Posts in general physical therapy
Eccentric Quad Strengthening Shown To Improve Strength And Flexibility Of Muscle
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Mobility exercises designed to improve range of motion within an affected joint or tissue are a valuable part of any rehabilitation program. Previously clinicians prescribed various bouts (3 x 30 seconds) of static stretching in an attempt to lengthen short muscles. Current research has shown these prescriptions are ineffective at changing muscle length and instead alter the stretch tolerance of the muscle. Thus individuals who stretch more frequently, have an increased tolerance to stretch, and therefore greater range of motion. Conversely, eccentric exercise has been shown to not only develop muscle strength and size, but also change the structure of the muscle improving its’ true length. Further, in randomized, controlled trials eccentric exercise produces greater gains in hamstring flexibility than static stretching alone. A recent study suggests this may also be true for the quadriceps.

Alonso-Fernandez and colleagues studied the effects of 8 weeks of eccentric quadricep training on muscle strength, cross sectional area, and flexibility (J Sports Med Phys Fitness. 2011). Authors placed 26 participants underwent pre and post training testing, as well as, a 4 week detraining period to determine the lasting effects of this exercise program. As expected, eccentric quadriceps training led to gains in quadriceps strength and muscle size. Consistent with prior research on the hamstrings, this eccentric training also improved muscle length and flexibility measurements. Reinforcing a commonly held belief “strengthen to lengthen”. in addition, all measures of muscle performance decreased following the 4 week detraining period. This study further supports our understanding of muscle architecture and the forces required to make a significant change in muscle tissue.

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3 Week Immobilization Shown Equivocal To 6 Week For Some Ankle Fractures
Photo Credit: wikipedia.org

Photo Credit: wikipedia.org

Ankle fractures are a relatively common traumatic orthopedic injury involving the two lower leg bones and ankle joint.  Among these fractures, the most common type involves a break of the outer lower leg bone (weber B).  These fibular fractures are commonly allowed to weight bear early than tibia fractures because they are less important for lower body weight bearing.  Common medical practice provides immobilization to avoid excessive weight bearing or forces for 6 weeks following fracture, but smaller studies have not demonstrated a significant increased risk of adverse events if fractures are immobilized for less than the standard 6 weeks.

A large randomized, controlled trial was published in the British Medical Journal documenting the effects of two types of non surgical management strategies for Weber B ankle fractures (Haapasalo et al. 2019).  Authors randomized 247 fibular Weber B, stable, ankle fractures to either a 3 week or 6 week immobilization period in an orthosis.  Patients were assessed on ankle function, pain, quality of life, ankle motion, and adverse events at 6, 12, and 52 weeks after the fracture.  Authors reported no difference in outcomes between the 3 or 6 week management groups except a slight improvement in ankle range of motion and deep vein clot risk in the 3 week group.  Patients are encouraged to speak with their orthopedist regarding the best course of action for their individual fracture management. 

Study Shows Cost Effectiveness Of Out Of Network Physical Therapy Practices
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When we opened MEND we wanted a Physical Therapy practice focused on excellent patient outcomes, in fewer visits, delivered by experts in their field. Our practice will not employ anyone other than board certified Physical Therapy orthopedic specialists and the care would be one on one in nature. To maintain our clinical principles we decided to become an out of network provider of Physical Therapy services and have seen our practice thrive as patients seek out an alternative to the standard quo.

Consumers often mistakenly believe out of network is more expensive than in network care. When you compare the number of visits utilized by MEND, on average 3-4, it is significantly less expensive than an in network model seeing a patient 2-3 times per week for 6-8 weeks. In addition, services provided in Physical Therapy clinics owned by physicians (POPTS) often bill under “incident to” allowing them to charge a more expensive rate than in or out of network Physical Therapy practices. Incident to billing, increased visits, and a higher utilization of technicians and aides contributes to the increased Physical Therapy costs seen with POPTS. A recent study highlights these trends and documents the cost effectiveness of the out of network Physical Therapy model.

Pulford and colleagues examined the cost effectiveness of Physical Therapy services provided by an out of network (cash based) provider (Health Care Manag. 2019). They analyzed the charts of 48 randomly selected patients over a 3 year period. Authors reported patients were seen a median of 5 visits at an average cost of $98 per visit for a total cost of $780. Conversely, in network care averaged $936. This is the first study to examine the practice patterns and health care costs associated with out of network or cash based practices. In the presence of higher deductibles and co pays, patients are advised to consider both in and out of network models of care to see which model is most appropriate for their clinical and financial needs.

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Daily Activity Shown To Improve Brain Health In Aging Adults And Elderly Even Those With Brain Pathology
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The cognitive benefits of aerobic exercise are well established with trained individuals demonstrating decreased risk of mental health disorders, including anxiety and depression, and improvements of cognitive function and memory compared to their sedentary peers. More recent research has documented daily physical activity is also associated with decreased risk of dementia in aging adults even in those with pathology on brain imaging such as neurofibrillary tangles and amyloid plaques. Both of these brain pathologies are associated with dementia and alzheimer’s disease. Further previous research has shown moderate walking, 45 minutes/day for 3 days/week, actually increased brain volume among particpants. A recent study suggests even general activity such as light housework and gardening may be enough to improve brain health within this population.

Buchman and colleagues examined the impact of daily movement (gardening, housework, exercise) on cognitive and motor function, as well as, brain health (Neurology. 2019). Researchers performed a well designed trial of over 450 aging adults (> 70 y.o.) and monitored their mental and physical function, as well as, daily activity each year over a 20 year period. Of these adults, 191 demonstrated clinical signs of dementia during the study period. In addition, researchers studied the donated brains of these individuals after their deaths to determine the presence of brain abnormalities and pathology.

Consistent with prior research, more active participants demonstrates higher scores on cognitive, memory, and physical tests. Interestingly, these results held up even among individuals with brain pathologies including neurofibrillary tangles and amyloid plaques. Although all of these individuals could have been diagnosed with neurological diseases such as Alzheimer’s, 30% tested normally on cognitive function tests at the time of their deaths. Authors suggested exercise and activity may have a protective effect on brain health (symptoms) even in the presence of brain changes (signs of dementia). Authors recommend more research in this area to determine if there is a cause and effect relationship between these two factors.

Reducing Your Risk Of Alpine Skiing Injuries
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Alpine skiing remains one of the most popular outdoor winter sports in Colorado. It is estimated over 6.8 million skiers participated in the sport over the 2016/2017 winter season. There are inherent risks of death and injury in both skiing and snowboarding, but thankfully due to technological updates and innovations overall injuries have fallen by half over the last 30-40 years. Although injuries on the whole have decreased some traumatic cases, such as ACL tears, remain common today. A recent article summarized the available evidence on the most common ACL tears, as well as, offered an update on injury prevention strategies in alpine or downhill skiing.

Davey and colleagues published the review article recently in the journal Sports Health (2018). Authors reviewed the available evidence on ski injury prevalence including injury location, known risk factors, and ski injury prevention. Data was available from a total of 64,667 ski injuries over a 25 year period. They reported the average age of skiers injured was 30 years old with a range of 24 to 35 years. Those found at highest risk included both the young, adolescents and children, as well as, older adults (>55 years). While males were more likely to experience lower extremity fracture, consistent with other sports females are more prone to ACL tears.

As expected, the lower extremity remains the most commonly injured area of the body accounting for up to 77% of all injuries. Further, 14% of injuries involve the thumb and shoulder and 13% involve the head and neck. The knee ligaments (ACL and MCL) remain the most common injury followed by thumb and head and facial injuries. Trend data showed a drop in tibial fracture, but an increase in ACL tears. Most common mechanisms included deep knee flexion with rotation or knee hyper extension and forward movement of the thigh over the stationary leg in the boot. In addition, despite advances in helmet use and technology, the number of traumatic skiing fatalities remained constant.

Ski technological advances, including helmets, bindings, and ski poles, deserve the most credit for the 50% reduction of ski injuries. Helmet use has increased to 80% of all skiers and has been a significant advancement in the safety of participants and reduction of head and face injuries. As expected, helmets have consistently been shown to reduce both the prevalence and severity of head injuries without a subsequent increase in “risky skiing”. The risk of death with head injury has stayed relatively constant either because the forces of impact exceed the protective capacity of the helmet or the skier sustained other bodily injury causing death despite sparing their head and face.

Ski boot binding systems have contributed to the large decrease in leg fractures and contusions due to improved release mechanisms. In addition, skiers who routinely have their bindings checked by certified ski shops sustain fewer injuries than those who ski without inspected bindings. These bindings are designed to prevent fracture and leg injuries, not knee ligaments, and bindings often do not release with common ACL injury mechanisms in skiing.

Established programs such as “lids on kids” and “heads up” remain effective at improving the awareness and utilization of helmets. ACL prevention programs (Vermont Ski Safety Equipment) have focused on educating skiers to avoid situations most associated with knee sprain, as well as, instructions in how to fall with decreased risk to your knee. These programs have been shown to reduce a skier’s risk of knee injury by 60%. Interestingly, ski lessons have not been shown to reduce the risk of knee injury among skiers. In our practice, strength also remains a key component of injury prevention programs. Skiers are recommended to work with a local Physical Therapist to design an effective ski injury prevention exercise program.

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Optimizing Glut Activation During The Crab Walk
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Strengthening the muscles of the hip, gluts, is a key component of rehabilitation for patients with low back pain, hip pain, and knee pain. These muscles help to optimize movement in the lower quarter improving joint mechanics and force distribution during life and recreational activities. In our Facebook posts, we have shown videos on optimizing the firing in the muscles on the back and side of the hips. These videos detail beginning, intermediate, and advanced exercises for each muscle group. One commonly utilized exercise is the crab walk which incorporates a lateral side stepping movement against a resistance band. A new research article highlights how placement of the band can optimize recruitment of the glut muscles.

Lewis and colleagues analyzed the activation of the glut muscles during a crab walk exercise using different elastic band positions (J Athletic Training. 2019). 22 healthy adults were asked to side step with the elastic band around the knees, ankles, and feet. During each 3 of the conditions, researchers analyzed EMG activity from the hip muscles including the TFL, gluteus medius, and gluteius maximus. As expected, increased glut work was found when the band was moved from the knees to the ankles lengthening the lever. Interestingly, placing the band around the feet increased the glut work without increasing the contribution from the TFL (often a muscle we try to utilize less during exercise). Thus, placing the band around the feet may be an optimal position to recruit the hip with less contributing from compensatory muscles.