Hypermobility

As physiotherapists we spend ALOT of time working with people who have stiff joints, tight muscles, reduced movement….. All of these things present as a lack of mobility, which is, in most cases, resulting in pain (hence why they are sitting in my waiting room).

BUT sometimes we forget about the other side of the coin….. The hypermobile ones, those that have TOO much movement, their joints have more range than required, their muscles are too flexible.

This is actually a problem that exists far more commonly than one may think, often it is asymptomatic & people won’t even be aware that their body is a little more like an elastic band than their best friends, BUT in some cases joint hypermobility syndrome can cause pain.

Joint hypermobility is usually inherited; if your mum is super super flexible, chances you will be too. There is nothing you can do to change it or prevent it, unfortunately its due to a gene representation in the connective tissue (the glue that holds our bodies together) causing it to become more pliable& more stretchy allowing for excessive movement at certain joints.

People with hypermobile joints have a higher incidence of dislocation and sprains of involved joints. The hypermobility tends to decrease with age as we naturally become less flexible.

When it comes to being hypermobility some people just live with it, other people may suffer from certain related medical conditions such as Ehlers-Danlos Syndrome (EDS), Marfan Syndrome and Osteogenesis Imperfecta BUT the purpose of this blog isn’t to overload you with information related to these issues but rather to give you a little insight into a more common presentation which is ‘hypermobility syndrome’ or HMS and when you may need to seek a little professional advice.

Do you have HMS?

There is a great little series of tests that you can do right no on your living room floor. Give yourself a score of 1 for each of the following that you CAN DO.

Touch the floor with your palms flat without bending your knees
Can you bend your left elbow back past straight
The same for your right elbow
When lying flat on floor with your left leg straight out in front of you can you lift your left heel off the floor approx 1-2 inches without lifting your knee or upper leg
The same for your right leg
Can you bend your left thumb under so that it touches your forearm
The same for your right thumb
Can you bend your left little finger back past 90 degrees
The same for your left little finger

For each one you are able to achieve give yourself a point.

What was your score out of 9? If you were able to do any of the above you have are classed as hypermobile BUT you don’t necessarily have HMS.

In a clinical setting your score along with the prevalence of certain symptoms would categories you into either minor or major hypermobility syndrome. Some symptoms include joint pain, history of subluxation or dislocation of joints, being particularly tall & slim.



If your hypermobility is causing you joint pain make an appointment with a sports physiotherapist. They will be able to assess you and answer all your questions about what you can, can’t, should and shouldn’t be doing. There are exercises that can be done to help with the pain and also allow you to partake in all the activities you wish to. It’s also nice to be educated about the risks that certain sports may present to you as a ‘hypermobile’ individual; for example if you are desperate to play high intensity collision sports such as rugby you should be aware that the risk of you dislocating your shoulder is slightly higher than your team mates who are not hypermobile.

So you have HMS? DON’T PANIC. This doesn’t mean you need to start doing things differently. Yes you can exercise, in fact it’s recommended that you do; yes you can play sport (some may be advisable to avoid); yes you can go trampolining; yes you can ski; yes you can LIVE a normal life.



via- http://yoursportsphysioblog.com/2014/05/30/are-you-hypermobile/

Why post exercise soreness is a good thing sometimes...

DOMS or delayed onset muscle soreness is the term given to sore stiff muscles following unaccustomed strenuous exercise. DOMS usually begins 24 hours after exercise and can linger for anywhere between 2-4 days.

When we talk of DOMS we’re not talking the heavy feeling in your legs when you cross the line of your first marathon, more so the pain you get the next morning when you descend the stairs for your morning coffee and your quads shake like crazy!

I personally love the feeling of DOMS… Sometimes.. It’s a sign that I’ve actually worked hard in the gym for once in my life!!

Everyone is susceptible to DOMS so don’t think if you train 7 days a week that you’ll avoid it, if you change up your exercise regime DOMS might come looking for you. When we exercise we program our muscles to deal with certain stresses and certain loads. Notice when you do your first session of squats / lunges your quads burn for days but after the 3rd or 4th time you do a similar session there is minimal post exercise soreness. This is all due to the ability of our muscles to adapt.

DOMS is thought to be the result of micro tearing of the muscle fibres; the amount of soreness will depends on what exercise you performed and for how long. Eccentric movements (where you’re loading the muscle as its lengthening) i.e. going down stairs or down hills; all seem to result in greater soreness.

The prevention or treatment of DOMS has been a much debated topic for several years, purely because no single treatment has been found to be 100% effective.

Some simple tips include:

Warm down and stretch properly: active recovery is best, it may be the last thing you feel like but a slow jog warm down with gentle stretching can help reduce post exercise soreness.
Ice baths: not really the weather for it but a lot of elite athletes swear by this method. (hot/cold shower may be more tolerable in winter months!)
Sports massage has been shown to have some effect
Rest: if you have just completed your first half marathon no need to engage in a strenuous training run the next day, your muscles need time to recover so take a few days off. However if your desperate to get out and about walking is a good way to get your legs moving!
Try taking Magnesium; The Great Muscle Relaxer (consult your health practitioner for more information)

Don’t be afraid of DOMS it’s often a sign that you have worked hard and pushed your body to its limits!


via- http://yoursportsphysioblog.com/2012/05/31/why-post-exercise-soreness-is-a-good-thing-sometimes/

Back Pain Myths

Back pain is one of the most common presenting problems that I see on a day to day basis… At some point in our lives 8/10 of us will suffer from an episode of back pain. Despite this statistic we arent exactly well educated when it comes to our backs!!! Here are some common “myths” about how to save our backs…

1.    “I shouldn’t lift heavy objects” : there is slight truth to this comment, repetitive lifting can put undue stress on our lower back and predispose to injury. However this can be avoided if the correct lifting technique is used. Lifting should come from the legs, bend the knees and keep the back straight….. Use your quads and buttocks; they are after all two of the biggest muscles in our bodies!!

2.    ” I always sit with good posture so I shouldn’t get back pain” while having good posture is important, even a perfect ergonomic setup won’t reverse the negative effects that 6-8 hours of sitting can have in our spine. Sitting places stress through our intervertebral discs which are the shock absorbers of the spine. The seated position also puts our hip flexors in the shortened position and encourages our deep abdominals to be lazy, particularly when you slouch ( that’s 80% of us by 3pm)

3.    “I do 100 situps a day so my back should be nice and strong”....unfortunately it takes a lot more than 100 situps a day to achieve a strong spine. Ideally you need a good core stability program. Our core stabilisers are the deepest layer of abdominals consisting of the tranverse abdominus, lumbar multifidus, pelvic floor and diaphragm. These muscles help to provide a corset and give support to the discs and joints of our spine.

4.    ” When I have back pain I should lie flat on my back in bed till it goes away”....there is no doubt that in an acute episode of back pain that rest is essential. However exercise is the best thing  for speeding up your recovery. You should consult your physiotherapist for appropriate exercises that will be safe for you in the acute phase and as your pain resides these exercises can be progressed and become a long term maintenance program for your back

5.    “Sleeping position doesn’t really impact our backs” for all the tummy sleepers our there it’s time to ditch this bad habit… The best way to sleep is on your side with a pillow between your knees (the lazy S). This position maintains the natural curves of your spine

6.    “Other health factors don’t affect my chance of developing back pain” incorrect there are several health factors that actually increase our chances of suffering from back pain.

Smoking: the chemicals in cigarettes actually dehydrate our intervertebral discs and speeds up the process of degeneration. Research indicates that smokers will take 6 months longer to fully recover from disc related back pain.

Extra pounds: carrying extra kilos will place excessive on the shock absorbers in our spine and also increase the load through the weight bearing joints causing them to wear out faster

Hydration: our intevetebral discs are made up of around 70% water. The amount of water will depend on the amount of load applied through the disc ( this will differ at night – discs tend to rehydrate over night as we sleep) when a disc is dehydrated its mechanical properties are altered significantly and can no longer absorb stress as efficiently.


via- http://yoursportsphysioblog.com/2012/05/07/back-pain-myths-busted-3/

Active Release Technique

Introduction

Active release technique (ART) is developed and patented by P. Michael Leahy. But there is little scientific proof about the effects of Active Release Techniques on different pathologies. Most evidence on ART is anecdotal and based on case reports.

Definition

Active Release Technique (ART) is a soft tissue method that focuses on relieving tissue tension via the removal of fibrosis/adhesion that develops in tissue. This is because the tissue is overloaded with repetitive use. (copied from External coxa saltans (snapping hip) treated with active release techniques: a case report). It is both diagnositic and treating techniques for the disorders which may lead to weakness,numbness, tingling, burning,aching etc.

History of ART

Active Release Techniques (ART) was developed and patented by Dr. P. Michael Leahy, DC, CCSP, a Doctor of Chiropractic, based  in Colorado Springs, Colorado, and the founder of Champion Health Clinic. Dr.Leahy noticed that the symptoms of patients are related to changes in their soft tissue so he developed a this technique which revolve completely around patient's problem and his related soft tissue. He documented his first work in 1985 under the title of Myofascial Release but later patented it under the nameof Active Release Techniques.
                                                      

Purpose

It is used to treat problems with muscles, tendons, ligaments, fascia and nerves.

Active release technique is designed to accomplish three things :

1. to restore free and unimpeded motion of all soft tissues ;
2. to release entrapped nerves, vasculature and lymphatics
3. to re-establish optimal texture, resilience and function of soft tissues.

Technique

First the clinician locates the areas of tension or adhesion in a specific tissue. Then the tissue is taken from a shortened position to a lengthened position while using a manual contact to maintain tension along the fibers of that tissue.

In treatment with ART the clinician uses compressive, tensile and shear forces applied by manual (hand) touch to address repetitive strain, cumulative trauma injuries and constant pressure tension lesions.
During ART therapy the practitioner applies deep digital tension at the area of tenderness. The patient is then instructed to actively move the tissue of the injury site through the adhesion site from a shortened to a lengthened position.

ART is used by conservative care practitioners (chiropractors, physiotherapists and massage therapists) with an understanding that anatomical structures throughout the body have traversing tissues located at oblique angles to one another. Areas of tissue overlap are prone to negative changes with trauma producing local swelling, fibrosis and adhesions that can result in pain and tenderness at the location of injury. During ART therapy the practitioner applies digital tension along the tissue fibers at tender areas of adhesion. The patient is then instructed to actively move the tissue fibers of the injury site from a shortened to a lengthened position. 

Effectiveness ART

A few pilot studies reported the effects of ART on different pathologies. Pilot studies do not have a control group and the group of subjects is small.
ART and adductor strains
The pilot study evaluated the effectiveness of ART to modulate short term pain in the management of adductor muscle strains amongst ice-hockey players (n= 9). Pre and post measurements were significant improved (p = 0,002 < 0,05). The study proved that ART is effective in increasing the Pain Pressure Threshold in adductor muscle pain sensitivity. The pilot study is a short term study.
ART and hamstring flexibility
The subjects (n = 20) were significantly more flexible after ART treatment on the hamstring origin and insertion. But these results aren’t generalizable because of the small sample that included only young healthy males. The pilot study was a short term study.
ART and carpal tunnel syndrome
ART was used to affect the median nerve of 5 subjects who were diagnosed with carpal tunnel syndrom. Both symptom severity and functional status improved after two weeks of treatment intervention. This is a small clinical pilot study that suggests that ART may be an effective management strategy for patients with the carpal tunnel syndrome.
ART and quadriceps inhibition and strength
ART did not reduce inhibition or increase strength in the quadriceps muscles of athletes (n = 9) with anterior knee pain. Further study is required. (copied from Influence of active release techniques on quadriceps inhibition and strength: a pilot study )

Case reports of ART
 
A patient with trigger thumb appeared to be relieved of his pain and disability after a treatment plan of Graston Technique and Active Release Techniques. There were 8 treatments over a 4 week time period. The range of motion increased and the pain was decreased at the end of the treatment.

An athlete with chronic, external coxa saltans is relieved from his symptoms because of treatment with ART. After her first visit the patient reported a pain reduction of 50%. After the fourth treatment the patient didn’t feel any pain anymore but the non-painful snapping was still present at that time. When the treatment was complete the non painful snapping was gone too.

A 51 year old male was treated for epicondylosis lateralis over two weeks (6 treatments) with ART, rehabilitation and therapeutic modalities. At the end of the treatment there was complete resolution of his symptoms. Active release technique was used in treating a novice triathlete. Initial treatment consisted of medical acupuncture with electrical stimulation, therapeutic ultrasound with Traumeel, Active Release Technique of gastrocnemius, soleus, and tibialis posterior muscles above and below the injury and Graston Technique soft tissue mobilization posterior to the medial malleolus followed by ten minutes of ice and elevation. The athlete was relieved of his symptoms and was able to return to his triathlon training.
An adolescent soccer player was relieved from his pain after 4 treatments over 4 weeks of soft tissue therapy and rehabilitative exercises focusing on the lower limb specifically posterior tibialis muscle. He had chronic medial foot pain due to striking on an opponent’s leg while kicking the ball. 

Post ART treatment exercises

Once the ART  has released the restrictive adhesions between tissues, post-treatment exercises become a critical part of the healing process and act to ensure the RSI does not return.

There are four fundamental areas that must be addressed in any exercise program:
 
Flexibility - Good flexibility enables muscles and joints to move through their full range of motion. Poor flexibility leads to a higher chance of injury to muscles, tendons, and ligaments. Flexibility is joint-specific; a person may have excellent range of motion at one joint, yet be restricted in another.
Stretching exercises are only effective if they are executed after the adhesions within the soft-tissue have been released. Stretching exercises that are applied to adhesed tissues will only stretch the tissues above and below the restrictions. The actual restricted and adhesed tissues are seldom stretched, leading to further biomechanical imbalances.

Strength - Strengthening exercises are most effective after the adhesions within the soft-tissue have been released. Attempts to strengthen already-shortened and contracted muscles only results in further contraction and restriction. This causes the formation of yet more adhesions and restrictive tissues, and exacerbates the Repetitive Injury Cycle. This is why the application of generic or non-specific strengthening exercises for RSI seldom works.

Balance and Proprioception - Proprioception describes the body's ability to react appropriately (through balance and touch) to external forces. Proprioception exercises should begin early in the rehabilitation process. Effective proprioception exercises are designed to restore the kinesthetic awareness of the patient. These exercises form the basis for the agility, strength, and endurance required for complete rehabilitation.

Cardiovascular - Cardiovascular or aerobic exercises are essential for restoring good circulation and for increasing oxygen delivery to soft-tissues. Lack of oxygen and poor circulation is a primary accelerant of repetitive strain injuries.

ART and performance

ART is seen effective in athlets of every level.It can provide patients with a means to enhance their sports performance by identifying and releasing restrictions that reduce their performance in that activity. This typically occurs after the practitioner conducts a biomechanical analysis of the patient's motion. During the biomechanical analysis and the subsequent treatment, the practitioner:

• Evaluates gait, motion, and posture.
• Identifies the biomechanical dysfunctions that are restricting the performance.
• Finds the soft-tissue structures that are the primary cause of the biomechanical dysfunction as well as affected structures along the kinetic chain.
• Treats the soft-tissue dysfunctions with ART to restore full function to the affected structures.

ART Performance Care is applied after trauma-based injuries have  resolved. ART Performance Care concentrates upon removing restrictions that inhibit full range of motion, and in restoring full function and performance to affected soft-tissues. This process can result in significant increases in sports performance - power, strength, and flexibility.

Abbreviations in Physiotherapy

Abbreviations assist healthcare professionals to make effective use of their time. These abbreviations should be recognised and agreed upon in order to ensure best practice.

For the detailed list of abbreviations used in Physiotherapy field, visit-
http://www.physio-pedia.com/Abbreviations_in_physiotherapy 

Physiotherapists: helping reduce sickness absence rates

Physiotherapists are established as one of the key types of professionals working alongside occupational health (OH) doctors and nurses to cut down on sickness absence rates. The collaboration between the two professional groups has led to discussions on how physiotherapists could be assessed under the Safe Effective Quality Occupational Health Service (SEQOHS) accreditation scheme.

Employers that contract physiotherapists to provide OH services are seeing good returns because people are able to stay in work through a combination of preventive measures and fast, effective treatment.

These physiotherapists work with employers to provide safe, effective work environments and offer advice and treatment to employees who begin to develop a problem that could result in sick leave. In many cases, this early intervention prevents any absence from being necessary.

If someone does go on sick leave, they are seen as soon as possible before their condition worsens, to ensure that symptoms are treated and any underlying behavioural or environmental factors, such as poor posture or a poorly designed work station, are dealt with to facilitate a swift return to work.

 

Physiotherapy and the Health and Work Service

This is good for the individual, saves money for the employer and boosts the economy overall by keeping a taxpayer in work.

This “triple win” was cited in early February 2014, when the Government made the latest announcement on its new Health and Work Service (HWS). The service will offer an assessment to anyone who has been off sick for more than four weeks to help identify ways to get them back to work.

Clearly, physiotherapists will play a big part in this service, fulfilling two roles. First, they will use their expertise in movement and function to assess a person’s condition, identify the causes of the problem and then suggest the steps that could help them return to work. These steps might include changes to working practices and patterns, alterations to the work environment or seeing a health professional for treatment.
This is where the second role comes in: providing treatment at the earliest opportunity to prevent problems from becoming long-term, chronic conditions.

Physiotherapists use body posture as a tool that can be adapted to meet job demands with minimum stress on the musculoskeletal system. They give expert advice to maintain fitness and flexibility, and to develop a reserve of strength to meet demands of an individual’s job. They also identify how habitual patterns of movement and working predispose musculoskeletal problems, and work with individuals and groups to improve musculoskeletal health, prevent injuries and improve efficiency.

Up to 30% of sickness absence is because of a musculoskeletal condition and, in many cases, early access to a physiotherapist could have dealt with the immediate problem and corrected any other factors to avoid a recurrence.

 

Evidence of improvement

Pilot schemes of the HWS have already shown promising results; for some people, physiotherapists have been able to support an earlier return to work than might otherwise have been possible.

In April 2013, the BBC reported on a scheme running in Leicestershire that helped a warehouse worker who had developed a shoulder injury. His GP referred him to the scheme, which in turn arranged for him to receive physiotherapy immediately, rather than wait on an NHS list for several weeks.

By providing this fast access to physiotherapy and then arranging a phased return to work, the employee was able to get back to his job much quicker than his GP had initially anticipated. As noted at the time by Dame Carol Black, whose report on sickness absence led to the creation of the pilot schemes, too many people fall out of work when their condition could have been managed: “It wastes human life. It ruins people’s sense of self-worth, dignity. It’s bad for families, bad for the economy, and bad for the community.”

 

Benefitting both the public and private sectors

Much of the coverage around that service has focused on help for the private sector, but OH physiotherapy is also helping public bodies make critical savings during this time of austerity.

In 2012, Staffordshire County Council contracted a private OH physiotherapy company to reduce its sickness absences. The rapid-access physiotherapy service begins with a telephone triage to allow contact with the employee within 24 hours of first being off work. During the call the nature of the problem is established, with self-management advice and exercises discussed. If necessary, a face-to-face physiotherapy appointment can be arranged at a convenient time and location for the employee.

Since the start of this rapid-access physiotherapy programme, the council has reported an 8% drop in staff absence, amounting to 9,000 fewer sick days per year, a 12% reduction in musculoskeletal absences and a 300% return on investment.

A dedicated physiotherapy service is now in place for staff with conditions such as pain and stiffness in joints, muscles, nerves and soft tissues. It offers rapid treatment to help staff to return to work quickly.

 

Rolling out good practice

In the NHS, although more work still needs to be done, there are signs that it is getting a grip on high levels of sickness absence. Perhaps ironically, the health service historically has not done a great job of looking after the wellbeing of its own employees. The Boorman Review, published in 2009, said that the NHS could save £555 million per year by providing fast access to services such as physiotherapy to help keep staff fit for work. The review also highlighted that improved staff health ensured better treatment for patients, because sickness absences had led to cancelled appointments and longer waiting times. Yet even last year, an audit conducted by the Chartered Society of Physiotherapy found that about 40% of health trusts in England still did not have a health and wellbeing strategy in place for its staff – despite this being a key recommendation from Boorman.

At a time when the NHS is tasked with saving £20 billion by 2015, it is remarkable that this simple way to reduce costs is being overlooked.

 

Services that work

There are, of course, pockets of excellence. Fast Physio is a dedicated, inhouse service that provides rapid access for employees at East Lancashire Hospitals NHS Trust. Urgent referrals are seen for an assessment, management and advice within three working days, and routine assessments within 10 days. Employees also get telephone and email advice to enable them to self-manage their injury more effectively, and there are recommendations for workplace adjustments where appropriate. Advice and support is provided for both managers and employees during an individual’s return to work. After the service had been running for 18 months, there had been a 32% reduction in days lost to musculoskeletal-related sickness.

 

Proven investment

Physiotherapists have been demonstrating their effectiveness and return on investment across all sectors for a number of years in OH.

When PricewaterhouseCoopers analysed the impact of health and wellbeing initiatives at 55 organisations, ranging in size from 70 to 100,000-plus employees, it found consistent evidence of reduced absence and increased productivity.

In one case, an employer experienced a return of £34 for every £1 spent on providing in-house and discounted physiotherapy for staff.

Now the effectiveness of those services looks set to get official recognition. SEQOHS is the system for accrediting an OH service that complies with a rigorous set of standards. The professional network, the Association of Chartered Physiotherapists in Occupational Health and Ergonomics (ACPOHE), is working with SEQOHS to introduce a quality assurance system for OH physiotherapy. ACPOHE has recruited six organisations that represent the breadth of OH physiotherapy services, and a one-year pilot project began in November 2013. During the pilot period the sites will provide documentary evidence to demonstrate how their organisation meets the SEQOHS standards. The feedback from the pilot will feed into the Faculty of Occupational Medicine’s review of the SEQOHS standards. At the end of the pilot, all participating organisations will receive a written report with regards to their level of achievement against the standards and an action plan identifying where further evidence improvement is required.

Organisations that can successfully demonstrate compliance will also receive a letter from SEQOHS stating that the organisation meets the standards. These organisations will then be ready to apply for full accreditation in 2015 when the updated standards are issued.

This would make the UK the first place in the world where OH physiotherapists can receive a quality assurance standard for their practice.

OH physiotherapists now work in a diverse range of settings across all sectors. Whatever type of workplace they are in, however, the evidence shows the employer will see an average return of £3 for every £1 invested in the service. As the economy continues to struggle back to life, the importance of that statistic speaks for itself.



via-http://www.personneltoday.com/hr/physiotherapists-helping-reduce-sickness-absence-rates/