Renaissance Physical Therapy Newsletter

Renaissance Physical Therapy

RENAISSANCE PHYSICAL THERAPY

Research Update

This update is intended as a means for us to keep busy clinicians in the medical community up to date with recent research as it relates to physical therapy. Hopefully, this will increase the options you have when prescribing physical therapy for your patients.

Complete Ruptures of the Achilles Tendon
Atkinson TS, Easley M. Medscape Orthopaedics & Sports Medicine. 5(3). 2001

Achilles ruptures occur despite it being the thickest and strongest tendon in the body. Although we hear about athletes rupturing their Achilles, the most common victims are “weekend warriors,” 30-40 year old, sedentary, male, white-collar worker, who over-exerts himself while playing sports on the occasional weekend.

The mechanism of injury most often involves pushing off the weight-bearing foot while extending the knee joint, as with sprinting or jumping. 17% of the ruptures occur when the warrior suddenly and unexpectedly dorsiflexes his ankle stepping into a hole, falling forward, or slipping on a ladder. 10% of ruptures result from jumping/falling from a height and violently dorsiflexing the plantarflexed foot.

Treatment of acute Achilles ruptures remains controversial. Those who prefer a nonsurgical approach argue that equally good results can be obtained with cast immobilization without the complications associated with surgery.

Of the conservative protocols, a more functional study compared a group placed in a rigid cast for 8 weeks to a group placed in a rigid cast for 3 weeks followed by a Sheffield splint for 6 to 8 weeks. This splint is an ankle-foot orthosis that holds the ankle at 15 degrees of plantar flexion and allows controlled motion with physical therapy. The group with the splint gained dorsiflexion motion more rapidly, returned to normal activities quicker, and preferred the splint to the cast. Also, there was no increased rate of re-rupture.

Despite the resurgence of the conservative camp, surgery still remains the treatment of choice since the late 1980’s. Studies have shown that surgery leads to increased strength and less calf atrophy. 92% of athletes were able to return to their sports at a similar level 6 months postoperatively. Surgical repair also has a smaller re-rupture rate; recent studies have shown 1.4% and 13.4% for surgical and conservative approaches, respectively.

Increased operative treatment also leads to more experience in treating complications effectively. For example, it is now shown that physical therapy can overcome many of the problems associated with adhesions between the repair site and the skin.

Postoperative treatment has been evolving to a more functional rehabilitation program. These protocols use an anterior plaster slab or an orthosis/walking boot for 6 weeks allowing full plantarflexion but limiting dorsiflexion to neutral. The patient begins progressive exercises and may WBAT with crutches. This approach has lead to smaller plantarflexion deficits and a higher percentage of subjects (80% vs. 50%) returned to their prior level activity as compared to the traditional rehab protocol.

Whether a surgical or nonsurgical approach is used for Achilles tendon ruptures, our physical therapists are well-trained to facilitate the recovery of these patients. We have a variety of tools and techniques to decrease edema, improve scar pliability, improve ROM and joint mobility, and to regain functional strength to enable return to sport and prior activities.

The Healing Power of the Pool: a Four-stage Approach to Client Recovery
Chek, P. Personal Fitness Profession April 2001, pg 33-35.

This article defines one method for pool therapy progression to increase recovery rates for patients. The author suggests the following protocol:

Phase 1 is the starting phase for those with an injured spine or weight bearing joint. This phase eliminates the axial load of injured tissue while exercising in a horizontal position. The buoyancy created by water helps decrease pain caused by weight bearing.

Phase 2 is the beginning stage of weight bearing exercises, with the exercises being performed in shallower regions of the pool, therefore decreasing the buoyancy offered by the water.

Phase 3 is the introduction phase of axial loading for injuries of the spine, rib cage, and lower extremities. Upper extremities progress from aerobic to anaerobic loading.

Phase 4 is the specificity stage, working on power development. This phase may include the use of elastic energy and plyometric drills.

Pool therapy increases recovery rates by allowing an interruption of the pain cycle through the following mechanisms.

Increased circulation equals decreased pain. The hydrostatic pressure assists musculature in providing venous return with increased oxygen and nutrient delivery to the tissue.

Stimulation equals decreased perceived pain. Moving of an injured joint through water increases the sensory stimulation of the skin receptors. According to the gate theory stimulation of these “faster” sensory and mechanoreceptive fibers decrease the ability for pain messages from the “slower” unmyelintated fibers to get to the spinal cord resulting in decreased perceived pain levels.

Movement equals relaxed muscles. Movement of a joint in water offers decreased tissue compression. Weights and floatation devices can also be used to further increase the decompression and even offer light traction of the joint, which can decrease spasms in the musculature and allow increased venous return.

Renaissance Physical Therapy NW recognizes these and many other therapeutic benefits of aquatic therapy. Our south Everett location is equipped with a full sized pool offering varying water depths for buoyancy options, as well as comprehensive therapeutic progression to eventually include full weight bearing activities.

The Clinical Effects of Intensive, Specific Exercise on Chronic Low Back Pain
A Controlled Study of 895 Consecutive Patients with 1-year Follow Up
Nelson BW, et al. Orthopedics. Volume 18, number 10. 1995

This study looked at 895 consecutive patients referred to rehabilitation for lumbar disease resulting in chronic low back pain. Their intent was to examine the effects of intensive, specific exercise for the lumbar extensor musculature. For this study, intensive was defined as “muscular exercise against dynamic resistance to volitional failure through full range of motion.” Specific exercise was defined as “with the pelvis immobilized so as to isolate the lumbar extensors” from the more powerful gluteals and lower extremity muscles.

Of the 895 patients, there were 107 patients that were recommended for inclusion, but decided to enter the program. These were used as the control group. Patients had had symptoms for an average of 26 months prior to starting the program and had seen an average of three previous providers. They had tried an average of six different treatments with very limited results. Forty seven percent of the patients had work related injuries.

The treatment protocol included an initial isometric strength test in a MedX lumbar extension machine. If a strength deficit was noted, progressive, resistive exercises of the lumbar extensors were performed twice a week, until completion of the program. The treatment ended if the patient a) was pain free or nearly pain free with near normal strength levels; b) was no longer making objective gains; or c) refused to cooperate. Treatment sessions also included aerobic exercises, strengthening of other muscle groups, and patient education regarding body mechanics and spinal function. Every 3-4 weeks, a follow-up isometric test was done to gauge progress. A follow-up questionnaire was completed at the end of treatment and at an average of 13 months after discharge. Cost data was also interpreted.

The authors found that 76% of their patients had good to excellent results initially and 94% of these maintained this rating at the follow-up. Pain was decreased substantially in low back (64% of patients) and leg (62% of patients). Seventy-one percent of patients reported substantial improvement in perceived ability to perform activities of daily living. Patients in this study had a lower reutilization of the healthcare system following this study when compared to the control group.

The authors also found that diagnosis does not significantly affect results, but psychosocial factors do. Patients with potential for secondary gain, such as worker’s compensation, litigation, or symptom exaggeration, had generally poorer results. These patients also demonstrated greater reutilization of healthcare.

The authors concluded by stating that chronic low back pain can be effectively treated with intensive, specific exercise regardless of diagnosis. These gains can be maintained over time. They argue that this is a safe, effective, and economical program for patients with chronic low back pain.

Renaissance has lumbar MedX equipment at all three of our clinics. This equipment allows us to work effectively with patients who have complaints of low back pain. We feel that the objective data improves our outcomes and can be beneficial for patients with cases under review through L&I and in litigation. If you would like to see this equipment for yourself or obtain a full copy of this article, please do not hesitate to call us at 206-361-2225.