Posts tagged rehabilitation
Should I Use R.I.C.E. Or Call The P.O.L.I.C.E. After An Injury?

The acronym R.I.C.E. (rest, ice, compression, and elevation) has been utilized for decades in the clinical and self management of acute injuries. Clinicians have updated RICE to PRICE adding in protection of the injured area, but this acronym needs further updating. In general, the 4 of the components of this self treatment approach have merit for injuries, but rest is being challenged in injury management. Immediate rest, 2-3 days, is required after a ligament, tendon, or muscle injury to facilitate the healing process, but newer research has highlighted the importance of exercise to facilitate an optimal recovery

A clinical commentary in the British Journal of Sports Medicine advocates for a new acronym in acute injury management, POLICE, which includes progressive optimal loading ice compression and elevation (Bleakley et al. 2011). Physical therapists are now utilizing progressive, optimal loading strategies due to research documenting accelerated recovery compared to an immobilization approach. For example, both ankle sprains and tendon injuries respond best to early mobility vs. prolonged rest. Progressive loading of injured tissues creates a beneficial cascade of events in the body through a process called mechanotransduction. Early exercise creates cellular changes in injured tissues allowing them to remodel into stronger, healthier tissues.

Authors state the difficulty in recovering from injury is finding the balance between rest and exercise. Many factors including, but not limited to, the patient, injured tissue, time since injury, severity and irritability of the injury play important roles in this decision making. In many cases, moving from rest into incremental exercise accelerates the recovery process and optimizes a patient’s return to activity. Patient’s are encouraged to work with their local Physical Therapist to determine which progressive, optimal loading interventions are best for their specific injury.

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Strength training focus optimizes recovery after total knee replacement

The first total knee replacement was performed in the late 1960s and the surgery has become one of the most successful procedures in orthopedics.  Authors estimate up to 600,000 total knee replacements are performed each year to reduce pain and improve function in patients with knee arthritis.  Many of these patients will undergo both pre and post operative Physical Therapy to accelerate the healing process and achievement of functional goals.  A recent study compared two different rehabilitation approaches to patients after a total knee replacement.

Pozzi and colleagues compared patients after a total knee replacement who underwent a traditional physical therapy program against a strength training focused group  (Physiotherapy Theory and Practice. 2018).  Each of these two groups was also compared to their age matched peers who did not undergo the procedure.  Both Physical Therapy groups were seen 2-3 times a week for 12 weeks.  The authors reported lower levels of function in the operative groups compared to the non operative group.  This is consistent with past research indicating patients with are post operative rarely reach the functional levels demonstrated by their asymptomatic peers.  Patients in the strength training focused group demonstrated better range of motion, strength, and stair climbing ability compared to the traditional Physical Therapy approach.  In addition, a greater percentage of the strength training patients reached their functional goals compared to the traditional rehabilitation group.  

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Physical Therapy Reduces Healthcare Costs and Opioid Utilization After Hip Surgery

Arthroscopic hip surgery rates have dramatically increased in the last decade due in part to increased MRI imaging.  MRIs are very sensitive, but lack specificity in many musculoskeletal disorders with high rates of false positives among asymptomatic populations.  Hip pathologies such as impingement (cam or pincer) and labral tears can be found in up to 68% of patients without hip pain.  As we described in our previous blog posts, many patients with these pathologies are able to improve pain and function with Physical Therapy alone.  Further, authors report no differences in long term outcomes between surgery and Physical Therapy.  A new study highlights the importance of post operative Physical Therapy in patients who do not respond to conservative treatments.  

Rhon and colleagues followed patients who underwent hip arthroscopic surgery between 2004 and 2013 to determine their outcomes and healthcare utilization (Physical Therapy. 2018).  The authors reported on 1870 patients of which 83% received Physical Therapy alone, 72% received opioid medication, and 56% received both Physical Therapy and opioid medication.  Authors reported a $5000 savings on healthcare expenditure, a reduction in subsequent hip surgeries, and opiod utilization among patients receiving Physical Therapy first.  Not surprisingly, patients receiving opioids first utilization more medication, over a longer period of time compared to patients receiving Physical Therapy.

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Knee Joint Mobilizations Improve Quadricep Strength After ACL Surgery

After any knee surgery, the quadricep muscle group becomes difficult to contract and recruit.  These inhibition or impairment is usually secondary to both knee pain and knee swelling.   Weakness in the quadriceps can lead to pain, impaired leg function, and prevent a full return to life or sport after knee surgery.  Physical Therapists often utilize exercise and electrical stimulation to try to improve the ability the quadriceps to contract, but new research is highlighting the role of manual therapy in restoring quadricep function.  

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A recent case study of a patient status post ACL reconstruction surgery documented the improvement in quadriceps force production after three commonly used Physical Therapy interventions (Ruggirello et al. 2017).  A 23 year old patient began post operative Physical Therapy 2 weeks after ACL surgery.  Due to weakness in his quadriceps the Physical Therapist tested the patient's knee strength before and after providing 3 different interventions including knee mobilizations, lumbar manipulation, and electrical stimulation.  Exercising alone without additional interventions increased force production the least.  Conversely, knee mobilizations followed by lumbar manipulation and electrical stimulation had the greatest improvements in force recruitment.  This study adds to the existing literature on the importance of manual therapy in order to improve pain, range of motion, and strength production.  

ACL Risk and Re Injury with Return to Sport
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We written many blog posts on ACL injuries as they continue to be a risk to our youth and amateur athletes in Boulder County.  Thankfully, evidence shows we are able to screen athletes at risk for future injury as well as reduce their risk through Physical Therapy strength, balance, and conditioning programs.  Another group at risk of future ACL injury are those athletes who return to sport after surgery and Physical Therapy.  A percentage of these athletes are at risk for re injuring their knee, but they are also at risk for injury to their uninvolved knee.

A recent study in The American Journal of Sports Medicine documented the incidence of second ACL injuries either to the involved or uninvolved knee after the athlete returned to sports (Schilaty et al. 2017).  The authors followed over 1000 athletes over a ten year period to determine the number of 2nd ACL tears.  They reported 66 (6%) of repeat ACL injuries with a surprising 67% occurring on the opposite side.  A few factors including graft type, reconstruction vs. conservative care, and an athlete's sex were correlated with this 2nd injury.  Allografts were associated with higher re injury risk compared to ACL autografts with patellar tendon autografts having the lowest risk of re injury.  The highest risk of re injury was found in females younger than 20 years old.  This study highlights the importance of completing a full course of post operative Physical Therapy after ACL surgery as well as delaying return to sport until 9-12 months.  

The Impact of Pre Operative Physical Therapy on ACL Recovery
ACL injury-surgery-physical therapy-pre operative physical therapy

ACL injuries  are becoming more common among both recreational and professional athletes.  The majority of these athletes who sustain complete tears of their ACL ligament will undergo ACL reconstruction and intensive post operative Physical Therapy.  Often, the ACL surgery is delayed after the injury to allow the athlete to regain their lost range of motion and strength, as well as, reduce signs of swelling and inflammation.  This pre operative period is an excellent opportunity for the patient to work with a Physical Therapist to address these impairments and improve their post operative recovery.  An athlete's condition entering surgery has a significant impact on their condition following surgery.

A recent review article studied 8 previous articles on pre operative Physical Therapy prior to ACL reconstruction (Alshewaier et al. Clin Rehab. 2017).  The 8 studies included 451 patients who underwent pre operative Physical Therapy from 3 up to 24 weeks.  The authors reported pre operative Physical Therapy was effective for improving strength and function prior to ACL surgery.  They concluded pre operative Physical Therapy is beneficial to patients with ACL injury and should be utilized to improve recovery and functional outcomes.