by ptfadmin | Jan 11, 2023 | Health Tips
by Tyler Tice, PT, DPT, MS, ATC
Background:
Rotator cuff disorders have been reported to occur in 30-50% of people over the age of 50 and the number of rotator cuff repair surgeries performed each year continues to rise. The rotator cuff is comprised of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis, and plays a vital role in stabilizing the shoulder during arm movements. Previous research has demonstrated that rotator cuff healing correlates with outcome. In patients that had an intact supraspinatus had improved functional outcome scores and satisfaction, along with a reduction in osteoarthritis progression compared to those who experience a re-tear. In surgeries that were deemed to be biomechanically superior, research has demonstrated only modest improvements in healing rates. This suggests a need for further improvement in the biological environment rather than the mechanical environment to substantially improve rotator cuff healing.
Pathology of rotator cuff tendon:
Rotator cuff disease is a spectrum ranging from tendinopathy to eventual degenerative tear. One research study has suggested the gradual degeneration of the tendons occurs as a consequence of simple anatomical variation, inciting repetitive microtrauma to the rotator cuff. Because of the repetitive trauma and inefficient loading of the tendon that would assist in the natural repair process, eventual tendon failure will occur, resulting in a tear. After undergoing a surgical repair, remodeling at the site where the tendon meets the bone gradually occurs over time. Animal studies have demonstrated that following repair the tensile strength that is achieved is approximately half the amount of normal tissue, putting the individual at risk for a re-tear.
Patient factors and clinical decision making:
Prior to any surgical procedure, there is the potential to influence the biological environment and outcome of repair through clinical decision making. Patient factors to consider are history of smoking and presence of comorbidities such as Diabetes Mellitus (DM). Presence of factors like this have been shown to have negative impacts on tendon healing, which would put the patient at further risk for re-tear following repair. A patient’s BMI may also play a role in tendon healing, however there is current insufficient evidence available. History of receiving corticosteroid injections have also been shown to impact tendon healing, despite them frequently being used in the treatment of rotator cuff disease. The size and location of the rotator cuff tear as well as fatty infiltration has also been shown to impact post-repair outcomes. In animal studies, vitamin D levels have been implicated in cuff healing however there is insufficient evidence in human studies.
Growth factor/cytokine-based augmentation:
Growth factors have the potential to improve the environment in which the repair occurs.
Matrix metalloproteinase (MMP) inhibitors: One study demonstrated tendon degeneration in the presence of overactivity of MMPs or underactivity of tissue inhibitors. One animal study demonstrated the effectiveness in MMP inhibitors following repair however further research in human participants needs to be conducted.
Rotator cuff repair and platelet rich plasma (PRP): One meta-analysis demonstrated a significantly higher healing rate in small-medium and medium-large rotator cuff tears when PRP was administered at the time of surgery. Another meta-analysis demonstrated conflicting results regarding the use of PRP as both groups, control and experimental, had significant reduction in re-tears. One study proposed delayed application of PRP intra-operatively may be more beneficial and improve retention at the repair site, however no significant improvement in healing or functional outcomes was observed.
Partial thickness rotator cuff tear/tendinopathy and PRP: One meta-analysis demonstrated short-term benefit from receiving a PRP injection in the non-operative management of either partial rotator cuff tear or tendinopathy. Another study demonstrated PRP injections were only beneficial in reducing pain in rotator cuff tendinopathy after 24 weeks, however no functional improvement was observed at any point throughout the study.
Stem cell-based augmentation:
There are a number of techniques that have been developed to be utilized in treating rotator cuff tears and tendinopathies. However, research on these techniques either has shown minimal benefit in the utilization of these procedures or were tested on small sample sizes, making the application of the results difficult to the general population.
Biomaterials/scaffold-based augmentation:
In rotator cuff repairs, scaffolds are principally used to mechanically and/or biologically augment the repair site. They improve the biomechanics of the repair site and induces a more acute inflammatory response for improved healing. Extracellular matrix (ECM) scaffolds are biocompatible as they can be derived from human or animal sources, however there is an argument that re-purposed and structurally do not resemble tendon. In two studies that utilized this type of scaffold, reduced re-tear rates were observed up to two years after the surgical procedure. Synthetic scaffolds have also been utilized and research has demonstrated reduced re-tear rates in those who receive this type of scaffold vs. control participants. Degradable synthetic scaffolds are recently emerging, however current research demonstrates high re-tear rates after 1.5 years post-surgery. Bio-inductive scaffolds that are designed to induce biological repair while having little to no mechanical support to repair construct. There is currently little research regarding this technique, however smaller studies utilizing it have produced promising results.
Take Home Message:
There are a number of biologic techniques that are available to improve tendon healing either rotator cuff tendinopathy or following rotator cuff repair. Those who are experiencing rotator cuff tendinopathy or have sustained a rotator cuff tear should look into their available options for treatment before considering surgical intervention. Keeping open communication with your doctor about different ways to manage pain and function will ultimately give you the tools to manage your diagnosis in a way that is most suitable to you.
Reference:
Rohman, M. L., & Snow, M. (2021). Use of biologics in rotator cuff disorders: Current concept review. Journal of clinical orthopaedics and trauma, 19, 81–88. https://doi.org/10.1016/j.jcot.2021.05.005
by ptfadmin | Jan 2, 2023 | Health Tips
by Tyler Tice, PT, DPT, MS, ATC
Introduction:
Tendinitis is defined as inflammation or irritation of a tendon that is generally caused by overuse. Common treatments for this condition are rest, NSAIDs, physical therapy, laser therapy, and shock wave therapy. Due to the presence of inflammation, corticosteroid injections are widely used as it can reduce the inflammation, reduce pain, and improve function. This is highly effective for short-term management of tendinitis; however, a significant side effect of corticosteroid injections are tendon degeneration and later rupture. Frequent use of corticosteroids can inhibit tendon repair, delay tendon healing, and produce tendon degeneration. Following tendon rupture, treatment consists of surgical debridement and repair. The purpose of this article is to review cases of spontaneous tendon rupture after corticosteroid use to reduce post-operative complications.
Methods:
Patients were retrospectively identified who had presented to the hospital with pain or deformity after corticosteroid injection. Inclusion criteria were individuals of tendon spontaneous rupture after corticosteroid injection in the hospital. Exclusion criteria are patients had history of injury, patients were compared with type 2 diabetes, rheumatoid arthritis, or other autoimmune diseases. MRI was utilized to identify tendon injury or inflammation as well as locate the ends of the ruptured tendon before the operation. Depending on the appearance of the injured tendons, optimal surgical technique was determined for that specific patient. If the rupture was small enough (less than 0.5 cm), tendon suturing was completed. If present in the patient and if the injury was too large, the palmaris longus was utilized for tendon grafting. Following imaging, patients with suspected tendon rupture were recommended to mobilization with a splint before operation. The goal of operation was to restore hand function and return to work. Three days following surgery, patients began physical therapy and were to wear braces with the wrist in neutral for 3 weeks (if receiving tendon suture) and 6 weeks (if receiving tendon grafting).
Results:
Regardless of what tendon in the hand ruptured, all patients appeared to have significant degeneration of the tendon during operation. Common post-operative complications were tendon adhesion and tendon rupture. The two patients who sustained tendon adhesions underwent a tendon release 3 months after the first operation. The one patient that sustained a subsequent tendon re-rupture underwent another operation where they received a tendon graft. No patient in this study had complications of infection, vascular, or nerve injury.
Discussion:
Use of corticosteroid injections can lead to serious consequences in tendon quality. In this study, the use of pre-operative MRI to identify the injured tendons and to estimate the extent of the injury was beneficial. The one patient in this study that sustained a re-rupture following surgery may be attributed to the patient receiving a direct suture to the tendons. Following surgery, immobilization and tendon release in supplemental operation are also needed. MRI can be a valuable tool to use throughout the rehabilitation process to monitor healing quality of the repaired tendons.
The usage of corticosteroid injections for wrist and hand pain is still ambiguous. Some patients included in this study were unaware that they were receiving corticosteroid injections. Due to the lack of standardization in the application of corticosteroid injections, further standardization is needed to appropriate address the underlying risk factor of tendon spontaneous rupture. Currently, the most common reason for receiving a corticosteroid injection to the hand/wrist is tenosynovitis of the radialstyloid. Despite this, the most commonly ruptured tendon is the extensor pollicis longus. The researchers of this study hypothesized two reasons for this finding: 1) mistaken injection sites and 2) corticosteroid extravasation. In this study, the longest rupture time after injection was 32 weeks, so it is critical to touch on delayed spontaneous rupture when educating patients.
Take Home Messages:
Spontaneous tendon rupture following a corticosteroid injection to address tendinitis is a serious complication. To minimize the risk of spontaneous rupture, more standardization regarding the application of corticosteroid injections is needed. Additional, appropriate education for both the patient and the doctors administering the injections is crucial to avoid unnecessary exposure to corticosteroids. Patients should always be fully educated on the treatment that they receiving as well as any potentially harmful side effects to enable to them to make educated decisions regarding their own health. Following spontaneous tendon rupture, the use of MRI to visualize the injury as well as to monitor healing after surgery was highly beneficial.
Reference:
Lu, H., Yang, H., Shen, H., Ye, G., & Lin, X. J. (2016). The clinical effect of tendon repair for tendon spontaneous rupture after corticosteroid injection in hands: A retrospective observational study. Medicine, 95(41), e5145. https://doi.org/10.1097/MD.0000000000005145
by ptfadmin | Dec 25, 2022 | Health Tips
Reviewed by Mark Boyland PT, DPT, CSCS
Knee osteoarthritis is a common condition that produces pain and limits patient function. Patients are regularly referred to Physical Therapy for complaints related to knee osteoarthritis and practice guidelines indicate exercise therapy should be the primary emphasis in the treatment of knee osteoarthritis. The authors were well aware and sought to compare two exercise types and their effect on patient’s knee pain.
Patients included in the trial were of 50 years age and up, able to walk without an assistive device, and has x-ray findings noting knee osteoarthritis. The study had 86 patients complete the study. There were 42 participants who completed the hip abductor and quadriceps strengthening protocol and 44 participants in the quadriceps strengthening protocol only. Participants completed the Knee Injury and Osteoarthritis Outcomes Scores (KOOS) throughout the study.
The exercise protocol explored only two exercises. The quadriceps strengthening group performed a knee extension exercise again for 4 sets of 10 with a 10 second hold at the top of the motion, performed in the morning and in the evening. The hip abductor strengthening group performed 4 sets of 10 of sidelying hip abduction with a 10 second hold at the top as well as the quadriceps strengthening exercise, performed in the morning and in the evening. The patients added a weight as needed to increase the difficulty as directed by the study design. The patients began with 50% of their 10 rep maximum for weeks 1 and 2, 60% for weeks 2-4, 70% for weeks 4-6, 80% for weeks 6-8, and 90% weeks 8-10.
Both study groups had improvements in their KOOS scores every 2 weeks. At the 10 week mark participants had at a minimum of 9.09% of improvement on the symptoms KOOS subsection up to 27.09% improvement in regards to quality of life. On average there was a 17.98% improvement across all subsections of the KOOS regardless of the group participants were placed in.
What can this mean for my patients? I attempted the 4 sets of 10 for 10 second holds with a 3 lb ankle weight and found it relatively challenging for myself and starting with a lighter weight was likely recommended. If my patients can tolerate this exercise protocol they only need to do 1 exercise for about 20 minutes per day. If my patients crave a little more variety they could do two exercises which would take about 40 minutes per day. The authors note that further studies need to be completed and that this may have been a relatively small sample size but I think most of my patients would be quite pleased with a minimum 9% improvement in the pain, function, and quality of life with just 1 exercise even if it could take up to 10.
doi: 10.1186/s12891-020-03316-z.
by ptfadmin | Dec 14, 2022 | Health Tips
Written by Mark Boyland PT, DPT, CSCS
What if I told you there was a non pharmaceutical way to promote pain relief or maybe more accurately a way to reduce your perception of pain through exercise? What if you could continue moving and exercising your other non painful body parts and that the exercise would benefit your painful body parts? What if it only took 15 minutes of aerobic exercise where your heart rate reached at least 120? Would you take that option? Let’s explore more.
This study explored patient’s pain perception levels before and after a bout of aerobic exercise. The study design included 20 females and 10 males who averaged 20.6 years old. The researchers made sure that the participants had no history of shoulder pain prior to performing the study. The researchers used an algometer, a device that applies pressure and measures the pounds/cm2 applied until there is a report of pain. The researchers performed this measure 4 times in total. Twice in the first day with 15 minutes between measurements and then again 24-48 hours later with the third test being prior to performing aerobic exercise and the fourth and final test after aerobic exercise. The researches chose a NuStep for the aerobic exercise and told participants to only use their legs to perform the exercise bout.
As an average the participants had relatively similar algometer readings at measures 1,2,and 3 with an increase in tolerance for the 4th measure after aerobic exercise of approximately 1.5-1.9 pounds/cm2. Of note however, the females had a more consistent baseline measure at 11.4, 11.0, and 11.9 with a 4th measure of 13.6 whereas the male participants had decreasing readings with a generally increased 4th reading at 17.3, 16.5, 15.6, and 17.4.
The evidence may not be very strong for the use of aerobic exercise of non painful extremities to reduce pain in painful extremities however there may be some merit. Regardless, continuing with a form of tolerable and preferred aerobic exercise is still recommended for general health and wellness regardless of the presence of pain. Additional studies are needed with larger sample sizes and possibly to include participants who have shoulder pain as opposed to recreating shoulder pain with a tool. Regardless, as a physical therapist if I can provide my patients with a non pharmacological and non modality based pain relief who am I to deny them?
Do you think it’s worth 15 minutes of your time?
PMCID: PMC7015025
by ptfadmin | Dec 5, 2022 | Health Tips
Reviewed By: Evan Peterson PT, DPT
Ankle sprains are one of the most common injuries and occur in a variety of different settings. Whether it is a young athlete or an individual who rolls their ankle by missing a step, many will experience and ankle sprain at least once in their lifetimes. Chronic Ankle Instability or CAI is typically caused by repetitive lateral ankle sprains and can result in articular changes or degenerative osteoarthritis in the ankle. The ankle is an important joint for walking and balance and in order to perform both tasks well, a person must be able to utilize various neuromuscular strategies which include both feedback and feedforward control. In its simplest terms, feedback control is reactive whereas, feedforward control is proactive. Feedback control is our body’s ability to respond to a changing environment and feedforward control is our body’s ability to prepare for an environment we expect. It is proposed that those with CAI have deficits in both feedback and feedforward neuromuscular control. What this means for preventing reoccurring ankle injury is that a person with CAI may have difficulty adjusting their foot and ankle posture to create stability while attempting functional or recreational activities.
Yen et al. 2016 wanted to confirm their belief that people with CAI have impairments in their feedforward and feedback control during walking. Previously, they conducted a similar study testing feedback control of healthy subjects while walking. They found significant increase in ankle positioning (less inversion) while walking due to external loads.
Methods
The authors selected 12 students from Northeastern University who had no significant differences. The subjects filled out a Cumberland Ankle Instability Tool (CAIT) to determine the severity of their recurring ankle sprain. In this study, recurring ankle sprain was defined as at least 2 ankle sprains in the past 6 months. Control subjects scored highly on the CAIT and did not report ankle sprain in the past year. Ankle movement was captured via a motion capture system comprising of 6 cameras. Patients were asked to walk on a treadmill at a self-selected comfortable pace for 3 separate conditions. The first condition acted as a baseline, the second was the intervention phase in which sandbags were placed on the subject’s lateral metatarsal bones, forcing inversion, and the third condition had the bags removed.
Results
The baseline condition showed no significant difference between amount of inversion; however, the CAI group had a trend toward more inversion. During the intervention phase of the trial, both groups showed a change in the amount of eversion over a period of time. The group without CAI had increased eversion throughout the trial whereas the CAI group originally corrected to a more everted position but soon returned to baseline measures. After the weights were removed in the third condition, the increase in ankle eversion carried over in the control group. The CAI group showed a return to baseline suggesting no after effect from the external load.
Discussion
The results show that with external load both the control group and the group with CAI are able to respond to changes in their environment but the CAI group has difficulty doing so for a prolonged amount of time. The authors of this article were unable to identify a specific reason for this occurrence, but were able to formulate a few hypotheses. First is that the individuals were able to detect changes in the environment, but overtime became less sensitive to these changes. A less likely explanation is that the individuals with CAI have decreased everter muscle strength and endurance. These results suggest feedback control is somewhat diminished in those with CAI. The period in which the sandbags were removed was utilizing to assess a person’s ability to rely on feedforward control. The authors believe due to small changes in the after effect further studies should be conducted to determine the quality of feedforward control in those with CAI.
Physical Therapy First
At Physical Therapy First, our therapists are trained to develop exercises and assess a patient’s strategies when balancing or walking. Following ankle sprain or recurring ankle sprains it can be important to practice utilizing your feedback and feedforward controls in order to retrain your ankle and foot musculature for prevention of future ankle sprain. If you are struggling with an ankle that continues to roll with sports or with household tasks, please contact us and we will be happy to assist you.
Reference:
Feedback and Feedforward Control During Walking in Individuals With Chronic Ankle Instability (jospt.org)
by ptfadmin | Nov 28, 2022 | Health Tips
by Tyler Tice, PT, DPT, MS, ATC
Introduction:
Over the last few decades, the treatment options for Parkinson’s disease (PD) has significantly improved, resulting in effectively prolonged period of time people with PD live with disability. Due to this, the role of effective physical therapy (PT) and rehabilitative management for people with PD has greatly increased. PD affects dopamine within the brain, resulting in the presence of motor symptoms such as tremors and bradykinesia (slow movement) and non-motor symptoms such as changes in mood and changes in sense of smell. Diagnosis of PD is usually made after the classical motor signs of bradykinesia, rigidity, tremor, and postural instability (balance issues) emerge. Currently, there is no neuroprotective treatment for PD available so medical treatment is focused on treating the symptoms. As PD is projected to continue affecting higher numbers of our population as well as younger individuals, there is a need for effective non-pharmacological treatment early in the course of the disease. This review investigates the effects of a variety of modes of exercise and PT in the treatment of PD.
Aerobic Training:
Moderate to high intensity aerobic training may be the most beneficial in managing motor symptoms, improving physical function, and reducing disability in persons with PD. Studies where treadmill training was completed demonstrated better results regarding improvements in walking, most likely due to the intensity in which it could be completed, however, cycling is a viable option for persons with PD where walking may not be a safe option when initially beginning aerobic exercise. Additional research needs to be completed regarding the effect of aerobic exercise on non-motor symptoms, however existing research is promising as one study showed an improvement in executive function (higher level thinking needed to plan and carry out tasks), attention, and memory after one month of treadmill training.
Resistance Training:
Moderate to high intensity resistance exercise focused on movement speed or muscle power production may be beneficial in reducing disease severity, improving physical function, and reducing disability. One study demonstrated an improvement in cognition in addition to strength and mobility after the 2-year course of the study, suggesting long-term motor and non-motor benefit of participating in resistance exercise. Multiple studies also demonstrated benefit of resistance exercise when specific functional limitations such as climbing stairs or standing from a chair were targeted. Additional research is still needed to investigate the benefit of resistance exercise, especially in relation to their effects on non-motor symptoms.
Balance Training:
For persons with mild to moderate PD, balance training has demonstrated a significant ability to reduce fall rates. Additionally, studies that were clinic-based rather than home-based provided a greater level of supervision and intensive training, resulting in greater reductions in fall rates. Balance training also improved non-motor symptoms such as reductions in pain, depression, and apathy. However, it is important to note that in patients with severe PD appeared to have an increase in falls rate following participation in balance training. What causes this increase is unknown but may be attributed to increased gait-related mobility without an improvement in postural control or increased exposure conditions that challenge the individual’s balance without having the skills to manage these challenges.
Gait Training:
Gait training is effective in improving various aspects of walking in persons with PD. Treadmill training and moderate intensity overground walking have been shown to improve gait speed, walking capacity, and step/stride length. This is important as gait is not primarily impacted by current pharmacological treatments for PD. Providing cueing while ambulating has also been shown to improve various aspects such as giving auditory cues for gait speed or auditory and visual cues for freezing of gait. Dual-tasking such as walking and talking or walking and carrying an object is an aspect of ambulation that can be difficult for persons with PD. Practicing dual-tasking in a safe and controlled environment is effective in improving walking under dual-tasking conditions.
Physical Therapy:
Despite the evidence that supports early and regular exercise intervention in persons with PD, the utilization of PT services in the US is remarkably low. There are many factors that may contribute to this such as insurance coverage and other medical provider knowledge on the benefit of exercise and PT in persons with PD. Typically, to justify the need for PT to insurance companies, the patients must demonstrate functional improvement in order to continue with PT, however, policy and guideline changes have been implemented to improve access to PT for persons with PD. By initiating PT earlier in the disease process, more preventative measures can be taken, which ultimately will positively impact the quality of life of the individual.
Secondary Prevention Model:
Once initially diagnosed with PD, patients consult with a PT with expertise in PD. The PT performs what is referenced as a clinical battery of tests to establish a baseline level of function that can be tracked throughout the disease course. In the first few visits, the PT will prescribe an exercise program that is tailored to the individual and give them the tools to be success in consistently completing the program. A critical element of this approach is regular follow-up visits. Just as regular visits to the neurologist are necessary for reassessment of PD symptoms so appropriate adjustments to medication can be made, regular follow-up visits to a PT allow for reassessment of functional status and necessary adjustments to their exercise program to address changes in symptom presentation. There has also been an increase in community-based exercise programs, which further expands access to physical activity. These exercise programs can vary in intensity, however regular follow-up visits to PT can allow PTs to assist in finding programs that appropriately challenge their patient.
Take Home Message:
Regular exercise is highly beneficial for persons with PD. The advantage of beginning PT early in disease progression is that it can help mitigate the extent to which the motor and non-motor symptoms impact daily life. Additionally, if there were to be a change in function, receiving PT treatment can directly help with being able to successfully complete functional tasks such as climbing stairs to promote safe independence of persons with PD.
Article Reference:
Ellis, T. D., Colón-Semenza, C., DeAngelis, T. R., Thomas, C. A., Hilaire, M. S., Earhart, G. M., & Dibble, L. E. (2021). Evidence for Early and Regular Physical Therapy and Exercise in Parkinson’s Disease. Seminars in neurology, 41(2), 189–205. https://doi.org/10.1055/s-0041-1725133
