RHP Physiotherapy Blog
The latest from RHP Physiotherapy
RHP Physiotherapy is one of Brisbane’s premier physiotherapy practices. We’ve started this blog in order to provide an informed and authoritative discourse on a range of health related topics.
Our hope is that we can provide you with up to date information and events associated with a range of health topics not limited to sports injuries and musculoskeletal problems as may be associated with traditional ‘physio’ or physiotherapy.
Our sports physiotherapists are amongst the country’s elite but we have worked hard to establish a culture of excellence across a range of health related issues. Many of these topics we hope to discuss in coming blogs.
We walk who we are!
The way we walk often reflects who we are as an individual personality. Laid back and free? Hustle and bustle? Stomping and full of purpose? Slouched and succumbed?
We are how we walk!
In turn, the way we walk determines which muscles in the body are being engaged on a daily basis, or what shape our spine is held in, and how much load is transmitted through our joints. These factors all contribute to our physical wellbeing.
A good walking pattern helps to maintain physical health through activation of our stabilising muscles. These include the important gluteal, abdominal, and back muscles, among many others.
A good pattern will absorb and dissipate what we call ground reaction forces. These are the jarring loads that occur when we land on the ground. Excessive jarring will overload and contribute to joint stress, particularly in the feet, knees, hips, and lower back.
A good walking pattern will help to maintain ideal posture, which is crucial for optimal spinal health.
A poor walking pattern can bypass these stabilising muscles, and encourage overuse of the wrong muscles. This often leads to tightness and muscle imbalance problems, which in turn loads up our joints and promotes injury. These injuries can include low back pain, hip joint degeneration, gluteal tendinosis, and knee pain.
Image from Professor Vladimir Janda
Walking utilises the whole body, and becomes a firmly fixed motor memory in the brain. Learning to walk well and over time reshaping the brains gait memory can have a massive effect on our joint and muscle health, and help eliminate ongoing or recurring pain conditions.
At RHP Physiotherapy we have expertise in movement analysis including walking and running. We can propose exercises and strategies to mould your walk into a smooth, co-ordinated and cohesive pattern. So perhaps it is time to ask yourself “how do I walk?”
Post by Sam Donaldson (M.PhtySt, BAppSci(HMS), Physiotherapist APAM SMAM)
Recently, a patient presented with a lengthy (>3 month) history of lower back pain. This individual’s pain wouldn’t behave as typical lower back pain. There was also a complaint of some discomfort in other body regions that didn’t fit a typical spinal pain presentation. Upon being made aware of some recent illness, it became apparent that we might be dealing with something systemic or auto-immune.
Fortunately, these suspicions were justified once this patient attended a Rheumatologist, with a Spondyloarthropathy diagnosis being made and subsequent treatment being positive.
What was interesting in this case is the rarity of these patients and the challenge for the health professional that this type of patient presents from a diagnostic perspective.
It is, among other things, one of the Physiotherapists primary roles… ensuring that Physiotherapy treatment is appropriate for the patient in front of them. Through thorough questioning and examination of the patient in their initial appointment, we are essentially deciding whether we can help, and if not, what health professional might.
Fortunately, there are strong guidelines for the appropriate referral of a patient that we might suspect is suffering a Spondyloarthropathy. A recent “NICE Guideline” presented a number of clinical features of a patient’s presentation and at what point should a referral to a Rheumatologist be made. Bearing in mind (for any Physiotherapists reading), this might mean a phone call to the patient’s GP to discuss the possibility and for the referral to be made via the appropriate pathways.
One of the first decision for us to make is: is this patient suffering “Inflammatory Low Back Pain?” This is generally described as:
- Lower back pain lasting >3 months
- Better with movement and worse with rest
- Pain at night, improves upon getting up in morning
- Alternating buttock pain
- Insidious onset
Following the recognition of inflammatory lower back pain, a range of clinical features might also be present (see infographic). If 3 or more criteria are present, it is reasonable to be suspicious of a Spondyloarthropathy. Particularly since the average time between symptom onset and diagnosis is 8.5 years. This is a significant amount of time losing quality of life and suffering pain.
So, if this is the case for yourself or a loved one, a discussion with a primary health care provider such as your GP or Physiotherapist is certainly appropriate. For the Physiotherapists, hopefully some greater awareness and interest is sparked and further reading performed. We have a great role in assisting in musculoskeletal management of various spondyloarthropathies and the impact on our patient’s life can be astounding!
McAllister, K., Goodson, N., Warburton, L., & Rogers, G. (2017). Spondyloarthritis: diagnosis and management: summary of NICE guidance. BMJ, 356, j839.
Akgul, O., & Ozgocmen, S. (2011). Classification criteria for spondyloarthropathies. World J Orthop, 2(12), 107-15.
Post By Elyse Nayler (BPhty APAM, Physiotherapist)
A neurological examination is part of your physiotherapist’s assessment and helps determine the correct diagnosis of your symptoms and the integrity of the nervous system. This should be tested if you are experiencing pins and needles, numbness, weakness, co-ordination issues or pain that radiates into your limbs that could be from your spine. The physiotherapist is looking for alterations in your sensory and motor systems, as well as your reflexes that could be due to the nerve pathways being impaired in their ability to send electrical impulses that co-ordinate these important functions. As your nerves leave your spinal cord, they travel throughout your body and provide many functions via electrical impulses, and this can be compromised with certain conditions such as if you have a disc bulge that is blocking the nerve on its pathway out of the spine.
A test will consist of comparing muscles on either side of the body to ensure that the power is the same on either side and is normal, that there is no muscle wasting which could indicate that a nerve is no longer stimulating a muscle as is seen below. Your physiotherapist will work their way through a series of different muscles ensuring they have comprehensively tested all levels of the spine that provide motor stimulus to the upper or lower limbs.
We will also follow the sensory distributions of each level of spinal cord for the sensory component of the examination, which will involve as a general screen a light touch on the same area on both limbs comparing how strongly you feel the touch side to side. An indication of a nerve pathway being affected would be that you don’t feel the pressure is the same on each side or the area is numb. If this is the case, the physiotherapist can look at other tests to see how affected the nerve is by testing your ability to determine the difference between a firmer touch, a sharp versus a blunt object, or between a hot and cold object in the specific area that was altered.
The third component to the neurological assessment is testing your reflexes which is commonly done at the knee, ankle, elbow and wrist. The stretch reflex (also called the myotatic reflex or deep tendon reflex) is a pre-programmed response by the body to a stretch stimulus to the tendon or muscle. This reflex is designed as a protective mechanism for your muscles so that in response to a stretch, impulses are sent to the spinal cord resulting in a muscle contraction which prevents the muscle from being stretched too forcefully or beyond a normal range. Often people have experienced the knee-jerk test where a tendon hammer is tapped onto the patellar tendon resulting (in a normal response) in a quick mild contraction of the quadriceps muscles, which gives you a kicking motion. If the reflex is absent, or reduced on one side compared to the other, this could indicate a problem in the integrity of the nervous system.
This assessment is an important part of a thorough examination into the integrity of the nerve pathways and will be used when appropriate by your physiotherapist. If you have any questions with regard to the assessment process, speak to your physiotherapist or call us on 3856 5566.
Post by Andrew Hall, Accredited Sports Dietitian & Exercise Scientist (BExSc, BHSc (Hons), MDietSt) – Apple to Zucchini Sports Nutrition
Did you know that it takes three times more energy to cover the same distance on crutches as it does compared to walking normally? If you have ever experienced a sporting injury, it’s likely you will have an inkling of what happens and the frustration involved. How do you cope with this nutritionally? Read on.
IN THE EARLY DAYS
Injuries severe enough to result in immobilisation of a limb and/or bed rest lead to considerably reduced levels of physical activity, fitness levels and a change in energy requirements. Disuse of a limb (e.g leg in cast, arm in a sling) results in loss of muscle mass, reduced muscle strength and function. Consider the shrinking muscles around a knee after ligament surgery for example. During the early stages of recovery, it is important to match the amount of energy from foods and drinks to the body’s need for energy. Surprisingly, immediately following an injury, energy expenditure may be increased by 15 % up to 50 %, depending on the type and severity of the injury. Nevertheless, it is common for an injured person to eat less due to reduced activity levels, and while this thought is understandable, it could impact on tissue healing and muscle wastage in the early stages (bad news).
A structured and supervised nutrition plan can assist in maximising the rehabilitation speed by prescribing correct energy, protein, healthy fats and other important nutrients. This will aid in holding on to that hard-earned muscle mass while keeping body fat levels in check.
Someone who is constantly finding themselves injured, or if the injuries linger for prolonged periods of time, should consider the influence of nutrition and its impact on systemic inflammation. While inflammation is a vital tissue healing response from the body in the first 24-48 hours post injury, chronic systemic inflammation can negatively impact on injury healing over time.
Research tells us that the more fruit and vegetables someone eats, the lower their inflammatory markers are likely to be. Studies have also found that a diet rich in antioxidants (from plant foods) may dampen down the inflammatory response in early inflammatory joint disease, slowing its progression. I’m sure we all know someone with joint pain who takes anti-inflammatory drugs, pain killers, and fish oil supplements. But there is much more that can be done by consuming the best foods and aiming for quality food choices. Health conditions which can potentially benefit include: tendonitis, ankolysing spondylitis, arthritis, gout, and cartilage damage. Food quality has also been shown to influence the perception of pain, and many people notice pain reduction simply from focussing on adequate hydration and nutritious eating. I’ve had clients tell me that their knee pain reduced noticeably by cutting out soft drinks (including diet versions), which is absolutely a good reminder of how significant what we choose to eat and drink is.
Bone health is a critical consideration for any athlete. Yet it is particularly important for those indoor sports (away from sunlight and Vitamin D opportunity), non-weight bearing sports (swimming) and physique sensitive sports (diving, gymnastics, body building). For all the runners out there, bone-stress injuries make up a great deal of the injuries that stop you from pounding the pavement. If not you, I’m sure you can think of many in your running group that had to stop or modify their training due to stress fractures
Vitamin D and Calcium are the most commonly known dietary influences on bone health. But big picture considerations also include total energy intake, fruit and vegetable intake and protein source selection. The Framingham Osteoporosis Study has shown both men and women with fish intakes ≥3 servings per week gain hip bone mineral density over four years compared to individuals with low to moderate weekly fish intakes who lose bone mineral density. Fruits and vegetables contain a vast range of vitamins, minerals, carotenoids, and antioxidants which all have a role to play in health and bone strength. Higher fruit and vegetable intakes are also linked to higher bone strength and less bone loss over time.
GET BACK IN THE GAME
Playing a range of sports has personally led me to a variety of injuries over the years. So I researched profusely what could be done nutritionally to get back in the game asap. The answer is, that there is plenty.
Post by Sam Donaldson (M.PhtySt, BAppSci(HMS), Physiotherapist APAM SMAM)
Pain and pain science is an ever evolving and incredibly complex field of study with many, MANY contributing factors. For some more information on what pain is, how the brain is involved and why that is important to be aware of, see a previous blog posting by Tim: http://www.rhpphysiotherapy.com.au/uncategorized/is-it-all-in-my-head/
In some musculoskeletal pathologies, pain may feel worse at night time. This can be a harrowing experience and quite disconcerting. Typically, we think of night pain as suggestive of more sinister pathologies. So, importantly, mention this to your physio at the next appointment or discuss it with your Doctor. Even more importantly, often there is a very normal cause for this pain.
One such instance is bone related pain. A stress reaction or stress fracture is a good example. Bone stress injuries occur because of an unfamiliar increase in physical activity and is related to overuse, under recovery and several considerations that result in the bone not being able to keep up with the required adaptations.
A fracture can result and this will cause pain at night time. It has been proposed that this may be a result of attention. We are busy throughout the day, the mind is attending to many inputs and outputs, which we don’t attend to at night. Perhaps the brain allows this pain stimulus information to come to the fore?
Another explanation, scientifically justified, is related to our circadian rhythm and inflammation. Healing tissue requires inflammation to occur, bringing cells to the area that work to fix the problem. Interestingly, our circadian rhythm aids in modulating this inflammatory response, particularly for bones. Markers for bone turnover fluctuate throughout the day in a diurnal pattern, with increased metabolic action occurring at night. This might be due to an interaction of hormones controlled by the brain and responsive to day/night environments. They allow the increase in inflammatory markers and thus an increase in bony metabolism at (Dimitri & Rosen, 2016).
As Tim wrote in his blog, inflammation increases the responsiveness of nerves. Bones are innervated. Thus, with this increase in inflammation to the bone, helping with growth or remodelling, the nerves are responding and letting the brain know. This might feel painful!
How interesting that this bone metabolism occurs more during the dark hours. Our children truly can shoot up overnight!
This is just one example as to why pain might be worse at night. As I wrote earlier, there are many other reasons for pain, not just a bone fracture. So, if you are suffering some pain and are unsure as to why, get it investigated by having a discussion with your Doctor or Physiotherapist.
Dimitri, P., & Rosen, C. (2016). The central nervous system and bone metabolism: an evolving story. Calcified tissue international, 1-10.