Myth Busting Adhesions

Today we’ve got you one incredible article from my friend Jon Hodges of Nevada PT. Whether you are a coach, clinician, or just someone who has ever been injured, you’ve likely heard about adhesions. Shocker – what you’ve been told about them is probably not quite so accurate. Let’s learn why!

Adhesions have commonly been used as an explanation for the source of an individual’s pain, loss of mobility, etc. going so far as this website calling it “possibly the most common musculo-skeletal pathology in existence”.

Subsequently, this has spawned countless treatment systems used to address these alleged patho-anatomical anomalies.but where did this come from? Do adhesions even exist?

Img Credit – https://lmimirror3pvr.azureedge.net/static/media/13242/d9c78537-01f6-4b4c-8bde-e03eccf8db2a/fp_foamrolling_960x540.jpg

Greg Lehman remarks on the topic comparing them to the classic chiropractic myth of vertebral subluxations, “Believe it or not there is more research behind subluxation than there is behind an adhesion”.

There are two primary definitions used for the purpose of this discussion. The first is an atypical fibrous connection between the fascia and muscular layers or “myofascial adhesions.” If you have seen Gil Hedley’s infamous video, it’s enough to make you believe you need to do spinning roundhouse kicks in the morning just to prevent the “fuzz” from building up.

Paul Ingraham breaks down that video over at PainScience.com better than I ever can for those interested. The other definition will be aberrant fibrotic development in the muscle or “muscular fibrosis.” We’ll throw scar tissue in for good measure as well.

The fear of adhesions has been routinely established in the rehab and fitness industries, but what does the literature say? A Pubmed search of “myofascial adhesions” revealed 23 findings in total.

Not one of the 23 studies established the presence of adhesions outside of surgical trauma or pathology. We do see post-surgical adhesions in the tendon sheath after surgical repair in the hand (Wong et al., 2009); adhesions in the intra-abdominal cavity after abdominal surgeries or trauma (Beyene et al, 2015), and we see adhesions in potential genetic disorders (Wiseman, 2008) – there is even a case report showing interosseous-lumbrical adhesions after a cat bite infection (Muder & Vadung, 2014).

https://akm-img-a-in.tosshub.com/indiatoday/images/story/201501/catstory_650_010615030200.jpg

In fact, non-traumatic adhesions appear to be so unusual, there was a need to publish a case report on the “anatomical variant” of adhesions in the bicep tendon to the undersurface of the rotator cuff (Hammond & Bryant, 2014). Which, by the way, they attributed to a traumatic event. Not one published paper could be found on the presence of myofascial adhesions in any other scenario, let alone the usual exercise mechanisms sold by practitioners.

Image source: Notes on Visceral Adhesions, Hedley, 2010

While there are no studies, that I could find, that showed the presence of myofascial adhesions in non-traumatic or non-pathological conditions, they do continue to be referenced. Take Salvi Shah for example who says

“Structures that were originally designed to be functionally separate will form adhesions which will impair their ability to slide freely over one another…”

but alas, the only reference is to a textbook from 1991 on Myofascial Release by Regi Boehme (a pupil of John F. Barnes, the founder of www.myofascialrelease.com and self-claimed “icon” in healthcare therapy-also the guy that served a cease and desist and threatened to sue several well-respected evidence-based clinicians for posting scientific evidence refuting his claims back in 2008).

Img Credit – https://www.myofascialrelease.com/images/merchandise/books/mfr_sfe_cover.jpg

The Salvi Shah publication is, incidentally, listed as one of the top 10 cited articles on http://www.ijhsr.org/. A word of caution, do not visit that website if you have any visually-induced seizure disorders or are currently suffering from a migraine.Similarly, Gil Hedley’s “Notes on Visceral Adhesions as Fascial Pathology” paper (2010) is also worth mentioning because while he presents many fascinating dissection photos, there are no literary references regarding insidious adhesion formation here either, other than “in the author’s experience”. In fact, of the 16 references in his publication, only 6 are scientific papers published in literary journals, 4 are references to Hedley’s own DVD series. Yes, DVDs.

If we venture outside of published scientific literature (a fool’s errand admittedly), we see how this concept of myofascial adhesions is perpetuated in the industry despite the paucity of actual scientific support. Expanding my search, I came across a Masters of Exercise Science thesis presentation by Fama and Bueti (2011) in which they reported “when irritated, the fibrous tissue forms adhesions, decreases compliance of the fascia, limiting circulation through the underlying tissue and inhibit function due to ischemia” which, surprisingly does have a few references attached.

Img credit – https://memegenerator.net/img/instances/65851783.jpg

The first, an article by Vernon & Schneider (2009), and second, an article by Holt and Lambourne (2008), upon review neither ever mention adhesions, the latter does not even mention fascia.

Curran et al. (2008) in their article about foam rolling, state “injuries stimulate the development of inelastic, fibrous adhesions between the layers of the myofascial system that prevent normal muscle mechanics and decrease soft-tissue extensibility” with a reference attached. That reference? A textbook on Myofascial release. I could go on as this pattern is simply repeated with many references for citations being either articles that never mention them, textbooks, or “experience”.

It would appear that while there are many references to adhesions, there appear to be very few published studies on the presence of myofascial adhesions outside of trauma, surgical intervention, or pathology. In fact, I could not find a single one. What about scar tissue then? It seems the common argument for many of these trademarked interventions is to break up “adhesions or scar tissue” in the muscles and fascia.

Baoge et al. describe the scarring process in more detail:

…when a muscle is injured, the myofibers rupture and necrotize. A haematoma is formed. At the same time during this first phase, the inflammatory cells can freely invade the injury site because the blood vessels are torn….The scar tissue gives the muscle strength to withstand contractions, and it gives the fibroblasts an anchoring site to invade the granulation tissue.

A few things stand out: tearing of blood vessels and scar tissue being needed to restore mechanical properties of the muscle fiber unit. It would appear that the “microtrauma” argument made from chronic exercise may fall short of the tearing of blood vessels seen in the induction of scar tissue formation. It should be noted that after 10 days, the scar tissue is actually stronger than the muscle unit and any future tearing happens within the muscle fiber itself (Jarvinen et al., 2005).

Img Credit – http://otteastbourne.com/wp-content/uploads/2017/11/OTTEastbourne_Post_operative_scar_tissue_soft_tissue_therapy_muscle_structure.jpg

So it would appear that we need: 1) a trauma of the magnitude to rupture blood vessels to induce scar tissue formation in most cases, 2) scar tissue is needed to restore the mechanical integrity of the force-production capabilities of these muscles, and 3) scar tissue is normal and necessary in the healing of injured muscle and any intervention to disrupt that may actually be counter-productive in the first 10 days and beyond that, we are more likely to damage the muscle fiber than the scar tissue. What about chronic microtrauma and/or inflammation? A quick search on “chronic exercise and adhesions” yielded 0 results on pubmed. However, interestingly, it would seem exercise is actually a potential treatment for chronic inflammation as Gleeson et al. (2011) state:

the protective effect of exercise against chronic inflammation-associated diseases may, to some extent, be ascribed to an anti-inflammatory effect of regular exercise.

Additionally, a Pubmed search of “chronic exercise and scar tissue” yields 32 results – yet only one from 2001 (Weldon et al.) actually mentions exercise. However, the “scarring” they describe goes unreferenced. That being said, while it is established in the literature that pathological inflammation can create fibrotic development, this discussion seeks to establish if there is any validity to the concept that exercise is a mechanism for this fibrosis pathway. Wynn and Ramilingham (2012) list many of the causes of this pathway including:

inherited genetic disorders; persistent infections; recurrent exposure to toxins, irritants or smoke; chronic autoimmune inflammation; minor human leukocyte antigen mismatches in transplants; myocardial infarction; high serum cholesterol; obesity; and poorly controlled diabetes and hypertension

While not an exhaustive list, chronic exercise is never mentioned. Interestingly, they conclude with the “need to begin viewing fibrosis as a pathological process distinct from inflammation”.

The jump in logic in our industry seems to be that inflammation is equal to the mechanism for fibrosis development which does not seem to be well-supported in the literature. *Sam’s Note – comically, for a good portion of the causes, we see exercise being a treatment intervention to reduce the impact of those conditions.

Img Credit -https://article.images.consumerreports.org/prod/content/dam/CRO%20Images%202019/Magazine/January/CR-Magazine-January-2019-Treadmills-Main-1116

Chronic exercise, specifically, does not seem to check this box. In fact, investigating exercise itself, we actually see it as a mechanism for anti-inflammation as established by Peterson et al. (2005) who report:

The fact that the classic proinflammatory cytokines, TNF-α and IL-1β, in general do not increase with exercise indicates that the cytokine cascade induced by exercise markedly differs from the cytokine cascade induced by infections…

And:

Another finding in relation to exercise is increased circulating levels of well-known anti-inflammatory cytokines, cytokine inhibitors such as IL-1ra and sTNF-R…

Further, they conclude that their investigation:

“..suggests that physical activity as such may suppress systemic low-grade inflammation…”

While we have established mechanisms of both scar tissue formation and muscular fibrosis, there seems to be no evidential support for exercise, even chronic exercise, as a condition that would drive this pathway. While muscular fibrosis is noted in those with muscular dystrophies and in the aging population (Mann et al., 2011) the treatment is actually, wait for it, EXERCISE (Horii et al, 2018).

Burpees Aren’t a Bad Exercise! The Practical & Scientific Reasons Why

Many personal trainers and strength coaches argue that the Burpees exercise is bad or inherently dangerous. I’m not one of them.

In this post I’m sharing how I perform the burpee exercise differently than it’s traditionally done, and also explain my rationale for doing so while addressing some of the common concerns I’ve heard about the burpees exercise from other trainers and coaches.

Plus, below the video I provide some cool research findings on the burpees exercises, and also show why the debates trainers and coaches get into about things like burpees aren’t nearly as trivial as they may seem. This is because these debates aren’t actually about the burpee exercise, but about something much deeper and more important.

Burpees Exercise: A Better Way to Do Them, Why They’re Not Bad

Watch this video below to:

1. See how to perform what I call “Gorilla Buprees”
2. Learn a unique a challenging advanced variation to Gorilla Burpees
3. Understand my rationale for using the (Gorilla) Burpees exercise
4. Hear my direct responses to some of the common concerns and criticisms about the burpees exercise

How to Do Gorilla Buprees

As you see in the video above, I don’t perform the Burpees exercise in the traditional manner. Instead I do what I call Gorilla Buprees, which are an exercise I’ve included in all three of my books: Building Muscle and Performance, Strength Training for Fat Loss and (my newest book) Your Workout PERFECTED.

To give you more detail on how and why to perform the Gorilla Burpees exercise, here’s the section on them from my book, Your Workout PERFECTED:

Setup

With your feet slightly farther than shoulder-width apart, hold your arms straight in front of your body (see figure a).

Action and Coaching Tips

Bend your knees and hinge forward at your hips so that your torso leans forward. Place your hands on the ground, with your wrists directly below your shoulders (see figure b), and jump backward to move into a push-up position (see figure c). Make sure that your body forms a straight line and that you do not allow your hips to sag toward the floor in the push-up position. Jump back up so your feet are outside your hands (see figure d), then return to a tall standing position to complete the rep (see figure e).

WHY IT’S BETTER

You start with your feet slightly farther than shoulder-width apart, instead of the way the burpee is commonly done, which has them closer together. Then, in this version, you’re lowering and raising your torso by mainly bending and extending from your knees and your hips, which places more emphasis on the lower body. Burpees are commonly performed by bending over mostly from your lower back and placing your hands on the floor in front of your feet, involving less contribution from the lower body and placing more stress on the lower back.

Benefits

• More involvement from the lower body
• Less unwanted stress on the lower body

Science on the Burpees Exercise

A 2014 study published in the Journal of Strength & Conditioning Research did a comparison of responses to sprint interval cycling and the burpees exercise. The study was done on U.S. Army Reserve members who had at least 1 year of preplanned, supervised exercise a minimum of 3 days per week for a duration of approximately 1 hour per before the start of the study,

The sprint interval cycling group did “all-out” bursts against resistance for 30 seconds. And, during the 4-minute active recovery period after each sprint, participants cycled against no resistance. The burpee exercise group performed as many burpees as possible for 30 seconds, followed by 4 minutes of active recovery involving stepping in place at a self-selected pace. Both groups repeated this cycle 3 times for a total of 4 sets.

The results of this study suggest that “the cardiovascular strain elicited by a single session of low-volume, high-intensity intermittent burpees may be sufficient to confer cardiorespiratory and metabolic adaptations equivalent to those reported in studies using sprint interval cycling.“ (1)

Another important finding of this study was that participant perceptions of exertion were significantly different. Although the self reports ranged from “hard” to “very hard,” and the reported rating of perceived exertion during both sessions characterizes the exercise intensity as vigorous; the subjects perceived the burpees exercise to be easier. (1)

The researchers stated that this may be because sprint-interval cycling primarily involves the leg flexor and extensor muscles, whereas a greater amount of whole-body musculature is active in performing the burpees exercise. (1)

The researchers went on to state that these findings should be of specific interest to strength and conditioning professionals who want to provide athletes and other clients with a vigorous whole-body aerobic and anaerobic conditioning alternative to traditionally programmed running, cycling, or swimming. Unlike sprint interval cycling that requires specialized equipment or a running protocol that requires access to at least a minimum amount of terrain or to a treadmill, the burpees exercise is cost-free, accessible to all, and may be completed in small space. (1)

In short, this research demonstrates that not only are burpees an effective metabolic exercise that requires no special equipment and very little space to perform; it also may be a more tolerable conditioning option (which can increase adherence) based on perception of fatigue over other traditional conditioning options such a bike sprints.

What Exercise Debates Are Really About

Put simply, it’s a myth that the debates about the efficacy of exercises like crunches, hip thrusts and burpees are actually about the particular exercise in question.

Many trainers and coaches will say it’s very important that one be able to justify what they’re doing in their training. This is because they know that what separates good trainers and coaches from those who don’t know any better goes beyond the use of any particular exercise. It’s about how well one can justify the use of a given exercise in they way they’re utilizing it. Therefore, they feel it’s very worthwhile to discuss the reasons why one is using a particular exercise in the way they are because, if one is presenting bad reasons as justification for what they’re doing, those reasons can be discussed and modified for the better.

Well, that’s exactly what’s going on with debates about crunches, hip thrusts, and burpees. It’s far less about the use of the exercise in question, and far more about how good or bad the justifications are that people are providing for the claims they’ve made about a given exercise. Yet, many of the same trainers and coaches who proudly say how important it is that one be able to properly justify what they’re saying and doing in their programming, will turn around and label such debates as being about nothing more than a trivial exercise. And, therefore they’re quick to write off such debates as being petty and unimportant. That’s the very definition of a logical contradiction.

In short, these debates are not about what you think about a give exercise such as burpees, but rather about how you think in general. More specifically, the reliability and validity of how you think. And, how you think is crucial because if someone is presenting poorly reasoned, logically flawed arguments in attempt to support their own positions on something like burpees, it reveals a deeper reality about the (sloppy) thinking processes they use that drive their training decisions. It also shows they’re less able to identify poorly reasoned arguments and unjustified claims when they’re made by others who struggle with critical thinking.

You see, it’s not simply whether someone can explain their perspectives that drive their decisions on exercise programming; it’s whether or not the explanations they’re providing are valid and reliable. We tend to want to focus on the conclusions people hold about a given topic when we should be focusing on the thinking processes they used to reach the conclusion they’ve come to. This is because claims and beliefs are only as good as the evidence and rationale that’s given to support them. Hence, why not all (conflicting) information/opinions are equally valid.

Can MRI predict the future for low back pain patients?

A recent study sought to determine the extent to which degenerative disc changes in young low back pain patients predict progression of degenerative changes, disability, and pain 30 years later!

What you’ll read below is actually a snippet of our research review service, where we have experts break down the most recent research for you 💡 

Key points from the study

• Decreased signal intensity of lumbar discs at baseline predicted severe degeneration at 30-year follow-up.
• The mean number of discs with degeneration increased from 0.9 to 3.5 per subject.
• Early disc degeneration did NOT predict future pain or disability.

Okay, let’s dive into it!

Background and Objective

MRI is an accurate method of measuring degenerative changes in intervertebral discs. The long-term consequences of such changes remain unclear however.

Methods/What They Did

In 1987, 75 low back pain patients aged 20 had lumbar spines MRIs. The subjects were all military recruits whose pain was severe enough to prevent service. 30 years later, 69 of these patients were contacted. Of these, 35 completed a pain and disability questionnaire, and 26 of these 35 received an MRI and clinical examination. MRIs were evaluated for decreased signal intensity and other degenerative changes.

Results/What They Found

Decreased signal intensity at baseline predicted severe degenerative change at follow up. For example, 57% of discs with decreased signal intensity at baseline had severely decreased signal intensity at follow-up, compared to 11% of healthy discs.

Importantly however, severity of disc degeneration at baseline was NOT associated with pain or disability at follow-up. The authors concluded that in young low back pain patients, early degeneration in lumbar discs predicts progressive degenerative change, but not pain or disability.

Limitations/Things to Keep in Mind

• Researchers did not have the MR images from the original study – only the values for signal intensity.
• The sample size was relatively small.
• Many subjects from the first study did not participate in the follow-up.

Clinical Implications

The long-term effects of early disc degeneration remain unclear. This study found that early disc degeneration in young low back pain patients was associated with severe changes after 30 years, but not pain or disability.

This study adds to a large and growing body of research showing that low back pain is complex, and that tissue damage is only one of many different factors that may contribute to pain. In fact, such damage may have little ability to predict the future course of events.

Tissue damage is only one of many different factors that may contribute to pain.

This study also presents encouraging evidence that 2/3 of a group of people with severe back pain in youth had only mild or no pain 30 years later. This information might benefit patients in reducing catastrophization, increasing optimism and self-efficacy, and informing decision-making about the need for potential surgery.

Do you want to save time by not having to wade through endless piles of studies?

Let us do the hard work for you!

Every month we summarise 12 of the most recent and clinically relevant studies in physio, for immediate application in the clinic.

Here’s the 11 other studies from our July issue just published:

• Bilateral Changes in Tendinopathy
• Effect of Massage on Performance + Recovery
• Hip Musculature in Greater Trochanteric Pain Syndrome
• Management of Thoracic Outlet Syndrome
• Psychologically Informed Practice in Physio
• Exercise Therapy for Axial Spondyloarthritis
• Rearfoot vs Forefoot Striking During Cutting
• Management of Pelvic Floor Dysfunction and LBP
• Is Inflammation Involved in Tendinopathy?
• Medication Use + Gait Mechanics in Older Adults
• Exercise-Induced Hypoalgesia

Copenhagen Hip Adduction Exercise: The Science and Unique Variations

It’s common for personal trainers, strength coaches, athletes and exercises enthusiasts alike to regularly use exercises that focus on training the hip abductors (i.e., the glutes), like lateral band walks (with a mini-band around their knees and/or ankles). However, I find it’s a lot less common to see them doing exercises that are targeted at training the hip adductors.

In this post I’m providing you a brief overview of the scientific evidence that explains why I regularly include hip adductor exercises into comprehensive fitness and conditioning programs, and I’m also showing you a few ways that I perform the Copenhagen Hip Adduction exercise, which is one of my top hip adduction exercises.

Why Use Hip Adductor Exercises?

A 2015 systematic review (a study of studies) published in the British Journal of Sports Medicine found that hip adductor strength was one of the most common risk factors for groin injury in sport (1).

One study of note on professional ice hockey players found that they were 17 times more likely to sustain an adductor muscle strain (i.e., groin injury) if their adductor strength was less than 80% of his abductor strength (2).

What Are The Most Effective Hip Adductor Exercises?

With the above in mind, it’s not uncommon for personal trainers and strength coaches to claim that you don’t need to do specific exercises to target your adductors, as compound exercises like squats and lunges do the job effectively. However, the research in this arena shows this common belief/claim to be false.

A review investigating the barbell squat found that a greater hip external rotation position (feet turned out) along a wide stance of the feet, as well as an increased load will increase hip adduction activation during this exercise (3). However, the highest values in muscle activity for the wide-stance squat (4), along with those found during a single-leg squat and a lunge, are relatively low compared to exercises that focus primarily on the hip adduction movement (5). So, with respect to reaching greater levels of muscle activation in the adductors, exercises targeted at training the hip adductors are superior to exercises like wide-stance squats, single-leg squats and lunges.

How To Do the Copenhagen Hip Adduction Exercise – Performance U Style!

Since most people are already familiar with the conventional exercises for targeting the hip adductors, like standing hip adductions with a band or cable and the seated hip adduction machine, below I’m highlighting the Copenhagen hip adduction exercise.

Put simply, the Copenhagen hip adduction exercise has been shown to be a very effective movement for training hip adductors (6,7), and it’s certainly one of my favorite exercises for targeting the hip adductors.

Check out this video (filmed at Gravity & Oxygen Fitness in Boca Raton, FL) to see how I perform the Copenhagen hip adduction exercise, which is a bit different than it’s commonly done.

Also, check out these two-part versions I also like to use of the Copenhagen hip adduction exercise, which are both highlighted in this video.

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