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Gut Check on holistic treatment of Parkinson’s

by | Jul 4, 2022 | Health Tips

Summarized by Mark Boyland PT,DPT, CSCS 

This was an interesting perspective paper due to the implications it has on how we can potentially test for Parkinson’s earlier and opens up avenues for treatment methods in a holistic style incorporating diet and nutrition in addition to exercise and pharmaceuticals.  While this perspective primarily focuses on Parkinson’s Disease, the paper also mentions potential effects on other conditions including Alzheimer’s and Huntington’s.

Parkinson’s is the second most common neurodegenerative disorder.  It has been primarily thought to be a brain disorder.  However there have been suggestions that changes in the gut microbiome, gut dysbiosis, could be linked to Parkinson’s.  Common symptoms of gut microbiome disruptions include constipation and increased inflammation.  Neurodegenerative diseases such as Alzheimer’s, Huntington’s, and Parkinson’s gut dysbiosis has been linked to cognitive impairments/reduced performance and motor dysfunction. Motor dysfunction includes postural instability and gait impairments. The authors indicate that dysbiosis can be improved with exercise, which calls to question how? 

First, we must understand how dysbiosis can affect the brain.  The gut biome regulates immune function, signaling of neurotransmitters including dopamine (over 50% of dopamine production comes from the gut), and metabolism support.  If there is disruption in our gut (dysbiosis) the impacts include increased inflammation, decreased neurotransmitter signaling, and deregulates metabolic function.  This perspective paper suggests that Parkinson’s can begin at the gut level and that as the condition progresses it impacts the motor system progressively.

As mentioned previously, exercise can restore the gut microbiome.  In those without Parkson’s having higher exercise capacity (aerobic/muscular strength) has been associated with higher bacterial diversity and reduced gut inflammation.  Restoration of the gut microbiome comes with both aerobic and resistance based exercise.  There are some differences in the benefits provided by each exercise modality however resistance exercise has been less studied at this point. 

Exercise to promote physical capacity may not be the sole factor for improving patient outcomes however.  For those with Parkinson’s exercise is now integral to their care but could be related to learning new skills which helps to keep the brain plastic (neuroplasticity). Additionally, as we begin to exercise more we also tend to eat a greater variety of healthy foods which could promote holistic changes as well. 

The gut and its bacteria are the recent quick fix hot topic but may have implications for our future in prevention and care of neurodegenerative conditions and maybe more.  Further research and study is required to establish a better understanding of the gut biome and it’s relation to our health at this time. Fortunately, improving gut health can be as simple as completing regular exercise and meeting the daily activity recommendations of the AHA as opposed to taking an unknown pill or supplement.  Eat well, stay active, be well

Direct link to article: https://doi.org/10.1093/ptj/pzac022

2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels

by | Jun 27, 2022 | Health Tips

Article Reviewed by: Evan Peterson PT, DPT

“Return to sport” (RTS) has been a topic of discussion throughout the physical therapy community and has been researched for a variety of sports related injuries. One of the most common injuries looked at is ACL reconstruction or other lower extremity injuries. Not as widely discussed in return to sport is for athletes with shoulder injuries. In response to minimal high-quality evidence or guidelines to direct the return to sport decision making process, The Athlete Shoulder Consensus Group convened. Their goal was to create guidelines for clinicians, athletes, and coaches in order to provide the best quality care following shoulder injury. This particular statement was ascertained through the use of several rounds of questionnaires to obtain a consensus for rehabilitation in athletes. Following these surveys, the group had an in person discussion to solidify the results of the questionnaires. The consensus that was established is categorized into 4 main points. 1) Managing injury risk 2) Managing and progressing load 3) Shoulder injury rehabilitation and 4) evidence to support RTS decisions.

Managing Injury Risk

One of the first ideas brought up in managing risk is to understand the risk factors and predispositions athletes my have for each sport, as each sport involves different types of shoulder mechanics. Some risk factors have been pulled out that encompass many shoulder related sports include: loss of ROM, strength imbalances in rotational planes, change in load, player positions, level of sport (i.e. amateur or professional), previous history of shoulder injury, and psychosocial aspects. Attempting to screen athletes to prevent injury has not shown good evidence; however, it may be important for the RTS decision making process.

The consensus agreed that injury risk can be managed with both primary and secondary prevention programs. Primary programs should be initiated at young ages, particularly in overhead athletes, to allow decreased injury rates and increase the likelihood of adhering to healthy shoulder programs. It is recommended that secondary programs begin soon after injury. The article discusses general principles for training, including sport specific exercise, multiple joint exercises, emphasis on team training, and programs that take no more than 15 minutes at a time. They suggest these programs should be done at a minimum of twice per week to encourage adherence and self-efficacy.

Managing Shoulder Specific Loads in Athletes

Two types of load exist in the shoulder athlete. There is the external load such as a swimming pool’s resistance or the number of pitches in a game. Then there is the internal load, which is the physiological forces placed on the shoulder. It has been difficult to determine which of these factors is most important when managing load and currently there is no measure in order to determine the internal load. External load is much easier to measure (for example, number of pitches thrown); however, in games such as handball it is hard to have a “pitch count” due to the more chaotic nature of the game. At the consensus meeting, it was proposed to utilize a rating of perceived exertion scale to measure the internal load the shoulder. A combination of perceived exertion of the shoulder and overall fatigue of the body are good indicators to help assess a patient’s overall load. One study supported the idea that decreased external shoulder rotation strength or scapular dyskinesis is an indicator of decreased tolerance for load during sport.

Key Principles for Quality Rehab After Shoulder Injury in Athletes

Experts at the consensus meeting agreed that rehabilitation programs should emphasis on:

  • Improving sport specific mechanics
  • Challenging the patient in rehab at the limit of their capacity
  • Building resilience in patients’ ability to load at the physiological and physiological level
  • Multi-disciplinary decision making

The Key principles proposed are as follows:

  • Let Irritability Guide Rehab Process
  • Address Glenohumeral Range of Motion Deficits Using Active Therapy
  • Address the Scapula but Do Not Screen for Dyskinesis
  • Injury Tolerated Exercises
  • Introduce Plyometric Activities Early
  • Retrain the Brain/ Expose Shoulder to Fearful Positions Safely
  • Sport Specific Tasks
  • The consensus suggested objective repeated measures on a weekly basis to assess response to rehab

Return to Sport

The authors suggest that “Return to Sport” is a continuum consisting of three aspects: Return to participation, Return to sport, and Return to performance.

  • Return to Participation: the athlete is continuing rehabilitation, but participating in modified training in their sport at a level lower than their usual; they are not physically or psychologically ready for regular sport activities.
  • Return to Sport: the athlete can return to their sport but is not performing at an optimal level or their desired level
  • Return to Performance: the athlete is performing at their usual level without any restrictions

6 Domains to Consider when Returning to Sport

  • Pain: pain may be present when returning to participation but should not be present in return to performance
  • Active Shoulder Joint ROM: this is a sport specific criterion and should be evaluated as such. For example, pitchers require much more rotational ROM as compared to a collision athlete (i.e. football)
  • Strength, Power, Endurance: the importance of each is sport specific; however, the importance of overall strength in internal and external rotation as well as shoulder stability is crucial for return to sport
  • Kinetic Chain: be able to identify issues outside of the shoulder including the elbow, wrist, and thoracic spine
  • Psychological Readiness: athletes must be able to demonstrate confidence in muscle testing or activities that cause collisions before returning to participation and sport
  • Sport Specific: if possible compare to norms of other athletes in sport to determine readiness for play

Summary

One of the major takeaways from this consensus is that there is room for improvement in how we measure athlete performance in rehab and how to prevent injuries from happening/reoccurring. This consensus did however highlight the importance of multidisciplinary and all-encompassing approach for an athlete to return to their sport following injury.

Here at Physical Therapy First, therapists are trained to assess for shoulder abnormalities and detect faulty mechanics in those who have shoulder pain or sport injury. We also look to work with the patient and all involved with their care to prevent future injuries while returning to a high level of performance.

Reference:

Schwank A, Blazey P, Asker M, Møller M, Hägglund M, Gard S, Skazalski C, Haugsbø Andersson S, Horsley I, Whiteley R, Cools AM, Bizzini M, Ardern CL. 2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels. J Orthop Sports Phys Ther. 2022 Jan;52(1):11-28. doi: 10.2519/jospt.2022.10952. PMID: 34972489

Aerobic and Resistance Training for Individuals with Spinal Cord Injuries: a summary

by | Apr 25, 2022 | Health Tips

by Mark Boyland, PT, DPT, CSCS

The joy of training allows for many populations of people to be able to exercise and as trainers and strength coaches we need to be aware of individual differences between some of these unique populations. There are some considerations to make prior to training a client with a spinal cord injury however they fall into the same targets set by the ACSM and AHA for exercise targets: 75 minutes of vigorous aerobic activity or 150 minutes of moderate aerobic activity per week or some combination of these with the exercise sessions spread throughout the week. Strength training and stretching should also be performed multiple days per week focusing on total body strengthening/stretching. While there are more significant considerations to be made in regards to creating a fitness plan for your client with a spinal cord injury these plans should be specific to their current presentation and their goals.

At this time there are about 300,000 people in the United States with a spinal cord injury, or approximately 10% of the current US population, meaning there is a good chance for a potential client with a spinal cord injury could come through your door trying to maintain or improve their health and wellness. Considerations for these clients include: partial/incomplete injury, level of the client’s injury, paraplegia/tetraplegia, overuse injuries, autonomic dysreflexia, and current medications. Considerations for you and your gym are temperature/humidity control and accessibility in regards to parking, accessing the gym from the outside, as well as being able to navigate between equipment at your gym while using a wheelchair or other assistive device.

Regarding your client’s specific considerations in regards to their injury: a complete spinal cord injury is one that results in a total loss of sensation and motor activity including the lowest sacral nerve levels. An incomplete spinal cord injury is where there is still partial sensation or motor activity below the level of injury. Most spinal cord injuries results in tetraplegia with 59.5% of spinal cord injuries being considered tetraplegic and only about 40% of injuries being considered paraplegic. About two-thirds of spinal cord injuries are a result of vehicular accidents or falls. Another consideration is the level of the patient’s injury and their ASIA score. The ASIA score describes the amount of sensation/motor function available to the patient based on their injury level. There are online resources to explore each level and what motions/sensations are preserved based on the patient’s level of injury. An additional consideration is your client’s medications. Your client may be on several medications that are directly related to their injury and other non spinal cord injury related conditions so be sure to review their medications, the intended effects, side effects, and red flags prior to beginning working with your client. While this article and blog are meant to cover the basics of working with clients with spinal cord injuries it cannot be an exhaustive review especially when considering medications. Commonly spinal cord injury patients may be placed on medication for pain management, tricyclic drugs, antispasmodics, bladder control, and autonomic dysreflexia. Common side effects of medications across these classes include but not limited to: drowsiness, dizziness, fatigue, sedation, and weakness which could lead to generally reduced exercise tolerance and balance.

Client and gym/training center considerations include being aware that due to the loss of neurological control beyond the level of injury there can be negative reactions that your client may experience while training with you. These include your client overheating due to a loss of the ability to sweat below the level of their injury so a gym that is excessively hot/humid can cause a negative reaction. Make sure to monitor your client’s status while training with them to avoid overheating and monitor the ambient temperature/humidity of your training facility. Another serious reaction is Autonomic Dysreflexia. Autonomic Dysreflexia is a reaction to a noxious stimulus which can result in: abnormal systolic blood pressure elevation of greater than 20 mmHg, pounding headache, flushing above the level of the injury, increased heart rate, and can also be asymptomatic. Autonomic Dysreflexia can also be asymptomatic and can become life threatening quickly. Common causes for Autonomic Dysreflexia include muscle spasms, pressure sores, bladder/bowel distension, lower extremity injuries (broken bones). One of the most common causes is due to a kinked catheter which results in an inability to empty the bladder resulting in a back up of urine in the bladder.

Having gone past the major considerations clients with spinal cord injuries coming to you are similar to clients without a spinal cord injury. Their training to should be specific to their needs/goals and with what they are capable of doing. Initially clients with spinal cord injuries may only be able to tolerate 1 or 2 sessions of aerobic/resistance training per week using an arm crank ergometer, Nustep, or wheel chair treadmill for aerobic conditioning. For a beginner resistance training program the use of household items such as can is advised, however you can also use dumbbells, elastic bands/tubes, wrist weights. As your client progresses they can advance their resistance training with use of machine-based resistance training, dumbbells, and medicine balls. You can progress your clients to multiple training sessions per week progressively increasing the duration/intensity to match the recommendations by the ACSM/AHA however you must consider that your clients may be reliant on their upper extremities for most of their daily activities and training. This increased use of their upper extremities to manage their daily life can result in overuse injuries so exercise programming to avoid overuse injuries is important.

Training clients with a spinal cord injury can be initially intimidating but so are most things that you are not familiar with. You can familiarize yourself with the levels of impairment present depending on the level of the injury, the ASIA scale, and reach out to your client’s Doctor’s and Therapists to form a relationship with them early on to help your client as a team. Keep your clients safe, don’t be afraid to ask questions, and always look to learn more.

For more details you can read the full article at the NSCA
Aerobic and Resistance Training for Individuals with Spinal Cord Injuries
Joshua M Miller, DHSc, CSCS, ACSM-EP
Department of Kinesiology and Nutrition, University of Illinois-Chicago, Chicago, Illinois
1. Following a spinal cord injury, if there is some feeling or activity lower than the injury site, this is called a(n) ____________ injury.
b. Incomplete

2. How many people in the United States are likely living with a spinal cord injury at this moment?
c. Nearly 300,000

3. Which of the following is the most accurate representation of the amount of spinal cord injuries that result in paralysis of the lower body?
b. Less than 1/2

4. Which of the following recommendations for training is true for both paraplegics and tetraplegics?
c. 75 minutes per week of vigorous aerobic activity

5. Thermoregulation is a major environmental concern in those with a spinal cord injury due to _______________.
c. The inability to sweat below the level of the injury

6. Which of the following would be considered an advanced resistance training method for those with a spinal cord injury?
b. Dumbbells and resistance machines

7. Acute changes in systolic blood pressure during exercise can be an issue in those with spinal cord injuries and it is primarily due to _____________.
a. The lack of communication between the nerves and brain below the injury site

8. A common site of overuse injury related to locomotion in those with spinal cord injuries is __________.
c. The shoulder

9. A frequent side effect of medication on exercise in clients with spinal cord injuries is ____________.
b. A reduction in exercise capacity

10. A frequent potential adverse effect of pain and antispasmodic medication is __________.
a. Dizziness

Do Massage Guns Really Work?

by | Mar 8, 2022 | Health Tips

by  Sam Yim SPT

Introduction

Percussion massage guns have grown in popularity within the past couple years and sponsor many pro athletes such as Patrick Mahomes and Russell Westbrook. The price point ranges from $50 for lower end models to upwards of $700 for the most expensive models. The question is, are massage guns really worth the investment? Massage gun companies state that their devices can relieve pain, increase range of motion, and decrease symptoms of soreness or stiffness. The companies also market their massage guns as ways to improve recovery time post workout and to decrease warm-up times so individuals can start their workouts faster. We’ll dive in and see if these claims are supported by the current literature.

Range of Motion and Strength

In an article published in 2020, researchers analyzed whether massage guns could actually improve range of motion as they advertise. This study took 16 adult males and split them into two groups. One group received a 10-minute warm-up on the bike with 5 minutes of treatment using a massage gun. The control group received just a 10-minute warm-up on the bike with no massage gun treatment. The treatment area of focus were the plantar flexors, which are a group of muscles in the calf that aid with pushing off the ground. The results demonstrated a 5.4 degree increase in plantar flexion with the massage gun group and no increase in range of motion in the control group.

The researchers of the above study found no difference in strength between the massage gun group and the control group. These results are supported by a study done in 2019 that delved into the effects of massage guns on vertical jump height. The researchers found that use of a massage gun did not improve physical performance measured by vertical jump height compared to general rest.

Recovery

The claim to fame of massage guns is their ability to decrease soreness, pain, and to facilitate recovery. Researchers put this idea to the test and assessed whether or not massage guns were just as good or better than traditional massage therapy in preventing delayed onset muscle soreness (DOMS). The preliminary research identified that vibration therapy for 5 minutes displayed reduced DOMS equal to that of traditional massage therapy 24 hours, 48 hours, and 72 hours post exercise. Vibration therapy additionally resulted in a decreased accumulation of lactate 48 hours post exercise and reduced subjective pain levels.

Risks

There are some risks that one should consider before purchasing and using a massage gun. The main risks include causing increased soreness, bruising, and potential muscle damage. Recently there was a reported case where an individual utilized a massage gun post exercise and developed rhabdomyolysis, which is breakdown of muscle tissue. Rhabdomyolysis can be a potentially life-threatening condition if not treated appropriately. The individual in this case study did not participate in any overly strenuous exercise, just daily cycling and had no prior history of illness. The researchers attributed the cause of this case to be due to trauma from prolonged sessions of using the massage gun (greater than 10 minutes).

Conclusion

The current literature is not conclusive on whether or not massage guns provide the benefits that their companies say they do. Preliminary research shows that there could be some potential benefits to using massage guns such as improved range of motion, decreased subjective pain levels, and improved recovery time. However, all of the current research utilizes small sample sizes, young age groups, and minimal research is focused on the potential drawbacks of massage guns. The research also does not show the use of massage guns being any more effective compared to traditional massage techniques. Continued research with increased sample sizes are required to definitively determine the benefits, contraindications, and adverse risks associated with the use of massage guns. If you have a massage gun or are going to try one, start slowly and gradually increase the intensity and frequency of usage. If you notice abnormal aches or pain consult with your physical therapist or another medical professional.

 References

Konrad A, Glashüttner C, Reiner MM, Bernsteiner D, Tilp M. The Acute Effects of a Percussive Massage Treatment with a Hypervolt Device on Plantar Flexor Muscles’ Range of Motion and Performance. J Sports Sci Med. 2020;19(4):690-694. Published 2020 Nov 19.

Kujala R., Davis C., Young L. (2019) The effect of handheld percussion treatment on vertical jump height. International Journal of Exercise Science: Conference Proceedings 8(7). 75.

Imtiyaz S, Veqar Z, Shareef MY. To Compare the Effect of Vibration Therapy and Massage in Prevention of Delayed Onset Muscle Soreness (DOMS). Journal of Clinical and Diagnostic Research : JCDR. 2014 Jan;8(1):133-136. DOI: 10.7860/jcdr/2014/7294.3971.

Chen J, Zhang F, Chen H, Pan H. Rhabdomyolysis After the Use of Percussion Massage Gun: A Case Report. Phys Ther. 2021;101(1):pzaa199. doi:10.1093/ptj/pzaa199

Rehabilitation Guidelines for Meniscal Repair of Root and Complex Tears

by | Feb 22, 2022 | Health Tips

Article Review by Evan Peterson PT, DPT

Knee Structure

The knee joint is composed of several parts. It contains bone, ligament, tendon, joint capsule, and different types of cartilage. The knee contains 2 distinct cartilages: articular and meniscus. Articular cartilage is at the ends of bones which come together to form the joint. The job of the articular cartilage is to provide a smooth surface that allows for proper gliding on the joint surfaces against one another. The meniscus cartilage on the other hand is designed to help decrease the load placed through the knee joint itself. The meniscus is horse shoe shaped and is comprised of a medial and lateral end. Because the femur and the tibia are both rounded, the meniscus is needed in order to spread out contact forces. This allows for improved shock absorption and knee stability. The menisci are composed of an anterior and a posterior which are attached to the tibia by strong roots. The roots help to provide increased knee stability and decrease amount of tibial rotation. These functions are important to protect the articular cartilage.

Meniscal Tears

A meniscal tear can be either acute traumatic or degenerative. An acute traumatic tear typically occurs in the athletic population and is caused by knee twisting with a planted foot. Degenerative tears are more commonly in middle aged people both male and female. The symptoms of an acute tear are swelling, pain along the knee joint line, and locking or catching.

Root Tear Rehab Options for the Athlete

One option the athlete has is to attempt rehabilitation without surgery. Another option is for the surgeon to trim out a portion of the torn meniscus. The last option is for the surgeon to repair the meniscus. Whenever it is possible, the surgeon will prefer to repair the meniscal root of an athlete, which is based upon the desire to limit future knee arthritis. After meniscal surgery, it is recommended to attend physical therapy in order to address knee range of motion, strength, and neuromuscular knee control. The therapist can also assist in guiding the patient back to performing normal sport activities. After a meniscus root repair, there is a prolonged period of non-weightbearing and restricted range of motion to allow proper healing.

Phase I of Rehab: Surgery until 8 weeks

  • Typically begins 3-5 days after surgery
  • Precautions
    • Toe touch weight bearing with brace
    • Gradually unlock brace for 6 weeks; after 6 weeks no brace
  • Goal to restore range of motion from 0-90 degrees, decrease leg swelling, and restore control
  • Perform
    • Knee extension on bolster, prone hangs, quadricep sets, hamstring sets, straight leg raises, heel slides to 90 degrees
  • Progression to next phase
    • 8-10 weeks after surgery, pain free gait (no crutches), no swelling

Phase II of Rehab: 8 weeks post-surgery

  • Goals are to improve single leg control, normalize gait, and improve functional control
  • Precautions
    • No forced knee flexion past 60 degrees, no impact activities
  • Perform
    • Hip and core exercises, stationary bike tasks, and balance or proprioceptive drills
  • To Progress
    • Normal gait on all surfaces, functional tasks without unloading affected leg, and single limb stance greater than 15 seconds

Phase III of Rehab: Typically 12-16 weeks post-surgery

  • Goals are good control while performing sport and work specific movements with impact
  • Precautions
    • Avoid excessive post exercise swelling or posterior knee pain with flexion
  • Perform
    • Low velocity agility drills, closed chain progressive strengthening including unilateral tasks, begin low amplitude landing drills to prevent excess frontal plane trunk lean and reduce hip adduction during stance

Phase IV of Rehab: 20-24 weeks post-surgery

  • Goals
    • Normal multi planar motion performed at high velocities without compensation
    • Typical double leg landing mechanics
    • Demonstration of adherence and understanding of HEP
  • Perform
    • Progressive agility drills with increased velocity from the last phase
    • Perform higher amplitude landing drills both bilateral and unilateral
    • Reactive drills including cutting and pivoting
    • Sport and work specific proprioceptive/ balance exercises
    • Continue core and hip strengthening exercises.
    • Progressive running program
  • Returning to Sport/Work
    • The patient must be cleared by orthopedic surgeon as well as the therapist/athletic trainer.
    • The patient should be with a 15% deficit when performing all testing such as strength testing, hop tests, and force plate jumping.

Physical Therapy First

At Physical Therapy First, we have skilled therapists who are equipped to guide a patient through their recovery from a meniscal surgery. We take the time to examine the patient and help them to achieve their functional, recreational, and work-related goals. Please do not hesitate to reach out to us if you recently underwent or plan on having meniscal surgery.

Reference:

Rehabilitation Guidelines for Meniscal Repair of Root and Complex Tears – UW health. https://www.uwhealth.org/files/uwhealth/docs/pdf/Meniscus_Root_Rehab_final.pdf. Accessed February 10, 2022.