January, 2007 Volume 1, Issue 8

STRRRETCH

Jacksonville Orthopaedic Institute Rehabilitation San Marco 858-7045 Beaches 247-3324 Point Meadows 564-9594 South 288-9491 Westside/Riverside 389-8570 University 733-9948

Individual Highlights:

Heat or Cold??? 1-2

What is Sciatica 3

Adhesive Capsulitis 4-5

Ted Hose 6

Lumbar Stabilization 7-8

Which is Best; HEAT or COLD? By: Jim Harrison, PT Therapists and athletic trainers are asked this question constantly when patients are recovering from their injury and/or surgery. The answer is: “It depends on the circumstances.” There is no real best answer except to say that the appropriate modality is selected based on what the therapist/trainer/individual is trying to accomplish. To better clarify, it is first worthwhile to understand the physiological responses to the applications of the therapeutic heat or cold.

Physiological Responses Cold Heat Decrease swelling Increase swelling Decrease pain Decrease pain Decrease spasm Decrease spasm Decrease inflammation Increase inflammation Decrease metabolism Increase flexibility Decrease flexibility More comfortable Less comfortable Now that the physiological responses have been presented, we now can apply this to the decision-making process to determine which is the right modality – correct? Well, not quite. There are certain conditions that many individuals suffer that preclude the use of therapeutic heat or cold. Contradictions Decreased heat or pain sensation Impaired skin circulation Malignancy Neurological impairment Poor thermal regulation .

Okay, so now we know who we should and should not apply heat or ice to. Now we can proceed, right? Not quite yet! There is a question of methodology. In other words, when should they be applied, how long should they be applied, how frequently should they be applied, and how should they be applied. When Cold if the individual is tolerant of the discomfort of ice application Cold for acute situations – within the first 24-48 hours after injury Cold for pain Cold for spasm Cold for inflammation Cold for swelling Heat if comfort is a concern and inflammation and swelling is not a concern Heat for more chronic situations – after the acute phase of injury is over Heat for pain if the inflammation and swelling is not a concern Heat for spasm if inflammation and swelling is not a concern Heat for increasing soft tissue flexibility Application Time Cold- 15-20 minutes Heat- 15-20 minutes Application Frequency Cold- multiple applications are okay as long as there is allowed a minimum of 30 minutes is allowed between applications Heat- multiple applications are okay as long as there is allowed a minimum of 30 minutes is allowed between applications Application Types for the Home User Bag of ice Reusable ice packs Cracked ice in a washcloth Electric hot pack Re-heatable hot packs Bits and Pieces Do not let raw ice or a plastic bag with ice directly contact the skin – enclose in a cloth or pillowcase Check your skin after any cold or heat application The skin will normally turn a pinkish color with heat or cold Heat applications should be comfortably warm With cold in acute situations employ the R-I-C-E principle: Rest- remove yourself from the injurious situation and rest Ice- use the appropriate cold application method Compression- use a compression wrap (“Ace” wrap) under the cold pack Elevation- elevate the part above the heart for the duration of the cold application

Which is best……….....Heat or Cold, cont. Page 2

What is Sciatica?? By: Laura Stinson, PT Sciatica is a term used to describe pain radiating down the leg that may or may not include low back pain. The leg pain is caused by an irritation of the sciatic nerve. The question becomes what is causing the irritation of the sciatic nerve. The sciatic nerve is most commonly irritated by a disc bulge or ruptured disc (also called a herniated disc), degenerative disc disease, degenerative joint disease (which may lead to arthritic changes), sacro-iliac joint dysfunction, or a combination of these problems. Another less common cause of sciatica is spondylolithesis. Spondylothesis is the slipping of a vertebrae caused by a fracture of the vertebrae which may be acquired or congenital (from birth). Once the cause is determined, then an effective course of treatment can begin. Not everyone with pain down the leg is necessarily treated in the same way. Initially, a person should see their physician who may take a history, perform an examination and possibly obtain x-rays to rule out serious pathologies and determine a diagnosis. An MRI is an expensive test that is not always considered necessary when determining a diagnosis; however, may be used if further testing is needed. Often the physician will choose to take a conservative course of treatment including medicines to decrease inflammation, relax muscle tightness and decrease pain during the acute stages. The physician may also opt to send you to see a physical therapist. The physical therapist (P.T.) will also perform an evaluation to help determine or reinforce previous findings as to the cause of the sciatica. The P.T. will also assess your back and leg range of motion, flexibility and strength, and address deficits found in these areas. If you have been diagnosed with a disc bulge or ruptured disc, degenerative disc disease or degenerative joint disease, physical therapy will not eliminate the degenerative changes. Instead, you will be taught how to protect your back and correct your body mechanics to allow the body to heal itself and decrease the irritation and inflammation causing the pain. If the onset of pain is recent or acute and you have pain, inflammation and/or muscle tightness, your P.T. may choose to begin your treatment with modalities such as moist heat, ultrasound, or electrical stimulation. Modalities are generally used to control the level of pain during the treatment; however, by themselves, they do little to correct the problem causing the pain. A dysfunction of the sacro-iliac joint may also cause the symptoms of sciatica. A malalignment of the sacro-iliac joint, which often occurs after a fall or during pregnancy (due to ligamentous laxity), may cause the piriformis muscle to become tight. The piriformis is a muscle that goes across the buttock and attaches to the outside of the hip. When the piriformis muscle becomes tight it may also put pressure on the sciatic nerve which runs in close proximity with it. A malalignment of the sacro-iliac joint may present with pain in the buttock, hip, groin, thigh (front, side, or back) and/or the inside or outside of the knee. To correct the alignment of the sacro-iliac joint, the P.T. may perform manual joint mobilizations or instruct you in self-mobilizations. Deep tissue massage may also be used to restore proper muscle tone and flexibility to muscles that have been irritated.

Once the acute phase has been calmed down or the sacro-iliac joint alignment has been corrected, it is time to begin core stabilization exercises. You may have been instructed in some exercises along the way; however, strict attention needs to be placed on these exercises to return your normal strength and flexibility as well as emphasize stabilization of the lumbar spine. Restoring normal strength and flexibility, learning to stabilize the spine and using good posture and body mechanics will enable you to maintain a healthy back and prevent further injury or reoccurrence of back pain or sciatica.

Page 3

Adhesive Capsulitis By: Craig Torp, PTA Adhesive capsulitis is characterized by a marked loss of active and passive shoulder motion caused by inflammation and adherence of the capsule to the anatomic neck of the humerus. Three classic stages in clinical course of primary (idiopathic) frozen shoulder have been described:

Painful (or freezing ) Phase Lasts 2 to 9 months Gradual onset of diffuse shoulder pain, gradual loss of glenohumeral motion Patient uses arm less and less to avoid pain

Stiffening (or frozen) Phase

Lasts 4 to 12 months Shoulder movement often restricted

Thawing Phase Highly variable time course Gradual regaining of shoulder motion

Adhesive capsulitis cannot be identified by x-ray examination, but radiographs of the shoulder are used to rule out other conditions. Surgical intervention in adhesive capsulitis is rare. Physical therapy is the treatment approach of choice. Although often lengthy, a slow progressive exercise program can reduce the symptoms of adhesive capsulitis without the trauma of a closed reduction manipulation. The exercise program is complemented by pain reduction modalities and a home exercise program.

Page 4

Treatment:

The goals of treatment are to obtain pain relief and restore ROM of the shoulder.

Stretching:

Use pendulum exercises and hot packs or a bath to warm up for stretching exercises Concentrate on passive forward elevation and external rotation Perform forward elevation stretch by assisted elevation of the affected arm to reach up to a solid

object that is just beyond reach. Patients stand on tiptoes, and then lower themselves to maintain a moderate stretch, adjusted to tolerance, for 20 to 30 seconds. Lower the affected arm using the opposite arm to avoid a painful free fall. Repeat 5 times every several hours.

Perform external stretch with the arm at the side and the elbow flexed at 90 degrees. Carefully monitor this exercise. Patient rotates the trunk with the hand fixed on the side of a door frame to stretch the anterior structures, allowing progressive external rotation. A sustained stretch of 30 to 60 seconds 8 to 10 times a day is recommended.

Strengthening: Once stretching exercises are underway, begin strengthening within the limits of the newly achieved ROM.

Page 5 Adhesive Capulitis, cont. Kegel Exercises and the lumbar spine

Do I Have to Wear my TED Hose? By: Johanna Bergstrom, PT, CHT

Patients often complain about having to wear those uncomfortable, stark white compression stockings that clinicians call TED hose. Although inconvenient, they serve a very important role in preventing deep venous thrombosis, also known as DVT.

DVT is the formation of a blood clot in the deep veins, usually of the lower extremities. These clots can partially or completely block the blood flow in the vein resulting in dangerous consequences. The deep veins are located in the muscles and play a role in propelling blood upward toward the heart. Calf muscles, especially, function to squeeze and compress these veins as we walk and go about our daily activities to force blood back to the heart. When normal circulation of blood is slowed following an orthopaedic surgery, for example, blood can pool and eventually lead to a DVT. A DVT is a potential risk following a trauma, fracture, joint replacement, or other orthopaedic surgery. This is partially due to immobility and lack of the normal contract/relax action in the leg muscles essential for normal blood flow. However, there are several other factors that should also be considered. Individuals who have sustained an injury to the blood vessels, as in a blow to the leg, sports related injury, or radiation treatment for cancer are more susceptible due to a narrowing of the vein and/or tendency for trauma to initiate clotting. Others at higher risk include women who are pregnant or taking oral contraceptives, patients who smoke or are significantly overweight, people over 60, and those participating in long distance travel where prolonged sitting can slow circulation. DVTs can occur without significant signs or symptoms. In fact 50% of DVTs display minimal to no symptoms at all. Signs to watch for include pain and/or redness in the calf or thigh, swelling, and warmth and tenderness to touch. A clinician may also perform a Homan’s test (a squeeze of the calf with forced dorsiflexion of the ankle) to determine the presence of a DVT. However, this test to is only about 50% accurate. More conclusive tests include the use of Doppler Ultrasound, venography, or MRI. More serious signs that should immediately be brought to the attention of a doctor or clinician are chest pain, shortness of breath, increased heart rate, unexplained coughing, or coughing up blood. There are a variety of ways to prevent and treat a DVT. A clinician may ask a patient to perform ankle pumps, a flexing of the ankle which is extended in order to contract and relax the calf muscles. Also, the use of anticoagulant medications, which are designed to decrease the clotting action of blood, may be effective in high-risk individuals. Thirdly, YES, you guessed it, TED hose. These or other similar compression garments given to the patient by a clinician can help to treat or prevent a DVT when worn properly. The compression mechanism of the stocking gently squeezes the calf muscles, narrowing the veins, allowing the blood to flow more normally. In conclusion, DVTs are a potential hazard for individuals undergoing orthopedic surgery, such as THR or TKA, ORIF of a fracture, and/or other invasive procedure of the lower extremity. Therefore, a patient should know the clinical signs and symptoms (keeping in mind a DVT may have minimal to no obvious symptoms), if he or she is in a high-risk group, and the ways to prevent a DVT. These methods include medication, ankle pumps/exercises, resuming ambulation as soon as appropriate, and YES, wearing TED hose as instructed.

Page 6

Why is Lumbar Stabilization Important? By: Donna Ziegler, M.S., P.T.

Have you ever experienced this scenario? You bend, lift, or twist, and then feel a sudden pain and muscle spasm followed by difficulty bending, sitting, or even moving. Unfortunately for many individuals, this painful experience seems to happen again and again. Rest, ice, and medication are great for immediate relief. However, many doctors are now prescribing a specific type of exercise for their patients called lumbar stabilization, which has proven very effective in helping individuals who suffer from low back pain.

It has been estimated that approximately 80% of people in Western countries have experienced low back pain at some point in their lives. Most cases resolve within 2-4 weeks without any medical intervention. However, within 1 year following the first episode of low back pain, 60-80% of patients will have recurring pain. Current research has reported that in most cases of low back pain, certain muscles of the back that stabilize the spine are inhibited after injury. These muscles do not spontaneously recover even if patients are pain free with a return to normal activity levels. What Are the Stabilizing Muscles?

The muscles that work together to support and stabilize the spine and help prevent low back pain include the lumbar multifidi and the transversus abdominus. The transversus abdominus is the deepest of the abdominal muscles and is also a stabilizer of the spine. Support by this muscle is considered to be the most important of the abdominal muscles and has also been found to be in a weakened state in those who have chronic back pain or problems. Its normal action along with the action of the lumbar multifidus muscles function together to form a deep internal corset that acts to stabilize the spine during movement. This pattern of protection is disrupted in patients with low back pain.

It is uncertain why these muscles become dysfunctional after a low back injury, but specific exercises focusing on the contraction of these two muscles together will improve the protective stabilizing ability of the spinal muscles, reduce pain intensity, and improve activities of daily living as well as improve body awareness and posture.

Lumbar Multifidus Muscles

Transversus Abdominus

Page 7

What does a Lumbar Stabilization Program Involve?

The lumbar stabilization program is a program of back exercises designed to teach patients strengthening and flexibility in a pain-free range. It not only improves the patient's physical condition and symptoms but also helps the patient with efficient movement. It provides the patient with movement awareness, knowledge of safe postures, and functional strength and coordination that promotes management of low back pain.

Prior to starting a lumbar stabilization program, the patient should first be evaluated by his/her primary care physician and physical therapist. Together the MD and PT will design a comprehensive rehabilitation program along with a lumbar stabilization program specific to the patient. Since every patient is an individual and presents with different conditions, a physical therapist is needed to design and monitor the rehabilitation program.

Lumbar Stabilization, cont. Page 8

References http://www.nismat.org/ptcor/lbp