NIGEL's BLOG

Autumn news from the Physiotherapy Centre

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One of our physio's has damaged his cruciate ligament in his right knee and has undergone surgery to re-construct it.

Here he writes up his experiences and gives some insight into the structure of the ligament, why it may have snapped on him and what the reconstructive surgery involves.

My name is Nigel Howell and I am one of the physio's at the Physio Therapy Centre in Haywards Heath.

I play football twice a week, once on a gym floor and once on astro turf, or at least I used to!

On the day I ruptured my Anterior Cruciate Ligament (ACL), I played a 'one off' game on a '3G' surface, which is a matted surface, resembling grass, which I am not normally accustomed to playing on.

The format was a 'round robin' competition for charity, run by the Purple Carrot Cafe in Hassocks.

Half way into the competition I twisted my knee and I felt as if I had been struck by a fast moving cricket or hockey ball on the outside of my right knee; indeed this was my first irrational thought.

I soon realised that this was not the case and being a physio, I realised that I had probably caused some major internal structural damage to the knee.

I hoped it was not the ACL and I was pleased that there was no immediate and severe swelling, as this is often a sign of a ACL rupture.

After a few moments I got up and realised that I was in big trouble and that my knee felt completely untrustworthy.

Soon after the incident I went to visit a consultant, who authorised a MRI scan.  I went to see him for the results two weeks later and it confirmed what we had both been thinking, the ACL had ruptured.

On a scan the ACL normally looks straight and runs diagonally in the knee, but my ruptured ACL looked 'crinkly' and only ran about half way up.

I knew the options, from experience.

a) Try to rehab the knee, without surgery …. By building up the musculature around the knee and improve control and co-ordination. This works for many people, but, you must wear a brace if you ski or play football as twisting/turning sports can be very difficult.  There may also be an increased risk of osteoarthritis in the knee, as the ACL helps to make the knee joint operate in a normal bio-mechanical way.

b) Opt for the operation, either a hamstring graft or a patella graft, which both have reported advantages and disadvantages.

My consultant offered me the choice but my gut feeling was to go for the operation and the Consultant I saw does the ‘patella tendon’ type of ACL reconstruction.

A week later I was heading to the hospital for the operation!

If this ever happens to you, you do need to think carefully about your options and whether you feel the operation is for you!

This will depend a lot on your lifestyle.

If you don’t do much sport or you tend to do ‘straight line’ sports, such as cycling, running or walking, you may well find that you have enough stability in the knee, after you have done some rehabilitation exercises, which will be directed by your Physiotherapist.

You should not enter into the operation lightly, as it is not a small operation.

If you do opt for surgery, comically you would consider things such as cutting your toenails, before surgery, having good but easy shoes to slip on & off and have a space in your work diary to take a few weeks off and if you drive as part of your work, a month, unless you can negotiate working at home, from two weeks to a month, when you can normally drive again. Even if you are planning to work from home and your work is mainly desk based, you will still need two weeks off work.

Operation options

1) Patella tendon graft.  You have a tendon, which lies just below your knee cap and in fact blends with your knee cap, called the patella tendon.  If you feel directly below your knee cap, you can easily squeeze it between your thumb and index finger.

At its lowest most point, the tendon attaches on the shin bone (tibia) at a place called the tibial tuberosity.

The surgeon cuts into this tendon and takes  a rectangular shape out of the middle of it, ‘a window’.  They also take a plug of bone from the tibial tuberosity and a plug of bone from the knee cap (patella).

The surgeon then goes inside the knee with a camera and removes the remnants of the old ligament with specialised tools and ‘tidies up’ any damage that you are likely to also have done to the meniscus, which are the two semicircular discs, one on the medial side of the knee and one on the lateral side of the knee.  Normally these structures help to deepen a  joint slightly, provide shock absorption between the bone ends of the femur and tibia (thigh bone and shin bone) and help to provide fluid for the joint.

After ‘tidying’ the space within the joint, the surgeon now uses other specialised tools to drill a hole in the femur and one in the tibia, one for each of the bone plugs on either end of the Patella Tendon mentioned above.

With lots of clever techniques, the surgeon then manoeuvres the new ligament into place, inserting the two plugs of bone into the two bony holes, with the attached tendon between them. The two plugs of bone are held in place by small ‘silk screws’.

  This is the new ACL and the operation is complete, once the surgeon has sewn up the ‘portals’, which are the holes made by the camera and small specialised tools. Then an injection is put into the knee containing steroid and analgesics, to help with swelling and pain.

Immediately after the surgery, people have various reactions to the anaesthetic and surgery, some people will feel very queasy and others will feel fine and have a good appetite.

After my operation I felt fine and I was also fortunate enough to have a ‘game ready’, applied to my right leg, which is basically a top of the range cold compression unit, which intermittently inflates and deflates and surrounds the joint with very cold water.  Personally I found this very relieving.

Depending on your surgeon you will either have a brace on for two weeks, six weeks or not at all.

On the day of the operation or at the latest the next day (if your operation is in the evening) you must get up, with crutches and start to put a bit of weight through your leg. You can put maximum weight through it if you wish, with your brace on, if fitted with one.

You can go to the loo and shower, but not bath; you have waterproof dressings over your wounds.

Once the Physio has been and checked that you can mobilise well, including stairs, if you have them at home and the nursing staff have checked that they’re happy, you can go home.

Foot note: You wear a T.E.D.  stocking on your un-operated leg, which will help prevent any blood clots, which can ‘roam’ into your circulatory (blood) system and cause problems, where the moving clots can cause blockages in sensitive areas, such as the lungs, heart or brain and cause problems.

You can now follow Nigel’s blog on his progress ….

Overweight and obese people with knee arthritis tend to report more pain than slimmer people with the same degree of joint damage

Past studies have found that heavier people, especially women, are more likely to develop osteoarthritis and often have more severe osteoarthritis (OA). This study goes a step further. It suggests that people with a higher body mass index (BMI) may have more pain than normal-weight people with the same amount of arthritis-related damage.

Overall, 1,390 participants had already been diagnosed with knee osteoarthritis, 3,284 did not have the disease but were at risk of developing it, and 122 did not have osteoarthritis or related risk factors.

Weiss analyzed X-rays to determine the severity of patients' arthritis and used the health records to gather information on their BMI and pain levels during everyday activities.

She found that patients with a higher BMI reported more pain, even after adjusting for the severity of their joint damage. For each category of arthritis severity, pain scores were substantially higher among obese patients than among normal-weight patients. Scores for overweight patients fell somewhere in the middle.

Even though osteoarthritis is a progressive disease and its effects are irreversible, losing weight should help reduce pain related to the condition, Weiss wrote online June 17 in Rheumatology.

Losing weight could jump-start a healthy cycle, Weiss said: a decrease in body weight could lessen pain, which in turn might make people more likely to take on more physical activity, resulting in even more weight loss.

It might be difficult for a person who is already experiencing a high level of pain to become active in order to lose weight, however. Weiss suggested trying to lose the weight before starting exercise.

"It is easier to lose weight through dietary changes than through exercise. Small changes can sometimes make big differences," she said. "For example, drinking water rather than cola or finding ways to increase activity that will become a habit, like parking further from the store entrance or taking stairs instead of an elevator."

SOURCE: http://bit.ly/1mK8QcO

Rheumatology 2014.

Knee Osteoarthritis (OA): Daily Walking Maintains Function

Patients with knee OA can gain significant benefits and avoid physical function limitations by simply walking more.

"As clinicians, we should be promoting walking in our patients with knee OA. We should have them measure their physical activity with a pedometer, much like people measure their weight with a scale. Those starting on a walking program should get to a target of at least 3000 steps/day and ultimately try to reach 6000 steps/day. This is well below the popular anecdote of 10,000 steps/day, which may be good news to those starting out. It doesn't take much to get to 3000 steps/day," Dr. White told Medscape Medical News. He is research assistant professor, Department of Physical Therapy & Athletic Training, Boston University College of Health and Rehabilitation Sciences, Massachusetts.

Long-Term Study Documents Benefits of Walking in Patients With Knee OA

The researchers measured daily steps taken by 1788 people with or at risk for knee OA who were part of the Multicenter Osteoarthritis (MOST) Study, a large multicenter longitudinal cohort study of community-dwelling adults. Mean age was 67 years, mean body mass index (BMI) was 31 kg/m², and 60% of participants were female.

The researchers measured the number of steps patients walked with an ankle monitor over 7 days. They measured functional limitation at baseline and again 2 years later. The researchers defined functional limitation as walking speed less than1.0 m/s 

The authors reported, "Among study participants who did not develop slow walking at the two-year follow-up (<1.0 m/s), 80% walked at least 5300 steps/day." The minimum for preventing functional decline was between 3250 and 3700 steps/day. Walking an additional 1000 steps each day was associated with a 16% to 18% reduction in incident functional limitation 2 years later.

"Our findings add to the idea that walking is good for people with knee OA. Specifically, walking that occurs during unstructured activities, a few steps here and there, add up and do seem to make a difference in terms of prevention of functional limitation in this patient population. I hope that these findings will lead to clinicians encouraging their patients to use a pedometer to measure their physical activity and work towards the 3000 then 6000 steps/day goal," Dr. White said.

 Physical activity stimulates the expression of lubricin, a lubricant molecule of synovial fluid that is important for cartilage growth and that contributes to the delay of OA development.

More Walking Might Reduce Healthcare Costs Associated With Knee OA

According to Dr. White, data from the National Health and Nutrition Examination Survey showed that 80% of patients with OA have some limitation in movement and that 11% of adults with knee OA need assistance with personal care.

"Our findings strongly suggest that walking does work to prevent the onset of problems with physical functioning in the future in people with knee osteoarthritis," Dr. White said.

Arthritis Care Res. Published online June 12, 2014. Abstract

Treatments for Chronic Low Back Pain

An Update of the Cochrane Review

Luis Enrique Chaparro, MD, Andrea D. Furlan, MD, PhD, Amol Deshpande, MD, Angela Mailis-Gagnon, MD, MSc, FRCPC, Steven Atlas, MD, Dennis C. Turk, PhD

Disclosures

Spine. 2014;39(7):556-563. 

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• Abstract and Introduction
• Materials and Methods
• Results
• Discussion
• Conclusions

• References
• Key Points

Abstract and Introduction

Abstract

Study Design. Systematic review and meta-analysis.

Objective. To assess the efficacy of opioids in adults with chronic low back pain (CLBP).

Summary of Background Data. Opioids for CLBP has increased dramatically. However, the benefits and risks remain unclear.

Methods. We updated a 2007 Cochrane Review through October 2012 of randomized controlled trials from multiple databases. Use of noninjectable opioids in CLBP for at least 4 weeks was compared with placebo or other treatments; comparisons with different opioids were excluded. Outcomes included pain and function using standardized mean difference (SMD) or risk ratios with 95% confidence intervals (CIs), and absolute risk difference with 95% CI for adverse effects. Study quality was evaluated using Grading of Recommendations Assessment, Development, and Evaluation criteria.

Results. Fifteen trials (5540 participants), including twelve new, met the criteria. Tramadol was better than placebo for pain (SMD, −0.55; 95% CI, −0.66 to −0.44) and function (SMD, −0.18; 95% CI, −0.29 to −0.07). Compared with placebo, transdermal buprenorphine decreased pain (SMD, −2.47; 95% CI, −2.69 to −2.25), but not function (SMD, −0.14; 95% CI, −0.53 to 0.25). Strong opioids (morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol), were better than placebo for pain (SMD, −0.43; 95% CI, −0.52 to −0.33) and function (SMD, −0.26; 95% CI, −0.37 to −0.15). One trial demonstrated little difference with tramadol compared with celecoxib for pain relief. Two trials (272 participants) found no difference between opioids and antidepressants for pain or function. Reviewed trials had low to moderate quality, high drop-out rates, short duration, and limited interpretability of functional improvement. No serious adverse effects, risks (addiction or overdose), or complications (sleep apnea, opioid-induced hyperalgesia, hypogonadism) were reported.

Conclusion. There is evidence of short-term efficacy (moderate for pain and small for function) of opioids to treat CLBP compared with placebo. The effectiveness and safety of long-term opioid therapy for treatment of CLBP remains unproven.

Level of Evidence: 1

Does Eye Colour Predict Response to Pain?

The colour of  our eyes may predict our response to pain

Pain is known to be linked to many factors including gender; age; hair colour and so on and is likely to be governed genetically. For instance having red hair can mean an increased resistance to anaesthetics and and increased propensity to anxiety.

A recent study looking at pre and post partum women wanted to see if eye colour had a link to how these subjects responded to pain. The subjects included 24 dark eyed ( brown and hazel) people and 34 light eyed individuals(blue and green).

Those with dark eyes had increased levels of anxiety; sleep disturbance; pain  on rest and with movement and an increased likelihood of depression.

This indicates a genetic control the molecular physiology of pain.

American Pain Society 33rd Annual Meeting

Chiropody and Podiatry at the Physio Therapy Centre, Haywards Heath

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CHIROPODY & PODIATRY

When your feet hurt you hurt all over.

Our Foot Specialist takes great pride in the quality of professional advice and treatment you receive. Our aim is to ensure total foot health for you and your family through preventative, routine and corrective treatments.

As well as offering traditional Chiropody care of nail and skin conditions we also offer specialised services to treat foot Pain including Heel/Arch/ Ball of Foot Problems, Arthritic/Diabetic Problems, Foot & Ankle Disorders and Sports Injuries.

SKIN AND NAIL CONDITIONS

We treat problem nails (including painful, ingrown, thick and discoloured nails), corns and callus, verruca pedis and plantar warts (by herbal, chemical and freezing therapy), cracked heels, athletes foot, blisters and sweaty feet. We also offer diabetic foot assessments and advice. In addition we offer vascular and neurological assessments of the feet in relation to medical complications when indicated. Advice and education will always be offered to prevent reoccurrence of any of the above problems.

HEEL, ARCH /BALL OF FOOT & TOE PAIN

We specialise in treating the following conditions by diagnosing the problem, identifying the cause and prescribing corrective treatments including special shoe inserts called orthotics and shoe recommendations: Heel spurs/ Plantar Fasciitis (pain on the sole of your heel often worse in the morning), Metatarsalgia (generalised pain in the ball of the foot), Morton’s Neuroma (nerve entrapment causing pain in the ball of the foot extending into the toes), Bursitis & capsulitis (inflammatory conditions where pain is felt in one or more of the metatarsal heads), sore ankles, Achilles tendonitis, heel bumps, shin splints, arthritic joint pain (pain in the toe joints when walking and or pain on the top of the foot), Bunion problems (where a swelling of the bone and stretching of the tendons occur on the big toe joint causing pain when wearing shoes and walking).

GAIT ANALYSIS & BIOMECHANICAL EXAMINATION

If you have heel/arch pain, corns and callus, inflammatory conditions such as tendonitis or bursitis, joint problems or a sporting injury Biomechanics is the key to discovering why you are suffering these symptoms. By examining the complex movements of your foot joints and the relationship between your pelvis, thigh, hip, knee and leg, abnormality and compensatory problems can be identified and appropriate treatment or referral can be initiated. Podiatry Treatment can include the use of prefabricated insoles or bespoke prescription foot supports as well as a stretching and strengthening regimen.

FOOT ORTHOTICS /ARCH SUPPORTS & APPLIANCES

Orthotics – What are they? Also known as arch supports/ appliances etc they are fully custom made comfort devices made to your exact prescription that readily fit into regular shoes. State of the art, lightweight materials such as carbon graphite and thermoplastics may be used in their construction.

Orthotics – How do they help? They support weakened structures of the feet, deflect pressure from painful areas of the feet, re-align the feet and ankles. This therapy results in an improved posture – beneficial to so many leg and foot problems.

Orthotics – Are they for me? A biomechanical exam and gait analysis is always required before orthotic therapy is prescribed.

Arthritis sufferers listen to professional advice related to exercise and how it helps them

It was found that there is an association between health care providers' recommendations for physical activity and adherence to physical activity guidelines among adults aged 45 or older who had arthritis. This was less in those with other health problems and were overweight.

Subjects who received providers' recommendations were more likely to adhere to physical activity guidelines than those who did not. The rationale for why people follow providers' recommendations for physical activity can be explained by Parsons' traditional sick role perspective, which states that people respond to pain, discomfort, and overall sense of well-being. They consult health care providers when symptoms interfere with their ability to function in their daily activities and seek providers' care and cooperate with them in the process of recovery. The difference in knowledge between the health care providers and patients justifies both the providers' assumption of authority and the patients' trust, confidence, and norm of obedience. Hence, with the debilitating pain that interferes with their daily functions, people with arthritis are more likely to adhere to physical activity guidelines when they receive providers' recommendations.

It is recommended to take 30 minutes of low- to moderate-level physical activity 5 days per week for people with all forms of arthritis.  The low adherence to physical activity among people with arthritis can be addressed with providers' recommendations in clinical settings.

Providers may ask patients about their engagement in physical activity and advise them about the benefits of physical activity during their visits. Providers can assess patients' readiness to engage in physical activity and develop strategies to facilitate patients' physical activity engagement. Furthermore, providers may assist patients in planning and including physical activity in their daily schedule. Finally, in every subsequent visit, providers may follow up on patients' adherence to physical activity.

These results indicate that health care providers should be aware of the effect of their recommendations on patients' adherence to physical activity guidelines and should promote physical activity engagement in clinical settings. Future research should focus on the influence of race/ethnicity on the association between providers' recommendations and adherence to physical activity guidelines among people with arthritis and strategies to promote physical activity, especially in minority populations.

Shamly Austin, PhD, Haiyan Qu, PhD, Richard M. Shewchuk, PhD

Preventative Chronic Diseases. 2013;10