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Take a dip!

Take a dip!

Jun 18, 2024

Hydrotherapy, or aquatic based therapy, is a treatment method I have personally used with patients ever since first becoming an MSK physiotherapist. From my first ever exposure to the method in my early NHS, Junior Physiotherapist role, to using a pool with elite athletes competing in a number of different sports in my more recent career, I very rarely find that the patient doesn’t leave the session with some form of positive gain. Hydrotherapy is defined as the external or internal use of water in any of its forms (water, ice, steam) for health promotion or treatment of various diseases with various temperatures, pressure, duration, and site (Mooventhan and Nivethitha, 2014) (4). Like many good things, it has been used for 1000s of years to assist in the management of health conditions whether that be to aid movement or relieve pain. Today, we very much utilise the benefits of water to treat a variety of health conditions ranging from cardiovascular, to rheumatological, neurological and musculoskeletal injuries. So what are the benefits of hydrotherapy? Well, to break it into pointers, these are the reasons as to why we can find benefit from hydrotherapy:
  1. Pain Relief 
  • Immersion in warm water can help reduce pain and inflammation in muscles and joints. The heat increases blood flow, which can ease discomfort and accelerate the healing process. The pressure exerted by water also helps to reduce swelling and improve circulation
  1. Muscle Relaxation and Recovery
  • Warm water helps to relax tense muscles, reducing spasms and stiffness. It can also enhance muscle recovery after intense physical activity by promoting blood flow and reducing lactic acid buildup.
  1. Improved Circulation
  • Warm water immersion helps dilate blood vessels, improving circulation throughout the body. This can aid in delivering oxygen and nutrients to tissues and removing waste products.
  1. Stress Reduction and Mental Health
  • The soothing properties of water can help reduce stress and anxiety. The buoyancy and warmth create a relaxing environment that can promote mental calmness. This can have a direct positive correlation to improving a person’s ability to sleep due to the relaxed state they enter.
  1. Mobility
  • The buoyancy of water reduces the load on joints, making it easier to move and perform exercises. Water provides a low-impact environment for exercise, reducing the risk of injury. This makes hydrotherapy an excellent option for rehabilitation after surgery or injury.
It is easy to see how we can utilise hydrotherapy to benefit a variety of patients based on the benefits mentioned. Carere and Ore (2016) carried out a review which concluded that hydrotherapy has a positive effect on pain, quality of life, condition-related disability and functional exercise capacity. In fact, the perceived benefit of well-being was actually superior to land-based exercise protocols in cases where water temperature was within a thermoneutral range (33.5–35.5 °C). (2) Cikes et al. (2021) (3) looked specifically at the use of hydrotherapy as an alternative to dry land therapy for rotator cuff repair patients. Through their study they found that the use of pool-based rehabilitation was as effective as dry land rehabilitation at the 1 and 2 year follow up points but that Pool based rehab was in fact MORE effective than dry land exercise at the 3 month follow up point. This therefore suggests that the use of water in the early to mid stages of this particular recovery is beneficial. Then, away from rehabilitation, the pool can also be a useful tool in the role of optimizing recovery for athletes between heavier training sessions or competition. As such, the pool can be used as a recovery tool to support low load conditioning and accelerated recovery between training sessions or match play. This is particularly relevant following intense training days on the field and/ or in the gym, which are designed to load the athlete to develop their tolerance to increased training demands. (Buckthorpe et al 2019) (1) So, whether it be for: rehabilitation from surgery or an acute injury, pain management for a longer-term condition or as a tool in optimizing active recovery, hydrotherapy is another great string to our bow as physiotherapists and can be of great benefit to a large chunk of our patient population.

Reference List

 
  • Buckthorpe, M., Pirotti, E. and Villa, F.D. (2019). BENEFITS AND USE OF AQUATIC THERAPY DURING REHABILITATION AFTER ACL RECONSTRUCTION -A CLINICAL COMMENTARY. International Journal of Sports Physical Therapy, [online] 14(6), pp.978–993. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6878863/.
  • Carere, A. and Orr, R. (2016). The impact of hydrotherapy on a patient’s perceived well-being: a critical review of the literature. Physical Therapy Reviews, 21(2), pp.91–101. doi:https://doi.org/10.1080/10833196.2016.1228510.
  • Cikes, A., Kadri, F. and Lädermann, A., 2021. Evaluation of Three Different Rehabilitation Protocols After Rotator Cuff Repair, and the Effectiveness of Water/Pool Therapy. A Randomized Control Study. Journal of Shoulder and Elbow Surgery, 30(7), p.e421.
  • Mooventhan, A. and Nivethitha, L. (2014). Scientific evidence-based Effects of Hydrotherapy on Various Systems of the Body. North American Journal of Medical Sciences, [online] 6(5), p.199. doi:https://doi.org/10.4103/1947-2714.132935.
Take a dip!

The Posterior Oblique Sling

May 29, 2024

The posterior oblique sling (POS) comprises the latissimus dorsi and contralateral gluteus maximus which is connected through thoracolumbar fascia, erector spinae, multifidus and bicep femoris. This activation pattern provides stability of the lumbopelvic region by transferring force through the trunk. For insistence, erectus spinae generates force whereas the multifidus creates stability. The posterior oblique sling is thought aid recovery from lower back pain (LBP) and is often a fundamental part of rehabilitation despite minimal research on the topic (Kang and Hwang, 2019). However, most recent research suggests patients with LBP have abnormal motor recruitment in the lumbopelvic region (Kim et. al, 2014); therefore, activating the POS may offer spinal mobility, stability and prevent LBP (Kang and Hwang, 2019).

Prone hip extension (PHE) is a useful measure to assess and activate the POS. In healthy individuals, one should be able to maintain neutral lumbar and pelvic position during PHE, however patients with LBP have been found to have altered lumbar and pelvic movement. This in turn can cause lumbopelvic dysfunction, spinal instability and postural disturbance (Kim et. al, 2014). For example, Kang and Hwang found patients with LBP often have delayed onset of gluteus maximus and earlier onset of bicep femoris (Kang and Hwang, 2019).  When the gluteus maximus does not activate, there is a loss of pelvis control which can cause the contralateral latissimus dorsi to become dominant. Therefore, to aid lumbopelvic control, practitioners can manipulate the PHE to focus on the less dominant muscle (Kim et. al, 2014).

Lee et. al altered the PHE technique to assess the impact this has on POS. The PHE was compared to abdominal drawing in maneuverer prone hip extension (ADIM PHE). The ADIM PHE had increased contralateral latissimus dorsi and ipsilateral gluteus maximus compared to hip extension, whereas PHE had increased ipsilateral erector spinae and ipsilateral bicep femoris ((Lee et. al, 2020). Lee et. al also compared PHE to PHE with hip abduction and knee flexion. They discovered the contralateral latissimus dorsi, ipsilateral erector spinae and gluteus maximus electromyography was higher with phone hip extension with hip abduction and knee flexion than PHE (Lee et. al, 2019). Therefore, depending on the clinical presentation of the patient, practitioners can isolate specific muscle groups within the POS. PHE with hip internal rotation and shoulder internal rotation and shoulder extension with 1lb dumbbell was found to be the optimal PHE variation for POS activation to aid recovery with LBP (Kang and Hwang, 2019).

This research highlights the importance of using PHE as an assessment and treatment tool to identify weakness within the POS and then adapting the PHE to support recovery from LBP.

Reference List

Kang, D. and Hwang, Y.-I. (2019). Comparison of Muscle Activities of the Posterior Oblique Sling Muscles among Three Prone Hip Extension Exercises with and without Contraction of the Latissimus dorsi. Journal of The Korean Society of Physical Medicine, 14(3), pp.39–45. doi:https://doi.org/10.13066/kspm.2019.14.3.39.

Kim, J.-W., Kang, M.-H. and Oh, J.-S. (2013). Patients With Low Back Pain Demonstrate Increased Activity of the Posterior Oblique Sling Muscle During Prone Hip Extension. PM&R, 6(5), pp.400–405. doi:https://doi.org/10.1016/j.pmrj.2013.12.006.

Lee, J.-K., Hwang, J.-H., Kim, C.-M., Lee, J.K. and Park, J.-W. (2019). Influence of muscle activation of posterior oblique sling from changes in activation of gluteus maximus from exercise of prone hip extension of normal adult male and female. Journal of Physical Therapy Science, 31(2), pp.166–169. doi:https://doi.org/10.1589/jpts.31.166.

Lee, J.-K., Lee, J.-H., Kim, K.-S. and Lee, J.-H. (2020). Effect of abdominal drawing-in maneuver with prone hip extension on muscle activation of posterior oblique sling in normal adults. Journal of Physical Therapy Science, 32(6), pp.401–404. doi:https://doi.org/10.1589/jpts.32.401.

Take a dip!

The power of words!

May 21, 2024

Something I always try to personally remind myself when seeing a patient, is how important the use of my language and terminology is in providing them a safe, informative and hopefully, comfortable environment. I think it is fair to say that a large percentage of patient’s withhold some level of apprehension when attending a medical appointment, particularly that first meeting. For me, that first time with a patient is as much about building a strong and trustworthy relationship as it is providing a treatment plan or diagnosis. I am sure each and every medical professional has had those appointments where the time is up and nothing ‘objective’ or ‘physical’ has taken place. Instead, the time has been taken up by conversation, or possibly even one way conversation where the professional’s role has simply been to listen rather than talk. For me, this is still active treatment and often, very beneficial to the patient. On more than one occasion I have been glad to receive an email or contact from a patient with whom this has been the case, where they have simply said ‘thank you’ for giving them the time to tell their story and share their beliefs.

An interesting stat that I have always remembered is that 40-80% of medical information provided by healthcare practitioners is forgotten immediately. The greater the amount of information presented, the lower the proportion correctly recalled and furthermore, almost half of the information that is remembered is incorrect (Kessels 2003)(3). This amplifies the importance of trying to keep terminology simple and keep focus on the most relevant information for that patient. From personal experience, it is more often than not, also the negative information or language used by a health professional that the patient clings to and remembers. Linskins et. al (2023) (2) carried out a randomised control trial on the effects of negative language use of physiotherapists in the treatment of lower back pain. To no surprise, the findings were that the use of negative language heightened a patient’s state of anxiety, with higher rates of belief and concerns that their condition would last for longer. This is not to say we should be unrealistic in what a patient’s possible prognosis may be, however it is definitely an indicator that how we relay that information is key in how they may perceive their recovery or long term management of a condition. I personally always like to ensure a patient leaves their appointment having completed something ‘pain free’ or that they didn’t believe they could actually do prior to that session. It gives a great base for positive reinforcement and the use of positive language, hopefully giving them something to work with and focus on going forwards.

Through my own career to date I have been lucky enough to work with some fantastic doctors and physiotherapists and it is from these, that I believe I have been able to do my best in attempting to maximise my interpersonal and communication skills when face to face with a patient. I was recently asked by a physiotherapy student, what key pieces of advice I would give for taking an effective subjective assessment. My response was based round the following points:

  • Let the patient lead the conversation
  • Do not interrupt the patient when they are speaking – no matter if the clock is ticking
  • Make eye contact with them, not constant eye contact with your computer screen
  • Emphasise you are here as a tool for them, not as a solution – give the patient some self importance and responsibility
  • Do not make the patient feel hurried
  • Use simple terminology
  • address the negatives, but focus on the positives

Franx and Murphy (2018) (1) summarise the importance of language in a medical setting nicely. They state that ‘listening consists of following the lead of language, often along many strange paths, until a proper understanding is reached. In this way, a patient’s true background is opened that is required for an effective intervention.’

Reference List

 

  • Franz, B. and Murphy, J.W. (2018). Reconsidering the role of language in medicine. Philosophy, Ethics, and Humanities in Medicine, 13(1). doi:https://doi.org/10.1186/s13010-018-0058-z.

  • Fieke) Linskens, F.G., van der Scheer, E.S., Stortenbeker, I., Das, E., Staal, J.B. and van Lankveld, W. (2023). Negative language use of the physiotherapist in low back pain education impacts anxiety and illness beliefs: A randomised controlled trial in healthy respondents. Patient Education and Counseling, 110, p.107649. doi:https://doi.org/10.1016/j.pec.2023.107649.

  • Kessels, R.P.C. (2003). Patients’ memory for medical information. Journal of the Royal Society of Medicine, [online] 96(5), pp.219–22. doi:https://doi.org/10.1258/jrsm.96.5.219.

Take a dip!

Musculoskeletal Disorders in Menopausal Women

May 8, 2024

Menopause causes a deficiency in oestrogen which can result in an increased risk of cardiovascular disease, cancer, cognitive decline, chronic obstructive pulmonary disease, diabetes, metabolic syndrome, depression, sleep disturbances, vasomotor symptoms, migraines and musculoskeletal disorders. The most common musculoskeletal disorders in menopausal women are osteoporosis, sarcopenia and osteoarthritis (Dijk et.al, 2015).

During the menopausal transition, there is an increase of muscle degeneration which can progress to sarcopenia. The decrease in oestrogen and testosterone leads to ‘neuromuscular junction insufficiency, myofiber loss, mitochondrial dysfunction’ (Buckinx and Aubertin-Leheudre, 2022) and reduced muscle regeneration.  These physiological changes increase fat deposits in muscle and increase the difficulty in achieving hypertrophy and maintaining muscle mass (Buckinx and Aubertin-Leheudre, 2022). The prevalence of osteoporosis in menopausal women is extremely high, as more than two million women have osteoporosis in England and Wales. After the menopause, prevalence rises with age from approximately 2% at 50 years to more than 25% at 80 years’ (Peto and Allaby, 2013) This is likely due to the osteoclastic resorption activity increases and the osteoblastic activity decreases, resulting in more bone being absorbed than being formed (Ji and Yu, 2015).

There is an abundance of research illustrating the impact menopause has on osteoporosis and sarcopenia, however there is limited evidence on the impact of osteoarthritis on musculoskeletal disorders (Watt, 2018). However, Richmond et. al found oestrogen receptors in articular cartilage which potentially demonstrates a relationship between oestrogen and articular cartilage health. Zhang et al. discovered that oestrogen has a positive impact on cartilage. These studies illustrate there is relationship between oestrogen and cartilage however unable to identify an explanation for the clinical significance (Hame and Alexander, 2013). Lower back pain (LBP) is also more common in postmenopausal women than men who are within the same age group. This is most likely due to oestrogen deficiency causing postmenopausal women to have increased prevalence of disc degeneration; therefore, resulting in increased risk of spondylolisthesis and facet joint osteoarthritis. Also due to higher rates of osteoporosis in postmenopausal women, osteoporosis related spine fracture, especially at thoracolumbar junction, can cause LBP (Wang, 2017).

There is a wealth of research showing the importance of menopausal women participating in exercise to reduce the risk of musculoskeletal disorders and prevent the worsening of symptoms (Grindler et. al 2015). For example, Mendoza et. al found that exercise reduces osteoarticular pain in postmenopausal women with fibromyalgia or breast cancer (Mendoza et. al, 2016). Research suggests a combination of high impact exercises and weight training is optimal to increase muscle mass and bone density, alongside medical intervention such as hormone replacement therapy and supplementation. Metcalfe et .al found the combination of adding calcium, hormone replacement therapy and weight bearing movement increases bone mass density and muscle strength for post- menopausal women. The weight bearing movements included stair climber or stepping alongside resistance training and balance exercises to reduce the risk of osteoporosis, sarcopenia and fractures (Metcalfe et. al, 2001). Hettchen et. al 2021 also demonstrated the positive impact exercise has on early postmenopausal women with osteopenia or osteoporosis and disorders related to menopausal transition. The exercise regime included a combination of high intensity training, jumping sequences and velocity resistance training (Hettchen et. al 2021).  The evidence illustrates the importance of physical activity for menopausal women, however more research is required to see the impact menopause has on other musculoskeletal disorders.

Reference List

 

Working from home checklist

Working from home checklist

May 5, 2024

Photo by Ian Harber on Unsplash
Office jobs can often result in several injuries, including back pain and repetitive strains, to name a few. Now, in light of the pandemic, these injuries have been transferred from the workplace to home, with many of us now adopting the working from home life. The most prevalent injury in the workplace is back pain, with sedentary office jobs causing this to develop from long periods of physical inactivity, incorrect posture, and poorly designed workspaces.
Making the shift to working from home offers us an opportunity to address these injury risk factors and make work as comfortable as possible. But what do we suggest?
  1. Create an ergonomic workspace. The word ergonomic has been thrown around a lot in recent months and refers to a space designed for efficiency. This includes positioning everything you will need for your working day, whether that be pens, phones, or a water bottle, within an arm’s reach. How does this help prevent injuries? Well, if you can reach anything you need by reaching out your arm, there will be no need for you to lean and stretch, potentially causing strains. An ergonomic workspace also means adjusting your monitor height, ensuring the screen brightness is optimal and adjusting your desk and chair height to ensure maximum comfort.
  2. Choose the correct office chair. This is one of the most important points of the working from home checklist. The correct office chair can be the difference between back pain and no back pain. A good office chair will promote proper posture by having an adjustable height, an adjustable backrest, and adjustable armrests, alongside lumbar support and the ability to swivel.
  3. Practice good posture. Following on from a good office chair is practising good posture throughout the day. When sitting for extended periods of time, we often subconsciously slouch or lean, which can cause severe back pain if not corrected. Using correct posture reduces the gravitational pressure that is placed on your spine, improving comfort and reducing the risk of back pain.
  4. Take frequent short breaks. Short and frequent breaks minimise the length of physical inactivity during the day. Even if this solely involves standing for five minutes every hour and stretching your back and legs, this can have a profound impact on the incidence of workplace injuries.

If you are still experiencing back pain even after taking these suggestions into account, there may be something deeper going on, and it is worth you coming in to get this checked out by the team at Opus. An assessment from one of our sports medicine specialists may identify exercises and changes you can incorporate into your daily life that will ease any pain your are experiencing.