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Vitamin D deficiency adversely affects early post operative functional outcomes after total knee arthroplasty

by | Jun 30, 2021 | Health Tips

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

Introduction:

There is increasing evidence of the importance of adequate Vitamin D levels on muscle function and performance. Vitamin D is essential for calcium homeostasis and bone turnover which are essential following orthopedic surgeries. Total knee arthroplasties (TKAs) are a type of orthopedic surgery utilized for pain relief and improving quality of life in patients with end stage knee osteoarthritis (OA). The role of Vitamin D and its influence on functional recovery following TKA is not clearly established. The authors of the article, Vitamin D deficiency adversely affects early post‑operative functional outcomes after total knee arthroplasty, observed the effect of Vitamin D deficiency on post-operative functional outcomes following TKA.

Materials and Methods:

Ninety-two patients with a diagnosis of primary knee OA and scheduled for a unilateral TKA were included in the study. Patients were excluded if they had taken Vitamin D supplementation or had other comorbidities. Blood serum Vitamin D levels were obtained and the participants were divided into two categories: Vitamin D deficient (<12 ng/mL) and Vitamin D sufficient (>12ng/mL).

Following the surgeries, patients were scored on the American Knee Society Score (KSS) and four performance tests which included the alternative step test (AST), six-meter walk test (SMT), sit to stand test (STS) and timed up and go test (TUGT). Patients performed these tests one day before and three months after their TKA.

  • KSS: The KSS includes both a clinical and a functional portion. The clinical KSS includes pain, stability, and range of motion as the main parameters with deductions for flexion contractures, extension lag, and malalignment. The functional KSS includes walking distance and stair climbing with deductions for the use of a walking aid.
  • AST: This test is performed by alternatively placing the entire right and left foot as fast as possible on a step.
  • SMT: This test measures walking speed along a six-meter course.
  • STS: The number of times a participant can perform a sit to stand transfer with arms folded in thirty seconds is recorded.
  • TUGT: The participant is timed from rising from a chair wand walking around a cone 3 meters distance and returning to the chair.

Results:

There were no differences in the study population with respect to demographic data and clinical characteristics such as age, gender, BMI, and side of the surgery. There were no differences between groups in terms of post-operative clinical KSS. The man post-operative functional KSS was significantly lesser in the Vitamin D deficient group versus the non-deficient group. Additionally, the mean value times for the post-operative AST and SMT wee significantly longer in the Vitamin-D deficient group than in the non-deficient group. Both the STS and TUGT demonstrated high values for mean time taken in the Vitamin D deficient group but they were not statistically significant.

Discussion:

The most important finding of the present study was that early post-operative outcomes following TKA were affected by patients’ preoperative vitamin D status, and those in the vitamin D-deficient group had significantly poorer post-operative outcomes. Recent evidence suggests that Vitamin D deficiency associated with the development and progression of OA, though the underlying pathophysiology is unclear. There is also increasing evidence on the important role played by vitamin D in skeletal muscle pathology and supplementation of Vitamin D increase diameter of muscles. Because TKA results in substantial injury to the extensor mechanism of the knee, it is pertinent to evaluate the association between Vitamin D levels and functional recovery following TKA. Since vitamin D deficiency can usually be corrected by 6 weeks of oral supplementation, preoperative vitamin D supplementation may be considered for patients with deficiencies.

Conclusion and Clinical Implications:  

In the current study, early post-operative functional outcomes following TKA appear to be adversely affected by vitamin D deficiency. Surgeons should confirm vitamin D levels before performing a TKA and consider preoperative supplementation if necessary. As therapists, we many patients prior to their TKA surgeries and it is important to discuss this evidence with patients to determine whether supplementation is indicated due to the correlation between Vitamin D sufficiency and improved clinical outcomes post-operatively.

Reference:

Shin, K-Y., Park, K., Moon, S-H., Yang, I., Choi, H., Lee, W (2017). Vitamin D deficiency adversely affects early post‑operative functional outcomes after total knee arthroplasty. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA), Vol 25:3424-3430.

Physical Therapy Examination for the Diagnosis of Cervicogenic Headaches

by | Jun 21, 2021 | Health Tips

By Stephanie Beatty, SPT

What is a cervicogenic headache?

  • At some point in their lives, ~96% of people will experience headaches. The cause of headaches may be unknown, due to another condition, or due to referred pain from an adjacent area of the body such as the ears, neck, or facial structures including the mouth and nose. A cervicogenic headache is a headache that results from a musculoskeletal impairment in the upper part of the neck, known as the upper cervical spine. Cervicogenic headaches stem from a dysfunction in the complex nervous system connections between the trigeminal nerve (a nerve the originates in the region between the spinal cord and the brain) and the nerves of the upper cervical spine. This dysfunction causes neck pain to refer to different areas of the head, resulting in a headache. People will often experience referred pain around one or both eyes as well.

How are cervicogenic headaches diagnosed?

  • Cervicogenic headaches are typically diagnosed through a subjective examination, also known as a patient interview, and an objective examination during which a physical therapist examines the cervical spine and uses tests and measures to determine the cause of the patient’s headaches. According to a systematic review by Rubio-Ochoa et al., a physical examination of the cervical spine for a patient presenting with cervicogenic headaches should consist of sensitive tests such as accessory motion testing (PAIVMs) of the joints of the upper cervical spine as well as specific tests such as the cervical flexion-rotation test. During this test, the therapist will bend your head forward and rotate it side to side while monitoring any changes in your symptoms. The use of these tests assists the therapist in accurately diagnosing cervicogenic headaches and can guide treatment planning. Cervicogenic headaches have been shown to respond well to physical therapy intervention, so an accurate diagnosis is essential.

How can Physical Therapy First help with cervicogenic headaches?

  • Here at Physical Therapy First, we will evaluate you to determine the cause of your headaches and the best approach to treating them. Your initial examination will begin with a subjective interview during which the physical therapist asks questions about your headaches, any neck pain, and other pertinent medical history. The physical therapist will then conduct a physical examination that includes evidence-based tests and measures such as the ones mentioned above. The physical therapist will then develop a comprehensive, individualized treatment plan consisting of exercises and manual therapy to help alleviate your cervicogenic headaches and other symptoms.

Reference

Rubio-Ochoa J, et al., Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.09.008

 

 

FOOD FOR THOUGHT: Role of Nutrition Supplements on the Recovery from Total Hip Replacement and Total Knee Replacement Surgeries

by | Jun 14, 2021 | Health Tips

by  Tyler Tice PT, DPT, ATC

Nutrition is a major part of health and nutritional habits can influence outcomes for people after surgery, especially in older adults. Two of the more popular orthopedic surgeries that older adults receive are hip replacements and knee replacements. These are major surgeries that create a stressful stimulus to our bodies which result in an increased inflammatory response and impairs our immune system due to metabolic changes. It is known that it is always good to optimize nutrition, especially prior to surgery. There are multiple supplements available as well that can stimulate our body’s metabolic response with the potential to speed up recovery.

In an article titled: What Is the Role of Nutritional Supplements in Support of Total Hip Replacement and Total Knee Replacement Surgeries? A Systematic Review; the authors analyzed nine research studies to determine the effectiveness of nutritional supplements specifically on the recovery after hip and knee replacement surgeries.

After review, there were three types of supplements studied including carbohydrate drink supplements prior to surgery, amino acid supplements prior to surgery, and Beta-Hydroxy Beta-Methylbutyrate, L-Arginine, and L-Glutamine (HMB/Arg/Gln) supplements, as well as other conclusions the authors have made from the available research.

  • Carbohydrate Drinks Before Hip and Knee Replacement Surgery :
    • evidence is limited
    • may increase insulin-like growth factor 1 (IGF-1) levels which can be beneficial in reversing the metabolism changes that occur after the stress induced from surgery.
    • may reduce hunger, nausea, and help regulate insulin growth sensitivity.
    • One pilot study found that patients who took multiple nutritional interventions, one being a carbohydrate drink prior to surgery, had shorter hospital stays and decreased inflammation after hip replacement surgery.
    • No conclusive evidence for benefits; HOWEVER low risk and high potential benefits which may be most beneficial for those who are frail or with multiple co-morbidities
  • Amino Acids
    • Some evidence to suggest decreased muscle atrophy (muscle loss) after surgery and better performance on functional tests at 2 weeks and 6 weeks post surgery
  • Beta-Hydroxy Beta-Methylbutyrate, L-Arginine, and L-Glutamine (HMB/Arg/Gln)
    • HMB is reported to promote muscle protein synthesis and suppress muscle protein breakdown
    • Some evidence to suggest decreased muscle loss in quad muscle from 0-14 days post surgery
    • Might lead to early improvements in physical function and fall prevention
  • Additional Findings
    • Consumption of protein is vital for stimulating muscle protein synthesis and can have greater impacts in frail or malnourished individuals.
    • Pre-operative period is the most effective intervention time
    • future work needs to be done in researching nutritional influence on muscle inflammation susceptibility using antioxidant ingredients or polyunsaturated fatty acids
  • Study Limitations:
    • Limited amount of data
    • Small sample size in most research articles
    • 2 pilot studies were used

Nutritional therapy is most beneficial to support individuals with a high risk of developing post-operative complications or are sarcopenic, frail, malnourished/undernourished and have a limited protein reserve. There are multiple factors that go into recovery from joint replacement surgery and nutritional supplements can be one of these important factors. It is supported that a combination of physical, nutritional, and psychological pre-operative preparation all have positive impacts on the recovery from surgery.

For more information on this topic and for more details regarding the research that was reviewed, please see the article referenced below. It is important for each person to understand the multiple factors that go into recovery from joint replacement surgery and to know that each person’s recovery is unique. At Physical Therapy First, we want to help make your recovery as smooth as possible. We understand that each person’s recovery is unique, that’s why we spend a full hour with each of our patients and provide each person with a rehabilitative routine that is specific for them. Check out our website and give us a call to schedule an appointment with us!

Reference:

Burgess, L., Phillips, S. and Wainwright, T., 2018. What Is the Role of Nutritional Supplements in Support of Total Hip Replacement and Total Knee Replacement Surgeries? A Systematic Review. Nutrients, 10(7), p.820

 

Meniscus? What’s that?

by | May 26, 2021 | Health Tips

by Joseph Holmes, PT, DPT, CDN, FNCP

Introduction

Meniscus. It’s a strange word, right? Many people are not aware that the meniscus is the protective covering over the lower leg (tibia) which forms cushion and support for the knee (20 from CPG). There are many functions of the meniscus, including to facilitate joint gliding or movement, prevent the knee from over-extending, provide nutrition to the knee, serve as a support for the knee, and provide shock absorption (1). The meniscus is rarely strained like other structures of the body, but it can become injured through “wear and tear” over time or a specific acute injury in which a person feels a catch or a pop in the knee. The type of injury that occurs determines whether the person is more likely to benefit from physical therapy or surgery for treatment. Surgery is very common for this injury. In the United States, meniscal surgeries account for 10%-20% of all orthopedic surgeries which represents about 850,000 meniscus surgeries every year (2).

Should I have an MRI or X-Ray?

If you have had any type of injury to your knee, whether it is meniscal-related or not, the following guidelines are used to determine whether imaging such as an MRI or X-ray is appropriate. These guidelines, called the Ottawa Knee rules, recommend having an MRI if you meet any of the following criteria after a traumatic knee injury (3,4):

  • Age 55 or older
  • Isolated tenderness to your kneecap
  • Tenderness to the touch at the head of your fibula (just below your lateral or outside knee)
  • Inability to flex the knee to 90 degrees
  • Inability to bear weight immediately or unable to take 4 steps

Should I have surgery?

This is a very common question and the answer is complex. Evidence from a study in the New England Journal of Medicine demonstrated that among people with a meniscal tear and knee osteoarthritis at 6 months and 12 months, there were no clinical or significant differences found in functional outcomes between those who had surgery and those who did not (5). What does this mean? Surgery for a torn meniscus, especially one that is naturally worn over time as compared to a specific traumatic tear, often results in no benefit compared to performing non-surgical physical therapy. Physical therapists are clinical experts in diagnosing and treating meniscus injuries. Let’s take a look at what the latest research says about how physical therapists can help patients with meniscus injuries.

2018 Clinical Practice Guidelines for Meniscal Lesions

          First, your physical therapist will want to find out about the history of your mechanism of injury: What happened? Did you twist your knee? Did you feel a sharp pain? Is your injury tender to the touch? Are you able to put weight through it? How swollen is your knee? How bad does it hurt? Does it feel like it catches, locks, or buckles? What makes it feel better and what makes it feel worse? Does it have sharp infrequent pain or is it a subtle pain that is there almost always when you put weight through it? All of these questions will help to guide the physical therapist in performing objective tests to determine the diagnosis and severity of the injury. This examination will also include assessing the flexibility and strength of the hip, knee, and ankle and functional challenges such as climbing the stairs, walking for 2 to 6 minutes, and hopping on one leg. After these assessments are performed, the final step is performing specialized tests that are specific to the meniscus, including the “McMurray Manuever”. The McMurray Maneuver is the best test for assessing a meniscal injury according to the 2018 Meniscus Clinical Practice Guidelines and is defined as follows (6,7,8,9):

“With the patient supine the examiner holds the knee and palpates the joint line with one hand, thumb on one side and fingers on the other, whilst the other hand holds the sole of the foot and acts to support the limb and provide the required movement through range. From a position of maximal flexion, extend the knee with internal rotation (IR) of the tibia and a VARUS stress, then return to maximal flexion and extend the knee with external rotation (ER) of the tibia and a VALGUS stress.[1][2][3] The IR of the tibia followed by extension, the examiner can test the entire posterior horn to the middle segment of the meniscus. The anterior portion of the meniscus is not easily tested because the pressure to that part of the meniscus is not as great. Positive findings for the McMurray Maneuver include pain, snapping, audible clicking or locking can indicate a compromised meniscus.”

Image above courtesy of www.medscape.com

Intervention/Treatment

The following exercises are recommended for persons with a meniscal injury who did not have surgery:

  • Progressive range of motion and flexibility of the knee all directions
  • Progressive strength training of the knee and hip musculature
  • Neuromuscular re-training such as balance activities

What is the goal of rehab for a meniscal injury?  As with most joint injuries, the primary goal is to return to your normal function as soon as possible. In order to do this, you will work with your physical therapist to improve knee flexibility, progress the strength of all the muscles of your hips and knees which also provide support to your meniscus, and improve your balance and control. This will allow you to return to your daily activities pain free and prevent other meniscus injuries in the future.

Physical Therapy First

The orthopedic specialist at Physical Therapy First will provide you with the highest quality care based on the latest research combined with decades of clinical experience to assist in decreasing the swelling of your knee, returning your knee to full range of motion, and helping you to create an individualized exercise program that will allow you to avoid surgery and experience a higher quality of life. Our therapists provide 1-on-1 treatment sessions with all patients for one hour and offer the best care you will receive in the greater Baltimore area. Call any of our four clinics to schedule an assessment today.

References:

  • Brindle T, Nyland J, Johnson DL. The meniscus: review of basic principles with application to surgery and rehabilitation. J Athl Train. 2001;36:160-169.
  • Renström P, Johnson RJ. Anatomy and biomechanics of the menisci. Clin Sports Med. 1990;9:523-538.
  • Bachmann LM, Haberzeth S, Steurer J, ter Riet G. The accuracy of the Ottawa knee rule to rule out knee fractures: a systematic review. Ann Intern Med. 2004;140:121-124. https://doi.org/10.7326/0003-4819-140-5-200403020-00013
  • Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med. 1995;26:405-413. https://doi.org/10.1016/S0196-0644(95)70106-0
  • Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, Donnell-Fink LA, Guermazi A, Haas AK, Jones MH, Levy BA, Mandl LA, Martin SD, Marx RG, Miniaci A, Matava MJ, Palmisano J, Reinke EK, Richardson BE, Rome BN, Safran-Norton CE, Skoniecki DJ, Solomon DH, Smith MV, Spindler KP, Stuart MJ, Wright J, Wright RW, Losina E. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84. doi: 10.1056/NEJMoa1301408. Epub 2013 Mar 18. Erratum in: N Engl J Med. 2013 Aug 15;369(7):683. PMID: 23506518; PMCID: PMC3690119.
  • Magee, D.J Chapter 12: Knee, in Orthopedic Physical Assessment. Pg 791. Saunders Elsevier. 2008.
  • Piantanida, A.N. Yedlinsky, N.T. Physical examination of the knee, in The Sports Medicine Resource Manual, Editors: Seidenberg, P.H & Beutler, A..I. 2008 Saunders. DOI https://doi.org/10.1016/B978-1-4160-3197-0.X1000-2.
  • Waldman,S.D. Painful conditions of the knee, in Pain Management Vol 1., 2007. Saunders. DOI https://doi.org/10.1016/C2009-1-59662-1.
  • Logerstedt DS, Scalzitti DA, Bennell KL, Hinman RS, Silvers-Granelli H, Ebert J, Hambly K, Cary JL, Snyder-Mackler L, Axe MJ, McDonough CM. J Orthop Sports Phys Ther 2018;48(2):A1-A50. Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions. doi:10.2519/jospt.2018.0301

Recovery after volleyball

by | May 19, 2021 | Health Tips

by Elizabeth Kwon, SPT

There are a variety of recovery methods used to enhance the performance of athletes; however, the specific techniques and dosage are debated among various individual sports and athletes. Volleyball is an intermittent sport requiring bursts of high intensity movements during gameplay and with often little recovery time in between matches. While there is limited evidence on recovery techniques specific for volleyball players, several methods are discussed including the following:

Nutrition:

  • Nutrition for athletes requires a higher caloric intake, proper carbohydrate and protein intake, and sufficient nutrients and hydration
  • Overall, female volleyball players tend to consume less than the recommended caloric intake per day as well as proper levels of protein, fiber, iron, carbohydrates, iron, and calcium
  • Current recommendations may lack sex-specificity.
    • Female volleyball players were able to improve their power, speed, and body composition despite maintaining a lower caloric intake than recommended
    • Female volleyball players require less carbohydrates compared to the recommended dosage suggesting that they may be less reliant on glycogen during exercise and less responsive to glycogen synthesis during recovery
    • Female volleyball players consumed more protein on average than the recommended amount
  • It is recommended that volleyball players maintain an increased carbohydrate to protein ratio to facilitate muscle recovery rather than a direct focus on the absolute amount of consumed protein
  • Antioxidant supplementation shows promise in enhanced antioxidant defense against free radicals during periods of intense training
  • Proper hydration prior to a match is important to improve performance and recovery
    • In a study of beach volleyball athletes, players lost an average of 1.4 L of sweat during a match.

Sleep:

  • It is recommended for athletes to obtain 7-9 hours of sleep with upwards of 10-12 hours for athletes who are adolescents or train 4-6 hours per day
  • Lack of sleep led to a depletion of energy and decreased time to exhaustion during exercise, and athletes with higher levels of insomnia were associated with decreased performance
  • Quality of sleep is also important in athletes, where those with greater sleep quality and won their games exhibited decreased stress levels and lower levels of confusion in comparison to those with lower sleep quality

Mental and psychological techniques:

  • Athletes who have a decreased amount of perceived recovery time are at a higher risk for injury
  • Spending time with friends, team building activities, and amusement are associated with promoting recovery and preventing injury
  • In a study of 11 female intercollegiate volleyball players, a program focusing on cognitive behavioral skills demonstrated that increased use of imagery and using a routine increased serving performance
  • High levels of anxiety and stress may lead to impaired performance, yet few athletes utilize mental or emotional recovery techniques

Cold water immersion (CWT) and Laser therapy (LLLT):

  • Limited evidence is available for CWT and LLLT for athletes, and there is no consensus on the effectiveness or dosage for either recovery technique.
  • CWT is suggested to improve submaximal muscle function in comparison to active recovery and suppress post-exercise levels of creatine kinase (CK) and lactate dehydrogenase (LDH)
  • LLLT is suggested to reduce post-exercise CK levels and other inflammatory markers of muscle damage; however, the research is limited by some of the studies using rat models as well as there being mixed results among studies.

Overall, current nutrition recommendations for female athletes lack sex specificity, and athletes may benefit more from maintaining a high carbohydrate to protein ratio rather than using absolute numbers. Supplementation using antioxidants may be beneficial in improved recovery among athletes. It is important to maintain an adequate amount of sleep as well as quality of sleep to improve performance levels. In terms of mental and psychological techniques, routines involving imagery for closed activities, like serving, and managing anxiety and stress levels may improve performance. It is essential to educate athletes on recovery time as perceived recovery time is a risk factor for injury, and likewise, it may be beneficial to encourage activities, such as team bonding and spending time with friends to decrease risk of injury and improve recovery. At Physical Therapy First, your physical therapist can provide you with protocols for proper warm-up and cool down activities as well as discuss the factors listed above with you to maximize your recovery, decrease your risk of injury, and improve your performance.

References:

Closs, Brian. Burkett, Connor. Trojan, Jeffrey D. Brown, Symone M., Mulcahey, Mary K. “Recovery after volleyball: a narrative review.” The Physician and Sportsmedicine, Volume 48, Number 1: 8-16, (2020).