Why dancers need the perfect balance of strength and flexibility

By Kelsey Jack, PT

My ballet teacher once told me that given a choice between having strength and flexibility, she would choose strength. This has always stuck with me as there is such an emphasis on flexibility within the dance world that often there is a lack of focus on building the strength required to make use of that flexibility. This enhanced focus on flexibility instead of a balance between strength and flexibility creates muscle imbalances. If dancers work to improve their flexibility and ignore balancing the strength around the joints, it leaves the dancer vulnerable to injury.

Why is balancing strength and flexibility important?

Stability is provided to joints from a combination of passive and active structures. Passive structures include the bones that make up the joint and the ligaments that surround it and support it. Active structures are the muscles and tendons that act to both maintain stability and move the joint. Focusing on passive, static stretching, as is often the case in dance, can lead to instability of joints as the ligaments that are meant to stabilize the joint become stretched out and no longer provide joint support.

Flexibility, or range of motion can be divided into two categories: passive and active. Passive range of motion is demonstrated by how high a dancer is able to lift their leg using their hands whereas active range of motion is how high a dancer is able to lift their leg using their hip muscles and is demonstrated by doing a step like a developpé.  Practically speaking, flexibility without strength limits active range of motion and will hinder the height of legs when performing steps that involve controlled movements and sustained positions.

Back bends are a good example of a movement that is common in dance where strength is required to balance the flexibility of the spine. Dancers without good core strength and control will hinge through their spine, relying on one or two segments to gain all of their movement through. This leaves the spine vulnerable to injury as the ligaments and discs are relied on for support. Ideally when doing a back bend the spine should form a “C” curve. Many teachers instruct dancers to breathe up and extend through the top of their head into their back bend to encourage control into this movement pattern. Engagement of the abdominals and stabilizer muscles of the spine are required to move through each segment of the spine in a way that supports the passive structures of the back to create the desired curve.  It is subtle differences such as these in how a dancer moves, using strength to control their flexibility, that improves the quality of movement and decrease the future risk of injury.

Evidence to support strengthening to increase flexibility

As dancers are often concerned about their hip flexibility, a study was done looking into the best way to increase hip active range of motion. The researchers compared three stretching programs over a six week period. The first group of dancers completed a strengthening program where they worked at strengthening their hip flexors at the end of their available range of motion. The second group completed a “light” stretching program for their gluteals, hamstrings, calves, and quadriceps muscles, holding each stretch for 1 minute. This group was asked to perform stretches at an intensity of 3/10 on a scale where 0 is no stretch and 10 is an intense stretch that elicits a burning sensation. The third group performed the same stretches but at a “moderate-high” intensity which was rated as 8/10 on the same scale. The study found that all three groups had an increase in their passive range of motion but only the strength training and the low intensity stretching groups improved their active range of motion. The strengthening group saw the greatest improvements in both passive and active range of motion which is explained by the hamstrings relaxing as the hip flexor is contracted. This allows the hamstring to lengthen while the hip flexor is strengthened. Intense stretching without strengthening (as in the high intensity group) leads to lengthened, weakened muscles which functionally hinder a dancer’s ability to make use of their range of motion. This study demonstrates that exercises that specifically train the hip flexors progress flexibility in a way that translates into dance.

Strengthening allows dancers to maximize their flexibility without compromising the integrity of their passive support structures and increasing their risk of injury. A physiotherapist can assess a dancer’s strength and flexibility and develop a program that will safely allow a dancer to increase their flexibility while strengthening the muscles needed to support their joints, improve performance, and decrease risk of future injury.

References:

Wyon MA, Smith A, Koutedakis Y. A Comparison of Strength and Stretch Interventions on Active and Passive Ranges of Movement in Dancers: A Randomized Controlled Trial. Journal of Strength and Conditioning Research. 2013. 27(11)3053.

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How Physiotherapy Can Help With Osteoporosis

By Lana Kovacevic, PT

Osteoporosis is a condition of reduced bone strength that causes bones to be more likely to break (1). It is a progressive disease in which the density and quality of bone decreases over time making it more fragile. Current trends show that more and more people are affected by osteoporosis each year (1). Among Canadian men and women, an estimated 1 in 4 women have osteoporosis compared to 1 in 8 men (1).

Why is osteoporosis so concerning?

The major threat to healthy aging and independent mobility for those with osteoporosis is the risk of sustaining a fragility fracture. A fragility fracture is a broken bone that results from minimal trauma or stress – stress which typically would not cause a bone to break (1). An example would be breaking a bone in the wrist or hip after falling from standing height (1). After an initial fragility fracture, you become more than two times as likely to sustain another fracture in the future (1). The most common bones to be injured are those of the wrist, upper arm, ribs, spine, pelvis, and hip (1).

Who is at risk for osteoporosis?

Canadian guidelines recommend that all postmenopausal women and men over the age of 50 years be screened for their risk of osteoporosis (1). A diagnosis is made following an X-ray that measures bone mineral density. This test is recommended for those who have at least 1 major or 2 minor risk factors (1).

Figure 1: Some key major and minor risk factors for osteoporosis (1)

Major Risk Factors	Minor Risk Factors
Age over 65 years Family history of osteoporosis fracture Early menopause (before age 45) Glucocorticoid therapy for more than 3 months Falls	Smoking Diet low in calcium Body weight less than 57 kg Rheumatoid arthritis

How can I check if I am at risk for osteoporosis?

A convenient online tool for estimating the risk of osteoporosis fracture exists called the FRAX® Fracture Risk Assessment Tool. Click on this link to get an estimate of your personal risk. If you are concerned about your risk for osteoporosis, it is best to consult your family doctor.

How is osteoporosis treated?

Apart from medical management with medication and supplementation, exercise is a key component of treatment. Exercise has been shown to slow the loss of bone mineral density and reduce the risk of falling (1). This means that exercise can be beneficial for both preventing osteoporosis as well as managing symptoms for those already diagnosed with osteoporosis.

Can physiotherapy and exercise help if…

…I’m concerned about developing osteoporosis in the future?

For anyone at an increased risk of osteoporosis or those with a family history of osteoporosis, taking part in weight-bearing physical activity and activity that involves some impact is best for preventing bone loss. Starting this type of exercise at a younger age may make you less likely to suffer from osteoporosis in older age.

…I’ve already been diagnosed with osteoporosis?

For those with osteoporosis, exercise is important to help minimize bone density loss. It is also critical for reducing the risk of falling and therefore, a broken bone. Risk of falling is higher for people with poor strength, balance, posture, and with poor postural stability. All of these factors can be addressed and improved with a proper exercise program.

…I’ve already had a fragility fracture and want to avoid having another one in the future?

A safe exercise program is also beneficial for those who have already suffered a broken bone associated with osteoporosis. Less than 20% of women (or 1 in 5) and 10% of men (or 1 in 10) who have had a fracture are given the appropriate treatment to prevent a future fracture (2). It is important to restore safe movement patterns during recovery from a fracture as well as to reduce the risk of sustaining another fracture.

Each person is unique and should have an exercise program that is tailored to their specific needs. A physiotherapist can assess, treat, and teach you how to reduce your risk of osteoporosis, manage your symptoms, and improve your general health and physical functioning.

Reference:

1. Brown JP, Josse RG. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ. 2002. 167(10); S1-34.
2. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010. 182(17): 1-10.

Shin Splints

Medial tibial stress syndrome, commonly called “shin splints”, is a term used to describe pain and tenderness felt on the inside, lower border of the shin bone. Shin splints are commonly experienced by athletes who take part in activities involving repetitive running and jumping, particularly after a sudden increase in activity level (either duration, distance or intensity). The repetitive stress placed on the bones, muscles and joints of the lower leg during these high impact activities may result in irritation and inflammation of the shin bone (tibia).

Shin splint pain is usually described as a dull ache. It usually develops slowly over time, first being noticed at the end of activity. Some athletes may complain of pain at the beginning and end of activity, but not affecting their performance. Over time, pain will commence during activity and eventually may be felt during regular day to day activities such as walking. As shin splints progress, they also make the lower leg sore to touch.

There are a number of factors that may predispose an athlete to develop shin splints including: flat feet, rigid arches, muscle weakness, and/or muscle tightness. Other contributing factors may include running downhill, running on hard surfaces, running in worn-out footwear, or playing sports with frequent stops and starts (e.g. basketball, squash, tennis). While the pain presentation is often similar across individuals, there are a variety of bio-mechanical abnormalities in the pelvis, hips, knees, and ankles that can also lead to the development of shin splints.

Proper treatment requires a detailed assessment by a registered Physiotherapist to identify and target the contributing factors as well as the location of pain. Treatment includes rest, ice, specific joint mobilizations, an individualized stretching and strengthening program, and if needed a gradual return to regular activity. During recovery, aerobic fitness can be maintained with low impact activities such as swimming and biking. If left untreated, the repetitive stress on the tibia may result in a stress fracture yielding a longer recovery time.

A physiotherapist can perform a full assessment to determine the exact cause of an athlete’s pain and develop a treatment program to relieve pain, facilitate return to activity, and prevent future injury.

Physiotherapy for Carpal Tunnel Syndrome

Carpal Tunnel Syndrome
Carpal Tunnel Syndrome is pain, numbness, and tingling, in the wrist and hand particularly in the thumb, index and middle finger. This syndrome affects approximately 3-6% of the general population. The carpal tunnel is a small passageway at the wrist that tendons and the median nerve run through as they travel into the hand. The tunnel is surrounded by bone and connective tissue so it does not easily stretch or expand, making structures within it susceptible to irritation which can cause the median nerve to be compressed. If left untreated and the condition worsens, symptoms may progress to include weakness in the hand.

Causes and Risk Factors
A combination of several of the following factors can increase the risk of developing carpal tunnel syndrome:

• Chronic stress on wrist/hand – typically affecting the dominant hand, often due to working posture or repetitive motions (eg. using computers for several hours a day, assembly-line workers, musicians, using vibrating power tools)
• Trauma to the wrist (eg. fracture, sprain) – can cause damage to the nerve or swelling to other structures that will narrow the carpal tunnel
• Pregnancy – hormonal changes can affect tendons and cause swelling
• Arthritis – bony growths into the tunnel narrow the space
• Congenital Predisposition – women and smaller individuals may have narrower carpal tunnels, reducing space for the nerve
• Diabetic or Metabolic Disorders – negatively affect the body’s nerves

Symptoms
The most common symptoms of carpal tunnel syndrome include:

• Gradual onset of pain, burning, tingling, numbness or itching in the palm, thumb and/or index and middle fingers
• Feeling of weakness and swelling in the hand, with difficulty grasping small items, making a fist and performing fine motor tasks
• Urge to shake out the hand to relieve the tingling sensations

In the early stages, symptoms will often be intermittent. However, as the condition worsens symptoms are more severe and begin to persist for longer periods of time. Pain and numbness tends to be worse at night for a lot of individuals.

Treatment
It is advised to seek treatment from a professional as soon as carpal tunnel symptoms arise as the condition will not typically resolve on its own.

Medication: Over the counter anti-inflammatory drugs (eg. Ibuprofen) may provide short term relief from mild symptoms. Corticosteroid injections are a much stronger anti-inflammatory, and may also be a temporary option to help relieve pressure and symptoms for those with relatively mild symptoms.

Physiotherapy: Seeking help from a registered physiotherapist is one of the best options for treatment of carpal tunnel syndrome. Physiotherapy will include manual therapy on your wrist to improve the mobility of the joints and stretch tight muscles and tendons in the wrist and fingers, helping to remove any scar tissue buildup that may hinder recovery. The Physiotherapist will also incorporate nerve gliding techniques to help improve the mobility of the median nerve through the carpal tunnel. Ultrasound may be used over the carpal tunnel area to reduce inflammation which helps to relieve symptoms. Your physiotherapist may also suggest a brace or splint to immobilize the wrist while working or performing aggravating activities. They will provide education about activity modification to avoid aggravating positions, such as holding the wrist in a flexed (bent) position. Your physiotherapist will also prescribe specific stretching and strengthening exercises for the fingers, thumb, hand and arm to progress through later stages of recovery. They will provide education on proper posture while working to prevent relapse.

Surgery: With very severe cases of carpal tunnel syndrome where nonsurgical treatment does not provide any relief, surgery may be an option. The surgery typically consists of cutting the roof of the carpal tunnel, to provide more room for the tendons and median nerve and decrease compression. Full recovery back to original strength in the hand may take 6-12 months.

While carpal tunnel is a relatively common condition, it is often misdiagnosed, thus it is a good idea to seek treatment from a registered physiotherapist upon the onset of symptoms in order to have the best chance of full recovery and to prevent irreversible damage. Your physiotherapist will be able to recommend appropriate treatment options, whether that be manual therapy, bracing, or if necessary, surgical intervention.

Snow Shoveling Safety

If you are like us, you have probably spent a good chunk of time clearing off your car, driveway, and sidewalks these past few weeks. If you are not used to this kind of strenuous activity, you also might have felt tired and sore once you were finished. At BodyTech Physiotherapy we have already seen an influx of people with low back pain due to shoveling snow. As a result of this, we have compiled a list of safety tips to keep you moving injury-free until spring rolls around.

1. Consider hiring snow removal services if you have lower back issues or heart problems, including a previous heart attack, a known cardiac disease, high blood pressure, and/or high cholesterol.
   • Snow shoveling can be as strenuous on your body as lifting weights – a sudden increase in physical activity levels, especially without proper form, can predispose you to injury.
   • Studies have shown that exercise using your arms (like shoveling) significantly increases blood pressure levels compared to leg exercise (like walking), putting you at a higher risk of a heart attack.
2. Use the proper tools
   • Sturdy, non-slip winter boots and salting are essential to prevent slips and falls.
   • An ergonomic shovel can help reduce excessive amounts of forward bending, which could otherwise put a lot of strain on your lower back.
3. Use proper form
   • Stand with your legs hip width apart
   • Hold the shovel close to your body
   • Space your hands apart to increase leverage
   • Bend from your knees, not your back
   • Engage your core/tighten your stomach while lifting
   • Avoid twisting while lifting
   • Walk to dump your snow instead of throwing it
   • Pushing is easier than lifting
4. Warm up
   • Cold, stiff muscles are more prone to injury. Get your body warmed up and ready to go by marching on the spot, doing some small squats, and rotating your upper body from side to side.
5. Shovel early and often
   • Freshly fallen snow is lighter and fluffier than snow that has been sitting for a few hours, which makes moving it much less stressful on your body.
6. Slow and steady wins the race
   • Though it may be tempting to power through and get your shoveling done as fast as possible, work at a slow and steady rate while focusing on proper form to decrease your risk of injury.
   • If there is a large amount of snow, work in layers of 2-3 inches instead of trying to lift it all at once.
7. Take breaks and hydrate!
   • We recommend shoveling for 15 minutes followed by a 15 minute break
   • Remember to drink water or other non-alcoholic beverages during your break – shoveling is hard work!

Tennis Elbow

Lateral epicondylitis, more commonly referred to as “tennis elbow”, is a term used to describe pain just above the elbow joint on the outer side of the arm. Contrary to popular belief, tennis elbow is not a condition that is exclusive to tennis players or athletes. The term tennis elbow was coined from the fact it can be a significant problem for as many as 50% of tennis players during their careers. However, less than 5% of reported cases of tennis elbow result from playing tennis!

More specifically, tennis elbow is a tendinopathy at the origin of the extensor carpi radialis brevis tendon (the tendon that is responsible for wrist extension). This tendinopathy is due to degeneration of, or damage to the tendon causing inflammation and subsequently, pain. In order to understand what causes tennis elbow, it is important to first understand tendons and how they function. Tendons are like “ropes” made of collagen tissue. They are flexible, but do not stretch when pulled. It is the job of the tendon to connect muscle to bone. In the case of tennis elbow, the area on the bone where the tendons attach, just above the elbow on the lateral side (or outer side) of the arm, are sometimes incapable of handling the force of the arm muscles. Strong forces or sudden impact to the tendons at this point of attachment are what cause damage, like small tears in the fibers of the tendon (similar to a rope becoming frayed).

Activities that exacerbate tennis elbow symptoms are those that involve repetitive motion of the arm, forearm, wrist, and hand. Movements that are commonly associated with the development of tennis elbow are: lifting, gripping something tightly in combination with inward or outward rotation of the forearm, jerky throwing motions, swatting with the hand, and simultaneous rotation of the forearm and bending of the wrist. Racquet sports may be the most “popular” activity to associate with tennis elbow, but as previously mentioned most cases are the result of a wide range of actions that include, but are not limited to: painting/plastering, excessive and repetitive use of a computer mouse, carpentry work, gardening and repetitive lifting and carrying.

Tennis elbow can be suspected when performing routine tasks, such as gripping objects or turning doorknobs, become painful. A physician or physiotherapist can diagnose tennis elbow by discussing symptoms and examining the affected arm. Diagnostic tests are not typically necessary for an accurate diagnosis, however, a physician may request an X-ray or MRI imaging if symptoms do not improve with treatment.

Treatment options for tennis elbow include modifying activities that exacerbate symptoms. Movements that cause an increase in pain should be avoided to help allow the tendon to heal. Pain management is also important to consider. Anti-inflammatory painkillers are commonly used for some symptomatic relief, however physiotherapy remains the most successful tool in the treatment of tennis elbow long-term. A physiotherapist will perform manual therapy on the affected arm, to mobilize the underlying stiff joints and tight structures. Modalities such as ice, and ultrasound, as well as taping may be used to ease pain and encourage healing. A physiotherapist will implement stretching and strengthening exercises to help restore normal function of the arm, and also prevent tennis elbow from occurring in the future.

What is Trauma?

Physiotherapy is an effective tool to treat injuries that can range anywhere from minor to catastrophic. Occasionally, regardless of the severity of the injury, some people experience symptoms such as hypersensitivity or emotional stress as a product of, or in addition to, their physical trauma. For some, these psychological and emotional stressors can act as a difficult obstacle to overcome, and can actually hinder the success of physical injury recovery. Physiotherapists will often recognize these psychological and emotional symptoms, and will recommend the injured person see a qualified therapist who specializes in dealing with trauma. Working with a therapist is a great adjunct to physiotherapy and helps the client to achieve their recovery goals. The following article is a guest blog post by John Roche from Transformation Counselling. 

Trauma. It’s one of those words that gets thrown around without ever really being explained. Derived from the Greek word for “wound,” trauma could refer to an overwhelming psychological experience or the psychological imprint left by such an experience. Either way, it’s important to know how to recognize trauma and post-traumatic stress and how to recover from them.

Trauma is caused by an overwhelming experience in which someone perceives their survival to be threatened and/or their fundamental beliefs about themselves and the world are shattered. Sexual assault, military combat, child abuse, car accidents, and natural disasters are well-known examples of traumatic events.

Lesser known instances of trauma involve what’s called “attachment trauma.” Children’s development is extremely dependent on the attentiveness and responsiveness of their “attachment figures” (usually parents), and if an attachment figure is not attuned and responsive to the needs of a child, then, as far as that child’s brain is concerned, its survival is threatened and it will adapt accordingly.

Post-traumatic symptoms are painful and overwhelming, but, as scary as they are, they’re simply the result of the brain’s adaptation to traumatic situations. From an evolutionary perspective, this adaptation is an attempt to ensure the person’s survival, which is pretty much the brain’s number one priority.

Imagine that every brain has its own smoke detector. When it’s functioning properly, this smoke detector alerts us to legitimate threats and cues the release of protective firefighters who come and rescue us: heightened alertness, a pounding heart and restricted digestion to make sure we have plenty of energy to fight or run away, rage to help us fight off attackers, or, as a last resort if escape or self-defence aren’t possible, a freeze response like a deer in headlights.

Trauma hyper-sensitizes the smoke detector. At the slightest hint of smoke, these firefighters come rushing in to put out a fire that doesn’t actually exist.

People who have experienced trauma therefore tend to struggle with anxiety, rage, concentration difficulties, digestive issues, feelings of disconnectedness, and hypersensitivity to perceived threats. Understandably, survivors of trauma also tend to feel depressed, develop addictions as a means to escape their pain, and avoid anything that might trigger their smoke detectors.

Faced with such nightmarish symptoms, trauma survivors tend to imagine they’re broken. In reality, their brains have done exactly what they were supposed to do: adapt to threat and facilitate survival. Once upon a time, these adaptations made perfect sense and helped them survive. Unfortunately, such adaptations persist beyond the traumatic event and cause pretty major problems.

Recovery from trauma is essentially about training the brain to re-establish an internal sense of safety and leave behind survival adaptations that are no longer necessary. EMDR therapy in particular has been proven to be extremely effective at eliminating post-traumatic symptoms by healing trauma at its roots.

If you’re a survivor of trauma, you are not crazy. Your brain has actually done exactly what it was intended to do and, as unbelievable as it may sound, full recovery is possible. If you’re ready to get on with your life, contact us today to get started.

John Roche, MDiv, MSW, RSW
John is a therapist with two Master’s degrees in counselling and three years of clinical experience. He has specialized trauma training in both Cognitive Behaviour Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR). In his spare time, he loves to hike, reflect on the meaning of life, and eat nachos.