'm playing with that the value of tons of movement reps with light weight has a huge benefit for moving to larger loads in a new move because the threat has been reduced. The body knows how to do the move, so the only new thing to worry about is managing the load.
To come back to manual vs active work, in manual work, with less of the nervous system engaged in translating the work done to into any active effect, it seems threat response may stay pretty high in that a real lasting change pattern has not been initiated. Trust has not been built, perhaps? And so the benefits of the treatment may not have an ongoing effect. This lack of stickiness from manual work has been demonstrated in a recent video by the Z-Health team. Here, Eric Cobb demonstrates the immediate after effect of passive work vs active.
In the example, the participant is first muscle tested - strong - is placed in a jammed joint position at the ankle, is muscle tested again - weak. He is manually maniupulated to fix the joint (Cobb is a chiropractor by license); re-tested, strong. Supposedly, this person is now fixed. He gets up to take one step, comes back for a re-test, weak again. Goes away to do 3-4 reps of the toe pull drills for that joint that have been taught in the class, comes back after walking around post-drills, is tested again, and he's solid.
What we could draw from this example is
What i am not saying at all is that passive therapy is inapporpriate. A number of the athletes i 
coach who have decades of trauma in their bodies find that mixed methods help them, and that in particular, when they combine their passive work with active z-health drills, for instance, during or immediately after their treatments, the benefits are far more sticky. Books like the well-regarded Anatomy Trains on the fascial system
talks about the neural necessity of blending active participation with the manual manipulations of the fascia a therapist may carry out.
Indeed, one person has told me they've gotten through an intense patch of combined work of manual/active therapy and are on maintenance now with just the z-health drills. For most of my other athletes, combining the z-health work with their sport work has had significant benefit for their overall performance.
Give Active Work a Chance. What these demonstrations seem to show us is that there is a real both immediate and lasting benefit to carrying out dynamic active work around our own mobility - our own volitional control of our motion. In moves like the turkish get up, we see this control in the ability to exectute a high hip bridge when transitioning from back to kneeling, or being able to keep the chest high with the arm raised in lock out when in the upright seated position.
In a z-health drill it may be simply the ability to do a shoulder circle where say the left arm circles in front of the right side of the body without the left shoulder moving/torquing at all towards the right side to get the arm over to that part of the body - just for example. For some folks, one of the most challenging movements has been a wrist movement where the wrists, not the hands, lead the movements up and down.
The quest here is not hypermobility - it's not about doing the splits, per se. It's about at least in part having better control of independent ROM in our bodies in order to move better - to move as we are designed to move. That means that the hips can move independently of the pelvis; the thoracic spine can actually move back and forth and side to side independent of the lumbar spine; that there is an appropriate degree of ankle inversion and eversion, and so on. To find out more about why that independence of joint motion also leads to greater "map clarity" and better performance, here's an article more about that.
Take Away In this context of active in relation to passive care, a ket take away, i'd say, is that it's ACTIVE work that builds up this capacity to enhance our performance, and that by deliberately practicing active mobility our performance improves - and likely incidents of tweaks go down as well.
Places to Start
Specific Work: I start my athletes with a movement assessment to see if they have any issues with particular movements (what Gray Cook calls "weak links") that if addressed may lead to improved performance. If you don't have access to a CK-FMS trainer or Z-Health coach in your area for an assessment, some of us (me included) do them online (here's some reviews).
Anytime Work: At anytime it's a great idea to get an active mobility practice in your universe. There are all sorts of programs in this space, including traditional practices like t'ai chi. Fabulous. Here's a piece on where i see z-health being different from these practices and why i think the z-health progressions are valuable to know too.
My recommendation for the folks i coach is z-health drills because of the focus on joint by joint mobility control. My recommendation is to start with the first level of Z-health that starts in neutral stance - no moving around really - and as soon as comfy there, get into I-phase. Here's a longer discussion on why the progression from R (vocabulary of movement) to I (control of movement templates) is important for performance
Related Posts
Manual therapies all have that one trait in common. They are the act of something being done to us, while we remain primarily the passive recipient of these ministrations. In some contexts this can be fabulous. Various kinds of massage enact a relaxation reflex that can help us - and our bodies - calm down - at least while we're on the table. And that may be sufficient for us to move past whatever effect it is we're experiencing to get to the other side.Active approaches, in contrast, are when we do the work for ourselves. Active approaches have certain neurological benefits: they seem to require significantly great neurological engagement to be carried out. Models of motor learning that i've talked about before get engaged.
The differences between active and passive work might be expressed in the example of someone learning to swing a tennis racket. If a coach stands behind us, and does the swing for us, we get a sense of the feel of where the arc should be in our body - where our joints should move - but until we practice it for ourselves, we're not firing up all the muscle fibers in the correct sequences to hold the racket, and move the racket ourselves, through that arc. We certainly haven't coordinated the feel of that action while running one way and potentially looking another (blending in balance and visual acuity). So, pretty obviously, carrying out a movement actively engages a lot more of our systems than passively being lead through the same motion. And that active engagement is a Good Thing for our well being.
As i've written about before (here's a list), a lot of performance limitations (stalling out in a lift, or a swing or whatever) and a lot of pain seems to come from issues in movement - poor mobility (control over one's movement) in one area requires compensations in movement (that may be uncomfortable after awhile) in others.
Threat or No Threat In Z-Health, Eric Cobb looks at this kind of mobility (control of one's movement) as the fastest path to the nervous system that is the governor of the entire muscular-skeletal/sensory-motor system. I've written before how in this model, the only thing the nervous system cares about is threat or no threat. That a perceived threat (like jammed or less independently mobile joints) causes a reduction in outputs like force production. Help address the quality of movement, threat goes down as quality of information to the nervous system goes up; performance goes up.
Recently i've talked about a wee hypothesis i'm playing with that the value of tons of movement reps with light weight has a huge benefit for moving to larger loads in a new move because the threat has been reduced. The body knows how to do the move, so the only new thing to worry about is managing the load.
To come back to manual vs active work, in manual work, with less of the nervous system engaged in translating the work done to into any active effect, it seems threat response may stay pretty high in that a real lasting change pattern has not been initiated. Trust has not been built, perhaps? And so the benefits of the treatment may not have an ongoing effect. This lack of stickiness from manual work has been demonstrated in a recent video by the Z-Health team. Here, Eric Cobb demonstrates the immediate after effect of passive work vs active.
In the example, the participant is first muscle tested - strong - is placed in a jammed joint position at the ankle, is muscle tested again - weak. He is manually maniupulated to fix the joint (Cobb is a chiropractor by license); re-tested, strong. Supposedly, this person is now fixed. He gets up to take one step, comes back for a re-test, weak again. Goes away to do 3-4 reps of the toe pull drills for that joint that have been taught in the class, comes back after walking around post-drills, is tested again, and he's solid.
What we could draw from this example is
- how little all the systems of the body are engaged in passive manipulation
- how improved funtioning after a manual experience on a table is potentially very distinct from our experience in normal active movement
- how much more of our systems are engaged in even simple small but active movements
- how necessary that engagement seems to be for well being/performance
- how rapidly that engagement kicks in
- how easy that active engagement is.
What i am not saying at all is that passive therapy is inapporpriate. A number of the athletes i coach who have decades of trauma in their bodies find that mixed methods help them, and that in particular, when they combine their passive work with active z-health drills, for instance, during or immediately after their treatments, the benefits are far more sticky. Books like the well-regarded Anatomy Trains on the fascial system talks about the neural necessity of blending active participation with the manual manipulations of the fascia a therapist may carry out. Indeed, one person has told me they've gotten through an intense patch of combined work of manual/active therapy and are on maintenance now with just the z-health drills. For most of my other athletes, combining the z-health work with their sport work has had significant benefit for their overall performance.
Give Active Work a Chance. What these demonstrations seem to show us is that there is a real both immediate and lasting benefit to carrying out dynamic active work around our own mobility - our own volitional control of our motion. In moves like the turkish get up, we see this control in the ability to exectute a high hip bridge when transitioning from back to kneeling, or being able to keep the chest high with the arm raised in lock out when in the upright seated position.
In a z-health drill it may be simply the ability to do a shoulder circle where say the left arm circles in front of the right side of the body without the left shoulder moving/torquing at all towards the right side to get the arm over to that part of the body - just for example. For some folks, one of the most challenging movements has been a wrist movement where the wrists, not the hands, lead the movements up and down.
The quest here is not hypermobility - it's not about doing the splits, per se. It's about at least in part having better control of independent ROM in our bodies in order to move better - to move as we are designed to move. That means that the hips can move independently of the pelvis; the thoracic spine can actually move back and forth and side to side independent of the lumbar spine; that there is an appropriate degree of ankle inversion and eversion, and so on. To find out more about why that independence of joint motion also leads to greater "map clarity" and better performance, here's an article more about that.
Take Away In this context of active in relation to passive care, a ket take away, i'd say, is that it's ACTIVE work that builds up this capacity to enhance our performance, and that by deliberately practicing active mobility our performance improves - and likely incidents of tweaks go down as well.
Places to Start
Specific Work: I start my athletes with a movement assessment to see if they have any issues with particular movements (what Gray Cook calls "weak links") that if addressed may lead to improved performance. If you don't have access to a CK-FMS trainer or Z-Health coach in your area for an assessment, some of us (me included) do them online (here's some reviews).
Anytime Work: At anytime it's a great idea to get an active mobility practice in your universe. There are all sorts of programs in this space, including traditional practices like t'ai chi. Fabulous. Here's a piece on where i see z-health being different from these practices and why i think the z-health progressions are valuable to know too.
My recommendation for the folks i coach is z-health drills because of the focus on joint by joint mobility control. My recommendation is to start with the first level of Z-health that starts in neutral stance - no moving around really - and as soon as comfy there, get into I-phase. Here's a longer discussion on why the progression from R (vocabulary of movement) to I (control of movement templates) is important for performance
Related Posts
- Why Move of Die
- Arthrokinetic Reflex - model of systemic effect/interaction
- Why not Move through Pain
- The Refined Turkish Get Up
- Chronic Back Pain?
- Why and When I-Phase?
- The other side of the weight room: sensory-motor training
- Z-Health Article Index
- CK-FMS experience
- Mobility vs Flexibility: is there a difference?
Sunday, April 18, 2010
Mentor Support: an unsung key predictor of weight loss and weight loss maintenance
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There's one weight loss study that somehow has been in the public eye since 2003. Each time a version of its data gets published, it gets media attention for showing that LOTS of exercise helps maintain weight loss. Now from my reading of that data, that's actually kind of a misrepresentation of the findings in the paper. There are THREE factors that impact weight loss maintenance: caloric restriction (1200-1500kcals), 270-300mins of (vigorous) exercise a week AND (the under reported component) regular human contact intervention about compliance with the protocol. Finally, in yet another paper about this study, this later part of the work is being highlighted a bit more in the paper "Contribution of Behavior Intervention Components to 24-Month Weight Loss." I find it fascinating that such an interesting predictor of success - along with the more familiar caloric reduction - has been so seemingly downplayed in favor of hours of exercise.
Background
Last year (2009), discussion of a second paper (published July 2008) on a 2 year study of obese women losing weight generated lots of attention. In particular, Time focused on one aspect of the study, calling their piece "The Myth of Moderate Exercise." They focused on the finding that, in a trial of 201 obese women ("conducted between December 1999 and January 2003") who took off and kept off 10% of their body, did so by exercising at twice the amount of time recommended by the CDC (center for disease control), and by doing vigerous - not moderate - work.
A less well cited piece on the study at WebMD did make a bit more about the social aspect of the study that was seen to contribute to participants' ongoing success. One more even less cited post at FoodConsumer.org, unlike Time, got it, too:
Indeed, here's the latest version: April, 2010, Journal of the American College of Sports Medicine, "Contribution of Behavior Intervention Components to 24-Month Weight Loss."
Oh, and just a few months before this April 2010 version of the data, the American College of Sports Medicine put out a press release taking "strong exception to assertions [in that original Time Article?] that exercise can inhibit weight loss by over-stimulating the appetite." The key person cited in the PR is John Jakicic, author of the above study and who also just happens to "[chair] a committee on obesity prevention and treatment for the American College of Sports Medicine (ACSM) and helped write an ACSM Position Stand on strategies for weight loss and prevention of weight regain for adults."
Naturally, the ACSM statement says exercise helps maintain weight loss. And to that end, quotes an awful lot of Jakicic's singular study's findings. Now, that all sounds great, but let's face it, (1) this cohort was 201 obese women, and (2) the ACSM may have just a little invested in celebrating the importance of exercise. They were burning off 1800+ calories with exercise AND living on calorie reduced diets AND were still, after two years, considered overweight. So their health had certainly improved, but if nothing else, this cohort shows that losing weight from an obese state takes long, hard graft. But it also seems to benefit from something else that may be just as necessary, and that's the human expert support.
Telephones: The Secret Ingredient?
Just to be clear, i'm in no way suggesting that exercise doesn't help with weight loss. Recently i've discussed just two of many studies - one on HIIT, one on cardio - that shows benefit for fat loss. But what i am intrigued by, and what's been in the published data since day one, is the fact that exercise and BIG calorie restriction were not the only key factors in getting the weight off, and perhaps just as importantly, keeping it off. While the researchers have made this point repeatedly in the data, it's one they themselves seem reluctant to foreground, even in the latest study. Here's the abstract:
Here's a bit on the way social support with the protocol worked:
This is a pretty substantial result that is intriguingly reiterated in a smaller cohort study carried out over at Precision Nutrition awhile ago (and discussed at b2d here).
To the folks who were "extremely happy" with the progress towards their weight goals, 77% said that they'd had regular mentorship from someone who was in the shape they wanted to achieve.
It's important to note that not everyone needs social/expert support to achieve their weight loss goals. Brad Pillon, whose work is continually interesting and intriguing, blogged recently about how happy he was to carve his own path. And any guy who can fast regularly twice a week is probably just that kinda guy. But let's face it: Mr. Pillon of the terrific Eat, Stop, Eat has a heck of a background in nutrition and supplements, so perhaps he's not the Norm in the distribution here? Maybe?
Martha Beck of the Four Day Win
(your way to Thinner Peace [i love that]) reiterates the value of social support for success in body comp 
goals, encouraging folks who don't have it for free in their social network to go pay for it (precision nutriton - the forum - is the biggie i've praised for ages for this value; the lean eating program takes that to daily, direct contact).
For the rest of us, then, it seems we more than get by, but can thrive with a little help if not just from supportive friends, but from knowledgeable mentors.
And uptake of *that* human support component is, at least in this Never Ending Study, an unsung key predictor of success with caloric reduction and exercise for attainment and maintenance of body comp success.
Related Posts
PS Please Remember,
UNICK, J., JAKICIC, J., & MARCUS, B. (2010). Contribution of Behavior Intervention Components to 24-Month Weight Loss Medicine & Science in Sports & Exercise, 42 (4), 745-753 DOI: 10.1249/MSS.0b013e3181bd1a57
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Follow @begin2dig
There's one weight loss study that somehow has been in the public eye since 2003. Each time a version of its data gets published, it gets media attention for showing that LOTS of exercise helps maintain weight loss. Now from my reading of that data, that's actually kind of a misrepresentation of the findings in the paper. There are THREE factors that impact weight loss maintenance: caloric restriction (1200-1500kcals), 270-300mins of (vigorous) exercise a week AND (the under reported component) regular human contact intervention about compliance with the protocol. Finally, in yet another paper about this study, this later part of the work is being highlighted a bit more in the paper "Contribution of Behavior Intervention Components to 24-Month Weight Loss." I find it fascinating that such an interesting predictor of success - along with the more familiar caloric reduction - has been so seemingly downplayed in favor of hours of exercise.Background Last year (2009), discussion of a second paper (published July 2008) on a 2 year study of obese women losing weight generated lots of attention. In particular, Time focused on one aspect of the study, calling their piece "The Myth of Moderate Exercise." They focused on the finding that, in a trial of 201 obese women ("conducted between December 1999 and January 2003") who took off and kept off 10% of their body, did so by exercising at twice the amount of time recommended by the CDC (center for disease control), and by doing vigerous - not moderate - work.
A less well cited piece on the study at WebMD did make a bit more about the social aspect of the study that was seen to contribute to participants' ongoing success. One more even less cited post at FoodConsumer.org, unlike Time, got it, too:
But even among this group who sustain 10 percent weight loss, exercise may not be the only thing they did to have the effect. These people also completed more phone calls with the research staff and engaged in more eating behaviors recommended for weight loss and had a lower intake of dietary fat.This was the second time this same study data had garnered attention for the reason Time made primary. Back in 2005, WebMD published a story called "how much exercise sparks weight loss." It focused on the data that showed that the women who exercised for 4.5-5 hours a week, at an overall vigorous intensity, lost the most weight. This was the first time the full study data had been taken out for a walk - this time at a presentation at the North American Association for the Study of Obesity’s annual scientific meeting, Vancouver, Canada, Oct. 15-19, 2005. Prior to this, a one year version of the study, with pretty much the same findings at the 12 month point was reported in 2003 in the Journal of American Medical Association. Gotta say, i am amazed at the longevity of this data set. It's a lesson for academics about how much information one can get from a rich data set.
Indeed, here's the latest version: April, 2010, Journal of the American College of Sports Medicine, "Contribution of Behavior Intervention Components to 24-Month Weight Loss."
Oh, and just a few months before this April 2010 version of the data, the American College of Sports Medicine put out a press release taking "strong exception to assertions [in that original Time Article?] that exercise can inhibit weight loss by over-stimulating the appetite." The key person cited in the PR is John Jakicic, author of the above study and who also just happens to "[chair] a committee on obesity prevention and treatment for the American College of Sports Medicine (ACSM) and helped write an ACSM Position Stand on strategies for weight loss and prevention of weight regain for adults."
Naturally, the ACSM statement says exercise helps maintain weight loss. And to that end, quotes an awful lot of Jakicic's singular study's findings. Now, that all sounds great, but let's face it, (1) this cohort was 201 obese women, and (2) the ACSM may have just a little invested in celebrating the importance of exercise. They were burning off 1800+ calories with exercise AND living on calorie reduced diets AND were still, after two years, considered overweight. So their health had certainly improved, but if nothing else, this cohort shows that losing weight from an obese state takes long, hard graft. But it also seems to benefit from something else that may be just as necessary, and that's the human expert support.
Telephones: The Secret Ingredient?
Just to be clear, i'm in no way suggesting that exercise doesn't help with weight loss. Recently i've discussed just two of many studies - one on HIIT, one on cardio - that shows benefit for fat loss. But what i am intrigued by, and what's been in the published data since day one, is the fact that exercise and BIG calorie restriction were not the only key factors in getting the weight off, and perhaps just as importantly, keeping it off. While the researchers have made this point repeatedly in the data, it's one they themselves seem reluctant to foreground, even in the latest study. Here's the abstract:
That's an interesting conclusion. It separates out achieving a weight loss target to sustaining a weight loss target. It says, if i'm reading it correctly, that eating behaviors and social expert support about the progress in the program are potent factors for getting to weight loss equal to 5% of total weight, or for that matter to anything above 5%. To *sustain* weight loss that is equal to or greater than 10%, however, high level physical activity has to be there. At least if you're an obese woman.Sustaining weight loss at the long term is difficult.Purpose: To examine if eating behaviors, physical activity levels, and program participation influence ones ability to achieve ≥5%, ≥7%, and ≥10% weight loss during a period of 24 months.Methods: Data from 170 overweight and obese women (body mass index = 32.7 ± 4.2 kg·m−2) were analyzed in this study. All women followed a standard 24-month behavioral weight loss program in which they were instructed to decrease caloric intake and increase physical activity levels. Eating behaviors, body weight, and physical activity levels were assessed at baseline and at 6 and 24 months. Program participation was evaluated by the percentage of group meetings attended and the percentage of telephone calls completed with an interventionist. Three separate stepwise linear regression analyses were performed to identify variables that were predictive of ≥5%, ≥7%, and ≥10% weight loss at 24 months.Results: The percentage of telephone calls completed and change in weight loss eating behaviors predicted ≥5% (r2 = 0.16), ≥7% (r2 = 0.14), and ≥10% weight loss (r2 = 0.10) at 24 months. However, the change in physical activity levels from baseline to 24 months was only predictive of weight losses ≥10% (r2 = 0.11).Conclusions: Behavioral factors, such as adopting healthy eating behaviors and telephone contact time, are important components that assist individuals in achieving weight losses ≥5%. However, high levels of physical activity play a more prominent role in sustaining weight losses ≥10%. Therefore, innovative strategies to enhance long-term exercise adherence should be developed.
Here's a bit on the way social support with the protocol worked:
During the initial 6 months, participants attended weekly group intervention meetings that focused on specific behavioral strategies to adopt and maintain the recommended eating and physical activity components. From months 7 to 12, participants were to attend biweekly meetings, with the frequency of these meetings reduced to monthly during months 13 to 18, and these meetings no longer offered during months 19 to 24. The group intervention meetings were complemented with brief individualized telephone contacts between months 7 and 24. The frequency of these telephone contacts was biweekly during months 7 to 12, monthly during months 13 to 18, and biweekly during months 19 to 24. Phone calls were scheduled for a period of up to 10 min; however, the weight loss counselor could extend the call beyond the 10 min period if deemed necessary. All calls followed a structured script, and calls were prescheduled to facilitate the ability of the subject to participate in this callHere's some of the main findings correlating effect of this contact with results:
In other words, whether folks went to meetings or not wasn't the big factor; the time of direct contact that folks made seems to correlate with success. My humble take is that, gosh, this is a pretty significant component to ongoing success. So heere's a conclusion, given that, i don't quite understand. The authors state:
Telephone contact time, expressed as the percentage of telephone calls completed, was significantly greater (P G 0.001) using the Q5%, Q7%, and Q10% weight loss criteria, in the MAINTAIN group (79.4%, 79.5%, and 83.6%, respectively) compared with the NONMAINTAIN (69.3%, 70.6%, and 68.4%, respectively) and NONADOPT (64.4%, 67.7%, and 69.6%, respectively) groups. There was no significant difference in participant session attendance between groups for any of the weight loss criteria
On the basis of the results of this study, physical activity was a key factor in the ability to achieve this magnitude of weight loss when used in combination with improved eating behaviors and sufficient contact with the intervention staff (Table 4). Thus, innovative strategies that would promote the adoption and maintenance of sufficient doses of physical activity are needed, and this may facilitate the achievement of larger magnitudes of longterm weight loss.If "sufficient contact" and "improved eating behaviours" are key, why do the authors only want to propose only workout strategies? Not to worry, though: the authors seem to come around by the conclusion of the study:
In addition, data from the current study indicate that sufficient levels of physical activity in combination with appropriate eating behaviors and maintaining contact with a weight loss specialist are important predictors of Q10% weight loss at 24 months, which is the level of weight loss recommended by the National Heart, Lung, and Blood Institute (14). Therefore, to assist overweight and obese individuals in achieving and maintaining weight losses Q10% of initial body weight, innovative strategies that would enhance long-term adherence to appropriate exercise and eating behaviors and that facilitate continued contact with a weight loss specialist should be implemented.
This is a pretty substantial result that is intriguingly reiterated in a smaller cohort study carried out over at Precision Nutrition awhile ago (and discussed at b2d here).To the folks who were "extremely happy" with the progress towards their weight goals, 77% said that they'd had regular mentorship from someone who was in the shape they wanted to achieve.
It's important to note that not everyone needs social/expert support to achieve their weight loss goals. Brad Pillon, whose work is continually interesting and intriguing, blogged recently about how happy he was to carve his own path. And any guy who can fast regularly twice a week is probably just that kinda guy. But let's face it: Mr. Pillon of the terrific Eat, Stop, Eat has a heck of a background in nutrition and supplements, so perhaps he's not the Norm in the distribution here? Maybe?
Martha Beck of the Four Day Win (your way to Thinner Peace [i love that]) reiterates the value of social support for success in body comp goals, encouraging folks who don't have it for free in their social network to go pay for it (precision nutriton - the forum - is the biggie i've praised for ages for this value; the lean eating program takes that to daily, direct contact).For the rest of us, then, it seems we more than get by, but can thrive with a little help if not just from supportive friends, but from knowledgeable mentors.
And uptake of *that* human support component is, at least in this Never Ending Study, an unsung key predictor of success with caloric reduction and exercise for attainment and maintenance of body comp success.
Related Posts
- First Review of Precision Nutrition
- Change is Pain - how to work through the pain to success in Diets
- Set point theory is crap
- Fat Metabolism - a bit about how it works
- some thoughts on motivation as a skill
- sustenance - it's more than appetite
- Georgie Fear helps us Dig In
PS Please Remember,
Jamie Oliver's food revolution. Please check out the petition for better food in kids'schools.
JO's excellent TED talk on same.
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