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What You Should Do During and After Whiplash: Treatments and Guidelines

Admini Si - Thursday, September 28, 2017
whiplash injury after car accident

Whiplash and “Whiplash Associated Disorders” (WADs) are the single most frequently recorded CTP (compulsory third party) injuries. 



What is the definition of Whiplash?


Whiplash is defined by the Quebec Task Force as an “…acceleration-deceleration mechanism of energy transfer to the neck…It may result from…motor vehicle collisions… The impact may result in bony or soft tissue injuries (whiplash injury), which in turn may lead to a variety of clinical manifestations (whiplash associated disorders)


Apart from neck and spinal pain Whiplash Associated Disorders include headache, dizziness, tinnitus, memory loss, dysphagia and temporomandibular (TMJ or jaw) pain.



What to do if you have Whiplash:


You should follow your insurer’s guidelines about making a CTP claim.


If you have had a car or other accident and have acute neck pain or other symptoms as a result, you should consult your doctor. At this appointment you will be assessed and a decision will be made as to whether an x-ray is necessary. If an x-ray is necessary and there is a stable bony injury found, you may need to be immobilized in a rigid collar for approximately six weeks. 


rigid collar

Rarely, if there is a dislocation or unstable fracture, surgery may be required.



Treatment of Whiplash:


If x-ray and immobilization is not necessary, you will likely be referred for physiotherapy. After a thorough assessment you will be given gentle exercises to do quite early on, to improve your neck movement and strength. You will be given advice relating to your work, sport and other activities. You will likely be given hands-on treatment including gentle manual therapy, and possibly ultrasound, dry needling, taping and ice or heat. Your therapist should not perform forceful manipulation on your neck after any acute injury.


You will require fairly regular reviews at first, and as you improve these will reduce in frequency as you do more and more for yourself. Although the pain can be quite intense and you can feel quite fearful initially, most people slowly make a full or almost full recovery. In 40% of cases at 12 weeks, there should be complete resolution of symptoms. In more severe cases, symptoms are mostly resolved within a year, and people return to previous sport, work and daily activities.



The Most Important Guideline


walking a dog

The most important guideline made by the MAA is to stay active, keep moving as normally as possible and return to usual activities. Immobilization in a collar, prescription of muscle relaxants and steroid injections are not recommended in the most recent guidelines about the management of WAD. The use of anti-inflammatories and simple analgesics is recommended for pain.



Who can help?

Macquarie Street Physiotherapy

At Macquarie Street Physiotherapy we have assisted many patients with Whiplash and WAD.  Whether the injury is acute (just happened) or if you have stiffness or symptoms months or years later, we can assist with safe and appropriate treatment, exercises and education.




Reference: Motor Accidents Authority: Guidelines for the management of acute whiplash-associated disorders – for health professionals.  Sydney: third edition 2014


How important is calf stretching for prevention of injury?

Admini Si - Thursday, August 03, 2017

calf muscle

Stretching will make tight muscles feel more comfortable and freer.  Flexibility in the calf is essential for all running sports.  It reduces the chance of straining/tearing the calf muscle during a match or whilst running.  Stretching the calf will also relieve the strain on other muscles which might be working harder to compensate.


What are calf muscles?


They are the muscles of the lower leg which are involved with propulsion, hopping, and jumping by their attachment at the heel.  Racquet and other ball sports, running and cycling recruit calf muscles.


There are two main muscles which make up the calf.  These are:

1)      Gastrocnemius – this starts above the knee and attaches at the back of the heel via the Achilles Tendon.  It helps with propulsion (heel raise) as well as knee bending.

2)      Soleus – this starts below the knee and attaches at the back of the heel via the Achilles Tendon shared with gastrocnemius.  This muscle is important for propulsion upwards and forwards, and balance.  It is the most commonly strained (as many as 95% of calf strains are soleus strains).  Running is the main cause of calf strain.

Why are my calf muscles tight?


Calf muscles can be tight for a number of reasons:  after exercise they could be tight just from normal use (particularly if you are new to the exercise), or from over-use (often accompanied by DOMS – delayed onset muscle soreness).  If you are weak in the gluteal muscles, or tight in the hip flexor muscles the calf will tend to work harder when you walk or run.  Also, a tendency to weight-bear in your forefoot or wearing high heels can result in tight calf muscles.  Sitting shortens the gastrocnemius muscle of the calf, and so can make this tight.


Does stretching reduce calf tightness?


Stretching any muscle, be it hamstring, quadriceps, adductors or calf is relevant if the muscle is tight.  Stretch exercises reduce calf tightness by lengthening the muscle fascicles.


How should I stretch?



The gastrocnemius is best stretched with a straight knee (PIC).

The soleus is best stretched with a bent knee (PIC).

The heel can be flat on the floor or dropped over a step. Dropping the heels over a step could aggravate the Achilles tendon, so watch out for any tendon pain with this (PIC).

When should I stretch?


Static stretching should be performed regularly and held for 60-90 seconds.  It should not be done much sooner than 2 hours before a sporting match. Current research suggests that pre-match warm-ups should be more dynamic such as lunges and leg swings, jumping, etc., rather than static stretching.


Static stretching should also be performed after playing or training.  It can be performed as part of a daily routine, or for relief at any time the calf feels tight.


Other ways to stretch the calf:



Calf stretching occurs with a number of yoga poses, including downward dog.  These incorporate other muscles, fascia (or connective tissue) and the “posterior sling” which includes the structures at the back of the leg and spine.  This is more of a “whole body” stretch incorporating sciatic nerve and hamstrings, gluteals and back muscles, which can add benefit to a calf stretching programme.


Eccentric strengthening exercises (muscles lengthening as they contract) have been found to increase fascicle length in the muscles, and so increase flexibility.  An example for the calf is returning down from a calf raise exercise.  Dead-lifts, although mostly eccentric strengthening for the hamstring may also incorporate the calf and help lengthen and strengthen it.


Dynamic stretching such as squats, lunges, leg swings, and calf raises on a step, can also help keep the calf flexible.


In Summary:


Keep the calf muscles flexible using static stretching – either isolated to the calf or involving other muscles.  Closer to a match or run, dynamic stretches are preferable.  Eccentric strengthening also improves calf muscle length.  To reduce over-reliance on, hence tightness in, the calf muscles, make sure other leg muscles are strong to assist in propulsion during sport.


The Brain that Changes Itself Altering Pathways to Reduce Pain

Admini Si - Monday, August 08, 2016

Blog by Dione Barrett, Physiotherapist at Macquarie Street Physiotherapy Centre:

My physiotherapy colleague, Lisa Smith, and I recently had the privilege of attending a two-day conference conducted by Norman Doidge. He is a Canadian-born psychiatrist and author of the popular books "The Brain That Changes Itself" and “The Brain's Way of Healing."


Neuroplasticity

Norman Doidge along with other researchers and clinicians are leading the field in new ways to attack old problems by understanding neuroplasticity. Neuroplasticity, also called brain plasticity, is the process in which the brain's neural synapses (connections) and pathways are altered as an effect of environmental, behavioural, and neural changes.

Practice makes Perfect

Norman Doidge talks about “purposeful practice” in order to effect a change in neural pathways. Matthew Sayed also addresses this changeability in his book “10 000 hours”. Sayed points out the key elements to becoming successful in your field of expertise. One of the crucial components is purposeful practice over an extended timeframe. Doidge supports the effect this phenomenon has on success due to the effect on the brain.

When the Brain registers Pain.

Acute pain often starts in a familiar way - the body is exposed to painful stimulus – and the message travels from the tissues (for example, a disc injury in the lower back) to the brain. The brain registers the stimulus as pain. With ongoing, chronic pain, something has gone amiss, and the brain maintains the perception of threat or injury out at the periphery. Despite the threat no longer existing (long after the tissues of the back have healed) the brain still perceives that pain exists in the body. Chronic pain has been studied extensively. It costs millions of dollars a year as a society and costs many people their quality of life. We are only just beginning to understand what happens to drive chronic pain, and this is helped by new technology.

FMRI

Today we have technology which allows us to see what is happening in the working brain through the use of Functional Magnetic Resonance Imaging (FMRI). A brain that is registering pain looks very different on FMRI to a brain that is not registering pain. Norman Doidge describes the brain of patients with intractable pain as if a brush fire had gone through it.

Case 1:

Doidge describes the case of a man with intractable pain who was educated about the difference between pictures of brains experiencing no pain and those with pain. The man took the image of a brain that was pain-free, and every time pain was experienced he actively and vigilantly imagined the picture of the brain without pain. Initially, there was no apparent change, but the man persevered. Using this imagery in his meditation over a two-year period, he was able to eventually resolve the pain. Amazingly, his FMRI pictures changed to that comparable with a pain-free brain. The rewiring of neural circuits allowed a normal function to return. He had actually changed the workings of his brain.

Such imagery has been used effectively with elite athletes to visualize positive outcomes from the performance. We now understand better why this works, and visualizing the pain-free brain is not dissimilar.

Case 2

A similar process was described with a Parkinson patient called John Pepper. One of the traits of Parkinson’s disease is a poor initiation of movement. This makes walking very difficult and often their gait is shuffling in appearance. John Pepper worked out that if he cognitively analyzed walking and thought about every movement as he walked he could use a part of the brain unaffected by Parkinson’s and override the shuffling gate. Again this required vigilance, persistence and an extended period of practice to overcome the rigidity of his movement.

These are two examples where using cognitive methods to retrain automated systems within the brain have been effective in overcoming a deficit in the brain.

Why is this relevant to what we do as physiotherapists?

The main reason people come to see a physiotherapist is pain.

Daily we see people who are in pain. As a result, they may have altered the normal movement of their body. In the early stages, this is a protective mechanism to avoid aggravating pain. But over time, altered use of muscles and joints may lead to muscle weakness or tightness in the affected area. Joints may become stiff if not regularly used and in good alignment. Long after the injury has healed, the resultant altered movement patterns may of themselves cause pain. From the above research, we now know there may be altered brain pathways as well, which keep registering pain.

I have taken these modern theories and used Norman Doidge and Matthew Sayed’s theories to get patients to actively focus on using the muscles that should be used, introducing a strong cognitive element to exercise. In addition, patients can use imagery to picture activating the correct muscle, once they have been educated about the anatomy. Encouragement is given for the patient to purposefully practice using the muscle in daily activities to restore normal body and brain function.

Physiotherapists can be mentors in showing patients how to move properly and educating them regarding their body. It is also our job to educate our patients about the science behind a purposeful practice, so they can be engaged and motivated with the exercise and advice we give. We welcome people experiencing chronic pain to attend Macquarie Street Physiotherapy for expert advice.

Exercise, Tendons and Tendinopathy

Admini Si - Monday, May 30, 2016



A tendon is a structure which joins muscle to bone. It is white, non-contractile tissue made up mostly of collagen. It may be rope-like (e.g. biceps tendon), or flatter (e.g. rotator cuff tendon). It may be thin or thick depending on the size of the muscle and the load it is carrying. Its function is to transfer load from muscle activity through the skeleton to create movement.

Tendinopathy refers to a disorder or disease of Tendon. Tendinitis or tendinosis both fall under the umbrella of tendinopathy. Examples of tendinopathy often heard are Achilles tendinitis, Patella tendinitis, Tennis elbow, Golfers elbow, and Gluteus Medius tendinopathy (often in conjunction with trochanteric (hip) bursitis).

Research about Tendons

There has been a lot of research into tendon pathology over the past 10-15 years, largely because it is a common problem, often slow to respond to treatment, and because there has been disagreement about which is the best course of action (stretching, strengthening, injection, surgery, etc.). Recent research has helped us to understand how the tendon behaves when exposed to load, how to determine the stage of the tendinopathy, and which type of treatment is likely to succeed. 
 
Causes of Tendinopathy

Tendons are very good at adapting to gradual increase in load requirements (sport or other activity). Tendon break-down occurs when load requirement on the tendon increases quickly, and so exceeds the tendon’s capacity. This may be a sudden increase in training speed or distance, or taking on a new sport. It may relate to increase in work duties as a hairdresser (eg blow-dryer) or carpenter (eg screwdriver).

A percentage of tendinopathies are caused by compression or trauma, rather than by tensile load through the tendon. An example of compression is the effect on the gluteal muscles of crossing legs in sitting.

Some systemic diseases such as diabetes, and some medications, make people more prone to tendon problems. Age and weight are also factors which increase the likelihood.

Symptoms of Tendinopathy


Where is the pain?

Tendinopathy will be felt very locally at the site of the problem, not a diffuse ache, or radiating pain.  

What aggravates the pain?

Pain will often be worse first thing in the morning, or having been still for some time, and eases off with movement.  It is usually worse after any exercise which puts load through the tendon (e.g. after jumping sports when there is heel pain (Achilles tendon).


Imaging for Tendinopathy

Ultrasound and MRI are both able to detect tendinopathy. A negative or positive finding may be useful in diagnosis, but not particularly useful to gauge the stage of the tendinopathy or if the function is improving. That is, a lack of change on imaging does not indicate a lack of improvement.

In one study of women > 50 years old with no symptoms, 50% had Achilles tendon pathology detectable on ultrasound.


Treatment of Tendinopathy

Recent research has shown that of all possible types of treatment, exercise therapy is the best for tendon problems.

For a number of conditions, rest is prescribed for healing to occur. However, in the case of tendons, better results have been found with loading the tendon in a way that strengthens but does not cause pain during or after the exercise. The stages of rehabilitation often take the following path, but it varies with each individual:

Early exercise may include isometric holds where there is muscle activity but not movement, e.g. static calf raise for Achilles tendinitis. This strengthens muscle tissue, and creates anabolic tendon change and reduced inhibition from the brain. Indeed, research has shown this type of exercise not only increases tendon capacity, but also affords pain relief.


Later exercise may include heavy, slow resistance (HSR) within the pain-free range of movement (e.g. slow, weighted quadriceps curls for patella tendinitis). This is based on the fact that tendons better tolerate HSR than fast movement. This may be eccentric (lengthening the muscle) or concentric (shortening) or both. It depends on the individual, the sport, and what can be done within limits of pain.

 

Gradually speed can be introduced into the rehabilitation programme.  It would not usually be for some weeks or even months that very dynamic exercise can be commenced, such as jumping or running, as this is when the tendon needs to be particularly spring-like and resilient.

Forms of treatment such as ultrasound, shock-wave, injection, ibuprofen, etc. may be an adjunct to exercise therapy.  However exercise is essential; without it, the functional capacity in the tendon cannot increase.

Prevention

Correction of footwear and exercise technique may help prevent tendon problems from returning. Also between-season training should continue so that early-season tendinitis does not occur when there is a sudden increase in activity.

Tendon tissue is laid down and made stronger in the years prior to puberty. For this reason, exercise in children is vital for tendon strength.

Physiotherapy

Physiotherapists are well-placed to treat tendinopathy due to their familiarity with using exercise as treatment, and in analysing sports action, using taping/bracing and local treatment, and instituting preventive measures. Please seek the help of any of the highly qualified physiotherapists at Macquarie Street Physiotherapy if you think you have tendinopathy.



Benign Paroxysmal Positional Vertigo – Symptoms, Causes and Treatment

Admini Si - Tuesday, October 06, 2015

Prepared by Dione Barrett, Musculoskeletal Physiotherapist, Macquarie Street Physiotherapy

 

Do you feel like the world is spinning? You are nauseous, unsteady on your feet, feel like you are going to fall over, you can barely get out of bed and you just want to curl up and die.

Welcome to the world of BPPV, otherwise known as Benign Paroxysmal Positional Vertigo. It sounds very complex but it simply means harmless dizziness that comes and goes depending what position your head is in.

What is happening to me?  

Most of us just wake up with it for no reason at all. You may notice you roll over in bed and the whole world spins. Usually this will happen on one side only. You may also notice it bending over the tie your shoes or pick up something or when looking up to get something out of a cupboard. The dizzy feeling will feel absolutely terrible when it happens. BUT, there is some good news. It should last for only a few seconds and then subside. Despite this you will most likely feel nauseous for the first few days after the dizziness starts. Anti-nausea medication is effective in controlling this, but you will need to see your GP for a prescription.

What causes BPPV?  

BPPV is caused by small crystals in the inner ear dislodging from where they normally sit. The inner ear is made up of 3 canals that are filled with fluid. These canals connect to a vestibule which contains tiny hairs. Crystals sit on top of hair cells. The crystals weigh the hair cells down and respond to gravity. So when you bend your head to the side the crystals and hairs also bend to the side. The fluid moves in the canals, your eyes tell you your head is leaning to the side and the receptors in the joints of the neck tell you your neck is bending to the side.

When all the information matches you feel quite normal, but when the crystals dislodge they get stuck in the fluid filled canals where they are not supposed to be and the brain thinks the canals are giving it information that the head is moving. This mismatch in information between the eyes and neck and the fluid means we feel dizzy.

So what can we do to end this nightmare?  

If you have ever had BPPV you will know how hideous it feels and how frightening it can be to feel like you might fall over.

The course of BPPV may follow a couple of different paths. Sometimes it just goes away of its own accord. Big sigh of relief! But most frequently the dizziness persists and treatment is required.

Testing and Treatment  

Your GP or physiotherapist trained in this area, can assess you to see if you have BPPV by performing a Hallpike manoeuvre. If this test is positive your physiotherapist can perform a series of head movements that repositions the crystals back to where they will not cause you any trouble. This manoeuvre is quick, non-invasive and has good results. 80% of people will respond to one treatment, and a small percentage will need another treatment a week later. This mostly fixes the problem but in a very small percentage there may be persistence of symptoms.

What happens after treatment?  

You will feel a bit like you have been on a boat for up to a week after the manoeuvre is performed. However, what usually happens is there is a 10-15% improvement in your symptoms each day such that by a week after you are better. If you are not 95% better within a week following the manoeuvre, that’s when you need to second treatment.

Most people never have a recurrence of dizziness again. But a small number have repeated bouts and need treatment intermittently.

Pesistent dizziness – two possible causes:  

1) Following a bout of BPPV a small percentage of people develop a baseline “thick” feeling in the head. This can often be due to the joints in the upper neck, and a couple of treatments by your physiotherapist can resolve this problem quickly.

2) Some patients develop Psychosocial Anxiety following an episode of BPPV. This subconscious brain patterning maintains an element of dizziness, which can persist for years. It has a different cause from the original dizziness and it can be quite debilitating. There are approaches and treatment available for this form of dizziness, which you should discuss with your physiotherapist.

At Macquarie Street Physiotherapy we have two physiotherapists who are trained to identify and treat your dizziness. They can help make you more comfortable and confident that the world will keep turning, instead of spinning!

Benefits of Visiting a Physiotherapist

Admini Si - Thursday, September 24, 2015

 

Why visit a Physiotherapist?  

This is a good question, particularly considering there is choice between many different therapists available. When you have pain, you are vulnerable to the advice of many people.

Everyone wants you to see their therapist!

Fortunately for you there is Physiotherapy!

When you go to a registered physiotherapist in Sydney, you know that they have completed at least a Bachelor of Applied Science from a recognised university in order to be allowed to register to practise. Most physiotherapists (all at Macquarie Street Physiotherapy) become members of their professional body, the Australian Physiotherapy Association (APA). This association provides continuing education and advocacy for physiotherapists, and advice to the public, among other things. The letters APAM after your physio’s name demonstrates that they are a member of the APA.

A reflection of the professional standing that physiotherapy has in the medical community is that one no longer needs a doctor’s referral to visit a physiotherapist. If further medical imaging or opinion is required, it is understood that the physiotherapist has the expertise to decide upon and arrange this.

Physiotherapy prides itself in adhering to “evidence based practise” – this means that assessment and treatment techniques used by physiotherapist are backed up by research, rather than just “anecdotal” (unsubstantiated) evidence.

How did the physiotherapy profession develop?  

Physiotherapy has developed from a medical background – in the late 1800s throughout the world, there were medical practitioners seeking other forms of specialised knowledge and skills. One of the areas was physical treatment - exercise and massage. Massage was becoming recognised as useful to encourage healing by promoting circulation to the area of injury. The Australasian Massage Association was formed in 1906. Progressively, various other forms of treatment were added: ‘gymnastic’ exercises, medical ‘galvanism’, passive movement, postural drainage and manipulation. These types of treatments were closely associated with improvements and changes in the medical world.

World wars in the 1900s resulted in wounded soldiers requiring rehabilitation. This further advanced our approach to physical therapy. The name of the profession was changed from ‘massage’ to ‘physiotherapy’ in 1939.

Physiotherapy and Medicine  

Physiotherapy has continued to have a close connection with the medical and surgical world, there being physiotherapy departments in hospitals, inpatient and outpatient rehabilitation, pain management services, as well as private physiotherapy clinics.

When you seek the opinion of a physiotherapist today, they will have had experience in hospitals either as a student or a professional. They are familiar with pre- and post-operative patient requirements. Therefore you can have confidence in their skills to treat you after surgery or a stay in hospital for other reasons.

How can a Physiotherapist help?  

A great strength of the physiotherapy profession is assessment. Rather than treating all patients in the same manner, physios seek to find the source of the problem and tailor the treatment to the individual.

If you require more than a clinical assessment, liaison with your doctor regarding X-ray or MRI imaging, blood tests or referral to a medical specialist, this can be arranged.

What treatment will a physiotherapist give?  

Although hands-on treatment (mobilisation/massage) is regarded as an integral part of treatment, exercises and education are equally important. This gives you the ability to improve your situation further when at home, at work or at the gym. It reduces your reliance on coming in for physio, so that the number of treatments you require can be minimized. If you are able to have a ‘toolbox’ of exercises or positions you can use to make yourself more comfortable, you feel more in control of your situation. It may be that you then consult your physio intermittently or less frequently for review, depending on the problem.

How do I find a Physiotherapist?  

There is a “Find a Physio” tab on the Australian Physiotherapy Association (APA) website, which directs you depending on speciality or location.

As with any profession, trade or business, it is helpful to be recommended by someone you trust.

This may be your doctor, or other health professional. At Macquarie Street Physiotherapy half of our referrals are from friends, family and colleagues who have been satisfied clients of ours.

Overview   

Whether your problem relates to work, sport, or too much sitting and whether it be relating to joints, muscles on the spine, there is sure to be a physiotherapist to assist, educate and provide treatment of your problem.

At Macquarie Street Physiotherapy there are three physiotherapists, all with post graduate qualifications. As such we boast a broad range of experience and skill in management of musculoskeletal conditions.

Hip Pain and Bursitis

Admini Si - Friday, May 01, 2015


 

A commonly seen condition at Macquarie Street Physiotherapy is known as trochanteric bursitis, or more specifically titled Greater Trochanteric Pain Syndrome (GTPS). This is a condition commonly seen in women, particularly post-menopausal women, whereupon pain is felt over the lateral (outer) part of the hip. Typically it is made worse with lying on that hip, using stairs, crossing legs, and sitting in low chairs. Exercise such as walking is made more difficult due to this pain.

Interestingly, GTPS is not a hip joint or back problem, and is sometimes misdiagnosed. It was thought originally to relate mostly to the bursa (fluid filled sac) which is found on the lateral bony prominence, the greater trochanter. We know now that tendons which insert into the greater trochanter (those of the gluteus medius and minimus muscles) along with this bursa, are often involved in this condition.

Causes of trochanteric pain  

There are a number of possible causes of GTPS. They include posture, strength, skeletal structure and hormones.

Posture  

Standing and sitting posture can put strain on the outer muscles of the hip. Gluteus medius and gluteus minimus have the primary function of stabilizing the hip on the pelvis. These muscles work to avoid a “catwalk” style of walking which puts strain on hip, pelvic and lower back joints. If we walk in this style, the muscles have to shorten and lengthen repetitively, which is not their usual stabilizing role. This can cause strain on these muscles, as does standing on one leg and hanging the other hip. Ideally we should “walk tall” without side-to-side sway, and stand with weight evenly on both legs.

Sitting on a chair with one knee crossed over the other also can put the gluteal muscles of the top leg under constant stretch, which can be a cause of strain and pain. Better sitting posture is to keep the legs uncrossed, or if necessary crossed at the ankles, which helps these muscles as well as the blood vessels which travel down the leg. So while you are sitting better for your hips, you are also reducing strain on your veins and therefore the incidence of varicose veins.

Strength  

One of the best ways to avoid straining the gluteal muscles is to keep them strong. Avoiding the postures noted above, as well practising specific exercises can help reduce strain on these muscles and the trochanteric bursa. These exercises include squats, steps, lunges and any single leg balance exercise where good form is maintained. For those whose knees don’t tolerate squats, holding a squat position with one leg while moving the other (like dancing the “Nutbush”!) help to strengthen the standing leg.

Skeletal structure  

There may be more difficulty in maintaining lateral hip stability in women than men, particularly in women with wide hips. This is due to a greater “Q-angle”, between pelvis and femur (thigh bone), in this population. This places the gluteal muscles at a relative disadvantage as they have to work around a greater angle.

Hormones  

One cause currently under scrutiny is the positive impact of oestrogen on tendons, and the effect of its reduction during menopause. In post-menopausal tendons there is reduced collagen production, decreased tendon integrity, and an increased rupture rate. It may be that hormone replacement therapy can help reduce pain and dysfunction associated with tendinopathy. This would help explain why the majority of those suffering from this condition are post-menopausal women. This is an area of research currently under study.

What should I do next?  

Contributing factors which are most easily addressed relate to back, hip and leg posture and strength. For this reason, your doctor may suggest you seek a physiotherapy opinion first. At Macquarie Street Physiotherapy, we look at your posture, core stability and hip and leg strength. Part of this assessment may include analysing your walking or running gait on the treadmill. It may look at your ability to squat, rise from sitting and other functional tests. Based on our assessment, we guide you through any hip-specific postural changes to be made and exercises/stretches to be done. Local treatment may include massage, ultrasound and stretching. It may be that a soft mattress overlay also reduces the pain at night. At every stage the aim is to reduce the pain you experience.

Anything else?  

If physiotherapy alone is not enough to completely resolve your symptoms, we would liaise with your doctor about anti-inflammatory medication, cortisone injection, imaging or referral to a sports physician or orthopaedic specialist. We look forward to giving your hips a helping hand!

 

Back Pain and the “Slipped Disc”

Admini Si - Monday, April 20, 2015


 

Acute (recent onset) lower back pain is commonly seen at Macquarie Street Physiotherapy. 80 percent of people will experience lower back pain at some time in their life. Whether it be quite debilitating or just bothersome, it is worthwhile having your back pain checked out. If pain is related to a disc injury, management of it may be different than if you have a spinal joint sprain or back muscle spasm.


“Slipped Disc”   

Sometimes the term “slipped disc” is used to describe a disc injury. However, the disc doesn't actually "slip". Nor can it be "put back in". Part of the jelly-like inner part of the disc (nucleus) can escape through a weakening in the fibrous outer layer (annulus). This is known as a herniation. The three classifications of a herniated disc are protrusion, extrusion and sequestration. A disc bulge implies that there is pressure from within the disc on the annulus, pushing it out, without a disc rupture.

As a general rule, irritated or injured discs do not like the “flexion” activities of bending, sitting and lifting. These activities put more strain on the disc. Chances are you are happier to be upright and on the move if you have a disc bulge or prolapse.


Spinal joint sprains or back muscle strains   

If your back pain is due to joint or muscle injury, it may also not like bending, but problem movements are more likely to include getting up from sitting, and twisting or standing.


Combination back pain  

In many situations there is a combination of disc, joint and muscle involvement causing back pain, especially if there are degenerative changes which involve both discs and joints. These changes can be seen on x-ray, CT scan or MRI. It is interesting to note, however, that 25% of asymptomatic (pain-free) patients below 60 years old show disc herniation on MRI. In the population over 60 years, this number is increased to 33%. This suggests that a disc herniation will not always cause pain. The findings on any scan need to correlate with clinical findings in order to be relevant and determine the plan of action.


Treatment of Back Pain  

When there is a disc injury, there is a significant chemical inflammatory reaction. This inflammation alone can cause the pressure on a nerve which might give sciatic pain down the leg. As such, initial management needs to concentrate on reducing inflammation. This can be achieved by rest from aggravating activities, avoiding bending, lifting and sitting, using anti-inflammatory medication, and ice. Physiotherapy for “slipped disc” may include spinal rotations, extension in lying (McKenzie exercises) as well as therapeutic ultrasound, strapping or bracing. Exercises to improve core muscle recruitment may be used, as well as stretches for tight surrounding muscles (e.g., hip muscles).


Recovering from back pain and disc injury  

Most disc injuries heal with no need for surgery. If there is leg pain associated with the problem and treatment results in “centralisation” (pain moving closer to the back, and out of the leg) this indicates that treatment is being successful.

If back pain is due to muscle spasm or joint sprain, this often responds well to spinal mobilisation and massage.

At Macquarie Street Physiotherapy we see back pain in all its forms and will be able to treat you or direct you for further tests. These tests, along with specialist referral, are particularly important if your back pain is associated with significant leg pain, weakness, numbness or pins and needles.


Prevention  

Many back injuries occurs as a result of a trivial movement on a background of instability or poor posture. For example, acute pain can result from bending to pick a pen from the floor. Functional stability appears to be a paramount necessity for efficient movement and to reduce mechanical stress on the back. This stability is derived from postural training and specific exercises to improve motor control of both the deep core muscles (transversus abdominus, multifidus, pelvic floor and diaphragm) and the outer core (obliques, and rectus abdominus muscles). A general fitness programme is also helpful: this ensures activity of other important muscles, such as gluteals, and thigh muscles.


Chronic Pain  

If you have chronic (longstanding) back pain, whether it be due to disc injury or other cause, the direction of treatment is more to do with exercise and movement, as inflammation is usually not a major factor. Hands-on treatment may still be necessary, but emphasis will be on moving well and moving often. Your physiotherapist can help determine whether your problem is to do with too much or too little activity.

New Studies on Diabetes and Recovery After TKR and Other Physiotherapy Solutions

Admini Si - Saturday, March 21, 2015

 

The following two points summarize research that has been presented in the Journal of Physiotherapy, December 2014:


Diabetes and recovery after Total Knee Replacement (TKR)   

The risk of complications for diabetic patients after TKR is only increased if the patient finds pre-operatively that their diabetes impacts on the conducting routine daily activities. Physiotherapists can therefore identify people at risk of a slow or complicated recovery after knee surgery simply by looking into how people are finding diabetes is impacting on day-to-day life.


Kinesio taping for drainage of ankle swelling  

The Kinesio taping technique has become a popular treatment with athletes – most people have seen various sportspeople with this stretchy colourful tape supporting muscles or joints. A recent study from Brazil hoped to show that application of the tape also reduces swelling after acute injury. However, this particular study showed that while not questioning the benefit in terms of support, there was no particular benefit in reducing ankle swelling after acute injury. Further research will likely be conducted in the future, as reducing swelling after injury is an important early step in recovery.

The following was from “Research Roundtable” article in APA’s InTouch magazine, Issue 2, 2014


Treating a “droopy” shoulder blade  

Often we are told that shoulders need to be kept “down and back”, and in certain people who shrug their shoulders habitually, this may be good advice. However, research into shoulder pain in people with “droopy” (or downwardly rotated) shoulders shows that this one-size-fits-all approach does not work. These people need to be given exercises to increase the strength of upper trapezius muscles, and research in this area shows that such exercises reduce shoulder pain in these cases. An exercise as simple as a shrug will help recruit upper trapezius and allow the shoulder to move more normally. With the scapula correctly positioned, theraband exercises can then be used for strengthening rotator cuff and then develop into sports-specific strengthening. Your physiotherapist will tell you which type of shoulder exercise is best for you.

The following is based on an article titled “Eye on Research” in InMotion magazine, June 2014, which looked at the APA members who were conducting research and innovative change in the public sector:


Physiotherapists in the Accident and Emergency department.   

Musculoskeletal problems are one of the most commonly managed problems in the Casualty department of hospitals. In this acute setting, a high proportion of patients, once assessed, need casting, splinting, tape, crutches, advice. These are areas of expertise for physiotherapists, who can take the load off doctors and nurses who are needed for other urgent medical conditions. More and more, Accident and Emergency departments are employing physiotherapists to treat musculoskeletal conditions. This means that patients are also educated about whether they need to see a physio further down the track.

In addition to this, in Queensland, the Orthopaedic Physiotherapy Screening Clinic and Multidisciplinary Service has been an innovative model of care for the management of patients who are referred by their GP for outpatient specialist consultation at public hospitals. These patients can be waiting many months to see a specialist, so are referred to the Screening Clinic. Here they screen and select the ones who are appropriate for non-surgical management. Physiotherapy treatment is then provided along with possibly occupational therapy and social work, depending on the circumstances. This type of clinic is now successfully operating in 13 Queensland hospitals.

 

New: Joint Disuse as a Factor for the Onset of Osteoarthritis

Admini Si - Wednesday, March 18, 2015

Physiotherapists at Macquarie Street Physiotherapy are all members of the Australian Physiotherapy Association (APA). We receive monthly journals and newsletters about current research. The following comes from APA’s “InTouch” magazine for Musculoskeletal Physiotherapists:

These four points are summaries of latest findings from the Centre for Musculoskeletal Research, Griffith University:


Knee and Hip Osteoarthritis (OA)  

Researchers are examining the factors which lead to the progression and onset of OA. One of the main causes of OA is sporting injuries to these joints. We are seeing that loss of muscle appears to be a main determinant of development of OA. For example, subjects who had undergone anterior cruciate ligament (ACL) reconstruction tended to under-load, rather than overload their joints, and therefore it could be under-loading and disuse (followed by bouts of overloading) rather than consistent loading that is causing progression of osteoarthritis.

From a rehabilitation point of view, this knowledge is enabling physiotherapists to prescribe better, specific exercises for individuals, rather than using a recipe of exercises. It also encourages long-term attention to maintaining strength. At the Griffith University, a specific programme relating to strengthening the medial (inner) knee muscles has been developed – keeping this muscle strong and active in daily activities may help to slow progression of knee OA.


Tendinopathy  

Research is looking at the best combination of treatment for tendinopathy (eg Achilles tendinitis, tennis elbow and patella tendinitis) It continues to support the use of specialized exercises, in combination with injections. Alternatives to corticosteroid injections that are being looked at include PRP (platelet-rich plasma) and prolotherapy injections. The specialized exercises which load the tendon in a way which assists healing without aggravating the problem are eccentric (lengthening) exercises. An example of eccentric exercise is lowering the affected heel down from a calf raise for Achilles tendinitis. It is hoped that the best combination of treatments will result in the best outcome for the many people who suffer from tendinitis.


Preventing falls and fractures  

Adolescence is the time in life where building bone density is vital. The Centre for Musculoskeletal Research is instituting regular in-school training programmes which involve jumping and impact in order to improve bone density and muscle mass in adolescent boys and girls. This will give them an advantage as older adults when loss of bone density begins.

Osteoporosis is a disease in which bones lose calcium and become brittle, making them more likely to break. Women are at a greater risk because of the rapid decline in oestrogen levels during menopause. Bone loss of approx 2% per year occurs for several years after menopause, and 50% of all women have osteoporosis by the time they are 70 years old. At 70 years old, 30% of men are affected.

In older adults, high intensity strength training is being researched for post-menopausal women. These exercises programmes focus on trying to reduce the risk of osteoporotic factors, reducing falls and the consequence of falls if they do occur. Balance exercises are also an important part of training older adults. As with all exercise the body accommodates and it is being found very important to vary, challenge and ensure that the exercise is performed correctly. Also being researched is the use of parathyroid hormone to accelerate the healing of stress fractures.


Gait analysis  

The Centre for Musculoskeletal Research is also developing and implementing state of the art gait analysis methods which combine MRI and “motion capture” to provide highly detailed movement and muscle function data to help in planning treatments. This is being trialled in children with Cerebral Palsy in particular, but will have wide-reaching benefits for anyone whose gait is affected by conditions of the brain and central nervous system

For more information about research conducted at Griffith University, visit griffith.edu.au/health/musculoskeletal-research.

 


Macquarie Street Physio