(Mason J, trackademicblog.com, 2020)

​Peristaltic Pulse Dynamic Compression, commercially known as NormaTec, is a recovery system that uses pulsed compression that aims to reduce swelling, improve lymphatic return, increase blood flow and reduce pain.
Without getting too technical, here’s some of the evidence on how useful NormaTec is to aid recovery after exercise.

"One part of my job I'll never learn to love is the pre match warm up. I hate it with every fibre of my being. It actually disgusts me. It's nothing but masturbation for the conditioning coaches" - Andrea Pirlo, World Cup Winner, Champions League Winner and Serie A Winner.

Does he have a point?
​
I know some S & C coaches tend to over complicate elements of a workout or session and I am a firm believer of simplifying things for our athletes, but one thing that is universally accepted is the need of a well designed and planned warm up pre training or competition. We are all aware that a warm up increases our muscle temperature, core temperature and blood flow. But it also has an effect on the following:

​So often our glutes are blamed for lower limb injuries. Tight hamstrings? Your glutes are probably weak. Knee pain? Ah your glutes aren’t firing. Flat feet? Your glutes could be causing that. How can one muscle be responsible for so many injuries? We all assume everyone is aware of what our glutes do but, in truth, very few know about the subtle differences in the different gluteal muscles.
So, what do our glutes actually do?
Our glutes are made up of 3 muscles; gluteus maximus, gluteus medius and gluteus minimus. Yes, they all sound like characters from Gladiator so to avoid this confusion we’ve shortened it simply to “glutes”. Beneath these again are more muscles often grouped under the term glutes; specifically, our piriformis, obturator internus and gemmilli (superior and inferior). Did you realise there were that many muscles knocking about underneath your glute max? When each of these muscles has a different function is grouping them together often wisest?

So we’re over a week in. You’ve given away the last box of Roses, locked the drinks cabinet and the new runners that were under the tree are well on their way to getting broken in. We’re all guilty of this, going full steam ahead when we set new goals and it’s not a bad thing. January is a time for a fresh start, to set those new goals, to revisit old ones and to generally put the possible over indulging or negativity of 2018 to bed. So of course we feel we need to take advantage of our new positive mindset.
​
WARNING - this comes at a risk. At PhysioElite Physiotherapy and Sports injury clinic, we tend to see a spike in mid to late January of simple overuse injuries, unwanted and unnecessary muscular tension and avoidable compensatory patterns. Eager January beavers can take on the world, can train every day, and can ignore their training logs! In the inexperienced, new training goals literally take over, and we neglect to listen to our bodies crying out for a recovery session, some cross training or very simply, just a day off.

Anyone who is familiar with my work knows I am such a huge advocate of recovery. I believe it is an important as clocking miles, setting new PB’s and getting in those results guaranteed hill sessions. Recovery is an essential component to factor into every new training plan or new long term goal target. There are numerous methods of recovery and numerous benefits with too much science and research attached to them to ignore. Some of the most common methods include:

​The relationship between sleep, post exercise recovery and performance in elite athlete has become a topic of great interest in the sports science and medicine community. We all know that recovery is multifaceted, but do we ever even consider the importance of sleep in recovery from exercise. Amongst the timed nutrition, the compression shorts, the cryospa, and other modalities that claim to enhnce our recovery, does the notion of 40 winks ever feature in our recovery programme?

Concussion is the in-vogue medical term at the moment. Not only have concussion diagnoses been on the rise (the incidence of concussion in sport now at 0.1 to 2.5 per 1000 athletic exposures, Clay et al, 2013) but also the research around concussion has dramatically increased. The most recent Consensus Statement on Concussion in Sport (as a result of the 5th International Conference on Concussion in Sport in Berlin 2016) has included some of this new research and has outlined the best treatment protocols for concussion management in sport.

Changes to the Consensus Statement
​
FIFA release this Consensus Statement regularly using the latest research pertaining to sports’ concussions. The last Statement was released in 2012 in Zurich has had a number of changes made to it as outlined below:

• Rest for only 24-48 hours MAXIMUM:
  • Originally rest was the first phase of recovery for concussion but now it has been removed and our first phase is symptom-limited activity. Recent research has shown that the longer you rest with no activity, the worse your outcome post-concussion.
• Return to Learn Guidelines now included
  • For some of our younger athletes, it was unsure previously when they could return to school / learning but now we have a designated protocol for just that
• Neuropsychological Testing not Exclusive to return to play
  • Where before cognitive testing (where are you? Whose the president? Etc.!) was the be all and end all, now it’s understood that more disciplines need to have input before an athlete is safe to return to sport.
• Physiotherapy and Vestibular Rehabilitation
  • Physio is now acknowledged as beneficial in the assessment and treatment of prolonged concussion (> 7 days) and a physiotherapist trained in vestibular rehabilitation is recommended in the treatment of concussion

 
Return to Play Protocols
As mentioned above there is a graduated return to play protocol outlined in the guidelines. Once an athlete displays no symptoms at a phase, they can move into the next phase of recovery. The current recommendations are:

Phase 1
Aim: Symptom-limited Activity
Activity: Daily activities that do not provoke symptoms

Phase 2
Aim: Light Aerobic Exercise
Activity: Walking / Stationary Cycling. No resistance

Phase 3
Aim: Sport-Specific Exercise
Activity: Running, adding movement

Phase 4
Aim: Non-Contact Training Drills
Activity: Harder training drills e.g. passing, drills that require thinking. Can also start progressive resistance training

Phase 5
Aim: Full Contact Practice
Activity: Following medical clearance, full normal training session

Phase 6
Aim: Normal Match Play
 
It’s important to note that the player must have no symptoms before progressing to the next phase
 
Criteria for Physiotherapy Post-Concussion
So now that physiotherapy is recommended in the guidelines, when is it appropriate to be seen by one and what will they do?
Firstly, whoever is on the sideline at the time of your concussion should do a full evaluation of your head injury. 4 out of 10 concussions are better by week 1 but if you’re unfortunate to be one of the remaining 6 whose symptoms last longer than a week, then you need to see a physiotherapist trained in vestibular rehabilitation.
Your neck, balance and vestibular functioning will be assessed and an appropriate exercise programme for your neck pain / decreased balance / dizziness will be started. The only time you  should visit a vestibular physiotherapist immediately after your concussion is if you are suffering from vertigo (spinning sensation). Your therapist will assess the type of vertigo and treat accordingly.
Therefore it’s important to note that not all concussions require vestibular rehabilitation!
 
Concussion Assessment
So if there’s no healthcare professional available pitchside to assess a concussion what do you do?
Firstly, in order to assess a concussion both pitch side and fully, there are several assessment forms you can use and easily download. However if you’re not the most organised (like myself!) download the Concussion app from Acquired Brain Injury Ireland. This app will take you through a shortened and lengthy concussion assessment and is a must for any coach or parent.
Secondly, if you suspect a player has a concussion remove them from play immediately. You can see from the graduated return to play protocol that it’s important not to over-exercise with concussive symptoms as this can prolong your recovery. Let’s not forget that you’re dealing with a brain injury. Would you allow someone to play on if they had a stroke? Of course not, so why do it with a concussion? Don’t be negligent; if in doubt, sit them out!
References:

• Clay, M. B., Glover, K. L., & Lowe, D. T. (2013). Epidemiology of concussion in sport: a literature review. Journal of Chiropractic Medicine, 12(4), 230–251.
• McCrory P, Meeuwisse W, Dvorak J, et al. Br J Sports Med 2018;51:838–847.

How many of you out there have experienced vertigo? How many times have you simply rolled over in bed or stood up and felt dizzy? Are you one of those people who says you "just got up too quickly"?! Maybe you should get assessed for vertigo by a physiotherapist trained in vestibular rehabilitation. Physiotherapy can offer immediate resolution of your vertigo symptoms without the need for tablets or bed rest. Let us explain how!

​Vertigo is actually a symptom, and not a diagnosis. That means that when you're told you have vertigo, that's really only half the story. Vertigo is that horrible sensation where the world is spinning. It's an incredibly debilitating sensation as you struggle to walk, drive or even stand. Therefore you yourself can identify when you have vertigo, the tricky part is figuring out which type of vertigo it is.

Benign Paroxysmal Positional Vertigo or BPPV is the most common cause of vertigo. This is when tiny crystals (called otoconia) get displaced from the utricle (see diagram below) and can become either free-floating in the canals or at the end of each canal in your inner ear. Each canal has a specific test to determine whether the otoconia are located in it and from there your treatment plan can be decided. 

Treatment
The most commonly affected canal is the posterior canal and to test this the Hallpike Dix Test is performed. If positive, the eyes will move in a certain direction and the vertigo symptoms will be reproduced. From that position we can go straight into treatment which involves moving the head in certain directions to move the otoconia out of the canal and back into the utricle. This manoeuvre can be done a few times in one treatment but generally it resolves symptoms immediately. It's important you don't lie down for a couple of hours afterwards as this could undo all of the good work and allow those otoconia to get back into the canal!

​Research

A recent Cochrane review by Hilton & Pinder (2014) found that these re-positioning manoeuvres (as described above) are effective in completely resolving your vertigo in 56% of cases. There is unfortunately a recurrence rate of 36% which is why McDonnell & Hillier (2015) recommend a combination of vestibular rehabilitation and these manoeuvres to keep your vertigo at bay. Research in vestibular rehabilitation is certainly a growing area and there are currently several studies being carried on other forms of re-positioning manoeuvres.

One thing is for sure, vestibular rehabilitation is definitely worth a try for those of you experiencing vertigo or dizziness symptoms!  You can contact us here at PhysioElite for an assessment any time or if you've any questions!

References 

• http://vestibular.org/understanding-vestibular-disorders/types-vestibular-disorders/benign-paroxysmal-positional-vertigo (Accessed on 21/11/2016)
• Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD003162. DOI: 10.1002/14651858.CD003162.pub3.
  
• Hunt WT, Zimmermann EF, Hilton MP. Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV). Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD008675. DOI: 10.1002/14651858.CD008675.pub2.
  
• ​McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews 2015, Issue 1. Art. No.: CD005397. DOI: 10.1002/14651858.CD005397.pub4.
  

For those of you turning over a new leaf for 2014 and for all who are returning to training soon, the ultimate question remains; Why do I get sore after a tough session and is there anything I can do? 

Up until now, the majority of the treatment has been based on hearsay from "Make sure you do your stretches" to "Go for an easy run or walk tomorrow to loosen yourselves up". All sounds familiar but what does the evidence say? In a recent systematic review (the highest form of evidence) physiotherapeutic interventions are studied to see what is the best form of treatment for delayed onset of muscle soreness (DOMS)

We're all too familiar with that soreness and tightness in our muscles after a particularly tough session or a new type of exercise. But what exactly is DOMS? In a study by Clarkson et al in 1999, they described DOMS as "muscle damage caused by strenuous and unaccustomed exercise, especially exercise involving eccentric muscle contractions".

Our muscles contract in a number of ways. A concentric contraction is the one we're most familiar with where our muscle shortens (ex: our biceps shorten when we bend our elbow). An eccentric contraction is when our muscle lengthens while still exerting force (ex: a hurdler's hamstring while jumping over a hurdle is in a lengthened position but is still contracting). When one tears their hamstring, the hamstring is usually eccentrically contracting at that time.

Unfamiliar eccentric exercise frequently results in muscle damage at both a direct (cellular) level such as elevated creatine kinase activity, and an indirect level (changes in muscle function) such as strength loss, pain, and muscle tenderness. However following recovery of this "damage", a repeated bout of the same exercises results in minimal symptoms of muscle damage and has been referred to as the "repeated bout effect". But is there anything to minimise the symptoms between your first session and the next or do we just have to wait it out?

Torres et al (2012) pooled together a number of studies examining the effects of certain physiotherapy treatments for DOMS. These interventions included:

• Cryotherapy (ice)
• Stretching
• Low Intensity Exercise
• Massage

10 studies looked at the effects of cryotherapy in the form of ice baths on recovery from DOMS. The authors could find no evidence to support the use of cryotherapy. 

The studies did show a decrease in muscle soreness at 48 hours (1.22cm on a 10cm visual analogue scale - pain measuring tool) and at 72 hours (2.11cm on the same scale). However as the studies were so diverse, it was difficult to pool the results therefore these statistics should not be relied upon.

The studies also noted an improvement in muscle strength at 24 hours (6.93% increase) however again as the studies were not similar in format, we cannot rely on these results. 

Nine trials studied the effects of various types of stretching on recovery from exercise-induced muscle damage. The stretching included before exercise, before and after exercise and after exercise only.

The authors however found no positive effects of any form of stretching on both muscle soreness and muscle strength following DOMS

Seven studies looked at the effects of low intensity exercises on recovery from exercise-induced muscle damage. When all the results were pooled together however, there was no significant benefits of low intensity exercises at 1, 24, 48 or 72 hours post high intensity exercise that induced muscle damage.

Nine studies analysed the effects of massage and of all the interventions, massage was the only one with positive results. Massage reduced soreness at the 24 hour stage. On average, those who had received massage as an intervention had a 0.33cm decrease on a 10cm visual analogue scale (pain measuring tool). It also increased muscle recovery by 1.87%.

You don't have to be a mathematician to realise that a 0.33cm decrease in pain and a 1.87% increase in muscle recovery does not make for vast improvements. So is there any point in massage if the benefits are so small?

The results of this review show that

• Massage slightly improves muscle soreness and muscle recovery at the 24 hour stage following high intensity exercise
• Cryotherapy may or may not decrease muscle soreness and improve muscle strength at various stages following high intensity exercise. More evidence is needed in this area
• There is no evidence to support stretching or low intensity exercises in the prevention of DOMS

Does this ring true to you? Do you find there are few benefits of the above interventions when you're suffering from exercise-induced muscle damage? Should we stick to the evidence or follow the advice passed down from generations before? Comment below and let us know what you think!

Clarkson P. M., Sayers S. P. (1999) Etiology of Exercise-Induced Muscle Damage Canadian Journal of Applied Physiology, 24(3): 234-248

McHugh M. P., Connolly D. A. J., Eston R. G., Gleim G. W. (1999): Exercise-Induced Muscle Damage and Potential Mechanisms for the Repeated Bout Effect. Sports Medicine 27(3): 157-170
 
Torres R., Ribeiro F., Duarte J. A., Cabri J. M. H. (2012): Evidence of the physiotherapeutic interventions used currently after exercise-induced muscle damage: Systematic review and meta-analysis. Physical Therapy in Sport, 13(2): 101-114