Showing posts with label rehabilitation. Show all posts
Showing posts with label rehabilitation. Show all posts

Feb 12, 2015

When Is Cryotherapy/Ice Supported By Research?

Howdy Readers! After yesterday's post ice seems to be a hot topic. I may have misled some of you yesterday with my thoughts on ice. Like many things in healthcare, science, and research the answers to questions are often shades of grey...not black and white like many would prefer. Therefore, today I wanted to share with all of you a guest post that I wrote for another website regarding a study that showcased a time when icing is warranted and was found to be very beneficial. This isn't the first article that shows evidence for this idea but it is the most recently published.

Additionally, I wanted to hammer home the idea that ice can still be used to modulate pain...if a 14 year old high school athlete suffers a severe ankle sprain for the first time and is in a lot of pain it would be unethical and unreasonable to deny him a bag of "ice" because research shows that it may not change blood flow. I can still help to modulate his pain without the use of narcotics or NSAIDs (a whole different bag of worms).

Nevertheless, pain should still be viewed as a perception and as something that can alter movement/motor control. We do not want to associate pain purely with structural damage because we know that is not the case based off the latest pain science. What I am against however is clinicians that ice to "treat" or "fix" injuries instead of using sound clinical reasoning, causative biomechanics, and taking pain science into consideration. We need to question the mechanism of why we are choosing a certain treatment, exercise, or modality. Enough with the ranting, here is my article!


A Novel Approach for Treating Arthrogenic Muscle Inhibition in Post-ACLR Patients?

Hart JM, Kuenze CM, Diduch DR and Ingersoll CD.J Athl Training. 49:6, 740-746.

How many of you have had the struggle of dealing with an ACLR patient that has suffered from an inability to regain full volitional control of their quadriceps group? This is a known pathology called Arthrogenic Muscle Inhibition (AMI) which has been defined in the literature as an inhibitory reflex in response to damage that has been suffered by the joint structures of the knee and it affects the musculature surrounding the knee. It is currently theorized in this condition that efferent input to the quadriceps has been inhibited in response to “aberrant” afferent input from the joint and the amount of motor units available for volitional control has been decreased.

            Initially, AMI may work as a protective reflex loop to protect the joint structures from further damage. However, in the scenario of an athlete that has undergone arthroscopic surgery to reconstruct an ACL injury it can be a burden that prevents a return to pre-injury levels of strength and side-to-side asymmetries. This condition would definitely be considered a detriment when it prevents our patients from receiving the entire benefits from their rehabilitation program and may wreak havoc upon their gait and other movement patterns.


What if this could be overcome with a simple and cost-effective intervention; perhaps an intervention as simple and globally available as applying an ice-bag prior to exercise intervention? Well that is exactly what this group of researchers did in this current study. Hart et al built upon previous research that showed that Hoffman reflex (h-reflex) could be increased when cryotherapy was used on subject’s with inhibited quadriceps due to knee-joints that had been artificially effused.

There is lot to discuss when it comes to the intricacies of methods and procedures for this study and the SMR already had a great post recently going over those details. You can read their take in more depth right here. On a global and applicable scale you may be wondering what they found out. Well let me cut to the chase; using a cryotherapy intervention immediately before performing rehabilitation exercises resulted in better quadriceps function and strength gains compared to the other interventions. This study was another brick laid for this theoretical foundation and it is forming quite nicely. However, there is still more research to do on this topic such as investigating other knee injuries like PFPS, patellar tendinopathy, meniscal injuries, and longer intervention trials >2 weeks are definitely warranted.

This study should be kept in mind that sometimes cryotherapy is warranted. Especially at a time when so many love to blindly point fingers at “passive modalities” such as cryotherapy. Anything can be the perfect intervention if applied in the right place, at the right time, and especially if it is guided by the right evidence. This is something to keep in mind the next time you find yourself struggling with a patient/athlete who is struggling to regain quadriceps function. It can’t hurt to try (unless they have a cold allergy), uses something that is most likely already located in your athletic training clinic, and has some promising research in the works.

Dec 16, 2013

My SFMA: A Case Study - Cervical Breakouts

Time to make an assessment of myself

Today's post is second part of my self-SFMA(Selective Functional Movement Assessment) case study series.  Specifically, We will look at the dysfunctional cervical spine movement patterns from my SFMA Top Tier Post.  In the first post/video, I was dysfunctional/non-painful (DN) for the Cervical Flexion Pattern, and the Cervical Rotation Pattern to both the Right & Left.  However, I was functional/non-painful (FN) for Cervical Extension. In case you missed it, here is the 7 top tier tests again.

The SFMA works by assessing 7 general top tier movement tests. From there you perform a "breakout" of each dysfunctional pattern to determine the cause of dysfunction. Dysfunction movement patterns are broken down using an algorithm that funnels and filters the problem into either a mobility dysfunction or a stability &/or motor control dysfunction (SMCD).

This video will look at the dysfunctional cervical spine patterns. Specifically, cervical flexion and cervical rotation to the left and right. I was functional for the cervical extension pattern so that pattern does not require a breakout assessment. Here is the breakout video:

Cervical Flexion Top Tier = DN (Unable to bring chin to sternum. Why? We don't know yet.)

Active Supine Cervical Flexion Test = DN (Still Unable to bring chin to sternum. Why? We don't know yet.)
If I was now FN we would know that there is a postural and motor control dysfunction or stability/motor control dysfunction...or both, affecting cervical flexion. This includes the c-spine, T-spine, and shoulder girdle postural dysfunction. Laying supine removed the postural and stability requirements of the gravity dependent/loaded standing position from the top-tier tests

Passive Supine Cervical Flexion Test = FN (Chin is now to sternum)
We can now assume the cause of the dysfunction was due to an active cervical spine flexion stability dysfunction or motor control dysfunction...or both. We know it is not a mobility issue because I had full motion when all stability and motor control requirements were removed and the movement was performed passively. If it was due to mobility reasons then my GF would not have been able to passively bring my chin to my chest. Mobility problems always present with consistent findings!

Cervical Rotation Top Tier = DN to the Left & Right (Can not rotate chin to mid-clavicle or at least 80 degrees, Why? We don't know yet)
This test no longer requires this degree of rotation and the ability to bring the chin to the clavicle, at least this is how I was instructed in October of 2013.

Active Supine Cervical Rotation Test = FN (At least 80 degrees of rotation bilaterally without a significant asymmetry)
We now know that the dysfunction was related to a postural and motor control dysfunction or a stability and motor control dysfunction...or both. This is why my top tier cervical spine rotation test was dysfunctional, not because of my perceived tissue "tightness."

It is said that there are many ways to skin a cat...that being said the SFMA is a tool or a system of assessment. It is not a specific approach to treatment. However, there are general guidelines based off of the findings and it also lays a road map of treatment for you(eg. mobility before stability, working your way down the top tier tests). Specifically, in my case I do not have any mobility dysfunctions within the cervical spine but if I follow the philosophy of the SFMA then I need to address the SMCD of the cervical flexion pattern before attempting to correct SMCD dysfunction of the cervical rotation.

There are many avenues for treating this dysfunction from dry needling to IASTM to MDT principles to using the 4x4 Matrix or etc. I can't advocate that one approach will be better for addressing my dysfunction than another...but I do have a system of assessment to judge the efficacy of each potential intervention. Perhaps IASTM and MDT combined will work great for 90% of my patients but I don't know that...all I need to know is how to assess-intervene-reassess. Oh and I should probably stay within my practice act, so use what tools you have and those that you are comfortable with.

Thoughts? Do you think my breakouts and assessment have been accurate so far? What would you do with me? I know what I would do....finish the SFMA breakouts, first. Come back as I continue to break out my many dysfunctional movement patterns.

Sep 18, 2013

Bilateral Femoral Acetabular Impingement In a Collegiate Soccer Player

Today's case comes to us from one of my colleagues and classmates, Kathryn Deterding, ATC. Kathryn consulted with me about this case and then went on to implement a treatment protocol based off our discussion.

A Case of Bilateral Femoral Acetabular Impingement(FAI) and Labral Tears in a Collegiate Soccer Player. 


History: This was a 21 year old male collegiate soccer player. In the fall of 2011 he began to experience hip pain that he played through. In the upcoming spring of 2012 he was diagnosed with bilateral FAI and tried to rehabilitate his injury to prepare for the fall season of 2012. The fall season was just as painful as the previous season. This athlete then underwent two different surgical procedures in the winter of 2012. One for each hip, in attempt to lessen his FAI and correct additional labral tears of the hip. The athlete had minimal rehab for a month or so after his surgeries and refrained from heavy activity for a few months. 

Upon increasing activity to prepare for the fall 2013 season of soccer the athlete began to experience the same pain and symptoms. He consulted with an orthopaedic surgeon during the preseason and the physician told him that he may not see any improvements and that this was something that he most likely was going to have to live with.

It was at this point that Kathryn and I discussed the athlete's case together and came up with a plan of care.  The first thing that I did was discuss thought viruses with the athlete and talked about how current neuroscience is teaching us that pain is not necessarily patho-anatomically based but is a construct of the central nervous system. The athlete admitted to thinking that all of this discussion was a load of hogwash and didn't buy into any of what I said. Nevertheless, we continued on with our plan of care.


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