New Statistic: 70% Of Those With Low Back Pain Still First See A Medical Doctor. Why???

Truven Health Analytics-NPR Health Poll Finds Prescription Painkillers Most Common Treatment for Patients Seeking Care for Back Pain

More than half of Americans suffer from back pain, and for those who seek treatment, doctors turn most often to prescription drugs

 

Ann Arbor, MI, May 19, 2017 — Many Americans (51 percent) have experienced back pain in the past 12 months, and of the 58% of those who sought treatment from a medical professional, 40 percent said they were recommended prescription painkillers, according to the Truven Health Analytics-NPR Health Poll.Truven Health Analytics®, part of the IBM Watson Health business, and NPR conduct a nationwide bimonthly poll to gauge attitudes and opinions on a wide range of health issues. Following are the poll’s key findings:

  • Back Pain Plagues Americans: Fifty one percent of Americans said they have suffered from back pain in the last 12 months, and 46 percent of those who experienced pain said they are still in discomfort. More than half (58 percent) of back pain sufferers sought care, with 70 percent visiting a medical doctor and 14 percent visiting a chiropractor.
  • Prescription Pain Killers are the Most Common Treatment: Of the 70 percent of back pain sufferers who sought care from a medical doctor, 40 percent were prescribed prescription pain killers, a rate that tended to decrease with increasing age of the patient. Other treatments prescribed were exercise/physical therapy (31 percent), injections (20 percent), massage (17 percent), steroids (17 percent), over-the-counter painkillers (13 percent), surgery (12 percent), or some other form of treatment (37 percent).
  • Nearly a Third Remain in Pain, Even with Treatment: Among all respondents, 25 percent said their back pain stayed the same and five percent said their pain got worse. Forty-five percent said their pain improved, and 25 percent said it went away completely.

“Experiencing back pain is very common among Americans, and there are a number of factors that can contribute to it, some of which are treatable without prescription pain killers, ” said Anil Jain, MD, Vice-President and Chief Health Informatics Officer, Value-Based Care, IBM Watson Health. “These data show that when the patients do seek care, they are often prescribed pain-killers. Compounding this challenge, back pain sufferers who are prescribed opioids for pain may be particularly at risk for dependency and addiction. Curbing inappropriate opioid prescriptions for chronic pain is a focus of efforts by providers to combat the current opioid epidemic.” To date, the Truven Health Analytics-NPR Health Poll has explored numerous health topics, including generic drugs, vaccines, data privacy, narcotic painkillers, and sports-related concussions. NPR archives reports on the surveys online at the Shots health blog here. Truven Health maintains a library of poll results here. The Truven Health Analytics-NPR Health Poll is powered by the Truven Health PULSE® survey, an independently funded, nationally representative, multimodal poll that collects information about health-related behaviors and attitudes and healthcare use from 80, 000 U.S. households annually. The results depicted from the 2017 survey represent responses from 3, 002 survey participants interviewed from March 1 – 16, 2017. The margin of error is +/- 1.8 percentage points.About NPR
NPR is an award-winning, multimedia news organization and an influential force in American life. In collaboration with more than 900 independent public radio stations nationwide, NPR strives to create a more informed public—one challenged and invigorated by a deeper understanding and appreciation of events, ideas and cultures.

 

About Truven Health Analytics, part of the IBM Watson Health Business

Truven Health Analytics®, part of the IBM Watson Health™ business, provides market-leading performance improvement solutions built on data integrity, advanced analytics and domain expertise. For more than 40 years, our insights and solutions have been providing hospitals and clinicians, employers and health plans, state and federal government agencies, life sciences companies and policymakers, the facts they need to make confident decisions that directly affect the health and well-being of people and organizations in the US and around the world. The company was acquired by IBM in 2016 to help form a new business, Watson Health. Watson Health aspires to improve lives and give hope by delivering innovation to address the world’s most pressing health challenges through data and cognitive insights.

Truven Health Analytics owns some of the most trusted brands in healthcare, such as MarketScan®, 100 Top Hospitals®, Advantage Suite®, Micromedex®, Simpler® and ActionOI®. Truven Health has its principal offices in Ann Arbor, MI, Chicago, IL and Denver, CO.

Bringing awareness to the community opioid epidemic,

Dr. Phil Kotzan, DC

Heard Of The 5:2 Diet? How It Prevents Cognitive Decline and Diabetes…

I’m on the 5:2 diet,” actor Benedict Cumberbatch told the (London) Times. “You have to, for Sherlock.” That’s his hit BBC and PBS series. Cumberbatch, and most other celebrities who have used the 5:2 diet, do so to lose (or not gain) weight.

Why? “For many people, it’s easier to not eat much on two days of the week and eat normally– but not overeat — on five days, versus counting calories at every meal,” says Mark Mattson, chief of the laboratory of neurosciences at the National Institute on Aging.

As it turns out, the 5:2 diet—also called the 2-day diet or intermittent fasting—may do more than trim your waistline.

“In animal models, intermittent fasting increases the resistance of cells to various types of stress and disease,” says Mattson. But the human evidence in favor of on-and-off fasting is just emerging.

Diabetes.

On-and-off fasting may help lower the risk of type 2 diabetes not just by shrinking waistlines but by keeping the body’s insulin in good working order. That’s what happened in two studies, each on roughly 100 overweight or obese women.

“Half cut 25 percent of their calories every day, and half ate only 650 calories a day for two days per week” and didn’t cut calories on the other five days, says co-author Mattson.

After three to six months, “each group had lost about the same amount of weight,” he notes. “But the women on the 5:2 diet had better insulin function.”

And insulin matters.

Poor insulin function is “at the root of many weight-related diseases, such as type 2 diabetes, heart disease, some cancers, and possibly dementia,” wrote Michelle Harvie and Tony Howell in The 2 Day Diet.

The researchers, both at the Manchester Breast Centre in England, led the two studies in women.

Cancer.

“When you inject cancer cells under the skin of mice, alternate-day fasting slows the growth of the tumor cells,” says Mattson.

It’s not clear why. One possibility: “Almost all cancer cells use glucose as their energy source, so the fasting state is not ideal for cancer cells because the glucose levels are low,” explains Mattson. But studies in people are just starting.

“British researchers are putting women who have breast cancer on intermittent fasting diets throughout the entire five-month course of their chemotherapy treatments,” says Mattson. “The prediction is that intermittent fasting will enhance the effectiveness of the chemotherapeutic drugs by making cancer cells more vulnerable. And fasting may protect normal cells from the adverse effects of chemotherapy.”

Memory.

In a study on mice engineered to get an Alzheimer’s-like disease, the animals performed better on memory tests—how to find a hidden platform in water, for example—when put on diets that cut calories daily or every other day than when eating an unlimited diet.

And healthy mice that were fed few calories for four days twice a month did better on memory tests than mice that never fasted.

“Animals on intermittent fasting are more alert than animals that have constant access to food,” notes Mattson. “And they have increased activity in a region of the brain called the hippocampus, which is important for learning and memory.”

That makes sense, given that animals in the wild are hungry most of the time. “It’s normal for cougars to go a week without eating anything, so they’re burning fat,” explains Mattson. “And their brains have to work well, so they can figure out how to track down their prey.”

What about evidence in humans?

“We’re about halfway through a study on people aged 55 to 70 who are at risk for cognitive impairment and Alzheimer’s disease because of their age and because they are obese and insulin resistant,” says Mattson. Half are on the 5:2 diet, while half are getting the usual advice for healthy eating.

“Before they start and two months later, we do a battery of tests to look at learning and memory,” says Mattson.

If the 5:2 dieters do better, it will take another study to know if that’s due to fasting or just having lost weight.

What to do until we know more?

“The first thing is to make sure you’re not overweight or obese,” says Tufts’ Susan Roberts, “because there’s a legion of studies that show that carrying excess body fat is unhealthy for all kinds of reasons.”

And if you find it easier to slash calories two days a week than to make smaller cuts every day, why not try it?

“To my knowledge, there is no evidence that intermittent fasting has adverse effects on healthy people unless they’re a young child or a frail older person,” says Mattson. (Granted, on-and-off fasting hasn’t been tested in studies lasting longer than six months.)

What if you’re not overweight or obese?

“The research so far indicates that some caloric restriction is very likely to be healthy even if you’re already normal weight,” says Roberts. That is, unless you end up too thin.

Sources: Int. J. Obes. 35: 714, 2011; Br. J. Nutr. 110: 1534, 2013; Sci. Transl. Med. 2012. doi:10.1126/scitranslmed.3003293; Neurobiol. Dis. 26: 212, 2007; Cell Metab. 22: 86, 2015.

 

Written by David Schardt for Science In The Public Interest

 

Bringing attention to this diet,

Dr. Phil Kotzan, DC

Having A Shorter Leg Can Lead To Low Back And Hip Arthritis

Association of Mild Leg Length Discrepancy and Degenerative Changes in the Hip Joint and Lumbar Spine

Journal of Manipulative Therapeutics
Kelvin J. Murray, BAppSc(Chiro),Tom Molyneux, BAppSc(Chiro),Michael R. Le Grande, MPH,Aurora Castro Mendez, DPM, PhD,Franz K. Fuss, MD, PhD,Michael F. Azari, BAppSc(Chiro), PhD

Abstract

Objective

The purpose of this study was to evaluate the correlation between mild leg length discrepancy (LLD) and degenerative joint disease (DJD) or osteoarthritis.

Methods

We evaluated standard postural lumbopelvic radiographs from 255 adults (121 women and 134 men) who had presented with spinal pain for chiropractic care. Symmetry of femoral head diameters was used to exclude magnification errors. Pearson’s partial correlation was used to control for age and derive effect sizes for LLD on DJD in the hip and lower lumbar motion segments. Krippendorff’s α was used for intraobserver and interobserver reliability.

Results

A strong correlation was found between LLD and hip DJD in men (r = 0.532) and women (r = 0.246). We also found a strong correlation between LLD and DJD at the L5-S1 motion segment in men (r = 0.395) and women (r= 0.246). At the L4-5 spinal level this correlation was much attenuated in men (r = 0.229) and women (r = 0.166).

Conclusions

These findings suggest an association between LLD and hip and lumbar DJD. Cause–effect relationships between mild LLD and DJD deserve to be properly evaluated in future longitudinal cohort studies.

 

Interested in leg length shortness and it’s consequences,

Dr. Phil Kotzan, DC

Six Steps To Youthful, Supple Arteries

How To Slow Down Vascular Aging

Wouldn’t it be great to have the flexible, healthy arteries of a young person again? Arteries that are resistant to heart attacks, strokes, and dementia?

“Maintaining a youthful vascular function beyond age 70 is extremely challenging,” say researchers from the Framingham Heart Study.  But it’s doable they insist, adding that it requires a long term commitment to achieving six goals for good health.

As we age, the aorta, carotids, and other large arteries that keep oxygen-rich blood flowing through our body lose some of their capacity to widen or narrow. They become less compliant. With aging, arterial compliance declines and arterial stiffness increases. Arteries are most supple at about age 30 and then start stiffening.

Framingham Heart Study

The Framingham Heart Study has been tracking the health of several generations of residents of this Massachusetts city. It’s now a collaboration between the National Institutes of Health and Boston University.

Using new data from Framingham, scientists this spring showed exactly how much the six health goals can affect your chances of gaining and keeping healthy arteries.

The researchers defined the sign of healthy arteries as a blood pressure of less than 140/90 without drugs and a rate of blood flow through the arteries typical of a healthy person in their 20s.

Among the 3,196 residents of Framingham they studied, the researchers found healthy arteries in 30 percent of those in their 50s, in 7 percent of those in their 60s, but in only 1 percent — 6 of 617 — of those in their 70s. Hence, the challenge for older individuals.

The healthy goals that the researchers patterned after American Heart Association guidelines and measured in the Framingham residents were:

  • No smoking
  • A BMI of less than 25
  • Regular physical activity
  • Cholesterol level below 200 without the use of drugs
  • Fasting blood glucose below 100 without the use of drugs
  • A healthy diet rich in fruits, vegetables, fish and whole grains and limited in sodium and added sugars.

What the researchers found

Compared with achieving only one or two of these goals, the Framingham residents who met three or four of the goals increased by three-fold their chances of having healthy arteries. Hitting five goals, their odds jumped to seven times. And those who achieved all six were 10 times more likely to have youthful arteries than those who could manage one or two of the goals.

Avoiding vascular aging and stiff arteries can have a big payoff. The Framingham researchers tracked the city’s men and women for 10 years and found that those with healthy arteries had less than half the likelihood of suffering heart attacks or strokes during that time.

Stiffer arteries also increase the risk of cognitive decline. People who entered the Baltimore Longitudinal Study of Aging cognitively intact but with stiffer arteries were more likely to show declines in verbal learning skills and memory over the next decade than those who started out with less-stiff arteries.

The American Heart Association says that each of its healthy goals “have one unique thing in common: any person can make these changes, the steps are not expensive to take and even modest improvements to your health will make a big difference.”

Written by David Schardt for Nutrition Action of the Center For Science In The Public Interest

 

Bringing attention to our vasculature,

Dr. Phil Kotzan, DC

The Basic Anatomy Of Stretching The Adductor Muscles

This week we are going to take a look at the basic anatomy of stretching the hip adductors.

This is the group of muscles that make up your inner thigh muscles. The muscles specifically are the adductor longus, adductor brevis, gracilis, pectineus, and adductor magnus.

The only one of these muscles that crosses the hip joint and the knee joint is the gracilis. All the others only cross the hip joint.

The implication of this is that when the knees are bent, most of the adductors (especially by mass) are not slacked.

When you go down into a squat or a sumo deadlift where your legs are out to the side, the main muscular limitation is the adductors, especially when you externally rotate your femurs.

In the squat, the hamstrings are slacked because of the knee bend, but the adductors are not. They are the most likely muscular limitation around the hip to preventing good squat depth.

Ok the video goes into much more depth than this because this is really one of those things you need to see to understand!

 

Video: How To Stretch The Adductors

 

Written by Dr. Ryan DeBell for The Movement Fix

 

Looking to see more adductors stretched,

Dr. Phil Kotzan, DC

A Simple Strengthening Program

We tend to overcomplicate everything in life. Tell someone to “eat clean” and you need a 500-page manual to explain it. To get “in shape” might take several thick volumes of work to detail everything.

But, to get strong is one of the easiest things I know. As I often joke, and the research backs me up on this:

If you want to get stronger, lift weights.

The best method I know is simply “One-Two-Three.” It’s an old method that has recently seen the light of day again.

Pick a big movement.

 

Push: Bench or Military Press

Pull: Pull Up

Squat: Front Squat or Back Squat

Hinge: Deadlift

 

Find a load that you can do for five. It’s going to really vary for most of us, but a normal trainer will find that 80% of their max is about right. Now, follow this rep scheme:

1-2-3

Do a single, rest a bit, do a double, rest a bit, then do a triple. That is six total reps and the quality should all be excellent. For a solid workout, run through this three times: 1-2-3-1-2-3-1-2-3.

Never miss and never chase fatigue. Try to dominate each and every set. You WANT the weight to feel light and easy. Inch that load up over a few workouts. Like we discover in throwing the shot and discus, inching your effortless efforts up a bit seem to increase your best.

This is an old method of strength training that has been ignored for a while. You can train as you usually do and just sprinkle these throughout the workout. Many have found that this does wonders for the Pull Up, but experiment with the squat or deadlift too.

Getting stronger in these key lifts is the “secret” to power, mass and leanness. Speed up your progress by backing off a bit, but striving to increase load.

 

Written by Dan John of DanJohn.net

 

Simple, easy to execute, appreciated,

Dr. Phil Kotzan, DC

Coaches: Why To Build camaraderie With Young Athletes

Fostering teamwork among any group of individuals is not an easy job.  If you were to analyze coaches with successful careers they would tell you they didn’t win on talent alone. Geno Auriemma led the UCONN Huskies basketball team to seven national championships while John Wooden of UCLA secured ten national championships and is known as a genuine leader. Both coaches were shown to be great leaders in the world of college sports but what defines them. They knew and understood every individual on their team while challenging them in the right ways. They established consistent standards of performance and knew how to motivate their team despite personality differences. Most importantly they were not afraid to take risks to support them in their development to become better athletes. These same principles apply when working with younger teams but at a level that fits their stage of development.

Unfortunately many of today’s youth coaches are focused merely on recruiting and playing the most athletically talented.  A group that exhibits talent alone doesn’t necessarily correlate with team cohesiveness which is defined as a group of individuals who want to work together to achieve a common goal. A team with strong cohesion also has an emotional bond with one another as result of athletes’ investment to be successful as a unit and not just individually. When looking at top businesses, they are successful as a result of selectively choosing their team based on who works well together. The same applies with youth sports. Although they may not always be trying out for the team each athlete brings a variety of strengths that can benefit the group as a whole. Some of the most enthusiastic and hard workers are not always the most athletic, but know how to keep the energy up. While others who are self-disciplined challenge the team to hold each other accountable. Whether you are a new coach or building off an existing team, here are four simple ways to ensure strong team camaraderie.

Establish Team Rules: This is an essential step that should happen on the first day of practice. It sets a foundation of expectations for the team in order to achieve their goals. Rules should never be created with the coach alone, however there needs to be a baseline that guides athletes in creating their rules. As a coach there are several things to consider including the age of development, importance of autonomy, ownership by the players, modeling, consistency and accountability. If the coach doesn’t follow the rules or the athletes don’t hold each other accountable there is no foundation to work from resulting in poor cohesiveness. How you handle a six year old coming late to practice versus a teenager should look much different in consequences. Each athlete should know what they are responsible for and what they are expected to contribute. In today’s generation young athletes are often involved in multiple activities. The team needs to decide what’s acceptable and what’s not in attendance while recognizing the need for full participation from everyone. Rules should always create a safe and trusting environment for the team.

Create an Environment with Open Communication and Role Clarity: Every coach should know their athletes on an individual level including strengths, areas to develop and goals. Athletes will be more invested in the process when feeling cared about. This will also help in clarifying roles of all members on the team, whether it is on or off the field. There will be young athletes that tend to exhibit more leadership skills. They will lead by example athletically but also by their character. Some players respond better to peer instruction and support rather than from the coach. Others will be highly skilled but may not be self-motivated or disciplined. A great coach will utilize all of these skills to bring a team together and foster an environment of open communication. This includes paying attention to any conflicts and addressing them when they arise. When handled well, they provide further opportunity for growth in skill and character building. Coaches need to empower young athletes to solve problems themselves while teaching conflict resolution skills for the future.

Focus on the Vision: With any successful business or organization there is always a vision and the same applies with sports. Teams can be part of a bigger organization or be a representation of a school. Establishing a vision will set a foundation for the coaches, team and players. An important component of this is setting long-term directional goals. This will define the culture and expectations when building a cohesive team. Within the long-term goals there should be a variation of outcome, process and performance goals. Outcome goals include a number of team wins or hitting a specific time for an event. These will include both team and individual goals that the coach will establish with their players. Performance goals will be viewed as mastering a skill or increasing a percentage and process goals, which are often overlooked, are the behaviors and actions needed in order to accomplish the desired outcome. Every coach wants to be successful but will not reach the desired outcome without understanding the process it takes to get there. A vision statement should clarify the purpose of the team, set a standard of excellence, inspire enthusiasm and be easy to understand. All leaders of any team need to embody this message. If they are not connected and carry out the statement themselves through their daily actions the team will not either and therefore lack a sense of direction.

Foster a Safe and Playful Environment: This may not be a priority for most coaches when it should be.  In any organization if the environment is all work and no play than don’t expect big results on desired outcomes. This especially applies to the sports scene with the push for specialization at a younger age and an increase in sport specific clinics guaranteeing bigger, faster, stronger athletes. An important question for coaches to consider is what are the top responsibilities when working with youth? This should not include developing superstar athletes as the overarching goal.  Coaches play an intricate role in the teaching process while understanding the developmental needs of their athletes. This doesn’t mean challenging athletes, promoting hard work and teaching skills can’t be fun. However, in order for any athlete to reach their fullest potential they need to stay invested and be allowed ample opportunity for play both on and off the field. This may include incorporating various games into training sessions that also focus on skills. For example tag games are great for working on acceleration and deceleration techniques. Games that include goals such as hitting a set number in juggling, handball and relay races serve as team building exercises. In addition, events should be hosted outside of normal practice times, such as team dinners and other various outings that promote positive social interactions. Coaches who view play as a waste of time are missing several key learning components in building their athletes. These include communication, social skills, a sense of give and take, patience, perseverance and trust. Like adults who juggle numerous tasks the same applies for children and adolescents. They benefit from time away from technology, school and personal lives to engage with others in a playful manner. The end result is a stronger commitment to the team’s mission and mental clarity on the field.

Team cohesion never develops overnight and requires patience in the process. Every coach needs to know their individual athletes before understanding how the team functions as a whole. This will help utilize various personalities and strengths in order to build on areas of growth.  It’s important to recognize success, challenge appropriately and take risks when the team has established trust in their leaders. A coach who follows the vision and encourages direct feedback will have better camaraderie which will translate to desired performance outcomes.

Written by Melissa Lambert, M.Ed, LPC for AthletesAcceleration.com

 

Of interest to coaches,

Dr. Phil Kotzan, DC

How To Ice, Timing To Ice?

Does Cooling Method Matter?

It turns out that how you choose to cool down after exercise may be important. A 2013 meta-analysis by Poppendieck et al. found that CWI was more effective than ice packs and cryogenic chambers for performance recovery in trained athletes (92). This findings may be biased due to the large majority of studies that use CWI as their cooling intervention but there’s a reason for this: CWI is by far the most effective method for cooling the body (93) and, as such, it has become the gold standard in both research and athletic settings.

Whole-body cold water immersion also appears to be more effective than cooling only the exercised limb(s) (92). This may be due to a greater reduction in core temperature with whole body cooling than with partial-body cooling (94) in addition to the (potentially) therapeutic effects of hydrostatic pressure experienced during water immersion10. If CWI isn’t available, compression wraps can enhance the intramuscular cooling effects of ice packs (95,96) in addition to providing a compression effect (albeit to a far lesser degree than water immersion), although it’s not quite clear what effect (if any) this might have on recovery.

Whole body CWI is not only the most effective way to cool the body, it may also have the greatest therapeutic benefit, due to the temperature-independent effects of water immersion.

Is There an Optimal Temperature or Duration?

There is no definitive evidence on an “optimal” temperature or duration for cryotherapy; however, the available research provides some insight.

In their meta-analysis, Poppendieck et al. concluded that water temperatures of 12-15ᵒC are sufficient to elicit positive effects on post-exercise recovery in trained athletes and that cooler temperatures are not likely to produce any additional benefit (92).

As for duration, 10 minutes of whole body CWI at 12-15ᵒC is more than enough to elicit a reduction in intramuscular temperature (93) and 20 minutes seems to be the upper limit of what is used in the literature (with the exception of warmer immersions, of course). Logically, the less body mass that is exposed to cold, the longer the exposure needs to be to elicit a similar reduction in core body temperature (94). Similarly, colder temperatures require shorter exposures (97).

Further evidence suggests that CWI for longer durations (30 minutes) may exacerbate the inflammatory response to exercise (64) and there are several documented cases of peripheral nerve injury when ice packs are left on for too long (98,99). Don’t be the guy that falls asleep with an ice pack on!

A 10-minute, whole body immersion at 12-15ᵒC is more than enough to reap the benefits of CWI. Cooler temperatures or longer durations are unnecessary and potentially harmful, so always be sure to err on the side of caution.

What About Placebo Effects?

Despite the placebo effect being well-documented in sports (see Beedie et al. [100] for review), there hasn’t really been an attempt to quantify its role in the positive outcomes we (sometimes) see with cryotherapy. Sugar pills are one thing, but it’s not exactly easy to convince someone they’re taking an ice bath—without actually having them take an ice bath! So, when Broatch et al. published their placebo study in 2014 there was a lot of hype on the internets. And for good reason: it was the first study that compared CWI to, what I consider to be, a pretty decent shot at a placebo condition.

In the study, participants in the placebo group performed 15 minutes of thermoneutral immersion but were led to believe it contained a special “recovery oil” that was just as effective as CWI. And the results were pretty compelling: the thermoneutral placebo was just as effective as CWI at restoring quadriceps strength (MVC) up to 48 hours post-exercise and both groups recovered significantly better than the thermoneutral control group. In addition, both the CWI and the thermoneutral placebo group reported similar subjective ratings of recovery.

Now, we can’t generalize these results to all scenarios because the study looked at recovery of quadriceps strength following four 30-second maximal sprints on a cycle ergometer. We have no idea to what extent placebo effects are involved in recovery from, say, resistance training, endurance exercise, or team sports. I think it’s pretty safe to say they likely play a role, though.

So how do we interpret these results?

Well, we could throw the ice out with bathwater. After all, cold water immersion is no better than placebo, right? But I don’t think that’s necessary. As a coach, I think it’s always important to consider the preferences of your athletes. And I think this study supports the use of CWI with athletes who believe it to have a recovery benefit (e.g., Cook & Beaven found that repeat sprint performance following CWI was related to how much athletes “liked” it [67]). Said differently, there’s not enough solid evidence to encourage your athletes to use CWI, but I see no reason to discourage an athlete who sees value in it either.

This last point comes with one major caveat: as long as an athlete’s use of CWI does not impede on your training goals for that athlete. In this sense, it may be valuable to educate athletes who regularly use CWI on its potentially detrimental effects on long-term training adaptations and explain to them it is best used sparingly throughout the competitive season.

Placebo effects almost certainly play a role in the recovery benefits of cryotherapy, but it’s not clear to what extent. Coaches should pay attention to the preferences of their athletes, and not necessarily discourage an athlete who perceives cryotherapy to be beneficial from using it sparingly, and in a manner that is congruent with their training goals.

Practical Recommendations

If you’re an athlete (or if you coach an athlete) that likes using ice or ice baths for recovery, that’s great! Keep doing what you’re doing. But to make the most of it, I suggest you following my recommendations below:

• Use ice baths over ice packs or other forms of local cooling whenever possible.

• Make sure the water temperature is between 10-15 degrees Celsius but not any colder. Colder does not mean better. Warmer temperatures (up to 20 degrees Celsius) for longer durations can also be used.

• Ice baths should last between 5-15 minutes. The colder the water, the shorter the ice bath should be.

• Submerge your whole body (up to your neck/shoulders), or as much of your body as you can.

• After the ice bath, allow time for rewarming and ensure an adequate warm-up before your next game, event, or training session. Avoid using ice baths immediately (<1 hour) prior to exercise, particularly before training or events involving high-intensity or explosive efforts such as sprinting, jumping, or weightlifting. The exception to this rule would be if you’re competing in an endurance event in warm or hot weather. In this case, precooling may enhance subsequent performance.

• Use ice baths sparingly. Regular ice baths kill strength and muscle mass gains! They’re best saved for strategic use during the competitive season when you’re trying to recover performance within a few hours to a few days.

• Important: Be careful! Cryotherapy does not come without its dangers. Exposing your body to cold temperatures for too long can have potentially dangerous effects. (E.g., don’t fall asleep with an ice pack on your shoulder. I used to do this. It’s moronic!) Set yourself a timer and stick to it. And if things start to feel sketchy before the timer goes off, call it quits!

Written by Tavis Bruce for EricCressey.com

 

Looking to bring attention to Cryotherapy,

Dr. Phil Kotzan, DC

Cryotherapy: To Ice Or Not To Ice?

Sports and ice go together like peanut butter and jelly (or steak and eggs, if you’re into Paleo). From ice packs to ice baths, various forms of “cryotherapy” have long held a sacred place in sports medicine to treat acute injuries and facilitate recovery from training or competition. But despite its popularity and widespread use, the evidence in support of cryotherapy remains equivocal.

More recently, cryotherapy—particularly the use of ice baths, or cold water immersion—has come under increasing scrutiny from both the scientific community and the strength and conditioning industry at large…and rightfully so! However, in the process, we may be swinging the pendulum too far in the other direction, indicated by those who have come to the conclusion that “ice baths are a complete waste of time for every athlete in every sport in every possible situation.” Now, others may disagree with me on this one; but, the evidence (or lack thereof) for cryotherapy appears to be a little more nuanced than that.

I guess what I’m trying to say is: I’m not so sure I’m ready to throw the ice out with the bathwater just yet. Perhaps, instead of pondering black-and-white questions like, “to ice or not to ice?” we should be asking:

                         “When is ice appropriate?”

I’d like to examine why.

A quick note before we get started: this article will not discuss the use of cryotherapy for the management and/or rehabilitation of acute soft tissue injuries. I am NOT a medical professional; I just play one on Facebook.

As such, this article will only cover the efficacy of cryotherapy as a post-exercise recovery strategy.

Is there a Physiological Rationale for Cryotherapy?

Note: I’m not going to spend much time discussing the physiological rational (the “why”) behind cryotherapy for two reasons. First, the mechanisms are still quite hypothetical. Second, and more importantly, it’s a bit outside the scope of this article to convey practically relevant and actionable information for my fellow coaches and athletes. We can debate the mechanistic stuff until the cows come home, but in my humble opinion, the gold standard measurement for post-exercise recovery is the measurement of performance variables. And, I like to think that most athletes, coaches, and sports scientists would agree with me. That being said, I do think it’s always a good idea to establish if there is at least a physiological rationale for any method we may use with ourselves and/or our athletes. With that said…

Cryotherapy results in various physiological changes (most of which are temperature-dependent) that have long been proposed to exert a therapeutic effect post-exercise. Although the most cited physiological change is a blunted inflammatory response, there exists a range of other effects through which cooling the body after exercise may accelerate the recovery process. Of note, cryotherapy may:

• Improve tissue oxygenation1 and removal of metabolic waste (2) by reversing exercise-induced muscle edema (3,4).
• Reduce reactive oxygen species (ROS)-mediated muscle damage (5) by reducing local metabolism (1).
• Induce analgesia by decreasing nerve conduction velocity (6) in addition to directly activating sensory afferents (7).
• Restore parasympathetic tone by increasing vagal tone (8,9).

In addition, cold water immersion (or “ice baths”), a popular form of cryotherapy, may have additional benefits resulting from the compressive forces experienced during water immersion, but I won’t be covering them in this article (see Wilcock et al. [10] for a good review). For more information on the physiological effects of cold water immersion and other forms of cryotherapy, I encourage you to check out this (open access!) review by White and Wells.

The Effects of Cryotherapy on Recovery from Sport or Exercise

Perceptual Measures of Recovery

Cold water immersion reduces perceptions of fatigue (11-16) and increases perceptions of recovery (17,18) and physical readiness (19) between training sessions; however, it doesn’t seem to have much of an effect on ratings of perceived exertion (RPE) during subsequent training bouts (20-23).*

*Except for when CWI is used as a precooling strategy before exercise. (More on precooling later.)

Delayed-Onset Muscle Soreness

Though it’s pretty well accepted that cooling injured tissue can temporarily reduce or relieve pain (24), it’s not really clear if post-exercise cooling has any effect on delayed-onset muscle soreness (DOMS): the type of soreness you feel in the days following a bout of intense or novel exercise.

There is some evidence that cold water immersion (CWI) alleviates DOMS better than passive recovery (25), particularly when CWI is used following exercise that involves a large degree of metabolic stress (26) (e.g., running, cycling, or team sports). However, this effect is less clear when CWI is compared to warm (27), thermoneutral1 (4,28), or contrast (27,29,30) immersion, and recent evidence suggests that CWI may be no more effective than a placebo (19) for relieving DOMS. Collectively, these findings highlight the perceptual nature of muscle soreness and the importance of athletes’ perceptions of cryotherapy (or any recovery method, for that matter).

Icing and cold water immersion may help reduce delayed-onset muscle soreness after running or team sports, but the effect likely depends on the athlete’s belief in cryotherapy as a method of recovery.

Range of Motion

There is conflicting data on the effect of cooling on range of motion (ROM). Cooling alone does not appear to improve ROM (28,31-38), but it may enhance the effects of stretching (39-43) by increasing stretch tolerance (44). On the one hand, this increased tolerance to stretch does not appear to translate into long-term improvements in ROM (45-47). On the other hand, heat combined with stretching may have more lasting effects than stretching alone (44).

If your goal is to restore lost ROM following exercise, combine heat (not cold!) with stretching.

Strength

The short-term effects of post-exercise cooling on recovery of strength characteristics are mixed and seem to depend on the type of exercise stress from which you’re trying to recover before you hit the weights.

There is some evidence that CWI may reduce or recover losses in maximal voluntary contraction (MVC) following simulated team sports (48-50) or intermittent sprint exercise (51-53), but not after downhill running (54) or cycling (55,56). And, in the only study of its kind, Broatch et al. found that CWI following high-intensity sprint intervals recovered MVC no better than a thermoneutral placebo (19).

Roberts et al. demonstrated that CWI was effective for restoring submaximal (but not maximal) strength between two lower body training sessions within the same day (57). Vaile et al. found both cold and contrast water immersion were effective at restoring strength up to three days after heavy eccentric strength training (27)*, but most studies show no or non-significant improvements over this time period (28,58-62). However, it’s important to note that all of these studies used (potentially) “less effective” cooling methods (such as when only the exercised muscle is cooled) compared to more therapeutic methods such as whole-body CWI.

*I highlight the study by Vaile et al. because it is the only study that compared multiple hydrotherapy modalities in trained males, and in a cross-over design with a “washout” period between treatments of sufficient duration to eliminate any residual effects of the repeated bout effect. Thumbs up for study quality!

Cold water immersion may help recover muscle contractile properties following running or team sports. Benefits following resistance training are less clear and may require the use of cold water immersion over local cooling of exercised tissue.

Jump Performance

Most studies show significant recovery of jump performance within 24-48 hours post-exercise with no clear additional benefits to CWI (18,49,53,63,64). Furthermore, CWI may impair jump performance within the first two hours (57) possibly due to the acute effects of cold exposure on force production (65).

Here’s the deal: jump performance seems to recover just fine on its own. However, there is some evidence that CWI may maintain jump performance in scenarios of accumulated fatigue, such as during tournament play in team sports. One study of basketball players found that the CWI maintained jump performance better in players who saw more playing time throughout a 3-day tournament (66).

Sprint Performance

Like jump performance, many studies report that sprint performance returns to baseline within 24 hours after exercise, regardless of treatment intervention (18,49, 61). Accordingly, most studies do not find a benefit in favor of CWI compared to other recovery interventions because the initial exercise bout was not sufficiently intense to elicit a significant 24-hour performance decrement.

However, when exercise was sufficiently intense to affect 24-48 hour sprint performance, CWI maintained repeat-sprint performance (a measure of speed-endurance) better than thermoneutral immersion (67), contrast water therapy (12,13,48), and passive recovery (12,13,48,67).

The effect of CWI on absolute speed is less clear. Of the two studies I found, one found no benefit to CWI over passive recovery on immediate and 24-hour recovery of 50-m dash time (68), while the other showed that CWI maintained 20-m speed better than compression or stretching over a 3-day simulated basketball tournament (66).

There’s not a lot of data on the effects of CWI on same-day recovery of sprint performance, but one study showed no significant differences in repeat-sprint performance between CWI and passive recovery immediately and up to two hours after intermittent sprint exercise in the heat (61). This ties in well with the research in sprint cycling that shows neutral—or even detrimental—effects on 30-second Wingate performance following CWI when sufficient re-warming does not occur (69,70). This makes sense: reduced muscle temperature will negatively affect muscle contractile properties (71), impair energy metabolism (72), and slow nerve conduction velocity (6,73), which collectively will negatively affect the force- and power-generating capabilities of muscle. Thus, caution should be taken when using CWI between or prior to exercise that requires a high-degree of muscular force (sprinting, jumping, etc.). Athletes should allow sufficient time to rewarm following CWI and make sure to include a dynamic warm-up before their next event, which has been shown to offset the negative effects of cold exposure on power production in the vertical jump (65).

When exercise is sufficiently intense, CWI may help restore short-term (<48 hour) sprint and jump performance. However, reduced muscular temperatures negatively affect the force-generation capacities of muscle. Thus, when using ice baths between two training sessions or events within the same day, it is important to allow the body sufficient time to re-warm and/or to include an extensive dynamic warm-up.

Endurance Performance

Given the number of endurance athletes that use ice baths to recover between workouts or events, it was somewhat surprising that very few studies looked at endurance performance following recovery periods of 24 hours or longer. Two of those studies showed that CWI improves endurance performance following a 24-hour recovery period (17,74), and two other studies demonstrated similar recovery benefits across 3-day (75) and 5-day (23) training blocks.

Most studies that looked at the effects of CWI on recovery from endurance exercise utilized recovery periods of <60 minutes between exercise bouts. But here’s the thing: When an athlete takes an ice bath between two bouts of exercise with a short (<1 hour) duration between bouts that ice bath creates a “precooling” effect for the second bout. Precooling is proposed to increase performance (particularly in hot conditions) by increasing heat storage capacity, reducing thermal strain, and decreasing perceived exertion by reducing core body temperature prior to exercise (76).* And, based on the abundance of data showing a benefit to precooling on endurance performance** (particularly in hot conditions), this is probably why we see such an immediate recovery of endurance performance following CWI (56,77-81). This effect diminishes with longer recovery periods (82), presumably as core body temperature returns to baseline.

*If you’re interested in learning more about precooling check out this (open-access!) systematic review as well as the results of two recent meta-analyses here and here.

**Just to reiterate: the beneficial effect of precooling likely does not hold true for short-duration, maximal efforts (see above).

Ice baths may be useful for recovering endurance performance, particularly when an athlete has to compete in multiple games or events in one day.

The Effect of Regular Cold Water Immersion on Long-Term Training Adaptations

Very few studies have looked at the effects of ice baths on long-term training adaptations. But, the evidence-to-date paints a pretty clear picture:

Strength Training

The evidence is pretty clear on this one: regular use of CWI impairs long-term gains in muscle mass and strength (83-86) at least in part by blunting the molecular response to resistance exercise (84). This seems to apply to both trained (84) and untrained (85,86) individuals.

Ice baths blunt the acute molecular response to resistance training and impair long-term gains in muscle mass and strength. Athletes should reconsider using ice baths after strength training, particularly in the off-season or preparatory period when the focus is on adaptation rather than performance.

Endurance Training

The evidence for the effects of CWI on adaptations to endurance training is not so clear. One study in competitive cyclists found that regular CWI neither enhanced nor interfered with cycling performance over a three-week training block (87). Furthermore, recent evidence suggests that regular CWI may actually enhance molecular adaptations to endurance training (88). However, it’s important to interpret these results with caution, as molecular adaptations do not always reflect functional outcomes and the study did not measure changes in performance. Of note, there is some evidence that regular CWI at very cold temperatures (5ᵒC) for very long durations (>30 minutes) may disrupt local vascular adaptations and attenuate improvements in VO2max to endurance training in untrained subjects (85).

There is no direct evidence to suggest that ice baths enhance nor interfere with endurance training adaptations. In trained athletes, ice baths can be used sparingly after endurance training, but regular use is not recommended, particularly during the preparatory period when the focus of training is on adaptation. Finally, ice baths of excessive duration or at extremely cold temperatures should be avoided.

Major Take-Aways

The evidence for cryotherapy is pretty mixed, but there are some patterns that seem to emerge from the literature:

• Cold water immersion and other forms of cryotherapy reduce exercise-induced inflammation.
• This reduction in inflammation may lead to reduced perceptions of fatigue and muscle soreness and increased perceptions of recovery which may benefit performance in the short-term.
• Importantly, the short-term recovery benefits of cryotherapy may depend considerably on the mode exercise (i.e. the type of stress), the physiological and perceptual qualities one is trying to restore, and (as I will discuss further in Part 2) the athlete’s belief in cryotherapy as a recovery modality.
• Meanwhile, a growing body of evidence indicates that inflammation is a necessary process for tissue regeneration and, as such, regular use of cold water immersion may impair long-term muscular and vascular adaptations to exercise.
• As such, cryotherapy should be used sparingly, particularly in the off-season when the goal is to maximize training adaptations.

 

Written by Tavis Bruce for EricCressey.com

 

Looking to bring attention to Cryotherapy,

Dr. Phil Kotzan, DC

Om Your Way To Better Health Through Yoga

Yoga’s benefits stretch beyond boosting flexibility.  Researchers keep finding new reasons why everyone should hit the mat.

Relieve Lower-Back Pain

Forget bed rest–today’s docs often prescribe exercise, yoga included.  Practicing yoga may ease back pain better than avoiding exercise, concluded a scientific review tallying results from over 1,000 men and women, all suffering from low-back pain for three-plus months.  It may be better to do yoga than to skip your workout because of its relaxation, meditation and breathing elements.  Most studies asked participants to attend a 60- to 90- minute class (typically Iyengar-style) once or twice a week and practice at home on non class days.  Beginners should find a class designed to ease low-back pain so an experienced instructor can help you protect your back.

Foster Your Bones

Less than 15 minutes of yoga a day may keep your bones strong, according to a study published in Topics In Geriatric Rehabilitation.  Over 200 individuals, mainly women averaging 68 years old, did 12 minutes of yoga daily (or at least every other day) for two years.  They held 12 poses (including tree and twisted triangle) for 30 seconds each.  The result: improved bone density.  In fact, the progress surpassed bone-building results typically seen with osteoporosis-countering drugs.  Why?  Using your muscles makes your bones stronger.  Since yoga uses several muscle groups at once, you’re exerting force on the bone from multiple angles, possibly enhancing the bone-building process.

Help Your Heart

Move over, cardio.  Researchers evaluated almost 40 trials and found that yoga came with numerous heart-friendly benefits: lowering LDL (“bad”) cholesterol and triglycerides, increasing HDL (“good”) cholesterol and improving body weight, blood pressure and heart rate.  Yet how does this stack up against aerobic activity like jogging?  Surprisingly high.  “Yoga achieved similar improvements to aerobic exercise,” says Myriam Hunink, M.D., Ph.D., study co-author from the Netherlands.  The study points to several factors about yoga that may be responsible for these changes, including the strengthening, stretching, breathing, meditation and relaxation aspects.

Written by Karen Asp for Eating Well magazine.

 

Looking to bring attention to the importance of yoga,

Dr. Phil Kotzan, DC