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The Acute Effect of Cryotherapy on Muscle Strength and Shoulder Proprioception

by | Oct 12, 2020 | Health Tips

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

Introduction

Cryotherapy is a common intervention used in clinical and athletic environments, especially for acute injuries. Common forms of cryotherapy include an ice pack, ice massage, and cold-water immersion. Cryotherapy is used to decrease injury-related pain, muscle spasms and swelling. However, the cooling effect of cryotherapy can harm neuromuscular function, including muscle strength and proprioception. Proprioception is an individual’s ability to sense joint position, movement, and force as a means to discriminate body movement. The authors in the study, The Acute Effect of Cryotherapy on Muscle Strength and Shoulder Proprioception, analyze how cryotherapy affects the maximal force production of the shoulder external and internal rotator muscles and shoulder proprioception.

Methods

A randomized double-blind controlled trial was performed on 48 healthy women. The participants were randomly assigned to either the experimental or control group. The experimental group had 15 minutes of cryotherapy in the form of a crushed ice pack applied to shoulder and the control group had a body-temperature sand bag applied to the shoulder. Maximal voluntary isometric contraction (MVIC), force sense, threshold to detect passive movement (TDPM) and joint position sense (JPS) of the shoulder rotator muscles were assessed immediately before and after the intervention.

Muscle Strength Assessment

The MVIC of the shoulder’s internal and external rotators was recorded both before and after cryotherapy treatment. A dynamometer was used to record three MVICs and the average was recorded.

Force Sense Assessment

The force-matching procedures for the internal and external shoulder rotators were conducted at 20% and 50% of the participant’s MVIC. For force sense testing, participants were positioned like the MVIC assessment and instructed to achieve the target force using visual feedback. They were then asked to perform the same contractions without visual feedback. The mean from three trials was used for analysis.

Joint Position Sense Assessment

The authors passively positioned the participants’ shoulder into position and maintained for five seconds so the participant could memorize the position. The participant then actively moved her shoulder into the same position. The participants were blindfolded and wearing headphones during this test. Each participant performed this test three times and the average score was recorded.

Threshold to Detect Passive Movement Assessment

The participants were placed in the same seated conditions used to test JPS. Each participant was asked to press the remote button upon sensing any movement or change relative to the initial shoulder position, which was engaged at random by the tester. Three trials from two starting positions were used, and the shoulder was moved into either the internal or external shoulder rotation.

Results

The cryotherapy reduced the skin temperature of the experimental group to 12.5 degrees Celcius compared to 33.5 degrees Celcius in the control group as measured by a skin thermometer.

MVIC: There was significant impairment in the force production of both the shoulder internal and external rotator muscles by approximately 10% of muscle strength in the experimental group.

Force Sense: There were no significant changes in both muscle groups at 20% and 50% of MVIC in the experimental group when compared to the control.

JPS: The error of JPS in external and internal rotation increased significantly in the experimental group post-cryotherapy application.

TDPM: Cryotherapy significantly diminished the participant’s ability to detect motion in the rotator muscles.

Conclusions and Physical Therapy First Implications

The results of this study demonstrate impairments of shoulder strength and proprioception following cryotherapy application.  These results suggest that application of an ice pack is harmful when it precipitates activity or exercise. There is a growing consensus that reduced shoulder proprioception increases the risk for sustaining a musculoskeletal injury. Athletes and trainers shoulder be educated on the proper timing of cryotherapy application for overhead athletes in order to decrease the risk for injuries. Cryotherapy is a modality we administer during rehabilitation which can help to reduce pain, swelling, and muscle spasm. At Physical Therapy First, we are conscious about the timing of cryotherapy intervention.

Reference:

Torres, R., Silva, F., Pedrosa, V., Ferreira, J., and Lopes, A. (2017). The Acute Effect of Cryotherapy on Muscle Strength and Shoulder Proprioception. Journal of Sport Rehabilitation. 26, 497 -506

Whole-body Cryotherapy as a Recovery Technique after Exercise: A Review of the Literature

by | Oct 5, 2020 | Health Tips

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

Introduction

In the days following unaccustomed or intense training or competition, athletes often experience dull, aching pain, stiffness, and loss of muscle strength that can last for up to 5-7 days. This phenomenon is termed exercise-induced muscle damage (EIMD). Muscle damage is characterized by a sustained reduction in optimal force production, the delayed onset of muscle soreness (DOMS), and an acute inflammatory response. It has been proposed that cold therapies aid recovery following EIMD through a dampening of the inflammatory response, edema reduction, and through an analgesic effect.

A novel form of cold therapy, Whole Body Cryotherapy (WBC) has gained popularity in athletes as an anti-inflammatory treatment. A typical session of WBC involves standing in a chamber that fills with a safe, but extremely cold gas, maintained at temperatures of -110 degrees Celsius to -190 degrees Celsius (-166 to -220 degrees Fahrenheit) for at least two minutes and a maximum of five minutes. The authors in the study, Whole-body Cryotherapy as a Recovery Technique after Exercise: A Review of the Literature, present an overview of the current research on the topic and provide recommendations for its use by athletes.

Discussion

Four key outcome measures for EIMD utilized in this review include pain, muscle function and performance, inflammatory marker levels, and creatine kinase (CK) levels as a marker of muscle damage.

Pain

The visual analog scale was utilized in the five articles that used pain as an outcome measure. Four studies found a significant decrease in pain by at least 18% when compared to a control at 48 hours post WBC treatment. In one study, there was also decreased pain compared to the control group when performing a body weight squat post-WBC treatment, suggesting WBC treatment may reduce pain during subsequent muscle contractions.

Muscle Function and Performance

Patients received an average of 15 WBC treatment exposures across the six studies that measured muscle function. In one study, a group of tennis players were exposed to WBC every day over a five-day training program. In this study, the WBC group reached fatigue significantly later during a progressively more difficult tennis drill than a control group. The WBC group also experienced a 7.3% increase in stroke effectiveness during a tennis skill game that became progressively more difficult where the control group only increased by 2.6%. In another study, synchronized swimmers were exposed to WBC each day during a period of intensified training and found that a 400 m time trial swim speed was only 0.5% slower after WBC compared to a 1.1% time reduction in the group that did not receive WBC treatment.

Inflammation

The authors who focused on inflammatory marker levels used concentrations of interleukins, tumor necrosis factor (TNF), and C-reactive protein (CRP) to show the amount of inflammation present in the muscle. One study looked at the inflammatory response in runners following a 48-minute simulated trail run. Concentrations of the acute inflammatory marker, CRP, were increased by 515% from baseline in the control group and 123% in a WBC group. The increase of inflammatory interleukin cells that naturally occurs after damaging exercise was limited when participants were exposed to WBC compared to the control.

In another study which observed the effects of WBC prior to exercise, the concentration of the pro-inflammatory interleukin increased more than six times in the control group compared to athletes who were treated with WBC. In addition, interleukin concentration dropped by 11%, indicating that treatment blunted the inflammatory response and possibly reduced muscle damage. Yet another study found WBC increased the concentration of an anti-inflammatory cytokine to twice that of baseline compared to no change relative to baseline in the control group. Further, the interleukin concentrations dropped by 80 % in the WBC group compared to a drop of only 50% in the control subjects . The final study found that a five-day training protocol combined with WBC induced a 60% decrease in the inflammatory cell, TNF-α.

Muscle Damage

Muscle damage focused studies used a measure of CK to determine the amount of breakdown in muscles. One study showed a 30% decline in CK after ten exposures to WBC over a five-day period as compared to a control group. A second study reported that CK concentrations were 34% lower with the inclusion of WBC treatment six days into a training protocol compared to a training protocol without WBC treatment. These results were supported by a separate study that reported daily exposure to WBC over a five-day training program with elite rugby players reduced CK by 40%. Another study found WBC treatment significantly reduced CK in tennis players where concentrations of this muscle enzyme in the control group remained virtually the same after five days of training. A final study found no significant changes in CK relative to a control group with protocols using either three or six exposures to WBC. The results from this study suggest that there may be a dose response to WBC when assessing CK concentration, where a reduction in circulating CK is in proportion to the number of exposures to WBC during the recovery process.

Limitations and Future Research

The lack of ability to blind for recovery treatment in the research makes it impossible to eliminate the potential placebo effect. Further investigation into the effects of multiple WBC exposures during extended periods of athletic training is warranted to determine potential effects on recovery, performance and processes of muscle adaptation. Future studies will require larger sample sizes to determine the significance of immunological changes and stringent methodological control to identify the exact influence of WBC on these pathways.

Conclusion

In conclusion, the studies referenced in this article suggest that WBC may be successful in decreasing pain, inflammation, and muscle damage and increasing muscle function. With WBC treatment groups recording pain scores an average of 31% lower than control groups, evidence tends to favor WBC as an analgesic treatment after damaging exercise. Data from inflammatory markers and CK suggest that WBC may dampen the inflammatory cytokine response which means less tissue damage and a faster recovery. Multiple exposures of three or more sessions of three minutes conducted immediately after and in the two to three days post-exercise have presented the most consistent results. There are contraindications to this modality including hypertension, circulatory disorder, and history of a stroke, to name a few. The athlete or patient needs to be properly screened and perform a thorough healthy history prior to treatment.

PT First Implications

As the research on WBC continues to evolve, this treatment could be a good adjunct to skilled physical therapy during an athlete’s training. Localized cryotherapy is a common modality seen in a physical therapy setting to treat pain and inflammation. WBC provides an avenue to treat more widespread muscle pain in multiple area of the body and could be beneficial for athletes during their training season.

Reference:

Rose, C., Edwards, K., Siegler, J., Graham, K., Caillaud, C (2017). Whole-body Cryotherapy as a Recovery Technique after Exercise: A Review of the Literature. International Journal of Sports Medicine. 38: 1049-1060.

Symptoms, Signs, and Functional Disability in Adult Spondylolisthesis

by | Oct 2, 2020 | Health Tips

by Kayla Coad, PT, DPT

Introduction:

Spondylolisthesis is characterized by anterior slippage of a vertebrae. The purpose of this study is to determine if there are specific signs (what can be observed), symptoms (what is felt by the patient, eg pain), and functional disability that are associated with adult spondylolisthesis.

Methods:

Signs, symptoms, and disability of 111 patients with adult spondylolisthesis before randomized treatment with fusion or physical therapy were compared with those of 39 patients with nonspecific low back pain before lumbar fusion.

Results:

Symptoms were similar in patients with spondylolisthesis and chronic LBP, but chronic LBP reported greater functional disability. Patients with chronic LBP were on sick leave more often and reported a higher frequency of bladder and sexual dysfunction. Sixty-two percent of patients reported LBP as well as sciatica, 7% reported sciatica only, and 31% LBP only. Specific signs were not common. A positive straight leg raise test resulted in 12% and a L5 sensory distribution in 13% were the most common.

Conclusion:

The clinical presentation and functional disability is similar in patients with adult spondylolisthesis and low back pain of nonspecific origin. Patients with adult spondylolisthesis and sciatica do not typically have a positive straight leg raise test. Specific signs between the two groups were not common.

Clinical Relevance:

The physical therapist at Physical Therapist First will create a unique treatment plan based on research for patients with low back pain and adult spondylolisthesis in order to help them return to previous level of function. Reference: Moller, H., Sundin, A., Hedlund, R. Symptoms, Signs, and Functional Disability in Adult Spondylolisthesis: Spine. Vol 25, Number 6, pages 683-689.

Mechanisms of Acute Knee Injuries in Bouldering and Rock Climbing Athletes

by | Sep 29, 2020 | Health Tips

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

Mechanisms of Acute Knee Injuries in Bouldering and Rock Climbing Athletes


Introduction

The popularity of rope climbing and bouldering has increased significantly over the past few years and has recently been selected as a new discipline for the 2020 Summer Olympics. With the worldwide indoor bouldering boom comes an increase in injury numbers. In bouldering, the lower extremity tends to have more acute injuries unlike the upper extremity which are typically overtraining injuries. The authors in the study, Mechanisms of Acute Knee Injuries in Bouldering and Rock Climbing Athletes, analyze and describe various traumatic mechanisms of injury, patient demographics, and severity of acute knee injuries in noncompetitive and competitive athletes.

Methods

Between 2015 and 2018, noncompetitive and competitive athletes with acute knee injuries related to rope climbing or bouldering were evaluated at an outpatient sports medicine clinic specializing in rock climbing injuries. Diagnoses were made after a clinical examination by a senior orthopedic knee surgeon and radiographs. Athletes were asked to describe the exact mechanism of injury (MOI) which caused the injury and were assigned an experience level classification based on the Union Internationale des Associations d’Alpinisma (UIAA) metric scale. Patients were treated according to individualized protocols and gradually returned to their sport. All patients were seen for a follow-up evaluation at 6- and 12-weeks post-injury.

Results

Over the four-year period, 71 patients were treated with 77 independent acute knee injuries. Four types of traumatic MOIs were identified and are shown in the photo below: the high step position (A), the drop knee position (B), the heel hook position (C), and a fall to the ground (D). Almost half (48.6%) of all of the injuries happened during indoor bouldering, followed by outdoor rope climbing (26%), outdoor bouldering (22.1%), and indoor rope climbing (5.2%).

rock climbing injury

The most common diagnosis reported was a medial meniscus tear predominately caused by the high step, drop knee, and heel hook positions. Iliotibial band (ITB) sprains were the second most common diagnosis caused almost exclusively from the heel hook position. Anterior cruciate ligament (ACL) tears combined with medial collateral ligament (MCL) and medial meniscus injuries were detected in 9% of patients and isolated ACL tears in 2.6%. 91% of injuries that caused a partial ACL tear resulted from a fall to the ground. All athletes returned to rock climbing within twelve months.

Between-Group Comparison

High step and drop knee injuries were more common during rope climbing, whereas heel hook and fall injuries were more often caused by bouldering. Patients injured during the heel hook position had the highest ability level and highest training volume per week while patients injured during a fall had the lowest ability level. Competitive athletes were significantly younger and lighter than noncompetitive athletes. Medial meniscal tears and surgical intervention were more common in noncompetitive athletes.

Discussion

This is the first study to describe traumatic MOIs, injury patterns, and outcomes of acute knee injuries in rock climbing athletes. Injuries caused by bouldering activities account for almost 70% of all knee injuries sustained during climbing activities. One explanation is that bouldering routes normally consist of few but very hard moves which require strength and difficult body positioning, placing enormous stress on the medial knee.

ACL tears were more common in females and resulted from a fall. This pattern is similar to other sports were insufficient landing patterns with increased knee valgus is cause for an ACL injury. These ACL injuries were found in athletes with less experience and potentially less body control, stability and strength while landing. Many inexperienced athletes tend to choose indoor bouldering because of the ease of access. All of the athletes with ACL injuries had returned to the sport within one year. Unlike other sports which require running and jumping, the return to sport protocol for rock climbing is more gradual and relatively quick.

Medial meniscus injuries were predominately caused by the high step, drop knee, and heel hook positions. The peak load on the meniscus during these difficult positions is thought to be the cause of these injuries, in addition to insufficient technical skills and fatigue which might cause harmful rotation motion of the knee.

To prevent reinjury, rope climbing is preferred to bouldering to avoid falls and direct contact during the rehab process. The climber can also “down climb” (cautious decent) or “top out” (alternative easy decent) rather than jumping down. It may be possible to develop training programs for both competitive and noncompetitive athletes to address muscle weaknesses and landing patterns. Most climbers neglect the important leg muscles in their training. Active training of the knee stabilizers is important for improved joint control and stretching (ITB) may be advisable. Improved psychomotor skills and body control might better manage and reduce the risk of injury during falls.

Conclusion

There are four distinctive MOIs of knee injuries in rock climbers. Meniscal tears, ITB sprains, and ACL injuries are the leading injury diagnoses and the return to sport is relatively quick. Noncompetitive athletes have significantly more medial meniscus tears and undergo more surgical procedures than competitive athletes. ] Sport-specific awareness training programs to avoid excessive loads on the knee should be developed.

PTF Implications

With the increase in popularity and opening of indoor bouldering gyms near our clinics, our therapists are familiar with evaluating and treating climbing injuries. This study presents with data on acute knee injuries and important MOI data to assist in building preventative and rehabilitation programs. A skilled PT can help to assess knee loading during landing and screen for weakness and/or movement patterns in the lower extremities which could be concern for a knee injury. Our therapists are also highly trained in rehab protocols following an acute knee injury and aim to get patients back on the wall as quickly as possible.

Reference

Lutter, C., Tischer, T., Cooper, C., Franks, L., Hotfiel, T., Lenz, R., Schoffl, V. (2020). Mechanisms of Acute Knee Injuries in Bouldering and Rock Climbing Athletes. The American Journal of Sports Medicine. 48(3):730-738.

The Use of Platelet-Rich Plasma in Symptomatic Knee OA

by | Sep 21, 2020 | Health Tips

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

Introduction

Osteoarthritis (OA) is a disease which causes degeneration of joint tissue due to trauma, aging, and metabolic changes. The rising prevalence of knee OA has put an increasingly large physical and financial burden on the U.S. population. Traditional treatment options for OA include lifestyle modifications, pain management, physical therapy, and injections such as hyaluronic acid (HA), corticosteroids, or prolotherapy, with joint replacement as an option for those who have failed conservative measures. More recently, platelet-rich plasma (PRP) injections have started to gain traction in research and clinical practice.  The authors of the review article The Use of Platelet-Rich Plasma in Symptomatic Knee OA summarize the current research and offer suggestions for future studies.

What is PRP and How Does It Work?

PRP is plasma that contains three- to five-times more platelets than whole blood, which typically has 150,000 to 300,000 platelets per microliter. The platelets in PRP contain numerous proteins which are involved in the initiation of healing and growth of new cells. With more proteins in the joint space, the progression of OA may potentially be slowed or halted. PRP is created by taking venous blood from the patient, centrifuging it, and injecting it into the joint space.

PRP vs Control Group

In one double-blind randomized control trial (RCT), 30 patients with knee OA who failed at least 6 weeks of nonoperative treatment received weekly intra-articular injections for either PRP or saline (control group) and were evaluated at one year. The PRP group showed statistically significant improvements in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) functional scale than those in the saline group.

PRP vs HA Injection

There were a few studies which compared PRP injections with HA injections. The first study looked at patients who received either two PRP injections at 4-week intervals or three HA injections at one-week intervals, the standard for this injection. At 12 months, pain scores improved significantly more in the PRP group and only in the PRP group was there improvement on the WOMAC and Study 36-Item Short Form Health Survey (SF-36) functional questionnaires.

A second study reported similar improvements between PRP injection and HA injections at a two-month follow-up but PRP results were better than HA at the 6-month follow up, especially in younger patients, which suggests a longer-term benefit for PRP. When comparing patient age and the degree of OA, the study reported PRP and HA showed similar results in patients over 50 and in those with more advanced OA, suggesting PRP might have better outcomes than HA in younger patients with either cartilage lesions or early OA.

A third double blind randomized control trial compared PRP to HA using the WOMAC, International Knee Documentation Committee (IKDC) for overall function, and Visual Analog Scale (VAS) for pain. No difference was seen between groups in regard to WOMAC score, but there was significant improvement in the IKDC score and VAS score in the PRP group.

PRP vs. Corticosteroid Injection

In a study comparing PRP to corticosteroid injections, PRP provided superior pain and symptom relief for patients with OA as well as significantly improved quality of life when compared to those receiving a cortisone injection.

PRP vs. Prolotherapy

When compared to prolotherapy in a double-blind randomized control trial, PRP injections were more effective in improving WOMAC scores at 1 month, 2 months, and 6 months post-injection.

Limitations

The largest limitations thus far in PRP research is the lack of consistency among PRP processing and concentrations which makes it difficult to prepare an ideal clinical PRP solution. There are still only a few randomized control trials that look at long-term follow-up; more research is needed in this area. The high cost and lack of insurance coverage for PRP injections (out-of-pocket costs range from $500 to $2,000 per injection) limit the number of people who can afford PRP and thus limits the real-world evidence that can be gathered.

Conclusion and PTF Implications

There is clear evidence to support the use of PRP in knee OA. The main advantages of using PRP are its longer-lasting and more efficacious function in restoring articular function when compared with HA injections, corticosteroid injections, and prolotherapy. It appears that PRP is most beneficial for early/low-grade OA compared with more advanced OA. Better outcomes are seen in patient populations under 50 years old with earlier OA due to PRP preventing or slowing the progression of the disease. As research increases on this subject, the use of PRP to treat OA will potentially increase leading to a possible decrease in total joint replacements and financial expenditures associated with OA. A combination of PRP injections and a tailored PT program could prove beneficial for patients with early knee OA and prevent the need for total joint replacement.

Reference

Southworth, T., Naveen, N., Tauro, T., Leong, N., Cole, B. (2019). The Use of Platelet-Rich Plasma in Symptomatic Knee Osteoarthritis. The Journal of Knee Surgery. 32:37-45.