By Debra Anderson, DPT 

We were taught from a young age how important it is to have strong, healthy bones. In fact, almost 90% of your bone mass is gained by the time you are 18. And max density is reached by the late 20’s. Unfortunately, weak bones are extremely common – especially as we get older. Osteoporosis occurs when your body does not maintain a healthy bone density from either absorbing too much bone, not creating enough new bone, or a combination of the two.

This article provides information on the more common lay person perspective of osteoporosis – that related to aging; as well as poor bone health in the endurance athlete.

 

OSTEOPOROSIS RELATED TO AGING

Osteoporosis is more common in women, but it also occurs in men. Around 50% of women and 25% of men have an osteoporosis related fracture after the age of 50. One of the reasons women have an increased risk of osteoporosis is menopause. Estrogen has a protective effect on bone strength, and as the body stops producing as much estrogen during menopause the risk for osteoporosis increases. Another risk factor for osteoporosis is age. As we get older, the risk increases, especially over the age of fifty.

The good news is there are a variety of ways to maintain the bone strength you currently have and further reduce the risk of fractures by making sure your bones are as strong as possible. Receiving adequate nutrition as well as making sure to take the recommended amount of Vitamin D and calcium  are the first lines of defense against bone loss. Vitamin D is necessary for your bones to go through the process of remodeling as it helps your bones  process calcium. Without Vitamin D, calcium is not absorbed and utilized in our body. Hence why milk and calcium supplements are fortified with Vitamin D.

Your body can naturally produce vitamin D from sun exposure, but it is very important to ensure adequate sun protection with sunscreen. It can also be difficult to know if you create enough vitamin D from sun exposure. Supplements of vitamin D and calcium are the best way to obtain the recommended levels your bones require. It can also be beneficial to obtain more of these nutrients from your diet. Dairy products contain calcium, and some are also fortified with vitamin D. Fatty fish such as tuna and salmon also contain naturally occurring vitamin D.

Exercise is another vital component of maintaining bone strength, specifically weight bearing and resistance exercises. Impact exercises such as walking, hiking, and running are very important. Strength training with added resistance from weights or simply with your body weight is also a key component of a healthy routine to keep your bones strong. Squats, lunges, and push ups are great places to start. It is also essential to vary your routine and regularly progress your exercises to ensure your body continues to build up bone strength. For those with limitations in activity due to weak bones, fractures related to low bone density, and pain; seek the professional advice and guidance of a physical therapist who is experienced in managing people with osteoporosis.

There is evidence that exercise in adulthood decreases the risk of fractures even if bone density is only maintained and not improved. The American College of Sports Medicine has specific recommendations regarding exercise for adults. Resistance exercises such as weight lifting are recommended 2-3 times per week for 30-60 minutes. Impact exercises such as walking or running are recommended 3-5 times per week also for 30-60 minutes. These recommendations can be very helpful when determining your exercise plans for the week.

Bone health is determined by how dense your bones are. Bone density is generally measured by dual energy x-ray absorptiometry, also known as a DEXA scan. This is a low radiation full body x-ray that can be completed in just a few minutes. The results of the scan will show how your bone density compares to others of your gender in a similar age range.

 

OSTEOPOROSIS IN THE ATHLETE

While osteoporosis is generally thought of in individuals of increased age, there is another group of women who are at high risk. Adolescent and adult premenopausal female athletes, especially elite or multi-sport athletes, are at an increased risk for what’s known as the Female Athlete Triad. The Female Athlete Triad is composed of three interrelated parts: amenorrhea or irregular/light menstrual cycles, disordered eating or low energy intake, and low bone density ranging to osteoporosis. The triad is defined on a spectrum, and all three components do not need to be present before intervention is essential.

Sports in which a lean physique is beneficial for performance, such as distance running, gymnastics, ballet, and cheerleading have a higher incidence of participants at risk for the Female Athlete Triad. Eating disorders including anorexia nervosa and bulimia cause the body to be at a nutritional deficit and can impact the body’s ability to maintain bone health. As calcium is required for essential bodily functions, if enough is not consumed, the body will take calcium from the bones. This causes weak bones and increases fracture risk.

Defined eating disorders are not the only cause of nutritional deficits. There are athletes, especially multi-sport athletes, who burn an immense number of calories per day and may simply not realize they are not eating enough to maintain a nutritional and caloric balance to keep their bodies properly fueled. Caloric deficits can lead to abnormal menstruation or amenorrhea. This is a warning sign of nutritional deficits, but it also means that the body is not producing as much estrogen, which was previously described as an essential component for bone density regulation.

It is important that athletes as well as their coaches are aware of the signs and symptoms of the Female Athlete Triad. The triad increases the risk of stress fractures from overuse as well as more severe fractures from falls. Of further concern, adolescent girls with one or more components of the Female Athlete Triad are not able to adequately build up strong, healthy bones during the most important time period for this. If this condition is not treated, these young women may be at an increased risk for low bone density related fractures for the rest of their lives as it is much more difficult to improve bone density after young adulthood.

If you are concerned about your bone density,  speak with your doctor about it. Your doctor may recommend a DEXA scan, and they will be able to go over recommended management options including medication if necessary. They will discuss the importance of appropriate exercise and nutrition and should provide you with a list of recommended specialists who can help you. The physical therapists at Rose City Physical Therapy are well versed in managing age related osteoporosis as well as bone injury related to the Female Athlete Triad and would  be happy to help you develop a safe exercise routine focused on improving your bone strength.. We also have collaborative relationships with nutritionists in the Portland area that are well educated on managing bone health.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349390/pdf/10.1177_1941738116677732.pdf  Bone Health in Athletes: The Role of Exercise, Nutrition, and Hormones

https://www.nof.org/  National Osteoporosis Foundation

www.skincancer.org/blog/sun-protection-and-vitamin-d/  Skin Cancer Foundation

 

About Debra Anderson, DPT

Debra is from the small town of Boone located in the mountains of North Carolina. She went to Appalachian State University for her undergraduate education and received her degree in Exercise Science. While there, she competed as a NCAA D1 pole vaulter. Debra then attended graduate school at East Carolina University where she received her degree as a Doctor of Physical Therapy.

Debra has passion for treating patients with general orthopedic injuries as well a special interest treating patients with a variety of sports related injuries. She particularly enjoys the challenge of treating injured runners to enable them to get back to their sport as quickly as possible. She enjoys utilizing a variety of treatment techniques including individualized rehabilitation exercises as well as manual treatment to provide her patients with the best care possible.

In her free time, Debra enjoys hiking, traveling, cooking, skiing, and trail running. She also enjoys trying out new restaurants and breweries around Portland with her husband. Debra’s husband is a distance runner and avid member of the Jacuzzi Boys Athletic Club.

 

 

The AlterGⓇ Anti-Gravity Treadmill at Rose City Physical Therapy

By Sasha Kolbeck, DPT

The term anti-gravity can lead to thoughts of space. Dr. Robert Whalen, a NASA engineer worked to develop technology to help astronauts exercise in space to counteract the effects which lead to bone and muscle loss.  His son Sean looked to create anti-gravity on earth, leading to the concept of the anti-gravity treadmill in 2005, which uses air to lift or off-load the user’s body weight. Initially, the treadmill was used by Olympic runners, the NBA, the NFL, and at universities for their athlete’s rehabilitation and performance training. Now, it is found in physical therapy clinics for rehabilitation for patients that would benefit from decreasing body weight on their bones, joints and soft tissues.

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Managing Pain through Mindfulness

By Ari Witkin, DPT

This is Part Two of a two-part series. Click here to read Part One.

In recent years, mindfulness and meditation have crept into the mainstream. Not too long ago, we thought of this practice as religious or mystic. It was either inaccessible or too scary for most of us. With the inclusion of meditation in society at large comes a great deal of scientific research into its effects on various aspects of life. One of those is how mindfulness affects pain.

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Pain Education 101: Pain Science made Easy

By Ari Witkin, DPT

This article is Part One of a two-part series. Click here to read Part Two.

As children, we would sometimes fall and scrape our knee. Maybe it was bleeding; certainly it was painful. We thought the pain was caused by something at the site of the injury and it was sending a signal to our brain, saying, “THIS HURTS!” Our parents would give us a kiss, put a bandaid over our injury to soothe our pain. Again, we thought if we could cover the wound and heal the tissue we’d be in less pain. As it turns out, this entire concept of the pain experience was not wrong, but incomplete.

There are a number of myths about how we experience pain and why getting rid of it is often more complicated than simply healing our tissues. We will discuss three important myths and offer a more complete truth about the pain experience.

Myth #1 – Pain signals in your body send messages to your brain telling you when to hurt.

Truth #1 – The brain interprets messages from your body and decides how much pain, if any, you will experience. Thus, ALL pain originates in the brain.

A person wakes in the morning with excruciating pain in his right foot. Except, he doesn’t have a right foot; it was amputated 6 months ago. The pain is real. So, how is this possible?

Throughout our body, we have signal receptors called nociceptors, which have, in the past been deemed “pain receptors.” More accurately, they are “danger receptors.” When something happens at the tissue level – sprain, strain, bruise, break, puncture, pinch – these nociceptors initiate a signal to our central nervous system comprised of the spinal cord and brain. It is then up to our central nervous system to interpret that signal. That interpretation has many factors (more on this later). If the signal is deemed sufficiently dangerous, the brain will create a pain response. 

That response is sent to a genetically predetermined map in our brain that creates pain in our body. Sometimes, this pain signal is sharp and localized, other times it can be diffuse and dull. 

This map exists in your brain no matter what happens in your body. This is why someone with an amputation can feel pain in a body part they no longer have – their brain is creating a pain sensation, even without input from the body. It’s also why some signs of a heart attack are pain in the jaw and down the arm. And why sometimes back pain can feel sharp and localized and other times like your whole back is on fire. 

Myth #2 – Pain is dependent only on the amount of tissue injured.

Truth #2 – Many factors play a role in your pain experience including your environment and stress levels.

Imagine two women in their mid 30’s sitting next to each other at the PT clinic. They’re both generally healthy and active. Both have been experiencing neck pain for 3 weeks. MRI and x-ray imaging look identical. Anatomically speaking their injuries are the same, but one woman is experiencing significantly more pain than the other.

In order to find out why there’s a discrepancy with seemingly the same injury, we have to delve deeper. Pain is multifactorial and does not depend solely on the state of the tissues.

What if you knew that one of the women, the one in more pain, was going through a divorce? Or maybe she’s a swimmer and is nervous she may not be able to get in the water again. Perhaps she’s been fighting this injury for 3 years and hasn’t yet found a physical therapist she’s connected with.

What would change if that woman had a terrific social support system of close friends and family? Perhaps her pain would be different if her physical therapist listened to her whole story, understood what swimming meant to her, and made it their objective for the patient to achieve her goal. 

Injury at the tissue obviously plays a major role in the pain experience. However, it does not tell the whole story. Stress, anxiety, fear of future pain, social support system, happiness with career, nutrition, and numerous other factors play unique roles. The brain will interpret all of these factors and either up or down regulate the severity of pain. 

Myth #3 – There must be an injury in order for there to be pain.

Truth #3 – Pain is a signal of potential danger, rather than past injury.

This may be the most crucial aspect to understanding how pain works. Pain is not a result of tissue injury; it is a conscious alarm your brain sounds to beware of potential future danger. 

Lorimer Moseley, a pain scientist credited with much of the research in this field, shared a story in what is now a famous TED talk (https://ed.ted.com/on/Li50Ci7S). Moseley was walking in the desert and gets bitten by a snake. Thinking his leg was simply scraped by a tree branch, he keeps going, feeling no pain. He returns to town, ends up in the hospital and barely survives. Sometime later, he goes back on the same walk. This time, his leg does get scraped by a tree branch. Thinking it’s another snake bite, he is in agonizing pain.

Why the dichotomy? The pain experience Moseley describes in the latter case, shows that the brain remembered the life threatening experience of the snake bite and interpreted a skin scraping as a more dangerous and therefore, more painful.

Evolutionarily, the pain experience is no different than other biological protective mechanisms. Like the turtle’s shell or the rose’s thorn, pain helps protect us from threats. This process translates past experience into current pain in order to protect us from future danger. 

In more specific terms, when your brain interprets signals as a credible threat, it will increase pain levels. On the other hand, if it determines that you are in a safe and protected environment, it will reduce pain. 

The pain you’re experiencing is very much real. Our understanding of how it comes about has shifted in recent years. Knowing that the cause of pain is more multifactorial allows the treatment to be more holistic, giving physical therapists and patients endless options to assist in its relief. 

Resources

Louw, A., Diener, I., Butler, D. and Puentedura, E. (2011). The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Archives of Physical Medicine and Rehabilitation, 92(12), pp.2041-2056.

Louw, A., Farrell, K., Landers, M., Barclay, M., Goodman, E., Gillund, J., McCaffrey, S. and Timmerman, L. (2016). The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial. Journal of Manual & Manipulative Therapy, 25(5), pp.227-234.

Moseley, G. (2007). Reconceptualising pain according to modern pain science. Physical Therapy Reviews, 12(3), pp.169-178.


About the Author

Ari WitkinAri is originally from Austin, TX. He received an undergraduate degree in Economics and Political Science from UC Santa Cruz, and a Master’s degree in Public Policy from University of Texas. After years of working in the public policy sector in Washington, DC and Austin, TX, Ari decided to make a professional change, return to school and received his Doctorate of Physical Therapy from Texas State University.

Ari believes that movement is a fundamental human right and derives great joy from guiding clients towards achieving their goals. From getting on the ground to play with your grandchildren to preparing for your next marathon and everything in between, Ari wants to help you get there with a smile on your face.

Read more about Ari.

Aggressive Sports Injury Management

Original Article Published on Premax

There’s one question that is on the top every athlete’s list when they sustain an injury – when can I play or race again? It’s a question that I usually answer with another question; when do you need to? Sometimes there’s an important event or competition coming up and it needs to be considered in a management and treatment plan. Can you push the boundaries in returning to sport quickly? Yes. Is it the best thing to do? Read on.

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4 Tips For Preventing ACL Tears in Females

Article Originally Featured on US News | Images Courtesy of Listopedia

How to foil a common but preventable injury.

“It is very common for women — four to eight times more common than it is for men — to tear their ACL,” says sports medicine expert and orthopaedic surgeon Miho Tanaka, M.D., director of the Women’s Sports Medicine program at John’s Hopkins, “But we also know that 70 percent of ACL injuries occur without collisions, meaning there are things women and girls can do to help prevent this type of injury from occurring.”

Noncontact anterior cruciate ligament (ACL) tears and injuries often occur when an athlete goes to pivot or change direction quickly. The knee gives way and the muscles aren’t there to support it, causing the ligament to tear. However, Tanaka notes, “data shows that doing the right exercises can actually help prevent certain knee ligament injuries — like ACL tears — by strengthening the right muscles.”

A female athlete herself and former collegiate triple jumper, Tanaka shares the following tips to help keep women from experiencing an ACL tear:

Side squat Workout

1. Maintain a center of strength.

You want to strengthen your muscles, not strain them. Many athletes try to push themselves while working out — run one more minute, do one more rep, lift just five more pounds — but doing so can actually cause strained muscles and lead to injury. Instead, Tanaka suggests concentrating on building and maintaining strength across the board during your workouts.

“Having a strong foundation and strength in the muscles that you use in your sport or activity is what will help prevent injury,” she says. For women specifically, this includes building your core muscles and hamstrings — the muscles that run up the back of your thigh — which help prevent against ACL injuries.

2. Stretch for symmetry.

Having balance between the left and right sides of your body is very important in preventing sports injuries. “Studies have shown that even 15 percent side-to-side differences in flexibility and strength can increase a female athlete’s risk for injury, so it’s important for them to pay attention to any imbalances while stretching,” Tanaka says.

“This imbalance can cause the body’s center of gravity to shift while landing from a jump and places girls at risk for knee injury. Sometimes athletes think that stretching is boring and don’t pay attention while doing this, but subtle things, such as stretching the right side less than the left, can add up and create an imbalance.”

3. Activate the right muscles during exercises.

“Exercises that build the hamstring are very important for women participating in sports and physical activities to help prevent ACL injuries,” Tanaka says. In general, women have less hamstring strength than men, which leads to an inability to control the knee if it gives out during movement.

When doing landing drills, like jumping squats, for example, women need to get down low enough in their squat to activate their hamstrings and build that strength.

4. Eat a well-balanced diet.

“Nutrition does not equal dieting,” Tanaka says. “Generally women don’t eat enough and end up calorically deficient and/or dehydrated, which leads to fatigue.” When athletes are tired and worn out, they tend to stop concentrating on their form. That’s when an injury is likely to happen. Instead, women should concentrate on drinking enough water and eating a well-balanced diet, including fruits, vegetables, low-fat proteins and whole grains.

Research Shows …Retearing Your ACL

A torn ACL can be career-ending. Studies have shown that once an athlete has torn his or her ACL, the chance of re-tearing it is six times greater. Additionally, once a female athlete has torn hers, she becomes 16 times more likely to tear her ACL in the other knee. This is why it is especially important for female athletes to follow the right steps to prevent an ACL injury from happening.

Blood Flow Restriction Training for a Strengthening Edge

Lead Photo: Courtesy of B Strong Training System

What is Blood Flow Restriction (BFR) Training?

Whether facing a long surgery such as an ACL reconstruction or rotator cuff repair, or fracture recovery with precautions, or insurance limits and higher out of pocket costs, methods to help assist with strength gains is crucial. Blood Flow Restriction (BFR) training is a technique which creates a hormonal response to trick the body into thinking it is completing high intensity exercise and leading to gains high intensity exercise provides, despite actually utilizing low intensity and lower load based exercise. This is especially important for patients and athletes that have restrictions due to surgery, fractures, soft tissue and bone health, and limited load allowances or tolerances.

How does Blood Flow Restriction Training Work?

Blood flow restriction partially restricts arterial blood flow to your tissue while completing restricting venous flow (return from you tissue to your heart) during exercise. Pneumatic compression cuffs are placed around the upper arm and/or upper thigh and a pump is used to inflate the cuffs to a safe calibrated level of pressure, creating a tourniquet effect. This in turn causes a lack of oxygen for the muscles and stimulates physiologic responses in the body that mimic that of heavy resistance training. Exercise is completed with the cuffs in place.  You will find increased intensity and difficulty of exercise with BFR that otherwise would not prove as challenging.

The History of Blood Flow Restriction Training

The technique dates back to 1966 in Japan when Yoshiataki Sato noticed after being in prolonged kneeling, his legs felt similar to how they felt after strength training. In 1973, he had an ankle and knee injury while skiing.  He experimented with occlusion training while in a cast. After six weeks, his physicians were impressed with the minimal strength loss, despite the cast. Thereafter, over the years he tested various ways to restrict blood flow until KAATSU was developed in the 1990’s and the first research was published. Occlusion training and use was limited initially to Japan. In the last 20 years, research appeared in Western medical journals after the technique was used in the US Military for recovery post traumatic injury.  In the last 10 years, more frequent mainstream use has occurred in sports and physical therapy.

Benefits of Blood Flow Restriction Training

Research shows that strength gains and muscle hypertrophy (growth in size) is significantly greater with BFR training, than with low resistance exercise alone. These gains can occur within weeks, and are similar to high intensity and heavy load resisted exercise. Exercise recommendation is 20-40% of one’s 1-repetition max (RM), higher repetitions, frequent rest breaks, sessions of 20 minutes or less, 2-3 times a week, and for a duration of greater than 3 weeks. Blood Flow Restriction can also be added to aerobic exercise such as walking and cycling with research showing carryover for improved function for daily activity, aerobic capacity, and health. There are some limits due to the comfort of wearing the bands during cardiovascular exercise. Other promising benefits include pain control, bone healing, increased bone density, accelerated tendon injury recovery, and a complement after Platelet-rich Plasma (PRP) and Stem cell regenerative injections.

An understandable concern is safety. Research actually reports decreased deep vein thrombosis (DVT) risk and lower hypertensive response with exercise. Muscle damage can occur without the use of proper equipment as well, as not following instructions. The technique is not recommended for those who are pregnant and requires surgeon approval post-operatively and post fracture, and for cardiovascular medical conditions.

Is Blood Flow Restriction Training Right for Me?

To summarize, BFR training provides another tool for physical therapy treatment to increase strength gains sooner and with less load on injured tissue or during post-operative precautions.  Some of the exciting uses include post-operative rehab, fracture management recovery, athletes cross-training, load management, for the elderly, and for those with arthritis. Safe use requires medical guidance and adherence to established compressive loads applied to the cuffs. If your physical therapist and physician adds BFR training to your plan of care, expect to work hard, but the reward will be earlier increased strength and muscle muscle mass and quicker return to function.

Blood Flow Restriction Training

Left: B Strong BFR cuff set up on a patient’s thigh. Right: US Ski Team and Olympian Jacqueline Wiles using B Strong BFR during rehab at Rose City Physical Therapy

The physical therapists at Rose City Physical Therapy have been formally trained in Blow Flow Restriction using the B-Strong BFR Training System ™ co-developed by sports medicine physician and researcher Dr. Jim Stray-Gundersen, MD.

Article by Sasha Kolbeck

Ski season is approaching, and in the US, 50 of 100,000 skiers per day will tear their ACL. Overall, women are 2-8x more frequent to injure. Females are at higher risk for various reasons, some of which can be changed and some which cannot. The modifiable factors for females per Dr. Noyes research are Quadriceps dominance and Neuromuscular control:

  • Quadricep Dominance…The hamstring is the guardian of the knee. Women tend to activate the quadriceps, then the hamstring and have decreased hamstring strength, which puts the ACL at risk.
  • Neuromuscular Control…sensing, reaction time, and muscle pattern for movement and landing.

The modifiable factors for both male and female include: technique of jumping, cutting, pivoting, fatigue, knee position, and postural control.

What happens if I already have an ACL injury?

Despite the best efforts at modifying the above, you sustain an ACL injury, now what? Research supports the importance of prehab physical therapy to establish baseline for return to sport testing measurements, increase motion and strength, improve outcome, and increase return to sport.

After surgery, research shows physical therapy is again crucial. It should be at least 6+ months in duration. Patients who stopped treatment after 3 months were not able to pass return to sport testing. Treatment should be quality and comprehensive including hands on manual therapy, Blood Flow Restriction (BFR) training, sensory training, strengthening, neuromuscular control, and testing to adjust and progress as appropriate. Long term deficits for months to years including change in brain activation requiring reliance on vision, running deficits, and weakness.  Blood Flow Restriction training leads to strength and increased muscle mass, and benefits of heavy resistance training without the strain on healing tissues. (Watch for future article for further information).

How soon can I return to sports after an ACL injury?

After working hard in physical therapy, what is the return to sport timeline? For recreational and elite athletes, it is 9-12 months and for those less than 20 y/o – 12-24 months is recommended.  For every month you delay return to sport after ACL reconstruction, the risk of re-injury is reduced by 51%, until 9 months post-operatively. Our local US Ski Team downhill skier, Jaqueline Wiles, will return to competition December 2019, after her extensive knee injury February 2018.

Part of the criteria to return to sport (RTS) includes testing. Of 62 patients, only 3.2% passed all RTS at 6 months and 11.3% at 9 months. It is important to note, that you can still re-injure with passing testing, but your risk is greatly reduced if tested at 9 months and you meet criteria. Testing needs to be comprehensive with multiple tests.  Even professional athletes are at a 4x increased risk of 2nd knee injury by not meeting all criteria, so those of us that are recreational, without the same amount of resources, definitely need to put the time in and pass testing.

What is my risk of re-injury after an ACL injury?

What is the data regarding re-injury? The greatest risk is at 1-2 years post injury. ACL graft remodeling takes 12 months for autograft (your tissue) and 24 months for allograft (cadaver).  The graft needs loading for healing, but too much can stretch the graft; hence, need physical therapy guidance. Women more commonly re-injure, but the most concerning statistic is 21% for those under age 25. Overall, there is a 20% re-injury rate for those that return to sport. A second ACL surgery has a higher failure rate and decreased patient satisfaction, prolonged physical therapy due to slower healing, delayed return to sport, and decreased performance, so it is best to put in the work and time to decrease risk of re-injury.

How can I prevent an ACL injury?

Research shows the importance of injury reduction programs such as Sportsmetrics®, to decrease the risk of an injury in the first place, or an additional injury. The injury reduction with these programs is a significant 40-65%. Maintaining strength also helps support the knee to decrease risk of arthritis. The added benefit of these programs is increased performance for power, strength, sprint time, agility, single leg hop, and jump height.

In closing, once you are given the go ahead to click into the skis, it’s imperative to continue your strengthening and injury reduction program. And before each ski session, complete dynamic warm ups such as below, to prepare your tissue to tackle the slopes.

Warm up before hitting the slopes

ACL Injury Prevention Warmups


SASHA KOLBECK, MPT, DPT, OCS, COMT

About the Author

Rose City Physical Therapy’s Sasha Kolbeck, DPT has extensive experience in knee injury rehab and incorporates sound principles in testing and rehabilitation from the SportsMetrics™ program and extensive research from the teaching and mentorship by George Davis, DPT, MEd, SCS, ATC, FAPTA to provide evidence based knee injury and post-surgical rehab programs.

She provides free community lectures on ACL Injury and Return to Sport as well as Increased Performance and ACL Injury Reduction to local clubs and groups from the youth through adult audience. Contact us for more information, or to express interest in having her present to your group.

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12 Tips for Avoiding Low Back Pain While Raking Leaves

Fall is arguably the most beautiful season of the year.  Cooler temperatures, comfy sweaters, the smell of a fire burning in the fireplace and the changing colors of nature that surround us in the beautiful northwest.  Raking leaves can be an enjoyable way to spend time outdoors, soaking up the sights and smells of the season. Be careful out there, though, because if you’re not careful you could end up with back pain or sciatica or other potential injuries.

One of the most common complaints following several hours of raking leaves is low back pain. The repetitive movements and constant bending and lifting can wreak havoc on your back. If you’re not careful it’s easy to injure your back, making everyday activities and a good night’s sleep a challenge.

Rose City Physical Therapy is very familiar with back pain experienced by homeowners trying to keep up with constantly falling leaves. Every autumn they see many patients complaining of low back pain and sciatica after a weekend of raking leaves.

“One of the biggest mistakes many people make when raking leaves is not raking with both sides of the body,” says Rose City Physical Therapy. Most people only rake with their dominant hand causing the muscles and other tissues to strain on one side of the body. Switching hands is important to give those muscles a break and to build up strength in the same muscles on the other side.

Rose City Physical Therapy recommends following these 12 tips when raking leaves to help reduce muscle fatigue and to ideally avoid back pain all together.

Original Article found at easyrest.com
1. Warm up.
 Take a 5-10 minute brisk walk to warm up your muscles. Avoid any stretching of cold muscles prior to the activity. Scientific evidence reports that stretching without a warm-up increases risk of injury and there is no evidence that stretching before an activity prevents injury.

2. Choose the Right Rake. Use a rake that is proportionate to your body size. Using a rake that is too long or too short will cause you to alter your posture and strain your muscles. Consider the rake width. Narrow rakes may make the weight of the leaves lighter but they can also make the job longer. Extra wide rakes gather more leaves but can put more of a strain on your back.

3. Watch Your Posture. Like any exercise, proper form is important. Muscle pain and strain occurs when you put your body in awkward positions and then try to contract or extend muscles in these odd positions. To maintain proper posture while raking keep your legs slightly bent, your weight centered, and reach with your arms and not your back. After every 20 minutes of raking activity stand up, place hands on hips and gently stretch into a back bend for a few seconds 3-5 times especially before lifting anything. Do not extend to the point of causing pain.

4. Switch Hands Frequently. You exhaust your muscles with repetitive motion. Switch your lead arm frequently while raking to prevent, or alleviate, muscle exhaustion

5. Bend With Your Knees. When lifting leaves keep your back straight and bend with your knees and hips, not your back, when reaching down. The power for your lift comes from your buttocks and legs. Make the piles small to decrease the weight.

6. Rake With the Wind. Let Mother Nature give you a hand if possible. Rake leaves with the wind, even if the spot in the yard is different from where you wanted to rake the leaves.

7.Use a Tarp. Leaves are lightweight and can easily be moved on a tarp. Rake the leaves onto the tarp and pull one end of the tarp to move the leaves to your desired location. Doing this can save your back constant bending over to pick up piles of leaves to put into a garbage bag or wheelbarrow.

8.Drink Plenty of Water. Muscles need water to function optimally. When you maintain your body’s hydration during activity, you reduce the risk of muscle strain.

9.Wear Good Shoes. Wear supportive shoes with good support and skid-resistant soles. Standing on your feet and raking all day can put a lot of strain on your feet and legs. Good foot support can stop some of that strain from reaching your back and skid-resistant soles can minimize the risk of slipping on wet leaves and falling.

10. Consider a Leaf Blower. There are some lightweight gas and electric leaf blowers on the market that are hand held or can be worn like a backpack. Blowing all the leaves into one large pile or onto a tarp can save time and lots of energy.

11. Wear Gloves. Give your hands a break and wear gloves to prevent painful blisters.

12. Take Frequent Breaks. Taking your time will make it less likely for injuries to occur. Pushing yourself to the point of exhaustion can cause you to get sloppy with good posture and lifting techniques, setting you up for injury.

What can you do if you follow all of these tips and still wind up with low back pain?

We recommend conservative treatments including:

  • Ice pack for 20 minutes three times daily for 2-3 days for an acute injury. Alternate moist heat and ice treatments thereafter, or just use moist heat.
  • Exercise, stretching techniques, or physical therapy to repair and strengthen muscles.
  • Lifestyle changes such as weight loss and regular exercise.
  • Propping pillows behind your back when sitting to avoid slouched postures, and under knees when resting in bed to take pressure off of your lower back.

Contact us to set up a complimentary 20-minute consultation if you are experiencing back pain or sciatica, or if you have any questions.


Karl Kolbeck is a physical therapist and along with his wife Sasha they own Rose City Physical Therapy located in NW Portland. He’s been practicing for 25 years with specialties in treating the shoulder as well as runners. Karl is dual board certified in both orthopedic and sports clinical specialties, is certified in manual and manipulative therapy and is a fellow of the American Academy of Orthopedic Manual Physical Therapists. He teaches rehab based continuing medical education courses to physicians, physical therapists and athletic trainers across the nation. He and his staff are involved with multiple running groups in the Portland metro area, offering educational sessions and athlete screenings. Karl also provides care for the Bowerman Track Club Nike professional running team based in Portland.

By Ryan Bourdo, DPT

Fellow Oregonians, the time has come again (for the last time?!) for daylight savings to come to an end. And for those with the fortitude to brave the darkness during their runs, there are a few things that Rose City Physical Therapy would like to share to keep you as safe as possible. 

Last year, nearly 6,283 pedestrians were involved with traffic fatalities in the United States, a 3.4% increase from the year before. And while programs like Vision Zero can help reduce these fatalities, there is still plenty that runners can do to protect themselves during these sunless days and wet glaring weather we contend with in the Pacific Northwest.

Here are a few general principles to keep you safe:

Stay Defensive

A great approach to running in the dark is to stay on the defense: assume drivers cannot see you and always be aware of your surroundings. For example, running against traffic will allow you to know where cars are in relation to you. If you are crossing at a stop sign, go behind a stopped car, or wait for them to drive on. Finding long stretches of flat road will also allow you to see other pedestrians or motor vehicles ahead of time. And speaking of roads….

Find a good route

Stick to well lit streets that are easily accessible to pedestrians. But where can you find such a Shangri La you ask? Luckily in Portland, there is almost 70 miles of roadway specifically for pedestrians and cyclists with the Neighborhood Greenways initiative. And the City of Portland also provides a map of these streets! 

Stay Reflective/Get Lit

But running defensively in safer areas is only half of the solution! The other half is having the best gear to stay visible. Our good friends at Fleet Feet made this great video on different products they recommend. Our neighborhood Fleet Feet PDX in the Slabtown neighborhood of Northwest Portland also have some great items:

Another great option are these affordable reflective strips you can attach to your extremities.  

Run with friends!

What better than one set of eyes and ears? More! Get a friend and run together to keep both of you safe. Portland has plenty of running groups going on all year round to join with friends or meet new friends with similar interests 

Run with music?

Keep the volume low or wear only one earbud to allow you to tune in to sounds on the road easier.

These are some tips on how to stay safe out there on your runs. See and be seen. If you have any questions, please feel free to reach out to us. Have fun and stay safe out there!

Check out our Runner’s Safety Infographic Below!

About the Author

Ryan Bourdo completed his undergraduate education at the University of Oregon and received his Doctorate of Physical Therapy at Regis University in Denver, Colorado. He is an avid runner and enjoys treating runners of all skills and ability. He believes in treating the whole person and creating an environment that best enables the body to heal through exercise and manual therapy.