Happy New Year 2018 !

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Chronic pelvic pain and physical therapy

                                                                       (picture source)

As 2018 is approaching, new challenges, opportunities, ambitions, connections and dreams begin to take form ! New Year means new things in life either good or bad. We reflect from the past and we plan for the future. Anything new is welcome ! I hope that everyone finds true meaning for the new year as we leave 2017 behind us.

This last blog is based on Male Pelvic Pain.

Few months ago I completed a very informative course on Mens Health and Pelvic Pain. It was  instructed by Ruth Jones and introduced by Gerard Greene.

Chronic Idiopathic Pelvic pain in men is very common and if left untreated can cause serious issues in their life quality. Likely physiotherapy can help to treat pelvic related symptoms and encourage this population to take in charge of their situation through certain exercise and pain relieving techniques.

Physiotherapy including manual therapy, stretching and strengthening exercise, biofeedback and neuromodulation can help at alleviating chronic pelvic pain in male population. According to Masterson et al. 2017, the above modalities leave promising results for further facilitation of idiopathic pelvic pain for men experiencing it more than 3 months.

Specifically they have included 10 men with no history of prostatitis, trauma, infection, epididymitis or post urinary incontinence and prostatectomy. From these 50% showed statistically significant improvements with the above interventions based on GUPI ( Genitourinary pain index ) which is the modified NIH - CPSI ( National Institude of Health - Chronic Prostatitis Symptom Index ).

Despite the above results, further research is needed to identify which subgroup of men with CPPS can benefit the most from the above type of treatment.

Many thanks for reading, ✊

And...

Happy Christmas and New Year people 🙏!

Art.

Reducing knee loading after ACL injury

The study by Pollard et. al (2017) has investigated the kinematics and kinetics during the drop-landing test. They might have confirmed that through introducing the PEP ( Prevent Injury and Enhance Performance) program can reduce the incidence of ACL injury. This was reasoned by the fact that the person is using a hip strategy to prevent the increase in knee loading. 

The study included 30 female soccer players. Pre and posttraining measurements were taken via a biomechanical assessment of knee joint kinematics and kinetics before and after a 12 week ACL injury prevention program. Each measurement took place 2 weeks before and after the pogram.

Subjects were found to be enough to show statistical significance and clear exclusion criteria were met (1) no history previous ACL injury (2) previous injury which could result in ligamentous injury in the ankle, hip and knee (3) other medical / neurological condition that could impair proper landing (4) previous participation in ACL injury prevention program.

Clear information was given with regards to their biomechanical analysis of kinematics and kinetics where they used an 8 camera, 3D motion system and 2 separate force plates.

Results depicted a decreased knee extensor moment but no significant change in hip extensor moment. Despite an increased hip extensor energy absorption a statistical change was not measured in the knee extensor energy absorption. Knee/hip extensor moment and energy absorption ratios were decreased post-training.

They have concluded that the reduction of ACL injury can be attributed to above biomechanical mechanism ( decreased knee/hip extensor moment and energy absorption ratio can ). Introducing, a hip strategy through a PEP program can prevent occurence of such knee injury.

Movement Control and Pain

Pain has always been the focus of attention when it comes to treatment. Soft tissue massage, Spinal manipulation , joint mobilisations,  acupuncture, foam rolling and other techniques have been used to heal muscles, joints and tendons.

All the above work, in their own way, as novel impulses to our bodies making us focus the attention on the problem and feel better. Although they all work well, in some cases the problem with the above interventions is that they don't last.

Creating distractions via movement can produce new body pathways to feel and move better in the long term. This is not enough though. It is important that this movement is based on focussed attention, graded exposure, relevancy, motivation and play !

This can promote plasticity necessary for remembering old movement habits and creating new ways to move. Movement is a habit , skill that can be forgotten and sometimes a threat. If you move only through a certain pattern then all other are forgotten ( but not erased ! ). This is directly related to improving pain , disability and performance ( link ).

Sooo ... what is the difference between you and Lebron James ?
Tons of motrol control my friend , except if you've reached his skill and ability !

Lebron's workouts have been focussed on attention , coaching , motivation , challenge and fun.

Thanks for reading.

Art.

References

1. Todd Hargrove (2014), A Guide to Better Movement ''The Science and Practice of Moving with More Skill and Less Pain''.

The TFCC injury

The Triangular fibrocartilage complex (TFCC) is a group of soft tissues that provides support , load transmission and absorption between the carpal bones and the ulna. Also it stabilises the distal forearm (radius & ulna) during a gripping or rotational movement of the forearm. 

(picture link)

Anatomy

The origin involves the dorsal and volar radioulnar ligaments at the sigmoid notch of the radius. The insertion consists of the dorsal and volar radioulnar ligaments which converge at the base of the ulnar styloid process.

The Triangular fibrocartilage complex is formed by the soft tissues below

• The Dorsal and Volar Radioulnar ligaments (RULs)
• the Central Disc (CD)
• the Meniscus Homolog (MH)
• the Ulnolunate and Ulnotriquetral ligaments (UL & UT)
• the Extensor Carpi Ulnaris subsheath (ECU)

                                                                                                       (picture link)

The Blood supply

The periphery is vascularised by 10-40%

The central portion is avascular

It is very important to mention that the RULs are the main stabilisers of the DRUJ (distal radioulnar joint). There are superficial and deep fibers providing support during rotational movements with current dispute over which of them tighten during pron/supination

( superficial and deep fibers , picture link )

Common Signs

• Pain at the ulnar aspect of the wrist (just above the flexor carpi ulnaris)
• Pain with side to side movement of the wrist
• Painful gripping
• Swelling in the area
• Painful clicking

Causes

The injury of the TFCC can be traumatic (Type I) or degenerative (Type II)

Most common traumatic cause of injury is with the hand outstreched or during excessive rotation of the wrist. However, a traction force to the ulnar wrist might cause this type of injury. It affects mostly athletes in racquet or bat sports as well as gymnasts.

The degenerative injury occurs with time and age, mostly in people over 50 hovewer, it has been found that people can acquire such injury when in their 30s. This injury is associated with a positive ulnar variance or ulnocarpal impaction. Type II TFCC tears can also be caused in people with inflammatory diseases such as rheumatoid arthritis or gout.

Diagnosis

Diagnosing should start with careful examination of the wrist. It should be followed by an X ray to excluded any possible wrist fracture. The MRI provides the most reliable imaging to observe the extent of the TFCC tear as there are mildly useful provocative tests for diagnosing such an injury (link)

Management Non surgical options These can include the use of NSAIDs , CS injections and immobilisation. Immobilisation can take place via a splint, cast or wrap (favourable). There are few techniques that might help however I ve found that gently taping round the wrist  (check for P+Ns, hand / finger colour change after the application in case of nerve and/or blood vessel compression) might prove effective in the acute type I injury (link).Anecdotal Weight bearing on a scale might be a pain assessment tool for people who are doing a lot of hand bearing activities. There is no evidence on the effectiveness of manual therapy in such injuries apart from a case study of wrist bracing (link). Surgical options These include different methods depending on the extent of the TFCC tear (the classification of TFCC tears can be found here, link). Arthroscopic debridement Arthroscopic repain Open surgical repair If you' re interested in learning the literature behind the above then you could check this link. As always, thanks for reading. Art.

Conservative management over knee arthroscopy

Pic: http://thevanguardclinic.com/knee-pain/

Its been a long time again I know 😅 

Yet this recent paper supports once again that conservative methods 🙌 ( exercise therapy and more ) might be more beneficial in the long term ( after 3 months ) management of degenerative knee disease ( joint line / menisci) over knee arthroscopy . There has been an increasing evidence of no actual benefit from other invasive methods as well ( shoulder decompression, spinal surgery and knee osteoarthritis ) in overall function and pain.

Although, the patient mean age was between 42-62 and 39-64% women ,the above strong evidence by Petersen et. al  could encourage the use of movement over invasive treatments. 

If we could look improvement as a long journey rather than a short term relief then why physiotherapy can't impact for a better function and QUALITY of life ?

Spread the knowledge.

Thanks

Art.