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Rotator Cuff Repair and Exercise Rehabilitation Programme

I would like to share one of my success stories of my recent patient who sustained a left shoulder injury at work in February 2020. An MRI showed a full-thickness tear of the supraspinatus tendon, moderate subscapularis tendinopathy and complete long head of biceps tendon tear. My patient had a left shoulder arthroscopy and open rotator cuff repair March 2020 and commended his exercise rehabilitation programme in July 2020. The individualised exercise rehabilitation programme was implemented to facilitate a return to pre-injury duties as a Groundsmen.

 

Job Specific Programme

The patient was completing pre-injury hours with a lifting restriction of 5kg and working below shoulder height. The patient’s pre-injury duties involved maintenance of irrigation around the school grounds including digging, repair and replacement of sprinklers and checking underground electronics. The physical critical demands of the patient’s job role are sustained bent over postures, combined with predominately repetitive hand-arm movements between waist and shoulder height. He is required to lift and carry 20L buckets of sand.

The exercise rehabilitation programme initially focused on increasing pain-free range of movement, joint mobility and stability through his left shoulder. The patient’s programme quickly progressed to addressing recruitment patterns of the left shoulder and supporting musculature with a focus on a variety of positions and postures. The final stage of his programme was to increase upper limb strength in a variety of postures with a focus on correct manual handling and repetitive movements with lifting load away from the midline of his body. The programme included eccentric strengthening exercises for the rotator cuff, concentric and eccentric strengthening for the scapular stabilisers. The focus was external rotator cuff strengthening due to an imbalance between the over strengthen internal rotators and weakened external rotators.

 

Outcome of Exercise Rehabilitation

The patient is now at 100% functional capacity in the gym for his pre-injury role. The patient was compliant to his exercise rehabilitation programme and return to work plan. He initially completed one supervised session per week for the first eight weeks combined with two to three unsupervised sessions per week. The supervised session was reduced to once per fortnight, which allowed the patient to progress to self-management. At the end of the exercise programme, the patient showed significant improvements in his range of movements and mobility through his left shoulder. The patient has gained strength with lifting load away from the midline of his body and lifting load in various postures necessary for his pre-injury duties, which allowed for job hardening, giving him the confidence to perform his work duties pain-free. As a result, the patient was certified fit for pre-injury duties and due to obtain a final medical certificate at his next specialist review.

 

 

Daniel Nguyen (B.Sc. Exercise Physiology)

Senior Accredited Exercise Physiologist (AES, AEP)(ESSAM)

 

 

Reference

Byram IR. American Orthopaedic Society for Sports Medicine (AOSSM) 35th Annual Meeting Abstract 8363. Presented July 10, 2009.

A day in trade with Mr Daniel Meyerkort – Orthopaedic surgeon

As an Exercise Physiologist we normally see our patients in the sub-acute to chronic stages of post-operative rehabilitation. I recently had the pleasure of observing Mr Daniel Meyerkort from Perth Orthopaedic and Sports Medicine Centre in theatre at Hollywood Hospital in Perth. I was lucky enough to witness three procedures during the afternoon observations, two of which will assist with understanding the process of post-operative exercise prescription for my patients in the workers compensation system who have undergone these surgeries. I was able to witness a lateral ankle ligament and tendon repair, chronic exercise-induced compartment syndrome fasciotomy and an ACL reconstruction with meniscal root repair.

It was humbling to see the professionalism of the team in the room from wheeling the patient in and going through pre-op procedures to wheeling the patient out for post-operative recovery. The team run like clockwork whilst still taking the time to ensure every patient is safe. It was amazing to see the differences in skills required from delicate stitching through to pulling through new ACL grafts that are required with some force! It is easier to appreciate why some patients pull up with more pain than others due to the invasiveness and force of some of these procedures. I have quickly learnt over my time that two patients will not recover from the same surgery in the same way. I also learnt that a lot of the patients will present quite sore not only from the surgery but also the tourniquet applied above the surgical site.

Mr Meyerkort explained that despite patients presenting with the same injuries, advice will change depending on the patient themselves. Not only the amount of injury sustained is taken into account but their age, associated risks and comorbidities, the occupation of the person as well as their standpoint on having surgery. This is always why I encourage my patients not to “Dr Google” as the advice is never going to be the same for every person. Every person’s rehab journey post-surgery is never going to be the same either. It was also great to hear the amount of education that is given to the patient’s surrounding their surgery.

It was surprising to see that even with viewing the imaging of the patient’s knee prior to surgery it is sometimes never fully clear to see the extent of what is going on until you are in the surgery. Mr Meyerkort kindly talked through each of the surgeries whilst able to repair on the go. During the ACL reconstruction he was able to go through the knee and find out the exact parts of the meniscus that needed repairing and his team where able to demonstrate and explain the thread work required and the importance of positioning and precise drilling required through the tibia and femur. The ACL procedure was the longest and most technical of the three with the aim of restoring stability to the knee. Mr Meyerkort demonstrated the extraction of the hamstring graft first using a long instrument to take the semitendinosus and gracilis to use for the graft. Careful inspections of the tendons is a must to make sure the thickness is of exact amount to provide stability. While Mr Meyerkort was repairing the meniscal damage and clearing the fat pad of the knee, the hamstring graft was being meticulously prepared. Throughout the surgery the knee was regularly tested through flexion and extension to ensure everything was on track. This is something that as an exercise physiologist I can draw on, as functional testing should be intermittently performed on the patient to ensure treatment is effective. Through fine and technical threadwork along with some brute strength, the ACL graft was pulled through the knee and secured in a tight position to restore the patient’s stability with the entire surgery lasting approximately two hours.

It was fabulous to see the acute stages of injury repair and the start of a patient’s rehab journey. I was able to draw comparisons in Mr Meyerkort’s work which rings true in the exercise physiology world.

1. You always have to consider the patient as an individual and no one treatment will have the same effect on that patient.

2. No person will have the exact same outcome and it is important to consistently test and check along the way

3. To always have respect and care for the patient and listen to their needs and concerns and be able to adapt in your approach where possible.

It is important to empower the patient through their recovery. If you have a question surrounding pre or post-operative rehabilitation, you can contact an Accredited Exercise Physiologist.

Taylor Downes

Accredited Exercise Physiologist

BSc/GradDipClinExPhys | B.Ed. Human Movement | (ESSAM, AEP)

New Years Resolution?

Do you have a new years resolution for your health and exercise in 2021? It may be obvious to most that creating personal change is something that directly ties into growth and self-improvement.  The same principle is necessary when it comes to exercise habits, and therefore your fitness. Recent evidence-based psychological studies suggest that individuals who feel the need to rely on external prompts as a motivational influencer are far less likely to adhere to the goals they set. This blog will discuss how to create exercise–based change, the effect these changes may have, and why you shouldn’t wait until the new year to get fitter!

Bringing more exercise into your life doesn’t have to be drastic to begin with. Start small, log your progress with a note pad and pen, or in your iPhone notes, and build on it gradually week by week. This is essentially known as the progressive overload principle. Smart progressive overloading will make you fitter and bring you closer to your fitness goals, without the risk of overtraining and losing morale.

When you start exercising more often or bring about exercise-based change, the following physiological and psychological changes may come along with it:

  • Greater productivity at work or in the office; being physically disciplined can have a carry-over effect into all facets of life, particularly with regards to discipline.
  • Hormone balance; hunger hormones such as ghrelin and leptin stabilise which can help to suppress snacking temptations.
  • Greater daily energy expenditure; leaner muscle mass, as a result of being fitter, directly ties into a quicker metabolism. When this occurs, you may also feel sharper throughout the day, concentrate for longer periods, and be less dependent on caffeine to do so.
  • Mood; there is a direct link between exercise and mood change. Exercise can induce feelings of immediate happiness and focus, by releasing neurotransmitters such as serotonin and dopamine.

Get in touch with our team of experienced Exercise Consultants today if you’re interested in finding out more about how to create a healthier, balanced exercise lifestyle. After all, the most important conversations are those that we have with ourselves – so if you’re genuinely unhappy with how you look in the mirror each morning, NOW is the time to do something about it. Not on the first of January.

Jeremy Boyle 

Exercise Scientist 

 

References:

Jones, F., Harris, P., Waller, H., & Coggins, A. (2005). Adherence to an exercise prescription scheme: the role of expectations, self-efficacy, stage of change and psychological well-being. British journal of health psychology10(Pt 3), 359–378. https://doi.org/10.1348/135910704X24798

Kavanaugh, A. (2007). The Role of Progressive Overload in Sports Conditioning. Conditioning Foundamentals. NSCA’s Performance Training Journal6(1).

Klok, M. D., Jakobsdottir, S., & Drent, M. L. (2007). The role of leptin and ghrelin in the regulation of food intake and body weight in humans: a review. Obesity reviews8(1), 21-34.

Turn your walk into a workout!

With summer upon us, many people (myself included) will be spending a lot more time outdoors enjoying the hot sun and clear skies. There is already a noticeable increase in people going for a walk or run early in the mornings and in the evenings. Walking with purpose is a great way to improve or maintain your overall health. While improving or maintaining cardiovascular fitness, walking can reduce your risk of heart disease, diabetes, and mental health disorders. While many of us are guilty of spending too much time on our bums and on our backs, spending more time on our feet performing weight-bearing activities with moderate to high intensity helps to slow down bone loss and aging.

The key, however, is walking with purpose. Walking at a slow leisurely pace, although still beneficial, will not see you gain the most out of your time in the sun. Unless sickness or injury inhibits you should aim to walk at a brisk pace, faster than you would if you were walking around the house or going shopping – although I have seen some impressive power-walkers at the local Westfield. Walking with intensity gets your heart working harder and will lead to greater changes in your aerobic fitness and cardiovascular health.

If you’re already a pro at walking with purpose, you can take this one step further and introduce some bodyweight exercises along your walk. Depending on how far or how long you walk you can set yourself some stops or stations along the way. An easy way to do this is set a timer for your walk. Set a timer for 3-5 minutes depending on how long you intend to walk for. Every 3-5 minutes stop and perform high repetitions of an exercise/exercises before continuing. This will be sure to increase your heart rate and build strength and endurance in your muscles.

Example Walk Plan

Walk Duration: 20 Minutes

Every 4 minutes stop and perform:

  • 12 Squats
  • 12 Lunges
  • 12 Star Jumps

Aim to perform each repetition with quality and complete exercises one after another with little to no rest. Your walk will then become your “active recovery” period. Suddenly you have yourself a cardio workout plan built around your morning/evening walk. The same program can be adjusted if you decided to go for a run. Throwing in some body weight exercises during your walk can help you maximise the short time you have to walk the dog or clear your head. So, the next time you go for a walk, why not turn it into a workout!

If you have been limited to walking because of sickness or injury, please make sure you seek clearance from your GP and relevant health professionals before attempting to increase your activity levels. If that happens to be the case, our team of qualified Exercise Physiologists at Absolute Balance are well equipped to prescribe effective, outcome-based exercise programmes to assist in your rehabilitation and ensure safe exercise progression. You can contact us at info@absolutebalance.com.au

 

Bastien Auna

Accredited Exercise Physiologist (AES, AEP) (ESSAM)

 

References

Lee, I. (2007). Dose-Response Relation Between Physical Activity and Fitness. JAMA297(19), 2137. doi: 10.1001/jama.297.19.2137

Murtagh, E., Murphy, M., & Boone-Heinonen, J. (2010). Walking: the first steps in cardiovascular disease prevention. Current Opinion in Cardiology22(5), 490-496. doi: 10.1097/hco.0b013e32833ce972

Murphy, M., Nevill, A., Neville, C., Biddle, S., & Hardmann, A. (2002). Accumulating brisk walking for fitness, cardiovascular risk, and psychological health. Medicine & Science in Sports & Exercise34(9), 1468-1474. doi: 10.1097/00005768-200209000-00011

To take a break or adapt your training style – the holiday season dilemma

It’s safe to say 2020 has been a year full of adapting. Fitness-wise with the shutdowns and restrictions as a result of COVID-19 we are all well practiced in how to keep a fitness routine alive while gyms are closed – show of hands for using household items in place of weights! So the question is should you take a break or adapt your training style over the holiday season?

If you are looking to keep some consistency to your training regime but won’t have access to a gym or any gym equipment during the festive season try changing up the tempo of bodyweight exercises to make them more challenging by using the Time Under Tension principle. This is an easy and effective way to manipulate the amount of stress on your muscles when you aren’t able to add extra load through weights (or canned goods hello COVID-19 closures). For example, in a squat or push up try lowering for 5 seconds, holding at the bottom for 5 seconds then coming back up in 1. The idea being that by lengthening different phases of a movement will increase the volume of your training and force the muscle to work harder.

If you’d rather scale back your training and give your body a bit of a break that’s great too! Remember winding down or taking it easy doesn’t have to mean doing nothing at all. It doesn’t have to be strenuous but try to incorporate some type of physical activity into most days, we are lucky that for us the holiday season falls when the weather is beautiful making it easy to get outside and keep active. Remember anything is better than nothing so walk, run, swim, play, whatever it is just keep moving!

That being said, allow yourself to enjoy the festive season and if you decide you want to take a few days off completely then do it and don’t feel guilty about it. At the end of the day if you are usually consistent with your training a few days off isn’t going to ruin the hard work you’ve put in over the rest of the year.

We will all find ourselves somewhat overindulging this time of year, but it is important not to be tempted to overcompensate by hitting the gym twice as hard when you go back. We need to move away from the idea of using exercise as a punishment for eating more than we should have or not training for a few days, using guilt as an incentive to get into the gym is not a sustainable mindset. Instead, own the decision you made to take a few days off, eat the food you ate or the drinks you consumed and get back on track with a healthy sustainable goal.

Whether you decide to adjust your training or to take a break from your usual fitness routine we at Absolute Balance hope you have a restful and enjoyable festive season and look forward to working with you again in the new year.

Katie McGrath

Exercise Scientist

 

References:

Gentil, P., Oliveira, E., & Bottaro, M. (2006). Time under Tension and Blood Lactate Response during Four Different Resistance Training Methods. Journal of Physiological Anthropology, 25: 339–344.

 

 

 

HDL Cholesterol and LDL Cholesterol Explained: Made Easy to Understand

Cholesterol frequently gets a bum rap, but it’s necessary for your body to function properly.

Cholesterol is a waxy substance a bit like fat. It moves around your body via your bloodstream, in packages called lipoproteins. These packages are made of fat on the outside (lipo) and protein on the inside (protein).

Sometimes, these lipoproteins leave cholesterol in your arteries, which contributes to the build-up of plaque and increases your risk of heart disease and stroke.

Rather than two different kinds of cholesterol that are ‘good’ and ‘bad’, there are two different types of lipoproteins that cholesterol travels in. Having some of both types of lipoproteins is essential for good health.

High-density lipoproteins (HDL cholesterol) the ‘good’. They remove cholesterol from your arteries and take it back to your liver to process and eliminate.

Low-density lipoproteins (LDL cholesterol) the ‘bad’ cholesterol. They leave cholesterol in your arteries.

While you need some LDL and HDL cholesterol for your body to work properly, too much cholesterol in total can lead to health problems, as the extra LDL cholesterol builds up in your arteries.

Below are a few lifestyle habits to follow to lower cholesterol.

  • Following a balanced diet
  • Lower intake of saturated fats
  • Remaining physically active and avoiding a sedentary lifestyle
  • Manage your blood pressure
  • Maintain a healthy body weight
  • Quit smoking

If your cholesterol is high, your Doctor might prescribe medication that can help lower cholesterol too.

 

References:

Liu, J., Sempos, C., Donahue, R., Dorn, J., Trevisan, M. and Grundy, S., 2020. Joint Distribution Of Non-HDL And LDL Cholesterol And Coronary Heart Disease Risk Prediction Among Individuals With And Without Diabetes.

Van Lenten, B., Hama, S., de Beer, F., Stafforini, D., McIntyre, T., Prescott, S., La Du, B., Fogelman, A. and Navab, M., 2020. Anti-Inflammatory HDL Becomes Pro-Inflammatory During The Acute Phase Response. Loss Of Protective Effect Of HDL Against LDL Oxidation In Aortic Wall Cell Cocultures.

 

 

 

 

 

 

 

Mirror Box Therapy

Mirror box therapy is derived from the use of a mirror to reflect the use of a normal functioning limb to trick the brain to reinforce movement without pain. It involves placing the affected limb inside a box or covered with the reflective side displaying the “working limb” back to the person. From their perspective, they see two fully functional limbs. This type of therapy has been widely used for people with amputated limbs who experience phantom limb pain, complex regional pain syndrome and people recovering from stroke.

Phantom limb pain is where a person feels painful sensations from a limb that is no longer there. The mechanisms of phantom limb pain are not widely understood; however it is thought to be due to peripheral mechanisms due to the injury-causing disrupted input from afferent nerves back to the spinal cord and changed in central neural mechanisms. Mirror box therapy can assist people with phantom limb pain by using the mirror to assist with visual feedback making it real for the patient to see movement and move the “phantom limb”. They receive feedback through vision and proprioception which assist the person to see real movement and that this can occur without pain. The idea is to trick the brain to remodel the cortical systems that may provide relief through visual dominance of the motor-sensory process and activation of mirror neurons through visual movement.

There are some limitations to the use of mirror therapy in rehabilitation with restrictions to the location of injury as well as the extent of injury and the variety of pathologies that induce pain. Mirror box therapy can be easily added into exercise-based routines using active or passive range of motion movements and other exercises for patients based on their level of ability. It is best to consult an accredited exercise physiologist prior to undertaking treatment.

Taylor Downes |B. HM. | GradDipClinExPhys|

Accredited Exercise Physiologist (AEP) (ESSAM)

 

Najiha, A., Alagesan, J., Rathod, VJ., Paranthaman, P. Mirror Therapy: A review of evidences. IntJ Physiother Res 2015;3(3):1086-1090. DOI: 10.16965/ijpr.2015.148

Subedi, B., & Grossberg, G. T. (2011). Phantom limb pain: mechanisms and treatment approaches. Pain research and treatment, 2011, 864605. https://doi.org/10.1155/2011/864605

O’Connell  NE, Wand  BM, McAuley  JH, Marston  L, Moseley  GL. Interventions for treating pain and disability in adults with complex regional pain syndrome‐ an overview of systematic reviews. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD009416. DOI: 10.1002/14651858.CD009416.pub2.

Exercise and Back Pain

Almost everyone has experienced a degree of back pain throughout their lifetime, preventing them from completing activities of daily living and leisure activities. Most often than not a vast majority of people will completely cease involvement in exercise or sporting activities after experiencing a bout of back pain as they are fearful it will cause more harm than good. However, this is a common misconception and in most cases exercise and movement are the natural stimuli to begin the healing process.

It is recommended that no more than one- or two-days rest at the onset of back pain is needed, as inactivity protracts the likelihood of prolonged pain. Increased periods of inactivity cause deconditioning of the lower back leading towards increased stiffness, weakness, and decreased mobility. As the old saying goes use it or lose it.

Exercise plays a dual role of both treating and preventing lower back pain. Regular stretching and exercise help by nourishing and repairing spinal cord structures which will help solve pre-existing issues. Whilst continued movement will help prevent future exacerbations by ensuring the lower back is strong and mobile.

Exercise is known to have many benefits in the process of treating lower back pain and when completed in a controlled and sensible manner these benefits may include:

  1. Strengthens the muscles which support the spine, alleviating pressure on facet joints
  2. Reducing stiffness and promoting mobility
  3. Improving circulation to better distribute nutrients to the discs
  4. Increased release of endorphins, which may help with pain.

The key to a successful gym programme to aid in the reduction of lower back pain is adherence. Exercise is one of the most important factors long term pain relief, even small bouts of 10 minutes a day is enough to notice benefits. Start small and progress slowly, remember some movement is better than none. Below are 5 easy exercises to get you started on you pain free journey!

5 Exercise to Help with Lower Back Pain

  1. Cat Camel
  2. Lumber Rocking
  3. Lumber Roll Down
  4. Glute Stretch
  5. Glute Bridge

 

Cameron Galati

Accredited Exercise Physiologist (AEP, AES) (ESSAM)

Hochschuler, S. (2020). Exercise and Fitness to help your back. Journal of Spine Health.

Gopez, J. (2017). Exercise and Back Pain. Journal of Spine Health.

Whiplash

Whiplash and Whiplash Associated Disorders

Whiplash associated disorder (WAD) is a term used to describe the collection of symptoms associated with an injury of the neck usually sustained in an accident. Whiplash and whiplash associated disorder are often terms used with the intention of equivalent meaning, however whiplash refers to the mechanism of the injury instead of symptoms present whereas WAD is a range of neck-related clinical symptoms which are usually chronic in nature.  Both conditions are common and are usually the result of sudden acceleration-deceleration movements most commonly following the involvement in a motor vehicle or sporting accident.

Whiplash is one of the most controversial musculoskeletal conditions as a precise anatomical diagnosis is usually unachievable. There are 4 grades of whiplash depending on the severity, pathology, signs and symptoms present. Neck pain is the most common indicator of a whiplash injury, other symptoms include stiffness of the neck, headache, visual disturbances, shoulder pain and pain, numbness, tingling or weakness in one or both arms. For some whiplash patients their symptoms become debilitating and progressively worse, for these patients their condition develops into a whiplash-associated disorder. Psychosocial symptoms such as depression, anxiety and fear can also be seen in patients with a whiplash injury as well as psychological factors surrounding the accident itself. Anyone who has already sustained a neck-related injury in the past is more susceptible to whiplash.

For many reasons whiplash injuries can be difficult to treat. Factors such as severity and presence of pain symptoms, interactions of psychological, legal, and physical factors can impact the time to recovery and the effectiveness of treatment methods. Most recent studies suggest active treatment, early mobilization and a gradual exercise programme lead to improved outcomes compared to treatment options which include motion restriction and rest. An exercise programme incorporating specific neck range of motion, strengthening, and stretching exercises can assist with recovery of a whiplash injury. Studies also suggest an early intervention and exercise can reduce pain intensity, improve functional capacity, reduce absences from work and improve range of motion of the neck to pre-injury levels. In patients with chronic whiplash and whiplash-associated disorders exercise, early mobilisation and returning to activity improved long-term outcomes. Overall, recovery times can vary due to the interactions of many factors, however early intervention and exercise can offer the best chance for recovery.

Katie Lintott 

Accredited Exercise Physiologist (AEP) (ESSAM)

 

References

Michele Sterling (2011) Whiplash-associated disorder: musculoskeletal pain and related clinical findings, Journal of Manual & Manipulative Therapy, 19:4, 194-200, DOI: 10.1179/106698111X13129729551949

Yadla, S., Ratliff, J. K., & Harrop, J. S. (2008). Whiplash: diagnosis, treatment, and associated injuries. Current reviews in musculoskeletal medicine1(1), 65-68.

 

 

 

 

Joints Click

My Joints Click, Is There an Issue?

Do your joints click and pop when you are active? I would be surprised if you did not. The technical term for the noises coming from our audible joints is “crepitus” and people of all ages experience it. Personally, my knees “click”, my right hip “clunks” and when I roll my shoulders there’s an internal “thud” sound that accompanies the movement. I have a lot of clients who are initially worried about such noises, associating the crackles and pops with further damage to the joint.

The good news is it really is quite normal to experience crepitus and most of the time has no sinister affect on the body. As we age, of course our joints are aging with us, leading to general wear and tear to the structures of the joint, most notably the cartilage. Crepitus can then occur from these rougher surfaces rubbing together as you complete a movement, such as a click in your knee as you stand up from your chair or a pop in your ankle as you shift your weight on your foot.

In regard to exercise, it is also quite normal to hear repetitive clicking as you complete each repetition of a given movement. This could be caused by a tight muscle which is causing some friction around the bone. Some gentle, targeted stretching may be all that is required to sort that snapping out. Overall, exercise is a great way of maintaining your joint health, the more your body moves, the more your joints will lubricate themselves.  – “Motion is Lotion” as they say.

One caveat, if the crepitus is accompanied with pain then there is the possibility of an underlying injury and a review with a healthcare professional would be the best course of action to mitigate any risk of damage as you go about your day to day life. For further information please contact Absolute Balance through info@absolutebalance.com.au.

Callan Smith (B.Sc. Exercise & Sport Science, B.Sc. Exercise Science & Rehabilitation)

Senior Accredited Exercise Physiologist (AEP) (ESSAM)

 

 

References

 

Robertson, C., Hurley, M., & Jones, F. (2017). People’s beliefs about the meaning of crepitus in patellofemoral pain and the impact of these beliefs on their behaviour: A qualitative study. Musculoskeletal Science And Practice28, 59-64. doi: 10.1016/j.msksp.2017.01.012