Posts

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)

Client Feedback – Callan Smith

“I recently suffered a work injury and was referred to Callan Smith for aid in my recovery. I’m back to pre-injury fitness and probably a bit better, due in great extent to Callan’s assistance.

From the beginning he was realistic, friendly and thoughtful. He actually listened to my symptoms and (for which I was particularly grateful) never made it all about my weight.

He has given me a doable workout which doesn’t hurt, and has extended it as my symptoms have improved. I am actually enthusiastic about my gym visits as I know they will make me feel better instead of worse.

Thank you very much, Callan”

Biceps Tendon

Biceps Tendon Injury and Rehabilitation

I recently completed a successful rehabilitation programme with a client who was recovering from a biceps tendon rupture.  The injury was sustained at work and was surgically repaired.  The programme was implemented to facilitate a return to pre-injury duties as a Mechanical Fitter.

The biceps brachii muscle is located in the upper arm and originates from the scapula, via two tendons.  The distal biceps tendon crosses the elbow to attach the biceps brachii to the radius of the forearm.  These attachments enable the bicep to perform elbow flexion and supination of the forearm.  Injuries to tendons vary in nature and include gradual overuse or acute tears from lifting an excessively heavy object.  In this case, the injury was sustained whilst performing a heavy lift.

The exercise rehabilitation programme focused on progressively exposing the tendon to higher forces and variable movement patterns to facilitate a return to pre-injury capacity.  Due to the physically demanding nature of Mechanical Fitting, an emphasis was placed on work hardening to ensure conditioning was achieved to perform all aspects of the pre-injury role.  This included lifting, pushing, pulling, carrying and pronation-supination of the forearm.  The exercises were also performed at variable rates of contraction and incorporated isometric (static) interventions to further emphasise work-specific conditioning and to aid the rehabilitation of the tendon.  Research has shown that strength training is beneficial for stimulating adaptations in both muscle and tendon and is beneficial for tendon pain.

The outcome of the programme was successful, as all the critical physical demands specific to Mechanical Fitting were achieved and a final medical certificate was issued.  Two key reasons for the positive outcome were the high level of motivation and accountability for performing the gym-based programme.  It’s personally rewarding when an outcome like this is achieved.

If you would like more information on elbow injuries or other rehabilitation programmes that Absolute Balance specialise in, please don’t hesitate to contact us at info@absolutebalance.com.au

 

Daniel D’Avoine BSc(ExerSc&Rehab)

Exercise Rehabilitation Team Leader – Workers Compensation Specialist

 

References:

Borms, D., Ackerman, I., Smets, P., Van den Berge, G., & Cools, A. (2017). Biceps disorder rehabilitation for the athlete: a continuum of moderate- to high-load exercises. American Journal of Sports Medicine, 45(3), 642-650.

Rio, E., Kidgell, D., Moseley, L.G., Gaida, J., Docking, S., Purdam, C., & Cook, J. (2016). Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. British Journal of Sports Medicine, 50, 209-215.

Wentzell, M. (2018). Post-operative rehabilitation of a distal biceps brachii tendon reattachment in a weightlifter: a case report. The Journal of the Chiropractic Association, 62(3), 193-201.

 

Pubalgia

Pubalgia (Or Sports Hernia)

Pubalgia is a chronic condition where there is an imbalance of the adductor and abdominal muscles at the pubis, that leads to an increase of the weakness of the posterior wall of the groin. This imbalance leads to a deep groin pain. Complete tearing or displacement can occur unilaterally or across the midline to the other side.

Management with Exercise:

  • Rehabilitation with physical therapy is first-line treatment for most patients with athletic pubalgia. Recovery considerations include: Severity of the injury since onset, physical condition activity levels of the person
  • The treatment consists of rest, active soft tissue mobilisations in case of muscle tightness, anti-inflammatory medication and exercise rehabilitation, therapeutic ultrasound treatments, cold tubs and deep massage.
  • Stage of therapy include:
    • The range of motion must be recovered
    • Core strengthening exercise to target the abdomen, lumbar spine and hips
    • Stretching focusing on the hip rotators, adductors and hamstrings
    • Neuromuscular re-education focusing on the adductors and abdominal muscles where we begin with the controlled contraction of the Transversus Abdominis.
  • Overall, the goal is to correct the imbalance of the hip and pelvic muscle stabilizers. Another crucial part is the. Optimal training includes a variety of exercises, with a focus on proprioception, and co-contraction of various muscles to keep postural equilibrium.

An active training programme is superior to passive treatment without active training

Ronan Power, B.Sc Exercise Physiology (AEP, AES) (ESSAM)
Senior Accredited Exercise Physiologist

 

have a say

“Let your patients have a say in their rehabilitation”

Now you may have heard this before, but letting your patients have a say in their treatment leads to better outcomes. When health professionals hear this saying they may think that this means having a rehabilitation program that is convenient to the client where they advise what location is best for them, establishing realistic treatment frequencies and durations which suit their work/life schedule. This certainly plays a large factor in recovery and treatment adherence, but it is not the takeaway message from the saying “let your patients have a say in their rehabilitation.”

So, what is the takeaway message from the saying “let your patients have a say in their rehabilitation” and what does it lead to?

What if I told you there is evidence out there by Gardner, 2019 showing 21% increased improvement in disability and a 35% increased improvement in pain with a therapist who allowed the patients to set their goals when compared to a therapist giving standard exercise advice. Makes sense, right? Now think about your patients you are working with. Have you allowed them to think about their goals and what they require to improve their program adherence, improve their pain and disability levels?

My takeaway message from “let your patients have a say in their rehabilitation” is that there’s a difference between treating people and treating pain.  Working in the workers compensation field it is important to make relevant work and life goals to ensure program adherence is consistent and thus leads to goals being reached. If you would like more information on individualised client-focused goal setting and how to build a stronger rapport with your patients please don’t hesitate to contact us on info@absolutebalance.com.au.

Jason Peschke

Accredited Exercise Physiologist (AEP, AES) (ESSAM)

Gardner T, et al. Combined education and patient-led goal setting intervention reduced chronic low back pain disability and intensity at 12 months: a randomised controlled trial BR J Sports Med, 2019.

Pain Theory Continued

In my last blog I discussed the Progression of Pain Theory looking at one of the first theory’s from the ancient Athenian philosopher Plato to more recent theories by David Wall and Ronald Melzack which views pain through a mind-body perspective. At present pain is defined as “an unpleasant sensory and emotional experience associated with the actual and potential tissue damage or described in terms of such damage”. This definition fits well when considering the biopsychosocial pain model which recognises an individual’s biology or pathology, cognitive aspects and social aspects of an individual’s life.

The biopsychosocial model was first introduced in medicine by George L. Engel and was mostly related to all chronic illness. Engel’s model suggested that as a medical illness became more chronic in nature, then psychosocial “layers” e.g., distress, illness behaviour, and the sick role emerged to complicate assessment and treatment. Later, J.D. Loeser, applied this model to pain. Taking into account these perspectives, there were four dimensions related to the idea of pain: nociception, pain, suffering, and pain behaviour.

  • Nociception refers to the physiological components associated with sensory input—such as nerve receptors and fibre
  • Pain is described as a subjective perception resulting from sensory input.
  • Suffering can be seen as a negative affective response to nociception or pain.
  • Pain behaviour is described in one’s actions while suffering from pain e.g. fear of recurrence of injury often leads to inactivity which, in turn, can delay the progression of recovery.

The current Biopsychosocial model is described as a pain experience with three dimensions,

Biological factors, psychological factors and social factors.

  • Biological factors include genetics, physiology, neurochemistry, tissue health
  • Psychological factors include perceived control, catastrophic thinking, depression, anxiety, hypervigilance
  • Social factors include socioeconomic status, social support, social learning, scepticism.

As time has gone on and our understanding of pain theory has developed, how someone experience pain unique to the individual and their circumstances. When assessing chronic pain conditions as exercise physiologist we have to consider all of these components in order to effectively treat an individual and get the best outcome possible.

Stayed tuned for my next pain theory instalment where I will look at the assessment process and what Exercise physiologists need to consider when assessing chronic pain.

Claire Hills ( B.EXSpSc,Grad.Dip.(Clin.Ex.Phys))
Senior Accredited Exercise Physiologist (AEP) (ESSAM)

References

Adams, L., & Turk, D. (2018). Central sensitization and the biopsychosocial approach to understanding pain. Journal Of Applied Biobehavioral Research23(2), e12125. doi: 10.1111/jabr.12125

The Biopsychosocial Approach. (2020). Retrieved 24 September 2020, from https://www.practicalpainmanagement.com/treatments/psychological/biopsychosocial-approach

 

Patient Interview

Patient Interview: Phulpreet was referred to us following a lower back injury he had obtained at work. Given Phulpreet’s pre-injury job role was quite heavy and labour intensive, I recommended he commence a gym-based program to ensure we had adequate equipment so he was able to demonstrate lifting capacity in order to return to full pre-injury duties. Phulpreet, however, was not 100% confident with attending the gym on his own given he had no previous gym experience. Fast forward to now, just five short weeks into his program, Phulpreet is averaging 4 weekly visits to the gym (one of these being supervised) and has gone from being certified fit to complete supervisory duties, to close to full capacity whilst also reporting a significant improvement in lower back symptoms.

I asked Phulpreet a few questions at our most recent consultation to understand how he (and I assume quite a few others) feel when we recommend a gym membership and they have not stepped foot in a gym before. I also wanted to address how he has gone from feeling quite anxious in a gym environment, to attending 4 times per week and more importantly how he feels as a result.

Prior to your injury, what is your exercise history?

“Absolutely nothing, it was all just work-related. I felt because I lifted heavy things at work, I did not really need to attend the gym because I was doing enough”.

What was your view around the gym prior to starting this program?

“I was nervous about what other people thought of me. Was I doing exercises with the right technique? What if I was doing it wrong?”

What did you expect when getting referred to us at Absolute Balance?

“I thought you were going to push me too hard I was going to be so sore and wouldn’t want to come back.”

2-3 sessions in, how did this change?

“Was such a big improvement, I started with mat work which was good to start and once you had taught me to breathe properly and release the tightness throughout my back my pain improved almost immediately. Because you taught me the technique, I didn’t even think about other people watching me at the gym. Because I felt so much better it made me want to come to the gym to get better.”

How has your perception around pain changed?

“Significantly, I don’t have to rely on other people for my daily activities and I’m no longer in pain throughout the day. It also helped me get my health back on track, I feel a lot better after coming here.”

What advice would you give to someone else who has been recommended to attend the gym but has no previous experience like yourself?

“Do not compare yourself and do not look at others for comparison, pay really good attention to your instructor as they are there for you to help you.”

 At our initial assessment, Phulpreet was able to lift 5kg from floor to waist and waist to shoulder, he struggled to complete full range squats or multiple cable rotations due to on-going pain throughout his back. Phulpreet’s average pain score was 6/10 following prolonged sitting or standing and was very guarded when asked to move into lumbar flexion and extension. The photos below were taken just five weeks into his program and his average pain score has decreased to an intermittent 1/10 pain.

Given Phulpreet was quite reluctant to attend the gym given the minimal prior experience, I spent additional time throughout our sessions on teaching him correct technique, how to adjust machines, gave him a few key points on what to focus on throughout each movement and tried to limit the exercises I prescribed to one area of the gym. From speaking with Phulpreet, it was these little changes that reportedly made him feel much more confident with attending the gym as he felt no one was staring at him for doing something with wrong technique or not being able to adjust the machines.

By identifying these barriers early, it ensured that I could address these and make sure there was not going to be any push back when it came to Phulpreet’s progress and compliance to the program. This has helped immensely when proving functional capacity within the gym and making sure he was comfortable within the gym environment. Phulpreet also mentioned to me at our last meeting that he was planning on continuing his gym membership even after our supervised sessions have ceased.

Please feel free to contact our team at info@absolutebalance.com.au if you have any queries regarding how best we can help.

Channai Graham (B.Sc-Ex.Sp.Sci,Post.Grad.Dip.(Clin.Ex.Phys))

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

My Recovery Journey (Part 2)

It has been a while since I wrote my first blog (My Recovery Journey Part 1) and a bit has changed over the last few weeks. I am now currently three months post my ACL reconstruction, which I am very grateful has been coming along really nicely, however, I would be lying if I didn’t say that I am definitely starting to miss being able to go for a run or complete a high-intensity circuit (especially with summer coming!). Below I have listed another few tips for those also on this journey about how I have kept myself as motivated and positive as possible over the last six weeks.

TAKE REGULAR PHOTOS AND VIDEOS

During the first 1-6 weeks of my rehabilitation there were noticeable differences with pain, range of movement and ability to stand and walk. Over the last 4-6 weeks, as I am getting stronger and more functional, the improvements are becoming smaller and harder to notice. At times I have found myself becoming impatient with the “lack” of progress I perceived I was making. Luckily, I have been documenting my recovery each week through photos and short videos and have found this EXTREMELY helpful and reassuring. I can clearly see in my video’s, improvements with the quality of my movement, range of movement and even tempo of movement whether that be fast or slow and controlled.

JOURNAL YOUR RECOVERY

Following on from the above point, I would recommend choosing a few tasks or challenges and commenting on these each week. My main examples are my ability to walk up and downstairs, my gait and how long it was taking me to walk a lap of my local park. Looking back now I can see that when I was four weeks post op, it was taking me 16 minutes to walk one lap of the park and I still felt I was limping quite heavily, and at 10 weeks post-op it was taking me on average 9 minutes and I had written that I felt my gait was almost back to normal. It has been a great “pick me up” for when I am having a frustrating day and serves as a reminder that even if some points of the rehab cycle aren’t as significant or rapid as others, all of the little things I am doing are pushing me in the right direction.

RETURN TO WORK/LEISURE ACTIVITIES AS QUICKLY AS YOU CAN

I returned to work and the gym as fast as I could after my operation (after consulting with my treating specialist first). I was very lucky that I had a supportive workplace that were able to assist with transport and a second (able bodied) person to complete the physical tasks I could not. I firmly believe that having a regular routine again, having to complete some physical demands within my job role (within my limits) really assisted with speeding up my recovery. It also really boosted my mood having that mental stimulation as well as a social outlet (I had a lot of talking to make up for…!)

TRUST THE PROCESS!

Although I know I am still a while away from a “full recovery” it is important to constantly remind yourself to trust the process. We know that rehabilitation works and is a fundamental part of recovery post-surgery. It is important to make it part of your routine and lifestyle as motivation can come and go, especially if your recovery is going to take a long duration of time. Remember, management of your rehabilitation is a lifelong process! If you need assistance with an exercise rehabilitation treatment plan following an operation, feel free to contact us at info@absolutebalance.com.au for more information.

Tayla O’Halloran (B.Sc. – Exercise Physiology)

Exercise Rehabilitation Team Leader (AEP) (ESSAM)

Flexibility

Improving Our Flexibility and Functional Range of Motion

In today’s fast-moving society, people are finding it harder to keep up with the demands of a busy schedule and physical health slowly becomes less of a priority. As we get older, become more stressed and less active, our flexibility begins to suffer and if not addressed has the potential to lead to a host of functional issues and muscular imbalances.

Muscle weakness and poor flexibility are the two major components for joint pain and dysfunction. Enhanced flexibility decreases the chances of injury, relieves pain, and improves overall performance. Regular stretching exercise protocols increase the flexibility of muscle, range of motion and also provide functional benefits.” (Jyoti et al., 2019; Sexton et al., 2006)

According to Sexton et al.; “Loss of functional range of motion can alter the function of the various components of the kinetic chain, thereby increasing injury susceptibility.”

It is important that we maintain our flexibility to ensure there is facilitation of normal functional motion. “If one link of a kinetic chain is hypomobile, the proximal links must alter their function to preserve the overall “normal” function of the integrated kinetic chain. This compensatory alteration of proximal joint function leads to long-term changes in the flexibility associated soft tissues (muscles, tendon, ligament and fascia), as well as changes in neuromuscular activation patterns, as each component of the kinetic chain seeks of the path of least resistance during performance of functional movement patterns.” (Sexton et al.)

Our kinetic chain is the result of numerous interdependent motions within each of our joints. For example, the amount of forward flexion occurring between the first and second lumbar vertebrae is relatively minor but the sum of all the movements from the joints involved between different spinal segments produce larger overall movements of the spine.

Discrepancies with functional range of motion may result in overcompensation within different areas of the body and if left unaddressed over a long period of time, may produce a larger affect on the whole kinetic chain.

How can we improve our flexibility?

There are a few ways we can improve our flexibility. Two of the most common methods that you may have heard of are static stretching and dynamic stretching.

Static stretching means to hold and maintain a posture, whether that is sitting or standing while flexing or extending the involved body segment.

Dynamic stretching can be explained by using whole-body movements to take the body segments through their normal range. For example, performing leg swings forwards and backwards or swinging the leg side to side to warm-up the muscles prior to exercise.

According to a study by Muh et al.; their aim was to determine static and dynamic stretching towards changes in limb muscle strength and flexibility among volleyball players.

In the study sample of 20 volleyball players, the results showed significant differences between static and dynamic stretching towards changes in muscle strength of the limbs. Muh et al. found that static stretching is proven to increase limb muscle flexibility but demonstrated decreased muscle strength, while dynamic stretching demonstrated a lower increase of limb muscle flexibility but displayed an increase in limb muscle strength. They concluded static stretching was more influential in improving limb muscle flexibility.

Until more recently, static stretching had become a basic part of warming up but dynamic stretching has proven benefits in better priming the body for exercise due to requiring the whole body to move, increasing body temperature, proprioception, motor stimulation and whole body range of motion.

In conclusion, by improving our flexibility we can minimize the risk of muscle, tendon and joint injury, while also improving muscular performance capability.

If you would like more information on improving your flexibility and functional range of motion, please contact Absolute Balance by mail at info@absolutebalance.com.au or view or website www.absolutebalance.com.au

Chris Chen (BSc – Exercise Physiology)

Senior Accredited Exercise Physiologist

 

 

Muh. Ismail H, Ita R, Erfan S. Comparison between static and dynamic stretching in changes of limb muscle strength and flexibility of volleyball players. Journal of Physics: Conference Series. 2020; 1-6

Jyoti, Shabnam J, Vikram Singh Y. Knee joint muscle flexibility in knee osteoarthritis patients and healthy individuals. International Journal of Health Sciences and Research. 2019; 6: 156-161

Sexton P, Jeffrey C. The importance of flexibility for functional range of motion. International Journal of Athletic Therapy and Training. 2006; 11: 13-17