Fighting Foot Drop in Humans Translates to Pets, Too!

Fighting Foot Drop in Pets

This Post:

  1. Helps you understand why the foot doesn’t go flat on the floor
  2. Gives you suggestions to fix that condition
  3. Helps you see how human rehabilitation can be helpful for pets

RehabDeb Comment:

Employing these techniques for foot drop in pets is what I do and is highly successful. You may also build neuromuscular strength in pets by doing proprioceptive training.

Boots and Splints –

I use foot-bed hard splints and  dorsi-flex assist soft boots on a case-by-case basis for foot drop in pets. Both of these helpful tools serve a different purpose; they are not necessarily interchangeable in use!

People sometimes order a soft boot with toe flexion help when they actually need a hard splint and vice-versa. Please confer with an experienced rehabilitation specialist who has used both of these products. They should have experience with a large variety of cases so that you don’t waste resources or damage your pet.

I also urge you to listen to your common sense in the matter of braces or splints. Sometimes staff at brace or splint companies have suggested to mutual clients equipment that is too generic.

The course of action with assistance tools should be based on a broad problem-solving thought process. Each client will do best with a solution unique to them. I have had discussions with physical therapists at brace and orthotic companies to point out functional and physics errors in their designs for some few cases. I love that orthotics for pets are available! Getting the wrong fit leads to unnecessary expenses, possible pet injuries, and not as much help with recovery. Plus you have to spend lots of time on the phone working out the problem. Meh.

Making Braces at Home –

See the end of this post for a brace I made for Anatolian Shepherd Parker with hind limb dysfunction and partial paralysis. I purchased the materials at local stores for less than half the cost of commercial boots. This method was less expensive, however the client had also paid for a commercial boot I measured and ordered.

We needed the boot right away and the boot we ordered was going to take almost two weeks to arrive. I wanted to give the caretakers proper tools for the situation and use those tools to avoid paw dragging and new sores on the top of the paw. The commercial boot works better, in general, than my temporary boot. If I spend more time on my creation boot, then it works as well as the commercial boot. Regardless, we had mine to help in the meantime while we waited for the other one.

I create many helpful tools for pet rehab on a case-by-case basis. I know what results I am hoping to achieve and have a lot of MacGyver-type experience. If you try this at home, I recommend you get a veterinarian or a human physical therapist to help you with design. These professionals should have the most experience with neurological problems and help your pet get the best results.

The standard education for most veterinarians and veterinary rehabilitation specialists does not train them in advanced neurological problem drills. I am not slighting them; I am guiding you so that you may have more options for helpful tools. That is why I suggest a human physical therapist, hopefully one with lots of neuro experience. Your veterinarian will usually tell you if they have a lot of advanced experience with diagnosing and recovering neurological cases. Many veterinarians do not have this experience because of the advent of great veterinary specialty education. Board-certified veterinary neurologists are a thing.

From “Advance Journal for Human Physical Therapy”

The Foot Drop Fight
Early treatment and compliance with a home exercise program are essential.
By Rebecca Mayer Knutsen

Originally Posted on: December 20, 2012

Foot drop, a general term for difficulty lifting the front part of the foot, can be a temporary or permanent condition. The condition signals an underlying neurological, muscular or anatomical problem.

A patient with foot drop due to weakness or paralysis may exhibit behavior such as scuffing her toes along the ground. Or she may develop a high-stepping gait so her foot does not catch on the floor as she walks.

Beyond the obvious frustrations and limitations that accompany this condition, these patients are at greater risk for falls. According to physical therapists, early treatment and patient commitment to a prescribed home exercise program is often the best approach for patients with this gait abnormality.

Gaining Control –

The source of foot drop is most commonly a central neurological impairment such as stroke, multiple sclerosis or traumatic brain injury or a peripheral injury such as nerve damage stemming from knee replacement surgery.

“Controlling foot drop through strengthening, orthotics or a functional electrical stimulation foot drop system may address the instability of the ankle, limit the possibility of catching the toe during gait and increase safety and stability to decrease the potential of falls,” said Gregory A. Thomas, PT, physical therapy supervisor, Rehabilitation Center at Eastern Idaho Regional Medical Center in Idaho Falls, ID.

Therapists must conduct a thorough PT evaluation that includes a complete patient history and an assessment of range of motion, strength, sensation, spasticity, reflexes and mobility. Treatment varies depending upon the cause and presentation of the foot drop. Treatment options range from therapeutic exercises including ROM, stretching and/or strengthening to electrical stimulation and gait training.

“The first thing I do with a patient is determine if the dysfunction is central or peripheral,” explained Douglas O. Brown, PT, CSCS, manager of Raub Rehabilitation, Sailfish Point Rehabilitation and Riverside Physical Therapy, all part of Martin Health System in Stuart, FL. “Is it a brain injury such as stroke or MS?” Brown asked. “Or is it a pinched nerve in back or leg or damage from a hip surgery?

After Diagnosis –

Once the origin of the foot drop has been determined, Brown must determine if the patient is flaccid with no movement whatsoever. If so, then the outcome /prognosis will not be as good as someone who exhibits some movement,” he shared. (Flaccid limbs or muscles in pets are the ones that need range of motion drills, NOT limbs that the pet moves moderately well on it’s own – Deb).

According to Thomas, PT exercises for this patient population include range of motion exercises for knees and ankles and strengthening leg muscles with resistance exercises. And, stretching exercises are particularly important to prevent the development of stiffness in the heel.

“There are no exercises that are off limits to these patients as long as the ankle is stable during the exercise,” Thomas explained. “The exercises can be closed chained or open depending on the level of stability.”

Focus Work –

We have to focus on restoring normal movement patterns but also on stability,” Brown said. “Can the patient stand on one leg without swaying back and forth? It’s important that we remember the static part because these patients function on different surfaces in real life.” (I focus on these principles with my patients that have neurological problems-Deb).

Brown prepares patients for challenges met in the community and at home by having patients walk on foam mats in the clinic and then on various surfaces outside.

“If my patient’s goal is to be able to walk the beach in her bare feet, then we need to work on uneven surfaces,” Brown said.

The therapists need to understand a patient’s case 100 percent and treat each one as an individual. These patients need to be assessed on their own merits, according to Brown. “If I have a patient with a traumatic ankle injury from being run over by a car, then I may stay away from certain load bearing exercises,” he shared.

Enter the AFO –

If a patient does not have functional use of his muscles, then an ankle foot orthosis (AFO) can be used to keep the ankle at 90 degrees and prevent the foot from dropping toward the ground, thereby creating a more even and normal gait.

The type of AFO used depends on each patient’s specific needs. Some of the types most commonly used include solid ankle, articulated ankle and posterior leaf spring and are most typically made of polypropylene. Articulated ankles allow for some ankle motion, dorsiflexion assist and partial push-off during gait and solid ankle AFOs are rigid and more appropriate if the ankle and/or knee are unstable. Patients typically need to wear a larger shoe size to accommodate these types of AFOs.

Goals –

“As a physical therapist, I need to realistically fulfill the goal of a patient, which in the case of foot drop, is most typically to stop using an AFO,” Brown explained. “But there are other issues to consider aside from the annoyance of the device. I may need to worry about comorbidities such as diabetes and how the AFO may be causing skin breakdown.”

Brown aims to improve his patients’ optimum function and quality of life while decreasing the fall risk. “Once a patient tells me his goals, I need to determine if they are realistic,” he told ADVANCE.

The goal of physical therapy with these patients is to use the least restrictive device, according to Thomas. “If there is active movement at the ankle and we can strengthen it back to normal, then a temporary brace can be used for support and to increase safety,” he stated. “If the foot drop is more long standing, a custom fitted AFO may be needed.”

In the last 10 years or so, AFOs have improved in quality and function, according to Brown. In fact, he says, some AFOs are made of carbon fiber and elicit a dynamic action instead of keeping the foot rigid while going through the swing phase of gait.

FES, Another Option –

Another option is a foot drop system that applies electrical stimulation in a precise sequence, which then activates the muscles and nerves to lift the foot and bend or extend the knee. This type of device assists with a more natural gait, reeducates muscles, reduces muscle loss, maintains or improves range of motion and increases local blood circulation.

The foot drop device allows a flexible ankle during gait to obtain a more normal walking pattern. A good alternative to bracing, the device’s gait sensor adapts to changes in walking speed and terrain, allowing the patient to walk easily on stairs, grass and carpet.

Brown recently treated a 37-year-old woman with early stages of MS. He put the FES foot drop system on her and it helped her walk normally for the first time in years, bringing tears to her eyes.

“FES can help patients develop great gait patterns and fire muscles,” Brown observed. “FES shows the potential for improvement and the patient can rent the device themselves to wear all day instead of an AFO. The technology is helpful but the device isn’t for everyone. There is a better response with central foot drop as opposed to peripheral lesions.”

The device works well when the peripheral nerve is intact. Patients with a peripheral nerve injury-from diabetes or trauma-who have no palpable muscle contractions may not see improvements.


“If the damage is peripheral nerve, then a FES foot drop system will not work in correcting foot drop and [you will have to use] a passive AFO system,” Thomas shared.

If disease or injury interrups the patient’s spinal cord in any way, then retraining the muscles is often very difficult.

An AFO remains the appropriate solution for patients with lower-extremity edema, unstable ankle stance or cognitive impairments. Those conditions will all interfere with operation of a foot drop system.

Complying at Home –

For this condition, patients typically go to therapy for about 45 minutes, two times a week, according to Thomas. “If a patient is going to make gains, it’s imperative that there is good compliance with a home exercise program,” he shared. “The patients who have the greatest success are the ones with a solid work ethic outside the clinic.”

Brown’s approach to ensure compliance with a home program begins with the patient’s first evaluation. “I tell them how important the home program is and that participation is crucial,” he shared. “I put them on the spot and go through the exercises the first day and send them home with illustrations. During a quiz at the beginning of the next session I will ask them to demonstrate the exercises I assigned.”

With this approach, Brown knows whether or not they’ve followed through based on their familiarity with the exercises. “I give additional exercises and instruction during each session,” he said. “And that’s how I make sure that they are compliant. It usually works because patients come prepared because they don’t want to fail.”

Therapy When?

When it comes to foot drop-and really any PT-related injury or diagnosis-Brown stresses the importance of seeking care with a physical therapist as soon as possible. “I don’t want to see someone with foot drop after 6 months,” he stated. “Once a patient is medically stable and safe to treat, they need to be sent to PT.”

Brown recalls seeing a patient with foot drop after having a stroke one and a half years earlier.

“There was a lot less I could do for her compared with what I could do right after her stroke”. “It’s crucial to treat these patients as soon as possible with exercise, stretching and weight bearing.”

Rebecca Mayer Knutsen is senior regional editor of ADVANCE and you may reach her at

(Updated February 23, 2018)

More Than Half of All ACL Reconstructions Could Be Avoided, Five-Year Follow-Up Study Shows

Another Human-Based Study, and I’ve Been Proving This in Canine Cases For Over 10 Years-

From RehabDeb: This report is from human medical research, however Colorado State University has since conducted some animal studies. I would love to conduct studies with advanced exercise physiology protocol that I have been using for over 20 years even with my own pets before doing “official” vet med work. I look forward to when I have resources to do those studies.

When I began independent practice in 2007, I used my accumulated research studies, experience, and knowledge begun decades before my work in veterinary medicine in order to create some simple functional exercise and drill protocol. These programs benefited hundreds of my pet patients whose people opted to not pursue surgery. I have used these programs for both cats and dogs.

In every case where people follow my protocol (and where there are no extenuating circumstances), the pets have stabilized the knee or other joint with muscle growth and strength and with proper scar tissue (sometimes we want some scar tissue).

These pets have also functioned very well after rehabilitation. You may do all this work in the home environment with no dependence on specialized equipment in a clinic. There is no need for specialized equipment when we are drawing from centuries of known exercise physiology.

My programs for conservative (no surgery) treatment are clinically and anecdotally successful. This means that clients and veterinarians do the work and get good results. You can too, if you want to do the work 🙂

Jan. 30, 2013 — In the summer of 2010, researchers from Lund University in Sweden reported that 60 per cent of all anterior cruciate ligament (ACL) reconstructions could be avoided in favour of rehabilitation. The results made waves around the world, and were met with concerns that the results would not hold up in the long term. Now the researchers have published a follow-up study that confirms the results from 2010 and also show that the risk of osteoarthritis and meniscal surgery is no higher for those treated with physiotherapy alone.

“We have continued with our study and for the first time are able to present a five-year follow-up on the need for and results of ACL surgery as compared with physiotherapy. The British Medical Journal published the findings and they are basically unchanged from 2010.

This will no doubt surprise many people, as we have not seen any difference in the incidence of osteoarthritis,” says Richard Frobell, one of the researchers behind the study, who is an associate professor at Lund University and a clinician at the orthopaedic department, Helsingborg Hospital.

Richard Frobell explains that the research group’s results from 2010, which were published in the New England Journal of Medicine, caused a stir and questions were raised as to whether it was possible to say that an operation would not be needed in the long term.

Half of the patients who were randomly assigned not to undergo reconstructive surgery have had an operation in the five years since, after they experienced symptoms of instability.

“In this study, there was no increased risk of osteoarthritis or meniscal surgery for ACL injury treated with physiotherapy alone compared to treated with surgery. Neither was there any difference in patients’ experiences of function, activity level, quality of life, pain, symptoms or general health,” says Richard Frobell.

“The new report shows that there was no difference in any outcome between those who had operations straight away, those who had operations later, and those who did not have an operation at all.

“The message to the medical experts who are treating young, active patients with ACL injuries is that it may be better to start by considering rehabilitation rather than operating straight away.

In Sweden, over 5000 people every year suffer an anterior cruciate ligament injury, mainly young people involved in sport. There are different schools of treatment and Sweden stands out with treatment that is in line with the results of the study.

“On an international front, almost all of those with ACL injuries have operations. In Sweden, just over half have surgery, but in southern Sweden we have been working for many years to use advanced rehabilitation training as the first method of treatment. Our research so far has confirmed that we are right in not choosing to operate on these injuries immediately. Longer-term follow-up is important to look more closely at the development of osteoarthritis in particular,” says Richard Frobell.

KANON, Knee ACL NON-operative versus operative treatment is the name of the research group. They are now moving on to the next stage. This year, the third part of the study will begin, following up the patients ten years after acl injury.

Richard Frobell has also entered into a collaboration with researchers at the School of Economics and Management at Lund University. He is evaluating the health economics aspects of different treatment methods for ACL injury.

Journal References

  • R. B. Frobell, H. P. Roos, E. M. Roos, F. W. Roemer, J. Ranstam, L. S. Lohmander. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ, 2013; 346 (jan24 1): f232 DOI:10.1136/bmj.f232
  • Richard B. Frobell, Ewa M. Roos, Harald P. Roos, Jonas Ranstam, L. Stefan Lohmander. A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears.New England Journal of Medicine, 2010; 363 (4): 331 DOI:10.1056/NEJMoa0907797

From ScienceDaily

Dietary Thiols in Exercise: Oxidative Stress Defence, Exercise Performance, and Adaptation

Biomed Central

Journal of the International Society of Sports Nutrition201714:12

DOI: 10.1186/s12970-017-0168-9

Received: 3 September 2016

Accepted: 14 April 2017

Published: 27 April 2017


Endurance athletes are susceptible to cellular damage initiated by excessive levels of aerobic exercise-produced reactive oxygen species (ROS). Whilst ROS can contribute to the onset of fatigue, there is increasing evidence that they play a crucial role in exercise adaptations. The use of antioxidant supplements such as vitamin C and E in athletes is common; however, their ability to enhance performance and facilitate recovery is controversial, with many studies suggesting a blunting of training adaptations with supplementation. The up-regulation of endogenous antioxidant systems brought about by exercise training allows for greater tolerance to subsequent ROS, thus, athletes may benefit from increasing these systems through dietary thiol donors. Recent work has shown supplementation with a cysteine donor (N-acetylcysteine; NAC) improves antioxidant capacity by augmenting glutathione levels and reducing markers of oxidative stress, as well as ergogenic potential through association with delayed fatigue in numerous experimental models. However, the use of this, and other thiol donors may have adverse physiological effects. A recent discovery for the use of a thiol donor food source, keratin, to potentially enhance endogenous antioxidants may have important implications for endurance athletes hoping to enhance performance and recovery without blunting training adaptations.

Read more…

Low Back Pain—Is Motor Control Exercise Superior to General Exercise?

Research from the human side…relevant regardless 🙂 Rehabdeb, 3/2017

Low Back Pain—Is Motor Control Exercise Superior to General Exercise? A Review of the Research
by NSCA Personal Training Quarterly (PTQ)
and Nick Tumminello

PTQ-3.3-3 Low Back Pain—Is Motor Control Exercise Superior to General Exercise? A Review of the Research

This article provides an overview of the scientific evidence comparing specific motor control exercise intervention to using a more general exercise approach, and concludes by discussing the practical implications for strength and conditioning professionals from an exercise programming perspective.


Low back pain (LBP) is one of the major concerns of current healthcare. Motor control exercises, which are often referred to as “spinal stabilization” or “core stability” exercises, are often used by healthcare professionals worldwide as a common treatment for LBP.

Motor control exercises are designed for the individual to learn how to preferentially contract the local stabilizing muscles of the spine (e.g., multifidus, transversus abdominis, internal oblique) independently from the superficial trunk muscles (e.g., erector spinae rectus abdominis). Motor control exercises involve low-load activation of the local stabilizing muscles of the spine isometrically and in minimally loaded positions (e.g., four-point kneeling, supine lying, sitting, standing, etc.). A common example of a motor control exercise is the transversus abdominis draw-in. This exercise is often performed either lying supine or in four-point kneeling position and requires the individual to perform a slight drawing-in maneuver of the lower part of the anterior abdominal wall below the umbilical level (18).

Since research has shown altered recruitment patterns of deep trunk muscles, such as the transverse abdominis and lumbar multifidus in patients with LBP, these motor control exercises are often used in attempt to reestablish coordination of the deep trunk muscles in order to improve control of the spine (1,2,8,16,17).

Consequently, motor control exercises have also drawn tremendous attention from strength and conditioning professionals. Many strength and conditioning professionals often prescribe motor control exercises to their clients with current or previous LBP issues. The motor control exercises prescribed usually focus on activating the deep trunk muscles to restore control and coordination of these muscles. Many strength and conditioning professionals will often dedicate a great deal of their programming time, especially in the early stages of training, to using motor control exercises in order to first address what they believe to be the individual’s “underlying dysfunctions.” This is because a key feature of the motor control exercise approach is the training of the deep trunk muscles in isolation before progressing to demanding tasks that train coordination of the deep and the superficial trunk muscles (18). Then they will often focus the training program on the use of more general trunk training exercises, such as plank and side plank variations, which are often selected on the basis of maximizing the contraction benefit/spinal loading ratio, according to recommendations provided from recent experimental studies (15). These general trunk muscle specific-exercises will often be included into a comprehensive total-body strength and conditioning program, which often involves a variety of conventional resistance exercises such as loaded squat and deadlift variations that integrate the activation of deep and global trunk muscles along with other muscle groups (14).

Contrary to common belief, the current body of scientific evidence demonstrates that there is nothing special about using motor control exercises as a means to prevent or reduce back pain. This article provides an overview of the scientific evidence comparing specific motor control exercise intervention to using a more general exercise approach, and concludes by discussing the practical implications for strength and conditioning professionals from an exercise programming perspective.

Overview of the Evidence
An early study randomized LBP patients into two groups: a conventional physiotherapy group consisting of only general activity exercises (aimed at improving the muscular strength of the lumbar and pelvic region and legs, such as the abdominals, erector spinae, gluteals, quadriceps, and hamstrings) and manual therapy, and a conventional physiotherapy plus specific spinal stabilization exercises group (3). This study found that patients with LBP showed improvements with both treatment packages to a similar degree. Therefore, the researchers concluded that “there was no additional benefit of adding specific spinal stabilization exercises to a conventional physiotherapy package for patients with recurrent LBP,” (3).

A randomized, controlled trial of patients with recurrent, nonspecific back pain (NSLBP), compared two groups: a general exercise treatment group and a combination of general exercise and spinal stabilization exercise group. This study reported that a general exercise program reduced disability immediately after treatment to a greater extent than a stabilization-enhanced exercise approach in patients with recurrent NSLBP. However, there were no between-group differences on self-reported disability at the three-month follow-up (9). Therefore, stabilization exercises do not appear to provide additional benefit to patients with subacute or chronic LBP who have no clinical signs suggesting the presence of spinal instability (9).

Another randomized, controlled trial compared the effects of general exercise, motor control exercise, and manipulative therapy on function and perceived effect of intervention in patients with chronic back pain (6). The researchers found that “motor control exercise and spinal manipulative therapy produce slightly better short-term function and perceptions of effect than general exercise, but not better medium or long-term effects, in patients with chronic non-specific back pain,” (6).

A recent systematic review found that “evidence of very low to moderate quality indicates that motor control exercise showed no benefit over spinal manipulative therapy, other forms of exercise, or medical treatment in decreasing pain and disability among patients with acute and subacute low back pain. Whether motor control exercise can prevent recurrences of low back pain remains uncertain,” (11).

Additionally, another systematic review, this one about chronic NSLBP, concluded that “there is very low to moderate quality evidence that motor control exercise has a clinically important effect compared with a minimal intervention for chronic low back pain. There is moderate to high quality evidence that motor control exercise provides similar outcomes to manual therapies and low to moderate quality evidence that it provides similar outcomes to other forms of exercises,” (21). The authors went on to say that motor control exercises are not necessarily superior to other forms of exercise, and that the choice of exercises for chronic LBP should depend on individual preferences, therapist training, costs, and/or safety concerns (21).

Evidence Using Subgroups
Many healthcare providers state that low back pain is a multidimensional, socioeconomic public health problem with almost 85% of patients being diagnosed with NSLBP (4,7,10,12,13,22,23). They will also likely readily admit that treating chronic LBP is complicated because neither specific diagnostic nor treatment-based approaches have been shown to be absolutely effective. Many practitioners often prescribe motor control exercises almost universally to people with LBP issues. One of the common concerns many health rehabilitation specialists and strength and conditioning professionals who promote the use of specific motor control exercise interventions have with the research discussed above is that those studies did not involve patient subgroups. These professionals believe that patients with a motor control impairment can be diagnosed as a LBP subgroup who would benefit from specific motor control exercises. Therefore, they encourage studies in such patient subgroups with a common diagnosis or prognosis to examine outcomes from specific motor control exercise interventions.

To meet this concern, a recent study used a tailored exercise program versus general exercise for a subgroup of patients with LBP and movement control impairment. This study assessed the short-term effect of a specific exercise program targeting movement control impairment versus general exercise treatment on disability in patients with LBP and motor control impairment.

At the conclusion of this study, “no significant difference was found following the treatment period. Disability in LBP patients was reduced considerably by both interventions,” (20).

Another randomized controlled trial study that also involved subacute or chronic low-back pain patient subgroups found that motor control exercise and general exercise appear equally effective at reducing LBP in the patient subgroup included in this study (19). The researchers concluded that “the contrast between both types of intervention did not bring additional value to the shared effects,” (19). Additionally, strength and conditioning professionals should pay special attention to the following statements from the researchers of this study: “it is possible that the type of exercise treatment is less important than previously presumed; that the patient is guided to a consistent long-term exercise lifestyle is of most importance. The results of our study support previous findings that exercise in general, regardless of the type, is beneficial for patients with NSLBP,” (19).

Conclusion and Practical Takeaway
The overall takeaway of these studies is that exercise is a moderately effective treatment for chronic LBP. Although moderate evidence suggests that special motor control exercise interventions may prevent recurrences of LBP, no good evidence has been found for a difference in effect between types of exercise. In other words, although special motor control exercise interventions have been shown to improve low back outcomes, these exercises do not appear to be any more beneficial than general exercises, which also offer a wide range of well-established health, fitness, and physique benefits. Therefore, when it comes to clients with LBP, the strength and conditioning professional should not be hesitant to focus their programming on the use of general exercises that fit with the individual’s ability, medical profile, and personal goals.

This article originally appeared in Personal Training Quarterly (PTQ)—a quarterly publication for NSCA Members designed specifically for the personal trainer. Discover easy-to-read, research-based articles that take your training knowledge further with Nutrition, Programming, and Personal Business Development columns in each quarterly, electronic issue. Read more articles from PTQ »

Related Reading
Systematic Review of Core Muscle Activity During Physical Fitness Exercises

1. Al-Eisa, E, Egan, D, Deluzio, K, and Wassersug, R. Effects of pelvic skeletal asymmetry on trunk movement three-dimensional analysis in healthy individuals versus patients with mechanical low back pain. Spine 31(3): E71-79, 2006.
2. Bogduk, N. Management of chronic low back pain. The Medical Journal of Australia. 180)(2): 79-83, 2004.
3. Cairns, MC, Foster, NE, and Wright, C. Randomized controlled trial of specific spinal stabilization exercises and conventional physiotherapy for recurrent low back pain. Spine 31(19): E670-681, 2006.
4. Champagne, A, Descarreaux, M, and Lafon, D. Comparison between elderly and young males’ lumbopelvic extensor muscle endurance assessed during a clinical isometric back extension test. Journal of Manipulative and Physiological Therapeutics 32(7): 521526, 2009.
5. Choi, B, Verbeek, JH, Tam, WW, and Jiang, JY. Exercises for prevention of recurrences of low-back pain. Cochrane Database of Systematic Reviews 20(1): 2010.
6. Ferreira, ML, Ferreira, PH, Latimer, J, Herbert, RD, Hodges, PW, Jennings, MD, et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial. Pain 131(1-2): 31-37, 2007.
7. Gondhalekar, GA, Kumar, SP, Eapen, C, Mahale, A. Reliability and validity of standing back extension test for detecting motor control impairment in subjects with low back pain. Journal of Clinical and Diagnostic Research. 10(1): KC7-11, 2016.
8. Harris-Hayes, M, Van Dillen, LR, and Sahrmann, SA. Classification, treatment and outcomes of a patient with lumbar extension syndrome. Physiotherapy Theory and Practice 21(3): 181-96, 2005.
9. Koumantakis, GA, Watson, PJ, and Oldham, JA. Trunk muscle stabilization training plus general exercise versus general exercise only: Randomized controlled trial of patients with recurrent low back pain. Physical Therapy 85(3): 209-225, 2005.
10. Luomajoki, H, Kool, J, de Bruin, ED, and Airaksinen, O. Reliability of movement control tests in the lumbar spine. BioMed Central Musculoskeletal Disorders 8: 90, 2007.
11. Macedo, LG, Saragiotto, BT, Yamato, TP, Costa, LOP, Costa, LCM, Ostelo, RWJG, and Maher, CG. Motor control exercise for acute non-specific low back pain. Cochrane Database of Systematic Reviews CD012085, 2016.
12. Maher, CG, Latimer, J, Hodges, PJ, Refshauge, KM, Moseley, GL, Herbert, RD, et al. The effect of motor control exercise versus placebo in patients with chronic low back pain. BioMed Central Musculoskeletal Disorders 6: 54, 2005.
13. Manchikanti, L. Epidemiology of low back pain. Pain Physician. 3(2): 167-192, 2000.
14. Martuscello, JM, et al. Systematic review of core muscle activity during physical fitness exercises. The Journal of Strength and Conditioning Research 27(6): 1684-1698, 2013.
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16. O’Sullivan, PB. Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism. Manual Therapy 10(4): 242255, 2005.
17. O’Sullivan, PB. Lumbar segmental “instability:” Clinical presentation and specific stabilizing exercise management. Manual Therapy 5(1): 2-12, 2000.
18. Richardson, CA, Jull, GA, and Hodges, PW, et al. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. Edinburgh: Churchill Livingstone, 1999.
19. Saner, J, Kool, J, Sieben, JM, Luomajoki, H, Bastiaenen, CHG, and de Bie, RA. A tailored exercise program versus general exercise for a subgroup of patients with low back pain and movement control impairment: A randomised controlled trial with one-year follow-up. Manual Therapy 20(5): 672-279, 2015.
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22. Tétreau, C, Dubois, JD, Piché, M, and Descarreaux, M. Modulation of pain-induced neuromuscular trunk responses by pain expectations: A single group study. Journal of Manipulative and Physiological Therapeutics 35(8): 636-644, 2012.
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Nick Tumminello
About the Author:
Nick Tumminello, NSCA-CPT
Nick Tumminello has become known as “the trainer of trainers.” He is the owner of Performance University, which provides fitness and personal trainer continuing education. Tumminello is a fitness expert for Reebok and the author of the book “Strength Training for Fat Loss.” He lives in Fort Lauderdale, FL, where he trains a select group of individuals and teaches mentorships. His DVDs, books, seminar schedule, and blog can be found at

Intense Exercise, Muscle Soreness, Recovery, and Anti-inflammatories

Rehab Deb’s Comments:

One of the most important bits of this report is something I’ve been reading more and more research regarding, and that is that nsaids (non-steroidal anti-inflammatories) subdue, limit, delay the healing process. I have also read several reports regarding the same being true when ice is used.

Nsaids in animal medicine include Previcox, Peroxicam, Deramaxx, Rimadyl, Metacam, among others…and for humans include Advil, Ibuprofen, Motrin, Tylenol, Aspirin, Aleve (sodium naproxen), etc…Does this mean to cut them out altogether? No, but I do think it means to consider the necessity of application and what is hoped to be achieved…is it really necessary?? Pain is often very well controlled or minimized by combining smaller doses of several analgesics, pain relievers, depending on the issue, rather than higher doses of just one medication and/or continuous doses of nsaids that probably aren’t doing much to help the pain problem.

This is only one suggestion.

Ultimately this information should be discussed with the medical practitioner who prescribed the medications in the first place if/when you have questions. There are other reasons to minimize nsaids and use Tramadol and/or Gabapentin and/or other prescription analgesics to alleviate pain for the short run while building muscle to support damaged joints. Many practitioners are aware of using these other drugs, and while they may not know about this more recent news regarding nsaids delaying healing and muscle growth, which came out of human sport science, veterinarians in my area seem to be interested in the information when it is presented to them.

Article from Dr. Gabe Mirkin’s Fitness and Health E-Zine
May 6, 2012

How to Recover from Muscle Soreness Caused by Intense Exercise

Muscle soreness should be part of every exercise program.  If you don’t exercise intensely enough on one day to have sore muscles on the next, you will not gain maximum fitness and you are also losing out on many of the health benefits of exercise. The benefits of exercise are much greater with intense exercise than with casual exercising.

You must damage your muscles to make them grow and become stronger.  When muscles heal, they are stronger than they were before you damaged them. All athletes train by “stressing and recovering”. On one day, they take a hard workout in which they feel their muscles burning.  Eight to 24 hours after they finish this intense exercise, their muscles start to feel sore. This is called Delayed Onset Muscle Soreness (DOMS). Then they take easy workouts until the soreness is gone, which means that their muscles have healed.
DOMS IS CAUSED BY MUSCLE DAMAGE. Muscles are made up of fibers. The fibers are made up of a series of protein blocks called sarcomeres that are lined in a long chain. When you stretch a muscle, you stretch apart the sarcomeres in the chain. When sarcomeres are stretched too far, they tear.  Your body treats these tears in the same way that it treats all injuries, by a process called inflammation.  Eight to 24 hours after an intense workout, you suffer swelling, stiffness and pain.

The most beneficial  intense exercise program  is:
* severe enough to cause muscle pain on the next day, and
* usually allows you to recover almost completely within 48 hours.

ACTIVE, NOT PASSIVE, RECOVERY:  When athletes feel soreness in their muscles, they rarely take days off.  Neither should you. Keeping sore muscles moving makes them more fibrous and tougher when they heal, so you can withstand greater forces and more intense workouts on your hard days.  Plan to go at low intensity for as many days as it takes for the soreness to go away. Most athletes try to work out just hard enough so that they recover and are ready for their next hard workout in 48 hours.

TIMING MEALS TO RECOVER FASTER:  You do not need to load extra food to recover faster. Taking in too much food fills your muscle cells with fat, and extra fat in cells blocks the cell’s ability to take in and use sugar. Sugar is the main source of energy for your muscles during intense exercise. Using sugar to drive your muscles helps them to move faster and with more strength. Timing of meals is more important than how much food you eat. Eating protein- and carbohydrate-containing foods helps you recover faster, and the best time to start eating is as soon as you finish a hard workout. At rest, muscles are inactive. Almost no sugar enters the resting muscle cell from the bloodstream (J. Clin. Invest. 1971;50: 2715-2725). Almost all cells in your body usually require insulin to drive sugar into their cells. However during exercise your muscles (and your brain) can take sugar into their cells without needing insulin.  Exercising muscles are also incredibly sensitive to insulin and take up sugar into their cells at a rapid rate.  This effect lasts maximally for up to an hour after you finish exercising and disappears almost completely in around 17 hours.  The best time to eat for recovery is when your cells are maximally responsive to insulin, and that is within a short  time after you finish exercising. Not only does insulin drive sugar into muscle cells, it also drives in protein building blocks, called amino acids.  The sugar replaces the fuel for muscle cells. The protein hastens repair of damaged muscle.  Waiting to eat for more than an hour after finishing an intense workout delays recovery.

WHAT TO EAT AFTER YOUR INTENSE WORKOUTS: Fatigue is caused by low levels of sugar, protein, water and salt.  You can replace all of these with ordinary foods and drinks. If you are a vegetarian, you can replace your protein with combinations of grains and beans. You can replace carbohydrates by eating virtually any fruits, vegetables, whole grains, beans, seeds and nuts. A recovery meal for a vegetarian could include corn, beans, water, bread, and fruits, nuts and vegetables.  If you prefer animal tissue, you can get your protein from fish, poultry,or meat.   Special sports drinks and sports supplements are made from ordinary foods and therefore offer no advantage whatever over regular foods.

BODY MASSAGE:  Many older studies have shown that massage does not help you recover faster from DOMS. Recently, researchers at McMaster University in Hamilton, Ontario showed that deep massage after an intense workout causes muscles to enlarge and grow new mitochondria (Science Translational Medicine, published online Feb, 2012). This is amazing. Enlarging and adding mitochondria can help you run faster, lift heavier weights, and even prevent heart attacks and certain cancers.

NSAIDS DELAY DOMS RECOVERY:  Non-steroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen, may help relieve pain, but they also can block muscle repair and delay healing.

HOT BATHS:  Most research shows that a hot bath is not much better than doing nothing in helping muscles recover from exercise (European Journal of Applied Physiology, March 2006)

COLD OR ICE BATHS:  A recent review of 17 small trials, involving 366 participants, showed a minor decrease in DOMS with ice water baths.  They found “little quality research” on the subject and “no consistent method of cold water immersion” (Cochrane Library, published online February 15, 2012).  Cold water immersion can reduce swelling associated with injury, but has not been proven to speed the healing of DOMS.

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