Kelowna Manual Therapy Centre Blog

Physiotherapists have long advocated that patients should try to improve their strength and mobility prior to undertaking any orthopedic surgery.

A previous blog showed the evidence for manual therapy and exercise in treating osteoarthritis of the hip and knee.  If the physiotherapy is not effective or if the pain continues to increase then a total joint replacement may be necessary. A recent study published in the journal of strength and conditioning showed that individuals who undertook a ‘prehabilitation’ program prior to undergoing a total knee replacement demonstrated improved strength and function i.e. walking and stair climbing.

It is very common due to the pain and swelling that the leg muscles become weak. The good news is that no matter how bad the pain is an exercise program can be prescribed to improve strength and mobility.

The exercise program consisted of walking, as well as strengthening and range of motion exercises for the hip and knee muscles. So if you do have to undergo a total knee replacement you should consider seeing a physiotherapist to learn an appropriate ‘prehabilitation program’.

It is reported that 90% of shoulder dislocations are in an anterior (forward) direction. The other 10% are posterior (backward) dislocations. An anterior shoulder dislocation is one of the most common traumatic sports injuries and is caused by a force that pushes the ball forwards in the socket. The most common causes of dislocation is a fall onto the shoulder.

After a dislocation the sooner the shoulder is reduced or “put back in” the better.

Icing and rest are critical in the next 48 hours to minimize inflammation. Gradual mobilization and strengthening can be initiated once soreness allows.  If all goes well one can resume activity over the next 4-8 weeks. Some experts no longer advocate use of a sling although one can be used for short-term comfort. There is no reduced rate of dislocation with prolonged use of a sling and immobilization.

The bad news is that younger people who suffer a dislocation have a much higher rate of recurrence; some experts report an 80-90% rate of recurrence. Individuals aged 25 years and older will typically do well with a program of physiotherapy aimed at regaining proper shoulder mechanics and strength. Individuals aged 40 and older have a smaller dislocation rate of only 10-15% and should do also well with a physiotherapy program mentioned above. Unfortunately, older people who suffer a dislocation have a higher rate of concurrent rotator cuff tear.

A consequence of dislocation can be damage to the shoulders labrum. The labrum is like a rubber ‘O’ ring that works to deepen the socket. This type of labral tear is termed a Bankart lesion. Less common are bony fractures, ligament and muscles tears.

Symptoms of a Bankart Lesion can include:

• A sense of instability i.e. “don’t trust the shoulder”
• Further dislocations
• Catching, locking, grinding, popping sensations
• Aching of the shoulder especially at night
• Loss of strength and mobility

These complaints are common to many other types of shoulder pain but if they occur post dislocation then they require further investigation by your physician.

Low back pain is a very common occurrence and is said to affect 80% of people at some time in their life.  Common causes of acute low back pain are sudden unexpected movements i.e. bending: lifting while twisting, or trauma such as a fall or a motor vehicle accident.

Others can injure their lower back simply if bending to brush their teeth.  The low back pain can come on instantly, with acute muscle spasm or locking.  Sometimes it is impossible to move or to straighten to an upright position.  Other acute low back pain can come on more slowly; up to 2 days post injury, as swelling gradually accumulates.

What to do

• Relax! No matter how bad the pain is it will get better.
• If the pain is less than 48 hours use ice, use heat if the pain has been present for more than 48 hours. Heat can be in the form of hot showers, an electric heating pad, a microwaveable pad or hot water bottle.
• Try to remain as active as the pain will allow. Some discomfort with moving around is normal. Research has proven that keeping active i.e. puttering around (stand a little, sit a little, walk a little) will allow you to get better quicker.
• If you are unable to move or if movement greatly increases the spasm then you may require more rest. See the sleep position article for some advice on the best resting positions.
• There is good evidence that Manual Therapy will get you better quicker. Research has proven that Manual Therapy performed in the first 16 days and when the pain is in the back and thigh is most effective.
• Pain radiating down the leg will also improve with manual therapy but might also require specific exercises and/or positioning to relieve the pain. Traction can be of benefit especially when the leg pain is radiating below the knee.
• Modalities such as electrical stimulation can be of benefit.
• If the pain is constant you may benefit from anti-inflammatory medication, if the pain is keeping you from sleeping you might consider a muscle relaxant.  If the pain is unbearable then you might consider a pain reliever. It is best to discuss this with your physician or pharmacist.

It is reported that one in six Canadians over the age of 15 is affected by arthritis. Osteoarthritis is one form of arthritis. This degenerative condition is characterized by wear and tear on the cartilage between joints.

Coinciding with the wear and tear is swelling and stiffness. The joints most commonly affected are the hip and the knee. Another common finding is the muscles and soft tissue around the affected joint will tighten and spasm.

Signs of hip osteoarthritis include hip pain (the pain can be deep inside the hip, on the outside of the thigh or in the groin and leg) a decrease in mobility (in rotation, moving the knee towards the chest and extending the hip), morning stiffness that lasts longer than 60 minutes and a limp.

Signs of knee osteoarthritis include knee pain, clicking or grinding with motion, more than 60 minutes of morning pain, joint swelling and bony enlargement around the knee. As well a limp develops while stairs, squatting and rising from chairs become increasingly difficult.

Physiotherapy will work best if the signs and symptoms of arthritis are recognized early and receive treatment in a timely fashion.

A recent study in Arthritis and Rheumatism showed a substantial improvement of symptoms in patients with hip osteoarthritis after 9 visits of manual physical therapy intervention. There was improvement of pain, stiffness, hip function and range of motion. Another recent study published in Physical Therapy demonstrated a decreased reliance on medications and improved function in patients who had knee OA after 8 treatment sessions of manual physical therapy combined with supervised exercise and a home exercise program.

Mulligan mobilization with movement (MWM) for hip stiffness

Manual Therapy is beneficial as it works to improve the mobility of sore and stiff joints as well as the tight muscles around the joint. The manual therapy can take the form of joint mobilization and manipulation, soft tissue work on the muscles and stretching.

Exercise is very beneficial in the treatment of arthritis and can be in the form of home exercise and/or aquatic exercise. In Kelowna there are a number of pool programs geared towards individuals with osteoarthritis. Typically exercise programs include both mobility and strengthening exercises.

The best current best research supports manual physical therapy combined with exercise for hip and knee arthritis.

Sleeping Advice

Poor sleep is a common complaint in a Physiotherapy practice.

Typical complaints include having to change positions frequently due to discomfort, having morning ‘stiffness’ that last for around 30 minutes, having to get out of bed throughout the night because of discomfort and waking with headaches.

Improving sleep while dealing with an acute or ongoing painful condition is important, as the body cannot heal as well without a good sleep pattern.  If you are tossing and turning due to discomfort it is best to get up and out of bed, try to move around, try some gentle exercise or movement before getting back into bed.

To help fall asleep a new technqiue called 'congnitive shuffling' developed by Luc Beaudoin, a Simon Fraser University professor, can be very helpful.  The technqiue involves either focusing on words or random objects to change your brains focus.  You can read more here or listen here for more information.  Professor Beaudoin also developed an app called 'MySleepButton' that helps coach you along the way.  The website for the app also has some great tips here.  While this technique was developed for stress and insomnia the technique can be helpful to improve sleep loss due to discomfort and pain.

It is useful to ask a client to show the position that they sleep in. This position can then be adjusted, incorporating a variety of pillows to find a position that is more comfortable. Generally speaking a side sleeper should consider a pillow between the knees whereas a back sleeper should consider a pillow underneath the knees.

The type of pillow used with patients that complain of neck pain or headaches is considered.

The type of pillow recommended depends on the body type and the position that they sleep in. As a general rule a thinner pillow is better for those that sleep on their back while a thicker pillow is better for those that sleep on their side. The goal is to try to support the neck in a comfortable ‘neutral position’.   Most people do not do well with the older cervical pillows made of foam, though the newer memory foam pillows seem better. Most people do well with regular polyester fill pillows. If that doesn’t work then a feather, water-filled or latex/memory foam pillow can be purchased. There is a huge amount of personal preference in pillows. Many cannot part with their favorite pillow, even if it is 20 years old!

Mattresses are supposed to have a life of around 10 years.

Some signs that you need to replace your mattress are an increased sag in the mattress, springs that pop or if the mattress has become lumpy.  As well, consider a new mattress if you are increasingly waking up more stiff and sore than normal. There are a lot of new materials being used in construction including wool, silk, bamboo, latex foam, memory foam, etc. The bottom line is that you need to test a lot of mattresses, keeping in mind your budget. Initially when testing mattresses you should try a range of firm to plush mattresses to find which balance of plushness vs. support you prefer. You can then try to narrow down your decision. When testing a mattress you should lay on the mattress in different positions with your partner to check for comfort. The mattress should not sag towards the middle. As well there should be very little movement felt when your partner rolls over. There are countless types of mattress construction and brands so you definitely have to get out and try the mattresses before you buy. Plan on spending a lot of time trying out a variety of mattresses.

Signs you should consider changing your mattress

• The mattress has an increase in sag or a ‘valley’
• The mattress has lumps in the top or springs that are popping
• Waking with stiffness or soreness
• Waking when your partner rolls over or get out of bed
• Having to frequently change positions

Kelowna Manual Therapy Centre is pleased to announce that we have now teamed up with Pacific Sport Okanagan as a Sport Health physiotherapy provider.

Sport Health is a program through Pacific Sport Okanagan that provides physiotherapy support to “carded” athletes. “Carded” athletes include BC development, BC elite, Canadian Elite and Podium athletes.

Pacific Sport Okanagan is a registered non-profit agency coordinating and delivering programs and services for athletes and coaches throughout BC.

Pacific Sport works in partnership with other provincial and local sport system providers to create a dynamic environment for sports excellence at all levels in BC by integrating world-class athlete services, coaching excellence and long-term sport development initiatives. The Pacific Sport Okanagan program provides these services to athletes and coaches throughout the Okanagan Valley. http://www.pacificsport.com

Another great benefit to athletes from Pacific Sport is the Canadian athlete insurance program (CAIP), details can be found Canadian Athlete Insurance Program: http://www.cscpacific.ca/Images/ProgramsService/2011_ACS_CAIP info.pdf

This program provides medical program reimbursement for athletes of all levels suffering both overuse and acute injuries.

Many times patients wonder how long does it take to recover from hip replacement.

A recent study in the Journal of Sports and Orthopedic Physical Therapy looked at recovery time and disability after a total hip replacement.
http://www.jospt.org/issues/articleID.2569/article_detail.asp

The authors found that the most rapid recovery takes place during the first 12-15 weeks. Progress was found to plateau between 30 and 40 weeks.

Another study found continued hip weakness and muscle atrophy up to 2 years post surgery. Other researchers found that an exercise program 4-12 months post hip replacement which targeted weight bearing and balance exercises resulted in improved strength, balance and reports of function.

These studies demonstrate how important it is to continue with an exercise program consisting of range of motion, stretching, strengthening, balance and cardiovascular exercises. This study and the other studies mentioned illustrate how important it is to continue with the home exercise program for up to 40 weeks post surgery.

With the recent good weather and opening of golf courses many eager golfers are taking to the courses.  The number one complaint of both recreational and professional golfers is low back pain, especially as the season starts.

Part of the pain can be due to the unaccustomed activity, this pain should settle within a few days and works itself out during the first few rounds.  More concerning is low back pain that is a result of a golf game or practice session that lingers more than 2 days.  It is important to consider all factors when assessing low back pain in golf.

The factors that should be assessed are the biomechanics of the spine, golf swing mechanics, poor flexibility and conditioning as well as the training techniques utilized.

The golf swing requires high levels of bending and twisting forces.  Low back pain is more common on the ‘trail’ side of the low back. The ‘trail ‘side would be on the right for a right handed golfer. The ‘trail’ side is under considerable stress during the clubs impact with the ball due to the combination of compression and side bending.

The low back is under more stress especially with a ‘hip slide’, a steep swing plane and too upright a finish position.   Most improper swing mechanics that cause low back pain can be traced back to improper set up position and improper hip rotation.   Correct posture at ball set up is the first place to start.   Proper position would be; back straight with normal spinal curves, knees and hips bent to 25-30° and both feet turned out slightly. (See Picture Below)

A manual therapist can also assess and treat any mechanical problems such as stiff lumbar, sacroiliac or hip joints.  Tight muscles can be treated with soft tissue techniques and stretching.  An exercise program would also be taught to strengthen weak muscles, stretch overly tight muscles.  Basic golf drill exercises will be taught to correct the swing mechanics.  More complicated swing mechanics are best analyzed by golf teaching professionals.

Other things to consider while golfing are the importance of proper warm-up prior to golfing which would involve hitting balls at the practice range and gentle stretching.   If you use a cart it should be pushed around the golf course, except on downhills where it is safer to have the cart behind you.  If you chose to carry clubs you should use a lightweight bag with backpack type straps.

Wry neck presents itself as an acutely painful neck either caused by a sudden unexpected motion or discovered upon waking.  In either case the pain is so debilitating that medical help is usually sought.

The acutely painful neck presents itself in one of two ways either a lack of mobility turning towards the painful side.  The other typical presentation is that the person suffering wry neck has to hold the head bend and turned away from the side of injury.

The most effective treatment is manual therapy consisting of a quick manipulation if pain allows (or joint mobilization).

After the manual therapy treatment is followed up by heat and electrical stimulation for 15 minutes. After the 15 minutes a series of exercised to regain range of motion is undertaken. This wry neck treatment program was first written about by New Zealand physiotherapist Brian Mulligan. http://www.bmulligan.com/about/concept.html

In the vast majority of cases after this physiotherapy session the mobility is considerably improved.  The patient is then instructed to continue this program again that evening and again next morning.  If sleep is disturbed a towel rolled up around the neck can be used at night.

The good news is that around 90% of patients will feel better with early treatment in 1-2 days.

Physiotherapists commonly see patients attending physiotherapy for ankle sprains.  While there is commonly swelling and pain there is also a lack of mobility in the ankle joints.

Manual physiotherapists have known for a long time that early manual therapy (including joint manipulation and mobilization) in conjunction with exercise and modalities allows people to resume activities or sports earlier and with less difficulty.

This 2009 research study confirms the benefit of manual therapy. See the Research here in the Journal of Orthopaedic Sports Physical Therapy:http://www.jospt.org/issues/articleID.2257,type.2/article_detail.asp

The authors found that those that benefited most from manual therapy reported they felt worse with standing and squatting, had signs of increased foot flattening and had a lack of ankle joint mobility.  The authors found that manual therapy combined with exercise allowed for quicker recovery, compared to exercise alone.

So if you sprain your ankle seek out treatment early on.  The treatment should include manual therapy.