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Periodisation of training

Endurance, efficiency, biomechanics of plyometrics, and immune considerations (Martin Krause 2012)

Endurance = "time to fatigue"

Training - "you need to stress, not strain the system to create change"

This section of the website deals with immune, physiological and biomechanical considerations of rehabilitation and training. Specifically, avoidance of 'staleness' and immune compromise from over-training is dealt with in consideration with the biomechanics of concentric and eccentric muscle exercise. The aim is to gain an oversight on how to train to recover from injury or prevent further injury. Ideally, this section should be read along with the sections, found elsewhere on this website, dealing with exercise and the immune system, exercise and muscle mass (Sarcopenia) and nutritional aspects of musculoskeletal health.

Altered biomechanical conditions as a result of misuse, disuse, overuse, abuse results in damage which can cause a viscious reciprocating cycle of muscle-tendon atrophy, degenerative changes, and immune-metabolic dysfunction that creates an environment of morbidity from chronic musculoskeletal dysfunction. At Back in Business Physiotherapy we use a combination of 'hands-on' therapy, exercise and nutritional supplementation to optimise the rehabilitative process. Importantly, development of a base training level of fitness through endurance exercise is considered essential for the development and maintenance of musculoskeletal health. Several reasons exist for this hypothesis, one of which is the fact that the deeper slow twitch postural muscles are the stabilisers of the body and these are more effectively trained through slow endurance training. In contrast the multi-joint superficial muscles are the mobilisers - ballistic muscles of the body and are important for speed and agility but must be trained on a good endurance base. Once an endurance base has been achieved, the more functional and difficult exercises of eccentric, muscle lengthening and loading regimes of plyometrics can be used, by building a graduated, progressive and periodised training regime. Finally, allostatic mechanisms of training for stress management can be employed which are immune enhancing, so long as good training involves cognitive goal setting through mental and physiological considerations that result in the avoidance of injuries and the minimisation of lost training days through ill-health from 'over-reaching' and lack of periodisation of training to recover and improve on 'over-training'

Symptoms of 'over-reaching' or over training include mood disturbances ("three bastards in a day"), non-restorative sleep and heart rate variability demonstrating a slow response from rest to activity and rest again. Physiological markers include raised cortisol levels.


Immunological factors as a result of disuse

Immune Considerations and Nutritional Supplementation

Immune System and training

Oxidative Stress after Ultraendurance Exercise (overuse)


Musculoskeletal stress and the immune system


Endurance training - "training the zones"

Endurance training - periodization


Muscle Biomechanics

Plyometric Biomechanics

Plyometrics and eccentric muscle adaptation

Inverse Dynamics

Muscle Control

Motor control and oscillatory systems

Hip-back stability exercises

Back and diaphragmatic dynamic stability

Heart Rate Variability

Training Phases

Competitive Phase

Cooling Muscles

Good Reading


Immunological factors as a result of disuse

A biphasic stress response has been described in muscles during 'reloading' after a period of 'unloading'. Mechanical unloading as a result of disuse results in substantial muscle atrophy. This atrophy is a result of both increased protein degradation and reduced protein synthesis. Signaling pathways leading to this, include oxidative stress, proinflammatory signaling, reduced stress response, including heat shock proteins (HSP) and insulin-like growth factor (IGF-1). Insufficient HSP and antioxidant enzymes elicits oxidative damage of proteins and lipids (Lawler et al 2003, Free Radic Biol Med, 35, 9-16). Hence, unloading elevates oxidative stress. Paradoxically, loading also elevates oxidative stress. Nuclear Factor kB (NF-kB) has been implicated in both processes. Unloading is thought to induce numerous pro-inflammatory genes including nitric oxide synthase, cytokines, ubiquitin pathway ligases as a result of withdrawal of the stress - response including HSP25, HSP70, IGF1/Akt pathway (Lawler et al 2006, Muscle Nerve, 33, 200-207). The early portion of reloading, after a period of immobilisation is characterised by muscle damage and inflammation which requires a cognitive approach using a realistic time-frame for recovery to take place. Although, muscle recovery after 7-10 days of unloading is rapid (7 - 9 days), prolonged immobilisation greater than 17 days exhibits impaired recovery of muscle mass (Kasper 1995, J Appl Physiol, 79, 607-614). Reloading of muscles have been shown to result in a large up-regulation of NF-kB DNA-binding activity (Lawler et al 2012, Med Sci Sp Ex, 44, 4, 600-609). HSP25 phosphorylation decreased during prolonged unloading but returned to normal after 28 days of reloading. HSP70 and IGF-1 remained depressed during short term reloading but returned to normal levels as muscle mass improved, whereas in contrast Akt phosphorylation was greater in short term reloading but returned to normal by day 28 (Lawler et al 2012).

Immune considerations and nutritional supplementation

Finally, recent investigations into the immune system of endurance athletes suggests that inflammation and immune sensitivity may be inversely proportional.  For example, upper respiratory tract infections are common amongst runners.  This may be due to irritation of the airways by air.  Alternatively, it may be due to the irritation set up by the mechanical loading of the musculoskeletal system during training.  Periodisation of training allows the body to recuperate, it provides a learning experience for the athlete of what they can tolerate and how to peak at the required time (see below).  Some of the recent investigations have highlighted the lack of salivary immunoglobulins in the period up to 2 hours after the cessation of training.  These investigators have suggested the use of carbohydrate nutritional supplementation immediately after exercise.  During my time in Switzerland, leading up to the Barcelona Olympic Games, there was an emphasis placed on carbohydrate supplementation (multodextrene), as well as magnesium for tired muscles in addition to regular blood checks of ferratin levels for women. These days, the supermarket and gym shelves are full of nutritional supplements.  With such a wide variety of choices available, it would seem appropriate to seek a consultation with a sports nutritionist.  Some information regarding carbohydrate supplementation can be found elsewhere on this website. Additionally, aging and vitality have been related to the capacity to enhance the immune system through exercise elsewhere on this website

Immune system and training

Title Overtraining effects on immunity and performance in athletes.


Institution School of Human Movement Studies, The University of Queensland, Brisbane, Queensland, Australia

Source Immunology & Cell Biology. 78(5):502-509, October 2000.

Abstract Summary:

Over-training is a process of excessive exercise training in high-performance athletes that may lead to over-training syndrome. Over-training syndrome is a neuroendocrine disorder characterized by poor performance in competition, inability to maintain training loads, persistent fatigue, reduced catecholamine excretion, frequent illness, disturbed sleep and alterations in mood state. Although high-performance athletes are generally not clinically immune deficient, there is evidence that several immune parameters are suppressed during prolonged periods of intense exercise training. These include decreases in neutrophil function, serum and salivary immunoglobulin concentrations and natural killer cell number and possibly cytotoxic activity in peripheral blood. Moreover, the incidence of symptoms of upper respiratory tract infection increases during periods of endurance training. However, all of these changes appear to result from prolonged periods of intense exercise training, rather than from the effects of over-training syndrome itself. At present, there is no single objective marker to identify over-training syndrome. It is best identified by a combination of markers, such as decreases in urinary norepinephrine output, maximal heart rate and blood lactate levels, impaired sport performance and work output at 110% of individual anaerobic threshold, and daily self-analysis by the athlete (e.g. high fatigue and stress ratings). The mechanisms underlying over-training syndrome have not been clearly identified, but are likely to involve autonomic dysfunction and possibly increased cytokine production resulting from the physical stress of intense daily training with inadequate recovery.

Endurance trainingExercise, Immune System, Cytokines, Heat Shock Proteins, Glutamine and muscle mass

allostasisExercise and fine-tuning the immune system through the development of sympathetic nervous system control over allostasis - implications for over-training, stress, pain management and cognitive behavioral therapy

Oxidative stress after Ultraendurance exercise (overuse)

Ultraendurance events have been shown to be associated with prolonged depletion of anti-oxidant capacity up to one month post event (Turner etal 2011, Med Sc Ex Sp, 43, 9, 1770-1776). Specifically, glutathione (GSH) remained depleted to approximately 1/3 of pre-race values, for up to 28 days after the race.

Quality of movement, and hence performance breaks down as fatigue sets in.

Fatigue is the stressor which affects change, however excessive fatigue from one bout of exercise or from successive repeated bouts of exercise without adequate recovery can cause strain. A failure to plan is a plan waiting to fail.

Training - "you need to stress not strain the system to create performance enhancing change"


A common symptom of over-training is non-restorative sleep, immune compromise and stress fractures. Approximately, 1/3 of young athletes have experienced 'non functional over-reaching (NFOR) or over-training (OT) at least once in their sporting life (Matos et al 2011, Med Sc & Sp Ex, 43, 7, 1287-1294). The rate was higher in individual sports (37%) when compared with team sports (17%). Individual sporting endeavors tended to consume more than 2 hours per day, 6-7 days per week, which was significantly greater than the training volume reported in team sports. Females were more prevalent in the OT cohort (36% vs 26%). Moreover, even in low physical intensity sports such as golf individuals may suffer from NFOR/OT. Training load and volume alone wasn't the sole contributor to OT, as sporting individuals appeared to devote more time to their sport and less time to socialising and other school activities.  Thus, they are at risk of developing a uni-dimensional personality which seems to place them at risk for NFOR/OT. Self esteem, identity and self-worth become intertwined which is fine whilst they are gaining sporting success, however sporting failure may result in stress and anxiety. Hence, young athletes should be encouraged to form multi-dimensional personalites through encouragment of a range of hobbies and interests. 

Over training in female athletes can be particularly severe as O-T leads to alterations in the luteal phase of the menstrual cycle which results in dysmenohrea and potential reductions in bone mineral density and metabolic dysfunction due to reduced estrogen levels.

Alterations in Mood

The 3 B's Rule - if you meet one bastard in a day that is just unfortunate, if you meet 2 then it is very unfortunate, however if you meet three bastards in a day then you are in over-training!!

Musculoskeletal stress and the immune system

Recovery may involve analysis of technique, examination of training load (duration, frequency, intensity), adequate rest and nutrition, as well as a sound state of mind (mental strength). Over-training has been shown, within 4 weeks, after the onset of training, to be associated with increased oxidative stress both at rest and during submaximal exericise in a group of men after they underwent 7 weeks of  intense military training (Tanskanen et al 2011, Med Sc Sp Ex, 43, 8, 1552-1560)

This principle applies equally to endurance athletes such as road cyclists and mountain bikers who need to avoid 'staleness' or stress from the monotomy or boredom in training and/or chronic fatigue from the high volume of training.  In fact, when I was working with elite and professional cyclists in Europe, we commonly had road cyclists go running in the forest during the winter months to obtain greater strength and agility.  Equally, we frequently asked skiers to mountain bike during the summer, or go hiking with very heavy backpacks up mountain sides. In one female downhill skier, she had been performing well early in the season, then began to perform poorly, to which she responded by training more. Our coaching team decided to send her to the beach for a holiday just weeks before the world championships. She became world champion!!! In some cases, reductions of stress consisted of cross training whereby road cyclists got on the track (in the former East Germany) and track cyclists got out on the road (Australian team in Mexico), as well as flat riders doing hills. Although specificity of training is of paramount importance, such cross training can reduce the risk of 'staleness' and excessive fatigue from doing too much of the same thing.  Importantly, these strategies were most commonly employed during the off-season and/or in athletes who were still in their developmental phase of learning.


Whole body cryostimulation has been demonstrated to limit over-reaching in elite synchronized swimming, where variables such as reduced sleep quantity, increased fatigue and impaired exercise capacity are mitigated (Schaal K, et al 2015, Med Sc Sp Ex, 47, 7, 1416-1425). This is presumably as a result of heat shock proteins (Krause 2002) which are discussed elsewhere on this site. 


Sleep plays a critical role not only in recovery but also in the restoration of function of the immune system. Immune system can be discussed in terms of cellular (T helper cell Type I) and hormonal (T helper cell Type II) components. Each part has a counter-balancing regulating effect on the other. Th1 has an active role in fighting pathogens such as viruses and some bacteria (common in travelling teams and sports where open wounds can occur) as well as a role in fighting inflammation. Whereas, Th2 cells play a role in fighting against most bacteria as well as parasitic worms (Clow & Hucklebridge 2001 Ex Immun Review 7; 5-17, and Miyazaki et al 2005, Biol Psychol, 70, 1, 30-37). Cortisol, Prolactin, Melatonin and Growth Hormone have all been implicated in have a balancing affect on Th2 cells. During the early phases of sleep the immune system is pushed towards the Th1 profile which is associated with inflammatory processes. During the early phase (30-45minutes) of waking cortisol levels rise between 50 -150% creating a Th2 bias (Cutalo et al 2005, Autoimmunity Reviews 4, 8, 497-502) and hence a bias away from a pro-inflammatory profile. This may be why people may feel stiffer in the morning as a result of injury or over-training..

Frequently, when a team or an athlete is underperforming the tendency is to train harder, more frequently and stress mentally about the underperformance. During my time as a physiotherapist to Swiss professional and elite athletes we demonstrated time and time again that good preparation, support and analysis of underperformance usually resulted in a quick return to optimum results. However, sometimes it was difficult to convince a Swiss National downhill skiing champion that she needed to spend a couple of weeks on the beach, just before their world championships!

At a competitive level, an endurance event is all about the conservation of energy, maximisation of efficiency, predictability, and maintaining some redundancy in the system for those unexpected moments in a race. Ultimately, it is about knowing yourself and learning to know your strengths and weaknesses as well as those of your competitors. The more multifactorial the training approach, the more experience which is gained and the greater the feedback for improvement. However, the immediate goals need to be attainable and be in synchrony with the long term goals (SMARTA - specific, measurable, achievable, relevant, timely, aligned).

Endurance training - "training the zones"

Zone One (<70% HR max): very low level light exercise, too low in itself to induce physiological adaptations. Minimal sensation of effort or fatigue. Easy to hold a conversation. Used as a recovery strategy between bouts of exercise (intervals) or as a recovery strategy after a hard training session or long race.

Zone Two: (endurance 71-80% HR max): classic long slow all day long distance training. Good for gaining and endurance base. However, if too much time is spent training slow, you become slow. Recovery from 2 hour sessions should be quite rapid, whereas longer sessions with some moderately fatiguing climbs may take 1-2 days to recover

Zone Three (tempo 81-85% HR max): intensity as a result of speed. Frequent sensation of fatigue, concentration required, conversation becoming difficult. Daily sessions possible so long as adequate energy requirements are met. HR recovery may be a good test to indicate how well you have recovered.

Zone Four (lactic threshold 86-94% HR max): efforts similar to time trialing on a bike. Continuous conversation very difficult. Continuous sensation of effort or fatigue in muscles being exercised. Mentally very taxing and generally performed in blocks or repeats of exercise with some recovery between bouts but not too long e.g. running 1-3 minute blocks with 1-3 minute rest in between; cycling 10-30 minutes with 10-30 minute recovery between blocks of exercise. Consecutive days of training possible, but check HR recovery every morning and also maintain an immune enhancing diet. Not wise to do just before a big race. Also unwise to do if there is a lot of other stress in your life. Recovery is super important.

Zone Five (95-120% HR max): short intense bouts of activity. Running 10-30 seconds, Cycling 3-8 minutes. Strong to severe sensation of fatigue. Laboured breathing. Repeated consecutive days of training not recommended and considered undesirable.

Endurance training - periodization

Periodisation of training allows the athlete to gradually build up their training volume and/or intensity, whilst allowing time for regeneration. Gradual increments of loading can occur, whilst reducing the risk of excessive over-loading and hence injury.  Additionally, training of various intensities allows the metabolic systems to develop in parallel.  Thereby the anaerobic and aerobic metabolic systems can be used to drive endurance.


The development of endurance may take months and up to 10 years.  Strength is required to develop power, as power is equal to the product of force times velocity.  Power is important for speed.  Frequently, endurance athletes train slow and stay slow.They also need power which in German is called "Steigungsvermoegen".

Maximising strength also enables the body to enhance the firing of impulses to the muscles by the central nervous systems.

Since power = force x velocity then strength training to attain power requires velocity.  However, an inverse relationship exists between force and velocity.  As velocity increases, the force of contraction decreases.  Soft sand running or running in knee deep water may be a good compromise in the quest to attain power. Additionally, these forms of training help reduce over-striding and high impacts of foot strike as speed increases.

In this example from cycling research, performance power can improve by 22% through improved technique of hip extension. Biomechanics can influence the immuno-physiology and vice versa.

Biomotor abilities specific to running ability may be attained using for examples eccentric (muscle lengthening) quadriceps, calf and hip muscle loading in lunging.

Muscle biomechanics

Understanding muscle biomechanics and length-tension relationships (Hill model) allows for more specific training stimuli. Ultimately, the optimisation of power requires a balance between velocity and force since P=Fv. Similarly, efficiency may be improved by considering Power as Work over time P=W/t

Plyometric biomechanics

Plyometric exerices designed to improve power use the concepts of elastic and kinetic potential energy to improve energy absorption and movement execution. The following equations are taken from Wikipedia (7May2008)

This allows better utilisation of the stretch-shortening cycle of the lower limb muscles, in addition to reducing excessive muscle hypertrophy.

Plyometrics and eccentric muscle adaptations (Martin Krause 2003)

The eccentric component to this exercise cause more profound changes to the connective tissue of the muscle (broadening and streaming of Z bands) than concetric exercise.  Investigations into eccentric exercise revealed pain 8 hours after initial exercise which was maximal 48 hours later (DOMS = delayed onset muscle soreness) (Newham, Mills, Quigley, Edwards 1983).   These investigators found low frequency fatigue 10 minutes after a 20 minute period of stepping (Newham et al 1983).  Additionally, they demonstrated progressive increases in IEMG during the exercise in the rectus femoris (160% increase) and vastus medialis (140% increase) in the eccentric contracting leg (Newham et al 1983).  Mechanical damage to the sarcoplasmic reticulum resulting in less calcium release for each excitatory action potential was suggested as the cause of the low frequency fatigue (Newham et al 1983).

However, a number of sites in the myofibrillar complex such as reduce binding sensitivity and capacity of Troponin C for calcium, altered troponin-tropomysosin interaction to impaired binding and force generation by actin and myosin have been implicated in impaired force generation (Green 1990).  Indeed, in the absence of any association between relaxation rates and Calcium kinetics raises support for the notion of a rate-limiting process controlling the relaxation of fatigued muscles being located in the contractile proteins (Hill et al 2001).  During fatigue the relaxation times can be prolonged as much as 50% (Bigland-Ritchie et al 1986) thus resulting in increased force generation during submaximal stimulation due to tetanic fusion despite a substantial fall in the maximum tetanic force (Bigland-Ritchie et al 1986).

The initial overall loss of force production seen may be due to Desmin and Titan damage (Lieber & Friden 2002).  Desmin acts as an extra-sarcomeric mechanical stabilizer between adjacent Z discs and the attachment to the costomere at the sarcolemma (Lieber, Shah & Fridén 2002).  The costomere complex contains Talin, Vinculin & Dystrophin which attach to the trans-sarcolemmal proteins Integrin and Dystrophin associated proteins.  These proteins allow the lateral transmission of force from actin to the basal lamina containing type IV collagen which is contiguous with the endomysium (Kovanen 2002).  Desmin loss after eccentric exercise can occur within 5 minutes, possibly as a result of increased intracellular Calcium leading to Calpain activation and selective hydrolysis of intermediate filament network (Lieber & Fridén 2002).  This may result in the ‘popping of sarcomeres' of different length thereby potentially loosing their myofilament overlap of actin and myosin (Lieber & Fridén 2002).  Hence, reduced force production would be expected.  Additionally, the release of matrix metalloproteinase (MMP) which may degrade the extramyocellular type IV collagen (Korskinen, Kovanen, Komulainen et al 1996).  However, this effect occurs many days after exercise (Korskinen et al 1996) and could even effect torque production 28 days after exercise (Lieber & Fridén 2002).  This has significant implications in exercise training prescription.

flash file created by Martin Krause 2003

Titan molecules span the gap between the ends of the thick filaments and Z-bands. At the 2007 MPA conference in Cairns, Rob Herbert, provided the AJP oration whereby he explained the significance of Titan as a major determinant of extensibility in muscle fibres. Additionally, he stated that Titan is differentially expressed in human skeletal muscle as short stiff fibres and long compliant fibres

Costomeres are 15 different proteins

  • Low oxidative muscles have a tendency to tear during eccentric exercise
  • Loss of desmin proceeds loss of fibronectin membrane
  • Fibre strain results in increased intracellular and extracellular calcium which ?may lead to desmin hydrolysis through calpaine?
  • Sarcomere shortening occurs to the detriment of tendon lengthening
  • Excitation-contractile coupling may be the area disrupted rather than pure sarcomere disruption
  • Structural changes of the disruption of the cytoskeleton include dystrophin (sublaminal membrane protein), sometimes desmin and titin, whereas alpha actin is always OK ?suggesting that calpaine is not the enzyme responsible for protein dysruption?
  • Creatine Kinase has no correlation with these cytoskeletal changes
  • Inflammatory process important for tissue cleaning and remodelling
  • Mechanism for muscle adaptation may be myosin gene regulation - heavy chain myosin isoform upregulation
  • Oxygen into the Mitochondria and through the electron transfer chain (ETC) results in ATP use of 20% for power and 80% for heat, therefore people producing less heat may be producing more power?
  • Slow twitch muscle fibre concentration varies with the years of training
  • Cycling cadence velocity at peak efficiency for slow twitch muscle fibres is 80rpm


Vibration fatigue is probably reduced through enhanced transverse forces by wearing pressure garments such as SKINS. Additionally, venous return is probably also improved through the pressure gradient which these garments provide.

Also check out the 'tensegrity model' as it applies to microbiomechanical and macrobiomechanical structure, flexibility and integrity - the new way of the future

tensegrity model

Inverse Dynamics

Inverse dynamics dictates that in an accelerating system, the forces are directed along the muscles which span more than one joint to provide a mechanism for the transfer of energy from one limb segment to the next. Clinically, this has important implications in training, as the entire limb must be functioning optimally to be able to attain efficiency of movement.

Muscle control

Peripheral muscle contractile efficiency may be enhanced if the muscles origin at the pelvis is stabilised by core stability muscles such as transverse abdominis, pelvic floor, diaphragm and internal oblique. Certain one joint muscles such as, for example, the obturator internus are biomechanically continuous with the pelvic floor and hence provide an important stabilising function as well as act as a conduit for the obturator nerve. The iliacus stabilises the hip whilst the Psoas membrane is continuous with the diaphragm and hence has an important lumbo-pelvic-costal stabilising function as well as acting as a hip flexor. Moreover, the 2 joint muscles acting as 'energy straps' between body segments eg knee - pelvis will require stabilising actions in the trunk based on Newtons third law of action-reaction. Importantly, these forces only occur in the same plane of motion. Therefore, muscles which act in multiple planes of motion are inherently better stabilisers of multidimensional joint motion than muscle which act solely in single planes of motion. Naturally, in a functionally unstable spine, it would be better that the reaction force is anticipated by the appropriate bracing beforehand. This would require 'feedforward' motor control of movement. Additionally lack of pelvic control would result in reduced lumbopelvic rhythm making leg movements not only inefficient but also potentially injury producing through 'misuse'. Therefore, the hamstring, quadriceps, gluteal, ITB-Tfl muscles would need to act synergistically with the trunk muscles. Regardless of how strong the core muscles are, 'the tail ends up wagging the dog' if the correct co-ordination and timing between muscle groups isn't present. Similarly, based on the 'energy strap' hypothesis even calf muscle tightness can produce increased anterior tilting and rotation of the pelvis making a person appear to be walking with their 'tail wagging in the air'. It is therefore important to provide verbal and visual feedback to the person so that they become cognisant with reasons for their ongoing problems of pain and/or reduced sporting performance.

Gym workouts using large muscle mass usually requires 48-72 hours rest between bouts of training. However, large amounts of concentric exercise with emphasis on 1 rep max will result in adverse weight to power ratios due to excessive hypertrophy of the muscle group. Therefore, when considering endurance type of sporting activity, 3 sets of 7-15 repetitions may be more beneficial, especially when eccentric contractions are used.

Motor control and oscillatory systems

Motor learning theory devised by Bernstein suggests that the body will use the momentum of the limbs to optimize the degrees of freedom in the system.  Similar to a mass-spring analogy where the perturbations of the mass will be dependent on the damping characteristics of the spring,  the brain will introduce muscle tone to dampen the angular velocity and hence acceleration of the system.  Therefore, instead of the muscles of the leg lifting the limb, the antagonistic muscles are decelerating the limb towards the end of trajectory.  Moreover, by using eccentric (muscle lengthening and contracting) muscle contractions the system becomes efficient through these decelerating movements through enhanced visco-elastic rebound as well as the conservation of momentum.

Changing speed of training, not only allows the use of various metabolic energy systems, but it also trains mechanical efficiency and therefore should reduce the rate of energy expenditure.  The more efficient the system the greater the time to fatigue may be.  Importantly, acceleration places an emphases on the changing velocity.  Sprint training, Fartlek training (progressive increases and decreases in speed), counterjumps (plyometrics), eccentric-concentric leg pressing, eccentric-concentric lunging, undulating hills, running-jumping are all exercises which may improve angular momentum and therefore efficiency.

Besides training implications, there are also clinical considerations when for example a component of the kinetic chain isn't functioning in it's stretch-shortening cycle and energy dissipation function as it is supposed.

Hip-back stability exercises

(right click on graphic to replay)

Stair and hill work should further tune the biomotor abilities. Core stability exercises for the abdominal region using a Swiss Ball or Body Blade may be another example of specific strength training, which should enhance efficiency through improved lumbo-pelvic rhythm. Poor technique can lead to inefficiency and injury (eg hip-low back pain). 

Back and diaphragmatic dynamic stability

Improved thoracic function through lateral diaphragmatic breathing for enhanced blood flow, improved eccentric iliopsoas and superficial abdominal oblique muscles efficiency, as well as enhanced scapula positioning and improved pelvic floor function.


Heart rate variability

More precise monitoring of the rate of recovery can be achieved by examining 'Heart Rate Variability'whereby the response of the heart from 3 minutes prone to 2 minutes of upright posture is measured. High variability dictates a fresh response - low variability indicates a 'stale response' or high stress related fatigue. This allows the athlete to more objectively determine which days should be recovery days and which ones are days where they can train a little harder. Importantly, chronically reduced HRV is suggested to be a 'red flag' for sudden cardiac arrest in otherwise fit and healthy individuals. Such individuals should have further testing by a cardiologist before recommencing their training regime.

Training phases


Training phases may be separated into various stages depending upon the age of the athlete and whether the athlete is a novice or an experienced athlete. General physical abilities may include multilateral development of endurance eg using cycling and swimming or even a team sport like soccer as an adjunct to running training.  Specific physical suggests more time devoted to the particular run eg 5000m vs 10000m vs marathon vs orienteering and less time devoted to other sports.

However, during the regeneration phase of periodisation or during an injury the other sporting abilities may play a greater role.

Specific biomotor abilities relates to those aspects of the sport which relate to specific training regimes to enhance co-ordination, strength and agility.  Plyometrics using depth jumps and rebound is an example of such a specific training regime and should only be used in the already well trained athlete. Sports such as Orienteering require endurance, power and agility in terrain and therefore utilises speed work on various ground, in various vegetation and on different slopes.


Don't increase your training volume by more than 10% in a week

Remember the 3B's (Bastards in a day) Rule

Competitive phase

As training proceeds into the competitive phase some athletes place a higher proportion of their loading on intensity whilst reducing the total volume of training.  Cycles such as this one may be biannual or biennial.  Importantly, periodisation and cyclic loading is not restricted to any particular time frame. Although,  it does place  emphasis on incremental loading moreover it places emphasis on optimal regeneration and recovery. Additionally, such a methodology provides a 'base' for the next cycle of training activities. Each macrocycle may be made up from microcycles which can last days, weeks, months or years. Remember, each time you train to change your bodies abilities you are stressing the system and therefore recuperation is important.

Cooling muscles

Cooling muscles will also profoundly affect the rate of contractile responses to neural input. Through cooling, the muscles resting tension increases.

 Good Reading


Altered biomechanical conditions as a result of misuse, disuse, overuse, abuse results in damage which can cause a viscious reciprocating cycle of muscle-tendon atrophy, degenerative changes, and immune-metabolic dysfunction that creates an environment of morbidity from chronic musculoskeletal dysfunction. Allostatic mechanisms of training for stress management can be employed which are immune enhancing, so long as good training techniques involve cognitive goal setting through mental and physiological considerations that result in the avoidance of injuries and the minimisation of lost training days through ill-health. Periodisation of training and correct technique reduce the risk of over-training, 'staleness', immune compromise and injury by considering the importance of rest, nutrition and correct biomechanical and physiological loading. Please look at Link to Training and Rehabilitation for further details


Bigland-Ritchie B, Bellemare F, Woods JJ (1986) Excitation frequencies and sites of fatigue.  In : Jones NL, McCartney N, McComas AJ (Eds) Human Muscle Power . Human Kinetics Publisher, Champaign Ill , pp197-213.

Green HJ (1990) Manifestations and sites of neuromuscular fatigue.  In:  Taylor AW, Green HJ, Ianuzzo D, Sutton J (Eds). Biochemistry of Exercise Human Kinetics Publisher,  Champaign,  Ill., pp 13-25

Hill CA, Thompson MW, Ruell PA, Thom JM, White MJ (2001).  Sarcoplasmic reticulum function and muscle contractile character following fatiguing exercise in humans.  Journal of Physiology , 531.3 , 871-878.

Koskinen S, Kovanen V, Komulainen J, Hesselink H, Kuipers H, Vihko V, Takala T (1996).  Type IV collagen, MMP-2, and TIMP-2 mRNA levels in skeletal muscle subjected to forced eccentric contractions.  Medicine & Science in Sports & Exercise , 28 , 153

Kovanen V (2002).  Intramuscular Extracellular matrix: complex environment of muscle cells.  Exercise Sports Science Reviews , 30 , 20-25

Krishnathasan D, Vandervoort, AA (2000).  Eccentric strength training prescription in older adults.  Topics in Geriatric Rehabilitation , 15 , 3, 29-40.

Lieber RL, Fridén J (2002).  Mechanisms of muscle injury gleaned from animal models.  American Journal of Physical Medicine and Rehabilitation , 81 , 11, S70-S79

Lieber RL, Shah S, Fridén J (2002).  Cytoskeletal disruption after eccentric contraction-induced muscle injury.  Clinical orthopaedics and related research , 403S , S90-S99.

Newham DJ, Mills KR, Quigley BM, Edwards RHT (1983).  Pain and fatigue after concentric and eccentric muscle contractions. Clinical Science , 64 , 55-62

Sun Tzu : The Art of War

mastery of energy, mastery of the heart, mastery of strength, and mastery of adaptation

they who know themselves and know their adversary will always win

Last update : 20 August 2015


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  • Sun 15 Oct 2017

    Neuroplasticity in Tendon Dysfunction

    Neuroplasticity in Tendinopathy by Martin Krause A multitude of contributing factors to altered motor control must be addressed when treating tendon dysfunction. What we have failed to consider in the past when dealing with chronic or recurrent tendon issues are motor control problems encompassing corticospinal control of excitation and inhibition as well as belief systems about pain and contextual factors related to imaging.  Research by Ebonie Rio et al (2015) (BJSM Sept 25, 10.1136/bjsports-2015-095215) suggest that the pain state sets up an adaptive pathway whereby the ipsilateral kinetic chain is directly inhibited by reflexogenic pathways, as well as being inhibited by contralateral hemispheric activity. Simultaneously excitation is enhanced in the opposite limb as well as in least in the case of enhanced excitation of the hamstrings in quadricep tendinopathy. If this is true, then so much for training the contralateral limb for 'cross training' purposes! This may also explain why a lot of people seem to have "all their injuries on the same side" (of the body). Furthermore, they recommend enhancing corticospinal drive through the use of 30-60 second isometric holds at 70-80% MVC to load the muscle whilst using isokinetics to load the tendon. Moreover, they recommend the use of a metronome at 60bpm (stages 1 and 2) with a count of 3 up, 2 down for quads, and 2 up, 3 down for calf isokinetics to optimally engage corticospinal drive through the visual and auditory stimuli (also shown by Kohei et al 2012 for motor imagery and M1 stimulation) more Cortical mapping of infraspinatus muscle in chronic shoulder pain demonstrating higher motor thresholds (aMT= activation MT) and hence reduced excitability on the affected side (39 vs 35) (Ngomo et al 2015 Clinical Neurophysiol, 126, 2, 365-371) Cortical mapping of pain and fear. Lots of overlap suggesting that taking away the fear from the pain with clear clinical explanations and a focused goal directed program using specific functional outcomes is important.  Individuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036,  Uploaded : 18 October 2017 Read More
  • Mon 09 Oct 2017


    Do I need a scan? "a picture tells a thousand words" - not really! by Martin Krause A scan, in it's self, will not improve anyone's condition. The purpose of a scan is to gain more information about the pathology. Sometimes this information may be irrelevant to the management of a patient's condition. For example, if you knocked your elbow on a door frame and suffered a bruise, which was already beginning to resolve, an ultrasound scan may show some minor soft tissue damage, but that was already obvious by the fact of the bruise, and the information gained from the scan has not helped nor changed the management of the bruise. Therefore, the main reason for getting a scan would be because there is concern that the presence of certain pathologies may lead to a change in the medical management. For example, sometimes a rolled ankle can be more than sprained ligaments, and may require surgey or immobilisation in a boot. If the therapists suspects this might be the case, then they will recommend or refer for a scan (probably an X-Ray) to check the integrity of the bones (especially the fibular and talar dome), because if there is no bony damage then the patient can be managed conservatively with taping, exercises, ultrasound, massage, joint mobilisations etc. However, if there is boney damage, for example, then it might be necessary for the ankle to be immobilised in a boot for three - six weeks, for example. This dramatically different medical management depends on the results of a scan, and it is therefore worth doing. However, scans have no predictive value to the presence or severity of pain. Thirty-three articles reporting imaging findings, in the low back, for 3110 asymptomatic individuals were investigated for pathology. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age. (Brinjikji, W et al Spine Published November 27, 2014 as 10.3174/ajnr.A4173). Hence, the results of imaging need to be assessed within the context of the entire clinical picture. Frequently too much emphasis is placed on the imaging not only by the clinician but also by the patient. Some people react to pathology seen on scanning as an affirmation of their problem and can either use it to gain clarity and become better or conversely become worse. Moreover, some people find imaging with inconclusive results as a 'panic moment' - "no one knows what is wrong". Similarly, ultrasound imaging of the tendond has good predictive diagnostic and aids in clinical reasoning when it comes to full tears. However, with partial tears it is a totally different 'ball game'. Ultrasound is highly user dependent, with specifically trained musculoskeletal radiologists able to produce high-quality images that may provide more clinically relevant information than those produced by clinicians with less experience in imaging. Sean Docking, a leading tendon researcher at Monash University, cited 7 authors who found pathological tendon chnages in 59% of asymptomatic individuals, whereas he found that 52% of asymptomatic elite AFL sportsmen had tendon pathology on imaging! Furthermore, symptomatic individuals who improved clinically to the point of resuming play, weren't shown to have improvements on imaging. Again, the clinical context and the clinical reasoning can in many instances prove to be the 'gold standard' not the imaging itself, when considering management options. Shoulder supraspintatus tendon pathology, in the abscence of trauma, is known, in many instances, to be a disorder of immune-metabolic compromise of the tendon and bursa. Imaging may show some changes in signal intensity but, unless it's a complete tear, it can reveal neither the intensity nor the severity of pain when taken outside of the clinical context. A thorough physical and subjective examination integrating all the clinical dimensions of the problem will have far greater value than any one single imaging modality. Yet, imaging still should be used in instances of progressive rapid deterioration and suspected serious pathology which may require surgery and/or immediate medical intervention. In summary, sometimes it is worthwhile getting a scan, because the information gained from that scan will determined the type of medical management that is employed. However, at other times, the scan may be unneccessary, because the information may be irrelevant or lead to an incorrect change in medical management, due to over-reporting of 'false positives'. You will be able to make this decision on the advice of your health care professional. On occasions it can actually be detrimental to have a scan, because some patients can become overly obsessed with the medical terms used to describe their scan results, which then can become the major focus for the clinician and the patient, rather than the more prefereable focus on their symptoms and functional abilities. For example, many people have lumbar buldging discs yet have no symptoms, yet sometimes when these patients have an MRI or CT scan, they can develop symptoms because they think they should have pain if the scan says so! Conversely, for some people the results of imaging can have a positive and reassuring affect. Therefore, it is very important to assess a clients attitude to scans before prescibing them so that the patient's expectations are managed appropriately, and not burdened by the additional, sometimes confusing, information supplied by a scan. Uploaded : 10 October 2017 Read More
  • Thu 14 Sep 2017

    Cervical Spine implications in concussion

    Neck aetiology, autonomic and immune implications, exercise and diet in the musculoskeletal physiotherapy management of Post Concussion Syndrome (PCS) by Martin Krause, MAPA, Titled member Musculoskeletal Physiotherapy Association of Australia  A 14 year old boy presented to A&E, in August 2016, after receiving an impact to the head during AFL (Australian Rules Football). Although his SCAT3 scores were relatively mild, he went on to suffer severe lethergy, resulting in a lengthy abscence from school, culminating in a return to school for exams in the first week of December 2016. By December, even a 30 minute walk was extremely fatiguing. To place this into perspective, he had been playing elite academy grade AFL for several seasons and was an extremely fit outdoor adventurer. Confounding Variables : end of season injury and hence no follow up from the academy suffers from Hypermobile Joint Syndrome (HJS) and possibly Ehlers Danlos Syndrome (EDS), however Beighton score 4/9. suffers from food intolerances, particularly to Glutin and diary, but also some other foods. Potential IBS and autoimmune issues. had just gone through a growth spurt (190cm) Imaging : Brain MRI normal Medical Examination : Balance remained impaired to tandem walking and single leg stance. The vestibular occular motor scale showed significant accomodation deficit of 15cm and there was a mild exacerbation of symptoms. ImPACT testing revealed adequate scores and reaction time of 0.65 which is within acceptable range. History : School holidays December - January. Return to school and was placed in the lower academic classes. Prior to his concussion he was a top 10 student at an academically selective high school. Took up basketball and rowing as summer sports. Academic results tanked. Several lower limb Basketball injuries (Feb - April 17') as a result of what apppeared to be muscular imbalances from the relatively recent growth spurt, as well as taking on a new sport. Showed little interest in returning to AFL as no-one from the AFL academy had followed up on his recovery (or in this case lack of recovery).  Current History : September 2017 showed a continued decline in academic levels. School teachers noted an inability to concentrate. Academic results still well below pre-concussion levels. Fatigue continuing to be problematic. Stopped going to school for 7 weeks due to another head impact, but this time at Basketball. Literature Review : Post Concussion Syndrom (PCS) is defined as "cognitive deficits in attention or memory and at least three or more of the following symptoms: fatigue, sleep disturbances, headache, dizziness, irritability, affective disturbance, apathy, or personality change"  One of the known risk factors for Sport Related Concussion (SRC) is a history of concussion. Although, most adults recover from concussion after 10 days, there is evidence to suggest ongoing abnormailities in the brain can pursist well beyond 10 days (Prichep et al 2013, J Head Trauma Rehabil, 28, 4, 266-273). Thus, with the above described symptoms and potential motor control problems, further complications of PCS also appear to be altered proprioception, an increased risk of musculoskeletal injury which in turn can lead to SRC. The following are the results from soccer players. Nordstrom et al (2014, BMJ Sports Med, 48, 19, Predictors of PCS are uncertain. However, the following clinical variables are considered factors at increasing risk. These include prior history of concussion, sex (females more prominant), younger age, history of cognitive dysfunction, and affective disorders such as anxiety and depression (Leddy et al 2012, Sports Health, 4, 2, 147-154). Unlike the 'good old days' which recommended a dark room and rest for several weeks post concussion, the consensus appears to be a graded return to exercise in order to restore metabolic homeostasis. Disconcertingly, highly trained young individuals can find even exercises in bed extremely demanding in the presence of sport related concussion (SRC). Kozlowski et al (2013, J Ath Train, 48, 5, 627-635) used 34 people,whereby 226 days post injury to conclude significant physiological annomalies in response to exercise which may be the result of 'diffuse cerebral swelling'. Researchers have noted lower systolic and higher diastolic blood pressure in PCS (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Due to autonomic dysfunction manifested in altered cardiovascular and pulmonary responses (Mossberg et 2007, Arch Phys Med Rehab, 88, 3, 15-320), wheerby some clinicians have recommended the use of the exercise program for POTS (Postural Orthostatic Tachycardia Syndrome). This is a 5 month program which recommends mainly exercise in the horizontal and sitting positions for 1-4 months, including recumbent bike, rowing ergometer and swimming laps or kicking laps with a kick board. Month 4 upright bike and Month 5 upright training such as a elliptical trainer or treadmill. Other progressive exercise therapies have also included 20 minutes per day, 6 days per week, for 12 weeks of either treadmill or home gym exercises at 80% of the heart rate at which their concussion symtoms are exacerbated. Their programs were individually modified as the heart rate provoking symptoms increased. When compared to the 'control group', this intervention was shown to improve cerebral perfusion on fMRI, increase exercise tolerance at a higher heart rate, less fatigue and were showing activation patterns in areas of the brain on performing math processing test which were now normalised (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Graded exercises could also have included 'motor imagery' as espouse by the NOI group and the work of Lorrimer Moseley (University South Australia) when dealing with chronic pain. Ongoing Symptoms : The literature review by Leddy et al (2012) found that ongoing symptoms are either a prolonged version of concussion pathophysiology or a manifestation of other processes, such as cervical injury, migraine headaches, depression, chronic pain, vestibular dysfunction, visual disturbance, or some combination of conditions. Anatomical considerations : Extensive anatomical connections between the eyes, neck and vestibular system (Wallwork et al 2007, JOSPT, 37, 10, 608-612) allow sensory information from neck proprioceptors to be processed together with vestibular information which, via the lateral vestibulo-spinal tract, affect the control of postural muscles such as the deep trunk muscles  (Hain 2011, Neuro-Rehabilitation, 29, 2, 127-141).  Psychological considerations : The Kubler Ross model of grief are applicable when it comes to chronic sports injuries. Physiotherapy Assessment : Current history One year PCS, fatigue continued to persist. Cognitive deficits with school work were reported to becoming more apparent. Assessment using various one leg standing tests employing oscillatory movement aroud the hips and knees for kinetic limb stability and lumbopelvic stability, which had been employed 6 months previously for his Basketball injuries were exhibiting strong deficits, despite these being 'somewhat good' previously. Significantly, during the acute phase of SRC, rugby union and rugby league players have been seen with alterations of both balance strategies and motor control of the trunk (Hides et al 2017, Musculoskeletal Sci Pract, 29, 7-19).  Physical Examination : cervical and thoracic spine Due to the Joint Hypermobility Syndrome (JHS) it was difficult to ascertain neck dysfunction based on range of movement testing. ROM were unremarkable except for lateral flexion which demonstrated altered intervertebral motion in both directions. Palpation using Australian and New Zealand manual therapy techniques such as passive accessory glides (upslopes and downslopes and traction) exhibited muscles spasms in the upper right cervical spine. In particular, the right C1/2 regions demonstrated most marked restrictions in movement. Eye - Neck proprioceptive assessment using blind folds and laser pointer also  revealed marked variance from the normal. Repositioning error (RPE) using the laser pointer with rotation demonstrated marked inability to reposition accurately from the left, tending to be short and at times completely missing the bullseye. Gaze stability with body rotation was NAD. Gaze stability whilst walking displayed some difficulty. Laser pointer tracing of the alphabet was wildly inaccurate and cognitively demanding. Thoracic ring relocation testing also revealed several annomalies, which may have also accounted for some of the autonomic dysfunction observed.  Occulomotor assessment and training Upper Cervical Spine : The upper cervical spine (atlas and axis) represents approximately 50% of the available rotation. An investigation into the environmental and physiological factors affecting football (soccer) head impct biomechanics found that rotational acceleration was one of the few factors approaching significance and concluded that more research should be undertaken to evaluate this (Mihalik et al 2017 Med Sc Sp Ex, 49, 10, 2093-2101). Headache : Commonly referred to as cervicogenic headaches, one in five headaches in the general population are thought to be due to the cervical spine. The Upper Cervical Spine is particularly vulnerable to trauma because it is the most mobile part of the vertebral column, with a complex proprioceptive system connecting the vestibular apparatus and visual systems. It also coincides with the lower region of the brainstem and fourth ventricle. The brainstem houses many neurones associated with autonomic responses to pain and balance. Imaging of the fourth ventricle for swelling of the 'tonsils' and Arnold Chiari malformations are recommended when symptoms persist. In particular, children and adolescents are more vulnerable to neck contusions due to the proportionately larger head and less developed musculature. Cervical vertigo and dizziness after whiplash can mimic symptoms of PCS.. Mechanoreceptor dysfunction and vertebrobasilar artery insufficiency should be part of the differential diagnosis. Mechanical instability of the Upper Cervical Spine should also not be missed. Cervicogenic Headaches Further Interventions : Neurocognitive rehabilitation of attention processes. Psychological intervention using cognitive behavioural therapy (CBT). Neuro-opthalmologist to assess and treat smooth pursuit eye tracking. Naturopath for food intolerances and dietician for the optimisation of diet. Diet :  In cases with chronic fatiguing factors, nutrition can be become a vital aspect into the reparative process. This may include energy and mineral rich foods such as bananas, green leafy vegetables for iron and magnesium (200-300mg), oranges for vitamin C (anit-oxidant and helps with the absorption of iron), anti-oxidant rich foods such as EPA/DHA (1000mg) fish oil, curcumin (tumeric), Cats Claw, Devils Claw, Chia seeds, fruits of the forest (berries), and CoQ10 with Vitamin B. Folate and Ferritin levels should also be checked. Calorific energy intake should balance with energy exependiture. However, as we are often dealing with young individuals, as in this case, some form of comfort food may be appropriate such as, nuts, legumes, homus and sushi. Protein intake prior to carbohydrate intake may help ameliorate any blood suger fluctuations due to Glycemic Index factors, however simple carbohydrates (high GI) should be avoided wherever practical. Even oats need to be soaked overnight and cooked briefly, otherwise they become a high GI food and may even affect the absorption of iron. The type of rice used can also influence GI, hence the addition of protein such as fish. Protein supplementations are generally over-used. Daily protein intake should not exceed 1.2g per kg of body weight per day. Dosage for children is less than that for adults. See Nutritional Section of this Site Trunk muscles : Researchers have found that a history of SRC had an increased possibility of having altered size and contraction of their trunk muscles, incuding smaller multifidus, larger quadratus lumborum muscles, and asymmetrical contraction of their transverse abdominis muscles, whereby an increased thickness and resting tone of the right anteroloateral abdominal muscle has been observed (Hides et al 2017 Med Sc Sp Ex, 49, 12, 2385-2393). In this case, by the second incident (Basketball impact), the subject was 15 years of age and 193cm in height. Apart from being very tall for his age he also has joint hypermobility. Combinations of SRC, growth spurt and hypemobility may have had a greater impact on his motor performance making secondary trauma more likely? A 3-6 increased risk of future SRC has been reported in the literature in cases of concussion (Abrahams et al 2014, Br J sp Med, 48, 2, 91-97). In our subject, using the laser repositioning error described above, marked inability to reposition the neck from the left was seen. This concurs with the findings in Australian Football Players (AFL), where a mean of 4.5 degrees of joint position error was reported on the left hand side (Hides et al 2017 Med Sc Sp Ex, 49, 12, 2385-2393). This is noteworthy, as our subjects initial concussion took place during AFL, with the subsequent concussion occurring in Basketball. It should also be remembered that this subject presented to physiotherapy for an ankle injury some 6 months after the initial concussion. Lower limb kinematic exercising ability, emphasising global balance and kinematic 'inverse dynamics' muscular energy strap transfer prinicples, demonstrated strength and balance deficits within the following prgramme. It should be noted that this regime places emphasis on repatitive loading; hence 3 x 40 reps. Interestingly, an investigation comparing lower limb (LL) and back exercises (lumbar extension LE and lumbar stabilisation LS) for runners with chronic low back pain reported  greater improvement in self-rated running capability and knee extension strength in the LL group vs LE and LS groups greater increase in running step length in LL and LE groups and similar reductions in running induced pain and improvement in back muscles across all three exercise groups. (Cai et al 2018, Med Sc Sp EX, 49, 12, 2374-2384) Extrapolation of these results to the current clinical setting suggests the importance of lower limb dynamic stability in cases of concussion. Moreover, recognition of these deficits may have prevented the second incidence of concussion? Conclusion  Investigations, into people with persisting PCS, demonstrated that they applied more force over time to control balance. Helmich et al (2016, Med Sc Ex Sp, 48,  12, 2362-2368) proposed that in regard to cognitive processes, the increase of cerebral activation indicates an increase of attention demanding processes during postural control in altered environments. This is relevant in so far as individuals with post concussive symptomatology have a variety of symptoms including headache, dizziness, and cognitive difficulties that usually resolve over a few days to weeks. However, a subgroup of patients can have persistent symptoms which last months and even years. Complications in differential diagnosis, can arise clinically, when neck dysfunction and altered motor control occur concurrently due to both neck and cerebral pathology. For example, Whiplash and other traumatic head and neck injuries can result in pathology to both regions, whereas, more discreet altered cognitive processing from concussion can result in altered neck motor control. Musculoskelatal Physiotherapy can play a vital part in the treatment of neck dysfunction including the re-establishment of occulomotor proprioception and managing localized strength and cardiovascular exercise regimes. A total body, multi-disciplinary approach which is well co-ordinated amongst practitioners is vital to an optimal outcome.    Updated : 10 February 2018. Original : 17 November 2017 Read More
  • Thu 24 Aug 2017

    Pain in the Brain - neural plasticity

    Pain in the Brain and Neural Plasticity by Martin Krause There are several mechanisms that can create a sensation of pain, which has been described as 'an unpleasent sensory and emotional experience in response to perceived or potential tissue damage'. Pain can be the result of peripheral sensitisation from peripheral inflammation, vascular compromise, necrosis, swelling, etc. Importantly, higher centres of the central nervous system not only perceive such sensitization of the peripheral nerve receptors, they can also modulate and control the intensity and tolerability of the perceived sensation through descending modulation at the peripheral receptor and in the spinal cord and through transcortical mechanisms depending on the 'meaning' and 'context given to the pain. Moreoever, the higher centres can create a 'state' of perceived 'threat' to the body through emotions such as fear and anxiety. Rather than the brain acting as a filter of unwanted sensation, in the higher centre induced pain state, rumination and magnification of sensations occur to create a pathological state.  Paradoxically, representation of body parts such as limbs and individual muscles can reduce in perceived size. In such instances the pain doesn't represent the sensation of pathology but rather pain has become the pathology. Hence, the brain generates pain in the brain, where the pain is perceived to be some sort of non-existant inflammatory or pathological sensation in the periphery. Evidence for this neural plasticity comes from imaging studies, where brain white matter structural properties have been shown to predict transition to chronic pain (Mansour et al 2013, Pain, 154, 10, 2160-2168). Specifically, differential structural connectivity to medial vs lateral prefrontal cortex and connectivity between medial prefrontal cortex and nucleus accumbens has been shown in people with persistent low back pain. In this case the back pain becomes the inciting event and given the persons' structural propensity, establishes specific functional coonectivity strength.  further reading Peripheral input is a powerful driver to neuroplasticity. Information gathered by touch, movement and vision, in the context of pain can lead to mal-adaptive plasticity, including the reorganisation of the somatosensory, and motor cortices, altered cortical excitability and central sensitisation. Examples of somatosensory reorganisation come from the work of Abrahao Baptista when investigating chronic anterior knee pain, who not only demonstrated reduced volume of Vastus Medialis but also is cortical translocation to another part of the cortex. ndividuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036,   AKP = anterior knee pain The same researcher (Abrahao Baptista) has shown that maximal tolerable electrical stimulation (eg TENS) of muscles can induce normalisation of the cortical changes through a process called 'smudging'. Transcortical stumilation has also been applied as a cortical 'primer' prior to the application of more traditional therapy such as motor re-training, exercise, and manipulation. Body illusions are another novel way to promote the normalisation of cortical function through adaptive neuroplasticity. Examples come from people with hand athritis, whose perception of their hand size is underestimated (Gilpin et al 2015 Rheumatology, 54, 4, 678-682). Using a curved mirror, similar to that in theme parks, the visual input can be increased to perceive the body part as larger (Preston et al 2011 DOI: 10.1093/rheumatology/ker104 · Source:PubMed ) . Irrespective of size, watching a reflection of the hand while performing synchronised movements enhances the embodiment of the reflection of the hand (Whitkopf et al 2017, Exp Brain res, 23, 5, 1933-1944). These visual inputs are thought to affect the altered functional connectivity between areas of the brain thereby affecting the 'pain matrix'. Another, novel way of looking at movement and pain perception is the concept of the motor engram. This has been defined as motor skill acquisition through the modification and organisation of muscle synergies into effective movement sequences. The learning process is thought to be acquired as a child through experientially based play activity. The specific neural mechanisms involved are unknown, however they are thought to include motor map topography reflecting the capacity for skilled movement reorganisation of motor maps in a manner that reflects the kinematics of aquired skilled movement map plasticity is supported by a reorganisation of cortical microcircuitry involving changes in synaptic efficacy motor map integrity and topography are influenced by various neurochemical signals that coordinate changes in cortical circuitry to encode motor experience (Monfils 2005 Neuroscientist, 11, 5, 471-483). Interestingly, it is an intriguing notion that accessing motor engrams from patterns aquired prior to the pain experience might lead a normalisation of brain activity. My personal experience of severe sciatica with leg pain, sleepness nights and a SLR of less than 30 degrees, happened to coincide with training my 9 year old sons soccer training. I was noticing that the nights after i trained the children, I slept much better and my range of movement improved. I commenced a daily program of soccer ball tricks which i had been showing the kids, including 'juggling', 'rainbows' and 'around the worlds'. Eventually, I even took up playing soccer again after a 30 year abscence from the sport. Other than new activity related pain issues (DOMS), four years on, the sciatica hasn't returned. I can only conclude that this activity activated dormant childhood motor engram, worked on global balance, mobilised my nerve, encouraged cross cortical activity and turned my focus into finctional improvement. Further explainations for my expereience comes from evidence suggesting that a peripheral adaptive pain state is initiated, whereby transcortical inhibiton occurs by the contralaleral hemisphere to the one which controls the affected limb. Additionally, excitation cortical (M1) drive of the muscles of the contralateral limb to the one which is in pain also occurs. In such cases re-establishement of motor drive to the affected side is important. In terms of tendon rehabilitation, external audtory and visual cues using a metronome have been employed and are showing promising results (Ebonie Rio et al 2017 Personal communication). In terms of my experience with the soccer ball tricks, the external visual cues and the cross talk from using left and right feet, head, shoulders, and chest during ball juggling manouvers, whilst calling the rhythm to the kids may have been the crucial factor to overcome the dysfunctional brain induced pain - muscle inco-ordination cycle, which I was in. Additionally, I was cycling which allowed me to focus on motor drive into the affected.limb. However, work by Lorrimer Moseley on CRPS has established that 'brain laterality' must be established before commencing trans-cortical rehabilitation techniques. Lorrimer's clinical interventions use 'mirror imaging' techniques which are only effective once the patient is able to discriminate the left and right sides of the affected body parts, presented visually, in various twists and angles.   Alternatively, the altered pain state can result in a hostage like situation, whereby the pain takes control. Similar to the 'Stockholm Syndrome' where the hostage begins to sympathise with their captors, so do some peoples brain states, where it begin to sympathise with the pain, creating an intractable bondage and dysfunctional state. One screening question which may reflect commitment to the process of rehabilitatation is to question whether they were able to resist the cookie jar when they were a child? Or were they committed to any sporting endeavours as a child? This may give some indication for the presence of motor engrams which can be used to overcome dysfunctional pain induced muscle synergies (neurotags), but also indicate an ability to be self disciplined, as well as being able to reconcile and identify goal oriented objectives, in spite of the cognitive pain processes? Remember that neurons that fire together, wire together. Uploaded : 18 October 2017 Read More
  • Thu 03 Aug 2017

    Sickle Cell Trait and Acute Low Back Pain

    Researchers believe that lumbar paraspinal myonecrosis (LPSMN) may contribute to the uncommon paraspinal compartment syndrome and that sickle cell trait (SCT) may play a role. Sustained, intense exertion of these lumbar paraspinal muscles can acutely increase muscle size and compartment pressure and so decrease arterial perfusion pressure. This same exertion can evoke diverse metabolic forces that in concert can lead to sickling in SCT that can compromise perfusion in the microvasculature of working muscles. In this manner, they believe that SCT may represent an additional risk factor for LPSMN. Accordingly, they presented six cases of LPSMN in elite African American football players with SCT. See link below Read More
  • Thu 03 Aug 2017

    Ibuprofen, Resistance Training, Bone Density

    Taking Ibuprofen immediately after resistance training has a deleterious effect on bone mineral content at the distal radius, whereas taking Ibuprofen or undertaking resistance training individually prevented bone mineral loss. Read More
  • Tue 11 Jul 2017

    Mitochondrial Health and Sarcopenia

    The aging process (AKA 30 years of age onwards), in the presence of high ROS (reactive oxygen species) and/or damaged mitochondrial DNA, can induce widespred mitochondrial dysfunction. In the healthy cell, mitophagy results in the removal of dysfunctional mitochondria and related material. In the abscence of functional removal of unwanted mitochondrial material, a retrograde and anterograde signalling process is potentially instigated, which results in both motor neuronal and muscle fibre apoptosis (death) (Alway, Mohamed, Myers 2017, Ex Sp Sc Rev, 45, 2, 58-69). This process is irreversible. Investigations in healthy populations, have shown that regular exercise improves the ability to cope with regular oxidative stress by the buffering and 'mopping up' of ROS agents which are induced as a result of exercise. It is plausible and highly probable that regular exercise throughout life can mitigate against muscle fibre death (Sarcopenia). Importantly, this process of muscle fibre death can commence in the 4th decade of life. and be as much as 1% per year. Reduction of muscle mass can result in immune and metabolic compromise, including subclinical inflammation, type II diabetes as well as the obvious reduction in functional capacity for activities of daily living. Published 11 July 2017 Read More
  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) by Martin Krause When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups. In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. An interesting case of EDS and it's affect on post concussion syndrome can be read elsewhere on this site. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 17 October 2017  Read More
  • Fri 09 Dec 2016

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More

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Updated : 10 May 2014

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Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected