What’s up, everyone. One of the many treatment options that we offer at Athletes’ Potential is something called Personalized Blood Flow Restriction Training (PBFRT). This is something I remember being blown away about while in physical therapy school and seeing the results that research was showing. To put it simply, it’s one of the best evidence supported treatment options out there and we are thrilled to be able to offer it to the Decatur and greater Atlanta area.

There are a ton of awesome benefits with PBFRT, but first let’s take a look at what exactly BFR is. PBFRT is the brief and intermittent use of a tourniquet in order to restrict the amount of blood flow from coming into your limb (arterial flow) while performing low-load resistance training. The way PBFRT works is it reduces the amount of oxygenated blood reaching a working muscle in order to trick your body into thinking it’s working at a higher intensity than it actually is. By using this form of engineered suffering, you’re able to use extremely light resistance and still get the same increases in size and strength as lifting at higher intensities with heavy weight! Exactly how this happens is laid out below:
​

• Occluding your limb creates an anaerobic environment by limiting the amount of oxygenated blood that reaches a working muscle.
• This anaerobic environment stimulates your fast twitch muscle fibers (the fibers responsible for power, speed, and strength).
• In an anaerobic environment with your fast twitch muscle fibers activated, a convoluted process starts called the Cori Cycle, which leads to the production of lactate in the muscles (fun fact: lactate production creates that burning sensation you feel).
• Because your limb is occluded, the lactate being produced begins to pool in the working muscles, which signals multiple metabolites leading to protein synthesis, muscle stem cells, capillary beds, and a 290% increase in human growth hormone (HGH).

Essentially, PBFRT is a true biohack that allows people to work at loads that are non-stressful on the tissue but still get improved size and strength. A true game-changer in the world of strength and conditioning.

But just like everything else in the world of sports medicine, PBFRT has to be used appropriately and with the right population. Otherwise, you could risk wasting your time and resources. So, who exactly would benefit? Below are three of the most common scenarios that people see the best results.

Post-Injury/Surgery:

Muscle breakdown (atrophy) after a surgery or injury happens incredibly fast. For example, when you’re injured or you’re not allowed to put any weight through one of your limbs, in as little as two weeks that limb goes into a state of anabolic resistance and protein synthesis shuts down leading to a 30% loss of muscle mass in that limb!  

This is obviously extremely problematic and slows down recovery from an injury dramatically. However, with PBFRT we now have the ability to combat that significant muscle loss because we are able to use low intensity and weight levels that are safe and tolerable to the patient and get the same increases in muscle size and strength as lifting at 65% of your one rep max or higher.

A great example of just how beneficial PBFRT can be for patients rehabbing from injury comes from Dr. Zach Long who was working with an elite level olympic lifter after tearing his ACL. With this type of injury, more than 65% of patients demonstrate quadricep weakness even a year out from surgery. However, Dr. Long’s patient’s surgical leg became one inch larger than his healthy leg in just three months time after his surgery!

Sport Performance:

PBFRT has shown numerous benefits to enhancing sports performance, but perhaps the most documented is the ability for athletes to maintain muscle size and strength without the dip in performance caused by muscle soreness. This is possible because there is no muscle tissue breakdown associated with PBFRT since the intensity is kept so low.

• This is a great way for barbell, endurance, and in-season athletes to compliment their current training programs without worrying about over-training.

PBFRT has also been shown to have a profound effect on your aerobic capacity as well by increasing your VO2 max and capillary beds.

• This means that research has demonstrated the ability to improve both your cardiovascular endurance and muscular size simultaneously!

Recovery:

Imagine this. You’re training for an upcoming triathlon and are starting to feel a little banged up from the volume pulling, or you’re gassed trying to prepare for a CrossFit competition, or maybe you’re midseason in soccer and have been trying to push through some nagging issues.

Now, imagine during your recovery day you rode for just 15 minutes, at a pace well below a typical recovery ride pace, and we’re able to give your tendons that increased HGH we mentioned above, all while boosting your VO2 max AND letting your tissue continue to recover.

Sounds pretty cool; right? We have people do that all the time here in the clinic and we are consistently seeing people hit PR’s and feel good doing it.


Rehab, Performance, Recovery. That covers a vast majority of the population, and that’s on purpose. The research (over 600 published studies) is incredible and the results we are getting wiht people speak for themselves. However, as the old adage goes, “If all you have is a hammer, everything looks like a nail.” Personalized blood flow restriction training isn’t for everyone, and that’s okay. At Athletes’ Potential we firmly believe we have the most skilled doctors of physical therapy who can use a vast array of treatment options to help you reach your injury or performance goals. Whether you are training through a nagging injury or looking to improve your performance, we would love to help you achieve your goals. Give us a call at 470-355-2106 or fill out the contact request form below and we will be happy to contact you.

In terms of injury risk, acute:chronic workload ratios within the range of 0.8–1.3 is considered the training ‘sweet spot’ where injury risk is at its lowest, while acute:chronic workload ratios ≥1.5 represent the danger zone. If you look at the trend of the curve before 0.80, you should notice the injury risk climbs back up – similar to a “U-shaped” curve. This relationship between workload and injury demonstrates that both inadequate and excessive workloads are associated with injury.

Now let’s say from the example above that week 5 workload came out to 3500 arbitrary units.

That would make the ratio: 3500/1808 = 1.94​

No bueno.

The way this is laid out is that you start with your MED, progress to MAV, then MRV to overreach. However, notice that you don’t dance with MRV often, nor do you want to.

Overtime, your MRV will increase, meaning you’ll get stronger and develop more work capacity, as long as you intelligently handle your training volume.

A good rule of thumb is The 10% Rule - While there can be some variability here, staying within a 10% increase from the previous week tends to work well for a lot of people. It pushes that threshold in a progressive manner and allows appropriate recovery from the increased demand on the body.

Next week, in Part 2, we’ll take a deeper dive into load management and training volume, explore exactly what this concept means, and how to practically apply it to yourself or athletes you work with.

​
Cheers,

Dr. Ravi Patel, PT, DPT, CSCS

It’s baaaaack. The largest fitness competition on Earth, the CrossFit Open, is finally here. Maybe you’ve trained all year for this, maybe you’re still new to CrossFit and are curious about all the excitement. Maybe you’re a seasoned vet, maybe this is your first Open you’ve ever participated in. Regardless of your CrossFit background, your fitness will be tested, your mental toughness will be challenged, and you will certainly have a blast working through these workouts with your crew at your local CrossFit affiliate.

That being said though, this is typically a time where we start seeing an uptick in the people we see coming in for CrossFit related injuries. Having an athletic background, where I had to personally sit out multiple seasons due to injuries, I speak from experience when I tell you there is nothing worse than working all year towards a goal/competition/test and not being able to perform at an optimal level, if at all, because of an injury. And, look, I get it. There is inherently an increased risk of injury when you're pushing yourself in a competitive environment. However, there are some very important things you can do to minimize this risk and allow you to perform your best. Let’s take a look at the three easy things you can do:​

#1 Don’t Be Reckless

This is huge and something I see year after year. If you’re a CrossFit coach, or even just an observant CrossFit athlete, I’m sure you’ve seen what I’m about to explain...You’ve worked all year to create movement patterns that are both safe and effective. You know the importance of good, quality movement. However, throw in the element of an international competition and it seems like all these lessons about technique go out the window.
​
For example, last year’s first Open workout (18.1) consisted of three movements:  toe-to-bar, dumbbell clean and jerks and rowing. Can you guess what type of injury we saw coming into our clinic after this workout? If you said back pain, you’re correct. But why? Well, with this workout people were trying to perform as many rounds as possible for 20 minutes. To get better scores people weren’t maintaining core control for a solid hollow position with their toes-to-bar, they stopped getting full hip and knee extension for optimal power production during the drive portion of the clean and jerks, and/or they started to over-extend during the rowing component.  All of these create situations that are destined to increase stress on your low back. Keep in mind that this was just the first workout! Now you’re either completely unable to participate in the other workouts or will not be performing at an optimal level because you’re trying to grind through an injury.​

#2: Protect Your Sleep

There are four main pillars of health care that we look at with every patient who walks in the door at Athletes’ Potential: Movement, Stress, Sleep, and Nutrition. Sleep is easily on of the biggest problems that we see out of these pillars. And check this out: Sleep affects everything you do and everything you do is positively affected by quality sleep. Good, quality sleep literally improves everything: every marker on a blood panel, weight management, sport performance and recovery, productivity, and numerous types of disease management. The list goes on and on, yet the percentage of sleep deprived Americans, particularly in Urban areas, continues to rise at an alarming rate. In fact, the U.S Centers for Disease Control and Prevention reports that more than 30% of Americans are sleep deprived getting fewer than 6 hours of sleep per night.

If you’re not getting enough sleep, you’re not giving your body a chance to recover. If you’re not recovering appropriately, then you're leaving yourself at risk for injury and decreased performance. So, bottom line: create an optimal sleeping environment, protect your night time routine, and get some good, quality sleep.

For more info on how to optimize your sleep, check out this article we wrote.

#3: Maintain Perspective

This comes full circle with tip #1. For those of you trying to make it on to Regionals, those extra few reps I mentioned could be the difference in making the cut vs staying home. However, for the vast majority of athletes competing in the CrossFit Open this is not reality. You all have careers, kids you need to take care of, and numerous other responsibilities that you need to keep rocking with once you leave the gym. Is bouncing off the top of your head to get an extra rep or two really going to mean that much if by doing so now you can’t look over your shoulder while driving? (yes, this is a real scenario that we’ve worked on at our clinic...I’m looking at you 17.4). Or is that two position jump on the leaderboard really all the important if now you can’t bend over to pick up your kids? ​

CrossFit is meant to be a competitive, fun, and challenging way to make all aspects of life outside the gym a little easier. This time of year is huge for all CrossFit athletes and it is truly impressive to see the physical accomplishments and PR’s that happen every single year in the Open. However, the Open isn’t an excuse to throw all safety out the window, but it isn’t something you should be afraid of either. Following these three easy tips will ensure that you have a great time, reduce your risk of injury, and maybe even hit a PR or two.

Thanks for reading, 


Dr Jake, DPT, CSCS, CF-L1

Recently, I had the opportunity to present to a local soccer club and their coaches on injury risk and reduction for the sport of soccer. In order to understand this, a “Needs Analysis” must be done. A Needs Analysis is a two-part analysis breaking down the sport into two components:​

• Evaluation of the Sport
• Assessment of the Individual

Today, our primary focus will be on evaluating the sport itself. This can be further broken down into:

• Movement/Biomechanical Analysis – body and limb movement patterns and muscular involvement
• Physiological Analysis – required physiological characteristics such as strength, power, endurance, speed agility, etc.
• Injury Analysis – common sites for joint and muscle injury and causative factors

Movement & Physiological Analysis

Soccer is a very lower-body dominant sport involving the hip, knee and ankle joints and muscle groups including the quadriceps, glutes, hamstrings and calves. A soccer athlete must be able to run, jump, accelerate, decelerate, land, cut, kick, pass, head, shuffle, tackle – all while handling a ball and avoiding defenders. Oh, they also need the ability to sprint and jog throughout the duration of a 90+ minute game. Now, you’re talking about a dynamic athlete with a sound aerobic and anaerobic energy system. That’s A LOT.

Injury Analysis
​
Sports injuries are inevitable. It comes with playing sports – exposure already puts you more at risk. You cannot prevent sports injuries, but you can help mitigate and reduce the risk of them happening – especially ones that are non-contact or overuse in nature.​

Here’s a breakdown of the most common injuries in soccer:

Muscle strain, ligament sprain and concussions are highest as expected.

What’s most interesting is the girls’ ligament sprain – very high for both practice and competition as compared to the boys’ group. Females are 2-5 times more likely to tear their ACL than males in a similar sport. There are a lot of factors that play into this and nothing is definitive. We do know that strength and neuromuscular control are big modifiable factors from an injury risk standpoint.​

In another study from 2015, Waldén and company analyzed 39 videos for movements related to non-contact ACL injuries in professional soccer players. They found that pressing, kicking, and heading were the 3 most common movements in relation to ACL injuries.

Ask questions​

Many postpartum women do not know all of the details after birthing their baby.  Some have told me they were not aware they had stitches down below until the 6-week check-up when the doctor wanted to make sure they were healing well!  The check-up at 6 weeks can be quick so arrive with questions. It is helpful to know about any tearing, episiotomies, tools used during the birth, etc.  These factors are all great to bear in mind as you return to exercise and daily functioning.

Another question to ask-- “Is there a pelvic health PT that you would recommend?”  They may know someone in the area or have worked with them prior.  However, do not become discouraged if they don’t have a name to offer.  A Google search for “women’s health PT” or “pelvic PT” should show professionals in the area.  Compare websites and reviews to see if the PT would be a good fit for you and your goals!​


​Pelvic Health Physical Therapy

Once you have been cleared by the doctor for “usual exercise” and intercourse, I highly suggest visiting a pelvic health or women’s health PT.  They will be able to further answer any questions about symptoms you may experience immediately postpartum and later.

A pelvic PT is specialized on evaluation and treatment of the pelvic floor musculature.  They can perform internal evaluations to test the strength and endurance of your pelvic floor, check for prolapse, address any soft tissue issues, etc.

For the evaluation, the therapist will use a gloved finger to palpate muscles internally. While a great deal of information can be gathered from an internal evaluation, it is not necessary for visiting a pelvic PT.   The therapist can then prescribe exercises to help relieve the symptoms and provide hands-on work to hips, back, sacrum and other involved areas. Your PT should be a huge help in getting you back to fitness postpartum!  Other areas they can treat and improve are bowel/bladder issues, painful sex, and pelvic pain.


Focus on healing and strength rather than weight loss

Social media and advertising may be all about “getting your body back” and fixing “mummy tummy,” but that is not the focus when you are postpartum.  The first step in returning to fitness is addressing foundational strength and continuing to heal from the pregnancy and birth.  Your body will go through so many changes in the months following your pregnancy and the timeline is different for every single woman.

Steer clear of programs that say at week 8 you do blank. It should all be self-paced and based on symptoms, your birth story, and prior activity level.  Do you need help starting out?  This was the number one question I received from women in the clinic.  “What can I do?  Where do I start?” So I developed programming to recover and rebuild your core after having a baby. Check out the THRIVE: Rebuild Bundle programming HERE.

​This is where education and setting the expectations is huge. When working with an athlete, it’s important to consider this as a part of rehab. Who wouldn’t have anxiety or emotions when they can no longer play their sport and get their knee operated on. It’s completely normal. Rather than hiding it, have a conversation with your athlete. Educate them on what to expect before, during and after the procedure and for rehab. Assure them that everything will be okay and that they will get back to their sport. When an athlete knows what to expect, there’s less psychological distress associated with the process, which can significantly impact the success of the rehab and return-to-play process.
​
​2. Self-Efficacy:

• Definition: belief in one’s ability to succeed in a particular situation or execute actions.

In addition to the 4 areas above, an objective measure can be very beneficial to quantify where the athlete stands from not only a physical perspective, but psychological. That’s where the ACL-Return to Sport after Injury scale (ACL-RSI) can be helpful. The ACL-RSI is a great outcome measures to assess athletes' emotions, confidence in performance, and risk appraisal in relation to return to sport.

Recognizing positive and negative psychological responses to injury is the first step in initiating treatment and potentially modifying beliefs through psychological interventions. It is important to identify patients who are at risk for poor outcomes because targeted psychological interventions may be successful. If you know of an athlete going through this injury and recovery process, don’t forget that there’s more to it than just what you can see.

​
Cheers,

Dr. Ravi, DPT


Sources:
- Christino MA, Fantry AJ, Vopat BG. Psychological Aspects of Recovery Following Anterior Cruciate Ligament Reconstruction. J Am Acad Orthop Surg. 2015;23(8):501-9.
- Sadeqi M, Klouche S, Bohu Y, Herman S, Lefevre N, Gerometta A. Progression of the Psychological ACL-RSI Score and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Prospective 2-Year Follow-up Study From the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST). Orthop J Sports Med. 2018;6(12):2325967118812819.
- Ardern CL. Anterior Cruciate Ligament Reconstruction-Not Exactly a One-Way Ticket Back to the Preinjury Level: A Review of Contextual Factors Affecting Return to Sport After Surgery. Sports Health. 2015;7(3):224-30.
-Schub D, Saluan P: Anterior cruciate ligament injuries in the young athlete: Evaluation and treatment. Sports Med Arthrosc 2011;19(1):34-43. Melissa A. Christino, MD, et al

This means that we need to get away from time- and isolated-based assessments and look at this from a holistic 360 degree view, taking into account not only the biological factors of the athlete, but psychosocial factors as well. Since there are many individuals involved in this process, it takes a team to make the outcome truly successful. This team consists of the individual, their family, physical therapist, athletic trainer, orthopedic surgeon, sport coach, strength coach, etc.

Remember – A single component alone (i.e. time) is not enough to determine whether someone is ready. All of the components below could have the box checked except the last one and this athlete would still not be ready. I hope this provides some insight to you if you are going through this process as an athlete, parent, or clinician looking to return to sport. ​

1. Time: > 9 months after ACLR.
2. Patient-Reported Outcome Measures:  IKDC2000, Tegner Activity Scale, ACL-RSI, K-SES.
3. Clinical Exam: Full range of motion, no pain, swelling, or laxity.
4. Muscle Strength: Pivoting, contact, competitive sports (>100% limb symmetry index); non-pivoting, non-contact, recreational sports (>90% limb symmetry index).
5. Hop Tests: Multi-directional (90% limb symmetry index).
6. Assessment of Movement Quality: Multi-segment movement quality with and without fatigue
7. Task and Environmental Constraints: Gradual progression of controlled tasks and environments to progressive, uncontrolled tasks and environments to replicate sport.
8. Medical and Sport Risk Modifiers: Age, sex, personal medical history, type of sport, level of sport, position played, ability to protect (e.g. taping/bracing).
9. Decision Modifiers: Timing of the season, external pressure from club, trainers, parents, conflict of interest (e.g. financial), lifestyle changes, priorities.
10. Psychological Factors: This one is commonly overlooked – that is why next week, we will dive deeper into psychological readiness and how we can make sure this becomes just as important as the physical component of ACL rehab and performance.

Cheers,
Dr. Ravi


Source: Dingenen B, Gokeler A. Optimization of the Return-to-Sport Paradigm After Anterior Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward. Sports Med. 2017;47(8):1487-1500.

​“Since 2008, average family premiums have increased 55 percent, twice as fast as workers’
earnings (26%) and three times as fast as inflation (17%).”

“Premiums for employer-sponsored family health coverage rise 5% to average $19,616; single
premiums rise 3% to $6,896.”

“Deductibles for covered workers has tripled since 2008, growing 8 times faster than wages.”

Not trying to be a Negative Nancy, but that’s no bueno. Unfortunately, this is where our current
healthcare system stands.

This data was released by the Kaiser Family Foundation in a recent survey.

The annual survey was conducted between January and July of 2018 and included 4,070
randomly selected, non-federal public and private firms with three or more employees (including
2,160 that responded to the full survey and 1,910 others that responded to a single question about
offering coverage).

Over the past decade, insurance premiums and deductibles have significantly increased relative
to workers’ earnings and inflation.

We continue to pay more for insurance, but get less in return.

We want a healthier country, but we continue to create barriers to access “healthcare.”

So how do we change this?

Use the system less and, more importantly, NEED IT LESS.

What I’m getting at is taking control of our own health. We have plenty of data to show that
chronic disease is impacting this country.

​Improving and maintaining our health and wellness through movement, nutrition, sleep, stress
management, and social relationships is crucial. With technology, we have this information at
our fingertips. While it can be tough to decipher through the guruism and instamodels these days,
it’s important to do your research and find professionals that you trust with your health.

Here are some general recommendations we give:

1. Move everyday. Strength train at least 2-3x per week. Test your heart and lungs.

2. Eat real food, not too much, mostly plants (but also.. protein is life).

3. Get at least 7 hours of quality sleep each night.

4. Stress management is often overlooked and this can be managed through self-reflection,
meditation, counseling, exercise, etc. Find what works best for you.

5. Social connection and relationships is an area I believe is very important for all of us. We
all have our people and it’s important to prioritize those relationships for our own health
and well-being.
​
If you want to dive further into the details of this survey, you can find the original article here:

https://www.kff.org/health-costs/press-release/employer-sponsored-family-coverage-premiums-
rise-5-percent-in-2018/?fbclid=IwAR2u9WY8T4eAiEOUaJQkjHXF7-p6xEVXPHXhx5Qpup-o-
NKz-slUBSK-1Bc

​Insurance and healthcare is expensive. Employers and employees are starting to take notice of
this tread. They’re being incentivized to take a proactive approach as well as minimize the use of
their healthcare.

At the end of the day, let’s get people moving better and eating less shit, and more importantly,
realize that we have the power to take control of our health and avoid being imprisoned by this
expensive healthcare system.

Cheers,

Dr. Ravi, DPT

​
​This drill is an all time favorite of mine for a couple of reasons. First, it allows you to feel how your lats should be contracting while you are going a pull up. Second, it allows you to strengthen your shoulders in a vulnerable/weak position. You’re only as strong as your weakest link and being strong in a weak position is a great way to prevent injuries.


Drill #2: Lat Pull Over

​Breaking up a bilateral movement (using both arms)  into a unilateral movement (using one arm) is a highly underutilized training modality that allows to balance out weaknesses. Plus, as an added bonus, you’re able to perform a vertical pulling drill at a slightly different angle which, as we talked about above, is how you train for healthy shoulders.


If you have shoulder pain while doing pull-ups, or want to prevent pain from coming, this two-part post is a great place to start. Ensuring appropriate mobility and then building appropriate strength is a common occurrence in the rehab world.

If you’re in the Atlanta area and are interested in working with a unique professional that can help you optimize your health in all of these areas, we need to talk. Being proactive and staying on top of your health will help you avoid serious health problems down the road.

Submit a contact request by clicking the button below and we’ll get you set up with one of our Doctors for a free 15-minute phone consult.​

​Thanks for reading,

Dr. Jacob, PT, DPT, CSCS