The Week in Research Review, etc 9-24-18

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Hey everyone, another great week of rehab-related posts that brought a lot of topics together. The week in research review for 9-24-18 involved:

  • Blood Flow Restricted Resistance study
  • RTP following an ACL
  • Prevalence of knee osteoarthritis in pain-free people
  • Training your core
  • Dosing Low load Long Duration
  • Using Boditrak during the deadlift

 

Blood Flow Restricted Resistance Exercise as a Post-Orthopedic Surgery Rehabilitation Modality: A Review of Venous Thromboembolism Risk JOSPT Bond et al 2018.

This paper is more of a review of the literature (so be cautious) but raises some important questions and thoughts about #BFR usage in our typical orthopaedic setting.

They talk about important decisions and concepts to be made including precautions, contraindications, and dosage.

They also admit that there are no universally agreed upon standards indicating which post-surgical orthopedic patients may perform BFR safely.

They also list close to 40 different precautions or contraindications including:⠀
❇️Age >40 yr⠀

❇️Creatine Supplement Use ⠀

❇️Diabetes⠀

❇️General/Local Infection ⠀

❇️Hypertension⠀

❇️Immobility >48 hr in the Past Month⠀

❇️Open or Unhealed Soft Tissue Injuries ⠀

❇️Amongst many others

Seems like a pretty strict list but curious to hear what others are using to determine if their client is appropriate for BFR resistance training.

💪🏼Thanks @kieferlammi for the swole session!

Let’s discuss below… tag a colleague who may be interested in discussing…thanks!

 

Return to Play after ACL

I posted this the other day on #Twitter because I keep hearing people talk about the failure rates after an ACL.

I feel like 1 major reason why people are failing within the 1st 1-2 years after returning is that they get back on the field with residual weakness.

When the patient’s insurance runs out, they workout on their own or often seek out a personal trainer to help them.

I feel we as PT’s can do a much better job at showing our value to our patients by keeping them under our care an progressing them back to their sport.

If we don’t have the facilities to do this, then we must work with others in our region to help our clients get the best care possible.

At @championptp, we often get referrals from area clinicians asking to take over their client’s care and advance them back to their sport. I definitely respect that clinician for recognizing their care may not be the best for the client at that time in the rehab process.

Do you utilize clinicians in your area in these situations? Do you think we could improve our ACL outcomes if we did this more?

Let’s discuss this below and make sure we have a plan in place when that 2-3 month rehab phase approaches. Tag a friend who may benefit from this post…thanks!⠀⠀

 

Prevalence of knee osteoarthritis features on MRI in asymptomatic uninjured adults: a systematic review and meta-analysis Culvenor BJSM 2018

This paper ‘performed a systematic review with meta-analysis to provide summary estimates of the prevalence of MRI features of osteoarthritis in asymptomatic uninjured knees.

They basically looked to determine the normal changes in the knee that may be diagnosed on an MRI in people less than and greater than 40 years of age.

The information may help clinicians educate their patients prior to getting an MRI.

Overall pooled date included:⠀
Cartilage defects was 24%⠀
Meniscal tears was 10%⠀
Bone marrow lesions 18% ⠀
Osteophytes 25%⠀

Cartilage defect <40 years 11%⠀
Cartilage defect ≥40 years 43%⠀
Meniscal tear <40 years 4% (seems low to me)⠀
Meniscal tear ≥40 years 19%⠀

Interesting stuff that you need to store in our mental database for future clients.

What do you think of this data? Will it help you in your decisions with your clients?

Tag a friend or colleague who may benefit from this information…thanks!⠀

 

4 WAYS YOU SHOULD BE TRAINING YOUR CORE

Great post by our strength coach @kieferlammi discussing the 4 ways to train your ‘core’. Simple yet a great view of the concepts needed to best address a client’s weaknesses. Give him a follow and see his original post below. @championptp

There are a million different exercises to train your abs/core/trunk/whateveryouwanttocallit. Regardless of which you choose, in my mind there are 4 staple ways that I think belong in every training program:

⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀
1️⃣Anti-Extension – These consist mainly of plank variations, Rollouts, Fallouts, etc.

2️⃣Anti-Rotation – The anti-rotation press or “Pallof Press” is the most popular of this category and can be done from a variety of stances with a variety of tools.

3️⃣Anti-Lateral Flexion – Side planks and unilateral load carries are king here, but this would include anything resisting side bend.

4️⃣Anti-Flexion – Loaded carries and Deadlifts are the top two in my mind, but anything where you have to work to avoid rounding forward, will do.

What are your staples? Anything I’m missing? Disagree? Comment below!

 

LLLD DOSING

What dosing should you prescribe your patient with a stiff joint when using low load long duration stretching? 🤔

That’s the million dollar question and very little is known.

The one paper that I’m aware of is more of a concepts paper but has been the guidance for my LLLD dosing.

McClure et al talk about 60 minutes per day of total end range of motion time or TERT.

Basically, I tell my clients to apply some form of over-pressure 4x per day for 15 minutes each session. I’ll sometimes do 3x 20 minutes/day if they don’t have the time at work or school.

It allows them to moderately stress the tissue but not take up too much of their time during the day.

The key to this form of stretching (we think) is to elongate the tightened collagen that is limiting the posterior capsule of the knee… see Zhou et al 2018 MSSE ‘Range of Extension Correlates with Posterior Capsule Length after Knee Remobilization.’

Check out this paper and consider this dosing as the basis for your future clients. Do you have any dosing schedules that you use or any research that specifically talk about this?

Let’s talk it out and hopefully help you dose your patients who are tight after knee or elbow surgery…thanks!⠀

 

 

Using Boditrak during the deadlift

This video was recently taken of my #ACL patient who is ~ 12 weeks s/p L ACL reconstruction with a patella tendon autograft and a medial meniscus repair.

I took this video (it’s a mirror image so don’t get confused) to analyze her weight distribution between the involved leg (Left) and the uninvolved leg (right).

As you can see, she spends a lot of time on the front part of her foot throughout much of the deadlift and has her weight shifted to the uninvolved side during her initial pull.

As she ascends up and reaches the max pull position, she is able to redistribute her weight more evenly between each side but continues to keep her weight more toward her toes on that involved side.

To me, I would like to see her weight distribution more equal side to side but also more towards the mid-portion of her foot during the pulling phases.

She self-admits that she is shifting her weight and can’t help it. Through the naked eye, you may be able to see the shift but not necessarily see the anterior/posterior weight distribution (toes/heels).

I like to use the @boditraksports to pick up little nuances and help give feedback to the client.

Did you notice anything else with this video? What would you critique (be nice!!)?

Tag a friend or colleague who may want to see this video and help @lms651 get back to her fencing competitions…thanks!

⠀

The Week in Research Review, etc 9-17-18

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Another week of some great discussions looking at the week in research review. Check it out below and let you friends know they need to subscribe to my blog! Thanks, everyone!

 

 

Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management. Grimaldi et al Sports Med 2015.

Great review of gluteal tendonopathy, which I think is more prevalent than we once thought.

It was often confused as greater trochanteric bursitis which was completely misleading, and treated with injections.

Non-inflammatory insertional tendonopathy of the gluteus medius and/or gluteus minimus is now considered the primary pathology underpinning lateral hip pain.

This paper does a nice job of outlining the pathomechanics, assessment, and management of patients diagnosed with gluteal tendonopathy.

In their conclusions they mention “The evidence for the best management is poor, and the underlying mechanisms of the condition are only beginning to be understood. Interventions reported in the literature do little to address potential underlying mechanisms.”

Found this pretty eye-opening but refreshing because as much as we think we know, we really don’t know.

Check it out and share with your colleagues and friends that may be interested…thanks!

 

 

 

The squat and deadlift definitely my go to exercises for most of my patients with a lower body injury. @kieferlammi@fitnesspainfree

Obviously, there’s a progression to get to heavy weights but the goal for MOST of my clients is to load their joints and muscles to be able to withstand the demands of their life and to meet their goals.

I also like to make sure their accessory movements and stabilizing structures can maintain good stability, as in the glute tendonopathy I posted yesterday.

My focus is typically on improving hip,. ankle and knee mobility and stability through hip flexor stretching and maximizing ankle dorsiflexion. These principles apply to many but not all (so calm down!).⠀

I’ll also focus on glute/Hamstring work through clams, bridging, band walks, etc. Again, my go-to exercises for the lower half, kinda like my go-to rotator cuff exercises.

Our lives can be repetitive but that’s because many people fall into similar buckets in their presentations.

What do you think❓Do you use these similar principles when treating your clients?

Share or tag a friend who may benefit from this post…thanks!⠀

 

 

 

Arthrogenic muscle inhibition after #ACL reconstruction: a scoping review of the efficacy of interventions Sonnery-Cottet et al BJSM Sept 2018.

This paper looked to ‘determine whether reported therapeutic interventions for arthrogenic muscle inhibition (AMI) in patients with ACL injuries, following ACL reconstruction or in laboratory studies of AMI, are effective in improving quadriceps activation failure when compared with standard therapy in control groups.’

780 potential articles were identified. 20 met the inclusion criteria.

Using the GRADE approach, there was moderate-quality evidence for the efficacy of cryotherapy in the treatment of AMI.

Moderate-quality evidence for the efficacy of exercise in the treatment of AMI.

Surprisingly, there was low-quality evidence for the efficacy of NMES, which seems to be pretty accepted treatment but vibration, ultrasound, and TENS also demonstrated low-quality evidence.

The available evidence does not support taping or bracing in AMI. They mentioned active release or local anesthetics as other modalities that have no effect on quadriceps inhibition.

No mention of blood flow restriction training, which would’ve been interesting. #BFR

What do you think? Does this study match what you do in your clinical practice? Tag a friend or colleague who may be interested in this open access paper…thanks!⠀

 

 

Is There a Pathological Gait Associated With Common Soft Tissue Running Injuries? – Bramah et al AJSM 2018.

I took an interest in this study because they actually used people that had been diagnosed with an injury, which is pretty unusual.

They wanted to look to see if Injured runners would demonstrate differences in running kinematics when compared with injury-free controls. They looked at 72 injured runners and 36 healthy controls.

The injured runners demonstrated greater contralateral pelvic drop (CPD) and forward trunk lean at mid-stance and a more extended knee and dorsiflexed ankle at initial contact.

Contralateral pelvic drop was found to be the most important variable in predicting the classification of participants as healthy or injured.

Importantly, for every 1° increase in pelvic drop, there was an 80% increase in the odds of being classified as injured.

Curious to hear my running PT/Physios chime in and drop some knowledge like @zerenpt and @running.physio
Share with your running friends and colleagues who may benefit from reading this post…thanks!⠀

 

 

 

[REPOST] Thought this was a great post showing some advanced hamstring exercises by @scottlogan_nz(twitter) @scottlogan03 (Instagram). Check it out and give him a follow!

Can be used in rehab after an #ACLsurgeryor any lower body injury. can also be used in injury reduction programs, especially for those struggling with chronic strains.

Loved the addition of explosive power production while trying to dissipate the forces.

See his post below. 👇🏻

Higher speed, fast eccentric and rapid isometric hamstring exercises are an important part of any performance or injury risk reduction program. Here are a few variations I have used recently. There are plenty more out there, this is not an extensive video database. Add one or two of these to your next cycle and let me know how you get on. Remember to be smart adding new exercises and stimulus to training. do it gradually and progressively.⠀

 

 

 

Power of positive words. We use these on a daily basis at @championptp. Like @drewbrees talks about during a recent interview.

Dr. Andrews said “If I did that surgery 100 times, I couldn’t do it as good as I did it this time.” I wanted to plant that positive seed…

Wow, powerful stuff by the doctor who I know completely gets it when he’s dealing with all of his patients…from the youth athlete to the highest paid players ever to play professional sports.

There’s a kinda game we play at times to make sure our clients can buy into what we have done or are about to do with them.

Whenever someone tells me that they couldn’t have done it without me, I always tell them that they did all of the work and I was just there to help guide the process.

Dr. Andrews alluded to this and knew the mental challenges that Drew and his family were going through right after the surgery. He was able to set the tone for the rest of the rehab that @wilk_kevin did over the many months following the surgery.

I was able to watch across the room at @championsportsm (and at times work with Drew when KW would hit the road) and see the tremendous progress that was being made.

I distinctly remember Drew’s 1st day of throwing a football and the relief that day. It was such a great moment to witness and one in my personal career that I’ll never forget.

With that, I just wanted to share this video because the interactions and confidence that we can exude can make or break a rehab session, so choose your words and actions carefully.

Tag a friend who may like to read this or may just be a @saints fan!

 

Lots of good stuff…Thanks for reading!

The Week in Research Review, etc 9-10-18

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Lots of good stuff this past week. We talked:

  • Dr. Andrews knowledge bombs
  • Frozen Shoulder video
  • AC joint Classification
  • Whether we should return our ACL patients at 6 months post-op
  • Eric Cressey quote on failing rehab


What I have learned about being successful as an orthopedic surgeon by Dr James Andrews

Great read by my friend, mentor and colleague who I was fortunate to work with from 2002-2014, before moving back home to Boston to help open @ChampionPTP with @mikereinold.

I learned so much from my interactions with him and how he handled each and every case. His approach has been the standard by which I carry myself as a PT

In this paper, he talks about: ⠀

✔️Availability⠀

✔️Communication⠀

✔️Compassion⠀

✔️Gentleness⠀

✔️A true love of caring for my patients

He also talked about being successful with a ‘purpose driven life’ and discusses 16 key recommendations to a successful orthopaedic career.

Take a look at this article and implement as much as you can tomorrow and every day thereafter.

Happy reading…share with a friend or colleague in the comments section below!⠀

 

Frozen Shoulder or adhesive capsulitis can be debilitating and frustrating for the patient.

This video shows why! Look at all of that red and inflamed tissue of the shoulder capsule. Those neovascular changes are a classic sign of frozen shoulder and the main reason why anti-inflammatories are probably effective in the early stages of the disease.

The pain associated with this presentation is often the main limiting factor, combined with the eventual capsular scarring/contracture that develops soon after.

This scarring leads to a loss of joint arthrokinematics, which leads to loss of mobility, functional loss and atrophy. This spiral effect can last months if not years for some.

Regaining mobility, strength and normal function is not guaranteed but PT can help speed up the process a bit by educating, guiding and mobilizing the patient.

if I see someone in an early stage of frozen shoulder, I usually recommend a cortisone shot followed by more PT to help maintain the patient’s shoulder ROM/strength.

What do you recommend? Any tests you use to help diagnose adhesive capsulitis?

Tag a colleague who may benefit from this post…thanks!⠀

 

With football season here, we’re going to hear a lot of talk about #shouldersaparation or AC joint sprains

The different Grades (Rockwood Classification) of AC Joint sprains are:⠀

1️⃣ AC ligament sprain, AC joint intact, CC ligaments intact⠀

2️⃣AC Joint disruption, Slight vertical separation of ACJ, CC ligament sprain, CC distance wide⠀

3️⃣AC ligament disruption, AC joint dislocated, CC ligaments torn⠀

4️⃣AC ligament disruption, AC joint dislocated, Clavicle displaced posteriorly into Trapezius, CC ligaments completely torn⠀

5️⃣AC ligament disruption, AC joint dislocated, CC ligaments completely torn,⠀
CC distance 100 to 300 % > than normal side.⠀

6️⃣AC ligament disruption, AC joint dislocated, CC ligaments completely torn, Clavicle in subcoracoid position.

I saw this video that @drroddymcgee put out on #Twitter and loved the visual effects to help simplify the typical tissues involved with each type of AC Joint sprain. You can slo find them at @thesportsdocs00 on Twitter too.

Hope it helps to put the AC joint sprains in a better view for you. Share with a colleague who may have an interest…thanks!

 

Return to play after an ACL is a complex decision that involves many variables. The research is telling us a 6-month return to play is too quick and should be delayed up to 9 months.

During that time, the focus of the rehab needs to be on gaining strength, power, and confidence in the patient’s lower body, particularly the quadriceps.

✅ 51% reduction for each month return to sport was delayed until 9 months after surgery…research by Grindem et al BJSM 2016.

Hewett et al have advocated for a possible 2-year return to play wait time to account for graft healing and time for the full strength, power and confidence to return.

I have adjusted my practice to educate my clients for a 9-month return and map out a timeframe from the beginning so they buy into that thinking. Often times, doctors will place a 6 month time for RTP and I have to overcome that thinking and ‘convince’ my clients that it’s too soon.

I think that much time is needed to get the quadriceps muscle back completely and to gain the full confidence in the limb through dynamic activities.

Do you agree? What do you recommend and do you agree with Coach Saban’s answer on RTP at 6 months? 😜

Tag a friend who would benefit from seeing this post or at least seeing Coach Saban…thanks! #RTR #notreally #neutral#switzerland 

 

Failing Rehab

As a PT, this really hit home with me and thought @ericcressey nailed it! See his original post below. @cresseysportsperformance 👇🏻

As with any professional offering – training, accounting, contracting, landscaping, or a host of other services – you’ll see good and bad rehabilitation scenarios. Make sure you do your homework about not only a rehab specialist’s experience and credentials, but also the business model in which he/she operates. 😵#cspfamily #sportsmedicine#rehab #physicaltherapy #physicaltherapist#athletictrainer #athletictraining#sportsperformance #rehabilitation