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The Injured Runner: An Evidence-Based Approach - Part Two: RunSmart Approach

The Injured Runner: An Evidence-Based Approach - Part Two: RunSmart Approach

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Published by Allan Besselink
Presentation to the Capital Area District of the Texas Physical Therapy Association - 3/24/2009
Presentation to the Capital Area District of the Texas Physical Therapy Association - 3/24/2009

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Published by: Allan Besselink on Apr 05, 2009
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05/10/2014

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The Injured Runner: An Evidence-Based Approach

Part Two: RunSmart Approach

Allan Besselink, PT, Dip. MDT
Director, Smart Sport International Smart Life Institute Austin, Texas

Background

Physical therapist (1988) McKenzie Diploma (1998) USA Track and Field Endurance sports coach (running, triathlon) Educator (PT; PTA) Author - “RunSmart: A Comprehensive Approach To Injury-Free Running” (2008)
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Allan Besselink, PT, Dip. MDT

Evidence

Allan Besselink, PT, Dip. MDT

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Evidence-Based Medicine

“The plural of anecdote is not data”
(Frank Kotsonis)

“In God we trust – all others bring data”
(Nik Bogduk)

Allan Besselink, PT, Dip. MDT

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Community Standards

Accepted Community Standards Of Care
(what providers and patients consider “acceptable”)
vs

Evidence-Based Standards Of Care
(clinical guidelines; outcomes-driven)

Allan Besselink, PT, Dip. MDT

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Problem
ACSC and EBSC are not the same! ACSC has unfortunately become “gold standard” with patients

Allan Besselink, PT, Dip. MDT

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Alf Nachemson
“Most of us in our present state of ignorance get 70 – 80% good results … “

Allan Besselink, PT, Dip. MDT

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Alf Nachemson
“ … it is within the interest of our patients, and ourselves, to prescribe simple and inexpensive methods in which the known clinical, biological, and mechanical factors can serve as guides”
(1979)

Allan Besselink, PT, Dip. MDT

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“Solutions, Not More Problems”
● ● ●

How can we best utilize the evidence? Principles vs practices; patient-centered Assessment/treatment algorithm:

Understand the loading capacity of the tissues within a functional context Implement graded loading strategies to foster normal tissue repair “Competent Self Care”
9

Allan Besselink, PT, Dip. MDT

Hippocrates
“First, do no harm Second, revere the healing powers of nature”

Allan Besselink, PT, Dip. MDT

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“Evidence-Based Cellular Physiology”
Well-established principles of cellular physiology:
– – – – –

Mechanisms Stimulus - Response Specific Adaptations To Imposed Demands Training Principles Tissue Repair + “Competent Self Care”

Allan Besselink, PT, Dip. MDT

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Mechanisms
Principles = Why Practices = What

Mechanisms of Optimal Human Performance = Mechanisms of Injury Recovery = Mechanisms of Injury Prevention

Allan Besselink, PT, Dip. MDT

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Stimulus - Response
Stimulus – response (homeostasis) “Injury occurs when the rate of application of stimulus exceeds the rate of adaptation of the tissues”

Allan Besselink, PT, Dip. MDT

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SAID Principle
Specific Adaptations To Imposed Demands Humans adapt to the demands imposed upon them i.e. astronauts “Form Follows Function” --- Wolff's Law

Allan Besselink, PT, Dip. MDT

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Training Principles
In order to understand the dynamics of running injuries, you must understand the principles that are underlying the training methods. Building sports performance capacity

Allan Besselink, PT, Dip. MDT

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Training Principles

Training, detraining, and periodization
Allan Besselink, PT, Dip. MDT 16

Principles Of Tissue Repair

Phases of tissue repair and remodeling

Acute inflammatory phase

Days 0 – 3 (5 to 10 possible) Days 3 - 21 Days 21 – 6 months – 2 years

Fibroplastic/repair phase

Remodeling phase

Allan Besselink, PT, Dip. MDT

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Tissues Require ...
… especially in the fibroplastic and remodeling phases

Allan Besselink, PT, Dip. MDT

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Fibroplastic Phase
… is “prime time at the cellular level” for protein and collagen synthesis

Allan Besselink, PT, Dip. MDT

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Principles Of Tissue Repair
Anabolic vs catabolic - “turn on the gene” Processes require critical parameters “dosage/potency and frequency”

Allan Besselink, PT, Dip. MDT

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Competent Self Care
Udermann BE, Spratt KF, Donelson RG, Mayer J, Graves JE, Tillotson J. Can a patient educational book change behavior and reduce pain in chronic low back pain patients? Spine 2004, 4(4):425-435.

Allan Besselink, PT, Dip. MDT

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Competent Self Care

How do I know if I have an injury?
– –

Is it limiting your normal training? Is it causing you to alter you normal running mechanics? Is it affecting your normal activities of daily living?

Allan Besselink, PT, Dip. MDT

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Competent Self Care

“Hurt Not Harm”

Allan Besselink, PT, Dip. MDT

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“Evidence-Based Cellular Physiology”
Well-established principles of cellular physiology:
– – – – –

Mechanisms Stimulus - Response Specific Adaptations To Imposed Demands Training Principles Tissue Repair + “Competent Self Care”

Allan Besselink, PT, Dip. MDT

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Running Injuries

Injury occurs when the rate of application of stimulus exceeds the rate of adaptation of the tissues Form Follows Function Eccentric loading capacity Training!!

● ● ●

Allan Besselink, PT, Dip. MDT

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Running Injuries

Allan Besselink, PT, Dip. MDT

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Eccentric Loading Capacity
Running - eccentric loading as compared to cycling or swimming Eccentric loading capacity is critical and yet is often ignored

Allan Besselink, PT, Dip. MDT

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Training
“Even with apparent lower extremity malalignment or abnormal biomechanical conditions, most runners do well with an appropriately designed training program. The body is a tremendously adaptable mechanism and, if given time to accommodate stress, will usually respond favorably”
(James and Jones 1990)

Allan Besselink, PT, Dip. MDT

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Training
“Every running injury should be viewed as a failure of training technique, even if other contributing factors are subsequently identified”
(Reid 1992)
Allan Besselink, PT, Dip. MDT 29

Overuse – Or Under-Recovery?

Allan Besselink, PT, Dip. MDT

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Classic Scenario
“Iliotibial Band Syndrome”
– – – – – – –

Tight IT band Poor shoes Leg length discrepancy ART “Inflammation” “Start running slowly” Aqua jogging
31

Allan Besselink, PT, Dip. MDT

Classic Scenario
“Iliotibial Band Syndrome”
– –

When? Long runs Why? Poor running mechanics, poor loading capacity Who? New runners > experienced “IT Band is tight” - that is it's function! Training!!

– – –

Allan Besselink, PT, Dip. MDT

32

RunSmart Approach
Goals of an assessment/treatment algorithm:

Understand the loading capacity of the tissues within a functional context Graded progression of loading strategies to foster normal tissue repair and development Return to running “Competent Self Care”

– –

Allan Besselink, PT, Dip. MDT

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Critical Parameters

Every loading strategy/treatment/exercise has an intent – and a desired cellular response Example: medication – critical parameters of dosage/potency and frequency Exercise is no different If too much … or if not enough

● ●

Allan Besselink, PT, Dip. MDT

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RunSmart Pyramid

Same for injury recovery as for injury prevention Intent and desired cellular response

Allan Besselink, PT, Dip. MDT

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Assessment

McKenzie assessment – understand the effect of mechanical loading strategies on symptoms and mechanics Responders vs nonresponders Directional preference of loading
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Allan Besselink, PT, Dip. MDT

Neuromuscular And Tissue Loading Capacity

Increase the loading capacity of the neuromusculo-skeletal system (especially eccentric and functional)
– – –

“Strength Training” Plyometrics Drills
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Allan Besselink, PT, Dip. MDT

Maintain Current Functional Capacity

Weightbearing vs non-weightbearing

Running injuries are typically an issue of weightbearing “running on the moon” (17%) shoulder level = 90% unloading walking on earth vs running on moon

The debate over aqua-jogging
– – –

Allan Besselink, PT, Dip. MDT

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Strength Training

Tissue integrity / “architecture” Dosage:
– – –

1 x (8 to 10) Resistance 2 on, 1 off

Questions: risk? bulk? soreness? endurance?
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Allan Besselink, PT, Dip. MDT

Plyometrics

Functional positions and activities Eccentric loading – progression of strength training Dosage

Allan Besselink, PT, Dip. MDT

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Drills

Involvement of central nervous system in functional activities “Being a better runner” Running mechanics

Allan Besselink, PT, Dip. MDT

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When Can I Start To Run?

The answer is NOT “just start back slowly” Graded progression of loading Is walking painfree (hurt vs harm)?

Allan Besselink, PT, Dip. MDT

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Competent Self Care

“Hurt Not Harm”

Allan Besselink, PT, Dip. MDT

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Neuromuscular Power
● ●

Interval training Can begin with 1:00/1:00 walk/run Running better mechanically when running faster improved loading Continuous running
44

Allan Besselink, PT, Dip. MDT

Neuromuscular Efficiency

“Long runs” are the last aspect to return to the training plan Power output Dependent upon longest run in past month + layoff time

● ●

Allan Besselink, PT, Dip. MDT

45

Iliotibial Band Syndrome

History
– –

Who? New runners > experienced When? Long runs (running mechanics degrade over time) Nature of symptoms: Is it a “true” inflammatory response?

Allan Besselink, PT, Dip. MDT

46

Iliotibial Band Syndrome

Solutions

Assessment: confirm mechanical diagnosis; directional preference? Apply appropriate loading strategies “IT band is tight” - that is it's function! Eccentric loading capacity – once mechanical diagnosis confirmed Running mechanics, especially as running duration increases
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– – –

Allan Besselink, PT, Dip. MDT

Injury Prevention

The same as injury recovery “Build a better runner” Increase sports performance capacity Running mechanics Training program
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● ●

● ●

Allan Besselink, PT, Dip. MDT

Training Myths
● ●

More is better Your success is related to how many miles you run per week Don't change your running form … change your running form … don't change … change … Endurance runners need heel strike You will get injured with speed work
Allan Besselink, PT, Dip. MDT 49

● ●

Training Myths
● ● ●

I need a heart rate monitor to train effectively Heart rate data is critical to my success Power and strength training have no place in endurance sports The primary limiter to my performance is my cardiovascular system Stretching prevents injury – and world hunger too
Allan Besselink, PT, Dip. MDT 50

Evidence

Allan Besselink, PT, Dip. MDT

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What Is Endurance?

The capacity to withstand physiological or psychological stressors over a sustained period of time Power = Work / time Power = Force x Velocity

● ●

Increase force – recruit more muscle and nerve fibers Increase velocity – recruit the muscle and nerve fibers faster
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Allan Besselink, PT, Dip. MDT

What Is Endurance?

Remind me again – why am I doing more repetitions at a lower resistance … why? Mitochondria = cellular powerhouse – active muscle fibers only If I can recruit more muscle fibers, I increase my capacity for mitochondria – if I have more mitochondria (and I provide them with fuel) … I can go longer
Allan Besselink, PT, Dip. MDT 53

Heart Rate
● ●

If you have never been active – it is valuable Once you have 3 months of activity – Rating Of Perceived Exertion and training pace are a better means of monitoring training load The problem with heart rate monitors in Texas ...

Allan Besselink, PT, Dip. MDT

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Running Mechanics
Imagine being a golfer, and someone told you to not work on your golf swing - you'd think they were crazy! Now imagine being a runner, and someone tells you to not think about your running mechanics Now what do you think?
Allan Besselink, PT, Dip. MDT 55

Running Mechanics

Allan Besselink, PT, Dip. MDT

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Recovery-Centered Training
● ● ●

Mechanical Cognitive Nutritional

Allan Besselink, PT, Dip. MDT

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Recovery-Centered Training

Mechanical

Neuro-musculoskeletal system Cardiovascular system

Allan Besselink, PT, Dip. MDT

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Recovery-Centered Training

Cognitive

Central nervous system Endocrine system Immune system

– –

Allan Besselink, PT, Dip. MDT

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Recovery-Centered Training

Nutritional
– – – –

“Fuel” “Building Blocks” Water Vitamins and minerals

Allan Besselink, PT, Dip. MDT

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Challenge Your Thinking!
“We can't solve problems by using the same kind of thinking we used when we created them.”
(Einstein)

Allan Besselink, PT, Dip. MDT

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For More Information:

Smart Sport International www.smartsport.info Smart Life Institute www.smartlifeinstitute.com “Consumer's Guide To Health” - every second Tues at 8:00pm CT www.blogtalkradio.com/abesselink “RunSmart: A Comprehensive Approach To Injury-Free Running” www.lulu.com/abesselink
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Allan Besselink, PT, Dip. MDT

Photo Credits
All photos Creative Commons (Attribution-No Derivative)
– – – – – –

#3, 51 “Evidence” on Flickr by billaday #10 “Hippocrates – 468=377” on Flickr by faiper #18 “Loading ...” on Flickr by steveleggat #21 Spinal Publications/McKenzie Institute International #16, 26, 30, 35-37, 39-42, 44-45, 48, 56, 62: Allan Besselink All others understood to be public domain/fair use and all attempts have been made to identify all image owners and licenses

Allan Besselink, PT, Dip. MDT

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