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Sleep Hygiene Tips and Tricks

by | Apr 13, 2021 | Health Tips

Gabrielle Herman, PT, DPT, CMPT

 The three pillars of health include diet, exercise, and sleep. Optimizing all three is critical to exercise recovery as well as overall health and well-being. Ignoring one pillar often causes the other two pillars to suffer. For example, someone that is sleep deprived may perform poorly in exercise or begin to crave unhealthy foods. These negative effects of sleep deprivation must be addressed regularly by sports medicine providers as well as general practitioners as there are clear negative effects of sleep deprivation on performance in athletes such as accuracy, reaction time, endurance, submaximal strength as well as cognitive functions including judgement and decision-making.

 Sleep Deprivation in Elite Athletes

High level athletes are known to get less total sleep than non-athletes due to demanding training and competition schedule and travel and time zone changes. Stress and anxiety before an upcoming game or match may also hinder an athlete from getting a healthy sleep. In addition to this, the significant increase in smartphone and electronic devices further interrupt sleep schedules with possible negative impacts on melatonin production from blue-light emissions.

Negative Effects of Sleep Deprivation

  • Neurocognitive, metabolic, immunologic, and cardiovascular dysfunctions are shown in general population
  • Physical effects in athletes:
  • Decreased running performance
  • Decreased muscle glycogen concentration
  • Reduced submaximal strength
  • Decreased soccer kicking skills
  • Decreased tennis serve accuracy
  • Decreased time to exhaustion

Positive Effects of Sleep Extension

  • Restoration of sleep and sleep extension can improve the following
  • Sprint times
  • Tennis serve accuracy
  • Swim and kick stroke efficiency and swim spring
  • Basketballs shooting accuracy
  • Time to exhaustion
  • Psychomotor vigilance tasks, alertness, vigor, and mood
  • Decreased sleepiness and fatigue
  • Newer studies demonstrate a nap the day following a night of sleep deprivation may be beneficial
  • A new concept of “banking sleep” which is a sleep extension prior to a night of sleep deprivation in a pilot study improved motor performance
  • Most studies agree upon increasing sleep by 2 hours with the goal of 9 hours for elite athletes
  • Future research is needed to further detail the benefits of banking sleep

Top Ten Recommendations for Healthy Sleep Hygiene

  1. Don’t go to bed until you are sleepy
  2. Regular bedtime routine/rituals help you relax and prepare body for sleep
    • Warm bath
    • Reading a book
  3. Try to get up at the same time every morning (including weekends and holidays)
  4. Try to get a full night’s sleep every night and avoid daytime naps (if you must nap, limit to 1 hour and avoid nap after 3 pm)
  5. Use the bed for sleep and intimacy only; not for any other activities including TV, phone use, or laptop
  6. Avoid caffeine if possible, if must use, avoid after lunch
  7. Avoid alcohol is possible, if must use, avoid right before bed
  8. Don’t smoke or use nicotine, ever
  9. Consider avoiding high-intensity exercise right before bed
  10. Make sure bedroom is quiet, as dark as possible, and a little on the cool side rather than warm

Additional Sleep Hygiene Recommendations

  1. Avoid blue light emitted from screens at least 2 hours before bed
  2. Get bright, natural sunlight upon awakening – some suggest at least a 10,000 lux lamp if you cannot get natural sunlight
  3. Don’t hit the snooze button, it does not improve sleep quality
  4. If you have difficulty waking up, some suggest a dawn-simulator alarm clock
  5. If you must use a computer at night, consider installing blue-light reducing software or wear blue-light blocking glasses
  6. Higher Carbohydrate foods at night may actually improve sleep, as well as high protein including tryptophan. High fat intake may disrupt sleep. Inadequate total caloric intake during the day may impair sleep at night.
  7. Topical magnesium (salt bath, topical mineral oil, or oral magnesium may help if you are deficient
  8. Melatonin naturally occurring in foods (Tart cherry juice, raspberries, goji berries, walnuts, almonds, tomatoes) may potentially improve sleep, but avoid artificial melatonin supplements
  9. Don’t fall asleep to the T.V. Sleep studies show you frequently wake up during the night and have poor quality sleep.
  10. Herbal supplements are largely unknown with potential serious side effects, and may be on the USADA-prohibited list or result in positive banned substance test for athletes
  11. Consider reducing fluid intake before bed so you don’t get up to go to the bathroom (Only if you maintain enough hydration during the day)
  12. Cooling body temperature may improve sleep. Some suggest keeping the room between 60-70 degrees; however, keep hands and feet warm
  13. Check your mattress – it may be too old and have allergens (most last 9-10 years)
  14. Recovery from exercise should not only focus on muscle recovery. Reducing mental fatigue is just as important for health sleep. Reduce external stressors in your life.

References:

Vitale, K. C., Owens, R., Hopkins, S., Malhotra, A., Sleep Hygiene for Optimizing Recovery in Athletes: Review and Recommendations. Int J Sports Med. August 2019: 40(8): 535–543. doi:10.1055/a-0905-3103

Carpal Tunnel Syndrome-2019 Clinical Practice Guidelines for Hand Pain and Sensory Deficits

by | Apr 5, 2021 | Health Tips

By Joseph Holmes, PT, DPT, FNCP

A leading group of physical therapists gathered over a couple year period to review all the most up to date literature on the conservative treatment of carpal tunnel syndrome (CTS). CTS is defined as having a compression of the median nerve going through the carpal tunnel of the wrist, and reproduces pain, numbness, or weakness in the thumb, index, middle, and half of the ring finger all on the palm side of the hand (Wipperman, 2016). 3.8% of the population experiences carpal tunnel syndrome annually, with the prevalence higher among women than men, most common in 40–60-year-olds, and as expected increases in frequency with an increased presence of the following co-morbidities (Ibrahim et al, 2012):

  • Smoking
  • Diabetes
  • Personal history of carpal tunnel syndrome
  • Family history of carpal tunnel syndrome
  • Work activities which put frequent force or vibration through the wrist such as typing

CTS can be treated surgically with successful outcomes, but also can be intervened with on a conservative basis, such as with physical therapy. I will summarize the latest evidence on how your physical therapists at Physical Therapy First will use the latest research and evidence to help you recover from your carpal tunnel syndrome, with guidance from the 2019 Clinical Practice guidelines for Carpal Tunnel Syndrome (Erickson et al, 2019).

The evidence to support these recommendations for the diagnosis and treatment of your carpal tunnel syndrome is based on a criterion of strong to very weak or poor evidence. The criteria are described in further detail below:

Image from the CTS: CPG, page 6.

 Diagnosis

The clinical practice guidelines recommend using the following criterion for proper diagnosis of carpal tunnel syndrome. Your physical therapist at Physical Therapy First will use the most up to date and accurate criterion to provide you with the best information available regarding your diagnosis. The CPG recommends using monofilament testing to assess a person’s response to the feeling of light touch, and the ability to discriminate that touch throughout various parts of your palm and hand. Your physical therapists will also assess the following risk factors which may put you at higher risk of having Carpal Tunnel Syndrome:

  • Age >45
  • Does shaking your hand relieve your symptoms?
  • Do you have loss of sensation in your thumb?
  • Is the depth of your wrist >.67% the size of the width of your wrist?
  • And upon completing the subjective Boston Carpal Tunnel Questionnaire-Symptom Severity Scale, do you score greater than 1.9? See the BCTQ-SSS, below:

Image courtesy of Levine et al. 1993, the creators of the BCTQ-SSS.

After completion of these 5 risk factors, noting positives on 3 of the 5 leads to an accurate diagnosis of Carpal Tunnel Syndrome. Next, the clinician will perform multiple hands on manual reproductive tests of the wrist (Phalen’s, Tinnel’s, and the Carpal Tunnel Compression Test) to see if compression or palpation of the carpal tunnel reproduces your carpal tunnel symptoms. All of the above diagnostic criteria are rated as ‘A’ or ‘B’, signifying good or very good evidence in support of their performance and accuracy.

Examination

There is either poor evidence or no evidence in support of the following examination criteria to test for Carpal Tunnel Syndrome:

  • Lateral Pinch Strength
  • Grip strength: Not accurate after surgery, but good examination tool non-surgical
  • Conflicting evidence for testing pinch tip strength of the thumb and first and second fingers
  • Little or conflicting evidence regarding sensory discrimination, threshold, or vibration testing

Interventions

The following interventions are recommended with strong (A), moderate (B) or weak (C) evidence for Carpal Tunnel Syndrome:

  • A neutral positioned wrist splint to be worn at night for short term relief
  • Therapeutic exercise including stretching for mild to moderate CTS
  • Manual therapy (joint mobilizations, stretching) to the cervical spine and upper extremity for people with mild to moderate CTS
  • A trial of electrical stimulation for short term pain relief
  • A trial of superficial heat for short term pain relief

Physical Therapists should not use the following treatment interventions due to poor or conflicting evidence for their effectiveness:

  • Low level laser
  • Iontophoresis
  • Thermal or Non-thermal ultrasound

 The physical therapists at Physical Therapy First look forward to assisting you in conservative strategies to relieve your carpal tunnel pain and subsequent dysfunction, guided by the best evidence available. Physical Therapy First provides the highest quality care in the Greater Baltimore region with 1 on 1 treatment sessions with your physical therapists for 1 hour. Contact any of our offices (Roland Park, Timonium, Clarksville, or Rosedale today to set up your 1 on 1 consultation with the area’s best physical therapists.

1) Wipperman J, Goerl K. Carpal Tunnel Syndrome: Diagnosis and Management. Am Fam Physician. 2016 Dec 15;94(12):993-999. PMID: 28075090.

2). Ibrahim I, Khan WS, Goddard N, Smitham P. Carpal tunnel syndrome: a review of the recent literature. Open Orthop J. 2012;6:69–76.

3) Erickson M, Lawrence M, Jansen CWS, Coker D, Amadio P, Cleary C. Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome. J Orthop Sports Phys Ther. 2019 May;49(5):CPG1-CPG85. doi: 10.2519/jospt.2019.0301. PMID: 31039690.

 

 

Sleep Hygiene and Athletic Performance

by | Mar 22, 2021 | Health Tips

Gabrielle Herman, PT, DPT, CMPT

It is well recognized that getting 7-9 hours of sleep for adults and 8-10 hours for adolescents is an essential component of health and general well-being. In the more recent years, there has been accumulating evidence regarding the importance of sleep for recovery from athletic training and competition as well as it’s effect on athletic performance. Unfortunately, athletes have been shown to consistently average les than 8 hours of sleep along with higher reports of poor sleep quality amongst elite athletes.

Barriers to Sleep in Athletes

  • Poor self-assessment of sleep need, duration, quality making athletes less likely to seek guidance or medical help
  • Excessive training volume
    • Studies showed an Increase in acute training load was associated with decreased sleep duration and quality in youth female soccer players and Australian football players
  • Training schedule: sleep duration significantly impacted by early morning training
  • Long distance travel and the associated disruptions in mood, stress, and anxiety
    • Retrospective 40 year study of NFL night game competitions show a consistently higher success rate for west coast based NFL teams compared to east coast teams due to altered sleep schedules and disruption of circadian rhythms
  • Increased levels of stress, anxiety, and insomnia around competition
  • Concomitant academic pressures in youth and collegiate athletes
  • Sleep-disordered breathing only affects 4% of the population but has been estimated to be present in 14% of professional football players

 Sleep and Performance

  • Poor quality sleep was an independent predictor of lost competition in a recent study in Brazil on elite male and female athletes
  • In team sports, improved sleep duration and quality are associated with increased changes of competitive success

Endurance and Anaerobic Power

  • Sleep deprivation inhibits performance perhaps through perceived exertion
    • 30-minute self-paced treadmill test was administered to 11 male subjects randomly assigned to normal night’s sleep and 30 hours sleep deprivation
      • The deprivation group had a decreased distance covered without differences in thermoregulatory functions or oxygen consumption
    • One night of sleep loss shown to decrease time to exhaustion in progressive testing in volleyball players
    • A single night of restricted sleep after a heavy exercise bout resulted in a 4% decrease in 3-km time trial performance the following morning in adult cyclists
  • Pre exercise muscle glycogen stores are decreased after sleep deprivation

Sprint Performance

  • Evidence for speed and strength training and sleep deprivation is conflicting
  • Studies vary in results for sprint tests with sleep deprivation as some results show increased times, decreased times and some no change

 Sleep, Injury and Illness

  • Impaired or decreased sleep is associated with increased risk of injury
    • Study in middle and high school athletes found those who slept less than 8 hours per night were 70% more likely to report an injury
  • The greatest risk for injury results when training load is increased and sleep duration decreased simultaneously, which is often seen in competitive travel and training camps
  • The underlying mechanism may be related to impairments in reaction time and cognitive function or may contribute to higher levels of fatigue
  • Decreased sleep is immunosuppressive and increases susceptibility to upper respiratory infection

 Interventions to Promote Sleep in Athletes

  • Athletes with complaints of poor sleep or excessive daytime fatigue should be screened for medical conditions such as insomnia, sleep disordered breathing, restless legs syndrome, depression, anxiety, or concomitant illness
  • A sleep monitor or daily sleep journal kept for 2 weeks can be used to quantify sleep duration
  • Gradually extend sleep by 30-60 minutes per night utilizing the following sleep hygiene techniques:
    • Sleeping in a cool dark environment without electronic devices
    • Minimal ambient noise or distraction
    • Establish consistent sleep and wake times
    • Incorporate 30-60 minutes of quiet relaxation before bedtime
    • Portable electronic devices may suppress natural melatonin production and interfere with sleep, therefore restriction from use for at least 1 hour prior to bedtime may be reasonable
    • Over the counter sleep aids should be avoided
    • Caffeine and stimulants limited to the morning hours
    • Variation in training schedule should be minimized
    • Early morning and late evening training/competitions should be avoided when possible

In conclusion, optimizing your sleep duration and quality can have a large impact on not only sport performance, but can also reduce sport related injury risk and keep you healthy!  Proper scheduling, travel protocols, time management, stress management, and sleep hygiene in athletes can improve overall well-being and athletic performance success.

Watson, Andrew M., MD, MS. “Sleep and Athletic Performance” American College of Sports Medicine, Volume 16, Number 6: 413-418, (2017).

 

Fast Track Approach to Total Hip Arthroplasty and Shortening Length of Stay.

by | Mar 15, 2021 | Health Tips

by Sean Phillips, PT, DPT, OCS

Total hip arthroplasty (THA) is one of the most common joint replacement surgeries performed around the world. In the past, it was common for patients to stay in the hospital for up to 2-3 weeks post-op and were typically forced to bedrest. Recently, however, there has been a shifting sentiment towards a “fast track” approach that greatly reduces the length of stay (LOS) in the hospital and leads to a quicker recovery overall.

In a study by Klapwijk et al, the first 6 weeks after a patient’s discharge from the hospital following a THA with fast track were observed. This prospective cohort study was performed in the Netherlands in 2015, and involved 94 patients who received a THA with an anterior approach. Each patient was provided a diary to document their pain and function on a daily basis for 6 weeks following their discharge from the hospital or outpatient center. These forms included…

  • Hip injury and osteoarthritis outcome score physical function short form (HOOS-PS)
  • Oxford hip score (OHS)
  • EuroQol quality of life (EQ-5D)
  • NRS pain score
  • 12-item short-form health survey (SF-12)
  • Intermittent and constant osteoarthritis pain score (ICOAP)

Out of the 94 patients who participated, 52 received an inpatient surgery and 42 were in an outpatient setting. The average LOS was one night for inpatient and released the same day for outpatient. Overall, the study found that over the first 6 weeks, patients reported gradual and significant improvements in a variety of factors including pain, sleep quality, walking ability, and functioning for daily activities (OHS, HOOS-PS, SF-12 PCS). Another result this study identified was that patients reported an improvement in a variety of these surveys within the first week post-op relative to their scores pre-op.

Although the study did have some limitations including limited sample size and only utilizing self-reported subjective values, it did shine a light on the efficacy of a fast-track approach following THA. They found that 97% of the participants reported that the were satisfied with their shorter LOS, and over the first 6 weeks patients’ pain gradually decreased as their function gradually increased.

Source:

Klapwijk LCM, Mathijssen NMC, Van Egmond JC, Verbeek VM, Vehmeijer SBW. The first 6 weeks of recovery after primary total hip arthroplasty with fast track: A diary study of 94 patients; Acta Orthopaedica 2017; 88 (2): 140–144

Motion control shoes reduce the risk of pronation-related pathologies in recreational runners: a secondary analysis of a randomized controlled trial

by | Mar 8, 2021 | Health Tips

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

Introduction:

Runners frequently encounter injuries to their lower extremities. An increased amount and poor timing of foot pronation have been cited as risk factors for running-induced lower leg pain, medial tibial stress syndrome, stress fractures of the tibia, Achilles tendinopathy, planter fasciitis, patellar tendinopathy, and anterior knee pain. Motion control footwear may be effective in reducing the amount of foot pronation and reducing injury risk in runners. The authors in the study investigated the effect of motion control shoes on the development of pronation-related running injuries in a prospective study.

Methods:

372 recreational runners ages 18-65 years old who ran at least one session/week for at least six months were included in the study.  Their baseline foot posture index was assessed and participants were randomized to receive either the “standard shoe” or the “motion control shoe.” Participants then kept track of training data on an internet platform where they reported type of activity, context, duration, subjective BORG scale, distance covered, running surface and shoes worn. They also reported any injury sustained which included those to the lower limbs or lower back and impeded running for at least one day. The injury description included anatomical location and participants were evaluated at the end of the session.

The injuries were classified as an overuse injury associated with over-pronation including Achilles tendinopathy, exercise related lower extremity pain, plantar fasciitis, or anterior knee pain. The Injuries which are not associated with overpronation include ankle sprains, hamstring strains, and iliotibial band syndrome, to name a few.

Results:

Data from 372 runners (mean age:40 years, 40% female) who completed the trial were analyzed. Twenty-five runners sustained pronation-related running injuries (PRRIs). Sixty-eight runners sustained other running-related injuries (ORRIs). The effect of type of shoe on injury showed that the probability for sustaining a PRRI with the motion control shoe is lower compared to the standard shoe. Shoe type was a significant predictor of PRRI but not ORRI and a previous injury significantly increased the risk for both a PRRI and an ORRI.

Discussion:

The results show that running in motion control shoes reduced the incidence of sustaining a PRRI, confirming the authors’ hypothesis. There was a 2.5x lower risk of developing a PRRI in motion control versus standard shoes. However, there was not a significant difference in motion control shoes on sustaining an ORRI. The authors encourage clinicians to recommend shoes to specifically target PRRIs as those shoes benefited the recreational runners in this trial.

Conclusion:

Wearing motion control shoes reduced the risk of pronation-related running injuries in middle-aged recreational runners, but not other running-related injuries.

Reference:

Willems, Tine., Ley, Christopher., Goetghebeur, Els., Theisen, D., Malisoux, L. Motion control shoes reduce the risk of pronation-related pathologies in recreational runners: a secondary analysis of a randomized controlled trial. Journal of Orthopedic and Sports Physical Therapy. Epub 11 Dec 2020. doi:10.2519/jospt.2021.9710

 

 

 

Low Back Pain in Golf: Physical Therapy’s Role in Returning to Sport

by | Mar 1, 2021 | Health Tips

by Sean Phillips, PT, DPT, OCS

Golf is one of the most popular recreational activities in America, with approximately over 25 million players country-wide. One of the most appealing aspects of golf is the ability to continue playing well into our 60s, 70s, and even 80s, but although the sport may not seem as physically demanding as others, injuries can be quite common. Losing the ability to play golf due to back pain can be very frustrating, but there has been research into rehabilitation in order to return to the sport quickly as well as prevention strategies to reduce the risk of reinjury. In an article by Christopher Finn, MSPT, CSCS, TPI CGMP, these concepts are reviewed and discussed.

As people age, the spine’s mobility and ability to absorb forces decreases. This can lead to lower back pain (lumbar pain) which has been attributed to approximately 1/3 of all golf injuries. The majority of these injuries are caused by the repetitive motions of the golf swing over time instead of one traumatic event, and are more likely to occur if muscular imbalances or poor swing mechanics exist. These injuries can include muscular strains, facet joint inflammation, spondylosis, disc herniation, and even stress fractures of the ribs.

The treatment of these issues usually benefits from a multidisciplinary approach involving both Physical Therapy to assess muscular imbalances and weakness, and PGA pros to assess flaws in swing mechanics. Physicians may also order medical imaging for further diagnosis, prescribe medication, or utilize cortisone injections to help reduce pain in the short-term.

Physical Therapy has been shown to be very effective in treating low back pain and other injuries in golfers. During someone’s time in physical therapy, they can expect to receive screening and treatment to restore muscular balance throughout the body. These include:

  • Core stabilization exercises
  • Spinal mobility and range of motion assessment
  • Diaphragmatic breathing techniques
  • Muscular flexibility training
  • Hip, trunk and shoulder strengthening
  • Transversus abdominis and multifidus activation

Since the body works in unison throughout a golf swing, it is difficult to say any one exercise is the most important. Muscle groups are constantly activating while others are simultaneously turning off, all while the joints and muscles require the proper mobility and flexibility to freely move through their required range of motion during the swing. Therefore, it is beneficial to have a professional identify these areas of limitations in order to develop a personalized plan for recovery and reduce the risk of injury in the future.

If you are interested in reducing your low back pain while golfing or would like to learn of any muscular imbalances that could be affecting your game, physical therapy may be a great option for you! The therapists at Physical Therapy First have an extensive background in treating orthopedic and sports injuries of all kinds, and are able to dedicate the one-on-one treatment time that you deserve to get you to where you want to be.

Sources:

Christopher Finn, MSPT, CSCS, TPI CGMP. Rehabilitation of Low Back Pain in Golfers: From Diagnosis to Return to Sport. In Sports Health. July/August 2013. Vol. 5. No. 4. Pp. 313-319