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Monthly Archives: August 2011

Hansen et al in a September 2011 article in the Journal of Strength and Conditioning Research investigate the ability of force-time and power-time tests to differentiate speed performance and to differentiate the competition level of rugby union players.

The authors studied forty professional rugby players. The athletes were evaluated on their 30m sprint from a standing start (with splits at the 5m, 10m, and 30m marks). They also performed squat jumps on a force platform with 40kg of resistance. These squat jumps were analyzed in terms of their force-time curves and power-time curves.

For the sake of analysis, the authors divided the athletes into fast (30m time 4.23 seconds) and slow (30m time 4.57 seconds) groups. The results are interesting:
• The slower groups produces 1-4% more peak force on the squat jump, but when this is expressed in terms of bodyweight the faster athletes produce 5-9% more peak force/body weight.
• The faster group produces -2 to 5% more peak power on the squat jump than the slower group. In terms of relative peak power, the faster group produces 8-14% more peak power than the slower group.
• The faster group has between 2-7% greater peak velocity (on the squat jump) than the slower group.

It needs to be noted that none of these results were statistically significant.

The junior athletes, when compared to the older ones, were slightly faster at all the time splits. The older athletes had greater peak force, peak power, and peak velocity in terms of absolute and relative measures than the younger athletes.

Because many of these results weren’t statistically significant, it’s difficult for the authors to make the conclusion that they effectively differentiate faster versus slower athletes. But it is also unclear why some a complicated assessment is desirable for rugby athletes especially when a sprinting test does a good job of differentiating faster and slower athletes. Even if there are bad weather periods, sprinting tests can still be done indoors.

Hansen, K.T., Cronin, J.B., Pickering, S.L., and Douglas, L. (2011). Do force-time and power-time measures in a loaded jump squat differentiate between speed performance and playing level in elite and elite junior rugby union players? Journal of Strength and Conditioning Research, 25(9), 2382-2391.

The last part of this three part series will focus on the size principle, synchronization, and changes to motor unit firing frequency.  This post will also include the references for all three parts.

Size Principle
The size principle states that the nervous system recruits the smaller motor neurons prior to the larger ones (13). The implication is that the nervous system may actually recruit the smaller slow-twitch muscle fibers prior to larger fast-twitch muscle fibers during movement. There have been suggestions that in certain circumstances, such as during very high speed contractions, the size principle may be bypassed (25). While this sounds logical in theory, there is not a great deal of support for this idea in the literature (6, 10, 26).

Motor unit synchronization occurs when motor units are activated at the same time more often than would be expected to happen randomly (2, 6). In their review, Cormie et al (6) postulate that this helps enhance rate of force development but it could also be considered to be the skill part of strength training. In other words, synchronization is enhanced through practice. While it is an idea that sounds logical, the literature is mixed on this topic. Behm (2) and Cormie et al 6) in their reviews point out that synchronization does not seem to increase force production or rate of force development, though Cormie et al (6) state that complex multi-joint movements may respond differently.
Some studies have found that synchronization occurs following strength training. Semmler and Nordstrom (23) studied index finger abduction, comparing strength trained subjects (trained for an average of eight hours per week over four years) to musicians, and found that the strength trained subjects exhibited greater motor unit synchronization at the first dorsal interosseous muscle compared to the musicians. The authors described this as a corticospinal adaptation from the two activities (strength and skill training), with the musicians requiring less activity of the corticospinal tract and the strength trainers requiring more.
Carroll et al (4) had subjects perform four weeks of strength training for the first dorsal interosseous muscle. After four weeks, abduction strength increased by 33% and the magnitude of the EMG response to TMS and TES decreased. The authors report that this might be evidence of motor unit synchronization.
It’s unclear if synchronization is an adaptation from strength training. If it is an adaptation, it may apply more to complex, multi-joint movements or be a long-term adaptation from strength training.

Firing Frequency
The motor unit firing frequency refers to the speed at which motor neuron commands are translated to the muscle fibers (6). In theory, this would enhance rate of force development and the amount of force that can be developed (2, 6, 8). There is evidence that firing frequency increases following training, but it is unclear how strongly this is related to increases in strength (5, 26). Carroll et al (5) report a correlation of 0.15 between increases in firing frequency and strength, which would indicate that it plays a role but not an extremely significant one.

Strength increases significantly in the presence of minimal hypertrophy. This is especially evident in the training of beginners. As there is not a significant amount muscle mass gained early in training, the theory is that this must be from neural training. Despite this, the literature is hardly conclusive concerning the nature of those neural adaptations. Research examining adaptations to the corticospinal pathway, muscle activation, and synchronization are conflicting.
It should be pointed out that the research on the neural adaptations of strength training has limitations. With some notable exceptions, the majority of this research focuses on finger or wrist movements with largely untrained populations. This is important because it is possible that the challenges to the nervous system from finger abduction may not be the same as a complex, large muscle movement and the adaptations may be different. It is also important because untrained subjects will be different than highly trained athletes and may not respond to training in the same manner. It is unclear as to the nature of the long-term adaptations to the nervous system from strength and power training. Field tests reveal athletes that are stronger, faster, and more explosive yet it is unclear what nervous system adaptations contribute to those performances.
If the intent is to establish nervous system adaptations to strength and power training, especially those relevant to athletes, there is a need to study neural adaptations in a more real world setting. This would involve using large, multi-joint movements, studies over a longer period of time, and studies that involve athletic populations.

1. Aagaard, P., Simonsen, E.B., Andersen, J.L., Magnusson, S.P., Halkjaer-Kristensen, J., and Dyhre-Poulsen, P. Neural inhibition during maximal eccentric and concentric quadriceps contraction: Effects of resistance training. J Appl Physiol 89: 2249-2257, 2000.
2. Behm, D.G. Neuromuscular implications and applications of resistance training. J Strength Cond Re 9(4): 264-274, 1995.
3. Cannon, J., Kay, D., Tarpenning, K.M., and Marino, F.E. Comparative effects of resistance training on peak isometric torque, muscle hypertrophy, voluntary activation and surface EMG between young and elderly women. Clin Physiol Funct Imaging 27: 91-100, 2007.
4. Carroll, T.J., Rick, S., and Carson, R.G. The sites of neural adaptation induced by resistance training in humans. J Physiol 544(2): 641-652, 2002.
5. Carroll, T.J., Selvanayagam, V.S., Riek, S., and Semmler, J.G. Neural adaptations to strength training: Moving beyond transcranial magnetic stimulation and reflex studies. Acta Physiologica 202: 119-140, 2011.
6. Cormie, P. McGuigan, M.R., and Newton, R.U. Developing maximal neuromuscular power: Part 1, biological basis of maximal power production. Sports Med 41(1): 17-38, 2011.
7. Daneshmandi, H., Hosseini, S.A., and Afsharnejad, T. Intermuscular and intramuscular neural adaptations of trained and contralateral untrained limb following unilateral resistance training. I.J. Fitness 3(2): 1-10, 2007.
8. Duchateau, J., Semmler, J.G., and Enoka, R.M. Training adaptations in the behavior of human motor units. J Appl Physiol 101: 1766-1775, 2006.
9. Gabriel, D.A., Kamen, G., and Frost, G. Neural adaptations to resistive exercise. Sports Med 36(2): 133-149, 2006.
10. Gandevia, S.C. Spinal and supraspinal factors in human muscle fatigue. Physiol Rev 81(4): 1725-1789, 2001.
11. Griffin, L. and Cafarelli, E. Transcranial magnetic stimulation during resistance training of the tibialis anterior muscle. J Electromyogr Kines 17: 446-451, 2007.
12. Hakkinen, K., Graemer, W.J., Newton, R.U., and Alen, M. Changes in electromyographic activity, muscle fibre and force production characteristics during heavy resistance/power strength training in middle-aged and older men and women. Acta Physiol Scand 171: 51-62, 2001.
13. Henneman, E., Somjen, G., and Carpenter, D.O. Functional significance of cell size in spinal motoneurons. J Neurophsiol 28: 560-580, 1965.
14. Izquierdo, M., Hakkinen, K., Ibanez, J., Garrues, M., Anton, A., Zuniga, A., Larrion, J.L. and Gorostiaga, E.M. Effects of strength training on muscle power and serum hormones in middle-aged and older men. J Appl Physiol, 90: 1497-1507, 2001.
15. Jensen, J.L., Marstrand, P.C.D., and Nielsen, J.B. Motor skill training and strength training are associated with different plastic changes in the central nervous system. J Appl Physiol 99: 1558-1568, 2005.
16. Kidgell, D.J. and Pearce, A.J. Corticospinal properties following short-term strength training of an intrinsic hand muscle. Hum Movement Sci 29: 631-641, 2010.
17. Kidgell, D.J., Stokes, M.A., Castricum, T.J., and Pearce, A.J. Neurophysiological responses after short-term strength training of the biceps brachii muscle. J Strength Cond Res 24(11): 3123-3132, 2010.
18. Knight, C.A. and Kamen, G. Adaptations in muscular activation of the knee extensor muscles with strength training in young and older adults. J Electromyogr Kines 11: 405-412, 2001.
19. Kubo, K., Ikebukuro, T., Yata, H., Tsunoda, N. and Kanehisa, H. Time course of changes in muscle and tendon properties during strength training and detraining. Journal of Strength Cond Res, 24(2): 322-331, 2010.
20. Lee, M., Gandevia, S.C., and Carroll, T.J. Short-term training does not change cortical voluntary activation. Med Sci Sports Exerc 41(7), 1452-1460, 2009.
21. Moritani, T. Neuromuscular adaptations during the acquisition of muscle strength, power and motor tasks. J. Biomechanics 26(S1): 95-107, 1993.
22. Schubert, M., Beck, S., Taube, W., Amtage, F., Faist, M., and Gruber, M. Balance training and ballistic strength training are associated with task-specific corticospinal adaptations. Eur J Neurosci 27: 2007-2018, 2008.
23. Semmler, J.G. and Nordstrom, M.A. Motor unit discharge and force tremor in skill- and strength-trained individuals. Exp Brain Res 119: 27-38, 1998.
24. Smith, L.K., Weiss, E.L., and Lehmkuhl, L.D. Brunnstrom’s Clinical Kinesiology, 5th Edition, Philadelphia, F.A. Davis Company: pp. 127-128, 424-427, 1996.
25. Stone, M.H. Literature review: Explosive exercises and training. NSCA J 15(3): 7-15, 1993.
26. Van Custem, M., Duchateau, J., and Hainaut, K. Changes in single motor unit behavior contributes to the increase in contraction speed after dynamic training in humans. J Physiol 513(1): 295-305, 1998.
27. Vila-Cha, C., Falla, D., and Farina, D. Motor unit behavior during submaximal contractions following six weeks of either endurance or strength training. J Appl Physiol 109: 1455-1466, 2010.
28. Yue, G.H., Ranganathan, V.K., Siemionow, V., Liu, J.Z., and Sahgal, V. Older adults exhibit a reduced ability to fully activate their biceps brachii muscle. J Gerontol 54A(4): M249-M253, 1999.

Johnson et al, in the September issue of the Journal of Strength and Conditioning Research, conducted a literature review on plyometric training for young children. Over the years plyometrics have received a lot of attention. They are an extremely effective way to improve power and explosiveness, but they do so according to specificity. In other words, training a vertical jump doesn’t necessarily improve horizontal jumping.

There are a number of recommendations regarding exercise classifications, progressions, and prerequisite strength levels for plyometrics. Much of this is not founded on research. This is one of the things that complicates the idea of using plyometrics with children – who by definition won’t have the techniques or strength levels. The problem is that children use plyometrics in play (jumping, hopping, skipping, bounding, etc.) – they just don’t view it as systematic exercise.

In their review, the authors focused on studies going back 12 years. Their inclusion criteria are important: the study had to describe the plyometric intervention, the study had to measure performance, the study had to focus on children aged 5-14, and it had to use a randomized control trial or “quasi” experimental design. The inclusion criteria is always important to be familiar with in a literature review because it can bias the results. They focused their review around looking at three areas: the effectiveness of plyometric training for children, the optimum exercise dosage, and the safety of plyometric training for children.

The studies reviewed found that plyometric training was effective. Now, some caution with this. Children are going to improve performance even without a structured exercise program. This is because they are growing between the ages of 5-14 and this growth alone will improve performance on strength and power measures. This is not addressed by the review.

In terms of exercise dosage, there isn’t a study looking at the optimum training frequency, intensity, or number of jumps – so this isn’t something that is being directly studied. The authors, in this review, synthesize the research that was reviewed and make some recommendations for plyometric dosage with children but this has to be interpreted with caution since it isn’t being directly studied. Their recommendations are essentially 2-2.5 months, twice per week, for 50 jumps/session which can basically double or triple over the course of 8-10 weeks.

None of the studies reviewed specifically looked at safety. The studies report that they had no injuries and that they received IRB approval, thus the inference is that this is safe.

This was a great literature review, very needed. When it comes to plyometrics, we know they are effective. But we don’t have a research base for frequency, volume, intensity, progressions, best exercises, or anything like that. This is true for adults and is true for children.

Johnson, B.A., Salzberg, C.L., and Stevenson, D.A. (2011). A systematic review: Plyometric training programs for young children. Journal of Strength and Conditioning Research, 25(9): 2623-2633.

Despite the focus of neural adaptations resulting from strength training, there is little known about how the nervous system adapts as a result of training (23, 26). One author goes so far as to call the specific mechanisms to identify neural changes “elusive” (26). This post will explore the following areas:
• Changes to the corticospinal pathway
• Changes in muscle activation

The last post in this series will cover the following areas and will include the references:
• Changes to the size principle
• Changes to motor unit synchronization
• Changes to motor unit firing frequency

Corticospinal Pathway
Strength training might result in changes to the excitability of the corticospinal pathway. A number of studies have examined the effects of strength training on the CS pathway measured via TMS and TES. These studies examined strength training and the biceps brachii (15, 17), tibialis anterior (11), soleus (22), first dorsal interosseous (4, 16), flexor carpi radius (20) and the extensor carpi radius and longus (20). Two studies have compared the results of strength training to the results of skill training (17, 22).
The majority of these studies do not support an increase in CS excitability as measured by MEPs (4, 15, 16, 20). Of the ones that do, Griffin and Cafarelli (11 found that four weeks of training for the tibialis anterior resulted in a 32% increase in MEP. Kidgell et al (17) found that four weeks of training for the biceps brachii resulted in significant increases to the MEP as well.
There may be an explanation for the differences in the effects of strength training on CS excitability. In the two studies that found significant increases, both involved subjects training at higher intensities and/or studied larger muscles than the studies that did not. Jensen et al (15) had subjects train the biceps brachii at MVC for six sets of ten repetitions, both Carroll et al (4) and Kidgell and Pearce (16) trained a much smaller muscle (the first dorsal interosseous) at 70%, Lee et al (20) trained flexor carpi radius, the extensor carpi radius and the extensor carpi longus . It is possible that some combination of the muscle’s size and the intensity of the effort could have an impact on CS excitability and adaptations from training.
When strength training is compared to skill training, there are different adaptations to CS activity. Jensen et al (15) studied four weeks of strength training for the right elbow flexors versus four weeks of skill training. The skill training involved the subjects being in the same position as those performing elbow strength training, and using their elbow flexors/extensors to follow a pattern on a screen using a cursor. At the conclusion of four weeks of training, the strength training group increased their dynamic strength by 31% and their MVC by almost 13%. The skill group improved their performance on the skills test by over 80%. The skill group increased their MEP by 50-75% depending upon the testing conditions. In contrast, the strength training group decreased their MEP by almost 41%. In other words, in the Jensen et al (15) study skill training increased their CS excitability whereas strength training depressed it.

Neural Activation of Muscles
EMG is frequently used to measure neural activation of the muscles. Gabriel et al (9) point out that EMG amplitude increases as a result of strength training before hypertrophy. This leads to the conclusion that this is a measure of the neural activation of the muscles. A number of recent studies have found a statistically significant increase in the EMG activity to the agonist muscles as a result of strength training (1, 7, 12, 27). Two of these studies also found a decrease in antagonist EMG activity as a result of strength training (7, 12). Though it should be pointed out that Hakkinen et al (12) only found this for one of their four experimental groups.
For reasons noted above, it is unclear if EMG measures the neural activation of the muscles. With that in mind, a number of studies have used twitch interpolation with mixed results (3, 18, 20, 28).
While studying twitch interpolation, it is not unusual to compare older individuals with younger ones. The idea being that older individuals would not recruit their muscles as fully and would make better gains in this area from strength training. This assumption does not necessarily hold true. In some studies, older individuals activate their muscles more fully than younger (3, 18), in others the opposite is true (28). Strength training also has mixed results with neural activiation as measured by twitch interpolation. Several studies find a two percent increase in activation (3, 18) while others find essentially no change (28). Table one summarizes the studies using twitch interpolation and muscle activation.
Based upon the literature, it is unclear of strength training increases neural activation and, if it does, how significant this increase is towards changes in strength and power.

Randsell and Murray have an interesting article looking at anthropometric and performance measures with elite women’s ice hockey athletes. This is an extremely interesting study because there is not a lot of information about female ice hockey athletes.

The study looked at the 23 women who were invited to USA Hockey’s Olympic trials (the pool that the 2010 Olympic team was drawn from). A number of tests were used to evaluate them including vertical jump, long jump, 1RM front squat, 1RM bench press, and pull-ups. Where possible, the authors attempt to compare their subject pool to other female athletes that are in the literature (some are hockey players, some are in different sports).

Taking all the information presented provides some interesting results (this includes the athletes studied and the comparison groups):
• Body mass averages 66-70 kg
• Height averages 168 cm
• Vertical jump is around 25-31% of height
• Long jump is around 127-188% of height
• Back squat 1-RM varies between 100-115% of body mass
• Front squat 1-RM is around 127% of body mass
• Bench press 1-RM is around 78-95% of body mass
• Pull ups averaged out at 10

Interesting differences between the hockey players studied and the “other” female athletes that the authors compare their subjects to:
• The American hockey players are taller and heavier
• Vertical jump seems better for the American athletes studied, but the standing long jump is not as good
• The front squat is an interesting measure and makes sense given the demands from hockey. In the study, the athletes’ front squat 1-RM exceeded the back squat 1-RM in the groups they were compared to.
• The bench press of the athletes studied was greater in absolute and relative terms than the groups they were compared to.
• It’s nice to have pull-up numbers.

These differences may show an increased emphasis on strength and conditioning for the American players (and especially American hockey players) than the other athletic groups. For those who are interested, the Americans took the silver medal in the 2010 Olympics.

Ransdell, L.B. and T. Murray. (2011). A physical profile of elite female ice hockey players from the USA. Journal of Strength and Conditioning Research, 25(9), 2358-2363.

When an individual begins strength training, strength increases faster than hypertrophy. This is thought to be from nervous system adaptations as a result of strength training (21). For example, Kubo et al (19) found that after two months of strength training, untrained subjects increased their isometric knee extension strength by almost 30% with no accompanying increase in hypertrophy. Other authors report a surprisingly small contribution of muscle size to strength and strength increases that are disproportionate to muscle size increases (14, 18).
Little is known concerning how the nervous system adapts to strength training. The next few posts will discuss how neural drive is measured in the literature, discuss the literature with regards to nervous system adaptations from strength training, and will conclude with observations on the limitations of the literature.  The references will be posted at the end of the last post in this series.
A number of tools are used to measure neural drive in conjunction with strength training. These include electromyography, twitch interpolation, and transcranial electrical/magnetic stimulation.
Electromyography (EMG) measures the electrical activity of the muscles. This activity is gathered via electrodes placed either on the surface of the muscle or inside the muscle. The EMG records the onset, duration, and peaks of muscular activity. In theory, this is measuring the neural drive to the muscles. In research, EMG activity is quantified by “integrating” it, which calculates the total amount of positive and negative electrical activity “seen” at the recording electrodes in each moment of time or via normalization, which compares the EMG activity measured to that established during a maximum voluntary contraction (MVC) (24). EMG is thought to measure the recruitment of motor units (i.e. a larger EMG would equate to more recruitment), the firing frequency of motor units, and the synchronization of impulses (2).
EMG as a tool to measure the neural drive to the muscles has limitations. Gandevia (10) notes that the following can impact EMG:
• The amplitude of single muscle fiber action potentials: This can change if the muscle fiber changes size, if there is a change in the fiber’s membrane potential, or if there is a change in the function of the sarcolemma.
• A change in the electrical conductivity around the muscle fibers: Changes in the content of the sodium/potassium pump will change the ionic concentrations at the muscle fiber would impact electrical conductivity.
• “Farfield” EMG sources: electrical activity from synergist and antagonist muscles could change the EMG being measured.
Each of the above needs to be controlled for before one can demonstrate that EMG measures neural drive (10).
In addition to the limitations mentioned above, EMG has other limitations. First, electrodes can move. Second, it is unclear if electrodes are measuring whole-muscle activity or if they are measuring activity that is only located under the electrode. Third, if the activity is limited to the site of the electrode, it is unclear if the entire muscle responds in a manner similar to the site being measured. Finally, EMG electrodes can pick up ambient electrical activity, which could affect the accuracy of the results.
According to Lee et al (20), twitch interpolation is the best technique to assess the voluntary neural activation of muscles. Twitch interpolation involves applying a supramaximal electrical stimulus to a motor nerve during a MVC. Any motor units not recruited during the MVC would yield extra force during the supramaximal stimulus and this would indicate that activation is submaximal (3, 20). The challenge with this technique is that there is an assumption that a MVC is in fact maximal. Gandevia (10) cautions that during this type of study maximal efforts should be accompanied with instruction and practice, feedback should be given during the efforts, verbal encouragement should be given to motivate subjects, subjects must be allowed to reject efforts that are not maximal, and feedback should be structured to maximize performance.
Transcranial electrical stimulation (TES) and transcranial magnetic stimulation (TMS) study the neural transmission from the motor cortex to the muscles. Both TES and TMS involve activation of the neurons of the cerebral cortex under the scalp. The size of the compound muscle action potentials resulting from this activation is called a motor evoked potential (MEP) (5, 10, 20). Twitch interpolation is also used during TMS studies to determine if cortical drive is considered submaximal (20).
The size of the MEP depends upon several factors. These include:
• The excitability of the underlying motor cortex.
• The strengths of the connections with motor neurons.
• The excitability of the motor neurons.
• The properties of the muscle fiber action potential (i.e. fatigue can slow muscle fiber conduction velocity) (5, 10).
To use MEP to estimate cortical responsiveness the last two factors must be controlled for (10).
Other tools are used to infer neural changes as a result of strength training. These include strength increases that are not accompanied with hypertrophy, performance on power tests, and changes in measures such as rate of force development.

I attended the Early Childhood Intervention Advisory Committee meeting today, which Governor Perry appointed me to as a parent member. Of the 23 people sitting on the committee today, I was one of only three parents. The rest were state agency employees and ECI providers.

Now that the 82nd Legislature and the special session are done, there are going to be some significant changes to ECI. Keep in mind that the post 2013 budget situation is expected to be even worse, and none of this factors in the Federal debt issues, AAA ratings, and the ripple effects all this will have on the economy.

First, the ECI budget was cut by 14%. This means that the program can serve fewer children. This is going to be accomplished by narrowing the eligibility of who is qualified to enter the program and narrowing the eligibility of current children in the program (which is effective when they are re-evaluated):
• Medically diagnoses are still qualified (like Down Syndrome, Cerebral Palsy, etc.).
• Basically anyone else needs to be able to show a 25% delay according to the standardized assessment that DARS is requiring (though there is some flexibility with this).
• Medically diagnosis excepted, for anyone to remain in ECI upon follow-up evaluations they must be able to show at least a 15% delay.

Second, there are major changes to ECI providers:
• There will be a single, standardized individual family service plan form statewide. Currently each provider uses their own.
• Providers must apply to managed healthcare (i.e. insurance providers) or Medicaid directly to be reimbursed. This means that they all have to add the billing skill set. Since this was announced four of 55 providers have left this business, more are expected to follow.
• Providers now have to be concerned with efficiency and outcome measures which means this becomes a lot more like a business than it used to be.

Third, DARS has a number of outreach initiatives about ECI:
• First, on their website you can find two informational videos about ECI. One is for parents, featuring parents. For the most part this is really good and is very helpful. It will also be great for the Legislature. It explains what ECI is, what it does, and how it works. Also talks a lot about family cost share, billing insurance, and Medicaid (which are all now realities). The advisory committee had three concerns: first, the families in the video are all clearly middle class. Second, they are not in Spanish yet. Third, there is a scene where the voiceover is talking about family cost share. While the voiceover is explaining this, there is a mother feeding her child. As this is happening an ECI professional is attempting to explain to the mother options for how to fund her child’s ECI services. It struck me as the mother was being hassled about payment while attempting to feed her child.
• Second, with the changes in ECI eligibility and cost sharing, ECI needs to be in front and explain these changes to stakeholders. It cannot be assumed that everyone is going to DARS’ website and getting accurate information. I encouraged them to focus on parents currently receiving the services and on the referrers (so that physicians are giving parents accurate info). In all honestly, there’s no way to do this really well and the onus is going to be on providers and refers to make sure they are providing accurate information to parents.

In many ways ECI was lucky to “only” be cut by 14%. As I mentioned in my last post, other HHSC agencies were slaughtered and I can only imagine how they are handling these cuts.

It’s been awhile since I’ve blogged about anything relating to advocacy. The 82nd Texas Legislature ended without a budget and the special session came during a busy summer personally and professionally. That said, I spent today in a meeting of the Children’s Policy Council. During this meeting, representatives from the Texas Health and Human Services agencies reported to the council about the budget and how this will impact the future.

In a word the situation is bleak and it’s going to get worse. There is an expectation that after this biennium (fiscal years 2011/2012 and 2012/2013) the situation in Texas will get even worse than it is currently. Not factored into what I’m going to cover is the fact that the U.S. lost its AAA rating and there is a debt reduction deal.

Let’s talk about the macro (i.e. Federal) perspective first. Many HHS programs in Texas depend upon Federal matching funds. Nobody thinks that the Federal government can reduce the deficit without touch Medicaid, which has an impact on many HHS programs. The rise in interest rates may have an impact as well.

Looking at the impact on the various state agencies:

Health and Human Services Commission:
In all funds, they are looking at a 17% reduction. Some of this is from the loss of the Federal stimulus funds. It assumes reductions in provider rates (i.e. Medicaid providers) in the form of hospital rate reductions, DME and lab service rate reductions. It also has “cost containment” (you’ll see this phrase a lot with the various agencies) initiatives.

An important thing to note about the budget, Medicaid is not fully funded. It’s only funded for the first six months on 2012/2013. The intent is for the Legislature to pass a supplemental bill to fund Medicaid. However, this usually doesn’t happen until March which means that HHSC and DADS will probably have a cash flow issue. Their expectation is that they will be unable to pay providers or meet their own payrolls in 2012/2013.

HHSC programs are not funded to take account of caseload growth, cost growth, or utilization growth.

Department of Aging and Disability Services:
DADS is (all funds) being reduced by almost 30%. No organization can withstand this and remain effective. As I have blogged about elsewhere, this includes many direct service programs to the elderly and the disabled. It impacts institutional programs and well as programs designed to keep people out of institutions.

In addition, DADS has a Legislatively-mandated cost containment initiative with all the Medicaid waivers. This initiative says that people will only be funded up to the 90th percentile of services in select waiver programs. In other words, let’s say that you receive 100 hours of a given service from one of the Medicaid waivers. If this service is greater than the 90th percentile of everyone else receiving that service, the service that you receive will be reduced accordingly. Now, there is an appeals process but this has to be initiated by the provider, not the consumer. This goes into effect December 1st, 2011 and DADS will have a stakeholder meeting tentatively scheduled for August 22nd. The Children’s Policy Council plans a letter to DADS expressing concerns over the details of implementing this, but with this being Legislatively driven DADS has few options.

Texas Education Agency:
TEA has had several waves of reductions in force over the last year plus resulting in an almost 30% reduction in the number of employees. In addition, TEA is being reorganized so that special education is being decentralized and spread across the agency. This will have an impact on knowledge, quality, and accountability.

The TEA rep expressed some concerns about HB1335 which gives classroom teachers the ability to order a review of IEPs. In theory this sounds good, but what it means is that there could be a situation where a school district and parents are happy with the IEP, but the general classroom teacher sets the whole thing on its ear. It’s also possible that this review could be conducted without the presence of the parents.

Department of Assistive and Rehabilitative Services:
DARS spent their time talking about the changes to ECI after the 14% reduction in funding. I’ve blogged on this elsewhere, but there will be a narrowing of eligibility, fewer ECI contractors, increased cost share from families, and measurable outcomes.

As you can see, direct service programs are hit hard by the “new normal” (i.e. do more with less). As I said earlier, the future is probably going to be a lot more bleak after 2013.

Lederman, in a 2010 article investigated whether postural, structural, or biomechanical factors contribute to injury – especially lower back pain.

Posture refers to things like standing posture, shape of the back, and pelvic angles. Structure refers to muscle lengths, fascia, and the integration of muscles into various kinetic chains. Biomechanics includes muscle strength imbalances, timing of the firing of muscles, etc. The author’s contention is that these things do not lead to injuries such as lower back pain.

To document this, the author reviews the literature dealing with many of these factors and attempts to see if there is a relationship between the postural, structural, or biomechanical (PSB) factor and pain. Before investigating, the author cautions that many studies examining this are looking at individuals who are already experiencing lower back pain (LBP), which may heavily influence the results. In other words, the changes in PSB may be resulting from the pain and not causing the pain.

The author reports no relationship between posture and lower back pain. They also note that there is no research relating spinal stability, or the lack thereof, and LBP except in vitro studies using cadavers, and notes that a significant amount of damage must be done to the cadaver tissue before it will fit the mathematical model.

Lederman reports that 90% of us have a leg that is slightly longer than the other leg. Despite this the author finds no relationship between leg length and back pain.

Long story short, the author feels that mechanical factors are not related to lower back pain. Rather, the author feels that a biological view of the musculoskeletal system needs to be taken. Since biological structures (and humans) are capable of self-repair, adaptation, change, emotions, awareness, behavior, etc. it may require a different model for lower back pain – what the author calls a biopsychosocial model.

In this model, there is a “biological reserve” where the body can compensate for asymmetries up to a certain threshold. However, the author feels that this brings up other questions:
1. If there is a threshold, how do we find it?
2. How do we asses this threshold? The author feels that most PSB assessments are low on validity and/or reliability.
3. Are exercises even effective at modifying inherent PSB factors?

I want to thank Anoop Balachandran ( for sending that article my way.

This is a really interesting article because it’s 180 degrees from a lot of assumptions made by people. I’d really be interested in people’s thoughts on this one after reading. The article can be found at:

Lederman, E. (2010). The fall of postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain. CPDO Online Journal, March, 1-14.

Brad Schoenfeld had an article in the August issue of Strength and Conditioning Journal exploring advanced tools for developing muscle hypertrophy. The article begins with a review of what is known concerning muscle hypertrophy. The bulk of the article explores forced repetitions, drop sets, supersets, and heavy eccentric training.

Regarding forces repetitions, if the article represents a comprehensive review of the literature then one walks away from this article with the impression that there is not a lot of research on these. Schoenfeld describes a study finding that using forced reps elevates the acute growth hormone response to training, but growth hormone’s role in hypertrophy is contentious.

Like force repetitions, there isn’t a lot on drop sets. The author notes two studies (by he same author) finding a growth hormone increase and more hypertrophy from using drop sets, but notes that there are some limitations to those studies.

The author was unable to find any studies showing that supersets facilitate increases in hypertrophy, though there is a hypothetical rationale behind why this might be the case.

Unlike the first three approaches, there is a great deal of research showing that heavy eccentric training increases hypertrophy. It does, however, have two downsides. First, it requires a spotter (after all, you can lower a lot more weight than you can lift). Second, the eccentric part of the lift is believed to be the thing that makes us sore…

The research reviewed by the author looks promising for forced reps, drop sets, and eccentric training. In theory supersets would work the same way. There’s also a lot of anecdotal evidence testifying to the effectiveness of these approaches.

That said, these approaches should be used selectively and with caution. First, they are enormously fatiguing which means that overdoing them leads to overtraining and burnout. Second, they will lose their effectiveness with time. Third, many of these approaches require a spotter. Fourth, whenever intensity is combined with fatigue there is greater risk of injury from training.

Schoenfeld, B. (2011). The use of specialized training techniques to maximize muscle hypertrophy. Strength and Conditioning Journal, 33(4), 60-65.