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.

NSAIDs: Not as Safe as Patients May Think

NSAIDs: Not as Safe as Patients May Think

Laurie Scudder, DNP, NP, Bill H. McCarberg, MD

April 02, 2014 (Discussion from the “human” side, which should help you when you are making decisions about medications for yourself and your pet. Similar research has been completed in veterinary medicine as well – RehabDeb)

Safety Issues With NSAIDs (Non-Steroidal Anti-Inflammatories)

From Medscape:

Medscape Interviewer: NSAIDs continue to be a widely used medication, particularly for patients with inflammatory conditions. A 2013 analysis of 7 years of data from the National Ambulatory Care Survey reported that they were used in 95% of the almost 7 million patients in the study sample who used at least 1 chronic pain medication.[3]

The next closest agent was only used in one quarter of patients. Are there any data indicating that the concerns about a lack of patient knowledge about safe and appropriate use have changed since the survey published almost a decade ago?

Dr. McCarberg: It’s an interesting conundrum. When patients have pain, they may not know what to do about it. They are unwilling to go in to be seen and pay a copay, because that is an increasing financial burden for them.

The recent acetaminophen warnings, particularly noting that it is included in multiple different products and that excess doses could cause liver damage, are worrisome.

The cardiovascular (CV) and gastrointestinal (GI) risks associated with NSAIDs have been widely reported; renal risk has not received as much attention in the lay press, but must be considered.

And of course everybody talks about the opioids, the prescription painkillers, and the overdose deaths that are occurring in the United States. I think patients are confused and concerned about what they should do when they have pain.

The National Ambulatory Care Survey, conducted over a period of 7 years, found that 95% of patients said they took NSAIDs, illuminating just how common the experience of pain is.

Although warnings about risk have been widely reported, patients don’t necessarily know how hazardous NSAIDs can be; otherwise, there wouldn’t be as many people taking them. Yet pain is so common that they have to take something, and they believe this is as safe as anything.

If you had a problem, what would you take? You would probably take an NSAID or acetaminophen, because there’s nothing else. What do you take when you have a headache, sprain your ankle, or have a recurrent back problem? Most of us would take something. And if you ask patients whether there is a risk involved, they would answer “yes,” but also note that these agents are available OTC and they wouldn’t be OTC unless they were safe.

I recently looked into use of NSAIDs by athletes, and the number of high school, college, and professional athletes who use NSAIDs regularly to help with muscle aches and pains from competition is astounding. And potentially hazardous. These agents have never been proven to help with those muscle aches. Gastrointestinal issues can be significant, because you don’t necessarily eat before an event. Athletes get dehydrated in an event, and with dehydration, there is more risk to the kidney. Now you put an NSAID on top of that, increasing renal risk. It’s interesting that even our healthy athletes are using NSAIDs. There are side effects even in the group that you would think is the healthiest in our society.

So, the reasons that so many people take these drugs are complicated, and it is a function of just how common pain is in our society and confusion on the part of patients who don’t know what to take.

Patients are also turning to alternative care — which we’re now calling “integrative care” because we don’t think it is alternative treatment but rather more mainstream treatment and includes acupuncture, chiropractic, herbal therapies, yoga, and massage. People are paying out of pocket for these therapies because there is some worry that regular medical care is too expensive, and that OTCs may not be safe.

So back to your original question about patient recognition of risk. Patients may not know the exact risk profiles of NSAIDs, but they know there is some risk. And they don’t know what else to do.

Medscape: Virtually all clinicians are familiar with the potential for GI mucosal damage from use of NSAIDs. Can you review the latest data regarding GI adverse events with these agents? Has the more recent trend toward combining them with gastroprotective agents mitigated some of these concerns? How does the combination of nonselective NSAIDs with proton pump inhibitors compare with cyclooxygenase type 2 (COX-2)-selective NSAIDs in terms of GI safety?

Dr. McCarberg: There have been multiple published guidelines for NSAID use. All state that persons with 1 or more GI risk factor (longer duration of use, higher dose, age 60 years or older, history of peptic ulcer disease, alcohol use, concomitant use of corticosteroids or anticoagulants, or general frailty[4]) should either lower their NSAID dose take the drug intermittently — or even better, try not to take it at all. If NSAIDs are used in this population, they should be combined with gastroprotective agents.

What we’ve found is that despite those guidelines, primary care providers are not following those recommendations, at least with regard to prescription products. I have had primary care providers tell me that they’ve never had a patient experience a serious GI event, or that these recommendations are not practical. I have heard such statements as, “My experience is that I know these drugs pretty well, I wouldn’t put my patient at risk, and I don’t have to use gastroprotective agents.” There are providers who believe that they know better than the recommendations.

Some of the recognized risk factors are fairly common in many patients. Patients 60 years of age and older are often seen in medical practices, and taking more than 1 NSAID at the same time is also a very common scenario. Many patients are taking aspirin as a cardioprotective agent and may have a comorbid inflammatory condition, for example arthritis, and be prescribed an NSAID or decide to take an OTC NSAID without consulting a healthcare provider. And these are likely to be older patients.

As I said earlier, 95% of patients are taking NSAIDs. Providers may neglect to ask about OTC use, and patients may not mention it even if asked. I have frequently had patients deny that they are taking other medications, only to respond, after I press them, that they are taking ibuprofen. They say, “But that’s not a drug — that’s over-the-counter.” And of course, it is a drug. Patients may be taking herbal agents that they also don’t think are drugs, and there are drug/herbal interactions as well.

Medscape: The CV risks of nonselective NSAIDs have been known for several decades. Concerns regarding COX-2-selective NSAIDs were raised a number of years later, primarily after licensure. Can you speak about data comparing the CV risk of these 2 types of NSAIDs? Are there new data that can shed some light on relative safety of these 2 types of agents in differing populations?

Dr. McCarberg: Rofecoxib (Vioxx) was studied to see whether long-term use would protect patients from cancer of the colon. There was an idea that inhibiting cyclooxygenase, which is what these drugs do, provides protection from developing polyps and later cancer. The result? It probably did protect from cancer, but there were more people dying from CV events. So, as we well remember, rofecoxib got pulled off the market.

After that, a number of researchers began looking at large databases with literally thousands of patients (including at Kaiser Permanente, where I worked at the time) and found that not only did rofecoxib produce this CV incidence, but it looked like all of the drugs in this class were associated events; all of the NSAIDs were producing CV events. And it appeared that this CV risk was dependent on how long the drugs were taken and the dose. The higher the dose and the longer period of time taken, the more risk. At the highest dose of rofecoxib, there was significantly more risk. At a lower dose, the risk was really much less.

Some drugs, even with regular exposure, had less risk than other drugs. For example, naproxen, even at regular doses, didn’t seem to have as much CV risk as other drugs in this class. So certain drugs are safer, and others, especially at higher doses, are more dangerous. That’s one of the reasons that the US Food and Drug Administration (FDA) came out with the recommendation to use NSAIDs at the lowest dose for the shortest period of time.[5]

The Alliance for Rational Use of NSAIDs, which I’m a part of, has also tried to promote this idea. Our message to patients is that they should not just take an NSAID because of a headache, but should think about it, take the lowest dose, and not take it all the time.

Medscape: Could you speak about the FDA Advisory Panel’s recent decision not to loosen the CV risk warning with naproxen, and some of the data that underpinned that decision?

Dr. McCarberg: Data do seem to suggest that naproxen is associated with less CV risk than other drugs in this class. I think one of the problems that had to be considered in making this decision is the very common belief in some patients that if 1 pill works, 2 pills are better. So if the FDA was to state that naproxen is safer, which it appears to be, a concern must be that the public would start using it preferentially and not hear safer as a relative risk, but rather hear that naproxen is safe. And if you take any drug in excess — start taking not 1-2 tablets, but rather 3-4 tablets, the kind of dose escalation that is common — all of a sudden, the drug isn’t very safe because it is taken at higher doses for longer periods of time. Had I been on this advisory panel, I would have had some concerns about pushing the concept of relative safety for fear that increased use may lead to more adverse events.

NSAID Use in Older Patients

Medscape: A recent article you wrote in Pain Medicine noted that 90% of all prescription NSAIDs were taken by patients 65 years of age or older.[6] Can you go over the key findings of your review regarding safety in this population?

Dr. McCarberg: As I said earlier, it’s a complicated answer. Pain and aging go together; osteoarthritis, neuropathic pain, and cancer are all more common in older patients.

Second, older patients have more chronic diseases, such as congestive heart failure, diabetes, hypertension, and emphysema — which means that use of multiple drugs at the same time is more common. Combine chronic diseases that require multiple drugs with a great likelihood of a pain problem, and this sets you up to have more difficulty when you add another drug to that mix, such as an OTC agent.

Older patients often have a decline in liver and kidney function. They may not be as well hydrated as a younger population. They may not have as much circulating protein because they don’t eat as well as a younger population, so that protein binding, one of the ways that the body protects itself from drugs, is lower. All of these factors together put the older population at particular risk for renal failure, bleeding from their stomach, or CV events when taking OTC drugs that they consider to be benign.

Medscape: Are topical NSAIDs a useful alternative to older agents in older patients?

Dr. McCarberg: In my own experience, I have found that older individuals are more interested in topicals than younger populations, who often don’t like the mess of the topical preparations and would rather swallow a pill and be on their way. Maybe it is because older folks grew up with ointments and lotions.

Topical NSAIDs have been found to be effective and, even though they carry the same warnings as the oral products, are much safer for the stomach, kidney, and heart.[7] In fact, it’s a preferred route in older adults because of the safety profile. Patients will frequently use OTC topical agents and tell me that they can get some relief from them. Pain management guidelines all recommend topicals. I recommend them to my patients, but access can be a problem. Many formularies do not include topical NSAIDs, so insurance coverage is often a problem.

Medscape: What about use in the frail elderly: those 75-80 years of age, who have thinning of the stratum corneum and often very fragile skin? is there more concern about skin reactions with topicals in those older patients?

Dr. McCarberg: No; actually, it doesn’t seem to be a problem. Patients who take aspirin or other oral NSAIDs have problems with their skin and can bruise very easily by just bumping their skin against furniture, for example. So this is already an issue with the oral agents. It doesn’t seem that the topical agents produce any more reactions on the skin than the oral agents.

Medscape: The 2012 American Geriatrics Society Beers Criteria includes nonselective NSAIDs in its list of potentially inappropriate medications for use in the geriatric population.[8] In your experience, are most providers aware of the Beers Criteria, and is that resource used in the primary care setting?

Dr. McCarberg: I don’t think they are. When I lecture about pharmacologic management, I often refer to the Beers Criteria. The question I hear most often is, “What is the Beers list”? So many primary care providers don’t even know what it is. When I list some of the drugs that are on that list — muscle relaxants, for example — physicians are often astounded. Often, I hear that a particular drug on the Beers list is “one of the drugs I use all the time.”

Medscape: Can you speak about the Alliance for Rational Use of NSAIDs’ goals and outreach? What are the key messages from the Alliance?

Dr. McCarberg: The main purpose for forming the Alliance was to get the message to people taking these drugs that there are side effects, and they can be serious. Just because a drug is available OTC, doesn’t mean that it’s safe. The consumer groups that are involved in the Alliance are important in getting the message out to their members and readers. Most people want to know about health and are proactive. A recommendation such as the one for limited use of NSAIDs is generally taken to heart.

The idea was pretty simple. Pain causes problems because it interferes with our social life and our sleep. But these drugs aren’t always safe. So the message to consumers is, if you’re going to take something, use the lowest effective dose for the shortest period of time. We don’t want people to suffer pain, because that has consequences as well. But consumers must be aware of issues related to NSAIDs and be educated to not take these drugs all the time.

From Dr. Gabe Mirkin’s Fitness and Health e-Zine

February 25, 2018

Do Not Take NSAIDs to Relieve Muscle Soreness –

Non-steroidal anti-inflammatory drugs (NSAIDs) can block gains in strength and endurance (PNAS, June 27, 2017;114(26):6675–6684; Med & Sci in Sports & Ex, April 2017;49(4):633–640).

The processes that heal damaged tissue in your body use the same immune cells and chemicals that fight infections. Certain prostaglandins that heal damaged tissues are the same prostaglandins that cause muscle soreness.

These prostaglandins can hasten healing of muscles damaged by vigorous exercise by increasing production of stem cells to replace damaged muscle cells.

They also increase endurance by increasing blood flow to damaged muscles, widening blood vessels and increasing the ratio of blood capillaries to muscle fibers.

Taking NSAIDs hinders this process and can prevent the gains in endurance that you would expect to get from your exercise.

Earlier studies in humans showed that taking NSAIDs can reduce the gains in endurance from aerobic exercise by restricting the ratio of blood capillaries to muscle fibers and decreasing the number of fibers in muscles (J Physiol Pharmacol, Oct 2010;61(5):559-63).

NSAIDs in human medicine include: celecoxib (Celebrex), diclofenac (Cambia, Cataflam, Voltaren-XR, Zipsor, Zorvolex), ibuprofen (Motrin, Advil), indomethacin (Indocin), ketoprofen (Ketoprofen), naproxen (Aleve, Anaprox, Naprelan, Naprosyn), oxaprozin (Daypro), piroxicam (Feldene).


Physical Therapy as Effective as Surgery for Torn Meniscus and Arthritis of the Knee, (Human) Study Suggests

“Surgery may not always be the best first course of action. A physical therapist, in many cases, can help patients avoid the often unnecessary risks and expenses of surgery. This study should help change practice in the management of symptomatic meniscal tears in patients with knee osteoarthritis.” Mar. 21, 2013 — A New England Journal of Medicine (NEJM) study showing that physical therapy is just as effective as surgery in patients with meniscal tears and arthritis of the knee should encourage many health care providers to reconsider their practices in the management of this common injury, according to the American Physical Therapy Association (APTA).

The study, published March 19, showed no significant differences in functional improvement after 6 months between patients who underwent surgery with postoperative physical therapy and those who received standardized physical therapy alone.

“This study demonstrates what physical therapists have long known,” explained APTA President Paul A. Rockar Jr, PT, DPT, MS. “Surgery may not always be the best first course of action. A physical therapist, in many cases, can help patients avoid the often unnecessary risks and expenses of surgery. This study should help change practice in the management of symptomatic meniscal tears in patients with knee osteoarthritis.” According to lead physical therapist for the trial and American Physical Therapy Association (APTA) member Clare Safran-Norton, PT, PhD, OCS, “our findings suggest that a course of physical therapy in this patient population may be a good first choice since there were no group differences at 6 months and 12 months in this trial. These findings should help surgeons, physicians, physical therapists, and patients in decision-making regarding their treatment options.” Researchers at 7 major universities and orthopedic surgery centers around the country studied 351 patients aged 45 years or older who had a meniscal tear and mild-to-moderate osteoarthritis of the knee. Patients were randomly assigned to groups who received either surgery and postoperative physical therapy or standardized physical therapy. Within 6-12 months, patients who had physical therapy alone showed similar improvement in functional status and pain as those who had undergone arthroscopic partial meniscectomy surgery. Patients who were given standardized physical therapy — individualized treatment and a progressive home exercise program — had the option of “crossing over” to surgery if substantial improvements were not achieved. Thirty percent of patients crossed over to surgery during the first 6 months. At 12 months these patients reported similar outcomes as those who initially had surgery. Seventy percent of patients remained with standardized physical therapy. According to an accompanying editorial in NEJM,”millions of people are being exposed to potential risks associated with a treatment [surgery] that may or may not offer specific benefit, and the costs are substantial.” Physical therapist and APTA member Mary Ann Wilmarth, PT, DPT, MS, OCS, MTC, Cert MDT, chief of physical therapy at Harvard University, said, “Physical therapists are experts in improving mobility and restoring motion. The individualized treatment approach is very important in the early phases of rehabilitation in order to achieve desired functional outcomes and avoid setbacks or complications.”

Story Source: The above story is reprinted from materials provided by American Physical Therapy Association. Note: Materials may be edited for content and length. For further information, please contact the source cited above.

Journal Reference:
Jeffrey N. Katz, Robert H. Brophy, Christine E. Chaisson, Leigh de Chaves, Brian J. Cole, Diane L. Dahm, Laurel A. Donnell-Fink, Ali Guermazi, Amanda K. Haas, Morgan H. Jones, Bruce A. Levy, Lisa A. Mandl, Scott D. Martin, Robert G. Marx, Anthony Miniaci, Matthew J. Matava, Joseph Palmisano, Emily K. Reinke, Brian E. Richardson, Benjamin N. Rome, Clare E. Safran-Norton, Debra J. Skoniecki, Daniel H. Solomon, Matthew V. Smith, Kurt P. Spindler, Michael J. Stuart, John Wright, Rick W. Wright, Elena Losina. Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. New England Journal of Medicine, 2013; : 130318220107009 DOI:10.1056/NEJMoa1301408
Note: If no author is given, the source is cited instead.

Here is a second report of the same issue:

Medscape Medical News from the:

American Academy of Orthopaedic Surgeons (AAOS) 2013 Annual Meeting
This coverage is not sanctioned by, nor a part of, the American Academy of Orthopaedic Surgeons.

Medscape Medical News > Conference News
Physical Therapy as Effective as Surgery for Meniscal Tear

Medscape Medical News from the: American Academy of Orthopaedic Surgeons (AAOS) 2013 Annual Meeting Physical Therapy as Effective as Surgery for Meniscal Tear Kathleen Louden Mar 20, 2013 CHICAGO, Illinois — Patients with knee osteoarthritis and a meniscal tear who received physical therapy without surgery had good functional improvement 6 months later, and outcomes did not differ significantly from patients who underwent arthroscopic partial meniscectomy, a new clinical trial shows. In the Meniscal Tear in Osteoarthritis Research (METEOR) trial, both groups of patients improved substantially in function and pain. This finding, presented here at the American Academy of Orthopaedic Surgeons 2013 Annual Meeting and published online simultaneously in the New England Journal of Medicine, provides “considerable reassurance regarding an initial nonoperative strategy,” the investigators report. Patients with a meniscal tear and osteoarthritis pose a treatment challenge because it is not clear which condition is causing their symptoms,” principal investigator Jeffrey Katz, MD, from Brigham and Women’s Hospital in Boston, Massachusetts, told Medscape Medical News. “These data suggest that there are 2 reasonable pathways for patients with knee arthritis and meniscal tear,” Dr. Katz explained. “We hope physicians will use these data to help patients understand their choices.” In an accompanying editorial, clinical epidemiologist Rachelle Buchbinder, PhD, from the Monash University School of Public Health and Preventive Medicine in Victoria, Australia, said that “these results should change practice. Currently, millions of people are being exposed to potential risks associated with a [surgical] treatment that may or may not offer specific benefit, and the costs are substantial.” These results should change practice. The METEOR trial enrolled 351 patients from 7 medical centers in the United States. Eligible patients were older than 45 years, had osteoarthritic cartilage change documented with magnetic resonance imaging, and had at least 1 symptom of meniscal tear, such as knee clicking or giving way, that lasted at least 1 month despite drug treatment, physical therapy, or limited activity. In this intent-to-treat analysis, investigators randomly assigned 174 patients to arthroscopic partial meniscectomy plus postoperative physical therapy and 177 to physical therapy alone. The physical therapy in both regimens was a standardized 3-stage program that allowed patients to advance to the next intensity level at their own pace, Dr. Katz explained. The program involved 1 or 2 sessions a week for about 6 weeks and home exercises. The average number of physical therapy visits was 7 in the surgery group and 8 in the nonsurgery group. Investigators evaluated patients 6 and 12 months after randomization. The primary outcome was the between-group difference in change in physical function score from baseline to 6 months, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). At baseline, demographic characteristics and WOMAC physical function scores were similar in the 2 groups. At 6 months, improvement in the WOMAC function score was comparable in the 2 groups. The mean between-group difference of 2.4 points was not statistically significant after analysis of covariance. There was also no significant difference between groups in pain improvement or frequency of adverse events. METEOR: Mean Improvement in Osteoarthritis Index at 6 Months Treatment Group Mean Improvement (Points) 95% Confidence Interval Surgery plus physical therapy 20.9 17.9–23.9 Physical therapy 18.5 15.6–21.5 There was 1 death in each group, and 8 patients in the nonsurgery group and 13 in the surgery group withdrew in the first 6 months of the study. Patients in the nonsurgery group were allowed to cross over to the surgical group at any time. Within 6 months, 30% of patients did so. “They were not doing very well,” Dr. Katz said. His team is still analyzing the reasons these patients did not benefit from intensive physical therapy. The 12-month results were similar to the 6-month results. In addition, by 12 months, outcomes for the crossover patients and for those in the original surgery group were similar. Meeting delegate John Mays, MD, an orthopaedic surgeon practicing in Bossier City, Louisiana, who was asked by Medscape Medical News to comment on the findings, said most patients don’t choose physical therapy. “In the real world, most people want a quick fix” and choose surgery, he noted. Dr. Mays said he would have liked to have seen a group of patients who underwent surgery but did not receive postoperative physical therapy. He explained that his patients with osteoarthritis and meniscal tear rarely get physical therapy after arthroscopic meniscectomy; they most often do home-based exercises. He added that “most insurance plans have limits on the number of physical therapy sessions they allow.” This study is funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Katz, Dr. Buchbinder, and Dr. Mays have disclosed no relevant financial relationships. N Engl J Med. Published online March 19, 2013. Abstract, Editorial American Academy of Orthopaedic Surgeons (AAOS) 2013 Annual Meeting: Abstract SE67. Presented March 19, 2013.

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

(From RehabDeb: This report is from human medical research, however animal studies are currently being conducted at Colorado State University. When I began animal rehab in 2005, I developed some protocol for people to use to benefit their animals if they did not want surgery for their pet, even though I was working at the time in a surgery specialty hospital. When I began independent practice in 2007, I took years of accumulated research, experience, and knowledge and created some simple functional exercise and drill protocol that has benefited hundreds of my canine patients whose people opted to not pursue surgery. That protocol and some other papers citing surgery text recommendations may be found elsewhere on this site-see the index to the right. In every case where my protocol has been followed (and there are no extenuating circumstances), the pets have stabilized the joint with muscle and scar tissue, and they have functioned very well. This work is all done in the home environment with no dependence on specialized equipment…no need when we are drawing from centuries of known exercise physiology and dynamic principles of body function. Blessings-)

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 findings have been published in the British Medical Journal and 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 experiencing symptoms of instability.

“In this study, there was no increased risk of osteoarthritis or meniscal surgery if the ACL injury was treated with physiotherapy alone compared with if it was 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 were operated on straight away, those who were operated on 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 5 000 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 are operated on. In Sweden, just over half are operated on, 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, however, if we are to look more closely at the development of osteoarthritis in particular,” says Richard Frobell.

The research group, whose study is called KANON, Knee ACL NON-operative versus operative treatment, is now moving on to the next stage. This year, the third part of the study will begin, following up the patients ten years after anterior cruciate ligament injury.

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

Journal References:

  1. 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 trialBMJ, 2013; 346 (jan24 1): f232 DOI:10.1136/bmj.f232
  2. 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

Fat is Pro-Inflammatory! Weight Loss Helps Relieve Pain From Arthritis (among other things!)

Copied from a recent post on the IVAPM*:

“…I would be looking for some of the non-pharmacologic strategies. You have already mentioned an important one, getting the weight off. Adipose tissue is the body’s largest endocrine organ, and it secretes, especially when in excess, a slew of nasty cytokines that essentially bathes the body – including the synovia and joints – in a soup of pro-inflammatory mediators. We have increasingly strong evidence in dogs that nothing more than weight loss will improve comfort and mobility in this species, including excellent one this year where the authors conclude “results indicate that body weight reduction causes a significant decrease in lameness from a weight loss of 6.10% onwards. Kinetic gait analysis supported the results from a body weight reduction of 8.85% onwards. These results confirm that weight loss should be presented as an important treatment modality to owners of obese dogs with OA and that noticeable improvement may be seen after modest weight loss in the region of 6.10 – 8.85% body weight”.”

Weight loss. There is no substitute. • Lago R, Gomez R, et al A new player in cartilage homeostasis: adiponectin induces nitric oxide synthase type II and pro-inflammatory cytokines in chondrocytes. Osteoarthritis Cartilage. 2008 Sep;16(9):1101-9. • Impellizeri JA, Tetrick MA, Muir P. Effect of weight reduction on clinical signs of lameness in dogs with hip osteoarthritis. JAVMA 2000 Apr 1;216(7):1089-91 • Burkholder, 2001 • Mlacnik E, Bockstahler BA, Muller M, et al. Effects of caloric restriction and a moderate or intense physiotherapy program for treatment of lameness in overweight dogs with osteoarthritis. J Am Vet Med Assoc. 2006 Dec 1;229(11):1756-60. • Marshall WG, Hazewinkel, HA, Mullen D, et al. Vet Res Commun. The effect of weight loss on lameness in obese dogs with osteoarthritis. 2010 Mar;34(3):241-53

*International Veterinary Association of Pain Management

Intestinal Bacteria Linked to Rheumatoid Arthritis

From ScienceDaily. com Nov. 5, 2013 — Researchers have linked a species of intestinal bacteria known as Prevotella copri to the onset of rheumatoid arthritis, the first demonstration in humans that the chronic inflammatory joint disease may be mediated in part by specific intestinal bacteria. The new findings by laboratory scientists and clinical researchers in rheumatology at NYU School of Medicine add to the growing evidence that the trillions of microbes in our body play an important role in regulating our health.

Using sophisticated DNA analysis to compare gut bacteria from fecal samples of patients with rheumatoid arthritis and healthy individuals, the researchers found that P. copri was more abundant in patients newly diagnosed with rheumatoid arthritis than in healthy individuals or patients with chronic, treated rheumatoid arthritis. Moreover, the overgrowth of P. copri was associated with fewer beneficial gut bacteria belonging to the genera Bacteroides.

“Studies in rodent models have clearly shown that the intestinal microbiota contribute significantly to the causation of systemic autoimmune diseases,” says Dan R. Littman, MD, PhD, the Helen L. and Martin S. Kimmel Professor of Pathology and Microbiology and a Howard Hughes Medical Institute investigator.
“Our own results in mouse studies encouraged us to take a closer look at patients with rheumatoid arthritis, and we found this remarkable and surprising association,” says Dr. Littman, whose basic science laboratory at NYU School of Medicine’s Skirball Institute of Biomolecular Medicine collaborated with clinical investigators led by Steven Abramson, MD, senior vice president and vice dean for education, faculty, and academic affairs; the Frederick H. King Professor of Internal Medicine; chair of the Department of Medicine; and professor of medicine and pathology at NYU School of Medicine.

“At this stage, however, we cannot conclude that there is a causal link between the abundance of P. copri and the onset of rheumatoid arthritis,” Dr. Littman says. “We are developing new tools that will hopefully allow us to ask if this is indeed the case.”

The new findings, reported today in the open-access journal eLife, were inspired by previous research in Dr. Littman’s laboratory, collaborating with Harvard Medical School investigators, using mice genetically predisposed to rheumatoid arthritis, which resist the disease if kept in sterile environments, but show signs of joint inflammation when exposed to otherwise benign gut bacteria known as segmented filamentous bacteria.

Rheumatoid arthritis, an autoimmune disease that attacks joint tissue and causes painful, often debilitating stiffness and swelling, affects 1.3 million Americans. It strikes twice as many women as men and its cause remains unknown although genetic and environmental factors are thought to play a role.

The human gut is home to hundreds of species of beneficial bacteria, including P. copri, which ferment undigested carbohydrates to fuel the body and keep harmful bacteria in check. The immune system, primed to attack foreign microbes, possesses the extraordinary ability to distinguish benign or beneficial bacteria from pathogenic bacteria. This ability may be compromised, however, when the gut’s microbial ecosystem is thrown off balance.

“Expansion of P. copri in the intestinal microbiota exacerbates colonic inflammation in mouse models and may offer insight into the systemic autoimmune response seen in rheumatoid arthritis,” says Randy S. Longman, MD, PhD, a post-doctoral fellow in Dr. Littman’s laboratory and a gastroenterologist at Weill-Cornell, and an author on the new study. Exactly how this expansion relates to disease remains unclear even in animal models, he says.

Why P. copri growth seems to take off in newly diagnosed patients with rheumatoid arthritis is also unclear, the researchers say. Both environmental influences, such as diet and genetic factors can shift bacterial populations within the gut, which may set off a systemic autoimmune attack. Adding to the mystery, P. copri extracted from stool samples of newly diagnosed patients appears genetically distinct from P. copri found in healthy individuals, the researchers found.

To determine if particular bacterial species correlate with rheumatoid arthritis, the researchers sequenced the so-called 16S gene on 44 fecal DNA samples from newly diagnosed patients with rheumatoid arthritis prior to immune-suppressive treatment; 26 samples from patients with chronic, treated rheumatoid arthritis; 16 samples from patients with psoriatic arthritis (characterized by red, flaky skin in conjunction with joint inflammation); and 28 samples from healthy individuals.

Seventy-five percent of stool samples from patients newly diagnosed with rheumatoid arthritis carried P. copri compared to 21.4% of samples from healthy individuals; 11.5% from chronic, treated patients; and 37.5% from patients with psoriatic arthritis.

Rheumatoid arthritis is treated with an assortment of medications, including antibiotics, anti-inflammatory drugs like steroids, and immunosuppressive therapies that tame immune reactions. Little is understood about how these medications affect gut bacteria. This latest research offers an important clue, showing that treated patients with chronic rheumatoid arthritis carry smaller populations of P. copri. “It could be that certain treatments help stabilize the balance of bacteria in the gut,” says Jose U. Scher, MD, director of the Microbiome Center for Rheumatology and Autoimmunity at NYU Langone Medical Center’s Hospital for Joint Diseases, and an author on the new study. “Or it could be that certain gut bacteria favor inflammation.”

The researchers plan to validate their results in regions beyond New York, since gut flora can vary across geographical regions, and investigate whether the gut flora can be used as a biological marker to guide treatment. “We want to know if people with certain populations of gut bacteria respond better to certain treatment than others,” says Dr. Scher. Finally, they hope to study people before they develop rheumatoid arthritis to see whether overgrowth of P. copri is a cause or result of autoimmune attacks.

Warm Up More Productive Than Stretching to Avoid Injuries

Warm up More Productive Than Stretching-

I’ve read studies on the topic of stretching for several decades and the consistent evidence is as Dr. Mirkin presents it (below).

Every opportunity I get to work with competitive dogs is an opportunity to reeducate the human clients about sport training and competition. People in the pet competition world often promote ball stretching as an acceptable form of pre-competition warm up or exercise.

Ball stretching before an event is more destructive than helpful. Coming out of a crate and trotting around just a short bit is not enough of a warm up prior to competition. Dogs should do better in events with at least a quarter-mile slow jog warm up and then a few sprints. This would also be beneficial prior to training drills as well. Just the basics…

The article below comes from Dr. Gabe Mirkin’s Fitness and Health e-Zine
April 7, 2013

Stretching Before Exercising Provides Only Flexibility

Whenever I see someone stretching before running, cycling, tennis, swimming, or any other sport, I worry that the person doesn’t know much about training.

Exercise First and Then Stretch

Stretching Before Exercise Only Weakens Muscles:

Two recent studies show that stretching before competition and training weakens muscles. Stretching prevents you from lifting your heaviest weights or running your fastest miles. It limits how high you can jump, and how fast you can run (The Journal of Strength and Conditioning Research. April, 2013; The Scandinavian Journal of Medicine and Science in Sports, April, 2013).

Stretching weakens muscles by almost 5.5 percent. The longer you hold the stretch, the more strength you lose. Holding a stretch for more than 90 seconds markedly reduces strength in that muscle. Stretching reduces power: how hard you can hit a baseball or tennis ball, how fast you can swim, run or pedal, Stretching also does not prevent next-day muscle soreness, and it does not prevent injuries. On the other hand, warming up helps to prevent injuries and helps you to run faster and lift heavier.

Rudi Stretching Naturally After Exercise
Rudi the Brittany Spaniel in Rehab After Hip Surgery, FHO, Femoral Head Osteotomy. He’s Doing Natural Stretching AFTER exercise, and NOT Doing Forced Range of Motion Work by His Mom Owner


How Muscles Move Your Body:

Every muscle in your body is made up of thousands of individual fibers. Each fiber is composed of sarcomeres, repeated similar blocks, lined end-to-end to form the rope-like fibers. Each sarcomere touches the sarcomere next to it at the Z line. Muscles move your body by contracting, a shortening of each muscle fiber. Muscles do not shorten (contract) equally throughout their lengths. Muscles contract only at each of thousands of Z lines. It is the cumulative shortening of thousands of Z lines that shorten fibers to make muscles contract and move your body.

How Stretching Saps Strength:

When you stretch a muscle, you pull on the muscle fibers and stretch apart each fiber at the thousands of Z lines. This damage occurs only at the Z lines throughout the length of the muscle fiber, to weaken the entire muscle.

Prolonged Stretching Limits the Ability of Muscles to Store Energy:

Muscles are like rubber bands. They stretch and contract with each muscle movement. This constant stretching and contracting stores energy. For example, when you run, you land on your foot and the muscle stops contracting suddenly.

The force of your foot striking the ground is stored in your muscles and tendons and this energy is released immediately to drive you forward. Your foot hits the ground with a force equal to three times your body weight when you run at a pace of six minutes per mile. Up to 70 percent of the force of your foot strike is stored in your Achilles and other tendons. This energy is released by your muscles and tendons to drive you forward for your next step.

Stretching decreases the amount of energy you can store in muscles and tendons and therefore weakens you and you have less stored energy to drive you forward, so you have to slow down.

Stretching Saps Speed and Endurance:

Elite college sprinters were timed in 20 meter sprints, with and without prior multiple 30-second stretches of their leg muscles. Both active and passive stretching slowed them down (Journal of Sports Science, May 2005).

Stretching Does Not Prevent Next Day Muscle Soreness:

A review of 12 studies published over the last 25 years shows that stretching does not prevent muscle soreness that occurs 8 to 24 hours after you exercise vigorously (The British Journal of Sports Medicine, December 2011; 45:15 1249-1250). Researchers in Australia reviewed five studies, involving 77 subjects, to show that stretching does not prevent next-day muscle soreness. (British Medical Journal. December 2007; 325:468-70 and 451-2).

Stretching Does Not Prevent Injuries:

A review of the scientific literature shows that there is no good evidence that stretching prevents sports injuries (Clinical Journal of Sports Medicine. March 2005). Muscles and tendons tear when the force applied to them is greater than their inherent strength, so anything that makes a muscle stronger helps to prevent injuries. Strengthening muscles helps prevent muscle and tendon tears, but stretching does not make muscles stronger. This review showed that stretching does not prevent shin splints, bone stress fractures, sprains, strains or other arm and leg injuries.


Original Post August 3, 2014. Updated February 19, 2018

Anecdotal Progress

Anecdotal Progress – Am I Seeing What I Think I’m Seeing?

Exercise is thought to have beneficial effects on Parkinson’s disease.

Jay L. Alberts, Ph.D., neuroscientist at the Cleveland Clinic Lerner Research Institute in Cleveland, saw this firsthand in 2003 when he rode a tandem bicycle across Iowa with a Parkinson’s disease patient to raise awareness of the disease. The patient experienced improvements in her symptoms after the ride.

“”The finding was serendipitous,” Dr. Alberts recalled. “I was pedaling faster than her, which forced her to pedal faster. She had improvements in her upper extremity function, so we started to look at the possible mechanism behind this improved function.” As part of this inquiry, Dr. Alberts, researcher Chintan Shah, B.S., and their Cleveland Clinic colleagues, recently used fcMRI to study the effect of exercise on 26 Parkinson’s disease patients.”

RehabDeb says: The above is a quote from an article regarding research looking at the benefits of exercise for Parkinson’s patients, found on Science Daily dot com, and as I read it this morning, I thought it to be a perfect example of the practice protocol I have developed that has proved beneficial for several orthopedic conditions in lieu or surgery…whatever reasons one might have for not having surgery performed on their pet.

I am one person working alone, however I have over 35 years background and experience in principles of human sport science, exercise physiology, program design, and the like. There are a few others with similar backgrounds working in veterinary rehabilitation. I began using simple principles based on years of experience, and I’ve seen much success, as evidenced by improved quality of life, improved function, and veterinary professional confirmation.

I don’t have money to drive clinical research, and while I have ideas about whom I could approach about getting involved with this research, I am busy in my practice and haven’t wanted to take the time aside to pursue individuals, grants or corporations. At some point I intend to write more about the beneficial outcomes and to further discuss cases, however in the meantime, take the first paragraph as affirmation that science is observation of a particular outcome or experience as well as the steps to prove what we imagine/postulate/thought we observed.

It has been proved anecdotally time and again that when the conservative and slowly progressive non-surgical interventions I have outlined in the homework discussions on this site and/or in my books are followed within the parameters I outline, improvement of the condition ensues, barring extenuating circumstances. I do not see the discussion as being whether surgery or no surgery is better; I present the protocol I use as beneficial guidelines instead of not giving a program of recovery to those who choose to wait or altogether forego surgery for some conditions.

AND, I have provided return-to-function programs that are for pets that have had surgery. Following a program of progressive and structured recovery will only serve to improve the outcome and the pet’s quality of life if done well and correctly.

In other words, for injuries and conditions that are not “life or death”, the fact is there are very many people who will not choose surgery for their pet (or for themselves, for that matter). The instead-of-surgery protocol I develop and use fills a need to help the pet recover.

Keep moving forward; there is no time constraint on the “one step at a time” methodology…you can always begin, again, now.


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