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  • Common soft tissue injuries

    Common soft tissue injuries

    Common soft tissue injuries We are nearing the end of the year here in Australia, which means the sun is heating up and people are starting to get outdoors a little more. It’s at this time of the year lots of people head into the gym in search of a better body. Unfortunately for some, this can mean an increased risk of injury, which is no fun for anyone, especially at Christmas. We’re here to give you a little run down on some common injuries we see here at [insert clinic name]. This blog will concentrate on injuries related to ‘soft’ tissues… Namely muscles, tendons and ligaments Muscle strain A muscle is made up of groups of tiny little fibres that shorten and lengthen to create movement around a joint. Muscles are flexible tissues that can withstand and create a lot of force. Sometimes movement can place excessive load through a muscle and some or all of the fibres within it can tear. Tearing of muscle fibres is known as a ‘strain’. A muscle will commonly strain when it is overstretched. Think of a soccer player reaching a leg out for the ball, or a gymnast kicking their leg over their head. If the muscle is not able to cope with the demands of the stretch, then the only option is for the muscle to tear. A strain is graded based on the severity of the tearing: Grade 1 - a few muscle fibres are torn, similar to unaccustomed exercise strain 24-48 hours post exercise Grade 2 - more muscle fibre damage with pain lasting beyond 72 hours Grade 3 - extensive damage to muscle fibres, but not completely torn Grade 4 - all fibres are torn Common symptoms of a strain include pain, swelling, bruising, loss of function and weakness. The range of symptoms depend completely on the severity of the strain. A low-grade strain is often painful with minimal loss to function and strength. A high-grade strain is often very painful with swelling, bruising, complete loss of strength and reduced function in the affected body part. Ligament sprain A ligament is a strong band of tissue that joins a bone to a bone, creating a joint. Ligaments provide stability at a joint, making them quite inflexible compared to muscles. They have to withstand extremely large forces that run through the body when we move. Therefore, it makes sense that it requires a very large force to injure one. Take a rugby player who gets tackled with their foot firmly planted on the ground as the opposition player runs into the side of their legs. The excessive force of the tackle on the knee could cause the ligaments to overstretch or tear. Tearing of a ligament is referred to as a ‘sprain’. Just like a muscle, a ligament injury is graded from one to three: Grade 1 - the ligament is overstretched but remains intact Grade 2 - some ligament fibres are torn, some remain intact Grade 3 - all fibres are torn Ligaments have a very poor blood supply compared to muscles which means they take longer to heal. If you look at muscle tissue it takes on a reddish appearance (i.e. a rich blood supply), compared to the silvery white colour of ligament tissue. Symptoms of a ligament injury again depend on the severity of the injury and include pain, swelling, bruising, loss of function at the joint, and joint instability… You may well feel a little wobbly on your feet following a severe knee or ankle sprain. Tendinopathy A tendon is what joins a muscle to a bone. It is similar in make up to a ligament in that it also has a much poorer blood supply when compared to a muscle. Tendon injury is referred to as tendinopathy and is usually broken down into acute inflammation of a tendon (called ‘tendinitis’) and chronic degeneration of a tendon (called ‘tendinosis’). Tendons are often injured due to overuse of a body part due to repetitive actions, such as throwing in baseball. Overuse of the tendon can lead to very small tears developing. If complete healing is not achieved before re-injury, the problem can progress. A single large force put through a tendon can result in an acute episode of pain and inflammation. If a force is large enough, or a tendon has become degenerated over time, it is possible for the tendon to tear in part, or completely. Symptoms of tendon injury include pain (often before and after activity), possible swelling, and reduced function and weakness of the affected body part. Because of the poor blood supply, tendons, like ligaments, can take quite some time to heal fully. Treatment and prevention of injury Each one of the injury types above is managed differently, and healing time depends on the severity. With any acute injury you’re pretty safe following the RICER protocol from the off (remember rest, ice, compression, elevation and referral). However, we recommend you get in touch with your us straight away because we will be able to get our hands on you to start treatment, as well as give advice on the whole rehab process. It is especially important to know when to begin putting load through the injured tissues again to ensure you decrease your healing time and any potential after-effects of the injury. Remember that prevention is always better than cure. We recommend you always warm up before performing your activity. A good rule to follow is warm up with exercises that are going to prepare your body for the activity you are about to perform… For soccer, warm up with ball drills, light jogging, short sprints, jumps and dynamic stretches (i.e. stretches with movement). It’s best to save your static stretches (i.e. held stretches) for your post-match cool down! If you need help with an injury or want further advice on how to prevent injury in the future, call our clinic on 02 9922 6806 or speak to your physio during your next session. References 1. Physiopedia. 2019. Muscle strain. [Online]. Available from: https://www.physio-pedia.com/Muscle_Strain. [Accessed 5 Nov 2019]2. Physiopedia. 2019. Ligament sprain. [Online]. Available from: https://www.physio-pedia.com/Ligament_Sprain. [Accessed 5 Nov 2019]3. Brukner, P. and Khan, K. 2017. Clinical Sports Medicine. 5th ed. McGraw Hill Education : Australia Uploaded : 22 November 2019 Read More
  • An unusual case - femoral artery compression

    An unusual case - femoral artery compression

    An unusual case - femoral artery compromise A 23 year old female cyclist presented with a 2 week worsening history of severe anterior and posterior hip pain when sitting, intermittent 'giving way' and 'loss of power' in the knee, especially worse going up stairs and going from sitting to standing. She reported a minor fall onto her right side a few weeks previously whilst mountain biking. Otherwise, no previous history of any specific injury to that area, however a few major falls off bikes over the years, but nothing serious enough to require hospitalisation or on-going treatment. Examination revealed a clinically stable knee. Step ups were described as weak but no 'giving way'. Knee extension strength was reduced. Sciatic nerve mobility testing was within normal limits. Hip flexion was uncomfortable but didn't reproduce the intense pain which she was describing. Ranges of motion testing of the hip, in flexion,were otherwise unremarkable. Gaenslen's testing in hip extension revealed some limitation of the Psoas Major and Rectus Femoris.   Patrick FABER's testing was full range as were other hip and SIJ tests Prone Knee Bend testing for femoral nerve demonstrated some restriction in movement as well as some sensitivity and restricted movement in the upper lumbar spine    At this stage of the clinical reasoning process, things weren't getting any clearer. I noted previously that the foot seemed a little cold, I then asked her to return to supine, where i questioned her on any recent plane travel. An adventure racing friend of mine had a pulmonary emboli from a DVT in the abdominal region after spending time at altitude in Tibet and then flying home to Switzerland. I also quizzed her on any Leyden's Factor V or other clotting issues either diagnosed in herself or in someone in the family. I tested the femoral pulse superior to the inguinal ligament and it seemed quite strong. She was not taking anti-coagulants but was on the contraceptive pill. I decided to treat L1-L3 with joint mobilisations and the anterior hip with various techniques, including soft tissue massage, trigger points to the iliacus, quadriceps and adductors. Hip traction at 90 degrees flexion 'felt good'.The combined treatment improved the quads strength. However, I still didn't feel convinced that either the history or the physical examination and treatment had really explained the symptoms. Five days later I received a phone call from her where she said she was falling frequently and that she could not sit due to extreme pain. I suggested to go to accident and emergency since the situation sounded desperate. Several tests were conducted, including a CT to the abdominal cavity and a doppler ultrasound which revealed a mass pressing on the femoral nerve and artery. Emergency surgery was peformed where a haematoma was discovered. This was evacuated resulting in an almost full immediate recovery. Some loss of quads strength was still evident 6 weeks later but was purely clinical.   Reviewing the literature revealed this to be a rare clinical presentation in the absence of taking anti-coagulant medication. When it did present, it was most common post surgically or in young adults and adolescents. "Compression of the femoral nerve secondary to iliacus haematoma is widely reported in patients with blood coagulation disorders and those on anticoagulant treatment. Femoral nerve palsy caused by traumatic iliacus haematoma in the absence of bleeding diathesis has not been reported widely in the literature. All published reports occurred in young patients aged between 12 and 24 years and most cases were precipitated by a traumatic injury while participating in sport. Haematomas in this region present insidiously and are not heralded by an obvious lesion or ecchymosis. Patients initially complain of groin pain with the onset of neurological symptoms occurring as late as 10 days following the injury. The differential diagnosis for this syndrome is large and early recognition requires a high level of suspicion. A simple muscular strain is a common diagnosis in young athletes and can mimic iliacus haematoma in the early stages, and is regularly treated with non-steroidal anti-inflammatory drugs. These drugs have been implicated in the progression of the haematoma in a number of published cases. The most common mechanism of injury in reported cases is a fall onto the back or buttocks, although more indolent precipitating injuries are described. Direct trauma to the pelvis or hyperextension of the hip may result in muscular tears leading to iliacus haematoma. Two separate syndromes of lumboscacral plexus compression are recognised. The entire plexus can be compressed within the psoas muscle resulting in weakness of those muscles supplied by the obturator and femoral nerves. Alternatively, the femoral nerve is compressed as it passes through the closed fibrous compartment formed by the iliac fascia and the ileum." Murray et al (2010) ttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027788/  Uploaded : 2 November 2019 Read More
  • Tape, tape and more tape!

    Tape, tape and more tape!

    Tape, tape and more tape! Have you ever been to see your physio and left with some additions stuck on your skin? Taping is a very popular technique used by physios in the treatment and prevention of musculoskeletal injuries. There are various types of tape, ranging from rigid to more flexible kinesiology (you may hear this referred to as K-tape) or active tapes. Here is the low-down on some different types you might come across during your time with your physiotherapist. Rigid strapping tape This is one of the most common and more conventional forms of tape used by physios globally. As the name suggests, it is rigid (i.e. it does not stretch). It is usually light brown or beige and is designed to hold firm, making it ideal for providing support or stability to a joint. Let's give you an example… A footy player has rolled their ankle and is returning to training after an intensive rehab period. Their physio may decide to apply rigid tape around their ankle for a few reasons; it will provide a barrier stopping the ankle from rolling again, but will also give the player confidence and an ability to play without fear of re-injury. It won’t be the aim of their physio to keep applying it every time they play, but it may be beneficial in the short term while the player is still working on match fitness. Other common areas of the body where it’s used include: • Across the front of the knee to aid with kneecap alignment during movement• Under the arch of the foot for people with flat feet that require extra support• In the management of pretty much any ligament injury in the knees, shoulders, fingers, ankles and feet Sports Tape This tape is a fairly rigid tape but has some degree of elasticity (approx 6%), which makes it a good tape for boney curvey regions of the body or where larger ranges of movement are required. Dynamic Tape This tape was developed by a physiotherapist on Norfolk Island which is an Australian external territory and island in the Pacific Ocean located between Australia, New Zealand, and New Caledonia, 1,412 kilometres from the mainland. It has exceptional elasticity (apprx 60%) and is very useful in areas of swelling.  Kinesiology or K-tape This tape has been developed in more recent years and is pretty much the opposite to rigid tape. This is very stretchy (approx 30% elasticity) making it pretty useless at providing stability to a joint, but it does have some very cool functions. It comes in a range of colours for no other reason than to allow a player or patient choice over which colour they prefer. Choosing a pink one over a blue one doesn’t mean you’ll get anything extra from it… They are all the same (we thought we should clear that up!). However, Japanese practitoners believe the different colours absorb different energy and hence maybe used where temperature and energy levels are part of the practitioners reasoning process.  K-tape may be used for the following reasons: • To provide moderate support to joints and muscles whilst allowing free range of motion and relieving pain. • When applied stretched over the skin, it creates a puckering effect lifting skin away from underlying tissue - this can be very beneficial in aiding blood flow and drainage of fluid from one region to another. It is also used to aid in myofascial release techniques and is often applied with the joint and muscles in the stretched position. • When applied to the skin over an injured joint, it can provide information to the brain about what the joint is doing and allow for increased muscle activation in the area. Hypoallergenic underlay Some people are sensitive to the glue used on certain tapes, in the same way people are sensitive to band-aids or plasters. In these instances, your physio will use a hypoallergenic underlay or wrap protecting the skin from glue, meaning those people who are allergic or sensitive can still get benefit from taping. Unless they are allergic to hypoallergenic tape as well, which some people are! These are by no means the only types of tape out there, but they are some of the most commonly used. There are some newer types of tape available now, including active or functional tape. This type of tape is similar to K-tape but will stretch more and is stronger and more elastic. It is particularly useful in offloading injured muscles and tendons and aiding with pain relief and recovery. Next time you are in the clinic, feel free to ask us about different types of tape. We will be in our element explaining what they are used for, and if warranted, will show you firsthand how it works! References 1. Brukner, P. and Khan, K. 2017. Clinical Sports Medicine. 5th ed. McGraw Hill Education: Australia2. Rock Tape. 2019. How it works. [Online]. Available from: https://rocktape.com.au/how-it-works/. [Accessed 09 October 2019]3. Strapit Medical Sports Supplies. 2019. Gripit activetape. [Online]. Available from: https://www.strapit.com.au/products/active-tapes/gripit-activetape-75mm-314. [Accessed 09 October 2019] Uploaded : 22 October 2019 Read More
  • Ankle Sprains

    Ankle Sprains

    Rolled your ankle? Have you ever rolled your ankle? Plenty of us have, especially people who partake in sports such as netball, basketball, volleyball, football and soccer, where ankle injuries are one of the most common injuries of all. These sports all involve pivoting, quick changes of direction, jumping and landing. The classic ankle injury involves rolling your ankle during landing on an uneven surface from a jump, or lunging for a ball during a tackle, where your foot rolls inwards and your leg outwards upon contact with the ground.   About ligaments Our ankles are stabilised either side by an outside and inside ligament (tissues that attach bone to bone). The inside (medial) ligament is much stronger than the outside (lateral) one, therefore injuries to these ligaments where you roll your foot outwards, are much less common. The outside ligament is made up of three parts - front, middle and back. The front part of the ligament is the weakest and is usually the most affected in ‘rolling’ injuries. With more severe injuries, it is possible to affect the other parts too. What happens when I roll my ankle? When you roll your ankle, forces placed on the outside ligaments may be too great, and the ligament will sprain. A sprain is broadly categorised into three grades:• Grade 1 - the ligament is overstretched but not torn• Grade 2 - the ligament is partially torn with some ligament fibres still intact• Grade 3 - the ligament is completely torn (also known as a ‘complete rupture’) Signs & symptoms As with most ligament injuries, it starts with a moment where too much strain or force is put through the joint/ligaments, and you feel something give. This is usually painful and may or may not be accompanied by a ‘pop’, which usually signifies that something has torn. Depending on the severity of the injury, you may start to see swelling and bruising appear quickly, or it may take time to develop. Either way, bruising is another sign something has torn and bleeding has occurred under the skin. Whether you can put weight through the joint and walk straight after injury is an important part of the process. If you can, this tends to indicate a less severe injury. If you can’t and require help to move off the field or court, this may mean something more serious has happened, like a fracture alongside a sprain. If this is suspected by your physio, you may be sent off for x-rays to confirm. Immediate treatment  It is important that the injury is managed well from the word go to ensure a speedy and hassle-free recovery. The first goal is to protect the joint from further injury. Depending on severity, this may require you to be off your feet for a short period, so crutches may be needed. Additionally, the use of an aircast may be required. After this, it is recommended to start putting weight through the joint to help reduce swelling and increase movement. Ice, compression and elevation are also recommended in these early stages. If it turns out you have a fracture too, there will be a short period of immobilisation in a moon boot to allow the fracture to heal.  Further treatment and return to play After the acute period is over and your swelling and pain are controlled, your physio will get to work on your ankle. You would have lost range of motion of the joints, so they will mobilise them and give you exercises to keep mobilising at home between treatments. You would have lost some strength as well, so you will need to strengthen the surrounding muscles, as well as work on other aspects of fitness including balance. During this period, you will get back to full weight bearing activities starting with walking and moving through to jogging, running, jumping and landing, adding agility exercises to retrain the ankles' ability to pivot and change direction without giving out on you again. You’ll need to complete some rigorous training before your physio clears you to return to the field of play to compete. The time it takes you to get back playing will depend on the severity of your injury, with a simple low-grade sprain taking anywhere from 2-4 weeks to heal, and a severe sprain and fracture taking months. The latter is particularly true if there is a tear of the syndesmosis and/or a Weber Fracture.  Weber Fracture Syndesmosis tears (picture c) can easily be missed and minor fractures of the malleolus can masquerade as acute tendonosis. Tears of the syndesmosis can lead to a chronically unstable ankle. These conditions are often treated in a moon boot, but occassionally surgical intervention is necessary. Take action If you have rolled your ankle and need some help to get back to the field or court, then look no further. Call us today on 02 9922 6806 to book your appointment, and we’ll have you hopping, skipping and jumping in no time at all! References 1. Brukner, P. and Khan, K. 2017. Clinical Sports Medicine. 5th ed. McGraw Hill Education : Australia2. Chen, ET. et al. 2019. Ankle sprains: Evaluation, rehabilitation, and prevention. Current Sports Medicine Reports. 18 (6). 217-223. https://journals.lww.com/acsm-csmr/Abstract/2019/06000/Ankle_Sprains__Evaluation,_Rehabilitation,_and.7.aspx Uploaded : 22 October 2019 Read More
  • The use of ultrasound for mastitis

    The use of ultrasound for mastitis

    The use of Ultrasound for the treatment of Mastitis Mastitis is a painful blockage of the milk duct of the breast. Symptoms include swelling, redness, tenderness, localised increased temperature, generalised malaise and occasionally fever. It is a painful condition occuring most commonly 2-4 weeks post partum in the breast feeding mother. Generally, the pain is derived from both the physical blockage as well as the resultant inflammation. Severe and prolonged mastitis can cause infection and sometimes abscess formation. The latter would need treatment with antibiotics, whereas the former can be treated with physiotherapy. Physiotherapy treatment may include gentle massage, self instruction on massage, reassurance to continue breast feeding, even the use of lactation aids such as expression pumps and ultrasound. During pregnancy you will have become familiar with ultrasound imaging. Another form of ultrasound is used extensively in physiotherapy for treatment of soft tissues injuries. Ultrasound is a sound wave, which delivers a mechanical massage at the natural resonance frequency of our bodies, 50hz. By using this frequency, in effect the ultrasound is massaging at a cellular level. This vibration most likely improves lymphatic drainage, cell membrane permeability, and increases arterial inflow and venous outflow. It probably also calms nerve endings. Physiotherapists have been using this form of treatment for over 40 years. Sharna Hinchliff, herself a mother of 4, including twins, knows a lot about issues associated with pregnancy and the post partum period. Don't hesitate to contact us for more information.  Uploaded : 17 October 2019 Read More
  • Preventing Falls in the Elderly

    Preventing Falls in the Elderly

    Preventing falls in the elderly Hello everyone and welcome to our October blog. This month we’re going to talk about the older generation of people we are fortunate enough to share this world with. It only seemed fitting given that on the 1st of this month it’s International Day of Older Persons. It’s no secret that the elderly population is growing. People are living longer, and in many cases, having to work longer too. Being a physio is not just about treating sports injuries. We treat people from all walks of life and we certainly see our fair share of elderly patients. Most people know that as we age our bodies go through a process of gradual degeneration. Our joints are susceptible to wear and tear, our muscles weaken and other areas of the body like eye-sight also become affected. Our ability to move efficiently declines and this can lead to an in-creased risk of falls and subsequent injury. Falls are actually one of the leading causes for injury in the elderly population and it’s not unusual for us physios to be called upon to help in the after-math of a fall. Common injuries include hip and wrist fractures, as well as shoulder and head trauma. It’s our job to get these people moving again and on a speedy road to recovery. Prevention is better than cure We are always there for anyone who has been unfortunate enough to experience a fall and have a resultant injury. Whether it’s getting them moving again following hip surgery or a wrist fracture, we have the tools and knowledge to get them back to their best. However, everyone knows that prevention is better than cure. And there are lots of things that can be done to prevent falls in the elderly. Let us outline some things we can do to help: • Biomechanical assessment - we know human biomechanics. We can look at how you move and highlight any dysfunctions within your body that may be a risk factor for falling. We can then provide you with hands-on treatment, a home exercise program and sound advice on how you can nip those issues in the bud to reduce your risk of falling.• Strength and conditioning exercises - a common cause of falling is weakness, particularly in the lower limbs. We can test your strength and provide you with a gentle strengthening program to ensure you are working towards a stronger body that can support you better as you age.• Balance and coordination exercises - our balance and coordination can also be affected as we get older. And you can imagine, if your balance is poor, then the likelihood of falling can in-crease. Well fear not, we can provide you with exercises that aim to improve your balance and coordination. You’ll be feeling steady on your feet in no time!• Advice for the home setting - it’s not just issues with the body that increase the risk of falls. It’s also important your home is set up in a way to reduce your risk of falling. For some elderly people, ensuring that carpets, rugs and mats are removed from common walkways, and ensur-ing there is plenty of room to maneuver around furniture can greatly reduce the risk of falling in the home.• Help with walking aids - some elderly people require the use of walking sticks or frames. We’re here to help you get the best out of your walking aids. We can teach you how to use them so that they are a benefit to you rather than a hindrance. During a consultation, we may highlight other areas that need attention outside of our domain. You may need a medication review from your GP to ensure your medications are not a risk factor. If you have poor eyesight, you may require the help from an optician or optometrist. And if your feet require some further expert eyes, we will be able to point you in the direction of a good podia-trist. We’ll ensure you know exactly which areas require attention so that the risks of falling are as low as possible. We understand that getting older is often a challenge and that it can be very difficult to come to terms with a body that is not working as well as it once was. We are here to tell you that help is at hand and we promise it’s not all doom and gloom. You have the power people! If you eat well, drink heaps of water, exercise regularly and work at keeping your body the temple it deserves to be throughout your life, your body will thank you for it later! References: 1. United Nations. 2019. International day of older persons. [Online]. Available from: https://www.un.org/en/events/olderpersonsday/. [Accessed 06 Sept 2019].2. Waldren, N. et al. 2012. Falls prevention in older adults: Assessment and management. Aus-tralian Family Physician. 41 (12). 930-935. https://www.racgp.org.au/afp/2012/december/falls-prevention/3. Richardson, M. et al. 2019. A study to evaluate the potential contribution of medication use to falls in elderly patients presenting to an acute hospital. In Hospital Pharmacists Association of Ireland Annual Conference 2019. Uploaded : 26 September 2019 Read More
  • Osgood Schlatters Disease

    Osgood Schlatters Disease

    Injury blog: Osgood-Schlatter disease With most of the winter sports coming to a close, we may start to see a few less sports injuries coming through the door. But far out, we have been busy treating all kinds of injuries this season! There are thousands of really active kids in Australia and across the world - and active kids are bound to pick up a few injuries here and there. Being young comes with its advantages, but it al-so comes with its hurdles. Growing being one of them. Active adolescents are particularly susceptible to developing a knee condition called Osgood-Schlatter disease. This problem usually arises around the time when a child goes through a big growth spurt when rapid changes are occurring in the bones and muscles. Does your child play lots of sport and sometimes has pain around the front of their knee? Are they currently in the mid-dle of a growth spurt? Then read on… What is Osgood-Schlatter disease? Osgood-Schlatter disease is a condition which is characterised by inflammation and pain on and around a bony prominence on the lower part of the knee joint. As your quad muscles run down your thigh to your knee, they merge to form the patella tendon which then inserts into the shin bone or tibia. Where the patella tendon inserts into the tibia is called the tibial tuberosity (you should be able to feel the small bump at the top of your shin bone). Inside this part of the bone is a growth plate, a highly active part of the bone where put simply, growth of the bone takes place. Now, because kids these days play a hundred different sports and activities, the quad muscles repeatedly contract, especially during running and jumping (footy and netball are classics for this type of injury). This can lead to the pulling, softening and irritation of the growth plate underneath where the patella tendon inserts. This leads to inflammation and ultimately, pain which is aggra-vated by exercise. Who does it affect? Boys are generally more affected than girls, and usually at slightly different ages due to the differ-ences in age when the growth spurt occurs in each gender. Once activity at the growth plate slows and eventually closes, the pain relating to this condition generally goes away. This is usual-ly around the age of 16 in boys and 14 in girls. Depending on how severe the problem is, the end result may be having to live with a slightly enlarged tibial tuberosity. Can treatment help? The simple answer is yes! And treatment is pretty simple too. After consulting your physio for diagnosis and advice, the most important aspect of treatment for this condition is activity modifi-cation. If the child can modify the amount of activity they are doing, it can greatly reduce the amount of pull on the bone and therefore less irritation to the growth plate. Because it is a devel-opmental condition, children and parents should be informed from the beginning that symptoms may come and go, but may last right up until the child reaches the age where the growth plate closes. So, play when you feel good, and rest when you are in pain. Your physio will likely re-lease excess tension in the quads and provide you with some light stretching to perform at home. Some people also respond well to strengthening and this is usually implemented when pain al-lows. Icing when pain is high may help to reduce pain and control inflammation and swelling. There are also some handy patella tendon de-loading taping techniques which your physio may well make use of to control pain and keep your child playing longer. We hope you found this an interesting and educational read. If you are young and reading this, or if you have a child with knee pain that is aggravated by exercise, please call and book an appointment so we can have a look and get you managing this problem from the get-go! Osgood Schlatter may feel like NotSoGood Schlatter disease (now that’s a dad joke!), but with our help, your child will be feeling good in no time! References 1. Brukner, P. et al. 2017. Clinical Sports Medicine. 5th ed. Australia: McGraw-Hill Education2. American Academy of Orthopedic Surgeons. 2019. Osgood-Schlatter disease (Knee pain). [Online]. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/osgood-schlatter-disease-knee-pain/. [Accessed 05 Sept 2019]. Uploaded : 25 September 2019 Read More
  • Physiotherapy

    Physiotherapy

    Physiotherapy… What is it exactly? Hello everyone and welcome to our September blog (it’s 4 months until Christmas - the countdown is on!). This month we are going to answer a question that we get asked A LOT by our patients. And because we get asked it so much, we thought we would dedicate a whole blog to it. The question we refer to is ‘What is Physiotherapy?’. To answer this question, we’ll give you some insight into what Physio is, how it can help you, and the sorts of things you can expect to experience during a typical consultation with a Physiotherapist. So… What is Physiotherapy? If you are looking for a simple definition of what Physiotherapy is, we think the Royal Children’s Hospital Melbourne sums the profession up very nicely. They say, “Physiotherapy is a clinical health science and profession that aims to rehabilitate and improve a person’s ability to move and function”. The lead governing body of Physiotherapy in Australia, the Australian Physiotherapy Association (APA) say that “Physiotherapists help you get the most out of life. They help you recover from injury, reduce pain and stiffness, increase mobility and prevent further injury. They listen to your needs to tailor a treatment specific to your condition”. We couldn’t have said it better ourselves! Basically, if you have hurt yourself or have a long-standing mobility issue, there is a good chance seeing a Physiotherapist is going to be beneficial to you. We use our expertise in the anatomy, physiology and biomechanics (i.e. how the body moves) of the human body to assess and provide treatment to people of all types with a wide range of health problems. And to ensure you are in the safest hands possible, each Physiotherapist has to obtain a university degree and be registered by law with the Australian Health Practitioner Registration Agency (AHPRA). So, you won’t be walking in and placing your health in the hands of any random off the street. Your Physio has been put through their paces to ensure they provide you with the best possible care. What to expect during your appointment For those who have never seen a Physio, we understand it can be quite daunting booking your first appointment. Fear of the unknown… What are they going to ask me? Will I have to get undressed? It’s perfectly natural to feel these things when you are trying something new. But ask someone who regularly uses the services of a Physio and they will be able to put your mind at rest. Physio’s are friendly and knowledgeable people. Yes, they ask you questions, and yes you might have to show your arms, legs and other body areas during the consultation, but everything is done with the patient’s well-being in mind. We know getting undressed can be embarrassing for some people, so we always advise you to wear comfortable loose clothes like shorts and a sports top, and if we require to see an area of the body like your abdomen or back, rest assured we’ll only look where we need to, and you should always, always, always keep your underwear on, and of course decline if you’re uncomfortable. Most Physio clinics will provide you with a robe or gown to wear during an assessment or treatment to ensure you feel safe and protected at all times and cover you with towels where appropriate. We promise there is nothing to be afraid of. After you have arrived for your appointment and have been greeted by your Physio or receptionist, you will likely be asked to fill out some paperwork that takes care of your personal details and all the administration stuff. Then you’ll be directed into a room or space where your Physio will sit down with you and talk to you about why you are there, and most importantly, what you want to achieve with their help. Once they have all the information they need (expect questions relating to lifestyle, occupation, social life, sleep, exercise and hobbies… They are all important), they will then carry out an assessment on you. During the assessment they will watch you stand and get you to move. They may even move some body parts for you and carry out a range of tests so they can come to an accurate diagnosis. Once they have a diagnosis, there’ll be a brief discussion to let you know exactly what is happening, what treatment is required, and a general plan laid out, so you know exactly what is going to be involved. Before your Physio carries out any treatment on you, they will always get your consent and tell you why they are wanting to perform that treatment. Physio’s use a wide variety of techniques to treat their patients. These might include soft tissue massage, joint mobilisation and manipulation, dry needling and acupuncture, hydrotherapy (i.e. the use of water in rehab), exercise and treatments that may use treatment aids such as splints, casts, braces, tapes, crutches and wheelchairs. This obviously depends on the issue you are being treated for, as each person and their rehab is completely unique. Appointments will usually last anywhere from 30-60 minutes and by the end of your initial consultation, you will have a clear explanation of what is going on with your body and a plan of attack to get you out of pain in the quickest and safest way possible. If your Physio thinks you require a scan of a body part, or the opinion of another health professional such as a GP or specialist, they will also discuss this with you. So, there you have it. We think we’ve covered just about everything. If you are wanting to book a Physio appointment, or are looking to find out more information, please do not hesitate to contact us on 02 9922 6806. We are ready to help you! Uploaded : 22 August 2019 Read More
  • Quadriceps

    Quadriceps

    Body facts: The Quadriceps muscles Fancy a stroll? Or is it leg day at the gym (groan)? It doesn’t matter whether you are old or young, a cyclist, fishmonger or a green-fingered gardener. To perform the simplest of everyday tasks such as getting out of a chair, walking or climbing the stairs requires a complex array of movements using many muscles and joints. One particularly important group of muscles which helps us to perform such tasks is the quadriceps muscle group. Here’s a little run down of what they are and why they are important to you. Some anatomy and biomechanics for you… The quadriceps or just ‘quads’ are a group of muscles found on the front of the thigh. As the name suggests, there are four muscles all together. As with most things on the human body, they have some fairly crazy names… We’re pleased to introduce you to Rectus Femoris (RF), Vastus Medialis (VM), Vastus Intermedius (VI) and Vastus Lateralis (VL). Start memorising now… We’ll test you on them later! The VM, VI and VL muscles all span from the thigh bone (femur) to the leg bone (tibia) running down the front aspect of the body. The RF muscle sits on top of the three Vastus muscles and spans from the front of the pelvis to the leg bone where the other three muscles also attach. Because all four muscles cross the knee joint, they all help you to straighten your knee (known as knee extension). But because the RF muscle also crosses the hip joint, it has a separate function in helping you to bring your thigh forward in front of you (known as hip flexion). As the muscles run down the thigh and cross the knee joint, they converge into one big tendon which houses the kneecap or ‘patella’. And because the patella lives inside the quad tendon (it literally floats over the knee joint), the quads also have the very important function of controlling the movement and tracking of the patella over the knee joint. These powerful soldiers of the lower limb are partly responsible for ensuring that your kneecap doesn’t constantly dislocate (just imagine that!). So, they are a pretty useful group of muscles to have around. Some real life examples Let’s give you some examples in everyday life where you are using your quads. Climbing the stairs is a good example. As your leg goes forward towards the step, your RF muscle (along with some other muscles) flexes the hip. As you take your step up and your knee straightens to drive you up, all four muscles are acting together. Kicking a soccer ball is another good example. You run towards the ball, plant one foot next to the ball and the other leg swings through. RF drives the hip joint forward and all four muscles contract to straighten the knee so you can blast the ball into the top corner. This is quite a simplistic way of looking at things because as we’ve already suggested, there are other muscles helping all of this to happen, but you get the idea of how the muscles are working together to help us do these actions. As with all muscles, there is potential for injury, and quad muscle or tendon injury is quite common. Muscles can be strained with varying severity, repetitive movements commonly lead to tendon related injuries, and taking a knee into the thigh from an opposing player for example can leave you with a nasty corked muscle, not to mention a dead leg! And now… …A TEST! Haha, we said there would be one! Look at the table below. On the left we’ve listed the two main movements that the quads are responsible for in the human body. It’s your job to list which muscles are responsible for those movements. Write down or tell yourself RF, VM, VI or VL for each movement. Try it first and then check back through the text to see if you’ve remembered. Who said tests aren’t fun? Movement Muscles responsible (RF, VM, VI, VL)Hip flexion ???Knee extension ??? Uploaded : 22 August 2019 Read More
  • Stress fracture in an adolescent foot.

    Stress fracture in an adolescent foot.

    Stress facture in an adolescent female track and field athlete A 16 year old female track and field athlete presented with a 6 month history of foot pain. However, it was never enough to stop her from competing and training. She did seek the intervention of a sports podiatrist. She was running 3-4 times per week, playing hockey and touch football. Her identical twin sister was doing a similar amount of exercise. Current History June 2018 - Combined Inter Schools X-Country race where she experienced no pain during the race which she won, but immediate intense pain once the race was over. Imaging An MRI was undertaken showing a stress fracture of the second metatarsal. A CT scan noted the callous formation either side without union Additional clinical findings were a Mortons toe and normal menarche and menstrual cycle. She was also excessively mobile and potentially has Ehlers Danlos Syndrome Mortons Toe is where the 2nd toe is longer than the first toe. Biomechanically this results in forefoot pronation and excessive loading of the 2nd ray. In Roman times this was considered a sign of beauty. Vikings generally had the opposite, a very large big toe and much smaller 2nd toe. Treatment Moon Boot for 4 months Daily bone stimulator -> Exogen Physio -> intrinsic muscles of the foot, calf and gluteal strengthening, Soft sand walking and running can become an ideal environment for this in the latter stages of rehab Eventually Alter G Treadmill program to recommence return to running Used Hoka A minimal shoes Land based return to running programme and agility exercises Fully returned to running 9 months later Uploaded : 8 August 2019 Read More
  • Avulsion Fracture of the ASIS

    Avulsion Fracture of the ASIS

    Avulsion Fracture of the ASIS ASIS avulsion fracture in a 16 year old playing soccer. An uncommon injury, in adolescents, where the sartorius and/or Tensor Fascia Lata pulls suddenly on it's pelvic attachment, near the growth plate. Depending on the extent of displacement, either surgical or conservative management can be undertaken. Conservative treatment consisted of bed rest, with the affected hip at 70–90° flexion for the first three weeks, with symptomatic treatment of pain and soft-tissue oedema. After three weeks, physiotherapy and ambulation with crutches can begin, determined by X-ray findings. Partial weight bearing using crutches is indicated until six weeks from injury, when an X-ray check should be performed, and gradual full weight bearing with restricted running, jumping and sports are allowed Sprinting and full participation in sports activity was allowed six months after the injury.    Sartorius Muscle Tensor Fascia Lata Further, complications may include damage or irritation to the lateral femoral cutaneous nerve resulting in meralgia paraesthetica. These cases should be considered for surgical intervention as a neurological deficit could occur. Additionally, fragment displacement of >3cm should also undergo surgical intervention. Time course of healing is quicker in the surgical group, with return to sport after 3 months vs 6 months in the conservative group. Ultimate outcomes appear to be the same regardless of intervation type. References : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4071503/ Uploaded : 1 August 2019 Read More
  • Repetitive linear head trauma

    Repetitive linear head trauma

    Repetitive linear head trauma can cause cummulative subclinical effects on visual and vestibular (balance) function Linear repetitive impact without concussion symptoms have been shown to have some impact on visual memory and vestibular (balance) function. Interestingly, although these researchers didn't find clinical neurolgical deficits, others, using MRI imaging, have reported anomalies. Speculation remains, that cortical cognitive reserve means that these deficits are not immediately apparent, Judicious use of ball heading is recommended and potentially should be completely avoided in the young. (Caccesse et al 2019. MedScSpEx, 51, 7, 1355-1361). https://www.back-in-business-physiotherapy.com/we-treat/concussion.html Read More
  • Calf Pain

    Calf Pain

    Calf pain? All you need to know about Achilles Tendinosis  It’s Sunday, which can only mean one thing… You’re meeting with your soccer team to play a friendly competitive game against your local rivals. After years out from playing, this season, you’ve decided to dust off the boots and start playing again. Life has been generous over the years, a doting partner, two healthy children, and maybe a generous waistline has come with it all too. It happens sometimes, but you were determined to get active again and do what you’ve always loved doing - running rings around the opposition’s defence and scoring goals! But now, you’re halfway through the season and your old calf injury has decided to rear its ugly head. It’s been years since you’ve felt the pain, but it’s very familiar, and it can really ache! So why did it rear its ugly head now? This scenario is a very common one us physios come across. We think it’s great that people decide to get themselves active again, and we’re here to help them achieve their goals. Unfortunately, that sometimes means getting them through an injury, often a recurrence of an old sports injury. The condition we described above affecting the calf is Achilles Tendinopathy, or more specifically ‘Tendinosis’. The Achilles tendon is a large broad tendon that sits at the back of the ankle. It is an extension of the calf muscles - the gastrocnemius and the soleus (bit of a mouthful hey!). It runs down the back of the leg and inserts into the heel bone (or calcaneus). The tendon is also often referred to as the calcaneal tendon. It is a very powerful tendon and functions as a spring to propel us forward and ‘push off’ when walking or running. Tendinosis refers to the degeneration and derangement of the tendon fibres that make it up. Usually the fibres run in parallel lines straight up the back of the leg, but with tendinosis, these fibres can become a bit of a higgledy-piggledy mess due to repetitive stress and consequent small tearing, followed by poor healing through the area. This means the tendon cannot function efficiently for you and eventually you can end up with a painful calf. This is very commonly seen in middle-aged, overweight people and most commonly affects the mid-portion of the tendon as it passes up the calf, much like our soccer star mentioned above. What to expect with Achilles Tendinosis The major symptom is pain, most often felt with movement after a long period of rest. As you continue to move, you may notice the pain goes away, only for it to return once you have finished your activity. There may or may not be swelling around the tendon insertion too. You may notice pain with activities such as walking up the stairs and hopping… Basically anything that loads the tendon and requires you to push off in order to move you in the direction you want to go.  What can be done to help? Lucky for you, you’ve just walked into your physio clinic to seek help, which is exactly the place you need to be. We, at Back in Business Physiotherapy, see this all the time and can really help you with it. We’ll get you in for some questioning (the friendly kind, we swear) and then have a look at you moving around. We’ll pick up on all the things that have led you to this point. This might relate to old injuries you’ve had — maybe you never managed to rehabilitate properly years ago, and it is still affecting you now — and/or problems with the way you move currently and the strength you have in your muscles. You might have poor ankle mobility, or flat feet, or weak hamstrings… All things that can eventually lead you to have an Achilles tendon issue. Our aim is to rid you of pain and to correct all the issues mentioned above, so we can keep you out of pain and on the field (or wherever you want to be) for longer. One aspect of your rehab will be getting you stronger. There is scientific evidence behind the use of strength training when rehabbing Achilles tendinosis. One example of an exercise your physio will likely get you performing is a heel raise with a slow controlled drop off the edge of a step. Without getting too deep into the science behind this, this exercise allows the tendon to be loaded whilst the muscle is being lengthened (rather than shortened), and aids with the re-arrangement of the fibres running up the tendon. Over time, the tendon will begin to restore to its former glory and will be stronger and able to spring you forward like Tigger on his tail… Okay so maybe not that much, but you’ll feel the difference and will be moving with confidence. Of course, the rehab will involve a lot more than just this exercise - you may need to do some foot, hamstring, glute or core strengthening, ankle mobility exercises, and some people may need to be fitted with orthotics to help them along the way too. But don’t worry, your physio will be able to guide you through it step by step. So, don’t wait around for your calf pain to go away on its own, give Sharna or myself a call and we’ll get you on the road to a speedy recovery! Cheers Martin Krause, 23 July 2019 References Li, H. and Hua, Y. 2016. Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. BioMed Research International. 2016. 1-9. https://www.hindawi.com/journals/bmri/2016/6492597/abs/ Sports Medicine Australia. 2019. Achilles Tendon Injuries. [Online]. Available from: https://sma.org.au/resources-advice/injury-fact-sheets/achilles-tendon-injuries/. [Accessed 03 Jul 2019] Brukner, P. et al. 2017. Clinical Sports Medicine. 5th ed. Australia: McGraw-Hill Education Aicale R., Tarantino D., Maffulli N. (2019) Non-insertional Achilles Tendinopathy: State of the Art. In: Canata G., d'Hooghe P., Hunt K., Kerkhoffs G., Longo U. (eds) Sports Injuries of the Foot and Ankle. Springer, Berlin, Heidelberg Karlsson J., Brorsson A., Jónsdóttir U., Silbernagel K.G. (2019) Treatment of Achilles Tendinopathies. In: Rocha Piedade S., Imhoff A., Clatworthy M., Cohen M., Espregueira-Mendes J. (eds) The Sports Medicine Physician. Springer, Cham Read More
  • Book Week

    Book Week

    Attention all bookworms! Let’s pack for your back! On your marks… Get set… GO! Let’sseehowmanybookswecanreadasquicklyaspossiblewithoutstoppingforbreathinbetween! And breathe… Yes, it’s that time of the year again for us book lovers. Book Week 2019 is being celebrated this August (17th-23rd) and it’s time to get prepared. For some of us, this might mean we’ll be reaching for an epic page turner for the first time in ages, or it might just be a great excuse to read an extra one (or two or three) books that week. For your children attending school, there will likely be several activities they will be taking part in to recognise the event, which means they’ll have one or two more books they need to carry in their school bags. As if they didn’t have enough already right?! You might be starting to think, why is my physio posting a blog on book week? Well, let us explain. Let’s face it, who doesn’t like grabbing a book, a mug of tea, a few biscuits, your favourite blanket, and snuggling down into your favourite armchair for endless hours of reading? OK, so it might not be for EVERYONE, but we love it, and for those that do too, it may mean being stuck in the same position for hours on end whilst your head is in your book and you become too engrossed in the story to realise you are straining your neck. And what about your kids? Their school bags are already heavy from packed lunches, sports kits and textbooks, and now they must take in their favourite books to read in class too. Just think what all that weight is doing to their developing little frames as they drag their backpacks around the school yard. We’re here to give you some sound advice on how you and your family can stay safe and healthy this book week. Although the advice stretches to the other 51 weeks of the year too. Sitting bookworms We’re all for snuggling up in your favourite chair or lounge to read a book. We just want to make sure that you aren’t putting yourself at risk of injury from being in the same cramped position for hours on end — and that’s not taking into consideration the possibility of falling asleep in the same spot either. If this happens, you might need to reconsider your book choice! To ensure you aren’t straining your neck and back whilst reading, try the following: Sit comfortably, but try to sit straight (this is achievable, honest) to keep your spine aligned If you do adopt a different position (i.e. lying down or curled up in a foetal position) make sure you move regularly to give your body a break from being in one position for too long Take regular breaks from reading to give your hands, shoulders and neck a rest At the end of a chapter, get up and do some stretches, squats, lunges or whatever else you enjoy doing (this includes grabbing a well-deserved cup of tea) Remember to attend to necessary life requirements like talking to family members, cooking dinner, and sleeping (hopefully not because your book is boring though) – yes, this one is tongue in cheek (although a reality in many cases)!  Backpack advice When sending your kids off to school with backpacks in tow, there are some important things to remember to keep the pressure off their backs and shoulders (remember this also applies to adults too — they are not immune to the effects of heavy baggage either). Try these: Always wear BOTH straps - a single strap might look cool and be convenient to sling over the shoulder, but it will increase strain down one side of the body leading you to a possible postural imbalance Tighten the straps so that the backpack sits above the waistline (avoid letting it hang below the waist) Tighten the straps enough to limit side-to-side swinging of the bag on your back when walking - if you have a chest strap, this will also help to reduce swinging and keep the straps in place If you have a waist strap, this can help to spread the weight of the backpack over the pelvis and hips, whilst reducing load through the shoulders. You rarely see a hiker not wearing their waist strap, so why shouldn’t you? After all, carrying around a heavy backpack for most of a school or working day, repeated five days a week, can take its toll. Follow the recommended backpack weight guidelines of no more than 5-10% of a person’s bodyweight (an average 11-year-old weighs around 36 kg, so ensure their backpack weighs no more than 3.6 kgs) If you follow the above advice, then you are taking positive steps towards keeping you and your family safe and reducing the risk of injury. If you would like further advice or have woken up with a stiff neck after a hefty night of reading, please call us to book an appointment. We will ensure you are the turning pages pain and risk free before you can finish the synopsis (you know, the bit on the back of a book that we sometimes forget). Oh… And keep your waistline healthy by only having one or two biscuits please. We know how moreish they can be! #longlivebooks References  The Children’s Book Council of Australia. 2019. CBCA Book Week [Online]. Available from: https://cbca.org.au/news/cbca-book-week-2019. [Accessed 10 July 2019]. National Safety Council. 2019. Back Pack Safety: It’s Time to Lighten The Load on Our Kids. [Online]. Available from: https://www.nsc.org/home-safety/safety-topics/child-safety/backpacks. [Accessed 10 July 2019] Uploaded : 23 July 2019 Read More
  • Anterior Cruciate Ligament

    Anterior Cruciate Ligament

    Sprained your ACL? Let us guide you through Hello everyone and welcome to our July blog. We’re halfway through the year already, which means the soccer season, rugby and netball are in full swing! Added to this the start of the ski season. Why is this relevant you ask? Well these are sports that send quite a lot of people our way. It’s this time of year where we start to see an influx of knee injuries and it’s an especially busy time of year for treating ACL sprains - the injury any keen sports person will want to avoid at all costs! Unfortunately, there has been a significant increase in ACL injuries over the last twenty years, with nearly 200,000 people requiring surgical repair between 2000-2015 in Australia alone. A bit of anatomy for you The ACL, or Anterior Cruciate Ligament is one of four main ligaments that support and stabilise the knee joint (the others being the posterior cruciate, medial collateral, and lateral collateral lig-aments). Deep inside the knee it connects the thigh bone (femur) to the shin bone (tibia) and its main purpose is to stop the shin bone from moving forward and over-rotating when we perform certain movements. It is particularly important at stabilising the knee during movements such as jumping and landing, pivoting with a quick change in direction, and deceleration (slowing down) movements. It’s no surprise then that the way people tend to injure this ligament is by performing exactly those types of movements. Injury occurs when the ligament gets taken beyond its capa-bilities of supporting and stabilising the knee, and the result is a sprain of the ligament. Imagine a netball player jumping to catch the ball, and then landing and pivoting on one foot to change di-rection quickly. As they turn, their knee twists and falls inwards while the foot is still planted on the ground… And that’s all it takes. Minor sprains involve only part of the ligament, but less fortu-nate occurrences may tear the ligament completely - known as a ‘rupture’.  What to expect when it happens If you are unfortunate enough to experience such an injury here is a list of signs and symptoms to look out for: • An audible pop or crack in the knee• Intense pain (especially in the immediate aftermath of a full rupture)• Inability to continue activity• A possible large swelling of the knee (this may be delayed in certain instances)• A feeling of instability if attempting to perform further movement• Restricted knee movements with inability to straighten the knee in particular• Widespread tenderness (especially on the inside and outside of the knee) It’s important to know that ACL injuries will often come with extra baggage. As if tearing a liga-ment inside the knee isn’t bad enough, unlucky recipients will also often damage the medial col-lateral ligament, the meniscus (a cartilage type structure inside the knee), or the cartilage that co-vers the end surfaces of the bones. Some refer to an injury which includes the ACL, MCL and meniscus as the ‘unhappy triad’. And you’d be quite unhappy indeed! However, there is light at the end of the tunnel! With the right guidance and professional care, your recovery journey can be a successful one! So what next? The first thing you need to do is see a professional. Contact our friendly team at Back in Business Physiotherapy today who can help to diagnose you. The sooner after initial injury the better, be-cause once the swelling kicks in, it’s a bit more difficult to diagnose accurately (at least until the swelling has reduced). Your physio may refer you on for imaging; often an MRI will be performed alongside an x-ray. Once you have a solid diagnosis, the next important choice is whether to treat surgically or conservatively. Generally, if it is a partial tear, a conservative approach would be taken, but this totally depends on the person and what their goal is in life. It’s quite possible to live life with no ACL at all, but you will have to be prepared to adjust what types of physical activities you partake in. A professional football player who is still young and has a career ahead of them may opt for a surgical repair with a subsequent intensive rehabilitation process to stand the best possible chance of performing at a professional level again. It’s a complex decision with many factors to consider, such as age, level of injury and the persons occupation. Your physio will be able to guide you to the right choice for you. If you opt for surgical repair, then the rehabilitation process generally takes around one year. For a partial tear without surgery, the process would be faster. Ultimately your physio will follow a structured protocol to get you back to fitness again. Phases of rehab will include the following: • Reduce swelling and restore full range of motion• Begin to progressively strengthen the lower limb muscles (i.e. quads, hamstrings)• Move from non to partial to full weight bearing (depending on the injury)• Improve balance and control of movement• Begin gross body movements such as squatting and lunging• Return to jogging, running and pivoting• Return to sport (training and fun match play) As stated before, the recovery process really depends on each person’s individual situation. For you it might be completely different than your neighbour or family member. Keep in mind, that it is possible to re-injure your ACL following surgery, with most cases of re-injury occurring within one year. For many, the risk of injuring the other knee is a distinct possibility, so it is pivot-al (no pun intended) that you follow our advice here at Back in Business Physiotherapy to ensure you achieve your goal and stay clear of injury in the future. Anyone for shooting some hoops? Safely, of course! ACL rupture and the menstrual cycle https://www.back-in-business-physiotherapy.com/latest-news/255-female-hormones-and-knee-strength.html References: 1. Zbrojkiewicz, D. et al. 2018. Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015. The Medical Journal of Australia. 208 (8). 354-358. https://doi.org/10.5694/mja17.009742. Brukner, P. et al. 2017. Clinical Sports Medicine. 5th ed. Australia: McGraw-Hill Education  Uploaded 28 June 2019 Read More
  • Gluteal Strength

    Gluteal Strength

    WEAK GLUTES? GET YOUR BUNS OF STEEL HERE! Nip into your nearest gym and you’ll hopefully see a bustling atmosphere of people working out, trying to reach goals and get their bodies stronger. You’ll see all kinds of movements occurring, push, pull, jump, squat, lunge, lift… The list is endless. Maybe your physio has advised you to get to the gym yourself and work on some strength training. —You’ve been getting a bit of lower back pain and they’ve highlighted that your glutes are weak and may be contributors to your pain. It’s hard to fit everything in! You have to sit all day at work, and you just don’t seem to find enough hours in the day after work, kids, cooking, washing and shopping to set aside time to concentrate on you and getting yourself stronger. So the bad news is, sitting for long periods of the day could be contributing to your back pain. When you sit for long periods, your hip flexors become shortened and tight. This prevents your hips from being able to extend properly (we need this to help propel us forward when we walk, run, jump and climb the stairs) and which muscle is responsible for hip extension? That’s right, your gluteus maximus muscle! Not being able to extend the hip well, means the gluteus maximus muscle becomes a bit lazy. It’s not being used properly, it’s not able to contract all of those muscle fibres through their full range to provide you with a powerful contraction. Therefore, weakness sets in and other areas of the body have to work harder to compensate for this. The lower back is one of the areas that works harder when your glutes slack off— and it lets you know it is working too hard by sending a signal to the brain that all is not well. You feel this as pain. Now it’s not all doom and gloom, don’t worry. There is good news! Your trusty physio here at Back in Business Physiotherapy will be able to use their magic to get your hip flexors released and the hip moving successfully into extension. But you’ll have to back up the work done on the treatment table by performing exercises at home. These exercises might include some hip flexor stretching, hip mobility, and gluteal activation, as well as strengthening exercises. To make it simpler for you, we’ve described three beneficial glute exercises that you can perform at home to ensure your glutes will be firing on all cylinders. Check them out below… 1. Hip thruster - Sit with your upper back against the edge of a bench (the seat of your couch will work just fine!)- Reach your arms out to the side along the bench for balance- Have your knees bent and feet flat to the floor approximately hip width apart- Squeeze your buttocks as you raise your hips up until your body and thighs form a horizontal line- Be careful not to over-arch your lower back- Return to the start position and repeat 2. Split squat - Stand tall and place your back foot behind you on a step or bench- Your front leg should be slightly out in front of you- Slowly bend your front knee, dropping your back knee down towards the floor- Squat with your front leg to an angle of approximately 45-90 degrees- Pause and then push up through your heel whilst you squeeze your buttocks- Return to the start position and repeat 3. Deadlift (using a resistance band) - Stand with your feet hip width apart on top of a resistance band- Squat down with a straight back and hold the ends of the band with each hand- Draw your shoulders back, chest up, and push up through your legs to a standing position against the resistance of the band- Return to the start position and repeat- A progression of this one may be to use a bar bell instead of a resistance band Suggestion: Try 3 sets of 10-15 repetitions, 3-4 times per week for each of the three exercises above. 4. Buttock Ups - Simply, in standing or sitting, tighten and hence lift your buttocks. Hold for up to 90 seconds and repeat every hour. As the buttocks contract you should feel the deep abdominal and pelvic floor muscles contracting. Test your upper arm strength. With the arm stretched at 90 degrees ask someone to push your hand down towards the floor. Your upper limb strength should be better with the gluteals contracted. Good gluteals should improve lower limb stability. Resistance exercise training has been demonstrated to improve insulin resistant diabetes and reduce the severity of sarcopenia (https://www.back-in-business-physiotherapy.com/latest-news/239-mitochondrial-health-and-sarcopenia.html)  Please remember to speak to your physio before attempting any new exercises and always give yourself rest days to allow for recovery and strengthening to take place. We have the expertise to guide you on which exercise is ideal for each stage of your rehabilitation. Be persistent, work hard, and you’ll be on a path to having fully functioning glutes and awesome buns of steel in no time!  References 1. Brukner, P. et al. 2017. Clinical Sports Medicine. 5th ed. Australia: McGraw-Hill Education2. Jeong, U. et al. 2015. The effects of gluteus muscle strengthening exercise and lumbar stabilization exercise on lumbar muscle strength and balance in chronic low back pain patients. Journal of Physical Therapy Science. 27 (12). 3813-3816. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4713798/3. All exercise descriptions taken from The Rehab Lab website Uploaded : 29 June 2019 Read More
  • Digestion

    Digestion

    Five tips for digestive bliss It’s bowel cancer awareness month, so we’re here to give you tips on how to keep your digestive system healthy, so you can be the best human you can be and reduce the risk of disease. Whether you are a professional soccer player, a tradie or an office worker, a healthy digestive system is key to you being able to function and carry out your daily tasks. Our bodies break down the food we eat into energy and this is what allows us to kick a ball, drill a hole, or sit and type on the computer. Now, your digestive system will only work properly if you feed it the right stuff… So don’t expect to last the 90 minutes and be at the top of your game if all you do is gorge on deep fried or fast food. That’s just a fast track to the subs bench and unhappy insides! Try out these little gems of advice to ensure your digestive system stays healthy, so you can give 100% every single day: 1. DRINK LOTS OF WATER: We’ll make this one nice and simple… Your body needs water for almost everything! From maintaining the health of every cell in your body, to keeping your blood fluid - you can see it’s pivotal for life to exist. Water is also needed for creating your digestive juices used to break down food and preventing digestive complaints like constipation. 2. EAT A HIGH FIBRE DIET: Fibre is basically all the parts of plant-based foods that we are unable to breakdown and digest. There are different types. ‘Soluble’ fibre (found in fruits, vegetables & legumes) helps to keep you feeling fuller for longer and helps to control blood sugar levels and lower cholesterol. ‘Insoluble’ fibre (found in the skin of fruits and vegetables, wholegrain breads/cereals, and nuts and seeds) absorbs water helping to bulk out and soften our stools and aids in regulation of bowel movements. Having a good mix is important to prevent diseases such as constipation, bowel cancer, diabetes, and heart disease. 3. EAT A PROBIOTIC: Probiotics are the bacteria found living in our gut. They are responsible for providing the ideal environment for getting the most nutrients out of the food we eat. They also protect us from the effects of nasty bacteria that may show their faces at different points. Without them, we wouldn’t exist. Sometimes our stores of bacteria can be put under threat, like when we are ill, stressed for long periods, or after a course of antibiotics. Having a poor diet can also be bad for them. Luckily, we can eat foods like probiotic or ‘live’ yoghurt and kefir daily to help keep our gut well-populated with these little soldiers. 4. GET PLENTY OF EXERCISE: The benefits of exercise are endless! When you move, it helps to promote movement of food through your gut, which keeps everything functioning well and helps to reduce the risk of digestive problems like constipation. So, move every day because your gut doesn’t tend to go on holiday for days here and there. It is always working hard for you! 5. LIMIT INTAKE OF ALCOHOL AND SMOKING: Too much of anything is a bad thing, but the effects of too much booze and cigarettes on the digestive system are well documented. Heavy, long term intake may lead to conditions such as reflux, digestive ulcers, and possibly more severe disease such as oesophageal, stomach and bowel cancer. Remember, you really are what you eat. Gut health is so important for you to do the things you want to do – work, playing with the kids, sports, everything! So don’t be surprised if your physio throws in some questions regarding digestive health when they’re treating you. It’s much more than just muscles and bones. We will delve deep if we need to, to make sure you are at the top of your game. If you are over 50, the Australian Government subsidises bowel screening testing. The kits are readily available from your doctor or pharmacy. If you are over 40 and have a family history of bowel cancer you should take the screening exam annually. References 1. State Government of Victoria. 2014. Water - a vital nutrient. [Online]. [Accessed 03 May 2019]. Available from: https://www.betterhealth.vic.gov.au/health/healthyliving/water-a-vital-nutrient2. Nutrition Australia. 2014. Fibre. [Online]. [Accessed 03 May 2019]. Available from: http://www.nutritionaustralia.org/national/resource/fibre3. Webster-Gandy, J., Madden, A., Holdsworth, M. eds. 2012. Oxford Handbook of Nutrition and Dietetics. Oxford: Oxford University Press4. Enders, G. 2015. Gut - the inside story of our body’s most under-rated organ. Melbourne: Scribe Publications5. Drinkaware. 2019. Is alcohol harming your stomach. [Online]. [Accessed 04 May 2019]. Available from: https://www.drinkaware.co.uk/alcohol-facts/health-effects-of-alcohol/effects-on-the-body/is-alcohol-harming-your-stomach/6. State Government of Victoria. 2019. Smoking - effects on your body. [Online]. [Accessed 04 May 2019]. Available from: https://www.betterhealth.vic.gov.au/health/healthyliving/smoking-effects-on-your-body 4 June 2019 Read More
  •  WHAT IS INCONTINENCE?

    WHAT IS INCONTINENCE?

     WHAT IS INCONTINENCE? Incontinence is the term used to describe the uncontrollable loss of urine from the bladder or faeces from the bowel. It ranges in severity from losing only a very small amount of urine, to a complete void of the bladder or bowel. If you’ve never experienced this, you can only imagine how distressing this must be. There are different types of urinary incontinence, including: • STRESS INCONTINENCE, where small amounts of urine leak due to small increases in pressure on the bladder during physical activity, or from coughing, sneezing or laughing.• URGE INCONTINENCE, where you get an unexpected, strong urge to urinate with little to no warning. This is usually as a result of an overactive bladder muscle.• INCONTINENCE ASSOCIATED WITH CHRONIC RETENTION, where your bladder cannot empty fully, and you get regular leakage of small amounts of urine. There are many causes for this, including an enlarged prostate in men, or prolapsed pelvic organs in women, as well as medications and certain conditions, such as diabetes and kidney disease.• FUNCTIONAL INCONTINENCE, where you are unable to get to the toilet, possibly due to immobility, or wearing clothes that are not easy to get off in time. Faecal incontinence is when you have a lack of control of bowel movements and you may accidentally pass a bowel movement, or even pass wind without meaning to. This may be due to weak muscles surrounding the back passage (Unfortunately ladies, this is common following pregnancy and childbirth), or if you have severe diarrhoea. TAKING THE STRESS OUT OF INCONTINENCE! For all those suffering in silence, it is time to speak out. There is no need to be embarrassed, it is surprisingly common – and like we have already mentioned, help is out there! You may not need to look very far. Your local physio may be able to help. The most common type of incontinence that we see and treat is stress incontinence. Although seen across both sexes, women are three times more likely to experience it than men. It is very common in women following pregnancy and childbirth (when the pelvic floor muscles get over-stretched, and sometimes even damaged), during menopause (due to hormonal changes) and in the elderly. It commonly affects men who have had prostate surgery. The pelvic floor muscles sit at the bottom of the pelvic bowl, spanning from the pubic bone to the tailbone (front to back) and from one sitting bone to the other (side to side). Imagine a tarpaulin stretched out with a person holding each corner and you kind of get the gist. When these muscles are strong, they help to support our internal pelvic organs (i.e. the bladder, bowel and the uterus in women) and wrap around the openings of the front and back passages, allowing us to control when we decide to do a number one or two. Following pregnancy for example, they may become weak and dysfunctional, and we can lose that ability to control voiding. It only takes something as small as a cough, or an activity like jumping or running (things many of us take for granted) that may cause a person to lose a small amount of urine. WHAT CAN BE DONE TO HELP? The most important thing to point out is that not all types of incontinence will improve or resolve with just strengthening of weak pelvic floor muscles. So, it is very important to get an accurate diagnosis, because there will likely be other factors that need addressing too. For instance, losing weight, stopping smoking, and making other lifestyle changes are just as important in the management of these conditions, if relevant to the person of course. Some people may also require release of tight and over-active muscles. Once you have your diagnosis, then strengthening may well be a part of your therapy. In order to strengthen, you need to know where the muscles are, and how to activate them. Below is a little step by step guide to getting a grip on those pelvic floor muscles (we don’t mean literally!): 1. Get in a comfortable position - try sitting or lying on your back and take a few breaths to relax.2. Imagine you are trying to stop yourself from urinating mid-stream by squeezing for about a second. If this is not easy to feel, next time you are on the toilet emptying your bladder, have a go at stopping mid-stream and then relaxing again to finish emptying (don’t hold it for too long please - just enough to feel which muscles you need to use).3. Do the same as step two for the back passage - this time imagine you are trying to stop yourself from passing wind by squeezing.4. Do these quick squeezes 3 x 20 reps a day. Once you’re comfortable, you can do it sitting or standing. Make it routine… Do it when you’re brushing your teeth, eating lunch, or in the ad breaks of your favourite TV show. These two contractions together form the basis of what you need to be able to do to begin your pelvic floor muscle training. If you struggle to feel this, then ask for help from your therapist. They will be able to help you perfect the activation of the correct muscles. We hope you have found this blog interesting and helpful. Please join in celebrating World Continence Week (17-23 June), References 1. Continence Foundation of Australia. 2019. World Continence Week. [Online]. [Accessed 07 May 2019]. Available from: https://www.continence.org.au/events_calendar.php/482/world-continence-week 2. Continence Foundation of Australia. 2019. Laugh Without Leaking. [Online]. [Accessed 07 May 2019]. Available from: http://www.laughwithoutleaking.com.au3. Continence Foundation of Australia. 2019. Key Statistics. [Online]. [Accessed 08 May 2019]. Available from: https://www.continence.org.au/pages/key-statistics.html4. Milsom, I. and Gyhagen, M. 2018. The Prevalence of Urinary Incontinence. Climacteric. 22(3). 217-222. DOI: 10.1080/13697137.2018.15432635. Continence Foundation of Australia. 2019. Pelvic Floor Muscles in Women. [Online]. [Accessed 08 May 2019]. Available from: https://www.continence.org.au/pages/pelvic-floor-women.html 4 June 2019 Read More
  • You are what you eat......and exercise

    You are what you eat......and exercise

    Exercise and the gut by Martin Krause We've often heard the phrase 'you are what you eat', however, did you know that exercise can have a profound affect on the gut flora, which in turn affects the way we digest our foods? Regular exercise has been proposed to alter the gut microbiota and gut epithelium. Specifically, exercise has been shown to increase the butyrate-producing taxa and fecal butyrate concentrations and reduce pro-inflammatory cytokines and oxidative stress (Mailing et al 2019, Ex Sp Sc Rev, 47, 2, 75-85).  The implications for the gut of regular exercise include affects on  Colorectal cancer Inflammatory bowel disease (IBD) Obesity and metabolic disease Mental and cognitive health Cancer Some observational studies have suggested the physically active individuals have a 24% reduced risk of colorectal cancer (Torii et al 2010, Ann Clin Biochem, 47, 5, 447-452; Wolin et al 2009, Br J Cancer, 100, 4, 611-616). Suggested mechanisms include simple biomechanics of increased abdominal muscle activity, improving intestinal mixing and reduced intestinal transition time through activities as simple as running and walking. Increased bile duct activity, improved circulation due to short term ischaemic regulation, the release of myokines, metabolites, and neurendocrines which interact with the gut directly or indirectly through the gut-immune interface are all considered potential agents in the regulation of cell function. Additionally, increased butyrate production through exercise, which is metabolised in the mitochondria, stimulates the expression of genes involved in cell proliferation and cell turn over, which effectively strengthening the intestinal barrier (Andrianopoulos et al 1987, Anticancer Res, 7, 4, 849-852). Animal studies transplanting gut microbiota from exercised and non-exercised animals showed a more regnerative cytokine profile and higher levels of transforming growth factor (TGF-beta) and interleukin 22 (IL-22) gene expression in the distal colon (Tambaugh et al 2006, Nature, 444, 1027-1031)  Irritable bowel disease Inflammatory bowel disease has been associated with increased abundance of Enterobacteriacae and reduced abundance of Roseburia, factors known to produce butyrate and induce redulatory T-cell formation, which is known to be important for immune function. Additionally, carbohydrate metabolism has been shown to be altered in the gut of people with IBD, whereas people who are physically active have increased SCFA (Short Chain Fatty Acids). Interestingly, positive gut changes in animal studies during voluntary wheel running were NOT replicated in forced treadmill running (Allen et al 2015, 118, 8, 1059-1066). Animal studies transplanting gut microbiota from exercised and non-exercised animals showed a more regnerative cytokine profile and higher levels of transforming growth factor (TGF-beta) and interleukin 22 (IL-22) gene expression in the distal colon (Tambaugh et al 2006, Nature, 444, 1027-1031). Obesity Obesity and metabolic disease has been shown to be related to gut microbiota in a seminal paper by Tumburgh et al (2018, Gut Microbes, 9, 2, 115-130) where they placed gut microbiota from obese mice into healthy mice and noted rapid weight gain. "I have a gut feeling" "Exercise your mood" The existance of a gut-brain axis has been well established, whereby gut microbiota affect the vagal nerve receptors. Certain gut microbes are capable of producing neurotransmitters such as serotonin and GABA. GABA is the chief neuro-inhibitor in the central nervous system and typically has an anit-anxiety and relaxant affects, whereas serotonin is associated with mood and depression. Both substances can be derived from Lactobacillus species (Carabotti et al 2015, 28, 2, 203-209). People with depressive or anxiety disorders have a unique and predictive gut profile with increased plasma levels of markers associated with intestinal permeability (Stevens et al 2018, Gut, 67, 8, 1555-1557). Butyrate seems to increase neuroplasticity and has anti-depressant activity, boosting brain serotonin levels (Matt et al 2018, Front Immun, 9, 1832) Uploaded : 9 May 2019  Read More
  • New Mothers

    New Mothers

    ATTENTION ALL NEW MUMS! May!!! We agree…. How is it May already? Well, May allows us to celebrate those very special people in our lives - our Mums. Being a parent can be very challenging at the best of times. And especially if you’re a new mum. It doesn’t matter whether it’s your first, second, or fifth child, being a new mum comes with a whole host of daily challenges. Your new little human requires all your attention - feeding constantly, changing eight nappies a day, bathing… Throw in another child, other family members, work, groceries (and the list continues) into the equation and it’s easy to see how life can be taxing on you and your body. The good news is, we’ve devised a little self-help guide for new mums! Below we give you tips on how to be kind to your body and not put yourself at risk of injury, so you can give your little munchkin the attention they need. FEEDING You’re going to be doing a lot of this. Your new recruit requires constant nourishment to ensure they grow strong and stay healthy. And it doesn’t matter whether you breast or bottle feed, it’s likely you are going to be seated for long periods, looking down at your baby. This all leads to extra strain through your neck, back and shoulders. So, try some of these little gems of advice to help keep this process pain free: 1. Get a comfortable, supportive chair - pick a chair that is going to feel good to sit in, but one you can easily get up and down from. If it’s too low, allowing you to slouch right back into, you’ll struggle to move yourself and your baby around without compromising your back.2. Keep your neck moving - feeding is a great time to bond with your baby. Eye contact is important but try not to spend the whole time looking down at a funny angle. Once your baby is comfortable feeding, it’s OK to break that eye contact every now and then to move your neck. Doing some light stretches will ensure you don’t end up with sore, overworked muscles.3. Consider a feeding pillow - these are great for taking the weight of your baby, so your shoulders and arms don’t have to. And they still allow you to have that important close contact.4. If you have a partner who can help feed, allow them to help regularly to give you a break. This tip is more for the bottle feeders of course, but it can make a huge difference.  CHANGING It’s going to be nappies galore! This can mean a lot of bending over, so it’s important you look after your posture so your lower back doesn’t take all the strain. Try to avoid changing your baby on the floor in these early days. Ideally, get yourself a changing table. It means you can place your baby down on the table and change them at a height where you don’t have to bend forward and hold an awkward position. And of course, the same advice can be followed when changing your baby’s clothes. Look after that back, you’re going to need it! OTHER USEFUL TIPS The following tips are by no means any less important, so try to take these on where possible: 1. Sleep when your baby sleeps: Getting those extra hours in when your baby is taking a nap is important to conserve your energy and reduce the risk of fatigue.2. Eat and drink well: It’s easy for the focus to turn to your baby, and rightly so, they are little and dependent on you. Remember though, you can’t look after your baby if you aren’t well. Eat for the health of you and your baby - lots of water and good nutritious food such as fruit and vegetables!3. Stretch: Especially your shoulders, neck and chest. Once baby comes along, our arms are always in front of us. Whether it’s holding, feeding, changing or playing, we’re usually a little slumped in our shoulders. Build stretching into your routine (like every time after baby feeds for example). We want to reverse the ‘slump’ position, so take your arms out wide, open up your chest and hold for 30 seconds (and repeat). Aim to do this three times a day (or whenever you get the chance!). Gentle shoulder shrugs and neck stretches can also help.4. Take time to relax: When the opportunity arises, get your partner, grandparent or friend to look after your newborn while you take a bath, read a book, or close your eyes for a little while. You deserve it, and it helps keep you sane and grounded during a very busy period in your life. 5 May 2019 Read More
  • Female hormones and knee strength

    Female hormones and knee strength

    Female Hormones and Knee Strength Muscle activation around the patella and the menstrual cycle The initial firing rate is lower in the VMO (vastus medialis oblique) compared with VM (vastus medialis) in women not men. The firing rate is affected by the menstrual cycle, showing increases in initial firing during the early follicular phase through to the late luteal phase. The initial firing was lower in VMO compared to VM during ovulatory and midluteal phases (Tenan et al 2013, Ex Sc Sp Ex, 45, 11, 2151-2157). This could play a bearing on anterior knee pain due to an increased lateral gliding of the patella over the femur, leading to patellofemoral syndrome. Anterior cruciate ligament (ACL) and the menstrual cycle Women are 2-8 times more likely to rupture their ACL than men, suggesting a hormonal mechanism behind this observation (Konopka et al DOI:10.1177/0363546516646374). The ACL is designed to prevent forward shearing of the shin bone (tibia) on the thigh bone (femur).  Anterior knee laxity (AKL) and hyperextension of the knees were shown to be significant predictors of anterior tibial translation (ATT) in both males and females. Interestingly the restraining structures to knee hyperextension are the posterior cruciate ligament (PCL) and popliteus muscle, suggesting that the knee in non weight bearing is in a relative posterior position and hence allows for greater total anterior excursion of the tibia. Notably, if a females AKL changes as much as 3mm across her menstrual cycle the ATT changes by 2mm which represented a change of approx 30% in mean magnitude of the ATT (Schultz et al 2011 Med Sc Sp Ex, 43, 2, 287-295). Furthermore, in another investigation, the same authors demonstrated increased absolute and relative magnitudes of multiplanar knee laxity changes. These were seen as increased valgus coupled with relatively greater external rotation of the tibia, making the knee more susceptible to injury on ground contact and early in the landing phase (Schultz et al 2012 Med Sc Sp Ex, 44, 5, 900-909) Women on the contracetive pill and ACL injuries Researchers looking at US insurance claims between 20007 and 2017 found that women on the pill were less likely to have an ACL injury whilst playing sport. Reconstructive knee surgery was performed on 569 out of 82874 women who were not on the pill versus 465 out of 82874. Thus the synthetic oestrogen and progesterone hormone were considered protective against knee injuries (De Froda et al 2019,The Physician and Sports Medicine, April) ACL injuries in football https://www.back-in-business-physiotherapy.com/sports-performance/knee-injuries-in-soccer.html  Uploaded : 5 May 2019 Updated : 28 June 2019 Read More
  • Thrombosis and caffeine intake during exercise

    Thrombosis and caffeine intake during exercise

    Caffeine augments the prothrombotic but not the fibrolynic response to exercise Development of clots pose a risk of cardiovascular and cerebrovascular accidents. Prothrombotic (clotting events) and fibrolynic (clot dissolving) can be influenced by altitude (thicker more viscous blood), inactivity (plane flights), genetics (haemochromatosis, prothrombin factor and/or Leyden's factor V), and paradoxically caffeine ingestion around exercise. Investigators studied the affect of a single dose of caffeine during a single acute high intensity. They found the fibrolynic effects of exercise were not affected by caffeine. However, caffeine did increase coagulation factor VIII, which suggests an elevated risk of clotting (Nagelkirk et al 2019, Med Sc Sp Ex, 51, 3, 421-425). 4 April 2019 Read More
  • Sodium Hyaluronate and Platlet Rich Plasma (PRP) for partial thickness rotator cuff tears

    Sodium Hyaluronate and Platlet Rich Plasma (PRP) for partial thickness rotator cuff tears

    Sodium Hyaluronate and Platlet Rich Plasma (PRP) for partial thickness rotator cuff tears Investigations have demonstrated improvements in pain and function, in small to medium sized supraspinatus tendon tears, up to 12 months after PRP and Sodium Hyaluronate injections, in 45 people who received PRP injections and 48 people who had a combination of sodium hyaluronate and PRP injections (Cai et al 2019, Med sc Sp Ex, 51, 2, 227-233). Read more on Rotator Cuff Injuries 21 March 2019 Read More
  • Three favorite exercises

    Three favorite exercises

    Three favorite exercises 1. Walking and runningA classic! An oldie, but a goodie, walking or running is a great all over body exercise. It works lower and upper leg, your buttocks, core, and even your arms! If you’re not much of a mover, start small with 15-minute walks, and build it up over time. Once you’re happily walking 30 minutes, start doing intervals, like running for 30-seconds and walking for two minutes (or more). Over time, increase your running time, decrease your walking time and soon enough you’ll be jogging for 30-minutes flat! Runners – interval training is great to mix up your training too. Try running at 90% effort for a minute, and then jogging for a minute. Play around with your run/jog times depending on your fitness and goals. 2. Squats These are a very popular exercise, and for good reason. These strengthen your lower body and back. Start with no added weights to ensure you have good technique. Stand with feet shoulder width apart. Keeping your back straight, push your bottom outwards to mimic sitting in a chair - try to keep your weight through your big and little toes, and your heels. When your thighs are parallel with the ground, return to the start position giving your buttocks a squeeze on the way back up. Keep your knees over your toes (which should point forward) – don’t let your knees waver in or out! A good progression is to add weight when you are ready; start with 1-2kg in each hand (or use bottles of water or books in shopping bags!) and work your way up! Eventually you can add weighted arm movements during or after your squat to get that whole-body work out. You can also do squats while brushing your teeth or waiting for the kettle to boil! 3. Box Jumps or step ups This is another lower body exercise but is also a great calorie burner and really engages the whole body to perform. You need a box (we strongly advise against cardboard ones!) or a strong raised surface that will take your weight with no issues (like a step/platform). Jump up onto the box, landing with both feet and raise to a standing position. Then jump back down and repeat. Start slow and low and build up to faster and higher jumps. Of course, if you aren’t quite at jumping yet, or you have any lower body injuries or heart problems, try stepping up and down to start. Try not to let your weight shift side-to-side too much as you step up. Start by doing 3 x 30secs, building up to 3 x 1-minute sets. Or try 3 x 10 jumps, building up to more as you progress. Make sure your knees and toes point forward, and if in doubt, start small! Uploaded : 16 March 2019 Read More
  • What pain relief is right for you?

    What pain relief is right for you?

    What pain relief is right for you? Pain has been a huge topic for discussion for a long time now. Nearly everyone feels it (I say ‘nearly’ because there is actually a very small minority of people with a special condition that does not allow them to feel pain), and it varies in character and severity depending on what part of the body is implicated. And for the most part, none of us like being in pain. When we feel pain, normally the first thing we do is to look for a way out of it (of course a small minority just ignore it - tut tut!). It’s a bit of a minefield knowing where to go for good pain relief. Some of us like a quick fix, others are more interested in fixing the problem long term by putting the hours in. When it comes to the body, we usually feel pain because our body is sending us a signal letting us know something is not quite right. That might be down to a simple muscle imbalance or joint restriction, which is leading us to walk or run differently. Or it might be down to something more serious like a tear of a muscle or tendon, or a problem with an organ deep inside the body - the list of causes is long and complex. Now once we have pain, we want to know how to get rid of it. A lot of us turn to the experts (i.e. manual therapists such as your local physio/osteo/chiro [delete as appropriate], and other professionals like doctors), and some of us like to self-diagnose using www.DrInternet.com (do this at your peril!). So, what is out there to help us relieve our pain? Some of the most common and well-known forms of pain relief include manual therapy, use of temperature, and numerous medications - you’ll find a brief overview of each below: Manual therapy Us humans have been using our hands to treat the body for a very, very, very long time! If you walk into a clinic in pain, be it you have a swollen ankle or the inability to lift your arm above your head, your therapist will get to work on you using a whole host of techniques (after they have carefully and correctly diagnosed you of course!). Soft tissue massage and release techniques are widely used in the management of musculoskeletal pain, and evidence suggests you aren’t wasting your time by getting the help of your local therapist. Your therapist may also utilise other techniques, including joint mobilisation and manipulation, to correct your problem and to help get your pain lowered and under control. Usually you will also be given some form of flexibility or strengthening exercise to perform between treatment sessions to back up what happens in the treatment room. Heat and cold therapy If you’ve hurt yourself in the past, there is a good chance you’ve tried some form of treatment relating to temperature to help relieve the pain. It’s difficult to know whether it’s best to use heat or cold therapy, but the following principles are pretty safe to follow. Cold therapy can help to reduce pain, blood flow, swelling, muscle spasm, and inflammation. Heat therapy can help to relieve pain, increase blood flow, and tissue elasticity. Although more evidence is needed to support the use of these therapies in certain scenarios, it may help, so it’s worth getting the advice from your local physio/osteo/chiro [delete as appropriate] for the best route ahead. Medication There are countless different medications out there that can help with pain relief - these are called analgesics. Without getting too complicated, they can generally be split into Non-opioid and Opioid analgesics. Non-opioid analgesics include your well known and easily accessible medications such as aspirin, paracetamol, and anti-inflammatories (such as Ibuprofen) - these are generally good for the control of musculoskeletal pain. Opioid analgesics are there for cases of more severe pain, and include codeine, tramadol and morphine (you won’t be able to get these ones over-the-counter though!). Remember it’s always safest to consult a medical professional before using any form of medication. We hope this has been a helpful overview to read. If you are injured or in pain, we advise you to book a consultation with us so we can talk through your problem, assess you thoroughly, and then advise the best course of action for you. Our aim is to help get you out of pain and moving better again! Say ‘au revoir’ to pain! Uploaded : 25 Feb 2019 Read More
  • Why your body is like a chain

    Why your body is like a chain

    WHY YOUR BODY IS LIKE A CHAIN The concept that the human body is like a chain has been around for a long time. The body is a complex network of systems that all work together to allow us to move and do the things we like to do. When referring to movement, most people straight away think of muscles, bones and joints. However, there are a whole host of structures required to function together in order to produce movement. The musculoskeletal system is primarily associated with movement. From head to toe, our bones are joined at various points called joints, which are held together by strong structures called ligaments. Muscles then attach to bones via tendons and the muscles exert forces on the bones, which basically causes a joint to move. But, without blood and electrical stimulation, the muscles themselves cannot function to exert that force on the bones - so the circulatory system (which carries the blood around the body) and neurological system (where nerve impulses travel around the body) play just as important roles. Of course, the overall picture is much more complex than this, but you can see how you need lots of different elements to work together so our bodies can do what they have evolved to do – MOVE! Us humans are what we call bipedal, which means we walk upright on two feet. Other animals that do this are birds (when they are walking and not flying of course) and apes (although not all the time). Even cockroaches and some lizards sometimes move bipedally (usually when running at full speed), and of course, our native Kangaroos hop and jump in the same fashion. Think back millions of years to Mr T. Rex, who also walked around on his two back legs – it has been around a long time! Unless we move around on our hands and knees (which we don’t tend to do much after learning to walk from a young age), our main contact points with the Earth are our feet. And once we have learned to hold that upright posture, our body acts as a chain from feet to head to allow us to function as humans - get up, go to work, drive, play sports, eat our meals, and so on… If something goes wrong somewhere in that chain of muscles, bones, joints and systems, then it can lead to the whole or parts of the chain becoming dysfunctional. And when we have dysfunction in the body, it quite often leads to pain. For example, you have flat feet or collapsed foot arches – this means your feet tend to roll in. Now because the foot bone’s connected to the leg bone, and the leg bone’s connected to the thigh bone (sing along!), the flatness of your feet directly affects what is going on above in the ankle, knee and thigh. The leg and thigh bones must compensate for the lack of foot arch, which will commonly mean the knees fall inwards and you may end up with a case of knock knees. Flat feet may not cause pain in the feet themselves, but it’s very possible that knee or hip pain (areas further along the chain of the body) could be caused by such a problem. However just remember that many people who have flat feet have no pain whatsoever, so just because you have flatter feet than your friend, it doesn’t mean you are going to get pain. It just means you may be more susceptible to certain conditions because of the extra stress on the body’s structures (e.g. muscles, ligaments, joint surfaces) due to the compensations it has had to make. The body will compensate well for you, but there is always a point where the body will start to tell you it needs some help. Pain is usually the first sign of this! Often manual therapy - soft tissue release, joint mobilisation/manipulation – and some form of strengthening exercises will get the body back on track to reconnecting the chain to its former glory. In the case of flat feet, you may need some form of orthotic in your shoe too. It’s at this point where you start to feel better and can get back to playing your sport, or even just getting in the car to drive to work without being in pain. All the elements start to function together again, the body can move without, or at least with less, compensation, and that equals a much happier you. So, if you think you have a little kink in your chain, don’t take it to the jewelers to get fixed. Book in for an assessment, treatment, and some expert advice on how to manage your problem. You’ll be back roaring like a T-Rex in no time. Roar. Uploaded 16 feb 2019 Read More
  • Beetroot Juice Increases Human Muscle Force

    Beetroot Juice Increases Human Muscle Force

    Beetroot juice increases human muscle force Beetroot juice has been shown to improve low frequency muscle force independent of Calcium-handling-proteins or REDOX reaction (Whitefield et al 2017, Med Sc Sp Ex, 49, 10, 2016-2024). Further benefits of beetroot juice are thought to include reduction of blood pressure protection from pre-mature aging aiding cancer survival lowering serveral inflammatory markers including interleukin-6, C-reactive protein and tumor necrosis factor alpha stabilising blood suger improving sexual performance anti-arthritic effects blood purification and enhanced red blood cells removing 'bad' estrogens from our blood stream Uploaded : 18 November 2017 F Read More
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  • Neuroplasticity in Tendon Dysfunction

    Neuroplasticity in Tendon Dysfunction

    Neuroplasticity in Tendinopathy by Martin Krause A multitude of contributing factors to altered motor control must be addressed when treating tendon dysfunction. What we have failed to consider in the past when dealing with chronic or recurrent tendon issues are motor control problems encompassing corticospinal control of excitation and inhibition as well as belief systems about pain and contextual factors related to imaging.  Research by Ebonie Rio et al (2015) (BJSM Sept 25, 10.1136/bjsports-2015-095215) suggest that the pain state sets up an adaptive pathway whereby the ipsilateral kinetic chain is directly inhibited by reflexogenic pathways, as well as being inhibited by contralateral hemispheric activity. Simultaneously excitation is enhanced in the opposite limb as well as in antagonists...at least in the case of enhanced excitation of the hamstrings in quadricep tendinopathy. If this is true, then so much for training the contralateral limb for 'cross training' purposes! This may also explain why a lot of people seem to have "all their injuries on the same side" (of the body). Furthermore, they recommend enhancing corticospinal drive through the use of 30-60 second isometric holds at 70-80% MVC to load the muscle whilst using isokinetics to load the tendon. Moreover, they recommend the use of a metronome at 60bpm (stages 1 and 2) with a count of 3 up, 2 down for quads, and 2 up, 3 down for calf isokinetics to optimally engage corticospinal drive through the visual and auditory stimuli (also shown by Kohei et al 2012 for motor imagery and M1 stimulation) .....read more Cortical mapping of infraspinatus muscle in chronic shoulder pain demonstrating higher motor thresholds (aMT= activation MT) and hence reduced excitability on the affected side (39 vs 35) (Ngomo et al 2015 Clinical Neurophysiol, 126, 2, 365-371) Cortical mapping of pain and fear. Lots of overlap suggesting that taking away the fear from the pain with clear clinical explanations and a focused goal directed program using specific functional outcomes is important.  Individuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036, https://doi.org/10.1093/pm/pnx036)  Uploaded : 18 October 2017 Read More
  • Imaging

    Do I need a scan? "a picture tells a thousand words" - not really! by Martin Krause A scan, in it's self, will not improve anyone's condition. The purpose of a scan is to gain more information about the pathology. Sometimes this information may be irrelevant to the management of a patient's condition. For example, if you knocked your elbow on a door frame and suffered a bruise, which was already beginning to resolve, an ultrasound scan may show some minor soft tissue damage, but that was already obvious by the fact of the bruise, and the information gained from the scan has not helped nor changed the management of the bruise. Therefore, the main reason for getting a scan would be because there is concern that the presence of certain pathologies may lead to a change in the medical management. For example, sometimes a rolled ankle can be more than sprained ligaments, and may require surgey or immobilisation in a boot. If the therapists suspects this might be the case, then they will recommend or refer for a scan (probably an X-Ray) to check the integrity of the bones (especially the fibular and talar dome), because if there is no bony damage then the patient can be managed conservatively with taping, exercises, ultrasound, massage, joint mobilisations etc. However, if there is boney damage, for example, then it might be necessary for the ankle to be immobilised in a boot for three - six weeks, for example. This dramatically different medical management depends on the results of a scan, and it is therefore worth doing. However, scans have no predictive value to the presence or severity of pain. Thirty-three articles reporting imaging findings, in the low back, for 3110 asymptomatic individuals were investigated for pathology. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age. (Brinjikji, W et al Spine Published November 27, 2014 as 10.3174/ajnr.A4173). Hence, the results of imaging need to be assessed within the context of the entire clinical picture. Frequently too much emphasis is placed on the imaging not only by the clinician but also by the patient. Some people react to pathology seen on scanning as an affirmation of their problem and can either use it to gain clarity and become better or conversely become worse. Moreover, some people find imaging with inconclusive results as a 'panic moment' - "no one knows what is wrong". Similarly, ultrasound imaging of the tendond has good predictive diagnostic and aids in clinical reasoning when it comes to full tears. However, with partial tears it is a totally different 'ball game'. Ultrasound is highly user dependent, with specifically trained musculoskeletal radiologists able to produce high-quality images that may provide more clinically relevant information than those produced by clinicians with less experience in imaging. Sean Docking, a leading tendon researcher at Monash University, cited 7 authors who found pathological tendon chnages in 59% of asymptomatic individuals, whereas he found that 52% of asymptomatic elite AFL sportsmen had tendon pathology on imaging! Furthermore, symptomatic individuals who improved clinically to the point of resuming play, weren't shown to have improvements on imaging. Again, the clinical context and the clinical reasoning can in many instances prove to be the 'gold standard' not the imaging itself, when considering management options. Shoulder supraspintatus tendon pathology, in the abscence of trauma, is known, in many instances, to be a disorder of immune-metabolic compromise of the tendon and bursa. Imaging may show some changes in signal intensity but, unless it's a complete tear, it can reveal neither the intensity nor the severity of pain when taken outside of the clinical context. A thorough physical and subjective examination integrating all the clinical dimensions of the problem will have far greater value than any one single imaging modality. Yet, imaging still should be used in instances of progressive rapid deterioration and suspected serious pathology which may require surgery and/or immediate medical intervention. In summary, sometimes it is worthwhile getting a scan, because the information gained from that scan will determined the type of medical management that is employed. However, at other times, the scan may be unneccessary, because the information may be irrelevant or lead to an incorrect change in medical management, due to over-reporting of 'false positives'. You will be able to make this decision on the advice of your health care professional. On occasions it can actually be detrimental to have a scan, because some patients can become overly obsessed with the medical terms used to describe their scan results, which then can become the major focus for the clinician and the patient, rather than the more prefereable focus on their symptoms and functional abilities. For example, many people have lumbar buldging discs yet have no symptoms, yet sometimes when these patients have an MRI or CT scan, they can develop symptoms because they think they should have pain if the scan says so! Conversely, for some people the results of imaging can have a positive and reassuring affect. Therefore, it is very important to assess a clients attitude to scans before prescibing them so that the patient's expectations are managed appropriately, and not burdened by the additional, sometimes confusing, information supplied by a scan. Uploaded : 10 October 2017 Read More
  • Cervical Spine implications in concussion

    Cervical Spine implications in concussion

    Neck aetiology, autonomic and immune implications, exercise and diet in the musculoskeletal physiotherapy management of Post Concussion Syndrome (PCS) by Martin Krause, MAPA, Titled member Musculoskeletal Physiotherapy Association of Australia  A 14 year old boy presented to A&E, in August 2016, after receiving an impact to the head during AFL (Australian Rules Football). Although his SCAT3 scores were relatively mild, he went on to suffer severe lethergy, resulting in a lengthy abscence from school, culminating in a return to school for exams in the first week of December 2016. By December, even a 30 minute walk was extremely fatiguing. To place this into perspective, he had been playing elite academy grade AFL for several seasons and was an extremely fit outdoor adventurer. Confounding Variables : end of season injury and hence no follow up from the academy suffers from Hypermobile Joint Syndrome (HJS) and possibly Ehlers Danlos Syndrome (EDS), however Beighton score 4/9. suffers from food intolerances, particularly to Glutin and diary, but also some other foods. Potential IBS and autoimmune issues. had just gone through a growth spurt (190cm) Imaging : Brain MRI normal Medical Examination : Balance remained impaired to tandem walking and single leg stance. The vestibular occular motor scale showed significant accomodation deficit of 15cm and there was a mild exacerbation of symptoms. ImPACT testing revealed adequate scores and reaction time of 0.65 which is within acceptable range. History : School holidays December - January. Return to school and was placed in the lower academic classes. Prior to his concussion he was a top 10 student at an academically selective high school. Took up basketball and rowing as summer sports. Academic results tanked. Several lower limb Basketball injuries (Feb - April 17') as a result of what apppeared to be muscular imbalances from the relatively recent growth spurt, as well as taking on a new sport. Showed little interest in returning to AFL as no-one from the AFL academy had followed up on his recovery (or in this case lack of recovery).  Current History : September 2017 showed a continued decline in academic levels. School teachers noted an inability to concentrate. Academic results still well below pre-concussion levels. Fatigue continuing to be problematic. Stopped going to school for 7 weeks due to another head impact, but this time at Basketball. Literature Review : Post Concussion Syndrom (PCS) is defined as "cognitive deficits in attention or memory and at least three or more of the following symptoms: fatigue, sleep disturbances, headache, dizziness, irritability, affective disturbance, apathy, or personality change"  Adolescents have been found to have impaired dynamic cerebral autoregulation after concussion that improves along with clinical signs and symptoms in some individuals, whilst remaining impaired in others (Moir et al, 2018 Med Sci Sp Ex,,50, 11, 2192-2199). Moreover, it would appear that measurement of dynamic intracerebral blood flow latency in reaction to chnages in position from lying to sitting to standing was more sensitive than static intracerebral blood flow monitoring. This interaction myogenic vasomotor response occurs at a vascular-astrocytic level. Of the 19 people in their investigation, 2 demonstrated complete recovery at 28 days post incident, whereas 7 experienced little change in intracerebral blood flow from the first to last visit (32 + 14 day). Surprisingly, there appears to be a greater incidence of concussion amongst females (Moir et al 2018; Halstead et al 2010, Pediatrics, 126, 3, 597-615; Dick et al, 2009, Br J Sports Med, 43, Supp, i46-50) One of the known risk factors for Sport Related Concussion (SRC) is a history of prior concussion (Collins et al 2002. Neurosurgery, 51, 5, 1175-9. Inversen et al 2004, Brain Inj, 18, 5, 433-43). Cummulative effects exist with three or more prior concussions but not with one or two concussions (Inverson et al 2006, 40, 1, 72-75) . Although, most adults recover from concussion after 10 days, there is evidence to suggest ongoing abnormailities in the brain can pursist well beyond 10 days (Prichep et al 2013, J Head Trauma Rehabil, 28, 4, 266-273). Thus, with the above described symptoms and potential motor control problems, further complications of PCS also appear to be altered proprioception, an increased risk of musculoskeletal injury which in turn can lead to SRC. The following are the results from soccer players. Nordstrom et al (2014, BMJ Sports Med, 48, 19, http://bjsm.bmj.com/content/48/19/1447) Visuomotor reaction time (VMRT) responses and whole body reactive agility (WBRA) have shown neuromechanical deficiencies in elite athletes who reported a history of concussion (Wilkerson et al 2018 Med Sc Ex Sp, 50, 9, 1750-1756). Dual task performances creates competition for neuronal cognitive resources required for higher executive function. Among demands placed by sport on the executive function are visuospatial processing, which can be crucial for management of environmental interactions. Deficits in dual task VMRT have been associated with both a history of concussion and subsequent musculoskeletal injury occurence.(Wilkerson et al 2017, Cirr Sports Med Rep, 16, 6, 419-427).  Sensory organistion test (SOT) balance scores show significant relationships with reaction time and executive function in people suffering concusion (Van der Vegt et al 2019, Med Sc Sp Ex, 51, 2, 264-270). Notably, the ability to use sensory information to adapt motor responses with varying environmental demands is essential for sport safety and performance.   Predictors of PCS are uncertain. However, the following clinical variables are considered factors at increasing risk. These include prior history of concussion, sex (females more prominant), younger age, history of cognitive dysfunction, and affective disorders such as anxiety and depression (Leddy et al 2012, Sports Health, 4, 2, 147-154). Unlike the 'good old days' which recommended a dark room and rest for several weeks post concussion, the consensus appears to be a graded return to exercise in order to restore metabolic homeostasis. Disconcertingly, highly trained young individuals can find even exercises in bed extremely demanding in the presence of sport related concussion (SRC). Kozlowski et al (2013, J Ath Train, 48, 5, 627-635) used 34 people,whereby 226 days post injury to conclude significant physiological annomalies in response to exercise which may be the result of 'diffuse cerebral swelling'. Researchers have noted lower systolic and higher diastolic blood pressure in PCS (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Due to autonomic dysfunction manifested in altered cardiovascular and pulmonary responses (Mossberg et 2007, Arch Phys Med Rehab, 88, 3, 15-320), wheerby some clinicians have recommended the use of the exercise program for POTS (Postural Orthostatic Tachycardia Syndrome). This is a 5 month program which recommends mainly exercise in the horizontal and sitting positions for 1-4 months, including recumbent bike, rowing ergometer and swimming laps or kicking laps with a kick board. Month 4 upright bike and Month 5 upright training such as a elliptical trainer or treadmill.  Other progressive exercise therapies have also included 20 minutes per day, 6 days per week, for 12 weeks of either treadmill or home gym exercises at 80% of the heart rate at which their concussion symtoms are exacerbated. Their programs were individually modified as the heart rate provoking symptoms increased. When compared to the 'control group', this intervention was shown to improve cerebral perfusion on fMRI, increase exercise tolerance at a higher heart rate, less fatigue and were showing activation patterns in areas of the brain on performing math processing test which were now normalised (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Graded exercises could also have included 'motor imagery' as espouse by the NOI group and the work of Lorrimer Moseley (University South Australia) when dealing with chronic pain. Exercise Dose (literature review by Howell et al 2019, Med Sc Sp Ex, 41, 4, 647-652) Frequency : 5d/wk of moderate intensity or > 3 d/wk of vigorous intensity Duration : 30-60 minutes/day (150min/wk) at moderate intensity or 20-60 minutes (75 min/wk) of vigorous intensity Mode : exercise using major muscle groups eg walking, jogging, cycling or swimming Volume : > 500-1000 MET/min/wk (MET = 3.5 ml O2/kg/min) Pattern : exercise is performed ideally in one continuous pattern; however multiple sessions of > 10min can be performed to accumlate the desired total duration and volume of exercise Progression : Gradual progression of exercise volume by adjusting duration, intensity and/or frequency is recommended to gain continued aerobic fitness improvements Ongoing Symptoms : The literature review by Leddy et al (2012) found that ongoing symptoms are either a prolonged version of concussion pathophysiology or a manifestation of other processes, such as cervical injury, migraine headaches, depression, chronic pain, vestibular dysfunction, visual disturbance, or some combination of conditions. Anatomical considerations : Extensive anatomical connections between the eyes, neck and vestibular system (Wallwork et al 2007, JOSPT, 37, 10, 608-612) allow sensory information from neck proprioceptors to be processed together with vestibular information which, via the lateral vestibulo-spinal tract, affect the control of postural muscles such as the deep trunk muscles  (Hain 2011, Neuro-Rehabilitation, 29, 2, 127-141).  Psychological considerations : The Kubler Ross model of grief are applicable when it comes to chronic sports injuries. Physiotherapy Assessment : Current history One year PCS, fatigue continued to persist. Cognitive deficits with school work were reported to becoming more apparent. Assessment using various one leg standing tests employing oscillatory movement aroud the hips and knees for kinetic limb stability and lumbopelvic stability, which had been employed 6 months previously for his Basketball injuries were exhibiting strong deficits, despite these being 'somewhat good' previously. Significantly, during the acute phase of SRC, rugby union and rugby league players have been seen with alterations of both balance strategies and motor control of the trunk (Hides et al 2017, Musculoskeletal Sci Pract, 29, 7-19).  Physical Examination : cervical and thoracic spine Due to the Joint Hypermobility Syndrome (JHS) it was difficult to ascertain neck dysfunction based on range of movement testing. ROM were unremarkable except for lateral flexion which demonstrated altered intervertebral motion in both directions. Palpation using Australian and New Zealand manual therapy techniques such as passive accessory glides (upslopes and downslopes and traction) exhibited muscles spasms in the upper right cervical spine. In particular, the right C1/2 regions demonstrated most marked restrictions in movement. Eye - Neck proprioceptive assessment using blind folds and laser pointer also  revealed marked variance from the normal. Repositioning error (RPE) using the laser pointer with rotation demonstrated marked inability to reposition accurately from the left, tending to be short and at times completely missing the bullseye. Gaze stability with body rotation was NAD. Gaze stability whilst walking displayed some difficulty. Laser pointer tracing of the alphabet was wildly inaccurate and cognitively demanding. Thoracic ring relocation testing also revealed several annomalies, which may have also accounted for some of the autonomic dysfunction observed.  Occulomotor assessment and training Upper Cervical Spine : The upper cervical spine (atlas and axis) represents approximately 50% of the available rotation. An investigation into the environmental and physiological factors affecting football (soccer) head impct biomechanics found that rotational acceleration was one of the few factors approaching significance and concluded that more research should be undertaken to evaluate this (Mihalik et al 2017 Med Sc Sp Ex, 49, 10, 2093-2101). Headache : Commonly referred to as cervicogenic headaches, one in five headaches in the general population are thought to be due to the cervical spine. The Upper Cervical Spine is particularly vulnerable to trauma because it is the most mobile part of the vertebral column, with a complex proprioceptive system connecting the vestibular apparatus and visual systems. It also coincides with the lower region of the brainstem and fourth ventricle. The brainstem houses many neurones associated with autonomic responses to pain and balance. Imaging of the fourth ventricle for swelling of the 'tonsils' and Arnold Chiari malformations are recommended when symptoms persist. In particular, children and adolescents are more vulnerable to neck contusions due to the proportionately larger head and less developed musculature. Cervical vertigo and dizziness after whiplash can mimic symptoms of PCS.. Mechanoreceptor dysfunction and vertebrobasilar artery insufficiency should be part of the differential diagnosis. Mechanical instability of the Upper Cervical Spine should also not be missed. Cervicogenic Headaches Further Interventions : Neurocognitive rehabilitation of attention processes. Psychological intervention using cognitive behavioural therapy (CBT). Neuro-opthalmologist to assess and treat smooth pursuit eye tracking. Naturopath for food intolerances and dietician for the optimisation of diet. Diet :  In cases with chronic fatiguing factors, nutrition can be become a vital aspect into the reparative process. This may include energy and mineral rich foods such as bananas, green leafy vegetables for iron and magnesium (200-300mg), oranges for vitamin C (anit-oxidant and helps with the absorption of iron), anti-oxidant rich foods such as EPA/DHA (1000mg) fish oil, curcumin (tumeric), Cats Claw, Devils Claw, Chia seeds, fruits of the forest (berries), and CoQ10 with Vitamin B. Folate and Ferritin levels should also be checked. Calorific energy intake should balance with energy exependiture. However, as we are often dealing with young individuals, as in this case, some form of comfort food may be appropriate such as, nuts, legumes, homus and sushi. Protein intake prior to carbohydrate intake may help ameliorate any blood suger fluctuations due to Glycemic Index factors, however simple carbohydrates (high GI) should be avoided wherever practical. Even oats need to be soaked overnight and cooked briefly, otherwise they become a high GI food and may even affect the absorption of iron. The type of rice used can also influence GI, hence the addition of protein such as fish. Protein supplementations are generally over-used. Daily protein intake should not exceed 1.2g per kg of body weight per day. Dosage for children is less than that for adults. See Nutritional Section of this Site Trunk muscles : Researchers have found that a history of SRC had an increased possibility of having altered size and contraction of their trunk muscles, incuding smaller multifidus, larger quadratus lumborum muscles, and asymmetrical contraction of their transverse abdominis muscles, whereby an increased thickness and resting tone of the right anteroloateral abdominal muscle has been observed (Hides et al 2017 Med Sc Sp Ex, 49, 12, 2385-2393). In this case, by the second incident (Basketball impact), the subject was 15 years of age and 193cm in height. Apart from being very tall for his age he also has joint hypermobility. Combinations of SRC, growth spurt and hypemobility may have had a greater impact on his motor performance making secondary trauma more likely? A 3-6 increased risk of future SRC has been reported in the literature in cases of concussion (Abrahams et al 2014, Br J sp Med, 48, 2, 91-97). In our subject, using the laser repositioning error described above, marked inability to reposition the neck from the left was seen. This concurs with the findings in Australian Football Players (AFL), where a mean of 4.5 degrees of joint position error was reported on the left hand side (Hides et al 2017 Med Sc Sp Ex, 49, 12, 2385-2393). This is noteworthy, as our subjects initial concussion took place during AFL, with the subsequent concussion occurring in Basketball. It should also be remembered that this subject presented to physiotherapy for an ankle injury some 6 months after the initial concussion. Lower limb kinematic exercising ability, emphasising global balance and kinematic 'inverse dynamics' muscular energy strap transfer prinicples, demonstrated strength and balance deficits within the following prgramme. It should be noted that this regime places emphasis on repatitive loading; hence 3 x 40 reps. Interestingly, an investigation comparing lower limb (LL) and back exercises (lumbar extension LE and lumbar stabilisation LS) for runners with chronic low back pain reported  greater improvement in self-rated running capability and knee extension strength in the LL group vs LE and LS groups greater increase in running step length in LL and LE groups and similar reductions in running induced pain and improvement in back muscles across all three exercise groups. (Cai et al 2018, Med Sc Sp EX, 49, 12, 2374-2384) Extrapolation of these results to the current clinical setting suggests the importance of lower limb dynamic stability in cases of concussion. Moreover, recognition of these deficits may have prevented the second incidence of concussion? Conclusion  Investigations, into people with persisting PCS, demonstrated that they applied more force over time to control balance. Helmich et al (2016, Med Sc Ex Sp, 48,  12, 2362-2368) proposed that in regard to cognitive processes, the increase of cerebral activation indicates an increase of attention demanding processes during postural control in altered environments. This is relevant in so far as individuals with post concussive symptomatology have a variety of symptoms including headache, dizziness, and cognitive difficulties that usually resolve over a few days to weeks. However, a subgroup of patients can have persistent symptoms which last months and even years. Complications in differential diagnosis, can arise clinically, when neck dysfunction and altered motor control occur concurrently due to both neck and cerebral pathology. For example, Whiplash and other traumatic head and neck injuries can result in pathology to both regions, whereas, more discreet altered cognitive processing from concussion can result in altered neck motor control. Musculoskelatal Physiotherapy can play a vital part in the treatment of neck dysfunction including the re-establishment of occulomotor proprioception and managing localized strength and cardiovascular exercise regimes. A total body, multi-disciplinary approach which is well co-ordinated amongst practitioners is vital to an optimal outcome.    Updated : 4 June 2019. Original : 17 November 2017 Read More
  • Pain in the Brain - neural plasticity

    Pain in the Brain - neural plasticity

    Pain in the Brain and Neural Plasticity by Martin Krause There are several mechanisms that can create a sensation of pain, which has been described as 'an unpleasent sensory and emotional experience in response to perceived or potential tissue damage'. Pain can be the result of peripheral sensitisation from peripheral inflammation, vascular compromise, necrosis, swelling, etc. Importantly, higher centres of the central nervous system not only perceive such sensitization of the peripheral nerve receptors, they can also modulate and control the intensity and tolerability of the perceived sensation through descending modulation at the peripheral receptor and in the spinal cord and through transcortical mechanisms depending on the 'meaning' and 'context given to the pain. Moreoever, the higher centres can create a 'state' of perceived 'threat' to the body through emotions such as fear and anxiety. Rather than the brain acting as a filter of unwanted sensation, in the higher centre induced pain state, rumination and magnification of sensations occur to create a pathological state.  Paradoxically, representation of body parts such as limbs and individual muscles can reduce in perceived size. In such instances the pain doesn't represent the sensation of pathology but rather pain has become the pathology. Hence, the brain generates pain in the brain, where the pain is perceived to be some sort of non-existant inflammatory or pathological sensation in the periphery. Evidence for this neural plasticity comes from imaging studies, where brain white matter structural properties have been shown to predict transition to chronic pain (Mansour et al 2013, Pain, 154, 10, 2160-2168). Specifically, differential structural connectivity to medial vs lateral prefrontal cortex and connectivity between medial prefrontal cortex and nucleus accumbens has been shown in people with persistent low back pain. In this case the back pain becomes the inciting event and given the persons' structural propensity, establishes specific functional coonectivity strength.  further reading Peripheral input is a powerful driver to neuroplasticity. Information gathered by touch, movement and vision, in the context of pain can lead to mal-adaptive plasticity, including the reorganisation of the somatosensory, and motor cortices, altered cortical excitability and central sensitisation. Examples of somatosensory reorganisation come from the work of Abrahao Baptista when investigating chronic anterior knee pain, who not only demonstrated reduced volume of Vastus Medialis but also is cortical translocation to another part of the cortex. Individuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036, https://doi.org/10.1093/pm/pnx036)   AKP = anterior knee pain The same researcher (Abrahao Baptista) has shown that maximal tolerable electrical stimulation (eg TENS) of muscles can induce normalisation of the cortical changes through a process called 'smudging'. Transcortical stumilation has also been applied as a cortical 'primer' prior to the application of more traditional therapy such as motor re-training, exercise, and manipulation. Brain White Matter microstructure of people with Lateral Ankle Sprain Lateral ankle sprains occur in approximately 70% of the population. These can become chronic and quite disabling leading to declines in physical activity and its concommitant morbidity. Additionally, in the elderly, this can lead to an increased risk of fractures due to falls. Ruptured ligaments have the capacity to alter the somatosensory input to the cortices, thereby altering in turn, the afferent input from the cortices to the periphery, as evidenced by increased use of hip musculature (Doberty et al 2015, Clin Biomech, 30: 129-135), over-reliance of visual input (Song et al 2017, J Sci Med Sport, 20, 10, 910-914) and the frequent use of external stabilisers such as braces and ankle supporting footware. Speculation of pyramidal grey matter changes in the motor cortices have also been made (Terada et al 2016, PM R, 8, 11, 1090-1096). Such altered mechanics has been associated with changes in the central nervous system microstructure of the white matter in the superior cerebellar peduncle (Terada et al 2019, Med Sc Sp Ex, 51, 4, 640-646). Cause and effect cannot be established, however, clinically, emphasis must be placed on both peripheral tissue issues as well as higher centre processes if the chronic cycle is to be broken.  Treatment Body illusions are another novel way to promote the normalisation of cortical function through adaptive neuroplasticity. Examples come from people with hand athritis, whose perception of their hand size is underestimated (Gilpin et al 2015 Rheumatology, 54, 4, 678-682). Using a curved mirror, similar to that in theme parks, the visual input can be increased to perceive the body part as larger (Preston et al 2011 DOI: 10.1093/rheumatology/ker104 · Source:PubMed ) . Irrespective of size, watching a reflection of the hand while performing synchronised movements enhances the embodiment of the reflection of the hand (Whitkopf et al 2017, Exp Brain res, 23, 5, 1933-1944). These visual inputs are thought to affect the altered functional connectivity between areas of the brain thereby affecting the 'pain matrix'. Another, novel way of looking at movement and pain perception is the concept of the motor engram. This has been defined as motor skill acquisition through the modification and organisation of muscle synergies into effective movement sequences. The learning process is thought to be acquired as a child through experientially based play activity. The specific neural mechanisms involved are unknown, however they are thought to include motor map topography reflecting the capacity for skilled movement reorganisation of motor maps in a manner that reflects the kinematics of aquired skilled movement map plasticity is supported by a reorganisation of cortical microcircuitry involving changes in synaptic efficacy motor map integrity and topography are influenced by various neurochemical signals that coordinate changes in cortical circuitry to encode motor experience (Monfils 2005 Neuroscientist, 11, 5, 471-483). Interestingly, it is an intriguing notion that accessing motor engrams from patterns aquired prior to the pain experience might lead a normalisation of brain activity. My personal experience of severe sciatica with leg pain, sleepness nights and a SLR of less than 30 degrees, happened to coincide with training my 9 year old sons soccer training. I was noticing that the nights after i trained the children, I slept much better and my range of movement improved. I commenced a daily program of soccer ball tricks which i had been showing the kids, including 'juggling', 'rainbows' and 'around the worlds'. Eventually, I even took up playing soccer again after a 30 year abscence from the sport. Other than new activity related pain issues (DOMS), four years on, the sciatica hasn't returned. I can only conclude that this activity activated dormant childhood motor engram, worked on global balance, mobilised my nerve, encouraged cross cortical activity and turned my focus into finctional improvement. Further explainations for my expereience comes from evidence suggesting that a peripheral adaptive pain state is initiated, whereby transcortical inhibiton occurs by the contralaleral hemisphere to the one which controls the affected limb. Additionally, excitation cortical (M1) drive of the muscles of the contralateral limb to the one which is in pain also occurs. In such cases re-establishement of motor drive to the affected side is important. In terms of tendon rehabilitation, external audtory and visual cues using a metronome have been employed and are showing promising results (Ebonie Rio et al 2017 Personal communication). In terms of my experience with the soccer ball tricks, the external visual cues and the cross talk from using left and right feet, head, shoulders, and chest during ball juggling manouvers, whilst calling the rhythm to the kids may have been the crucial factor to overcome the dysfunctional brain induced pain - muscle inco-ordination cycle, which I was in. Additionally, I was cycling which allowed me to focus on motor drive into the affected.limb. However, work by Lorrimer Moseley on CRPS has established that 'brain laterality' must be established before commencing trans-cortical rehabilitation techniques. Lorrimer's clinical interventions use 'mirror imaging' techniques which are only effective once the patient is able to discriminate the left and right sides of the affected body parts, presented visually, in various twists and angles.   Alternatively, the altered pain state can result in a hostage like situation, whereby the pain takes control. Similar to the 'Stockholm Syndrome' where the hostage begins to sympathise with their captors, so do some peoples brain states, where it begin to sympathise with the pain, creating an intractable bondage and dysfunctional state. One screening question which may reflect commitment to the process of rehabilitatation is to question whether they were able to resist the cookie jar when they were a child? Or were they committed to any sporting endeavours as a child? This may give some indication for the presence of motor engrams which can be used to overcome dysfunctional pain induced muscle synergies (neurotags), but also indicate an ability to be self disciplined, as well as being able to reconcile and identify goal oriented objectives, in spite of the cognitive pain processes? Remember that neurons that fire together, wire together. Uploaded : 4 June 2019 Read More
  • Sickle Cell Trait and Acute Low Back Pain

    Researchers believe that lumbar paraspinal myonecrosis (LPSMN) may contribute to the uncommon paraspinal compartment syndrome and that sickle cell trait (SCT) may play a role. Sustained, intense exertion of these lumbar paraspinal muscles can acutely increase muscle size and compartment pressure and so decrease arterial perfusion pressure. This same exertion can evoke diverse metabolic forces that in concert can lead to sickling in SCT that can compromise perfusion in the microvasculature of working muscles. In this manner, they believe that SCT may represent an additional risk factor for LPSMN. Accordingly, they presented six cases of LPSMN in elite African American football players with SCT. See link below http://journals.lww.com/acsm-msse/Fulltext/2017/04000/Acute_Lumbar_Paraspinal_Myonecrosis_in_Football.1.aspx Read More
  • Ibuprofen, Resistance Training, Bone Density

    Taking Ibuprofen immediately after resistance training has a deleterious effect on bone mineral content at the distal radius, whereas taking Ibuprofen or undertaking resistance training individually prevented bone mineral loss. http://journals.lww.com/acsm-msse/Fulltext/2017/04000/Effects_of_Ibuprofen_and_Resistance_Training_on.2.aspx Read More
  • Mitochondrial Health and Sarcopenia

    Mitochondrial Health and Sarcopenia

    The aging process (AKA 30 years of age onwards), in the presence of high ROS (reactive oxygen species) and/or damaged mitochondrial DNA, can induce widespred mitochondrial dysfunction. In the healthy cell, mitophagy results in the removal of dysfunctional mitochondria and related material. In the abscence of functional removal of unwanted mitochondrial material, a retrograde and anterograde signalling process is potentially instigated, which results in both motor neuronal and muscle fibre apoptosis (death) (Alway, Mohamed, Myers 2017, Ex Sp Sc Rev, 45, 2, 58-69). This process is irreversible. Investigations in healthy populations, have shown that regular exercise improves the ability to cope with regular oxidative stress by the buffering and 'mopping up' of ROS agents which are induced as a result of exercise. It is plausible and highly probable that regular exercise throughout life can mitigate against muscle fibre death (Sarcopenia). Importantly, this process of muscle fibre death can commence in the 4th decade of life. and be as much as 1% per year. Reduction of muscle mass can result in immune and metabolic compromise, including subclinical inflammation, type II diabetes as well as the obvious reduction in functional capacity for activities of daily living. See : Sarcopenia and Aging Published 11 July 2017 Read More
  • Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) by Martin Krause When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups.  https://youtu.be/4rj-4TWogFU In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. An interesting case of EDS and it's affect on post concussion syndrome can be read elsewhere on this site. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 17 October 2017  Read More
  • Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More

No responsibility is assumed by Back in Business Physiotherapy for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any

methods, products, instruction, or ideas contained in the material in this and it's related websites. Because of rapid advances in the medical sciences, the author recommends that there should be independent verification of diagnoses and exercise prescription. The information provided on Back in Business Physiotherapy is designed to support, not replace, the relationship that exists between a patient/site visitor and their treating health professional.

Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected

Updated : 15/03/2018