Hip Fracture

Home-based exercise program improves recovery following rehabilitation for hip fracture

Date:  February 18, 2014Hi
Source:  The JAMA Network Journals (ScienceDaily post)
Among patients who had completed standard rehabilitation after hip fracture, the use of a home exercise program that included exercises such as standing from a chair or climbing a step resulted in improved physical function, according to a study. More than 250,000 people in the United States fracture their hip each year, with many experiencing severe long-term consequences. Many of these patients are no longer able to independently complete basic functional tasks that they could perform prior to the fracture, such as walking 1 block or climbing 5 steps 2 years after a fracture. The efficacy of a home exercise program with minimal supervision after formal hip fracture rehabilitation ends has not been established. This new study addresses this type of cost-effective program.

More than 250,000 people in the United States fracture their hip each year, with many experiencing severe long-term consequences. “Two years after a hip fracture, more than half of men and 39 percent of women are dead or living in a long-term care facility. Many of these patients are no longer able to independently complete basic functional tasks that they could perform prior to the fracture, such as walking 1 block or climbing 5 steps 2 years after a fracture,” according to background information in the article. The efficacy of a home exercise program with minimal supervision after formal hip fracture rehabilitation ends has not been established.

Nancy K. Latham, Ph.D., P.T., of Boston University, and colleagues randomized 232 functionally limited older adults who had completed traditional rehabilitation after a hip fracture to a home exercise hip rehabilitation program comprising functionally oriented exercises (such as standing from a chair, climbing a step) taught by a physical therapist and performed independently by the participants in their homes for 6 months (n = 120); or in-home and telephone-based cardiovascular nutrition education (n = 112).

Among the 232 randomized patients, 195 were followed up at 6 months and included in the primary analysis. The intervention group (n=100) showed improvement relative to the control group (n=95) in functional mobility on various measures. In addition, balance significantly improved in the intervention group compared with the control group at 6 months.

“The traditional approach to rehabilitation for hip fracture leaves many patients with long-term functional limitations that could be reduced with extended rehabilitation. However, it is unlikely that additional months of highly supervised rehabilitation can be provided to patients with hip fracture,” the authors write.
“Exercise programs are challenging for people to perform on their own without clear feedback about whether they are performing the exercises accurately and safely and without guidance as to how to change the exercises over time. The findings from our study suggest that [the approach used in this study] could be introduced to patients after completion of traditional physical therapy following hip fracture and may provide a more effective way for these patients to continue to exercise in their own homes. However, future research is needed to explore whether the interventions in this trial can be disseminated in a cost-effective manner in real clinical environments.”

Story Source:
The above story is based on materials provided by The JAMA Network Journals. Note: Materials may be edited for content and length.
Journal Reference:
Nancy K. Latham, Bette Ann Harris, Jonathan F. Bean, Timothy Heeren, Christine Goodyear, Stacey Zawacki, Diane M. Heislein, Jabed Mustafa, Poonam Pardasaney, Marie Giorgetti, Nicole Holt, Lori Goehring, Alan M. Jette. Effect of a Home-Based Exercise Program on Functional Recovery Following Rehabilitation After Hip Fracture. JAMA, 2014; 311 (7): 700 DOI: 10.1001/jama.2014.469

Cognitive and Neurological – 3 Articles

Exercise Helps Nerve Pain

ScienceDaily (June 1, 2012) — Exercise helps to alleviate pain related to nerve damage (neuropathic pain) by reducing levels of certain inflammation-promoting factors, suggests an experimental study in the June issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS).

The results support exercise as a potentially useful nondrug treatment for neuropathic pain, and suggest that it may work by reducing inflammation-promoting substances called cytokines. The lead author was Yu-Wen Chen, PhD, of China Medical University, Taichung, Taiwan.

Exercise Reduces Nerve Pain and Cytokine Expression in Rats Neuropathic pain is a common and difficult-to-treat type of pain caused by nerve damage, seen in patients with trauma, diabetes, and other conditions. Phantom limb pain after amputation is an example of neuropathic pain.

Dr Chen and colleagues examined the effects of exercise on neuropathic pain induced by sciatic nerve injury in rats. After nerve injury, some animals performed progressive exercise — either swimming or treadmill running — over a few weeks. The researchers assessed the effects of exercise on neuropathic pain severity by monitoring observable pain behaviors.

The results suggested significant reductions in neuropathic pain in rats assigned to swimming or treadmill running. Exercise reduced abnormal responses to temperature and pressure — both characteristic of neuropathic pain.

Exercise also led to reduced expression of inflammation-promoting cytokines in sciatic nerve tissue — specifically, tumor necrosis factor-alpha and interleukin-1-beta. That was consistent with previous studies suggesting that inflammation and pro-inflammatory cytokines play a role in the development of neuropathic pain in response to nerve injury.

Exercise also led to increased expression of a protein, called heat shock protein-27, which may have contributed to the reductions in cytokine expression.

Neuropathic pain causes burning pain and numbness that is not controlled by conventional pain medications. Antidepressant and antiepileptic drugs may be helpful, but have significant side effects. Exercise is commonly recommended for patients with various types of chronic pain, but there are conflicting data as to whether it is helpful in neuropathic pain.

The new results support the benefits of exercise in reducing neuropathic pain, though not eliminating it completely. In the experiments, exercise reduced abnormal pain responses by 30 to 50 percent.

The study also adds new evidence that inflammation contributes to the development of neuropathic pain, including the possible roles of pro-inflammatory cytokines. The results provide support for exercise as a helpful, nondrug therapy for neuropathic pain — potentially reducing the need for medications and resulting side effects.

Practice Makes the Brain’s Motor Cortex More Efficient

**Repetitive motion drills are key to rehab protocol I design for animals with neurological defecits—so keep on keeping on if you are doing that, too! Blessings-RehabDeb

Aug. 4, 2013 — Not only does practice make perfect, it also makes for more efficient generation of neuronal activity in the primary motor cortex, the area of the brain that plans and executes movement, according to researchers from the University of Pittsburgh School of Medicine. Their findings, published online today in Nature Neuroscience, showed that practice leads to decreased metabolic activity for internally generated movements, but not for visually guided motor tasks, and suggest the motor cortex is “plastic” and a potential site for the storage of motor skills.

The hand area of the primary motor cortex is known to be larger among professional pianists than in amateur ones. This observation has suggested that extensive practice and the development of expert performance induces changes in the primary motor cortex, said senior investigator Peter L. Strick, Ph.D., Distinguished Professor and chair, Department of Neurobiology, Pitt School of Medicine.

Prior imaging studies have shown that markers of synaptic activity, meaning the input signals to neurons, decrease in the primary motor cortex as repeated actions become routine and an individual develops expertise at a motor skill. The researchers found that markers of synaptic activity also display a marked decrease in monkeys trained to perform sequences of movements that are guided from memory — an internally generated task — rather than from vision. They wondered whether the change in synaptic activity indicated that neuron firing also declined. To examine this issue they recorded neuron activity and sampled metabolic activity, a measure of synaptic activity in the same animals.

All the monkeys were trained on two tasks and were rewarded when they reached out to touch an object in front of them. In the visually guided task, a visual target showed the monkeys where to reach and the end point was randomly switched from trial to trial. In the internally generated task the monkeys were trained to perform short sequences of movements without visual cues. They practiced the sequences until they achieved a level of skill comparable to an expert typist.

The researchers found neuron activity was comparable between monkeys that performed visually guided and internally generated tasks. However, metabolic activity was high for the visually guided task, but only modest during the internally generated task.

“This tells us that practicing a skilled movement and the development of expertise leads to more efficient generation of neuron activity in the primary motor cortex to produce the movement. The increase in efficiency could be created by a number of factors such as more effective synapses, greater synchrony in inputs and more finely tuned inputs,” Dr. Strick noted. “What is really important is that our results indicate that practice changes the primary motor cortex so that it can become an important substrate for the storage of motor skills. Thus, the motor cortex is adaptable, or plastic.

Exercise for Parkinson’s Patients

(With adept application, many human interventions may be crossed over to non-human animal functional rehab :))

Becky G. Farley, PhD, PT, MS, knows that exercise is about more than fitness-it is a physiological tool that encourages the body’s own endogenous brain repair mechanisms.

“Exercise promotes brain health and, thereby, may protect the remaining ‘viable’ dopamine neurons, called neuroprotection,” she said.

It also optimizes brain function through activity-dependent plasticity mechanisms that can restore function to damaged pathways, normalize interference from inefficient signaling and increase reliance on undamaged systems.

In July 2010, Dr. Farley founded NeuroFit NetWorks, a non-profit program dedicated to developing and expanding access to research-based exercise programming that is proactive, optimizes brain health/function, and changes the lives of individuals living with a neurodegenerative disease.

Exercise, she said, may at the very least slow motor deterioration in patients with Parkinson’s disease, and, if started early enough, may be able to modify disease progression.

Research, Advocacy & Education
While at the University of Arizona, Dept. of Physiology, Dr. Farley researched muscle activation mechanisms that underlie one of the primary symptoms in patients with Parkinson’s disease. This research led to the development of an exercise program called LSVT BIG™ to target bradykinesia (a slowness of movement) and an NIH-funded randomized clinical trial.

After training more than 5,000 physical and occupational therapists around the world in how to instruct people with Parkinson’s disease in LSVT BIG™ methods, Dr. Farley realized that basic and clinical science research about exercise and Parkinson’s disease is not being translated to real-world application.

“For example, continuous access to proactive neuroplasticity-principled programs that have been shown in animals to slow disease progression.are not available,” she explained. “As it stands now, patients with Parkinson’s disease rarely go to therapy, and when they do, it is usually only after they lose function and start to fall. And those that do go are rarely seen by PD-exercise experts.”

Even if they do find therapists that understand Parkinson’s disease, most patients are not implementing approaches that adhere to the principles of practice that are required to promote learning and plasticity. Instead, outdated guidelines are implemented that promote using strategies or working on secondary impairments like weakness and flexibility.

“No doubt these things help make life better for patients with Parkinson’s disease, but they don’t target the problems that got them to that level of disability. So, ultimately nothing is changed,” said Dr. Farley.

NeuroFit NetWorks plans to change that. The non-profit is advocating for translation of this research now. They have started a national Parkinson Exercise Revolution to help people get better and stay better with exercise. Dr. Farley is conducting training workshops nationally for therapists and fitness professionals to become Parkinson’s disease exercise experts and to work together in their local communities to implement early intervention and continuous access to PD-specific exercise for life.

A model neuro-fitness center in Tucson, AZ, is currently being developed to show how rehab can be accessible and integrated with community fitness programming to optimize learning and function.

“This is the infrastructure that we think offers promise to delay disease onset, slow disease progression, restore motor function, and increase longevity and quality of life for people with neurodegenerative or neurological conditions, and for those individuals at risk for these conditions,” Dr. Farley noted.

It will take advocacy; education of the medical, fitness community and lay public; and working with health care systems to change existing paradigms, demonstrate health care cost savings, and document slowing of motor deterioration.

Research-Based Exercise Programs
All exercise programs at NeuroFit NetWorks are implemented within the context of the Exercise4BrainChange™ (E4BC) model that requires therapists and fitness professionals to incorporate instructions, feedback, and research techniques that promote four essential learning constructs: prepare, activate, reflect, motivate.

These constructs can accommodate multiple exercise approaches and be customized to address a disease’s specific physical/cognitive/emotional deficits. The depth of the content can be modified to allow for a system of communication with a similar language across a variety of therapeutic disciplines and exercise professionals. This is the first time that these essential principles have been described in a manner that can help clinicians implement these concepts immediately with their patients.

“We believe to effect disease modification, proactive models of health care continuums must embrace research-based exercise approaches that are guided by the essential principles of learning and neuroplasticity,” said Dr. Farley. “We call these essential elements “Exercise4BrainChange™ principles” and we have developed a model that integrates all these elements in a way that can promote optimal brain function and skill acquisition.”

Every staff member has undergone training to learn about Parkinson’ disease and exercise and how to modify their instruction/programming to make it PD-specific and optimize the potential for learning and plasticity.

The following programs are offered at the Parkinson Wellness Recovery (PWR!) Gym:

Rehabilitation – 1:1 Exercise4BrainChange. This is where an individual comes to the gym to get a ‘PWR! PLAN.’ They work one-on-one with a therapist that is a PD-exercise expert who educates them about the research on exercise and helps them develop a proactive PD-specific “Use It Or Lose It” program that includes ongoing coaching and tune-ups for life.

Other 1:1 rehabilitation treatments address and target specific problems, such as freezing or postural instability, to “use it and improve it.”

“We integrate research techniques to target bradykinesia/rigidity/coordination/postural instability/posture, such as the training of activated large amplitude whole-body movements; focused practice on axial rotation and extension exercises; paced, rhythmical movements to augmented sensory proprioceptive feedback; rhythmical; treadmill activities for endurance, coordination for gait and balance, and more,” Dr. Farley explained. Clients are progressively challenged to work harder than then self-select. Language and cognitive activities are integrated to increase difficulty, and emotional deficits are targeted through empowerment/education/affirmations to retrain their emotional brain about what they CAN do.

Community – Group E4BC Programming. This program offers PWR! MOVES; PWR! Circuit and specialty classes (agility, strengthening, stretching) that target PD-specific symptoms; and cardio programs for brain health and to prepare the brain to learn! (mobilize neurotransmitters, cell survival and growth factors, boost the immune system, reduce inflammation).

Other enrichment programming to optimize brain health and restoration includes nutrition, stress reduction, brain fitness, and other social or general group exercise activities (drumming, dance, tai chi, etc.).

Retraining the Brain

It is not enough to simply exercise when one has a neurodegenerative disease, noted Dr. Farley.
“It is important to target the anticipated and existing problems with intensive, repetitive practice while receiving certain types of feedback to help you learn and pay attention to critical aspects of the practice,” she explained.

It is also vital that a person is ready to learn and able to manage stress, anxiety and fear to optimize the conditions for learning. That’s why NeuroFit NetWorks has specially trained therapists and fitness professionals that understand how to implement programming to optimize brain health and function for people with different types of conditions.

“Our movements and ability to learn new skills requires active engagement. So, dysfunction in emotional or cognitive systems that interferes with planning, intrinsic motivation, self-monitoring, confidence, etc., interferes with learning,” explained Dr. Farley.

The cognitive deficits in Parkinson’s disease are in the area of executive functioning and attention. These cognitive components are essential for the planning and production of complex whole-body movements; ability to adapt movements/postures to changes in the environment, and automaticity (ability to divide or focus attention for multitasking).

In addition, the loss of dopamine contributes to emotional dysfunction, such as loss of motivation, self-efficacy, anxiety, fear and learned helplessness.

“Evidence suggests that physical exercise improves not only the sensorimotor deficits, but cognitive and emotional deficits as well,” Dr. Farley stated.

She noted that NeuroFit NetWorks is helping people with Parkinson’s disease get better and stay better with exercise, enrichment, education and empowerment.

“We want to have the infrastructure in place when the definitive research emerges that exercise that begins early and is continuous in nature slows disease progression,” she said. “It requires that we advocate for change to existing rehab/health care paradigms that don’t ever see people with Parkinson’s disease until they start to fall; years after the diagnosis.”

A window of opportunity has been lost to begin proactive and disease modifying exercise programs founded in research, said Dr. Farley. It will be years before clinical trials demonstrate the best exercise and the best dosage.

“In the meantime, we are going to implement the best of the best and incorporate new information as it becomes available,” she concluded. “There are studies showing that exercise augments the response to Parkinson’s disease medications in the short term and long term, yet people are rarely empowered after they are diagnosed, and so instead they go home and withdraw.”


Tendinopathy – 2 Articles

Low level laser treatment of tendinopathy: a systematic review with meta-analysis.


Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand. steve.tumilty@otago.ac.nz



To assess the clinical effectiveness of Low Level Laser Therapy (LLLT) in the treatment of tendinopathy. Secondary objectives were to determine the relevance of irradiation parameters to outcomes, and the validity of current dosage recommendations for the treatment of tendinopathy.


LLLT is proposed as a possible treatment for tendon injuries. However, the clinical effectiveness of this modality remains controversial, with limited agreement on the most efficacious dosage and parameter choices.


The following databases were searched from inception to 1(st) August 2008: MEDLINE, PubMed, CINAHL, AMED, EMBASE, All EBM reviews, PEDro (Physiotherapy Evidence Database), SCOPUS. Controlled clinical trials evaluating LLLT as a primary intervention for any tendinopathy were included in the review. Methodological quality was classified as: high (> or =6 out of 10 on the PEDro scale) or low (<6) to grade the strength of evidence. Accuracy and clinical appropriateness of treatment parameters were assessed using established recommendations and guidelines.


Twenty-five controlled clinical trials met the inclusion criteria. There were conflicting findings from multiple trials: 12 showed positive effects and 13 were inconclusive or showed no effect. Dosages used in the 12 positive studies would support the existence of an effective dosage window that closely resembled current recommended guidelines. In two instances where pooling of data was possible, LLLT showed a positive effect size; in studies of lateral epicondylitis that scored > or =6 on the PEDro scale, participants’ grip strength was 9.59 kg higher than that of the control group; for participants with Achilles tendinopathy, the effect was 13.6 mm less pain on a 100 mm visual analogue scale.


LLLT can potentially be effective in treating tendinopathy when recommended dosages are used. The 12 positive studies provide strong evidence that positive outcomes are associated with the use of current dosage recommendations for the treatment of tendinopathy.


19708800 [PubMed – indexed for MEDLINE]

Fighting Foot Drop

From Advance Journal for Human Physical Therapy

My (RehabDeb) Comment:
“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.”
Employing these techniques in animal-other-than-human rehab is what I do and is highly successful here, as well–proprioceptive training that can also build nerve strength 🙂 For dogs and cats, I utilize Orthovet footbed splints and Thera-Paws Dorsi-Flex Assist boots on a case-by-case basis.

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

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?”

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.

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.”

“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.”

Archive ImageA
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.

“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.

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 a passive AFO system will have to be used,” Thomas shared.

If the patient’s spinal cord has been interrupted in any way, then retraining the muscles would be a very difficult-and maybe even impossible-endeavor.

An AFO remains the appropriate solution for patients with lower-extremity edema, unstable ankle stance or cognitive impairments that 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, however, 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 I go through the exercises the first day and then send them home with illustrations. I say I will quiz them during the beginning of the next session and 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.”

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 have done right after her stroke,” he said. “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 can be reached atrmayer@advanceweb.com.

Ligaments – Overview of Injury and Recovery

Ligament Structure, Injury, and Recovery –

Former title: Stifle (Knee) Ligament Ruptures (Torn ACL, CCL) Information Overview.


The updated article is found here!

Prologue –

This is a piece I originally wrote for a client of Dr. Dennis Sundbeck, DVM, owner and practitioner at Round Rock Animal Hospital for 35 years.

Dr. Sundbeck retired in 2014, and passed away April 15, 2018. Our community remembers him fondly as we celebrate his life and contributions to many aspects of our Central Texas Community.

I remember Dr. Sundbeck specifically and warmly because he was possibly the first established, old school, veterinarian in my area to refer a case to me for non-surgical recovery of a torn knee ligament. I do not think he and I had been able to talk any prior to the referral, however he must have read the materials I dropped off at RRAH when I began my business in January, 2007, and evidently my methodologies made common and scientific sense to him.

I have always held that situation deep in my heart as a beacon to support my work to switch veterinary medicine off of the all-too-quick referrals to surgeons for injuries like torn ligament, torn meniscus, and “bad hips”. RRAH continued to support my rehabilitation practice over the years and often supplied my recovery booklets for their clients.

By the way, that case? Was a 2 yo in-tact male Chocolate Labrador hunting dog with extreme crate anxiety and parent-clients who both worked long hours in science-based jobs. I remain forever grateful for that referral.

(Updated April 18, 2018)


Deconditioning – 4 Articles

Lack of Exercise, Not Aging, Causes Weakness and Loss of Muscle in Older People

Aging does not cause you to lose muscles. Loss of muscle is caused by lack of exercise. You can preserve both muscle size and strength by continuing to exercise as long as you live.  Here are MRIs of the legs of 40- and 70-year-old triathletes, and a 70-year-old non-exerciser:
The dark spots are muscle, the light spots are fat. Which legs would you like to have?

Forty competitive athletes, aged 40-81, who trained four to five times a week, had the same size muscles, the same absence of fat around their muscles, and close to the same strength as much younger athletes (The Physician and Sportsmedicine, September 2011).

Many of the diseases and debilitating conditions associated with aging are caused by lack of exercise. “Exercise decreases body fat and obesity, increases muscle strength, improves balance, gait, and mobility, decreases likelihood of falling, improves psychological health, reduces arthritis pain, and heart
attacks, osteoporosis, cancer, and diabetes.”

After age 40, the average person loses more than eight percent of muscle size per decade. This loss increases to 15 percent per decade after age 75 years. Older people who lose muscles are four times more likely be disabled, have difficulty walking, and need walkers and other mechanical devices to help
them walk (Am J Epidemiol, 1998; 147(8):755-763).

From Deb:

This post was taken from Dr. Mirkin’s eZine on health and fitness.The primary benefit my practice brings to animals, human or otherwise, is the knowledge of how to develop and encourage the right types of movement to improve health. In short. 🙂

The primary attribute that YOU bring is follow-through, compliance. Thank you.

Which Nutritional Factors Help Preserve Muscle Mass, Strength and Performance in Seniors?

Jan. 18, 2013 — New review by International Osteoporosis Foundation (IOF) Nutrition Working Group examines role of nutrition in sarcopenia, with focus on protein, vitamins D and B, and acid-based diet.
Sarcopenia, or the gradual loss of muscle mass, is a common consequence of aging, and poses a significant risk factor for disability in older adults. As muscle strength plays an important role in the tendency to fall, sarcopenia leads to an increased risk of fractures and other injuries.
The International Osteoporosis Foundation (IOF) Nutrition Working Group has published a new review which identifies nutritional factors that contribute to loss of muscle mass, or conversely, are beneficial to the maintenance of muscle mass. The Group reviewed evidence from worldwide studies on the role of nutrition in sarcopenia, specifically looking at protein, acid-base balance, vitamin D/calcium, and other minor nutrients like B vitamins.

“The most obvious intervention against sarcopenia is exercise in the form of resistance training,” said Professor Jean-Philippe Bonjour, co-author and Professor of Medicine at the Service of Bone Diseases, University of Geneva. “However, adequate nutritional intake and an optimal dietary acid-base balance are also very important elements of any strategy to preserve muscle mass and strength during aging.”

The review discusses and identifies the following important nutritional factors that have been shown to be beneficial to the maintenance of muscle mass and the treatment and prevention of sarcopenia:

Protein: Protein intake plays an integral part in muscle health. The authors propose an intake of 1.0-1.2 g/kg of body weight per day as optimal for skeletal muscle and bone health in elderly people without severely impaired renal function.

Vitamin D: As many studies indicate a role for vitamin D in the development and preservation of muscle mass and function, adequate vitamin D should be ensured through exposure to sunlight and/or supplementation if required. Vitamin D supplementation in seniors, and especially in institutionalized elderly, is recommended for optimal musculoskeletal health.

Avoiding dietary acid loads: Excess intake of acid-producing nutrients (meat and cereal grains) in combination with low intake of alkalizing fruits and vegetables may have negative effects on musculoskeletal health. Modifying the diet to include more fruits and vegetables is likely to benefit both bones and muscles.

Emerging evidence also suggests that vitamin B12 and/or folic acid play a role in improving muscle function and strength.

As well, the Review discusses non-nutritional interventions such as hormones, and calls for more studies to identify the potential of antioxidants and anti-inflammatory compounds in the prevention of sarcopenia.

Dr. Ambrish Mithal, co-author and Chair and Head of Endocrinology and Diabetes division at Medanta, New Delhi underlined the need for further research in the field. “Strategies to reduce the numbers of falls and fractures within our aging populations must include measures to prevent sarcopenia. At present, the available evidence suggests that combining resistance training with optimal nutritional status has a synergistic affect in preventing and treating sarcopenia, ” said Mithal.

“We hope that further studies will shed light on other effective ways of preventing and treating this condition.”

From ScienceDaily.com


Bone Strength – From MedlinePlus

Exercise, lifestyle, and your bones
Osteoporosis is a disease that causes bones to become brittle and more likely to fracture (break). With osteoporosis, the bones lose density. Bone density is the amount of bone tissue that is in your bone.
Exercise plays a key role in preserving bone density as you age.

Why Exercise?

Make exercise a regular part of your life. It will help keep your bones strong and lower your risk of osteoporosis and fractures as you get older.

Before you begin an exercise program, talk with your doctor if you are older, have not been active for a while, have diabetes, heart disease, lung disease, or any other health condition.

How Much and What Type of Exercise?

To build up bone density, the exercise must make your muscles pull on your bones. These are called weight-bearing exercises. Some of them are:

Brisk walks, jogging, playing tennis, dancing, or other weight-bearing activities such as aerobics and other sports
Careful weight training, using weight machines or free weights
Weight bearing exercises also:

Increase bone density even in young people
Help preserve bone density in women who are approaching menopause
To protect your bones, do weight bearing exercises 3 or more days a week for a total of over 90 minutes a week.

If you are older, do not do high-impact aerobics, such as step aerobics. This type of exercise may increase your risk of fractures.

Low-impact exercises like yoga and tai chi do not help your bone density very much. But they can improve your balance and lower your risk of falling and breaking a bone. And, even though they are good for your heart, swimming and biking do not increase bone density.

Other Lifestyle Changes to Help Your Bones

If you smoke, quit. Also limit how much alcohol you drink. Too much alcohol can damage your bones and raise your risk of falling and breaking a bone.

If you do not get enough calcium, or if your body does not absorb enough calcium from the foods you eat,your body may not make enough new bone. Talk with your health care provider about calcium and your bones.

Vitamin D helps your body absorb enough calcium.

Ask your health care provider if you should take a vitamin D supplement.
You may need more vitamin D during the winter or if you need to avoid sun exposure to prevent skin cancer.
Ask your health care provider about how much sun is safe for you.
Alternate Names

Osteoporosis – exercise; Low bone density – exercise


Lewiecki EM. In the clinic. Osteoporosis. Ann Intern Med. 2011 Jul 5;155(1):ITC1-1-15; quiz ITC1-16.

National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington,DC: National Osteoporosis Foundation; 2010.

Update Date: 5/17/2012

Updated by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.

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Strength training stops bone loss and builds muscle in postmenopausal breast cancer survivors: a randomized, controlled trial.


School of Nursing, Oregon Health & Science University, Portland, OR 97239, USA. wintersk@ohsu.edu

Erratum in

  • Breast Cancer Res Treat. 2011 Jun;127(2):457.


Targeted exercise training could reduce risk factors for fracture and obesity-related diseases that increase from breast cancer treatment, but has not been sufficiently tested. We hypothesized that progressive, moderate-intensity resistance + impact training would increase or maintain hip and spine bone mass, lean mass and fat mass and reduce bone turnover compared to controls who participated in a low-intensity, non-weight bearing stretching program. We conducted a randomized, controlled trial in 106 women with early stage breast cancer who were >1 year post-radiation and/or chemotherapy, ≥ 50 years of age at diagnosis and postmenopausal, free from osteoporosis and medications for bone loss, resistance and impact exercise naïve, and cleared to exercise by a physician. Women were randomly assigned to participate in 1 year of thrice-weekly progressive, moderate-intensity resistance + impact (jump) exercise or in a similar frequency and length control program of progressive, low-intensity stretching. Primary endpoints were bone mineral density (BMD; g/cm²) of the hip and spine and whole body bone-free lean and fat mass (kg) determined by DXA and biomarkers of bone turnover-serum osteocalcin (ng/ml) and urinary deoxypyrodiniline cross-links (nmol/mmolCr). Women in the resistance + impact training program preserved BMD at the lumbar spine (0.47 vs. -2.13%; P = 0.001) compared to controls. The resistance + impact group had a smaller increase in osteocalcin (7.0 vs. 27%, P = 0.03) and a larger decrease in deoxypyrodinoline (-49.9 vs. -32.6%, P = 0.06) than controls. Increases in lean mass from resistance + impact training were greatest among women currently taking aromatase inhibitors compared to controls not on this therapy (P = 0.01). Our combined program of resistance + impact exercise reduced risk factors for fracture among postmenopausal breast cancer survivors (BCS) and may be particularly relevant for BCS on aromatase inhibitors (AIs) because of the additional benefit of exercise on muscle mass that could reduce falls.”

A comment from me, Deborah: I know of medical doctors, specialists, oncologists…who are ceasing to prescribe the pharmaceuticals that were developed to be used for osteoporosis and osteopenia yet have turned out to be destructive in the long run, and instead they are recommending weight-bearing exercise to improve bone density. Specific exercise under controlled circumstances is proved to be beneficial for healing of bone after surgery as well.