The Role of Isometric Interventions in Tendonopathy and Low Back Patients

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses isometric exercise, in particular, that isometrics are beneficial for more than pain reduction. Mark cites research from the tendinopathy space about the importance of not using isometrics as a quick fix for pain, but as the starting point to gradually reintroduce functional, full range of motion exercise including concentric, eccentric, and power movements in order to fully rehabiliate a tendinopathy.

Take a listen or check out the episode transcription below.

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EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. MARK GALLANT What is up PT on ICE crew? Sorry for being a minute or two late here having some technical difficulties over on the YouTube side. So it looks like that is trying to get going as we speak. We will see if that that comes online here as we're talking. What I'm what I'm currently seeing for you YouTube folks is just a spinning wheel of death saying going live, going live, going live for the last three minutes. So hopefully that'll that'll pop up here over the next second or two for you all. So I'm Dr. Mark Gallant, lead faculty for the ice extremity management division coming at you here, clinical Tuesday. We are done with live courses for the year. I believe there's one more live course, dry needling course this weekend. And other than that, we've got a few weeks off. So we'll be sharpening the iron over the next few weeks, gearing up for for the next year of the ice season. And we can't wait to see you all out on the road. So all of our courses, all of our online courses will be kicking off in January. And all of our live courses will be kicking off the first and second week of January. So if you all haven't been on here the past couple weeks, checking in, there will be a price increase for all ice courses starting January 1. If you've been eyeing those courses and you know a course you want to take over the next few months, we would highly recommend popping in, purchasing that now, save yourself $50. ISOMETRICS: CLINICAL VALIDITY & CLINICAL APPLICATION So what I'd like to talk about today is isometrics and their clinical validity, what they're good for in clinic. And isometrics have come up a lot recently. If you've been a daily listener to the podcast, what you'll have seen is Jordan Berry came on here two weeks ago and he talked about using isometrics for specifically for low back pain and then Alan Fredendahl came on last week and he did a podcast talking about how using the rack pull can be a nice way to add isometrics into a more functional movement, getting your folks back towards the gym. So clearly as a company, we really enjoy using isometrics and we believe that isometrics are a key part of clinical practice. However, isometrics have been under fire recently on social media, in the research, because they got touted as being a silver bullet for pain relief a couple years ago. So where this all came from, Ebony Rio published an article in 2015 looking at six male volleyball players who had patellar tendinopathy. And what she found with these six male volleyball players, if they held an isometric contraction at 70% of their max volititional contraction, for five sets, 45 seconds, that we would see a dramatic decrease in pain. And that's what she found. So for these young, healthy male volleyball players who had about five to seven out of 10 anterior knee pain, their knee pain was fully resolved after doing those isometrics and 45 minutes later. And so, of course, as a profession, we got extremely excited, like, oh man, these isometrics are the key to relieving pain. for our tendinopathy patients. We've gotta use these for everyone, so we extrapolated that to not only patellar tendinopathy, but to rotator cuff tendinopathy, Achilles tendinopathy, lateral elbow tendinopathy. We really just ran the gamut as far as tendinopathy goes, looking at this research. Again, it was one study, six healthy males, With that extrapolation, what of course followed was a lot of repeat studies. So this has been looked at about 10 times over the last eight years. So we've had people look at it in the rotator cuff, in the Achilles tendon, in the lateral elbow. We've had a couple editorials written. We've had one systematic review. And what's shaken out is it's been very inconsistent over the last eight years. There were a couple studies that showed very similar to what Ebony Rio showed, that there was a dramatic pain reduction using isometric contractions. And other studies did not get the same magic bullet results when it comes to isometrics. PAIN RELIEF OVERSHADOWS TENDON HEALTH And we really believe that this study has overshadowed the bigger picture with isometrics. and why we really love isometrics. So of course we live in a society that wants that instant pain relief. That instant pain relief is such a central nervous system component and it is unlikely to actually benefit the person who's got a true mechanical musculoskeletal problem long-term because what we see is if you get that dramatic quick pain reduction, although it's great, everyone wants to be out of pain, Oftentimes, that leads to the person not continuing out with rehab over the long term. And we know from a lot of research that most quick changes within the first six weeks are mostly central nervous system changes when it comes to how tissues respond, certainly to pain. And then at that six-week mark, we start to see a lot of muscular changes. And then for tendons, it can really take six months and up to two years to get a dramatic change. And so if we get that instant pain relief, we may actually be doing a disservice to the long-term health of that overall tissue and rebuilding that capacity. I don't like reading directly off of things, especially while we're here on the podcast, and I don't think that I need to defend Ebony Rio. She's one of the premier researchers in the world. listening to a lot of lectures that Ebony Rio has done, listening to her on multiple podcasts, reading basically every article that she's ever published. I believe that her intent was not for these isometrics to, for this small, small case study article to create such a huge wave and ripples across the rehab professions that anytime you listen to her speak, what she really dives into over and over and over again, is that isometrics are a nice starting spot and that we really need to rehab these people fully out with isometrics, heavy concentrics, eccentrics, dynamic speed and power training over a long period of time. So I want to read a quote from Ebony Rio that came out two years after the article with the Patella tendinopathy that sent ripples through the profession. And what the quote says, simply taking away someone's pain with a medical intervention may not result in a positive medium to long-term outcome, it is possible that simply removing pain does not equate to a positive tissue adaptation. So there's Ebony Rio directly saying that that quick removal of pain is not directly correlated to positive tissue changes. If we look at Karin Silbernagel, who's another premier tendinopathy researcher, and her response to the fad of isometrics being a huge pain reducing intervention. She states, a change in focus from improving resilience to a focus on acute pain relief may likely misguide patients and clinicians into thinking there is a quick fix. So what both of these women are saying, who are premier researchers in the tendinopathy spaces, there is no quick fix, that we need that long-term loading regardless of whether we get quick pain relief or not. THE LONG-TERM FIX: TIME UNDER TENSION, INTENSITY, SYMPTOM MANAGEMENT So why, despite all that, are we at ICE still advocating for and sticking with isometric interventions, both with our tendinopathy patients, our low back patients, literally for every region of the body, isometrics can be a nice tool to get your patients moving along the way. So let's break down why we believe that. So when we're looking at tissue care, there are a few things that we know have to be true to move and adapt those tissues in the long term. Number one is time under tension. There has to be enough time under tension for the nervous system in that tissue to respond to adapt. If it's just one quick motion that never gets repeated and has no time under tension, the nervous system doesn't have, isn't easily as easy to adapt to that stimulus. So time under tension is number one. Number two is intensity. There has to be enough of a stimulus to that tissue to create mechanotransduction to have that tissue adapt. And then number three is that we have to manage our patient's symptoms while trying to maximize the other two. So that's what makes us unique as physical therapists is we're creating time under tension. We're creating intensity while we have those symptoms on board to manage. It's really like this seesaw that we're managing. So we have symptoms on this side, we have time under tension and intensity on this side. It may start out that we've got more symptoms at first and we're trying to balance that scale and eventually have less symptoms, more time under tension, more intensity to our interventions. What isometrics, what we've gotten into over the last eight years is Even if you have 7 out of 10 pain while you're doing this, go ahead and do it because it's going to eventually reduce your pain overall. And we just need to get that time and attention. Well, what that creates with someone who's got fear of exercise and apprehension is a lot of yellow flags. So that's when you get people saying things like, I hate going to physical therapy. Oh, it's so uncomfortable. I really don't want to do this. And they start avoiding their intervention. The first thing we want to make sure is whatever that stimulus we're giving to the person, that they feel psychologically ready to tolerate that. Are you cool with exercising into three out of ten pain? Oh, you're not? One out of ten pain would be more tolerable to you? Okay, let's find an intervention that we can do there. So those are the three big components. Getting their symptoms, getting a stimulus that puts them in a symptom range that they can tolerate, creating a lot of time under tension, and creating enough intensity. ISOMETRIC EXERCISE: CONTROLLING MULTIPLE VARIABLES The reason we love isometric so much early on is because it's a much easier intervention to control all the variables that will allow you to balance those scales. So we go back to a podcast I did a few months ago talking about the guitar amp and things that stress tissues out. What we really are looking at is our knobs that we want to play with is the overall work volume, how much work has been going into that tissue over the course of a few days or a week. How much load has been going into that tissue? What is the actual weight on the bar, the body weight, the resistance of the band that you're looking at? What is the compression and strain on the tissue? So is that tissue all the way compressed in like that or is it strained all the way stretched out? That's gonna be one another way that the tissue can be stressed out and then the speed of the the speed of the intervention so if i do a heel raise versus sprint that's going to put a definite a very different type of force through that achilles tendon so again we've got overall work volume we've got the actual load on the bar we've got compression or stretch or strain and then we've got speed as all ways that that are going to manipulate and change the stress of the tissue. The beautiful thing about isometrics early on and why we're recommending them is you can control all of those variables much easier. So the overall work volume, you're going to be able to very cleanly set that with your patients. I want you to do five sets of 45 seconds or five sets of 30 seconds. whatever the agreed-upon work volume can be, and then it's clear with that isometric. It's very well set. As far as the load, that's not going to change with the isometric. You're going to determine with your client or patient, okay, I want 5 pounds on the bar, I want 10 pounds on the bar, I want 15 pounds on the bar, and then that becomes static. For compression and strain, you're going to find the range of motion they can tolerate. Okay, it's in a mid-range, that angle does not change. So we are no longer getting a change in compression or strain or say we bend it to 90. Now that's the new angle. There is no change during the actual intervention in compression or strain. So we have now controlled that variable. And then for speed, the speed is literally zero. Once you get that weight and that load into the position you want it, it's not moving for the remainder of that intervention. you can really control all the variables quite easily with the isometrics so that you know when something gets challenged or something gets flared up, well, ooh, it's really only these one or two variables that we're manipulating, and so you can much easier control the progression of treatment. So if we're looking back at Alan's example from last week, it's like, okay, Julie, we're gonna hold five sets for 30 to 45 seconds of this rack pull. We know very clearly that you can tolerate 135 pounds of weight. We know the angle of the hinge that you do well with is at about your knees pulling up there. And then once you start pulling, you're immediately going to get the block of that rack. So those angles are not going to change. You're not going to get any change in compression, stress, or speed from that movement. And then as you move that person on, okay, we can progress. Let's change the angle a little bit. or maybe we're going to change the load a little bit, and you can very isolated change these variables until that person's symptoms reduce enough, where then you get into your concentrics, your eccentrics, then you can progress them to your dynamics. So we are not looking at isometrics as this silver bullet of dramatic pain relief early on in tendinopathy. We're looking at it as a nice entry point into giving enough time of retention, enough intensity to a tissue while managing symptoms, because we can control more of the variables. And once those symptoms come down and we don't need to control those variables as much, then we can get more into our concentric eccentrics, more into our dynamic exercise where our buoys are a little bit wider. So Hope this helps. Hope this explains why we've been so excited about isometrics over the past couple days. For those of you on YouTube, sorry about that. I'm still getting the spinning wheel of death, but wanted to make sure that I got on here. Again, to repeat, isometrics, if they work for your patient as a dramatic pain reduction, that's wonderful. That's a home run. Make sure they understand that they've got to continue loading over the next six months to a couple years to get all of those positive tissue adept patients. If you do not get a dramatic reduction, it's six out of 10 pain down to zero, not to fret. As long as you can control their symptoms with the isometrics by controlling all the other variables, it is a wonderful entry point into moving those patients forward. Hope you all have a wonderful rest of the year. Have a happy holidays. Can't wait to see you on the road. Make sure you get those tickets to courses before the prices increase in three weeks. Have a great new year.

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