Treatment. Education. Prevention.

Physiotherapy Assessment

reflex hammer
In order to complete a physiotherapy assessment, it is important to carry out a proper and thorough examination. A correct diagnosis depends upon a knowledge of functional anatomy, an accurate patient history, diligent observation and a thorough examination. The purpose of the assessment is to fully and clearly understand the patient's problems and the physical basis for the symptoms that cause the patient to complain.

Initially, the physiotherapist will conduct a subjective examination whereby information regarding the mechanism of injury is obtained. Any history of previous injuries or conditions, the patient's occupation or hobbies that may aggravate or be affected by the condition is also obtained. Questions will be asked to determine the type and character of pain, and an effort will be made to quantify this pain. You will be asked to rate this pain on a scale from 0 to 10, 0 being no pain, and 10 being so severe that you would seek out an emergency room. This is a validated scale that provides outcome data unique to your condition and can be used as a measure to determine quantitatively if your pain is getting better or worse. The subjective examination is guided by the presenting system and complaint.

The objective assessment is guided by the history and the findings of the subjective exam. In an orthopaedic assessment the physiotherapist will observe posture, patterns of movement, any swelling, deformity, or asymmetry. Highly developed skills of palpation will identify crepitus (noise within the joints or tendons), areas of heat, tenderness, or palpable deformity. The objective examination will use quantifiable measures to establish base line measurements to monitor progress, establish a diagnosis and guide treatment intervention. Tests will be used to determine the type of tissues involved, hypothesize a pathologic process, and guide the selection of exercise. Therapists will use their clinical judgment with consideration of severity, irritability, acuity, and patient's medical history when selecting tests. Often the outcome of one test will be a crucial factor in the selection of additional assessment tools.

Through the use of all the assessment tools at our disposal, our physiotherapists in Whitby and Ajax can paint an accurate picture of the patient's status and monitor progress and treatment planning.

Manual and Manipulative Therapy

Joint mobilization refers to techniques that are used to treat joint dysfunction such as stiffness, reversible joint hypomobility, or pain. These are graded according to the amount of force applied and movement that occurs at the joint and can vary from small oscillations to treat pain and muscle spasms to larger manipulative thrusts that move a joint beyond its physiological range of motion.

Orthopaedic manual therapy, which includes mobilization, can be defined as a systematic method of evaluating and treating dysfunctions of the neuromusculoskeletal system in order to relieve pain, increase or decrease mobility, and in general normalize function. Mobilization and manipulation is one of the oldest forms of physical therapy mentioned in ancient medical records. Hippocrates (460-380 BC) in his book Corpus Hippocrates, listed methods of treatment which are comparable to mobilization techniques used today. During the renaissance, Ambrose Pare, a well-known physician, described in detail how to treat a dislocation by manipulation. Different philosophies of thought govern how we use mobilization and manipulation techniques today.

Cyriax, a British orthopaedist, believes that almost all spinal pain arises from a disruption of discs, which can be reduced by manipulation and traction. He is an enthusiastic proponent of the use of manipulation by physical therapists because of their training and expertise in understanding the musculoskeletal system. Maitland, a physical therapist from Australia has developed a system of dealing with a client's signs and symptoms through treatment with graded oscillations, and Kaltenborn, a Norwegian physical therapist, has developed a system of mobilization utilizing arthrokinematic principles to treat musculoskeletal dysfunctions. Kaltenborn and other members of a Scandinavian group of physical therapists categorize spinal dysfunctions into two main disorders: disc degeneration and facet dysfunction. Treatment is determined by loss of mobility and the presence of pain. Mobilizations are used with minimum force in the direction of the limitation in order to normalize the movement of the joint.

Mobilization is only one part of the management of a client with a neuromusculoskeletal dysfunction. There is at the therapist's disposal a multitude of approaches which can be used to develop individualized treatment programs. Therapy will also include appropriate range of motion, strengthening, and functional techniques. The proper incorporation of all procedures is needed for effective treatment of musculoskeletal problems.

McKenzie Mechanical Diagnosis & Treatment of the Spine

Robin McKenzie, a New Zealand physiotherapist, developed a technique of assessing, classifying, and treating patients based on their response to repeated movements. It is a philosophy of treatment that emphasizes education in the causes and self-management of pain, how to prevent recurrences, and the importance of posture and maintaining an active lifestyle.

Unique to the McKenzie Method, the process begins with a thorough history and testing of movements to identify distinct patterns of pain responses that are: reproducible, objective, reliable, and reflect the characteristics of the underlying pain generator.

The most common and meaningful pattern of pain response is "centralization", which is well documented in the literature as both a diagnostic tool and a prognostic indicator. This is defined as a patient's referred or radiating pain (whether just slightly off the centre, into the buttock, or all the way to the toes) promptly reversing, returning to the centre of the back, and then usually also abolishing.

Whether the patient's pain is acute or chronic, if centralization occurs through this logical step-by-step assessment process, good outcomes are favourable. It provides a benefit to the patient and practitioner by eliminating the need for expensive and/or invasive procedures. Ultimately it provides a rational guide to the most optimal treatment strategy for a specific patient.

On your initial visit the examination includes a series of exercises and repeated movements designed to determine what structure is causing your pain and what movements aggravate your pain. Using this system of classification we can separate patients with apparently similar presentations into identifiable and reproducible subcategories to determine appropriate treatment. From this information you are prescribed a specific exercise regime working in only the direction necessary. Exercise choice is based on a well-defined algorithm that depends on the relationship between pain behaviour and specific movements and positions.

The success of the McKenzie protocol is based on a correlation between spinal mechanics and symptoms during movement. How the symptoms change then can be used to determine the success of treatment. The use of over 40 different exercises can be customized to the patient's individual problem by affecting the internal dynamics of the disc.

The most basic faulty assumption made about the McKenzie Method is equating it with only extension exercises - it is so much more. When appropriate, the McKenzie treatment takes advantage of the patient's own movements and forces to abolish pain and restore function. A series of individualized exercises subsequent to the patient's responses during the assessment are prescribed and - most critically - are based on the directional preference that will centralize or abolish pain, i.e. extension or flexion, right or left lateral movement, etc. In essence, the treatment must match the assessment findings or the results will be inferior.

Furthermore, as Robin McKenzie states in his original 1981 text, "If no movement or position can be found to centralize or reduce the patient's presenting pain, the patient is not a suitable subject for mechanical therapy

In the case where a patient doesn't respond mechanically, alternative means of treatment or referral for further medical evaluation is warranted.

Most patients who do respond favourable to McKenzie methods of diagnosis and treatment can successfully treat themselves and minimize the number of visits to the clinic then provided the necessary knowledge and tools putting him or her in control of their treatment safely and effectively. Patients who stick to the prescribed treatment protocols are less likely to have persistent problems. Thus, by learning how to self-treat the current problem, patients gain hands-on knowledge on how to minimize the risk of recurrence and how to quickly manage themselves if symptoms to recur.

Achievable goals of McKenzie method of diagnosis and treatment of the spine are:
  • Reduce pain and deformity
  • Maintain the reduction with education and postural advice
  • Restore full function
  • Prevent recurrences

The Right Road to Restore Function
Assessment is the first step. Pain is a symptom, not a diagnosis. To successfully treat, one must first effectively evaluate.

While every patient can benefit from the McKenzie method of mechanical assessment, not all patients will be suitable for mechanical therapy - and this is determined quickly so that alternative treatments can begin as soon as possible.

In fact, research has shown that the initial McKenzie assessment procedures performed by competent McKenzie trained practitioners are as reliable as costly diagnostic imaging (i.e. x rays, MRI's) to determine the source of the problem and quickly identify those who will or will not respond to the treatment principles of McKenzie using the centralization phenomenon as a guide.

McKenzie protocol credits the patient's ability to learn the principles and be in control of their own symptom management, reducing their dependency on medical intervention and gaining lifelong pain management and preventive skills. It also promotes the body to heal itself without reliance on the practitioner.
Parts of this are excerpts from the Brochure "The Power to Control Pain" by The Robin McKenzie Institute Canada.

McKenzie Mechanical Diagnosis diagram
The Derangement
For instance, it is hypothesized that prior to a frank annular lesion and nuclear herniation there may be incomplete tears into which nuclear material may be displaced. This nuclear displacement (bulge) may alter joint mechanics causing a postural shift, disturbing the normal configuration of the spine, therefore changing the shape of the disc. Studies have shown the nucleus to move when various forces are applied to it and therefore choosing the correct exercise can decrease pressure on nerve roots when the nucleus is restored to its previous non-pathological state.

Donelson demonstrated it is possible to predict annular competence with the McKenzie mechanical assessment protocol. In his study patients were separated into centralizer's and non-centralizer's (a phenomenon whereby sciatica type pain is perceived to move back up the leg). Discography was performed in both groups. Centralizer's tended to have an intact annulus or Grade 1-2 tears. Non centralizer's had a disrupted annulus, which are fissures to the outer third of the annular wall or Grade 3 tear. This is very exciting news for those who appreciate the centralization phenomenon because it allows us to clinically assess the competency of the annulus. Patients who do not centralize on initial examination are excellent candidates for traction/decompression therapy.

References
Donelson R, Aprille C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and annular competence. Spine 1997; 22(10):1115-1122.

Vanharanta H, Sachs B, Spivey M, et al. (1987) The relationship of pain provocation to lumbar disc deterioration as seen by CT/discogram. Spine 12:295-8.

Spilker RL, Daugirda DM, Schultz AB. (1984) Mechanical response of a simple finite element model of he intervertebral disc under complex loading. J Biomech 17:103-12.

Krag MH, Seroussi RE, Wilder DG, Pope MH. (1987) Internal displacement distribution from in vitro loading of human thoracic and lumbar spinal motion segments: Experimental results and theoretical predictions. Spine 12(10):1001-7.

Clare HA, Adams R, Maher CG; (2004) Reliability of the McKenzie spinal pain classification using patient assessment forms. Physiotherapy; 90:114-119.

Clare HA, Adams R, Maher CG; (2005) Reliability of McKenzie classification of patients with cervical and lumbar pain J Manipulative Physiol Ther; 28:122-127.

Fritz JM, Delitto A, Vignovic M, Busse RG; (2000)Interrater reliability of judgments of the centralization phenomenon and status change during movement testing in patients with low back pain. Arch Phys Med Rehabil; Jan;81(1):57-61.

Acupuncture in Physiotherapy

Acupuncture involves the insertion of very fine needles through the skin and tissues at specific points on the body. There is no injection of any substance and the treatment itself causes minimal discomfort. Acupuncture stimulates the body to produce endorphins which attach to opiate receptor sites found throughout the nervous system. Endorphins help block pain pathways resulting in relief of pain. The World Health Organization has identified the benefits of acupuncture in the treatment of a wide range of medical problems.

Since 1976 a voluminous body of knowledge has been published in scientific journals in both China and the west elucidating some of the mechanisms of action of acupuncture. This evidence of the physiological effects of acupuncture has led to a deeper understanding of the complex neurophysiological events which take place when the body has to deal with pain.

Our physiotherapists are educated by the Acupuncture Foundation of Canada Institute. The AFCI has been training medical professionals in acupuncture since 1974. Membership includes medical doctors, physiotherapists, dentists, chiropractors, nurses, and naturopaths. The program is accredited by the Dept. of Family and Community Medicine, University of Toronto and incorporates both an anatomical approach to pain management and dysfunction and classical acupuncture.

In the hands of Western practitioners, acupuncture has served as a therapeutic modality for the following types of conditions:

  • Control of pain
  • Autonomic nervous system disorders
  • Promotion of tissue regeneration and healing
  • Surgical analgesia
acupuncture

References
Pomerantz, BH (1979) Suppression of noxious responses in single neurons of cat spinal cord by electroacupuncture and its reversal by the opiate antagonist Naloxone. Exp. Neurol. 64:327-341.

Chen GB, (1981) Role of the nervous system of the human body with regard to acupuncture analgesia, acupuncture and electrotherapeutics. Res. Int. 6:7-17.

Bradnam L, Larmer P (2001) Systematic reviews and acupuncture efficacy - What's the point? New Zealand Journal of Physiotherapy, 29(3):7-15.

David J, et al (1999) The effect of acupuncture on patients with rheumatoid arthritis: a randomized, placebo-controlled crossover study. Rheumatology (Oxford), 38(9):864-9.

Lasers in Physiotherapy

LASER stands for light amplification by stimulated emission radiation. It's coherent light (i.e. when the phase of oscillations in electromagnetic wave remains unchanged for a long time).

The biological effect of cool lasers is based on photochemical processes resulting from the resonance interaction of light with absorbing molecules. It is also hypothesized that the Kerr effect can cause a torque causing rotation of particles until their dipole moment becomes aligned along the electrical vector of the field created.

Cool LASERS may act by the following processes:
  • LASER is absorbed by light sensitive proteins situated in cytoplasm and cell membranes (some involved in the respiratory chain)
  • Changing local concentration and spatial orientation of particles
  • Changing composition of particles
  • Selectively increasing the partial temperature of larger particles
  • Causing small reversible distortions of particle's structure (i.e. cellular massage)
  • Stimulating conformational changes in enzymes and other proteins
laser

Studies have shown the following biological effects:
  • Increased healing rate in wounds and burns
  • Decreased inflammatory edema
  • Increased healing response of fractures
  • Increased regeneration of damaged nerve by stimulating axon sprouting
  • Modulation of nerve conduction velocity depending on treatment regime
laser therapy

Mid LASERS belong to that class of LASER systems that lack the output power to cause thermal damage to the tissues but can be used to treat pathological conditions directly. We use a probe mid laser equipped with a single diode laser source with emission in the near infrared range (825nm). The tissue is irradiated in spot fashion and power is sufficient for the treatment of deep pathologies.

References
Schindl, A et al (1999) Wound healing with He-Ne Photoderm Photoimmunol Photomed 18-21

Rochind, S (1992) Experimental and clinical wound healing with HeNe, Neurological Research 14:p.2

Schindl A, et al, (1998) He-Ne irradiation effect in patients with diabetes and reduced skin blood flow, Diabetes Care 580-4

Whittaker, P (2004) Laser acupuncture: past, present, and future. Lasers Med Sci 19(2):69-80

Ultrasound in Physiotherapy

ultrasound knee
Ultrasound is high frequency sound waves, greater than 20,000 Hz. Therapeutic ultrasound is in the frequency range of 0.9 - 3 MHz.

The utilization of ultrasound has been a 20th century phenomenon. In addition to its use by the military to detect submarines, it was also used in the 1930's for emulsification, and atomization of particles in a gas. Since then, ultrasound has been used therapeutically for its effects of cavitation, stable and unstable bubble formation and a phenomenon called acoustic streaming or microstreaming.

Ultrasound is used to:

  • Break up scar tissue and adhesions
  • Reduce inflammation, swelling and calcium deposits
  • Create a deep heat to a localized area to ease muscle spasms (much deeper than can be achieved with a hot pack - up to 5 cm)
  • Increase soft tissue extensibility prior to stretching and exercise
  • Facilitate healing at the cellular level
  • Speeds metabolism and improves blood flow
  • Reduces nerve root irritation
  • At low intensities can speed bone healing
  • Enhance transcutaneous drug delivery by phonophoresis
ultrasound diagram

The main piece of equipment is a high-frequency generator, which provides an electrical current through a cable to a transducer which contains a piezoelectric crystal. This crystal when exposed to the current will vibrate at a given frequency, expanding and contracting, which produces the necessary compression wave. By using a different frequency the therapist can target tissues at different depths for either healing or destruction, or simply use the device to reduce pain. Although simple in principle, the use of ultrasound as a therapeutic modality requires a comprehensive understanding of its effects on the body tissues and of the physical mechanisms by which its effects are produced. The lower the frequency used, the deeper is the penetration of the waves into the body. By varying the frequency from continuous to intermittent, the amount of heat applied can likewise be controlled by the physiotherapist.

For instance, contusions are one of the most frequent and debilitating injuries encountered in sports medicine. Although contusions may be caused by shearing and tension between over-stressed body parts, the most common cause is compression of soft tissue, usually when it is crushed between bone and some hard surface. This almost invariably involves capillary rupture and infiltrative bleeding, followed by edema and inflammation. This usually involves hematoma or "pooling" of blood, and occasionally myositis ossificans can result as a complication if not treated. This is a syndrome in which the body starts laying down painful calcium deposits within the muscle. Quick and effective treatment is crucial in sports injuries. Proper and efficient healing is essential to the health and career of any athlete, regardless of how minor or major the injury. Basic treatment involves the application of ice to contain the immediate inflammation, followed by timely applications of ultrasound to reduce the subsequent edema and further stimulate the healing process.

Ultrasound is effective in treating wounds in both the inflammatory and the proliferative stages. Ultrasound causes a degranulation of mast cells resulting in the release of histamine. Histamine and other chemical mediators released from the mast cell are felt to play a role in attracting neutrophils and monocytes to the injured site. These and other events appear to accelerate the acute inflammatory phase and promote healing.

In the proliferative phase of healing, ultrasound effects fibroblasts and stimulates them to secrete collagen. This accelerates the process of wound contraction and increases the tensile strength of the healing tissue. Connective tissues will elongate better if both heat and stretch are applied. Continuous ultrasound at higher therapeutic intensities provides an effective means of heating deeper tissues prior to stretching them.

Its effectiveness has been enhanced over the years by studies which help determine optimum techniques and patterns of application, and a wide range of injuries have shown to be responsive to this non-invasive therapy.

References
Edenbichler G et al (1999) Ultrasound therapy for calcified tendonitis of the shoulder. The New England Journal of Medicine. May 20;340(20):1533-8

Speed CA (2001). Therapeutic ultrasound in soft tissue lesions. Rheumatology, 40(12): 1331–1336

Crawford F (2004). Plantar heel pain and fasciitis. Clinical Evidence (11): 1589–1602

Anderson, M. (1981). Four cases of phantom limb treated with ultrasound. Physical Therapy Review. vol. 38: 419-420.

Nykanen M (1995). Pulsed ultrasound treatment of the painful shoulder: a randomized, double-blind, placebo-controlled study. Scand J Rehabil Med(27):105–108 Harvey, W, et al (1975) The in vitro stimulation of protein synthesis in human fibroblasts by therapeutic levels of ultrasound. Proceedings of Second Congress of Ultrasonic in Medicine. Excerpta Medica, Amsterdam, p 10

Rantanen J, Thorsson O, Wollmer P, et al. (1999) Effects of therapeutic ultrasound on the regeneration of skeletal myofibers after experimental muscle injury, Am J Sports Med 27(1): 54-59

Bierman W (1954). Ultrasound in the treatment of scars. Archives of Physical Medicine and Rehabilitation. 35: 209-213.

De Preux T (1952). Ultrasonic wave therapy in osteo-arthritis of the hip joint. British Journal of Physical Medicine, 15(10): 14-19.

McDiarmid T, Burns PN, Lewith GT, Machin D (1985). Ultrasound and the treatment of pressure sores. Physiotherapy, 71(2): 66-70.

Interferential Currents (IFC)

IFC uses the transcutaneous application of alternating medium-frequency electrical currents, amplitude modulated at low frequency for therapeutic purposes. You may recall from your high school wave physics classes:

MEDIUM FREQ. 1 + MEDIUM FREQ. 2 = LOW FREQUENCY Combination


Medium frequency currents encounter less resistance than low frequency currents and therefore are more comfortable at the higher intensities necessary for treatment.

The electrical current is applied to the affected area using four electrodes. The four electrodes are placed in such a way that the two currents produced cross each other in the affected area. Where the two currents meet, they actually 'interfere' with each other; hence the name "interferential". The electrodes will usually be used with a damp sponge placed between the electrode and the patient's skin or a conductive gel may be used. During treatment you will feel a tingling or "pins and needles" sensation at the contact area of the sponges and may also feel the tingling sensation throughout the area being treated.

IFC therapy
This sensation may continue for a brief period following treatment as well. The intensity of the current should be increased within the patient's comfort level. A stronger current will usually have a more beneficial effect but the intensity should not be turned up so high as to cause pain. This modality addresses the issues of pain, spasm, and inflammation. It is important that you also address other issues associated with your condition with an appropriate exercise and manual therapy program as prescribed by your physiotherapist.

The physiological effects of IFC include:

  • An increase in localized blood flow which can improve healing by reducing swelling (the additional blood flowing through the area takes edematous fluid away with it) and as a result helps remove damaged tissue and bring nutrients necessary for healing to the injured area
  • The stimulation of local nerve cells that can have a pain reducing/anaesthetic effect due to potentially blocking the transmission of the pain signals (pain gate mechanism) or by stimulating the release of pain reducing endorphins (opioid mechanism).
  • Relaxation of muscle spasms can be achieved through external application of an electrical current, overcoming some of the muscle inhibition often caused by local injury and swelling.
  • Increased permeability of the cell membrane which helps ion movement to and from cells thus promoting healing.

IFC is used to:

  • Reduce muscle spasms and promote muscle relaxation
  • Reduce inflammation
  • Block pain
  • Stimulate circulation

References
Jorge S, Parada CA, Ferreira SH, Tambeli CH. (2006) Interferential therapy produces antinociception during application in various models of inflammatory pain. Phys Ther. 2006 Jun; 86(6):800-8.

Johnson MI, Tabasam G. (2003) An investigation into the analgesic effects of different frequencies of the amplitude-modulated wave of interferential current therapy on cold-induced pain in normal subjects. Arch Phys Med Rehabil. 2003 Sep; 84(9):1387-94

Cheing GL, Hui-Chan CW. (2003) Analgesic effects of transcutaneous electrical nerve stimulation and interferential currents on heat pain in healthy subjects. J Rehabil Med. 2003 Jan; 35(1):15-9.

Jarit GJ, Mohr KJ, Waller R, Glousman RE. (2003) The effects of interferential therapy on post-operative pain, edema, and range of motion of the knee. Clin J Sport Med. 2003 Jan; 13(1):16-20.

Johnson et al. (2002) A single blind placebo controlled investigation into the analgesic effects of interferential currents on experimentally induced ischemic pain in healthy subjects. Clin Physiol & Func Im 187-196

Neuromuscular Electrical Stimulation (NMES) in Physiotherapy

NMES therapy
An NMES system produces an electrical stimulus that, when properly applied, activates specific muscles or muscle groups in patients who will not, or cannot, contract muscles voluntarily. The stimulator produces a mild electrical current that is transmitted through the skin to the motor end plates causing nerve depolarization and subsequent activation of muscle fibres.

NMES is useful to:

  • Re-educate muscle timing. Controlled movement consists of a series of coordinated and timed muscle contractions. In pathology this timing may by inhibited or altered.
  • Override the inhibitory effects of nearby joint pain or inflammation on muscle contraction. Sensory and painful input from joints will inhibit the recruitment of as many motor units as are called upon
  • Recruit a maximum number of muscle fibres during strengthening exercises. By using NMES in conjunction with active exercise we are able to recruit more muscle fibres than with exercise alone.

Transcutaneous Electrical Nerve Stimulation (TENS) in Physiotherapy

TENS refers to the transmission of small electrical pulses through the skin to the underlying peripheral nerves. The basic principle behind conventional or high frequency TENS is that large nerve fibres can be selectively stimulated by adjusting the pulse amplitude, pulse width and repetition rate of specially selected wave forms. These large fibres have a lower threshold for stimulation and faster conduction velocity than the small fibres that conduct pain messages. Therefore if they are recruited they can create a gating mechanism that blocks small fibre activity and stops the pain signals from reaching the spinal cord, thus blocking pain. The nerve supplying the painful area is stimulated preferably by placing the two electrodes over it. When placed accurately, the TENS current will influence the segmentally related spinal cord systems implicated in the pain problem. Maximal pain relief occurs after 20 minutes.

Low frequency TENS (1-10 Hz, but optimally between 1 and 4 Hz) may cause the body to release its own pain relieving substances, called endorphins. At this rate it is necessary that visible low rate muscle contractions take place. This method of pain mediation is similar to that achieved through acupuncture.

If your pain is chronic you may be prescribed a TENS unit for home use by your family physician or physiotherapist. Your physiotherapist can assist you with optimal electrode placement and parameters for your condition.

TENS therapy
References
Wall, D (1978) The gate control theory of pain mechanisms: a re-examination and re-statement. Brain 101:2.

Basbaum, A (1978) Endogenous pain control mechanisms: Review and hypothesis, Ann Neurol 4:451

Campbell, J (1981) Examination and possible mechanisms by which stimulation of the spinal cord in man relieves pain. App Neurophysiol 44:181.

Traction in Physiotherapy

traction chart
Traction today, otherwise known as "spinal decompression therapy", addresses the functional and mechanical aspects of discogenic pain and has been used by physiotherapists for years. Before the computer technology was available, and even now, we will occasionally do this manually.

We also have access to computerized systems that will cycle through preprogrammed patterns, ramping up and down the amount of axial decompression allowing for higher levels of spinal traction and disc rehydration. During spinal decompression therapy, a negative pressure is created within the disc. Because of that negative pressure, disc material that has protruded or herniated can be assisted back within the normal confines of the disc, and permit healing to occur. Pressure is released off of inflamed nerve roots allowing the inflammation to subside.

traction chart

A specific force predetermined by your physiotherapist gently separates the bones of the lower back or neck. This relieves the pressure on the outer fibers on the disc. With repeated treatments over a period of time this allows for the outer fibers to heal and hold the gel-like material back in the center of the disc. Additionally, this negative pressure forces nutrients and fluid into the disc to assist with rehydration and healing of the disc. By altering the position of the traction pull and the height of the table we may also localize the traction force to a particular segment of the spine and in a specific direction.

Treatments are painless. In fact some individuals get immediate relief from their pain once decompression takes place. There is little evidence that shows traction alone is effective in managing low back pain. It is important that you comply with the specific home exercises prescribed by your physiotherapist to minimize the stresses on the disc, and partake in an appropriate strengthening and stabilization program when appropriate. Your McKenzie trained practitioner can assist you with this.

Traction is effective for:

  • Bulging, prolapsed, or herniated discs
  • Spinal stenosis
  • Sciatica
  • Facet syndrome
  • Degenerative disc disease
  • Neck pain
  • Pain radiating down the arm
  • "Pinched nerves"
  • Spondylitis
   
Back Pain/Sciatica
A pelvic harness is worn by the patient. The specially equipped table on which the patient lies is slowly extended, and a distraction force is applied via the pelvic harness until the desired tension is reached. This is followed by a gradual decrease of the tension, and the cycle is repeated. The cyclic nature of the treatment allows the patient to withstand stronger distraction forces compared to static lumbar traction techniques. The level of tension is individually calibrated and recorded.

Neck Pain/Radicular Arm Pain
The patient's head is comfortably positioned into a supportive device that pulls behind their neck gently distracting the joints in the upper part of their neck. As more tension is used, distraction forces affect joints further down the spine. It is through careful calibration and positioning that we are able to apply just enough tension to relieve symptoms.

References
Ramos, G., & Martin, W. (1994). Effects of vertebral axial decompression on intradiscal pressure. Journal of Neurosurgery, 81 (3), 350-353. Retrieved April 19, 2002 from PubMed database.

Andersson GB, Schults AS, Nachemson AL.(1983) Intervertebral disc pressures during traction. Scand J Rehabil Med; 9:88-91

Earl E. Gose, William K. Naguszewski, and Robert K. Naguszewski. (1998), . "Vertebral Axial Decompression Therapy for Pain Associated with Herniated or Degenerated Discs or Facet Syndrome: An Outcome Study." The Journal of Neurological Research, Volume 20

Frank Tilaro, MD, Dennis Miskovich, MD., (January 1999). "The Effects of Vertebral Axial Decompression on Sensory Nerve Dysfunction in Patients with Low Back Pain and Radiculopathy." Canadian Journal of Clinical Medicine

Cryotherapy

When to Apply Cryotherapy
Cryotherapy shrinks the capillaries, which slows bleeding and helps to prevent swelling. When you sustain a strain or sprain, tissue is taken well beyond its normal length and is often torn, at which point bleeding and swelling then occurs. This swelling will interfere with the circulation to the area and thus normal healing, so if you can do something at this point that prevents or reduces edema and inflammation it will definitely help expedite your recovery from an injury.

The earlier you address the swelling the greater your chances for an earlier recovery, and the easiest way is by applying ice right on the injury immediately. Cryotherapy also prevents the spasms in the local muscles to relieve pain.

Cryotherapy for treatment of injuries dates as early as Hippocrates. Ways to apply ice are easier than 500 BC, but precautions and principles will always exist. Initially after the application of ice, the skin feels cold, and this will in itself often relieve pain. As icing proceeds, you may experience burning and then pain superficially, and at last numbness.

To prevent frost bite, stop icing as you start to lose sensation to light touch (not like "numbness" one initially feels as cooling begins to relieve the pain. Keep applying cold after the pain diminishes). Applying ice for more than the recommended time can cause skin damage or nerve damage. Cryotherapy isn't recommended for all injuries as some people will not be able to tolerate it.

Icing time will depend on which method you use to apply it and the location at which it is applied. Body parts that have little subcutaneous fat (like knees, ankles, and elbows) cannot handle ice times as long as areas with more subcutaneous fat (like the thighs and buttocks). For areas with bone closer to the surface, apply ice for a shorter period as follows.

It's best to apply cold regularly throughout your day, allowing for several hours between ice treatments. Time in between applications of ice will allow your skin and subcutaneous tissues to warm a little to a normal temperature. Ice bags remain the easiest cryotherapy treatment for most, but other options are out there:


Bags of Ice
Pros: Bags of ice are the usual method of applying deep cold. Simple fill one or two zip-lock bags with ice and wrap them in a wet towel. Apply right on the injury. The effect of zip lock bags full of ice lasts longer and has been found to penetrate deeper than other superficial methods such as ice massage. If ice isn't readily available, then grab a bag of frozen vegetables, wrap it in a wet tea towel and apply that.
Cons: Contouring the bag to the bumps and curves of your body for the best application may be difficult with large ice cubes. It molds better if you do not fill it full with ice or you can crush the ice instead.
Time: 10-20 min. This depends on the area of injury and level of comfort.

Gel Packs
Pros: Gel ice packs hold a gel that will freeze many times over. Keep these packs stored in a freezer to keep them handy. The gel keeps its flexibility when in the freezer, thus letting it mold to the body part concerned.
Cons: Gel ice packs cool the cutaneous and subcutaneous tissues much faster than bags of ice and so require caution. Don't apply them right on the skin and always put them in a wet towel to conduct the cold.
Time: 10 minutes, and monitor the body part for loss of sensation.

Chemical Bags
Pros: Chemical bags are stored at ambient temperature until the bag is squeezed and the chemicals are mixed. This produces cold. These are especially good on the sports field or when camping or hunting.
Cons: The temperature change of the bag is not as great as other methods, but the bags are good for first aid.
Time: The temperature change produced is not as low; therefore, 30 minutes is acceptable, and this method can be directed right on the injury

Submersion
Pros: Submersion requires placing the injured body part in an ice water bath filled with ice. This provides complete exposure to the whole injured part.
Cons: Only body parts such as the hand, foot, or elbow are suitable for this form of cryotherapy.
Time: 10-20 minutes. Discontinue if this becomes too uncomfortable.

Ice Massage
Pros: Massage with ice requires you to rub ice directly onto the injury directly. This focuses the cold on the injured area and is easy to apply. Often paper or foam cups can be used when filled with H2O and frozen. The top of the cup is then peeled away to expose the top of the ice - the covered edge of the cup is held to apply the ice. Ice cubes may be applied as well directly by this method.
Cons: This method of cooling the tissues is not as effective as penetration is not as deep and the cold effect is not as long lasting as other methods described above.
Time: Apply for no more than 5 -10 min., a little longer if the area has more subcutaneous fat.

Combination of R.I.C.E
To maximize cryotherapy, use RICE (rest, ice, and compression, and elevation). To add to cryotherapy, rest your injured body part, apply an elastic wrap firmly, and then keep your injured area elevated. New products combine RICE principles. For example, cold tape will compress the area it's applied to and due of a reaction of chemicals, cools the injured body part.

Remember you should ice early and frequently. Avoid skin and nerve damage by letting your skin recover between ice applications. Listen to what your body is telling you.

Heat may worsen inflammation and edema, so do not apply heat within the first 72 hours of an injury. Wait for inflammation to subside before applying heat.

When to Avoid Cryotherapy
Cryotherapy is not good for everyone. Those who are very sensitive to ice will not tolerate icing long enough to be effective. Also, those with a high tolerance to ice may be prone to injury by applying cryotherapy for long than a safe period of time.

Those with circulatory issues should avoid cryotherapy, (i.e. Raynaud's disease - whereby the vessels in your hands, toes, nose, and ears constrict if exposed to the cold or other stimulation). If you're at risk because of you are diabetic or have other conditions that can affect blood flow, see your family physician before applying ice to a strain or sprain.

This information isn't intended as a substitute for professional advice. If you've injured yourself seek a medical opinion.

Gait Training in Physiotherapy

Gait training is necessary to help a patient gain proficient ambulation within and outside the home and is necessary when there is an orthopaedic impairment.

Conditions requiring gait training include the following:
crutches
  • Pain that causes distortion of the normal gait pattern
  • Joint stiffness
  • Muscle weakness
  • Limb deformity
  • Spasticity
  • Loss of sensory input

Treatment involves strengthening, balance training, proprioceptive exercises, education in normal mechanics and the use of assistive devices, and mobilizing if necessary for the impairment.

Iontophoresis for Hyperhidrosis

iontophoresis machine
What is Iontophoresis?
Iontophoresis is the application of direct current. It can be used to introduce substances through the skin, but in the treatment of hyperhidrosis, the current alone is what is effective. This current is applied through the submersion in water. The result with several treatments is a reduction in excessive sweating. This is thought to be caused by a plugging of the sweat pores.

What is Hyperhidrosis?
Hyperhidrosis is a condition whereby the body produces sweat beyond what is necessary to maintain a normal body temperature. When this condition affects the hands or feet it is called palmer or plantar hyperhidrosis. People affected by this problem suffer social embarrassment and may be limited in some occupations where damp hands may soil or damage products. (i.e. paper, metal, electrical components) Hyperhidrosis affects approximately 3% of the population.

What Are the Treatment Options for Hyperhidrosis?
There are several ways to treat hyperhidrosis. Many of these treatments are covered by medical plans. In order to find the best treatment for you, speak to your dermatologist. Possible treatment options are as follows:

  • Topical treatments: the application of aluminum chloride hexahydrate has been shown in clinical studies to reduce swearing by approximately 50% for mild hyperhidrosis sufferers.
  • Iontophoresis: iontophoresis is appropriate for people who suffer from hyperhidrosis affecting the hands or feet. This application is not recommended for underarm or head/facial hyperhidrosis.
  • Botulinum toxin type A: Botox injections are appropriate for moderate to severe hyperhidrosis sufferers. Injection is done into the affected area and is effective for as long as the nerve to the sweat glad is deadened. Percentage reduction in sweating using this method was reported to be 83% in 95% of people studied. The average duration of effect is 7 months until symptoms recur.
  • Surgery: this is a last resort for people whose lifestyles are seriously affected by hyperhidrosis and for whom other more conservative methods have failed.
iontophoresis machine

Is Iontophoresis for Hyperhidrosis Safe?
Iontophoresis as a method of introducing substances through the skin has been performed since the 1930's. In 1952 it was found that a therapeutic effect could be achieved without introducing substances through the skin. The electric current alone was effective in reducing sweating in 85% of people with hyperhidrosis. See contraindications below.

What are the Side Effects of Iontophoresis?
Side effects of iontophoresis are few:

  • Palms or feet may occasionally become too dry resulting in cracks or fissures. This can be relieved with the use of moisturizers.
  • Redness of the skin is not uncommon, but occasionally hives may form. This can be treated with a hydrocortisone cream.

What are the Contraindications of Iontophoresis?
To ensure you are a suitable candidate for iontophoresis for hyperhidrosis you must not:
  • Be pregnant
  • Have a cardiac pacemaker
  • Have cancer
  • Have swollen, broken, or inflamed skin on the areas to be treated
  • Have metal implants in the area to be treated

How Many Treatments are Required to Treat Hyperhidrosis?
Sessions last 20 minutes for hands and 40 minutes for hands and feet. Research has shown that optimum results are obtained with 5 to 10 treatments administered every 2 to 3 days initially. After that, frequency is dependent on how symptoms recur. Sometimes one treatment every two weeks is enough to keep symptoms at bay.

Does Iontophoresis Hurt?
The current can feel uncomfortable or itchy, but should not be unbearable.

What Does Iontophoresis for Hyperhidrosis Cost?
Treatments at the Baywood Physiotherapy and Athletic Injury location in Ajax are as follows:
  • Hands or feet: $40 per visit
  • Hands and feet $60 per visit

How Successful is Iontophoresis?
85% of individuals with hyperhidrosis will show improvement in their symptoms.

Is Iontophoresis Covered by my Insurance Plan?
If your insurance plan covers physiotherapy, then iontophoresis is covered at our clinic. Treatment is administered by a physiotherapist.

References
Stolman LP MD,FRCP(C) Treatment of Hyperhidrosis Dermatologic Clinics Oct 1998;16(4):863-69.

Thomas I. Palmoplantar hyperhidrosis: a therapeutic challenge. Am Fam Physician. Mar 1 2004; 69(5): 1117-20.

Extracorporeal Radial Shockwave Therapy Using the Storz Masterpuls MP50

Extracorporeal Radial Shockwave Therapy Using the Storz Masterpuls MP50
Extracorporeal radial shockwave therapy originated in Europe and is used by professional athletes around the world.

Great Lakes Physiotherapy, leaders in the treatment of musculoskeletal disorders, is pleased to introduce Radial Shockwave Therapy (RSWT) to Durham Region out of their 200 Brock Street, Whitby location.

Improvement of circulation and metabolism seems to be one of the most stringent mechanisms responsible for muscle relaxation, pain reduction and enhanced healing processes.

What is extracorporeal radial shockwave therapy?
Since the early 1900's investigators in Europe have studied the use of shockwaves for the treatment of musculoskeletal conditions. Initially, treatments were administered using modified kidney stone lithotripters. Today, machines such as the MP50 use advanced technology but, the concept remains the same. Used by professional sports teams and high level athletes around the world, shockwave therapy treats the involved area using pneumatically generated acoustic waves traveling faster than the speed of sound. This bombarding of the affected tissue produces a number of biological responses resulting in scientifically demonstrated neovascularization (new blood vessel growth) which in turn dramatically accelerates the healing process.

Could you describe the treatment process?
A course of Radial Shockwave Therapy (RSWT) typically consists of four visits - three treatment sessions administered over a three week period after your initial assessment. The painful site is identified and approximately two thousand shockwaves are administered using a hand held applicator in combination with a conductive gel. The process is relatively pain free and can be adjusted for patient comfort. Remember, these are sound "shocks", not electrical shocks. The treatment lasts between five and seven minutes. Occasionally a fourth treatment may be indicated.

Are there contraindications or precautions with Radial Shockwave Therapy?
Yes, RSWT is not for everyone. You should consult with your physiotherapist prior to initiating treatment. Contraindications include the following:
  • Coagulation disorders and the use of anticoagulants such as Marcuma, heparin, and coumadin
  • Cancer
  • Pregnancy
  • Polyneuropathy in case of diabetes mellitus
  • No NSAIDS one week prior to treatment
  • No cortisone six weeks prior to treatment
  • No ice post treatment
  • No anti-inflammatory post-treatment

Has Radial Shockwave Therapy been clinically proven?
RSWT has been subjected to more valid scientific study than any other modality in physical medicine. The results far exceed other types of modalities and have been published in numerous well respected medical journals. Here are a few examples:

91% success rate calcific tendonitis of the shoulder (Journal of American Medical Association, 2003)

90% success rate plantar fasciitis (The Journal of Orthopaedic Research, 2005)

77% success rate tennis elbow (The Journal of Orthopaedics, 2005)

What is the cost of Radial Shockwave Therapy?
For current patients who have already undergone an assessment adding RSWT to your treatment protocol would be an additional $420 and would include three RSWT treatments. For new patients or conditions not yet assessed there would be an additional assessment fee of $80 added to the RSWT fee.

RSWT is administered by a registered physiotherapist and is an affordable treatment option. In addition the vast majority of extended health insurance plans, motor vehicle insurance and WSIB will cover all or a portion of the treatment. If requested, a quote can be provided for preapproval with your insurance company.

Where can I get Shockwave Therapy in Durham?
At present this service is only being offered at our Brock Street location in Whitby. If you have further questions please direct them to 905-666-8270 and one of the physiotherapists will be pleased to speak to you.