Your Head In The Game: Part III

With the 2014 Sochi Olympics over, attention has quickly turned to the unbelievable geo-political events happening in the Crimean peninsula at this time. More than usual, the Paralympics, which run March 7-16th, 2014, are being overshadowed. Before we get started on this last blog, I wish Canada’s 54 athletes competing in Sochi’s Paralympics, amidst human-rights scrutiny, partial boycotts and cows wandering into town, the very best of all performances coming together for them in competiton.


The Olympic Legacy. There always is one, whether it’s top notch training facilities, a knockout aquatic centre, war, or a giant debt. Unfortunately for some, the Sochi legacy will be concussion sideffects that might outlast speaking tours or sponsorship contracts.

Continuing with the last instalment of this three-part concussion series is what happens long-term after concussions. Before you think this is all doom and gloom, please remember that based on what we know at present, 80-90% of concussions take 7-10 days to heal. What lies ahead (pun intended) is for those 28,000 or more people per year who don’t fall squarely into that category.

Legacy #1: Time Off

At the beginning of the Olympics, Canadian researchers published a study where enhanced MRI technology was used to show that university hockey players with concussions sustained bleeds in their brains. Where there is blood, there is tissue damage and torn nerves. Concussions cause tissue damage. This study went on to continue imaging the brains of concussed hockey players throughout their recovery in order to determine what sort of time interval tissue healing really took. It was remarkably consistent with the athlete’s report of concussion symptoms, such as fogginess, confusion and lethargy. Symptoms tell us to rest. Listen up!

In a study where a physician specialising in concussion was on-hand to assess and diagnose concussions sustained during an entire hockey season, concussion incidence was seven times higher than any previous report. A brain injury happened in 36.5% of the hockey games in a season. Concussions are frequent. And that’s just hockey. If I were a betting woman, I would say that concussion prevalence numbers 5 years from now will be bigger; not because there will be more concussions, but because there will be fewer undiagnosed ones.

Legacy #2: Depression

Traumatic brain injury (TBI) is associated with a higher incidence of depression. The majority of individuals who suffer a TBI are juveniles and young adults, and thus, the risk of a lifetime of depressive complications is a significant concern. The cause of concussion-related depression might be brain cells’ tendency to over-react to stress, infection and injury after an initial concussion. That the human brain tends to naturally inflame with age is an additional factor explaining perhaps why mental health problems related to concussion show up sometimes many decades after the original injury.

Legacy #3: Chronic Pain

A review of long-term studies of people with mild and more traumatic brain injuries published by the American Medical Association asserts that “Chronic pain is a common complication of TBI. It is independent of psychologicdisorders such as PTSD and depression and is common even among patients with apparently minor injuries to the brain.”, and “Patients who appear clinically to have less severe brain injuries may in fact develop more pain symptoms.” Wonder why that back isn’t healing very quickly? Consider the role of a past head injury.

Concussion Legacy #4: Chronic Traumatic Encephalopathy

Chronic Traumatic Encephalopathy (CTE), was originally referred to as punch-drunk syndrome, and associated with people who have sustained multiple concussions over the course of a lifetime.   It continues to be poorly understood. Modern CTE is defined by gait disorders, speech slowing, and behavioural symptoms including mood disorder (mainly depression), paranoia, agitation, social withdrawal, poor judgement and aggression. Cognitive impairment tends to emerge later and reportedly progresses over time. As with many issues relating to concussion, there is lack of operational criteria to confirm either a clinical or pathological diagnosis of CTE, which currently limits researchers’ ability to assess for this condition and put numbers on incidence.

Take-Home Message

Concussion is a spectrum, with acute injury at one end and degenerative symptoms at the other. But it’s not a set path, and a lot has yet to be learned. One concussion might lead to all these legacies, or none. The take-home message from this three-part series  is that concussion is legitimate, its effects deserve respect and rest, and the magnitude of its impact merits that we re-examine the rules of our games.

Throughout this 3-part series I have conveniently used the Olympics and athletes as a focal point to discuss concussion. However, I did not want to conclude before acknowledging that another body of people who represent their countries – military forces – who are also subjected to repeated blows to the head and concussions throughout their training and service. In a tragically ironic twist on Lest We Forget, they come home with the same symptoms.


Let’s at least make a push for that which we can control – the rules and management of head injuries at play. Peace begins at home.

References: published online February 4, 2014; DOI: 10.3171/2013.12.JNS132093

Br J Sports Med 2014;48:84-90 doi:10.1136/bjsports-2013-092646

British Journal Of Sports Medicine [Br J Sports Med] 2014 Jan; Vol. 48 (2), pp. 81-3. Date of Electronic Publication: 2013 Nov 22.

Ofer Pasternak, Ph.D., et al, Hockey Concussion Education Project, Part 2. Microstructural white matter alterations in acutely concussed ice hockey players: a longitudinal free-water MRI study: Clinical article. J. Neurosurg published online February 4, 2014; DOI: 10.3171/2013.12.JNS132090. Pages 1-9 published ahead of print

Hartman JM, Berger A, Baker K, Bolle J, Handel D, Mannes A, Pereira D, St Germain D, Ronsaville D, Sonbolian N, Torvik S, Calis KA, Phillips TM, Cizza G. Quality of life and pain in premenopausal women with major depressive disorder: the POWER Study. Health and Quality of Life Outcomes. 2006; 4:2.

National Institute of Neurological Disorders and Stroke. Pain: hope through research. . Updated July 24, 2010. Accessed September 21, 2010.

Ashley M. Fenn, John C. Gensel, Yan Huang, Phillip G. Popovich, Jonathan Lifshitz, Jonathan P. Godbout. Immune Activation Promotes Depression 1 Month After Diffuse Brain Injury: A Role for Primed Microglia. Biological Psychiatry, 2013; DOI: 10.1016/j.biopsych.2013.10.014

JAMA. 2008;300(6):711-719


Your Head In The Game: Part II


Every so often, events coincide so as to heighten each other’s relevance. In this case, it’s the Start of the Sochi Olympics in one week, and the Fernie Screening of award-winning film The Crash Reel, on Monday February 3rd at 7pm, Vogue Theatre. The Crash Reel tells the story of Kevin Pearce, who sustained a traumatic brain injury (much larger scope than a concussion, but along the same spectrum) during his snowboarding training leading up to the 2010 Olympics. This film will say more about recovery from brain injury that I can in this blog, and may make you think differently about all you are about to see in Sochi. In case you can’t make the screening, and to learn more specifically about concussion recovery, read on (and consider trying to arrange your own viewing of this award-winning film).

Where did we leave off last time? Ah yes, without proper brain function, without a finely-evolved organ at the helm, none of the training camps, gym sessions or coaching in the world can keep an athlete going.

 How long does recovery from concussion take? For athletes who want to be better 5 minutes ago, the average of 7-10 days for 80-90% of cases (longer for those under 18 years old) can seem like an eternity. But remember the statistic that about 350,000 concussions are diagnosed annually in North America (and we know that concussions are typically under-reported)? That means each year, about 28,000 concussions take longer than 7-10 days to recover. Those cases need just as much respect.


Here are the steps that need to be followed to return to play:

1. No activity. Mental and physical rest until symptom free. If you’re reading this blog, that’s mental activity. Get it?

2. Light aerobic Activity, like walking or stationary cycling

3. Sport Specific Activity, like skating or running

5. Training drills without body contact

5. Training drills with body contact – only once cleared by a physician

6. Game play


Each step should last at least a day. Move onto next step only when symptom free at current step. If symptoms flare at current step, return to rest (yes, step 1) until symptom-free, then try again. Consult a physician if symptoms persist, in order to help decide on the involvement of a neuropsychologist or other professionals.

In the meantime, managing the symptoms of a normal concussion recovery process usually requires life adjustments. In the fog, irritability and easy feeling of being overwhelmed that accompany a concussion, it is important to pace the amount of stimulation in the injured person’s life. Important decisions should be considered early in the day, when energy and rest are at their highest, and ideally in consultation with others. Shutting off loud noises and bright lights (this includes computer and phone screens) helps to prevent overstimulation. Earplugs and sunglasses throughout the day may be necessary. Engaging in relaxation exercises, becoming aware of how each body part is feeling and naming emotions that are surfacing are important components of processing the grief and loss associated with concussion.


It is important to know that concussion recovery has a big emotional component. Irritability, anger, depression and feeling overwhelmed are signs that a person is moving through the healing process from concussion. Difficult is such an annoying word to describe these abrupt changes and dealing with them, but it’s a limitation of polite language. Accepting that concussion recovery is a process that may cause emotional, physical and financial strain is in the end healthier than copping out to blame, excess anger or rushing, which all have a backward effect on recovery.

I have used the word recovery eight times so far in this blog. Concussion recovery (there’s the ninth!) is possible, common and realistic. How a person recovers from concussion sets the stage for future recoveries. Thinking of any injury in terms of recovery immediately puts a positive focus on the process. In Kevin Pearce’s words, “Healing never ends. I will win, not immediately, but definitely”.

And once recovery happens? Don’t get another concussion! Part Three of this series will cover Second-Impact Syndrome and what’s known about long-term effects of multiple concussions.



Your Head in the Game: Part I


Happy New Year to all in the blogosphere. 2014 is already distracting us from post-holiday reckonings with the upcoming Sochi Winter Olympics and the announcement of Canada’s men’s hockey team, vying for its 2nd consecutive gold medal. While it remains true that most of our nation will be turning its greatest attention to concentrated/confused-looking coach Mike Babcock and his players, many of us will also take advantage of the other sports on offer.

The Winter Olympics has a preponderance of helmet sports: all the sliding ones (luge, bobsleigh, skeleton), a lot of the skiing (alpine, freestyle and ski jumping) speed skating and, of course, hockey. This indicates a high probability of knocks to the noggin. And where there are bumps on the head, there are concussions. As we get our Olympic cable packages and time-zone conversions sorted, I will begin a three-part series on this type of head injury, whose significance and diagnosis are becoming more serious with emerging research.

Part I: What is a concussion?


A concussion is a brain injury that is caused, in very lay terms, by the brain sloshing around in the skull. The terminology around concussion is tricky. According to the latest Consensus Statement on Concussion in Sport (2012), concussion is a traumatic brain injury. Concussion typically results in the rapid onset of short-lived impairment of brain function. This impairment of brain function is what distinguishes concussion – rarely are any structural changes seen on traditional neuroimaging (CT or MRI) studies. But, like carbon monoxide, just because you can’t see it doesn’t mean it isn’t a problem.

Concussion can occur anytime there is a blow to the head, direct or indirect. This movement causes damage that changes how brain cells function. There does not have to be a loss of consciousness in order to diagnose a concussion.

More than 350 000 athletes suffer concussion in North America yearly. Many athletes do not realize they have had one, and many deny their symptoms to avoid missing playing time. Helmets do not lessen concussion any more than they lessen the falls, fights and bad hits that cause a human head to knock against something. Helmets are best at protecting the part of the head they cover from gashes and superficial wounds.

 A concussion should be suspected if one or more of the following are present:

(keep in mind that concussion symptoms can evolve over minutes or hours after the injury)

  1. Physical symptoms: loss of consciousness or headache;
  2. Behavioural changes: irritability, feeling emotionally out of control or stunted
  3. Processing impairments such as slowed reaction times, feeling “in a fog”, or amnesia
  4. Sleep disturbance (eg, insomnia).

It is worth noting that standard orientation questions (eg, time, place and person) have been shown to be unreliable in the sporting situation when compared with evaluating balance, memory and behaviour over time in diagnosing concussion.

Following the 4th International Conference on Concussion in Sport held in Zurich, Switzerland in November 2012, the following tools were developed to help coaches, athletes and families assess for concussion. They are called the SCAT3 and the SCAT 3 child (for athletes under 18 years old). These questionnaires have more detailed equivalents that are to be used by physicians, physiotherapists and others trained in the evaluation and treatment of concussed athletes.


SCAT3 Child

If you are involved in a potentially concussion-causing sport, it’s worth becoming familiar with them.

If they seem long and detailed, especially to administer to an athlete in the middle of a game, practice or competition, consider that without proper brain function, without a finely-evolved organ at the helm, none of the training camps, gym sessions or coaching in the world can keep an athlete going. Lobby for rule changes if you need to. A concussion is no paper cut!

Next up: concussion management


Running Cats and Dogs

I’m more of a cat person than a dog person. In this regard I know I’m outnumbered in the wider communities of physiotherapists, athletes and people who live in Fernie. In fact my husband, by marrying me, may possibly have saved me from becoming a crazy lady with a houseful of felines.

 My husband is a dog person. Nonetheless, we have two cats. Our other family member is our daughter, whom I’ll call Two, who for the record is also a cat person.

 This entry started partly because of the cat-dog division in our household, but mostly because Two has a peculiar hero. I’ll grant that many kids her age idolise strange creatures with wings, swords, laser-phaser rays and other magical powers. Two worships an equally outlying and gifted creature, the recent female winner of the Sinister 7, a 148km (that’s a marathon after running 106km) trail run with 5250m (that’s 17224feet for you imperial-minded readers) elevation gain. Said hero, Abi Moore (a Fernie Physiotherapy sponsored athlete), accomplished this Herculean feat in just over 19 hours, the length of a bad day at work. Since the Sinister 7, Two has started running to the grocery store, “like Abi”, which is a distance of about 3km, but for Two to go that distance would be more like the equivalent of a 7.5km effort for me (physicists, hold your fire. These calculations are estimates at best.).

“Do you think all this running is bad for her hips?”, my husband asked, “I know they don’t like dogs running far when they’re young because it causes hip problems later on”.

 What do I know? I’m a cat person. But I’m also a physio blogger. Physios know about running, and there is even a branch of physiotherapy entirely devoted to animal rehab. So I took a look.


Don’t feel like you know your preschooler well? Don’t worry; neither do researchers (when it comes to exercise, anyway)

In the vast universe of research on people under 18 years of age, there is a notable lack of focus on physical activity for ages 0-4. While the benefits of exercise in terms of increased self-perception, decreased Body Mass Index (BMI – a ratio of weight to height), improved bone density and many other markers are well known even by the age of 5, it is risky to generalise these findings to younger children.

That said, a landmark literature review1 came out in 2007 using what available evidence there was in favour of physical activity in preschoolers. This spurned the creation of the Canadian Society for Exercise Physiology’s Guidelines for Physical activity. The gist of the guidelines for children 1-4 years of age is that they should accumulate 180 minutes, or 3 hours, of physical activity of any intensity, every day. This includes running, dancing to repeated playbacks of Gangnam Style, or throwing clothes from dresser drawers into the crib.

What are the benefits of this much activity? The studies behind these guidelines say that, in infants, physical activity translates to improved motor skill and cognitive development as well as healthier body fat percentages. Activity improves toddlers’ bone health as well. In addition to these benefits, once a child reaches preschool age, exercise helps with heart and metabolic health as well as providing a source of psychological well-being.

 Preschooler psychology experts say that task mastery is a key component of self-evaluations in this age group. The combination of positive adult feedback and task mastery gives a huge mental boost to youngsters that helps them feel good and want to pursue mastering other tasks1. The ability to play and exercise sets the grounds for task mastery. Mastering tasks plants seeds for continued enthusiasm about all kinds of learning.

 Remember those physical activity guidelines? Here’s a more shocking publication:

It is a strong remark on the times in which we live that in 2007 the CSEP also created Guidelines for Sedentary Behaviour for children. Put another way, there are now minimum standards for how much children should be moving and maximum standards for how much they should be sitting around. For instance, screen time (computer or television) for children 2-4 years of age should be limited to less than one hour per day. Ideally, much less. Children with active parents tended to be more active, and children who spent more time outdoors were more active than children who spent less time outdoors.2 Families are therefore encouraged to show a good example and to build physical activity into every day, through play, structured exercise, transportation and just getting outside.

So, is it safe for my preschooler to run?

In a nutshell, yes! There is the potential for your child not only to benefit in the areas of health, well-being and learning, but the possibility that he or she will end up wanting to keep doing it with you later on.

However, it should be emphasised that younger children with less advanced cognitive development tend to take on a negative pacing strategy, i.e., going out hard and flaming out fast, indicating an inability to anticipate exercise demand.3 This seems to be a natural anti-injury mechanism. Running or any other activity should therefore be self-driven. For an excellent commentary on (older) children running long distances out of their own volition, I invite you to check out Jonathan Beverly’s 2011 contribution to’s Running Times column.

If a preschooler has a strong desire to run to the grocery store and gets ‘er done under their own framework of time and pace, the reward of mastering a task is huge, not to mention the other physical benefits. Becoming proficient at fundamental motor skills of all kinds (running, hopping, catching, throwing, balancing, twisting) seems to go hand-in-hand with learning and moving through developmental stages.4 So, tots should be encouraged to embrace activities that address all aspects of physical activity, from balance and coordination to strength, endurance, power and agility.

Turns out the same reasoning applies to dogs.

A review of canine injury literature states that forced exercise in puppies can lead to problems with joint cartilage and elbow dysplasia. “Forced exercise is defined as anything beyond what the dog would engage in with dogs of the same age. Gentle play time with other like aged puppies? A-OK. Running around with adult dogs, meanwhile, is bad (the puppy will overdo it trying to keep up with the big guys). Fence-running, excessive ball/stick/Frisbee chasing, and jogging with the owner are considered “forced exercise,” too.”

Since no data exist to show that preschoolers or children who run of their own volition are any more likely to incur joint problems in later adulthood than children who don’t run, and that we are at a stage of evolution where we need to be reminded how little to sit around, it seems almost urgent to continue nurturing Two’s interest in running. And whatever comes after running. And whatever comes after that…

And since we’re at it anyway with Two, maybe it’s a good time for this cat lady to get a puppy.


1. Physiologie appliquée, nutrition et métabolisme, 2012, 37(2): 345-356

2. Am J Prev Med 2008;34(5):435–441

3. Pacing strategy in schoolchildren differs with age and cognitive development. (English) By: Micklewright D; Angus C; Suddaby J; St Clair Gibson A; Sandercock G; Chinnasamy C, Medicine And Science In Sports And Exercise [Med Sci Sports Exerc], ISSN: 1530-0315, 2012 Feb; Vol. 44 (2), pp. 362-9

4. Fundamental movement skills in children and adolescents: review of associated health benefits. (English) By: Lubans DR; Morgan PJ; Cliff DP; Barnett LM; Okely AD, Sports Medicine (Auckland, N.Z.) [Sports Med], ISSN: 1179-2035, 2010 Dec 1; Vol. 40 (12), pp. 1019-35



Caught on Tape

Taping has been synonymous with athletes since before Cassius Clay changed his name to Muhammad Ali. While duct tape and many other products have been used to prevent blisters during sport, this blog focuses on taping for problems with muscles and joints. White athletic tape has been wrapped around the peripheral joints of the arms and legs in every possible sports venue. Recently, Kinesiotape has come on the scene, with its wide bands or sinewy fingers making bold, colourful statements on athletes’ bodies (and even faces), statements seen all over the world during last summer’s London Olympics.

 Other than looking hardcore or at the very least, provocative,


is tape actually helping with performance, or is it just helping spectators and competitors look at the tape?

 Let’s start with rigid tape

Rigid tape includes the standard white athletic tape under Muhammad Ali’s boxing gloves as well as the more recent addition of Leukotape(TM), a BSM product that is brown in colour, and is stronger and stickier than white tape. Rigid tape has been used and studied as a means to reduce pain, prevent injury, reduce strain on injured or vulnerable tissue, provide stability and biomechanical correction and improve an athlete’s mindset.

 Rigid tape has been proven to be better than no tape or kinesiotape at stimulating the muscles that prevent ankle sprains1. There is some evidence to show that rigid tape can also maintain good joint alignment in the knee2,3 during exercise. This sort of kneecap taping, pioneered by Jenny McConnell, and Australian physiotherapist with a passion for rigid taping, has also been shown to change activity in different regions of the brain while study subjects exercised with and without the tape in place3. Rigid tape has been used with mixed success at reducing pain and changing muscle activation patterns in the shoulder as well4. Down at the foot, the high dye and low dye methods of taping have been shown to reduce pronation (aka arch collapse)5, 6.

But how long do all these effects last? One study on the foot showed that of the 19.3% improvement at the arch observed right after tape was applied, only 4% of that improvement remained after 48hrs5.

 In terms of its effect on soft tissue, rigid tape has been used and studied by McConnell and others in particular at the elbow to improve grip strength and pressure sensitivity in folks afflicted with tennis elbow 3,7.

What About Kinesiotape?

Kinesiotape was invented in the 1970s by Japanese Chiropractor Kenzo Kase. It is the brightly-coloured elastic tape popularized by many summer sport athletes at the London 2012 Olympics. It has been used and studied as a means of decreasing pain, improving lymph drainage, preventing over-contraction, and improving joint position and bodily awareness 3. The Kinesiotape site itself boasts several promising studies showing the tape’s effectiveness on a variety of body problems, mostly case studies, several of which have not been published in peer-review journals elsewhere. Translated, these promising findings need yet to be subjected to larger studies and re-examinations by other groups of scientists before the use of Kinesiotape for these conditions can become an accepted, trustworthy practice.

When Kinesiotape has been put to the test by vigorous scientific methods and larger studies, it has been shown to have a likely beneficial effect on grip strength, some supported findings for increased muscle strength elsewhere, and effects on muscle activity, though whether these are harmful or beneficial remains unclear. Kinesiotaping has also been shown, even after a trip through scientific meta-analysis, to decrease pain by 50%. Pain reduction in the shoulder was also significant when Kinesiotape was used in conjunction with manual therapy 3.

How About For Neurological Conditions?

Although no known studies exist describing taping techniques to help Muhammad Ali with his advanced Parkinson’s, tape has been shown to help people living with MS, cerebral palsy, stroke and pediatric neuromuscular disorders.

Taping for subluxed shoulders after stroke trends toward a significant decrease in pain and increase in function8. And after Botox, those whose stroke had led to an equinus foot (tight calf resulting in toes pointed downward) got better results on walking and ROM tests if they’d been taped instead of just following a stretching program9.

Children with congenital torticollis (see this earlier blog entry for an explanation of torticollis), had an immediate effect on muscle balance when treated with Kinesiotape, and Kinesiotape used in conjunction with physiotherapy improved the sitting posture of children with cerebral palsy more than physio alone. Similar pilot study results have been achieved using Kinesiotape in conjunction with physio for children whose CP affects their arm3.

People with Multiple Sclerosis have experienced decreased postural sway and improved scores on tests of walking and overall health thanks to Kinesiotape-related techniques on the calves and hamstrings3. Although the body (har, har) of literature in favour of taping is deeper for musculoskeletal problems, emerging science is showing the benefits of taping for neuromotor problems as well.

It is impossible to ignore that tape, from white and rigid to electric blue and stretchy (and every flavour in between), affects one’s sense of sight and touch. So what of these sensory pathways into effectiveness? You may have guessed it – taping provides athletes with perceived self-confidence, reassurance and stability during a dynamic activity10. This sort of “placebo effect”, where there may be more changes in the brain than in the joints that have been taped, is nevertheless, still an effect11. Given that taping is relatively low-cost and low-risk, with demonstrated hard scientific findings with respect to joint range of motion as well as a high potential for more psychologically-mediated benefits, it is an excellent tool in the treatment kit.

Is there a caveat here? Of course! All these study results are only as good as the starting tape job. Your physio’s level of knowledge and experience with taping, and your own skin’s cleanliness and reactivity to the tape, are factors to be considered for greatest success. That is, unless you’re just going for looks, in which case a wrinkly, blistered tape job on swollen, itchy skin, will turn even more heads.



1. J Orthop Sports Phys Ther. 2011 May;41(5):328-35. doi: 10.2519/jospt.2011.3501. Epub 2011 Jan Effects of kinesio tape compared with nonelastic sports tape and the untaped ankle during a sudden inversion perturbation in male athletes.

2. Briem K, Eythörsdöttir H, Magnúsdóttir RG, Pálmarsson R, Rúnarsdöttir T, Sveinsson T.Journal of Applied Research (J APPL RES), 2011; 11 (2): 97-104. The effect of taping on patellar position as determined by video fluoroscopy in patients with PFPS: a pilot study. 3. Martin, P, Hoens, A. (2013). The ‘Ease’ (E’s) of Practice: Evidence, Experts & Experience Taping Webinar April 17, 2013. [Powerpoint presentation] Retrieved from Physiotherapy Association of British Columbia members-only site

4. Physiother. Res. Int.12: 203–204 (2007)

5. A biomechanical analysis of the effects of low-Dye taping on arch deformation during gait. Foot (FOOT), 2012 Dec; 22 (4): 283-6

6. Efficacies of different external controls for excessive foot pronation: a meta-analysis. British Journal of Sports Medicine (BR J SPORTS MED), 2011 Jul; 45 (9): 743-51.

7. Vincenzino, B. Lateral epicondylalgia: A Musculoskeletal Physiotherapy Perspective. Manual Therapy (2003): 8(2) 66-79.

8. American Journal of Occupational Therapy November/December 2012 vol. 66 no. 6 727-736

9. Casting, taping or stretching after botulinum toxin type A for spastic equinus foot: a single-blind randomized trial on adult stroke patients Clin Rehabil December 2011 25: 1119-1127

10.Effect of Ankle Taping or Bracing on Creating an Increased Sense of Confidence, Stability, and Reassurance when Performing a Dynamic Balance Task. J Sport Rehabil. 2013 Apr 9. [Epub ahead of print]


Physios Know Squat


When I was in high school, my dad introduced me to peanut butter and garlic sandwiches as a late-night snack.  A common reaction to this is usually, “WHAT?!?!?!”.  Folks tend to be shocked at the juxtaposition of three commonly appreciated things:  peanut butter, garlic and sandwiches.  Here’s a visual depiction:

PBG Sandwich

I’m a huge fan of Venn diagrams.  According to one website’s definition, a Venn diagram is an organizational tool made up of two or more overlapping circles, which are used to compare and contrast information and to examine relationships.

As you can see, the circles are pretty big.  Lots of people like peanut butter, garlic, and sandwiches as individual entities.  People who like Thai food are often fans of peanut butter and garlic together.  The marriage of peanut butter and sandwiches is practically as old as time itself.  All kidding aside, one can see from the above Venn diagram that although the circles themselves are very big, the area of overlap of all three, the lovers of peanut butter and garlic sandwiches, is small.  It’s even smaller since my father passed away a year ago.

What this has to do with physiotherapy, and the main point of this entry, is that both physiotherapists and exercise can be thought of as Venn diagrams.  Physios have regulated, university-credentialled, world-recognised, evidence-informed training and practice in many aspects of health: neurological, musculoskeletal, cardiopulmonary, oncological, community, education, ergonomics, pain management and visceral to name a few…  This is why statements like the following one, which was posted for feedback on Crossfit Fernie‘s Facebook site a while ago, keep me up at night:


There is simply no other exercise, and certainly no machine, that provides the level of central nervous activity, improved balance and coordination, skeletal loading and bone density enhancement, muscular stimulation and growth, connective tissue stress and strength, psychological demand and toughness, and overall systemic conditioning than the correctly performed full squat.” -Mark Rippetoe

Really?  If one were to imagine a Venn diagram of all these markers:  nervous system activity, balance, coordination, and the like, would SQUAT be what’s indicated in the tiny area of overlap?  Wanting to give Mr. Rippetoe and the squat their full credit, and always open to surprises, I did a literature search.

Before I tell you what I found, let’s first lay down a definition.  The correctly performed full squat that’s up for discussion is pictured here, with the option of holding a bar in front or behind the body, or with arms extended up above the head:

Does the squat improve balance?  Yes, as measured by the Timed Up and Go.  Folks with spinal cord injuries and healthy individuals got better at a measure of balance after doing squats1.  squat-variants

Is the squat great at skeletal loading?  From what is known about bone density comparisons across healthy people doing different sports2,3, increases in bone density are really specific to the area of loaded bone.  Given that the most frequent areas of fracture due to bone loss density are the spine, femur, shoulder and wrist4, are squats good medicine?  We don’t know for sure, but the biomechanics of the full squat look favourable given the loads on the back and legs, with overhead squats (bar held overhead with arms extended) adding load to the upper extremities.

Do squats stimulate muscle growth and connective tissue enhancement?  Definitely in the quadriceps.  Quads volume goes up when study participants perform squats5,6, as does the cross-section of the patellar tendon5.  Getting back to the squat-as-better-than-any-other-exercise-for-you idea, do we know whether squats increase tendon cross-section anywhere else?  Nope.  Muscle volume?  Nope.  How about if the squatter held the bar over his or her head, to get arm muscles working a bit harder?  It’s known that isometric exercise does increase muscle strength and tendon stiffness7, so we can give the squat some points on upper body advantages as well.

Systemic conditioning is hard to define.  One interesting feature of squats, however, is that they produce big changes in blood pressure and heart rate, changes that can used to measure how well the nervous system is working.8 Does this mean that squats can condition the cardiovascular and nervous systems?  What is known for sure is that conditions affecting these systems, such as diabetes, result in reduced squat performance. The corollary, that squatters have more responsive hearts and nervous systems, seems likely but is unproven.

Lastly, the brain.  What do squats do to the human brain and spinal cord?  Are they really the exercise that produces the most central nervous system activity and requires the most toughness?  Back squats done at 90% of 1RM (conditioning lingo for the maximum weight liftable in 1 repetition) showed no greater rating of perceived exertion (RPE) than bench press, overhead press, bicep curls or tricep pushdowns performed at 90% of 1RM.  Heavier squats are hypothesised to provide more sensory input to the brain than lighter squats, because of the loads placed on verious body systems, which therefore stimulates more motor output9.  In that way, heavy deep squats stimulate the brain quite a bit.  Although one set of  4-5 squats at 90% 1RM is less work than a set of 15 squats at 70% 1RM, it scores a higher RPE.10  Interestingly, this means that exercise which loads our tissues more tends to demand more of our brains, whether it ends up actually being more work or not.  But does a heavy, butt-to-ground overhead squat light up a functional MRI of the brain as much as a meditating monk11 or Sting at a jam session12?  Is it the same amount of tough as using your own steam to bring your adult son along on an entire Ironman triathlon?  This is where unbridled praise of the squat as being toughest becomes quite difficult to prove.

Squats are indeed beneficial to many bodily systems, as well as being predictors of sport performance13.  The ability to hold a deep squat helps with bowel and bladder function14, reduces low back pain15, and conditions the joints and tissues needed to navigate stairs or get in and out of a sitting position.  Better bones?  Check.  Better tendons?  Check.  Better balance, coordination, heart and lungs and brain?  Check, check, check and check.  But as a qualified physio, can I go to sleep saying, without exclusion, that squats are better than anything else at being great for the human body in so many ways?  No.  This sort of critical evaluation would be a life’s work, or at least a solid thesis’s worth of time.  Never mind that dropping into a deep squat is physically impossible or not immediately recommended for many folks out there, as deep squats put high loads on the knee16, 17 and demand excellent ankle flexibility18.  Given that Western men and women perceive deep squatting to be more difficult than semi squatting or stooping19, 20, those interested in reaping deep squats’ many benefits should consult a qualified professional such as a physio to advise and assist them in getting all the way down and back up again without injury.

As usual I urge you to be awake while reading anything about exercise (including physiotherapy literature) in order distill the beneficial information and intelligently leave the rest behind.  Your exercise life, itself, should be a Venn diagram of components which move your body and mind in lots of different ways, with an intersection labelled FEELING GREAT.

And after your workout, a peanut butter and garlic sandwich might just be… squat on.


1. Estape D, Jacobs PL, Lopez R. Effects of body weight squats on balance and upright mobility in participants with incomplete spinal cord injury. In Cleary MA, Eberman LE, Odai ML, eds. Proceedings of the Fifth Annual College of Education Research Conference: Section on Allied Health Professions. [online conference proceedings]. April 2006;1:12-15. Miami: Florida International University.

2. Greene DANaughton GABradshaw EMoresi MDucher GMechanical loading with or without weight-bearing activity: influence on bone strength index in elite female adolescent athletes engaged in water polo, gymnastics, and track-and-field.  [J Bone Miner Metab] 2012 Sep; Vol. 30 (5), pp. 580-7. Date of Electronic Publication: 2012 May 22.

3. Nilsson MOhlsson CMellström DLorentzon MSport-specific association between exercise loading and the density, geometry, and microstructure of weight-bearing bone in young adult men. [Osteoporos Int] 2013 May; Vol. 24 (5), pp. 1613-22. Date of Electronic Publication: 2012 Sep 26.



6. Bloomquist K, Langberg H, Karlsen S, Madsgaard S, Boesen M, Raastad T.  Effect of range of motion in heavy load squatting on muscle and tendon adaptations.  Eur J Appl Physiol. 2013 Apr 20. [Epub ahead of print]


8. Diabetes Metab. 2011 Dec;37(6):489-96. doi: 10.1016/j.diabet.2011.09.004. Epub 2011 Nov 8.

9. Journal of Strength and Conditioning Research, 2004, 18(2), 353–358

10. Journal of Sports Sciences (J SPORTS SCI), 2012 Sep; 30 (13): 1405-13.


12. The Musical Brain, CTV documentary, 2009.

13. Int J Sports Physiol Perform. 2013 Apr 23. [Epub ahead of print]


15. The Orthopedic Clinics Of North America [Orthop Clin North Am] 1975 Jan; Vol. 6 (1), pp. 93-103.

16. Lorenzetti, S., Bulay, T., et al. Comparison of the Angles and Corresponding Moment in the Knee and Hip during Restricted and Unrestricted Squats. Journal of Strength and Conditioning Research. 2012. 26(10), 2829.

17. J Strength Cond Res. 2013 Jul;27(7):1765-74

18. Marcum, E., Bell, D., et al. Effect of Limiting Ankle-Dorsiflexion Range of Motion on Lower Extremity Kinematics and Muscle-Activation Patterns During a Squat. Journal of Sport Rehabilitation. 2012. 21(2), 144-150

19. Straker, L and Duncan, P.  Psychophysical and psychological comparison of squat and stoop lifiting by young females.  Australian Journal of Physiotherapy.  2000.  46:  27-32.

20. Straker, L and Cain, C.  Psychophysical and physiological comparison of squat and semi-squat lifting by young males.  Occupational Ergonomics.  1999.  2(1):  17-26.

The Trampoline – A Newer, Bouncier Circle of Neglect?

A Newer, Bouncier Circle of Neglect?


More and more people are doing it, and it’s not surprising because it feels great.  Sure, you know it’s a bit risky but so is crossing the street, right?  Everyone loves the high and it’s hard to get enough of it.  Nothing says summer quite like it.


It sounds illegal and some people think it should be.  What’s up for discussion is the ultimate back yard kid-magnet, the trampoline.  What a sweet, sweet relief to grab a cold drink and watch your child – or better yet, just turn an occasional eye in that direction – bounce away for literally hours, with friends, soccer balls, hockey sticks or umbrellas in there with the mix.  Then, as the saying goes, it’s all fun and games until someone loses an eye…


Just how safe are trampolines?  According to Canadian Data from 14 emergency departments1, it’s fractures and not lost eyes that are the most common trampoline-related injury.   Trampoline has far fewer rates of hospital visits than bicycling, soccer, basketball, hockey, football or snowboarding but this may be due to exposure.  Trampoline season is shorter than basketball or hockey, and trampolines are in fewer supply than bicycles.


The shocker, however, is that of the sports surveyed in Canadian and American Emergency departments1, 2trampoline was in the top two for all sports with respect to hospital admissions.  That means that trampoline was on par with alpine skiing in terms of causing injuries that required a hospital stay, and for injury frequency.  Put in those terms, it’s a bit more, er, sobering.  Far fewer parents see alpine skiing as a chance to let their young child go solo with few or no check-ins than they do a back yard trampoline.

Since 2001, emergency department visits related to back yard trampolines have increased 55%1.  In that time, trampoline “safety equipment” such as netting and spring padding have been introduced, confirming that most trampoline injuries continue to be directly related to bouncing on the tramp itself1, 2.  Multiple jumpers increase the risk of injury, particularly for the smallest jumpers.  The little ones are often subjected to reaction forces a lot higher than jumping on the ground, because heavier jumpers create more recoil on the mat.  This is why kids under 6 are at greater risk of fractures and dislocations from trampoline use.

To extend the comparison between ski and trampoline injuries a bit farther, the ski hill also has all kinds of waivers and insurance policies and systems in place to deal with injury.  Does your home insurance cover trampoline-related injuries?  Some other things to consider when visiting or setting up a trampoline are:

– the number of jumpers (should be just one; injury rates skyrocket with the addition of others)

– that current trampoline equipment has shorter warranties for the safety parts, which may need replacing within the lifetime of the structure

– regular inspection and making sure supervising adults are familiar with these guidelines and able to enforce them


It’s not surprising that many governing bodies for health professions have taken a hard stance against recreational trampoline usage.  Below is a sampling from Canada, the US and Australia.  Now that you’re a bit more well-informed, you can make the leap with regards to how your family will roll with trampolines.

The Canadian Paediatric Society and the Canadian Academy of Sport and Exercise Medicine recommend that:

Trampolines should not be used for recreational purposes at home (including cottages and temporary summer residences) by children or adolescents.

Health care professionals, including family physicians and paediatricians, should warn parents of the dangers of trampolines as a recreational toy at routine health care visits. Parents should be advised to avoid the purchase of trampolines for the home because enclosures and adequate supervision are no guarantee against injury.

Trampolines should not be regarded as play equipment and should not be part of outdoor playgrounds.

Physicians should advocate for legislation to require warnings of trampoline dangers to be put on product labels.

More research on trampoline injuries sustained in supervised settings, such as schools, gym clubs and training programs, should be conducted to assess the risk of injury in these settings.”

Health Canada, 2005:  Advises caution with restrictions: adequate supervision; one person at a time; older than six years of age; no ladders; no somersaults; shock-absorbing pads; enclosure netting; trampoline at ground level.

American Academy of Pediatrics, 1999 :  Trampolines should not be used at home; parents should never purchase or allow children to use home trampolines. Trampolines should not be in playgrounds, viewed as play equipment or be part of physical education classes. Limited use of trampolines in supervised training programs with use of safety pads, safety harnesses or spotting belts, trampoline mat at ground level, only one person at a time, competent spotters.

Safe Kids Canada, 2005: Adheres to the American Academy of Pediatrics’ recommendations.

American Academy of Orthopedic Surgeons, 2005:  Trampolines should not be used for unsupervised recreational activity and never by children younger than six years of age. Adherence to Consumer Product Safety Commission guidelines.

Consumer Product Safety Commission, 2000:  Only one person at a time; no somersaults, shock-absorbing pads covering springs, hooks and frame; placing trampoline away from structures/play areas; no ladders; older than six years of age; supervision at all times; enclosures.

Department of Consumer and Employment Protection,Government of Western Australia/Kidsafe WA, 2001:  Children younger than six years of age should be supervised at all times; older children should have strict guidelines for use; one person at a time; bounce near centre of mat; step on and off mat; avoid risky manoeuvres.

Victorian Injury Surveillance System, 1992 and 2000:  Trampolines should not be regarded as play equipment; parents not encouraged to purchase backyard trampolines. Ideally trampolining should be done in a supervised setting with trained personnel, using harnesses for difficult manoeuvres. If parents purchase backyard trampolines, they should only be used with strict adult supervision; no somersaults; one person at a time; keep to centre of mat; step on and off mat.