This is a great website with lots of information about exercise and staying healthy.
http://exerciseismedicine.org.au/
You might find these factsheets particularly helpful about exercise for certain common health conditions such as asthma, diabetes, heart disease and chronic pain.
The pain tool kit is a simple information booklet that could provide you with some handy tips and skills to support you along the way to manage you pain.
http://www.paintoolkit.org/assets/downloads/PTK-AUSTRALIA.pdf
A Doctor-Professor answers the old question “What is the single best thing we can do for our health” in a completely new way. Dr. Mike Evans is founder of the Health Design Lab at the Li Ka Shing Knowledge Institute, an Associate Professor of Family Medicine and Public Health at the University of Toronto, and a staff physician at St. Michael’s. http://www.youtube.com/watch?v=aUaInS6HIGo
Patients with low back pain (LBP) compromise a high proportion of patients with musculoskeletal conditions managed by Physiotherapists. Although LBP is a common condition outcomes for treatment are variable with many patients failing to experience significant reductions in pain and disability (Fritz, 2007).
One strategy proposed for improving treatment outcomes in people with LBP is better identification of prognostic factors indicating an increased risk of a poor outcome, with subsequent treatment targeted towards factors that are modifiable. Several important prognostic factors predictive of chronicity and disability in patients with LBP have been identified. Physical prognostic factors include presence of leg pain or widespread symptoms. Psychosocial factors such as pain related fear, catastrophising, depression, and self-efficacy, also have been identified as important prognostic determinants for patients with LBP.
Recently Rob attended a four day STarT Back training course run by Jonothan Hill and Gail Snowden from Keele University, UK. They have developed and researched a brief, easy to use screening tool, the STarT Back Screening Tool (SBST). The SBST is a valided tool (Hill, 2008) designed to screen primary care patients with LBP for prognostic indicators that are relevant to initial decision making. The instrument is designed to be used by GPs, physiotherapists and pain management practitioners to systematically identify patients ‘at risk’ of persistent symptoms.
The 9-item tool is designed to classify patients into one of three subgroups for targeted primary care management:
Low risk
Medium risk (physical indicators)
High risk (physical and psychological indicators)
The following link has further information including access to the SBST. There is also a 6 item tool developed for use by GPs (it’s quicker).
http://www.keele.ac.uk/research/pchs/pcmrc/dissemination/tools/startback/
The SBST and approach formed the basis of a clinical trial recently run in the UK (data unpublished at this stage). Some observations in the UK were of highly variable decision making in clinical practice, guidelines weren’t helping (e.g. wait and see policy) and sophisticated treatments (i.e. biopsychosocial approach) are better than usual care for LBP.
The key questions were
How best to move on from a ‘one –size fits all’ approach to LBP?
How to reduce inefficient referral mechanisms?
Can patients be stratified into care pathways according to risk of persistent disabling problems?
Is this a cost-effective model of primary care?
The study compared targeted treatment to a ‘care as usual’ control group. This was a large trial with 851 patients randomised between the groups. The figure below illustrates the Keele STarT Back Screening and targeted treatment concept.
The overall results at 4 and 12 months were significant improvements across the groups in: Disability (Roland Morris Disability Questionnaire); Fear avoidance beliefs; Time off work; Patient satisfaction and Qualify of life. Targeted treatment was also cheaper with less consults, medication use and reduced rates of surgery.
The study also highlighted that primary care practitioners who didn’t use the SBST were poor at identifying risk. The patients who filled out the SBST were significantly more likely to receive targeted treatment: 98% vs 60% in the high risk group and 100% vs 65% in the medium risk group.
The targeted treatment was given by Physiotherapists using the STarT back approach and consisted of;
Low risk: assessment, exam, advice, reassurance, secondary prevention and self-management
Medium risk: course of physical therapy treatment, focused on evidence based practice
High risk: course of physiotherapy, enhanced psychosocial factor targeting
The conclusions of the study are that a stratified management approach to primary care with screening and matching pathways significantly improves patient outcomes and is very cost-effective. At Central Bassendean Physiotherapy we are using the SBST and our approach is consistent with targeted treatment approach described above. We would strongly encourage a visit to the website above and use of the SBST. If you have any queries or questions regarding this newsletter we would be happy to discuss this further.
Overuse disorders of tendon or tendinopathies frequently affect active young people (20-30 years old) and middle-aged people (40-60 years old) and are often difficult to manage successfully. Tendinopathy occurs in loaded tendon in the upper and lower limb. Typical areas affected are the achilles, patella, ITB, lateral gluteals, groin, wrist, lateral elbow and shoulder. Repetitive energy storage and release and excessive compression appear to be a key factor in onset of tendinopathy. The amount of load (volume, intensity, frequency) that induces pathology is not clear, however sufficient time between loading to allow a tendon to respond to load appears important. Load volume, intensity and frequency are critical in the capacity of both normal and pathological tendons to tolerate load. Load is modulated by an interaction of intrinsic factors such as genes, age, sex, biomechanics and body composition.
The term tendinopathy has replaced the primary inflammatory model. Cook and Purdam (BJSM, 2009) propose that there is a continuum of tendon pathology that has three stages; reactive, disrepair (failed healing) and degenerative. Adding or removing load is the primary stimulus that drives the tendon forward or back along the continuum, especially in the early stages.
Reactive Tendinopathy is a non-inflammatory proliferative response in the cell and tendon matrix that occurs with acute tensile or compressive overload. This results in a short term adaptive thickening of a portion of the tendon that will either reduce stress by increasing cross sectional area or allow adaptation to compression. This normally results from acute overload, usually a burst of unaccustomed physical activity. The tendon can return to normal if the overload is sufficiently reduced or if there is sufficient time between loading sessions. Clinically this is most common in a younger person (less than 20 years old).
Tendon Dysrepair describes the attempt at tendon healing, similar to reactive tendinopathy but with great matrix breakdown. There is a marked increase in proteoglycan and collagen production. The increase in proteoglycans results in separation of the collagen and disorganisation of the matrix. There maybe an increase in the neurovascularity of the tendon. US imaging will show small areas of hypoechogenicity. On MRI the tendon is swollen and there is increased signal within the tendon. Clinically this stage is harder to distinguish but typically occurs in the 20 to 40 year old age group. An older person with stiffer tendons may develop this stage but at relatively lower loads. There is reversibility of the pathology at this stage with load management and exercise to stimulate the tendon matrix structure.
Degenerative Tendinopathy is clearly described in the literature, with progression of changes within the tendon compared with disrepair. There are areas of cell death and large areas of the matrix are disorganised and filled with vessels and little collagen. There is little capacity to reverse the pathological changes. US scans will show greater hypoechogenicity and MRI shows increased tendon size. The stage is primarily seen in the older person, but is seen in a younger person or elite athlete with a chronically overloaded tendon. There is often a history of repeated bouts of tendon pain. 97% of tendons that rupture have degenerative change.
Treatment of Tendinopathy: Cook and Purdam consider clinical treatments that are directed at effecting change in tendon structure are optimal. Assessing and managing load is essential.
A reactive tendinopathy or early tendon disrepair will respond quickly to a change in load. Changing the load may be as simple as allowing a day or two between very high tendon loads. Adding exercise may not improve outcome.
Late tendon disrepair and degenerative tendinopathy respond to treatments that stimulate cell activity to increase collagen and restructure the matrix. Exercise has been shown to affect both tendon structure and pain. Specific tailored exercise has been shown to increase collagen production, improve tendon structure in both the short and longer term. A meta-analysis reported that exercise is beneficial for pain, function and return to activity (Woodley, BJSM 2007). This will typically occur in a 4-6 week period. Pain during exercise at this stage may be tolerated by the tendon and a study showed that allowing activity pain of less than 5/10 didn’t affect outcome.
Corticosteroids are controversial in the treatment of tendon pain, please read the attached editorial. If used, corticosteroids should be accompanied by appropriate physical rehabilitation.
At Central Bassendean Physiotherapy we have been using this model of tendinopathy for a few years. We are seeing encouraging results by applying this model and the results are improving as we learn more about tendon exercise and managing tendon load.
Clinical Pilates is a form of exercise that focuses on posture, balance, control, strength, flexibility and movement patterns. The Pilates method was originally developed by Joseph Pilates over a substantial period of time back in the early 1900’s and evolved into a method of managing ballet dancer’s to improve injury recovery and performance. Clinical Pilates evolved much more recently when rehabilitation specialists, particularly Physiotherapist began to incorporate Pilates Exercises and equipment into their protocols in the late 1980’s and 1990’s. Modern Clinical Pilates involves individual programmes in a supervised environment using equipment such as reformers, cadillac frames as well as balls, wedges etc.
Some aspects of traditional Pilates did not and still do not sit well with the best available research evidence, but by infusing Pilates exercises with established, evidenced based physiotherapy concepts Clinical Pilates has evolved and will continue to further evolve as further research is released.
A recent (2009) review of studies (published in the Journal of Bodywork and Movement Therapies) that examined the use of Pilates method for treating non-specific low back pain found that the result was improved general function and reduced back pain. It is important to note that these programmes were patient specific with the Pilates method having been individualised and adapted for rehabilitative purposes. At Central Bassendean Physiotherapy we continue to aim for fulfilling evidence based criteria.
It is well acknowledged that pain can change the way we use our muscles even after the original injury has ‘healed’. It is also thought that our brain changes as well. That is, the area of the brain that corresponds with coordination and movement of the injured area changes, but specific movement re-training can restore this to ‘normal’. Clinical Pilates is ideal for this. Patients are individually assessed before they commence their programme to fully establish their needs. Any pathology is considered and programmes can be modified accordingly. A Real time ultrasound scan is utilized on the initial assessment to establish adequate pelvic floor contraction.
Our Physiotherapist, Sarah Clay who will be conducting the Clinical Pilates has over 20 years experience in the physiotherapy industry and underwent extensive further training to gain expertise as a Clinical Pilates instructor.
This involved approximately 400 hours of training as well as undertaking extensive classes herself. She has been working as a Clinical Pilates Instructor at Lifecare Physiotherapy Wembley and Midland Physiotherapy for the past two years.
Pilates can be poorly taught and recent publicity regarding this (e.g.‘Core Promises’ the Weekend Australian magazine August 21 2010) highlight the need for correct expert and patient specific instruction
The types of patient that will benefit from Pilates include those with:
Lumbar spine dysfunction:
Non specific Low back pain, Discogenic injuries, Posture related pain,
Poor movement patterns, Poor control
Shoulder:
Rotator cuff and impingement/bursal problems, Dislocation, Sports injuries, Osteoarthritis
Hip & Thigh:
Osteitis pubis, Trochanteric bursitis, Recurrent hamstring and quadriceps problems
Knee:
Patello-femoral dysfunction, ITB problems, Ligamentous strains
Ankle:
Ankle sprains, Achilles tendon problems, Recurrent calf strains
Cervical Spine dysfunction:
Discogenic problems, Postural related problems, Whiplash injuries
Acute muscle strains are a common musculoskeletal injury that can take longer to heal if not managed correctly. With an accurate initial early diagnosis and appropriate management plus screening for more serious injury, not only can you recover quicker but you will also be set realistic goals for recovery and return to normal activities such as work and sport. As such with this newsletter we aim to highlight current research regarding best practice both with assessment and management of these injuries.
Classification of Muscle Strains
Muscle strains are a common lower limb injury to muscles such as the hamstrings (back of thigh), gastrocnemius and soleus muscles (calf muscles). Injuries can occur due to excessive tension being placed on the muscle due to repetition of a task, high force/trauma or fatigue. Muscle strain severity is commonly graded using the classification below:
GRADE 1 = There is damage to individual muscle fibers (less than 5% of fibers). This is a mild strain which requires 2 to 3 weeks rehab/recovery.
GRADE 2 = There is more extensive damage, with more muscle fibers involved, but the muscle is not completely ruptured. The rehab/recovery period required is usually between 3 and 6 weeks.
GRADE 3 = This is a complete rupture of a muscle. In a sports person this will usually require surgery to repair the muscle. The rehabilitation time is around 3 months.
Causes of a muscle strain
Muscle strains are common in activities where a muscle is required to produce a high amount of torque, e.g. when accelerating from a stationary position or when lunging forwards in sports such as tennis, squash, football and athletics or in the non-athlete when gardening or lifting. A muscle strain may also occur due to fatigue associated with overuse, such as distance running, repetitive jumping or walking excessively (Woods et al., 2004). Poor body mechanics may also cause a muscle strain, for example a hamstring strain is commonly due to poor lower back biomechanics or training faults, such as too much load, sudden increase in training or technique errors. Hamstring muscle strains have a high recurrence rate as the cause of the injury often involves many factors.
Diagnosis
A thorough subjective and physical examination from a physiotherapist is usually sufficient to diagnose a muscle strain and its severity. In particular some physiotherapists can use acupuncture to differentiate between a muscle cramp and strain in a muscle. In higher grade injuries further investigations such as an Ultrasound or MRI may be required to guide further management.
Treatment of acute muscle strains should follow the following algorithm SPRICEMMM and HARM (this is an extended version of the well known “RICE” regime):
Treatments to avoid in the first 24-72 hours follow this algorithm:
After the acute inflammatory phase of healing (24-72 hours), we commence a graduated flexibility and strength program, to recondition the muscle and reduce injury recurrence. Our physiotherapists will assess factors that contributed to the injury e.g. poor flexibility, inappropriate training, poor biomechanics, muscle weakness or inadequate rehabilitation following previous muscle strains. There is a high rate of re-injury with muscle sprains so rehabilitation continues until you return to your pre-injury activity levels. In many cases it is appropriate to continue with specific exercises designed to minimize the risk of re-injury.
Case study
This case study of a recent patient highlights how physiotherapy management can improve recovery times from an acute calf strain. The patient was referred by her GP with a right calf strain. Unfortunately, the patient decided to wait 2 weeks before seeing us and for the duration of this time she had been non-weight bearing with crutches and had taken time off work to recover. The injury occurred doing step-ups at the gym and she had done the RICE regime after the injury for 1-2 days.
Objectively she had reduced right ankle range due to pain and her calf muscles were tight. Her calf muscles were tender to palpate and there was observable muscle wasting. She was diagnosed with a grade 1 medial head of gastrocnemius strain. Treatment consisted of ultrasound, dry needling (acupuncture), massage and stretches to facilitate a return to a normal walking pattern. She was given home exercises alongside facilitating walking without crutches. At her second treatment session (3 days later) she was walking without crutches and with a normal walking pattern (7 days later). The patient had 5 treatment sessions in total and by discharge had no calf pain and had returned to cycling and walking for exercise (2 weeks later).
Due to the patients 2 weeks on crutches her rehabilitation was lengthened and risk of deep vein thrombosis (DVT) in this phase was increased. If this patient had chosen to come to physiotherapy within the inflammatory phase of healing (24-72 hours) of the injury her recovery could have been quicker (with a grade 1 strain, total recovery should have been 2-3 weeks not 4 weeks).
Whiplash and and whiplash-associated disorders (WAD) represent a range of injuries to the neck caused by or related to a sudden distortion of the neckassociated with the neck being forced backwards due to the momentum of the accident. Whiplash is commonly associated with motor vehicle accidents, often when the vehicle has been hit in the rear however, the injury can be sustained in many other ways, including falls from stools, bicycles or horses. It stands out as one of the main injuries covered by the car insurers.
Symptoms can include: pain and aching to the neck and back, referred pain to the shoulders, sensory disturbance (such as pins and needles, numbness) to the arms & legs and headaches. Symptoms can appear directly after the injury, but often are not felt until days afterwards.
The Motor Accidents Authority in NSW developed guidelines for Whiplash in 2001 which were recently updated in 2007. The guidelines help us to identify symptoms which may indicate the need for early or more intensive treatment and also to classify the severity of your injuries.
The guidelines particularly recommend early management (Day 0-7 post injury). The treatment they advocate includes education, exercise, prescribed function and painkillers (as advised by a medical professional).
Early referral to physiotherapy for appropriate exercise prescription and education is key to ensure effective management of this condition. Sometimes it can be as simple as just understanding the right things to do, and what not to do to allow your body to heal quickly and effectively.
Assessment
When you are first assessed by our physiotherapists, we will take a though history and perform a full physical examination to determine the extent of your injuries and the specific functions and movements that you are struggling with to allow us to make your treatment very specific to your individual condition. We may also use more formal outcome measurements such as questionnaires to allow us to assess you further. The use of certain questionnaires is recommended by the NSW whiplash guidelines and we can use these at future appointments to assess your progress. We also use these measures to report back to your GP and to give them detailed information about your progress
All of our physiotherapists are highly skilled in the assessment of whiplash injuries, specific exercise prescription and in educating patients regarding appropriate levels of function related to their specific injury.
Treatment
The guidelines summarise the evidence behind treatment for acute whiplash (first 6 weeks post injury. In the acute stages advice to stay active, education and exercises are supported by good research evidence. Treatments that show some benefit include simple painkillers, joint manipulation and passive joint mobilization. Physiotherapists are highly trained in joint and soft tissue mobilizations to improve range of movement and pain. Hydrotherapy is very beneficial in regaining range of movement and improving pain, hence regaining function post whiplash injury. Our physiotherapists are highly skilled at prescribing specific exercise programmes (both on land and our hydrotherapy pool to restore function.
Prognosis
Most people recover completely from a whiplash injury in the first six weeks. Others’ symptoms continue to improve over the course of a year. There is a 40% chance of experiencing some symptoms after three months, and an 18% chance after two years. Often investigations are not required for whiplash injuries and in fact x-ray changes have been shown not to have any connection to a bad prognosis. Your physiotherapist will discuss with your doctor if further investigations are indicated.
The Motor Accidents Authority in NSW developed guidelines for Whiplash in 2001 which were recently updated in 2007. The guidelines help to alert health care professionals to adverse prognostic indicators which may indicate the need for early referral or more intensive treatment.
They classify whiplash into specific grades:
0 – No complaint about the neck, no physical signs
I – Complaint of neck pain, stiffness or tenderness only. No physical signs
II – Neck complaint AND musculoskeletal signs (including decreased range of movement and point tenderness)
III – Neck complaint AND Neurological signs (including decreased or absent tendon reflexes, weakness and sensory deficits)
IV – Neck complaint AND fracture OR dislocation
For the purposes of our client base, the following information will mostly relate to groups I to III.
Early management (Day 0-7) recommended includes education, exercise, prescribed function and pharmacology. Early referral to physiotherapy for appropriate exercise prescription and education can be key to ensure effective management of these clients. All of our physiotherapists are highly skilled in specific exercise prescription and in educating patients regarding appropriate levels of function related to their specific injury.
Outcome Measures
At both initial assessment and from day 7 onwards the guidelines recommend regular outcome measurement assessment using the VAS pain scale and the Neck Disability Index (NDI). The NDI is a 10 point questionnaire designed to measure neck-specific disability and is based on the Oswestry Disability Questionnaire. It is scored out of 50 with higher scores representing greater disability. An NDI >20/50 is associated with poor prognosis. If thought relevant, at 3 weeks post MVA the Impact of Event Scale (IES) can also be used. This is used to measure current subjective distress related to a specific event. A score of >43 is severe and >26 is moderate. A high IES score may highlight the need for psychology management. We are increasingly using these measures in our communication with GP’s to improve the objectivity of information provided and to accurately assess progress.
Treatment
The guidelines summarise the evidence behind treatment for acute whiplash. In the acute stages advice to stay active, education and exercises both have Level I and Level II evidence. Treatment that shows some benefit although there are limited RCT’s include simple analgesics/NSAIDS, manipulation and passive joint mobilization which all have some Level II evidence. Physiotherapists are highly trained in joint and soft tissue mobilizations to improve range of movement and pain. Hydrotherapy is very beneficial in regaining range of movement and improving pain, hence regaining function post MVA. Our physiotherapists are highly skilled at prescribing specific exercise programmes to restore function.
Prognosis
There is strong evidence to show that high initial pain intensity (VAS>7) and high initial disability (NDI > 20/50) are associated with ongoing pain symptoms. Early detection of poor prognosis is key to optimize management. High initial disability, limited education and reduced cervical range of movement are associated with ongoing disability. X-Ray changes, age (>65) sex, marital status, crash factors and increased EMG activity on superficial muscles are not associated with poor prognosis.
When most people think of Women’s Health Physiotherapy they think of incontinence. However this newsletter will discuss the variety of women’s health problems which can be treated by a physiotherapist. One of our physiotherapists, Amy Tinetti has worked at Mercy Hospital and has gained experience in the assessment and management of a variety of women’s health conditions. She has a special interest in antenatal and postnatal care.
Core strengthening exercises have become popular for many people with a variety of claims, such as to reduce low back pain, improve posture, prevent injury and address continence issues. However sometimes core strengthening can be inappropriate and/or non-specific which can cause an exacerbation of incontinence symptoms, low back pain and pelvic girdle pain. Core strengthening exercises that involve drawing in the lower abdomen (activating the transverse abdominus) can frequently overload the pelvic floor muscles. The current scientific evidence does not provide a clear link between poor abdominal activation and low back pain. In fact there is growing evidence to suggest many people with low back pain and pelvic girdle pain have too much abdominal activity and over-protect their movement. Several randomized controlled trials now have only shown limited benefit from doing core strengthening exercises. There is no evidence to suggest trying to increase core strength via training the transverse abdominus has any benefit in preventing injury. The current evidence does show that individually targeted retraining of posture and functional movement via concentrating on body position rather than specific muscle activation can lead to significant benefits.
Doing core strengthening exercises may strengthen your abdominal muscles but they can also stretch and further weaken an already weak pelvic floor. People also tend to over brace when doing these exercises and therefore are unable to relax their abdominals or pelvic floor which can also cause the pelvic floor to become shortened, weak and sometimes even painful. Therefore it is important that people get educated on how to effectively contract their pelvic floor but it is just as imperative to make sure they are able to relax afterwards. A programme of pelvic floor exercise would aim to restore the normal functioning of the pelvic floor and hence bladder function.
If patients describe leaking whilst exercising/cough/sneezing (stress incontinence) or going to the toilet ‘just in case’ (urge incontinence) this may be an indication that their pelvic floor muscles are weak. Postnatal women and mature women need to be particularly careful about core strengthening and may be more at risk of injury.
Patients who have had gynaecological surgery are also at high risk. If these high risk female groups exercise inappropriately with core strengthening, they are at a higher risk of developing a vaginal prolapse. For men urinary incontinence can occur more frequently in the radical prostatectomy group who are involved in high impact exercise. Exercises to avoid if people are within this risk category and already have stress/urge incontinence are high impact exercises such as running and jumping. Also they should avoid over training their abdominals with excessive amounts of sit ups, intense core training and exercises with both legs raised off the ground.
One aspect of antenatal/postnatal care is the education on pelvic floor exercises to prevent and treat urinary and faecal incontinence. A recent Cochrane review in 2009 looked at pelvic floor muscle training (PFMT) for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. They found “for women having their first baby, antenatal pelvic floor muscle training appears to reduce the prevalence of urinary incontinence in late pregnancy (34 weeks or more) and early postpartum (less than 12 weeks). With regard to postnatal PFMT, it appears that this is an effective treatment in women who have persistent urinary or faecal incontinence after delivery. The greatest treatment effect was seen in the trial with the most intensive, supervised strengthening PFMT programme (with the addition of weekly electrical stimulation).”
Most antenatal/postnatal women wouldn’t go to a physiotherapist just for pelvic floor exercises (unless they are concerned about urinary or faecal incontinence) however these women often experience musculoskeletal problems such as sacroiliac joint pain, lumbar and thoracic pain. They often develop these problems during the antenatal period due to the increase in load on the back and the increase of the hormone relaxin in the body. At Central Bassendean Physiotherapy we can treat these musculoskeletal problems and also educate the patient of how to manage and treat their pain. In conjunction with treating the patient’s musculoskeletal problems their pelvic floor impairments are addressed.
Postnatal women can experience pelvic pain, coccyx pain, back pain, diastasis recti/abdominal muscle separation, thoracic and neck pain, wrist and thumb pain. These issues normally occur due to a significant increase in lifting, breastfeeding and repetitive movements especially during the baby’s first year. At Central Bassendean Physiotherapy we will educate the patient on how to manage their condition and we can treat their musculoskeletal impairments. Many women struggle with antenatal and postnatal pains, so having a physiotherapist to ask for advice is sometimes all that is required to solve their aches and pains.
Did you know…
At Central Bassendean Physiotherapy we can help treat mastitis and engorged breasts that are causing the patient discomfort. As a physiotherapist we can use ultrasound to improve the healing of mastitis (in conjunction with medications prescribed by the GP). Physiotherapists can also educate patients on the management of mastitis such as feeding positions, when to use heat/ice, massage and signs/symptoms. Women treated with the above treatment techniques for mastitis normally report a significant reduction in their symptoms in 1-2 treatment sessions.