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.
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.
Post by Sam Donaldson (M.PhtySt, BAppSci(HMS), Physiotherapist APAM SMAM)
Do you get some odd tingling in your hand, or have you had some clumsiness with fine motor skills like holding a pen or opening a door? Do you have a reason why?
These symptoms suggest that there might be an issue relating to a nerve that supplies your hand. Chances are there was no particular injury that caused this. If the symptoms seemed to randomly start, one possible diagnosis is Carpal Tunnel Syndrome. Importantly, check with your physio first before claiming that this is what ails you!
About Carpal Tunnel Syndrome
Carpal tunnel syndrome affects approximately 3-5% of the population, so chances are you know someone who has suffered with it. It is a compression injury to the Median Nerve as it passes through a small space in the wrist, called the Carpal Tunnel.
It is characterised by sensation loss (tingling or numbness) in 3 ½ fingers: the thumb, index, middle fingers and the thumb side of the ring finger. More severe Carpal Tunnel Syndrome might affect the motor control of those fingers as well, so using a pen, handling paper or gripping might have become difficult. Pain might also be a feature and often these symptoms are relieved with a flicking of the wrist.
It is not common for the palm of the hand, the little fingers and anywhere in the forearm to be affected with similar symptoms. However, if the symptoms are left for a long time and have continually been getting worse, it is not unreasonable for symptoms to progress into the forearm, although this is much less common and may indicate that the problem stems from further up the arm, shoulder or neck.
Carpal Tunnel Syndrome is usually made worse by overuse of the wrist and hand. The compression injury of the nerve results in some damage to the nerve tissue and the subsequent symptoms. So in rehabilitation of Carpal Tunnel Syndrome, the aim is to initially reduce the compression before targeting the nerve health. There may also be other medical conditions that can affect this Carpal Tunnel space, so be sure to discuss it all with the Physiotherapist.
Conservative management usually involves the use of a splint, particularly at night time. Your physiotherapist can also help with other management options such as massage and acupuncture to relieve some pain. Occasionally pain relief in the form of a corticosteroid injection or oral tablets may be prescribed by your doctor.
If tolerated, some interesting dance-like movements involving the wrist and whole upper limb can help move the nerve through its space. These are often very specific to each person. Mobilising the nerve tissue has been shown to improve normal healing of the nerve and even improve electrical conduction of the damaged nerve.
Carpal Tunnel Syndrome that is severe, constant and chronic (over 3 months), may not resolve with conservative management and may require a surgical release. In severe cases symptoms may never fully resolve, but appropriate management can result in a return to normal daily function. However, if caught early, many people will return to normal function over approximately three – six months.
If you, or someone you know is suffering something similar, it is recommended that they seek some assistance in getting an accurate diagnosis and managing the condition appropriately.
Yes! But that is normal. The pain experience is something that occurs in the brain. When you damage a muscle, tendon or ligamentous tissue, chemicals are released into the surrounding tissues. These chemicals, like substance P, bind with nerve endings and generate an electrical impulse, which travels by special nerve pathways to the brain. Neither substance P nor the electrical impulse, are in and of themselves painful. However, once that impulse arrives in the brain, the brain computes that stimulus together with other information to interpret it as pain. This other information may include someone’s previous pain experiences or the level of stress, anxiety or fear in the person at the time.
An example of this may be; if you were to squeeze the webbing between your thumb and index finger, then you can feel the mechanical compression of the tissues. However, if you squeeze that area firmly enough, then that mechanical compression feeling will become a painful feeling. This pain experience is to warn you that this compression may soon damage the tissues, and so to make a change to avoid that pain. Sometimes the threshold at which that mechanical stimulus becomes a painful stimulus can change. That threshold may be reduced by the presence of inflammation in the hand for example, or it may be reduced due to a previous negative experience you have had with a similar pain. Sometimes this threshold can be reduced to such a level that people develop a hypersensitivity to that stimulus.
Central Sensitisation is the technical term to describe physical, chemical and biological changes within the brain which lead to a hypersensitivity to pain or other symptoms. It is a normal response to any painful stimulus for the brain to change. If pain persists, then these changes can become more pronounced. Sometimes, these changes in the brain remain, even after the damage to the muscle, tendon or ligament has completely resolved. This is when Central Sensitisation can become the primary driver of some one’s pain experience.
Recently developments in the research have provided clinicians with a proven objective measurement tool to enable physiotherapists to accurately assess the presence of central sensitisation in patients with chronic low back pain.
It is possible for Central Sensitisation to explain the entirety of someone’s pain presentation, but highly unlikely. It is very likely that Central Sensitisation is a component of someone’s chronic pain. If the therapist and patient are aware of the presence of Central Sensitisation, and understand what that means, then there are physiotherapy treatment techniques that a patient can utilise. In some patients, there may also be a role for a psychologist to work together with the patient, the physiotherapist and the GP to resolve the pain experience, or at the very least, learn how to manage the pain.
Post by Sam Donaldson (M.PhtySt, BAppSci(HMS), Physiotherapist APAM SMAM)
Now that the Rio Olympic Games has concluded (and the Paralympics can have its time!), it seemed like a good chance to post some information on recovery from competition.
To maximise what you can achieve out of your body in whatever event takes your fancy, it is imperative that you a) stay healthy, b) stay injury free, and c) can perform at a high level throughout your training program.
It is well established that to maximise your training benefits and therefore perform at your best, you will benefit from staying injury free (1,2). To achieve this, it is important you are adequately recovered for your next training, match or event (3).
So, what are the options for recovery?
- Appropriate nutrition
- Active recovery
- Cold water immersion
- Contrast bathing/ showers
All of these modalities for recovery are effective, but it might be useful to consider what you are recovering from, what the next session involves and when the next session is.
Nutrition is vital for restoring the energy used during training or competition, replenishing the H2O lost and the quantity, quality and timing of this can all be considered. This is outside the scope of physiotherapy and therefore outside the scope of this blog post, but there are some great resources out there:
- (American Dietitians Position Statement) http://www.medscape.com/viewarticle/717046?src=rss
Active and Passive recovery:
Considering active or passive recovery options, this usually involves a significantly reduced level of similar aerobic activity (jog/ walk for runners or swim for swimmers) as well as dynamic stretches or the passive alternative might include massage therapy or light stretching. If we consider a single day competition with multiple events, it might be more beneficial to consider the passive approaches (4). Repeated high intensity running to exhaustion efforts with short recovery times remained at higher intensity and lasted longer when the participants performed passive recovery rather than the active recovery group (4). This suggests that when both aerobic and anaerobic energy systems are required, a passive approach might be warranted. However, when considering power output in a bicycle study, the active recovery group showed significantly better retention of power on repeated efforts (5). This involved only 30 second rest intervals, suggesting that by maintaining a slightly higher heart rate (and blood flow to the working muscle), the anaerobic power was maintained (5).
Cold water immersion versus contrast bathing may come down to personal preference. Subjecting the body to water immersion after exercise has physiological effects, primarily:
- Reduction in muscle oedema
- Improved flow of blood around the body
- Delivery of nutrients to recovering regions
- Removal of by-products such as lactate (5).
Psychologically, there also seem to be benefits, with athletes reporting improved recovery, improved feelings of freshness and reduced muscle soreness when they have performed a water immersive therapy (5). It is still an area of debate and ongoing research, but the body of evidence suggests:
- Cold Water Immersion: 5-15 minutes of immersion in 10-15° Celcius (6),
- Contrast therapy: <20° x 2-5 minutes followed by >36° for 2-3 minutes repeated. Total up to 15 minutes and finish on cold water rather than hot (6).
This is usually done in the first two hours after exercise, but can still be useful up to 24 hours after, particularly if the session was especially exhausting.
Compression garments have shown sound improvements in similar measures of physiological recovery including power output (cycling), improved post-exercise lactate elimination and reduced post-exercise muscle soreness (7). These are often worn after exercise/ competition and can be work overnight if it doesn’t disturb your sleep!
Finally, sleeping is one of the best forms of recovery (in our opinion). Players that suffered with reduced sleep in football reported very poor recovery when asked subjectively (8). It’s reported that sleep plays a vital role in restoring normal cellular function, metabolism of by-products from exercise (e.g. lactate), as well as restoring nerve function both in the limbs and in the brain (9). Everyone varies in their sleep habits, so ensuring you get a typical, good night’s sleep will ensure you have done what you can to recover the mind and the body.
- Hägglund M, Waldén M, Magnusson H, Kristenson K, Bengtsson H, Ekstrand J. Injuries affect team performance negatively in professional football: an 11-year follow-up of the UEFA Champions League injury study. British journal of sports medicine. 2013 Aug 1;47(12):738-42.
- Gabbett TJ. The training—injury prevention paradox: should athletes be training smarter and harder?. British journal of sports medicine. 2016 Mar 1;50(5):273-80.
- Laux P, Krumm B, Diers M, Flor H. Recovery–stress balance and injury risk in professional football players: a prospective study. Journal of sports sciences. 2015 Dec 14;33(20):2140-8.
- Dupont G, Blondel N, Berthoin S. Performance for short intermittent runs: active recovery vs. passive recovery. European journal of applied physiology. 2003 Aug 1;89(6):548-54.
- Wilcock IM, Cronin JB, Hing WA. Physiological response to water immersion. Sports medicine. 2006 Sep 1;36(9):747-65.
- Versey NG, Halson SL, Dawson BT. Water immersion recovery for athletes: effect on exercise performance and practical recommendations. Sports medicine. 2013 Nov 1;43(11):1101-30.
- Engel F, Stockinger C, Woll A, Sperlich B. Effects of Compression Garments on Performance and Recovery in Endurance Athletes. InCompression Garments in Sports: Athletic Performance and Recovery 2016 (pp. 33-61). Springer International Publishing.
- Fullagar HH, Skorski S, Duffield R, Julian R, Bartlett J, Meyer T. Impaired sleep and recovery after night matches in elite football players. Journal of sports sciences. 2016 Jul 17;34(14):1333-9.
- Fullagar HH, Duffield R, Skorski S, Coutts AJ, Julian R, Meyer T. Sleep and recovery in team sport: current sleep-related issues facing professional team-sport athletes. IJSPP. 2015 Mar 10;10(8).
A concussion may occur when the head hits an object, or a moving object strikes the head. A concussion is a minor or less severe type of brain injury, which may also be called a traumatic brain injury. A concussion can affect how the brain works for a period of time.
Medical providers may describe a concussion as a “mild” brain injury because concussions are usually not life-threatening. Even so, the effects of a concussion can be serious. It is important to know that if somebody shows or reports one or more of the following signs and symptoms listed below, or simply say they just “don’t feel right” after a bump, blow, or jolt to the head or body, they may have a concussion or more serious brain injury and must be removed from play until they are cleared by a medical professional.
Signs and symptoms generally show up soon after the injury. However, you may not know how serious the injury is at first and some symptoms may not show up for hours or days. The injured person should be monitored especially in the early stages of a concussion, and the signs of concussion should continue to be checked for a few days after the injury. If the concussion signs or symptoms get worse, you should seek medical attention immediately.
The pocket Concussion Recognition Tool shown below is a great printable sheet that coaches, sports trainers and parents could have on the sideline to use as a non-medical professional to determine whether the athlete has a concussion in the absence of a trained medical professional being available for assessment.
Available free online: http://bjsm.bmj.com/content/47/5/267.full.pdf
The brain needs time to heal and rest post-concussion, and those with symptoms or who return to play too soon—while the brain is still healing—have a greater chance of getting another concussion. A repeat concussion that occurs while the brain is still healing from the first injury can be very serious and in the worst case scenario could even be fatal.
Determining when the player has recovered so that they can safely return to competition
The decision regarding the timing of return to play following a concussive injury is a difficult one to make. Expert consensus guidelines recommend that players should not be allowed to return to competition until they have recovered completely from their concussive injury. Currently, however, there is no single gold standard measure of brain disturbance and recovery following concussion. Instead, clinicians must rely on indirect measures to inform clinical judgment. In practical terms this involves a comprehensive clinical approach, including:
- A period of cognitive and physical rest to facilitate recovery
- Monitoring for recovery of post-concussion symptoms and signs.
- Neuropsychological testing to estimate recovery of cognitive function.
- Graduated return to activity with monitoring for recurrence of symptoms.
- A final medical clearance before resuming full contact training and/or playing.
Period of cognitive and physical rest to facilitate recovery
Early rest is important to allow recovery following a concussive injury. Physical activity, physiological stress (e.g. altitude and flying) and cognitive loads (e.g. school work, videogames and computers) can all worsen symptoms and possibly delay recovery following concussion. Individuals should be advised to rest from these activities in the early stages (initial 24 to 48 hours) after a concussive injury, particularly while symptomatic. Similarly, the use of alcohol, opiate analgesics, anti-inflammatory medication, sedatives or recreational drugs can exacerbate symptoms following head trauma, delay recovery or mask deterioration and should also be avoided. Specific advice should also be given on cessation of activities that place the individual at risk of further injury (e.g. driving, operating heavy machinery).
(McCrory et al., 2013)
Tests for Concussion & Brain Injury
A medical provider may do a scan of the injured players brain (such as a CT scan) to look for signs of a more serious brain injury. Other tests such as “neuropsychological” or “neurocognitive” tests may also be performed. These tests help assess your child or teen’s learning and memory skills, the ability to pay attention or concentrate, and how quickly he or she can think and solve problems. These tests can help the child’s medical provider or physiotherapist identify the effects of the concussion.
Baseline testing can be done pre-season to determine a level for re-evaluation if a concussive injury is suspected during the season, and this can be carried out through your RHP Physiotherapist in the form of a SCAT-3 test.
A concussion can be a scary injury, particularly for those who are monitoring the injured athlete or player and determining the best course of action. If in doubt, always get the person checked by a health professional as soon as possible. If there are any signs and symptoms of deterioration, loss of consciousness or any of the red flags above get the person to the Emergency Department/call 000 for assistance and management. It is also important to note that through the mechanism of injury to cause a concussion, signs of spinal injury must be monitored and if suspected do not move the injured player, follow first aid protocol, and call 000 immediately.
McCrory, P., Meeuwisse, W. H., Aubry, M., Cantu, B., Dvořák, J., Echemendia, R. J., . . . Turner, M. (2013). Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine, 47(5), 250-258. doi:10.1136/bjsports-2013-092313