Did you know that two of the most common ankle injuries, specifically for sports, include ankle sprains and ankle fractures? Ankle sprains occur in 600-700 per 100,000 persons, and ankle fractures happen in 107-187 per 100,000 persons per year. After a sprain, persistent symptoms may linger for up to 30% of individuals, and a history of an ankle sprain remains a predisposing factor for recurrent future ankle sprains. Similarly, after an ankle fracture, symptoms may limit lower limb activities and persist long term.

This study aimed to identify the current treatments for ankle sprains and ankle fractures using the most recent systematic reviews and randomized controlled trials.

Treating Ankle Sprains:

Ankle sprains are usually managed conservatively; the acute phase involves symptom management followed by a period of rehabilitation. Current evidence supports the use of non-steroidal anti-inflammatory drugs (NSAIDs) and functional support during the immobilization or acute stage of an ankle sprain. When compared with a placebo, the participants who used NSAIDs during the first two weeks following the sprain reported a significant improvement in function in the long term. Functional support implies the use of braces, elastic bandage, tape, semi-rigid support, and lace-up ankle support over the injured ankle. Studies have found all supports equally effective in decreasing pain, swelling, preventing recurrent sprains, and providing support for ankle instability. When compared to adults who didn’t use functional support, the group of adults who used this form of support demonstrated greater range of motion (ROM), less persistent swelling, and reported a higher percentage of return to sports or work-related activities. Additionally, performing balance and ankle strengthening exercises during and after the subacute phase is beneficial for those with chronic ankle instability and those predisposed to recurrent ankle sprains.

According to the review, electro-physical agents (Ex: TENS Unit) were not recommended during the acute stage of an ankle sprain. There is weak evidence for the use of manual therapy for positive short-term or acute effect and this could be partially attributed to small randomized controlled trials and cross-over studies. Nonetheless, in one study, manual therapy has shown to increase ankle function up to one month following the treatment. In addition, current evidence proves that Mulligan’s mobilization with movement technique (anterior to posterior glide of the talus) during the subacute phase, is effective in increasing dorsiflexion range for participants with Grade 2 ankle sprains.

Treating Ankle Fractures:

As opposed to ankle sprains, ankle fractures usually involve surgical or a conservative fracture reduction and are followed by immobilization and rehabilitation. Usually, rehabilitation for ankle fractures is followed after the period of immobilization. This study suggests that early rehabilitation including weight-bearing exercises with an orthosis or brace during the immobilization phase may be beneficial for people after surgical fixation. In one randomized controlled trial, using an orthosis with ankle exercises led to better outcomes in function and ankle range of motion when compared to the group that only received cast immobilization. However, it is important to note that the use of a brace or orthosis to allow for exercise during the immobilization period of a fracture may also lead to a higher rate of adverse effects. Caution must be taken as early mobility during the acute stage may only be tolerable for some individuals. Current evidence on treatments for ankle fracture suggests the use of manual therapy, a gradual increase in activities, and a structured exercise program to enhance outcomes for individuals following immobilization.

Summary

Evidence-based treatment of acute ankle sprains should include functional support and NSAIDs during the acute phase after the injury. Manual therapy may also provide additional benefits during the subacute phase. Additionally, performing ankle strengthening and stabilization exercises have been shown to reduce recurrent sprains and chronic ankle instability. After an ankle fracture, current evidence supports early weight-bearing during the immobilization period for patients who are able to do so safely. After the immobilization period, treatment should be structured with a comprehensive and progressive exercise program.

The physical therapists at Physical Therapy First are trained and equipped to provide you with this specific care while meeting your individual needs. Questions? Feel free to contact any of our skilled therapists by phone or by appointment.

References:

Lin CW, Hiller CE, de Bie RA. Evidence-based treatment for ankle injuries: a clinical perspective. J Man Manip Ther. 2010;18(1):22-28. doi:10.1179/106698110X12595770849524

30% of postmenopausal women in the US were reported to have Osteoporosis, and at least 40% of these women will sustain one or more fractures during their lifetime. That’s a significant number to think about.  Fractures can lead to pain, disability, loss of activity tolerance, and functional independence. Also, after an initial fracture, individuals are 2x at risk for secondary fractures within that year.

While the disease is more common in women, men are also at risk for osteoporosis. Nonetheless, if you are diagnosed with this or are at risk of being diagnosed, it’s essential to know that our bodies are still incredibly adaptable. Countless research has shown that exercise is an EXCELLENT evidence-based tool to decrease modifiable risk factors for falls and fractures! Your bone is a dynamic tissue that responds to your body and external loads by changing its structure/strength and alters its mass. It does so to withstand any excessive loads that are likely to result in a fracture.

This systematic review highlights the following key points:

1. Principle of Specificity: target specific areas of the body that are most susceptible to fractures: wrist, hip, and spine
   • Incorporating back extension strengthening exercises was associated with increasing spinal bone density.
   • High impact jumping exercise interventions 2-3x/week in post menopausal women were found to have a significant positive impact on the femur 12 months after it was performed. (We recommend discussing with a Physical therapist to find a strengthening program that’s right for you- our bodies respond differently based on our needs)
2. Principle of Progressive Overloading: as your bone adapts to an exercise, it must be increased progressively (Ex: increase time spent, add more reps, add weights or resistance bands)
   • We recommend progressing your exercise once it starts becoming easier/every 2 weeks as a guideline.
3. Principle of Reversibility: Any skeletal changes from exercise training will be lost once you stop it. Minimum dose to have a positive effect on your bones for the long term is 2 sessions per week.
   • For true physiological skeletal changes to occur, the exercise intervention must last over 12-18 months. Patients may see the greatest changes in their bone mineral density during the first 5-6 months of starting the program.

Research-based parameters:

• • • Weight-bearing exercises 4-7x/week
      • Ex: sets of jumping 20-40 times, bounding, skipping, hopping, playing tennis, dancing, recreational gymnastics, or playing football
    • Challenging balance training for ~3hrs/week reduces falls by 39% and doing reactive or volitional stepping training reduces falls by 50%
      • Ex: leaning/reaching over your toes, being able to stand still despite any perturbations, stepping over surfaces, and walking on unstable surfaces.
    • Type of exercise: water-based exercise has been proven to reduce age-related bone loss at the hip and lumbar spine. Land-based exercises are better for improving your bone health overall.
    • Resistance training: maintains and helps to improve bone mineral density when performed at high-intensity loads.
      • Minimal requirements: 2 sets, 12 repetitions, at 70% of your maximal muscle strength. Performed 2-3 times per week.
      • The exercise has to be progressively increased over time, and it must target your large muscle groups. Ex: squats, lunges, hip abduction/adduction, and abdominal strengthening/Transverse Abdominis focus.

At Physical Therapy First, our clinicians are highly knowledgeable and trained to create a program that is tailored to your needs. If you are someone who is at risk or have been diagnosed with osteoporosis or low bone mineral density, you could benefit from an evaluation by one of our therapists to decrease any modifiable risk factors and maintain your physical health.

Reference:

Daly RM, Dalla Via J, Duckham RL, Fraser SF, Helge EW. Exercise for the prevention of osteoporosis in postmenopausal women: an evidence-based guide to the optimal prescription. Braz J Phys Ther. 2019;23(2):170-180. doi:10.1016/j.bjpt.2018.11.011

by Jeslin Thomas

It’s not as tricky as you may think. If you are curious or have been diagnosed with one of these, the therapists at PT First can help you out!

Spondylosis: refers to when you have degenerative osteoarthritis (OA) of the spine- this essentially means that the space between your vertebrae narrows as the protective cartilage that cushions the ends of the vertebrae wears down with age. With time, you may notice you have more of a flexed (forward bending) posture. Individuals suffering from this may experience lower back pain, leg pain, and/or numbness when standing or walking; symptoms may only seem to improve with sitting or lying down1.

Spondylolysis: refers to a stress fracture defect in the pars interarticularis of the vertebrae (commonly found in the L4/L5 region). This is usually caused by repetitive stress or trauma at the Lumbar spine from strenuous activities involving excessive twisting/rotating or back bending (ex: gymnastics, dancing, wrestling, and football.). Symptoms may or may not be present initially, but as the injury progresses, these individuals may complain of pain as they bend backward or pain with general activities2.

Spondylolisthesis: often refers to the progression of a spondylosis injury, but it may also be congenital or idiopathic in nature. Spondylolisthesis is defined as the displacement of one vertebra over the vertebral body below it (commonly known as a “step off” or “slip” at the L5/S1 level); individuals may even notice the presence of a bump by the area of the slippage. There are 5 different grades of this slippage, and it’s defined by the extent to which the vertebral body has slipped:
Grade I: O-25%        Grade III: 50-75%        Grade V: > 100%
Grade II: 25-50%      Grade IV: 75-100%
Individuals with this may complain of localized pain that may come and go with certain activities, and this may be the most notable when bending backward or forward at the affected segment. They may experience radicular pain down to one or both legs as the vertebrae slides and causes compression of the nerve root below, tense hamstrings, loss of bowel/bladder (rare), and difficulty with balance or walking.

What can we do?

First, you can consult with your Doctor to obtain an MRI, CT, Bone scan, or X-ray to confirm the diagnosis and determine the extent of the injury. Treatments can involve both operative (surgical) or nonoperative/conservative management (Physical Therapy, NSAIDs/analgesics, and bracing). Generally, surgical interventions are reserved for those with significant symptoms or failure of conservative treatments.

With spondylosis, conservative management involving aerobic exercises such as biking and general strengthening and stretching of your whole body has been correlated to greater quality of life among adults with lumbar osteoarthritis 3. In addition, maintaining good posture throughout and maintaining our postural muscle strength can help to decrease pain and promote proper muscle length-tension relationships.

With spondylolysis, as with any fracture, your body will need time to heal. This means 4-8 weeks (or longer) of rest from high impact activities such as sports and lifting heavy items. Your Doctor may also recommend pain medications such as NSAIDs or steroids to help reduce pain and inflammation. During this time, Physical Therapy may be recommended and can help with facilitating the healing process, reduce pain, strengthen and stabilize specific muscles, and help you navigate through your everyday activities.

In addition, with both spondylolysis and spondylolisthesis, studies have shown that specific strengthening of the deep multifidus and transversus abdominis can be beneficial for spinal instability that commonly occurs 3,4. Overall, exercises to promote the full spinal range of motion and lumbar strengthening exercises have been proven to be a successful treatment option for decreasing pain and functional limitations 2,4,5. At PT First, our therapists have treated multiple patients with success when using this evidence-based method. If you have any questions, don’t hesitate to ask any of our licensed therapists!

References

Middleton, Kimberley, and David E. Fish. “Lumbar Spondylosis: Clinical Presentation and Treatment Approaches.” Current Reviews in Musculoskeletal Medicine 2, no. 2 (March 25, 2009): 94–104.

Garet M, Reiman MP, Mathers J, Sylvain J. Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: a systematic review. Sports Health. 2013;5(3):225-232. doi:10.1177/1941738113480936

VIEIRA, S., et al, Abdominal muscle strength is related to quality of life among older adults with lumbar osteoarthritis. Journal of bodywork and movement therapies, 2015. (level of evidence 2A)

Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008;17(3):327-335. doi:10.1007/s00586-007-0543-3

Back Pain: Spondylosis, Spondylolysis, and Spondylolisthesis. SPARCC Sports Medicine – Tucson AZ. https://sparcctucson.com/2019/03/21/back-pain-spondylosis-spondylolysis-and-spondylolisthesis/. Published October 23, 2019. Accessed August 2, 2020.

Images:

https://www.braceability.com/blogs/articles/lumbar-spondylolisthesis-vs-spondylolysis
www.youtube.com/watch?v=3SoNJ5ELR6Y

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.

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.