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.
Rehabilitation after ACL reconstruction surgery.
The ACL (Anterior Cruciate Ligament) rehabilitation protocol I use to guide rehabilitation for my patients is a goal based progression. We can move through the ACL protocol at our own pace, and let the criteria govern how quickly we go, rather than a traditional pre-determined timeline. This is really helpful for setting goals and determining the appropriate exercises for each patient at each stage. Rehabilitation after ACL surgery must be individu alised and requires clinical reasoning that the experienced therapists at RHP Physiotherapy can provide.
Image from www.ihealthsphere.com.au
This simple and elegant protocol was designed by Randall Cooper, a specialist sports physiotherapist from Melbourne, and is broken down into 5 phases. There is a list of goals and outcome measures that need to be satisfied at the end of each phase to move onto the next one. The five phases are:
• Phase 1: Recovery from surgery
• Phase 2: Strength & neuromuscular control
• Phase 3: Running, agility, and landings
• Phase 4: Return to sport
• Phase 5: Prevention of re-injury
Interestingly the rate of return to same level sport after ACL reconstruction may not be as high as you would think, and certainly not what we see reported in the media of quick returns to high level sport by high level athletes. A recent Australian study revealed that of 314 participants, less than 50% of the study sample had returned to playing sport at their preinjury level or returned to participating in competitive sport when surveyed at 2 to 7 years after ACL reconstruction surgery. Return to the preinjury level of sport at 12 months after surgery was not predictive of participation at the preinjury level in the medium term, which suggests that people who return to sport within 12 months may not maintain their sports participation. At follow-up, 45% were playing sport at their preinjury level and 29% were playing competitive sport. Ninety-three percent of the study sample had attempted sport at some time after their ACL reconstruction surgery. Long term effects after reconstruction are being investigated by researchers at UQ now with Steph Filbay and her colleagues.
So, taking your time, progressing at your own pace, and being mentally and physically prepared for return to sport could maximise our success of returning to sport.
Here are a few tips on how to progress through an ACL rehab protocol with minimal problems:
* Get the knee straight early (within the first 2-3 weeks), and keep it straight. Flexion (bending) can progress gradually. If you have had meniscus repair, this may happen after you are allowed out of a brace as recommended by your surgeon.
* Use knee pain and knee swelling as a guide. Listen to your knee. If either or both are increasing, the knee isn’t tolerating what you’re doing to it.
* Build high impact forces gradually. The articular structures in the knee joint will take time to adapt to a resumption of running, jumping and landing.
* Complete your ACL rehabilitation. Once people are back running with no knee pain it’s easy to think that it’s all done. But the last 1/3 of the protocol is the most important – to help reduce the chance of re-injury, increase the chance of a successful return to sport, and possibly to reduce the likelihood of osteoarthritis down the track.
* Technique is everything. Compensation patterns develop after an ACL tear, so focusing on correct muscle and movement/ biomechanical patterns is paramount. A copy of the complete ACL Rehabiltation Guide from Randall Cooper can be downloaded from the Thermoskin website.
A copy of the complete ACL Rehabiltation Guide from Randall Cooper can be downloaded from the Thermoskin website.
In the next of my blogs I will explain how we use the Melbourne Return To Sports Score at the end of Phase 4 to determine readiness for return to training and sport.
Want to know the greatest exercise in the whole world?
It’s a stretch that will change your life – and you just have to lie down to do it!!
Spinal mobility/flexibility is vital for pain-free movement. Our thoracic spine (the part between your shoulder blades and the area that all of your ribs attach on to) is especially important. The thoracic spine has a tendency to get stiff and bend forward. Gravity is a big factor in this, as is the amount of sitting we do and the fact that most of the things we do are in front of us.
· Neck pain
· Low back pain
· Shoulder pain and restriction (especially in over head athletes: throwers, swimmers, racquet sports)
· Thoracic rib or chest pain
· and even difficultly with breathing (if the ribs are not able to move easily)
HOW CAN WE STOP THIS HAPPENING?
Try this incredibly simple but amazing powerful and effective stretch to improve your thoracic spine mobility – You will need a pillow and a bath towel (not a bath sheet or beach towel as they are too big!)
1. Fold dry towel in ½ lengthwise and roll it up
2. Place it on the floor (or your bed if you can’t get down and lie down on the floor) on your back on top of the towel. The towel needs torun along the length of your spine – the top of it at the base of your neck and the rest running down between your shoulder blades towards your lower back.
3. Have a pillow to support your neck (or 2 pillows if you need).
4. Bend your knees up to protect your lower spine.
5. Relax and breathe!!! Stay in this position for 2-3 minutes letting gravity and your body weight work for you to gently stretch and straighten (extend) your thoracic spine.
6. For an extra beautiful stretch across the front of your chest, straighten your arms out to the side to make a “T” shape. N.B. Importantly this must FEEL GOOD. If it dosn’t – STOP!!
It should feel really nice – NO PAIN. You may experience some clicks and cracks in your spine while doing this. If so – don’t worry – it is quite normal as long as it is not painful.
Relax and breathe easily for 2-3 minutes. When it is time to get up – roll off the towel onto your side and then get up.
If we could all do this stretch daily we would have so many less problems.
Try it for yourself and see – you could be amazed!!
And to answer the common questions:
· You can use a pool noodle or foam roller (it’s just not as comfortable for some people)
· You can also do this with the towel/roller going across your back to target a specific area if directed.
· It is useful for most people – not all. Modifications can be made for some people if necessary.
Remember – it should feel really good! If it doesn’t – STOP!
and keep calm and call RHP Physiotherapy!
Lumbar Stress Fracture (Spondylolysis) in Teenagers
and Competitive Swimmers
A lumbar stress fracture or ‘Spondylolysis’ is a non-displaced fracture of a part of the lumbar vertebrae called the pars interarticularis.
Spondylolysis is a common and costly cause of back pain in competitive swimmers as well as a range of other adolescent sports people (e.g. gymnasts, divers).
Spondylolysis most commonly occurs at the L5 vertebrae (90-95%), and is caused by repeated or excessive trunk extension (backward arching), which places stress on this area of the vertebrae.
The stress fracture can occur on either the right or left side of the vertebrae, and in some cases, both sides!
Most Spondylolysis heal with conservative management. Around 25% suffer non-union. In these cases, the fracture becomes thickened with fibrous connective tissue rather than bone.
Spondylolysis can be classified based on its causative mechanism:
· Dysplasic/Congenital (born with it)
· Isthmic (sport related, due to repetitive/excessive extension stress)
· Degenerative (related to ageing and degeneration)
· Traumatic (result of an acute hyperextension injury)
About 50% of Spondylolysis progress to a Spondylolisthesis (a slip forward of one vertebrae on another).
This is more common in those with a bilateral Spondylolysis (i.e. a stress fracture on both the right and left side of the vertebrae).
Spondylolisthesis are graded on a scale of I-IV based on how far the top vertebrae has slipped forward on the bottom vertebrae. Grade I and II are usually conservatively managed, while GIII and IV may require stabilization surgery.
Diagnosis of spondylolysis is made through an assessment of subjective pain history and physical examination by a Physiotherapist or Sports Physician, as well as radiological investigation to identify the fracture line. XRAY may be able to identify the fracture in some cases, although SPECT bone scan and CT scan are more sensitive. MRI is not as sensitive, but might be prescribed as an alternative to bone scan and CT in adolescents, to avoid exposure of the immature skeleton to radiation.
With regard to competitive swimming, Butterfly and Breaststroke swimmers are most at risk, due to the repetitive lumbar extension movement that occurs during these strokes, particularly on the breathing stroke:
A key technique factor is related to minimizing the amount of vertical (up/down) movement throughout the stroke, particularly on the breathing strokes. Not only does this reduce drag and improve efficiency, it also reduces lumbar extension stress:
Image: Butterfly breathing high breath position vs. low breath position
Swimming is a total body exercise, so achieving a good body position, and avoiding excessive lumbar extension in swimming, requires adequate mobility and postural strength throughout the entire body-line:
Tight shoulders can result in excessive lumbar extension in the swimmers effort to achieve a streamline position:
Similarly, tight hip flexors can result in increased lumbar extension in a swimming position. Thirdly, weak trunk musculature can cause the abdomen to ‘sag’ in the water, resulting in increased lumbar extension:
It is important to maintain balanced mobility throughout the thoracolumbar and lumbopelvic spine and hip in order to distribute extension load throughout the kinetic chain. “Hinging” at one spinal segment can focus stress on one vertebral level:
· Lumbar spine bony abnormalities (e.g. pseudoarthrosis or sacralised L5)
· Male gender (2:1)
· Early childhood (learning to stand and walk)
· Adolescence (highly active people playing sport with skeletal immaturity)
· Tight hip flexor and/or hamstrings muscles
· Weak trunk and gluteal musculature
· Poor postures and gait patterns (hyperlordotic postures)
Conservative management of spondylolysis is successful in 85% of adolescents that present with an acute case, however, there is a high potential for recurrence if the aforementioned risk factors are not addressed.
Conservative management pathways vary on a case by case basis, but generally consist of:
· Relative rest from aggravating activities for 6-12 weeks to allow bony healing
· A Physiotherapy guided core strengthening, neuromuscular control and range of motion and flexibility exercise program. Pilates is often useful during this rehabilitation.
· Symptom free stationary cycling for aerobic maintenance
· Pain management through Physiotherapy and the use of pharmacological analgesia, which may include non-steroidal anti-inflammatories
· Progressive, symptom limited return to sport including analysis and correction of sport specific technique errors related to lumbar extension stress
Some Physiotherapists or Sports Physicians may also recommend using a semi-rigid trunk brace during the rest and rehabilitation period in order to help control pain symptoms. These are prescribed on a case-by-case basis and are not always necessary.
Spondylolysis is the most common cause of low back pain in adolescent athletes.
If you have low back pain, visit RHP Physiotherapy for an assessment and up to date, evidence based treatment. Call us on 07 3856 5566 for an appointment
Where’s your head at?
Headaches, Migraines and Physiotherapy.
Many of us experience headaches during our lifetime, it is one of the most common ailments that we as a society face. Headaches can range from being just nagging and frustrating, to debilitating – resulting in time off study, work, and affecting the things we love to do. Sometimes there are simple causes, perhaps we should have gone to bed a little earlier, drank more water, or perhaps had a little less red wine. There could seem to be no cause at all, or perhaps more serious causes such as a head injury or a motor vehicle accident. There are many different types of headaches and Physiotherapists play an important role in the treatment and management of this condition.
There are many different classifications (hundreds!) of headaches, however the most common types are:
There are distinct characteristics of how these headaches present, and by having a detailed examination at the clinic we can establish how best to treat your symptoms. Also, importantly we can assess you to ensure that you aren’t one of the unlucky few whose headache could be a warning sign of something more serious going on – in which case we would refer you on.
So what would a Physiotherapist do for my headache?
We have a lot of different Physio’s at RHP all with different backgrounds, experience and knowledge – however as a group we are very interested in the body as a whole and how simple things like small changes in the way you may be walking, or sitting can affect your body. To successfully treat your headache, we would narrow down what the cause of your headache is by looking at the “whole picture”. We know that the neck is a major cause of headaches and migraines, so we would spend time looking at the muscles and joints in your neck. But in order to be successful at stopping the frequency and intensity of your headaches, we would need to gain an appreciation for WHY we are seeing changes in these structures and so may treat other areas as well.
The neck plays a very important role in the production of headaches and migraines. Stress, postural overload, and trauma can lead to the build-up of tension or overuse of muscles in the neck which can then cause referral of pain into the head, face and down the neck. In the top of the neck, are three very important joints C1, C2 & C3. These joints are closely related to your brain stem which can be likened to a central computer hub – there is a lot of information coming in and out of this segment. If irritated, these neck structures feed pain signals into upper neck nerves, and from there the irritation feeds into the brainstem, which then transmits those signals up into the head and face – activating this pathway can also result in the feelings of nausea, dizziness and a fullness in the ears.
One technique that I personally have found very effective in the treatment of headaches and migraines is the application of the Dean Watson method, a physiotherapist who has decades of specialisation in this area and who has found through his own clinical experience and research that the alignment of the top three joints in the neck directly relate to headaches and migraines. Some of the treatment techniques involve releasing the muscles in your neck, and looking at the alignment of these vertebrae and using techniques to firstly bring on your symptoms (to confirm where your symptoms are coming from!) and holding this technique while your symptoms fade away. By doing this, we can alter the sensitivity of that “central hub” of information in your brain stem and decrease your symptoms. Importantly, after your Physio session would be exercises to do at home to maintain good posture and form, as well as help to fix the causes of the headache whether that be tight muscles, weak muscles, poor posture or alignment.
Some simple tips for those headache sufferers is to firstly look at your posture at work (or at home), often changing your desk set-up can reduce the load on those neck muscles and joints. Drink plenty of water, try to fit in some gentle exercise into your day, have a look at your diet and cut out anything that may be a trigger – that 4th coffee, that sugary treat for instance. And to come in and get assessed as you may be amazed at how effective Physiotherapy can be for your headaches, even if you are a long-term sufferer. This can be a debilitating condition, and we at RHP Physiotherapy are dedicated to giving you the best quality of care to get you to function the best that you can, as pain-free as possible.
Sixty percent of all injuries in netball were knee and lower leg injuries in a recent report published by the Australian Institute of Health and Welfare in December 2014. Most of these injuries occur on landing and changing direction, often in a non-contact situation.
The anterior cruciate ligament (ACL) is commonly injured, representing approximately 25% of serious injuries annually reported (Netball Australia National Insurance Data). A study of ACL injuries in Australia published in 2011 found netballers were not far behind the football codes when it comes to knee surgery, needing 1085 ACL reconstructions each year, compared with 1162 for those playing AFL. Rehabilitation and recovery from surgery for ACL injury often takes 9-18 months. For a long time we have known that prevention is better than cure, but the search for the holy grail of injury prevention has been, and continues to be, extremely challenging.
As a result of a massive project, Netball Australia has recently released their KNEE program. KNEE stands for Knee injury prevention for Netballers to Enhance performance and Extend play.
The KNEE Program is an on court warm up program performed before training and matches and is designed to enhance movement efficiency and prevent injury. It targets three specific groups of players – junior, recreational and elite level athletes with different exercises tailored to match the predicted capabilities of each group, and it has been designed to educate athletes, coaches and support staff.
The website at http://knee.netball.com.au has the entire programs, information for parents, coaches and players, and even videos of the drills and exercises.
The programs are similar to the PEP (http://smsmf.org/smsf-programs/pep-program), and the FMARC/FIFA 11+ (http://f-marc.com/11plus/home/programs) that have well established research data in support on injury prevention in football (soccer). Teams that performed the “FIFA 11+ ” at least twice a week had 30-50% fewer injured players. The Netball Australia KNEE program is the first of its kind for one of Australia’s most commonly played sports.
Congratulations to Alanna Antcliff (sports physio), and the sports medicine and high performance teams at Netball Australia. RHP Physiotherapy staff continue to work with Netball Australia and other ANZ championship teams’ sports medicine staff in the analysis of movement patterns; athlete assessment and screening; injury statistics and athlete monitoring; and management of serious injuries to better our understanding of how to help netball athletes.