Chiropractor, Dr. Alexander Jimenez looks at the way this common injury shows itself.
Introduction
Iliotibial band syndrome (ITBS) between the knee is frequently diagnosed in sport injury clinics. ITBS presents having an incidence rate of around 22% in most lower extremity running-related injuries (1) also has been said to be the second most common complaint amongst distance runners (2). ITBS has been given the expression ‘runner’s knee’.
Trainers like endurance runners who perform flexion and extension combined with loading are subjected to this illness. ITBS presents during the first two or three miles in running with no mechanism of injury, which can make identifying the cause more interesting. With plenty of factors having been considered within the literature, changes are often purported to be a cause of ITBS. But some biomechanical factors have been researched and have been found to have little or no effect in the start of ITBS. Therefore this text’s point would be to examine the biomechanical changes which may induce an individual to the beginning of ITBS. The research published reviewed is largely based on a current systematic review that was published in Physical Therapy in Sport in 2014 (3).
Anatomy & Function
The iliotibial band (ITB) encapsulates the tensor fascia latae (TFL) presenting with both deep and superficial fibre attachments at the pelvis (4). In addition to attaching to the TFL, approximately three-quarters of the gluteus maximus tendon also conjoins with the ITB (4). The ITB courses along the lateral aspect of the hip and passes the greater trochanter. The ITB maintains an attachment on the posterior ridge of the femur whilst attaching itself to the fascia. The ITB has a fixed attachment at the lateral femoral condyle where it then divides into three segments with the first being the lateral patella (3). The remaining two segments cross the knee joint to insert at the head of fibula and most distally at the infrapatellar tubercle also known as Gerdy’s tubercle on the tibia (3). Figure 1 illustrates the location of the ITB.
The ITB passively functions to resist hip adduction, hip internal rotation and internal rotation of the knee in accordance with its attachments at the pelvis, femur and tibia(3). The gluteus maximus functions, through its attachment, to increase stability through the hip and knee complex by increasing the tension of the ITB(4). It is possible to see, based on its attachments at both the knee and hip, how changes could bring about the onset of ITBS.
Studies have proposed that as the knee flexes and extends the ITB ‘slides or flicks’ over the lateral femoral condyle of the knee causing an irritation beneath. This notion was debated by Falvey and colleagues (5), who stated that it was highly unlikely that the ITB would flick or slide over the bone during knee flexion due to it not being a loose structure. But the authors did agree that the impact of compression on the richly innervated fat pad was pain’s cause but by strain of the ITB where pain presents crossing the lateral femoral condyle. Strain rate and strain magnitude were measured in a prospective study involving female runners (6). The results indicated that frequency of strain of the ITB at the lateral femoral condyle was greater that the strain magnitude. This implies that a runner might have the ability to run for a short period but then incur lateral knee pain because of the strain to the ITB.
MRI scans have ascertained the knee flexion angle of 30� elicited the greatest compression of the ITB at the point of heel strike, whereas others have said that maximal compression occurs between 20-30�(2,6). A knee flexion angle at the point of heel strike has been found to be significantly different with 20.6� in ITBS patients compared to 15.3� in the control(7). Downhill running produces a greater knee flexion angle at the point of heel strike eliciting a larger strain load to the ITB and therefore this is often a main precursor to ITBS (6). Although an elevated knee flexion angle at the point of heel strike has been considered to contribute to ITBS, it is essential to examine the lower extremity from the frontal and transverse planes too and not solely from the sagittal plane (2).
Rearfoot Eversion
It’s possible to envisage how rear foot eversion could contribute to ITBS causing internal rotation of the tibia resulting at the distal attachment in greater strain of the ITB. In contrast Ferber and colleagues (2) indicated that there was no significant difference in the peak eversion angle of the female subjects, who were previously diagnosed with ITBS but were now symptom free, compared to controls. In a similar study non-significant differences were found between the currently symptomatic ITBS patients and controls for rear foot eversion (8).
Louw & Deary(3) found that ITBS patients sometimes demonstrated decreased eversion angles, accompanied by decreased internal rotation of the knee, at the point of heel strike. Ferber and colleagues (2) noted an increased inversion moment in the ITBS group which was suggested to control and limit the eversion moment. By comparison, currently symptomatic ITBS patients demonstrated a substantial difference compared to a control group with twice the rear foot motion during running (9).
Knee Internal Rotation
Peak internal rotation angle of the knee was found to be significantly greater in the ITBS patients when compared with controls at the point of heel strike (2). This research was supported by other studies who also found a significant effect for increased internal rotation of the knee following a run of moderate intensity to physical exhaustion(7). With excessive rotation comes compression due to increased strain of the ITB at the attachment.
An explanation of increased internal rotation of the knee was attributed to excessive external rotation of the femur perhaps due to shortening of the piriformis, gemellus inferior and superior and the obutrator externus (8). The authors added that excessive rotation at the hip might result from muscular activity of the rotators that were hip being the medius, minimus and the tensor fascia latae. These studies(2,7) were retrospective in design in that they tested healthy runners with a history of ITB pain, whereas(8) was a prospective study of patients with ITBS at the point of testing.
Hip Adduction Angle & Hip Abductor Strength
The hip adduction angle during the stance phase has been suggested to be greater. Ferber and colleagues(2) found that the peak hip adduction angle was significantly greater in the ITBS cohort and stated that with 95% confidence. Increased angle results in increased stress to the ITB and consequently increased compression at the lateral femoral condyle when combined with increased internal rotation of the tibia.
Figure 2 illustrates, when peak hip adduction and internal rotation combine, how this may result in increased the compression of the ITB at the lateral femoral condyle. Louw and Deary(3), however, stated that it remained inconclusive whether the peak hip adduction angle was a substantial element. Additional research is therefore required to support Ferber and colleagues'(2) initial findings as this study was a retrospective study carried out on healthy female runners with a history of ITBS.
Hip Abductor Strength
It’s been proposed that an increased peak hip adduction angle may coincide with hip abductor activity involving the gluteus medius in this group. During the stance phase of gait the gluteus medius functions to keep stability. Research has indicated that during stance the adduction forces can exceed three times an individual’s body weight(3). What’s more, it was stated that these forces were beyond the metabolic capacity of the gluteus medius to main pelvic stability during the stance phase using just this muscle alone(3).
Louw and Deary (3) were not able to identify a heightened hip abductor moment in the ITBS patients with increased peak hip adductor angles and suggested that it was more of an issue of timing as opposed to the size of the hip abductors. Louw and Deary (3) stated that the research is yet to examine trunk and pelvic movements in ITBS patients and it is plausible to suggest that biomechanical changes from higher up the kinetic chain has the potential to be a contributing element in ITBS etiology.
A research study of 24 (14 female, 10 male) patients with ITBS undertook a six-week rehabilitation programme to increase the strength of the hip abductors(10). Following six weeks of hip abductor strengthening to running 22 patients reported being pain-free and had returned. The female patients reported an average hip abductor torque increase of 34.9% and the male patients found 51.4% increase. However this study used a hand held dynamometer to measure isometric strength and therefore Fedricson (10) findings should be viewed with caution.
A more recent study assessed the hip abductor strength of currently symptomatic patients with healthy controls in a fixed position(11). The results indicated that no substantial differences occurred for static and dynamic hip abductor strength between the groups. Further research should look into the EMG and strength of the hip abductors in the role of managing ITBS. Table 1 shows of significance in the some of the variables of the studies used in this text.
Rehabilitation programs, following periods of immobilization and during, should include gluteal exercises to provide stability to the leg that is involved. If active exercises for the gluteal muscles are provided in a manner that is secure and effective then this can influence the period of transition from non weight. It’s prudent based on the research provided to date to develop function although research is lacking in terms of quality and volume as to the biomechanical influences on the etiology of ITBS. This guarantees that once load bearing commences that the leg that is involved has the stability and control that is active to keep the beginning of load of the ITB.
Summary
The recent review published by Louw and Deary(3) indicates that much of the research published within the literature depending on the etiology of ITBS is inconclusive. The level of research is relatively low and is based on retrospective trials. The research does indicate that knee biomechanics and abnormal hip is involved in the occurrence of ITBS. The authors ascertain that muscle strength is involved as is foot biomechanics that are abnormal. It is recommended that future research should measure kinematic movements of the hip and knee during downhill running as this is a complaint of ITBS onset.
References
1.Clini J of Sports Med, May 2006,16, (3), 261-268
2.J of Sports Phys Therap, Feb, 2010, 40, 2, 52-58.
3.Phys Therap in Sport, 2014, 15, 64 e75.
4.Surgic and Radiologic Anatomy (Dec) 2004; 26, (6), 433 – 446
5.Scand J of Med & Sci in Sports, Aug 2010, 20 (4), 580-587.
6.Clini Biomech, 2008, 23, 1018-1025.
7.Gait Posture. 2007 Sep, 26 (3), 407-13
8.Clini Biomech, Nov 2007, 22 (9), 951-956.
9.Med Sci in Sport & Ex, 1995, 27, 951-960.
10.Clini J of Sports Med, 2000, 10:169�175.
11. Int J of Sports Med, Jul, 2008, 29 (7), 579-583.
Spinal cord injury (SCI) can have many causes. The way a person’s injury affects them can differ depending on the origin of SCI. SCI can generally be described as being ‘traumatic’ or due to a trauma, or ‘non-traumatic’ being due to other causes.
Spinal cord injuries occur in an assortment of ways. In adults, damage to the spinal column is usually involved and the cord is affected, bruised, stretched or compacted due to movement or an external force. Wear and tear on the spinal column, can lead to narrowing of the canal called stenosis. This results in pressure on the spinal nerves and the spinal cord, causing loss of function. In children, a spinal cord injury occurs by an over-stretching of the spinal cord.
Automobile accidents involving pedestrians or occupants, falls, sport-related accidents and diving into shallow water are considered to be the most common cause of traumatic SCI.
Spinal cord damage can be caused by the following kinds of injuries:
Flexion Injuries
Flexion injuries occur when there is a forcible forward movement of the head. This results in injury to the vertebrae in the neck (cervical) area of the spinal column. The vertebrae then impact on the spinal cord, causing damage. Spinal ligaments are often torn. These types of injuries occur in auto accidents.
Rotation Injuries
Rotation injuries occur alongside an injury, often where there is rotation of the spinal column. This leads to an associated injury of the spinal cord. Ligaments are often torn where the side rotation injuries happen in automobile accidents. They can also occur with people in motorcycle accidents, and wearing lap seat belts.
Compression Injuries
Compression injuries occur in diving accidents, where the force is transmitted through the head; or falls from a height, where the force is transmitted through the base of the spine or limbs. Impact causes the vertebrae commonly in the cervical or lower thoracic and lumbar region, to fracture into pieces and protrude into the spinal canal, damaging the spinal cord. The discs may be displaced and protrude into the spinal canal.
Hyperextension Injuries
Hyperextension injuries occur during an incident, such as a fall, where the neck is extended in a backward direction, stretching the cord. The spinal cord is damaged by the opening up of the discs and stretching of the ligaments if there’s minimal damage to the spinal column. This injury is often seen in people, and those injured in assaults and auto accidents. Hyperextension of the neck is the way children damage their spinal cords. The force of the trauma causes stretching of the spinal cord, although there’s often no or little damage to the spinal column.
Penetrating Injuries
Penetrating injuries occur when the spinal cord is penetrated by an object such as a knife or bullet. This type of injury can occur at any level of the spinal column and is often not associated with column damage.
Whether an injury is caused by events that are traumatic or non-traumatic, a person with a SCI has the ability to benefit from a variety of treatment options and rehabilitation, performed by a qualified and experienced healthcare professional. Research has indicated that the outcomes for people with a SCI are better if they have rehabilitation in a specialist unit as opposed to a general rehabilitation unit.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
By Dr. Alex Jimenez
Additional Topics: Automobile Accident Injuries
Whiplash, among other automobile accident injuries, are frequently reported by victims of an auto collision, regardless of the severity and grade of the accident. The sheer force of an impact can cause damage or injury to the cervical spine, as well as to the rest of the spine. Whiplash is generally the result of an abrupt, back-and-forth jolt of the head and neck in any direction. Fortunately, a variety of treatments are available to treat automobile accident injuries.
In the first part of the 2-part article on femoro-acetabular impingement (FAI), chiropractor, Dr. Alexander Jimenez discussed FAI and how it can lead to insidious onset abdominal pain and damage the hip joint labrum, leading to early arthritic changes. Given that conservative management generally fails in young athletes and needs operation, part two describes the post-operative rehabilitation period required to take an athlete back to full competition.
The post-operative rehabilitation period is highly dependent on the magnitude of pathology and the subsequent procedure; weight-bearing development is consequently variably reported in the literature.
If the labrum is surgically repaired, then protected weight bearing is encouraged to allow the repair site in order to be protected during the early healing phase. Also, avoiding extremes of flexion (beyond 60�) and also internal/external rotation for the initial 4 to 6 weeks is important to safeguard the repaired labrum. Any positions that possibly create an impingement and boost inflammation ought to be prevented. These include:
Deep squatting
Prolonged sitting
Low couch sitting
Lifting off the ground
Pivoting on a fixed foot
These positions are more safely tolerated following the six week post-operative period. But on account of the selection of hip flexion limitations imposed in the initial six months, usual activities of daily living are rather restricted, making yield to work and daily chores challenging if not impossible from the first few weeks following surgery. Therefore, the post- surgical patient does have to make substantial lifestyle changes and they need assistance in the first six weeks following surgery.
Special precautions in certain types of FAI processes. Reshaping of the femoral head- neck junction can weaken the rectal neck so particular care must be taken in this post- operative period. Fracture of the femoral neck is an unlikely but potentially serious complication after a reshaping process. The athlete may be allowed to bear full weight, but crutches are needed to avoid twisting movements during the initial four weeks after surgery. High impact pursuits and high torsion moves should be prevented in the first 3 months, as bone grafting requires around three weeks to attain full structural integrity.
Furthermore, if microfracture of this femoral head is also done for femoral head cartilage defects, then the athlete ought to be restricted to partial weight- bearing for two weeks so as to optimize the premature maturation of the fibrocartilaginous healing response.
Key points
1. Weight bearing status is dependent on the kind of reshaping procedure, whether the labrum was repaired, and also what the surgeon favors
2. Steer clear of hip flexion beyond 60� in the first 4-6 Weeks
3. Avoid extremes of rotation
Post-Surgical Rehab
Rehabilitation protocols provided in the literature have a tendency to be quite generic in their own advice and at best explain broad transitional phases during the rehab process. They usually describe the transition in weight bearing status, the development of gait through walking into jogging, and give general guidelines as to how to and when to progress activity based on a time dependant strategy.
They then progress describing transitions into twisting and affect actions — usually explained as beginning at 3 weeks following surgery — and generally the guidance is that the speed with which the athlete progresses is variable and might need yet another 1 to 3 months to get full return based on the game. Trainers are usually advised that return to sports after surgical correction of FAI can require 4 to 6 weeks. However it’s critical that progression through rehabilitation phases is driven more by subjective and objective measures during the transition phases. This allows the athlete and therapist to track load (type and quantity) and ascertain whether the joint arrangements are able to withstand changes in load securely.
Wahoff et al (2014) have provided some standards which may be utilized to guide the transition from one point to the next(1). They describe their rationale and supply a complete description of all of the cited tests in their printed clinical comment. Essentially, the exit criteria they offer in each phase are as follows;
So as to advance through the six clarified stages, the athlete may undergo extensive physiotherapy, focusing on hip range of movement exercises, manual therapy and trigger point releases, active stretching, potentially deloaded activities like hydrotherapy or Alta G walking/ running and strong hip rotator and gluteal strengthening exercises. Much of this will be ‘controlled’ and led by the wishes of the surgeon as they will provide the framework on if and what happens concerning loading.
But more direct physiotherapy Interventions have been devised to direct the physiotherapist through the rehabilitation protocol. The Takla-O�Donnell Protocol (TOP) is a validated physiotherapy intervention program which may be utilized to induce the arthroscopically handled FAI patient (Bennel et al)(2).)�This protocol is shown in box 2.
Hip Muscle Control
The focus of the rest of this article Will be to summarize some common yet powerful hip strengthening exercises which may be used to progress the hip muscle control throughout the rehabilitation phases.
Regaining hip muscle power, particularly in the heavy hip external rotator group, is imperative from the FAI recovering athlete. Good muscle endurance and strength in those muscle groups will ensure adequate hip joint compression happens with motion to reduce any shearing effect between the head of femur and acetabulum(3). The muscle groups needing focus are (see figure 5):
Posterior fibres Gluteus Medius (PGMed)
Gluteus minimus
Superior and Inferior Gemellus
Internal and External Obturator
Quadratus Femoris
Piriformis
There’s plenty of exercises that can be utilized to fortify the hip joint musculature. The chosen ones below are a sample of some effective exercises that can be used throughout the rehabilitation phases. However, the key requirements of the contained exercises include:
1. Performed in neutral stylish places to no more than 60 degrees hip flexion. This range of movement protects the hip joint from any possibly damaging impingement.
2. Minimal rotation of the hip, letting them be used in most stages of the rehabilitation process.
3. Performed isometrically or utilizing little oscillating concentric/eccentric contractions — to contract and hold to maintain the hip joint compacted and stable. This represents how these muscles work in individual function.
Summary
In many ways. hip joint labral tears, capsule sprains, cartilage and muscle accidents and bony architectural issues like FAI can all lead to debilitating hip pain. FAI is a real concern for the athlete as the existence of a bone abnormality may lead to a painful hip impingement, damage to the acetabular labrum and premature onset degeneration. FAI’s don’t respond to conservative management. If the athlete suffers debilitating pain that affects competition then the options are either to cease competition all together or have the FAI surgically corrected. Once corrected by the surgeon, regaining complete motion and muscle strength and ultimate game related functional skills will require some time. Hip rotator muscle strengthening must shape the foundation of all handling post-surgical FAI issues.
References
1. International Journal of Sports Physical Therapy. 9(6); pp 813-826
2. Arthroscopy. 2006;22(12):1304-1311
3. Int J Sports Phys Ther. 2012;7(1):20-30.
It’s high season for grilling and backyard barbecues, with July 4 celebrations planned across the country. But experts say it’s important to be aware that the popular summer pastime is riddled with minefields when it comes to health and food safety.
“Grilling is generally a healthy way to cook food if you take certain precautions,” says registered dietitian Joan Salge Blake, an associate professor at Boston University’s Sargent College of Health and Rehabilitation Sciences.
Here are some tips from Blake and other experts:
Avoid food contamination: Mixing cooked food with juices from raw meat is a big no-no. “When it comes to food safety, we have to be careful about cross-contamination,” Blake tells Newsmax Health. “People bring the raw meat out on a platter, grill it and then put it back on the same platter without washing it. That’s how you can transfer pathogens that can cause a range of food-borne illnesses.”
Use a thermometer: You can’t trust your eyes to tell you whether or not meat is cooked enough. “One in four hamburgers turn brown prematurely, before they are at a safe internal temperature to be consumed,” says Blake. “Rather than trust our vision to determine if food is safe to eat, use a meat thermometer and make sure the internal heat is at least 165 degrees Fahrenheit.”
Keep the flame down: Cooking with high heat from an open fire creates carcinogenic compounds in beef, pork, poultry, and seafood. So while that flame-licked steak or salmon may have a great grilled flavor, it also contains heterocyclic amines (HCAs) from the charred part and polycyclic aromatic hydrocarbons (PAHs) from the fire’s smoke. Lab studies suggest that they can cause mutations in DNA that may boost the risk of cancer.
Pre-cook meat: One way to reduce HCAs and PAHs is to partially cook meat — by boiling or microwave — before grilling it. That will reduce the time it is exposed to the high heat and smoke that creates these dangerous compounds.
Flip frequently: “You want to keep turning the meat to keep it from getting charred, because that’s where the [biggest] problem is,” says Blake. “If it does get charred, don’t eat that part.” Aim to flip grilled foods at least once a minute.
Foil flare-ups: One thing that can make the flame flare up is when fat from the meat drips down to the heating source. Blake suggests putting some foil down on the grill, which will keep the melted fat from hitting the flame.
Use marinade: Studies show that marinades can significantly reduce the HCAs and PAHs in grilled meat. Researchers believe it works by helping to keep the meat moist, and it can also improve flavor. One study showed that using the herb rosemary lowered HCA levels by 90 percent. Other things that can cut down on the bad compounds are garlic, onion and honey.
Watch your sauce: Blake warns not to use the leftover marinade for a sauce on the grilled meat, unless you cook it as well, because it could contain bacteria and other pathogens from the raw meat.
Grill veggies: “One of the best things you can do for overall health is to grill more vegetables than protein sources,” says Blake. “They don’t produce HCAs and PAHs, and they have a wide range of health benefits.”
Be fire smart: The most obvious health threat of grilling is the fire itself. According to the National Fire Prevention Association, about 9,000 blazes are sparked by grills every year, causing an average of 10 deaths, 160 injuries and more than $100 million in property damage.
Using common sense can reduce fire risks. The NFPA cites the main fire causes as placing the grill too close to anything that can burn, not cleaning it regularly, and leaving it unattended. If you’re using a propane grill, don’t turn the gas on for too long before lighting it. You should also check lines and connections for leaks.
In the prior writing we explored the criteria for vehicle integrity. In this writing we’ll expand on conservation of momentum. You’re encouraged to do so when you haven’t read the previous article.
Expanding on Conservation of Momentum
Remember we previously said, “The momentum moving into a collision could be accounted for at the outcome” when we discussed the concept of conservation of momentum. Here we will introduce the formula and walk through its parts; we have to comprehend this in order to explore each other influence.
The full formula:
Let�s walk through this, on the left side of the equation we have which is the weight of the first vehicle before the collision multiplied by which is the velocity (in feet per second) of the first vehicle before the collision. is the weight of the second vehicle before the collision times which is the velocity (in feet per second) of the second vehicle before the collision. On the right side of the equation we have which is the weight of the first vehicle after the collision multiplied by which is the velocity (in feet per second) of the first vehicle after the collision. is the weight of the second vehicle after the collision times which is the velocity (in feet per second) of the second vehicle after the collision.
Ok, I know this looks very intricate and the explanation is not jumping off the page so let’s write with a bit more ease of comprehension. Let us take the National Highway Transportation Safety Administration (NHTSA) standards for testing and place two of the identical mass vehicles in this. Let us use a 2012 Toyota Corolla, and we will say the other is blue and one is red because we need two of them.
Red Corolla * 5 mph + Blue Corolla * 0 mph = Red Corolla * 0 mph + Blue Corolla * 5 mph
The 2012 Toyota Corolla has a curb weight of 2,734 pounds, substituted in the formula it looks like this:
Now when we do the math to show the conservation of momentum we end up with the following:
20,094.9 + 0 = 0 + 20,094.9
20,094.9 = 20,094.9
Momentum conserved
Now we have proved the concept so we are going to apply it to a collision involving two different vehicles. We will substitute the 2012 red Toyota Corolla for a 2012 red Chevrolet Tahoe. The 2012 Chevrolet Tahoe weighs 5,448 lbs. Now the formula looks like this:
Red Tahoe * 5 mph + Blue Corolla * 0 mph = Red Tahoe * 0 mph + Blue Corolla * 9.96 mph
Now when we do the math to show the conservation of momentum we end up with the following:
40,042.8 + 0 = 0 + 40,042.8[1]
40,042.8 = 40,042.8
Momentum conserved
Three significant points can be observed in this protest.
First, when testing is done notice the change in rate at the Tahoe is 5 mph (5 to 0). This is less than the rates used by the Insurance Institute and we would expect the Tahoe to have minimal damage and no structural deformation.
The second point to note is the change in speed the Corolla experiences, 9.96 mph (0 to 9.96). This change in speed is four times the original.
Conclusion
Finally, neither vehicle exceeds the speed of 10 mph, which the automobile manufactures and insurance institute for highway safety often consider threshold for injury. This confirms that cars can easily deform and residents become injured in low speed crashes once you begin to check out the conservation of energy (momentum) and coefficient of forces moved to the target car.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .� References
Edmunds.com. (2012). 2012 Chevrolet Tahoe Specifications. Retrieved from Edmunds.com: www.edmunds.com
Edmunds.com. (2012). 2012 Toyota Corolla Sedan Specifications. Retrieved from Edmunds.com: www.edmunds.com
Brault J., Wheeler J., Gunter S., Brault E., (1998) Clinical Response of Human Subjects to Rear End Automobile Collisions. Archives of Physical Medicine and Rehabilitation, 72-80.
Additional Topics: Weakened Ligaments After Whiplash
Whiplash is a commonly reported injury after an individual has been involved in an automobile accident. During an auto accident, the sheer force of the impact often causes the head and neck of the victim to jerk abruptly, back-and-forth, causing damage to the complex structures surrounding the cervical spine. Chiropractic care is a safe and effective, alternative treatment option utilized to help decrease the symptoms of whiplash.
In the first part of this 2-part series, chiropractor, Dr. Alexander Jimenez looked at the likely signs and symptoms of disc Herniation, in addition to the selection standards for micro-discectomy surgery in athletes. In this report he discusses the lengthy rehab period following a micro-discectomy procedure, and provides a plethora of strength based exercises.
Surgeries to ease disc herniation, with or without nerve root compromise, comprise traditional open discectomy, micro-discectomy, percutaneous laser discectomy, percutaneous discectomy and micro- endoscopic discectomy (MED). Other surgical conditions are employed in The literature like herniotomy that’s interchangeable with fragmentectomy or sequestrectomy. The saying ‘herniotomy’ is defined as removal of the herniated disc fragment just, and the ‘standard discectomy’ as elimination of the herniated disc along with its degenerative nucleus in the intervertebral disc space.
When surgery is required, minimizing tissue disruption and strict adherence to an aggressive rehabilitation regimen may expedite an athlete’s return to perform(1), that explains why micro discectomy is a favored surgical procedure for athletes. Micro discectomy procedures entails Removing a small part of the vertebral bone over a nerve, or removing the fragmented disc stuff from under the compressed nerve root.
The surgeon can then enter the spine by removing the ligamentum flavum that insures the nerve roots. The nerve roots can be visualized with functioning eyeglasses or with an operating microscope. The surgeon will then move the nerve to your side and to subsequently remove the disc material from beneath the nerve root.
It’s also sometimes required to eliminate A small portion of the related facet joint to permit access into the nerve root, and additionally to relieve pressure on the nerve root resulting in the facet joint. This procedure is minimally invasive since the joints, muscles and ligaments are left intact, and the process doesn’t interfere with the mechanical construction of the spinal column.
Endoscopic Lumbar Discectomy
Local Doctor performs lumbar discectomy using minimally invasive techniques.�From the El Paso, TX. Spine Center.
Surgical Outcomes
In general, athletes with lumbar disc Herniation have a favorable prognosis with traditional therapy; more than 90 percent of athletes using a disc herniation improve with non-operative treatment. Many demonstrate a response to conservative treatment with increased pain and sciatica within 6 weeks of the initial onset(2). This implies that the requirement to function immediately could be considered hasty.
However, in case of failed Conservative therapy, or together with the pressure of a significant upcoming competition, surgery might be needed in some instances. Even though it involves surgical therapy, micro-discectomy has been reported to have a high success rate — over 90 percent in some studies(3,4). Patients generally have hardly any pain, are able to return to preinjury activity levels, and therefore are subjectively happy with their results.
The achievement rate of micro-discectomy is The following studies have been summarised to underline the success rate of micro-discectomy procedures:
1. In a survey on 342 professional athletes Diagnosed with lumbar disc herniation in sports like hockey, football, basketball and baseball, it was discovered that powerful return to perform occurred 82% of this time, and 81 percent of surgically treated athletes returned for an additional average of 3.3 years(5).
2. From a limb paresis which might be associated with a disc herniation following surgical treatment. If the preoperative paresis was mild then they could anticipate an 84% likelihood of full recovery. Patients with more severe paresis have less chance of recovery (55%)(6).
3. Wang et al (1999) in a study on 14 athletes demanding discectomy processes found that in single degree disc procedures, the return to game was 90%. However when the procedure involved 2 levels enjoyed considerably less favorable results(7).
4. In a study of 137 National Football League players with lumbar disc herniation, surgical treatment of lumbar disc herniation led to a significantly more career and greater return to play rate than those treated non-operatively(8).
5. Schroeder et al (2013) reported 85% RTP rates in 87 hockey players, with no substantial difference in outcomes or rates between the surgical and nonsurgical cohorts(9).
6. A study by Watkins et al (2003) coping with professional and Olympic athletes revealed the acceptable outcomes of micro-discectomy concerning return to play, since elite athletes in general were highly encouraged to return to perform(10). Also, athletes who had single-level micro- discectomy were more likely to come back to their original heights of sports activities than were people who’d two-level micro- discectomies.
7. A study by Anakwenze et al (2010) investigating open discectomy at National Basketball Association participants demonstrated that 75% of patients returned to perform again compared with 88 percent in control subjects who did not undergo the operation(11).
8. A recent review found that conservative therapy, or micro-discectomy, in athletes using lumbar disc herniation seemed to be satisfactory concerning returning the injured athletes into their initial levels of sports activities(12).
These studies conclude that though a Analysis of lumbar disc herniation has career-ending potential, most gamers have the ability to return to play and generate excellent performance-based outcomes, even if surgery is required.
What is also apparent from research Studies is the level of this disc herniation can also determine prognosis after surgery. Athletes shower a greater difference in progress between surgical and non-operative treatment for upper amount herniations (L2-L3 and L3-L4) compared to herniations at the L4-L5 and L5-S1 levels. Patients using the upper level herniations needed less progress with non-operative treatment and marginally better operative outcomes than those with lower degree herniations(13).
There are several possible explanations A range of studies have revealed that low spinal canal cross-sectional area is associated with an increased likelihood of symptomatic disc herniation, and increased intensity of herniation symptoms. The spinal cross-sectional region is the smallest (thus contains a larger possibility of nerve compromise) at the most upper posterior section and the cross-sectional region increases further down to the lower lumbar spine(14).
The location of the disc herniation�(foraminal, posterolateral or central) may also contribute to differences.�In this study, upper lumbar herniations were more likely to happen in the much lateral and foraminal positions than were people in the lower two intervertebral degrees(13).
Post-Surgical Rehab
After micro-discectomy surgery, the Small incision and restricted soft tissue injury makes it possible for the patient to be ambulatory reasonably fast, and they’re usually encouraged to start rehabilitation sooner or later during the 2-6 weeks after surgery.
In a review on the efficacy of busy Rehabilitation in patients following lumbar spine discectomy, it may be reasoned that individuals can safely take part in high or low-intensity supervised or home-based exercises initiated at 4 to 6 weeks following first-time lumbar discectomy(15).
Herbert et al (2010) discovered that with Effective post-surgical rehabilitation plans, there was a key accent on lumbar stabilisation exercises(16). Second, positive trials tended to initiate rehabilitation earlier in the postoperative interval compared to negative trials (about 4 vs 7 weeks).
Outcome Measures
The most widely used result Measure following back injury and/or disc surgery is the Oswestry Disability Questionnaire(17). This questionnaire is reported to have good levels of test-retest reliability, responsiveness, and also a minimum clinically important difference estimated as 6 percent(18) Furthermore, treatment success has been defined as a 50 percent decrease in the Modified Oswestry Disability Questionnaire score(19).
Concerning physical performance measures following back disc or pain operation, a commonly used clinical examination is that the Beiring-Sorensen Back Extension examination (see Figure 1)(20). This test is performed in a prone/horizontal body position with the spine and lower extremity joints at neutral position, arms crossed at the chest, lower extremities and pelvis supported with the top back unsupported against gravity.
Rehabilitation Program
Presented below is a five-stage rehabilitation program. The stages involved in rehabilitation are:
1. Optimize tissue healing — protection and regeneration
2. Early loading and foundation
3. Progressive loading
4. Load buildup
5. Maximum load
This program has been designed to get a field hockey player with had a L5/S1 lumbar spine discectomy. Even though the progressions from one point to the next are driven by the exit standards related to that stage, it might be anticipated that the athlete could progress in post-surgery to ‘fit to compete’ in about 12-13 weeks.
In this phase it’s anticipated that the athlete will remain relatively quiet for 2-3 weeks post surgery. This allows for full tissue recovery to happen, including scar tissue maturation. The athlete is allowed to completely mobilize in full weight-bearing; however care needs to be taken using any flexion and rotation motions and no lifting will be allowed.
The athlete can begin with the physiotherapist with the objective to manage any gluteal and lumbar muscle trigger points and start�nerve mobilization techniques that show how to engage the TrA and LM muscles (see Figures 2a and 2b).�If the physiotherapist has access to your muscle stimulator (Compex), then this can be utilized in atrophy manner on the lumbar spine multifidus and erector spinae. The key criteria to exit this early phase are curable walking as well as also an Oswestry Disability Score of 41-60%.
Early Loading & Foundation
The primary feature of this phase is that the athlete can start early and low-load strength exercises focusing on muscle activation in a neutral spine position, along with a progressive selection of motion program to improve lumbar spine flexion, extension and rotation. In this stage that the physiotherapist will guide the athlete through safe and gentle stretches to your hip quadrant muscles like the hip flexors, gluteals, hamstrings and adductors. The athlete also lasts gentle neuro-mobilization exercises to advance the freedom of the sciatic nerve — an issue in this condition as neurological tethering is a chance as a result of scar tissue formation caused by the surgical procedure.
The athlete can also be encouraged to start hydrotherapy in the form of walking in water (waist high) along with swimming fitnesscenter. In addition, he/she must start a string of low degree muscle activation drills in this stage (see Figure 3) that can be performed every day. This exercise teaches the athlete to hip flex (fashionable hinge) whilst maintaining a neutral spine. The neutral spine is maintained by using a light broomstick aligned with the back with the touch points being the occiput, the 6th thoracic vertebrae (T6) and the posterior sacrum.
Progressive Loading
In this phase the athlete continues with a variety of movement progression along with the physiotherapist progresses manual therapy to the pelvis and lumbar spine. Neuro-mobilization techniques can also be progressed. The significant change in this phase is that the progression of load on many of the strength and muscle control exercises.�Two exercises here are the �standing twisties� and the �crook lying pelvic rotation� exercise (Figures 4 and 5).�These movements are the introductory spinning based movements. The primary progression about fitness drills is the athlete can begin pool running drills.
Load Accumulation
This is the stage where the athlete begins to advance the load in strength-based exercises. Resistance is used in the form of barbell load and band resistance. Three exceptional exercises performed here are the ‘kneeling hip thruster’, ‘deadbug antirotation press’ and also the ‘quadruped walkout’ (Figures 6-8 — explained in detail in the online database of exercises).
The athlete also begins running drills at this phase and it might be expected that as well as building running Amount, the athlete should progress over four weeks to close to full sprint speeds. This is also the stage whereby they would initiate mild to moderate sports special skills drills. Another characteristic of this stage is that the athlete starts the ‘Sorensen test’ exercise (Figure 9) and it will be expected that they can maintain the position for no less than 90 seconds before advancing to the next phase.
Maximum Load
In this final stage, the athlete spreads all core and strength exercises to maximum loads, and they work with the fitness trainer on coming to squat and functional fitness center lift movements. Skill progression can also be advanced alongside sprint and agility drills. The last exit standards prior to advancing to endless strength and training work is they have to keep the ‘Sorensen test’ for 180 seconds and their self documented Oswestry scale ought to be someplace between 0-20%.
Concussion, also known as mild traumatic brain injury (MTBI), has been a poorly understood condition known to the majority of healthcare providers as difficult to objectify and manage.
Historically, there has been no testing available to conclude an accurate diagnosis. In the absence of objective imaging findings of bleeding in the brain, a diagnosis of “mild traumatic brain injury” has been affixed to the condition, whereas if there’s evidence of traumatic bleeding then the diagnosis “traumatic brain injury” is applied.
Although Hartvigsen, Boyle, Cassidy and Carroll (2014) reported that 600 out of 100,000 Americans are affected every year by concussion, Jeter et al, (2012) reported that close to 40 percent of people experiencing a mild brain injury do not report it to their doctor, making accurate statistics very tricky to conclude. Despite potential under reporting in the people, we realize concussion is an issue that has consequences that are important from the perspective of a clinical result and we cannot afford to ignore this condition.
Mechanism of Injury: Mild Traumatic Brain Injury
Mild traumatic brain injury or concussion results from transfer of mechanical energy from the outside environment to the brain due to traumatic events where there’s a sudden acceleration and then a sudden deceleration of the mind and brain, such as in a Coup/Contrecoup injury during a whiplash scenario. As the brain is freely moving to a degree because it’s only surrounded by cerebral spinal fluid, it continues moving in the original direction and as the head “whips” rapidly in the opposite direction, the brain bounces off parts of the inner skull, which in turn rebounds shortly after the head changes direction. This is one easily defined mechanism of MTBI that doesn’t cause gross bleeding, yet leaves the brain injured through direct compression or overstretching (axonal shearing) of central nervous system components.
Although this has been examined extensively in the military, it’s been recently investigated in professional sports, where after several lawsuits and lives at risk, there are now definitive “concussion protocols” in place. Part of the protocols as reported from the British Journal of Sports Medicine (2016) is the Sports Concussion Assessment Tool 2 or SCAT2 that’s been adopted by numerous professional sports leagues. However, the majority of concussion victims are not active participants in the military or a professional sports team and many find their way into chiropractic practices as a consequence of sports injuries, car accidents, slip and falls and every other sort of head trauma etiology. Even though the mechanisms might vary, the induced end results are the same.
For generalized patient intake protocols, according to both Medicare and academia standards, a questionnaire outlining a summary of body systems is mandated, and part of those questions center on brain function. As reported by Jeter et al behavioral and cognitive symptoms, signs and symptoms are reported on standard patient intake questionnaires and require consideration of a diagnosis of concussion.
Prominent symptoms of concussion include: balance issues, vomiting, nausea, headache, drowsiness, dizziness, fatigue, vision, light or noise sensitivity and sleep disturbances. Cognitive symptoms include deficits in attention, concentration, memory, mental processing speed, and working memory or decision making. Behavioral symptoms include anxiety, depression, irritability, depression and aggression. The researchers went on to report that approximately 25 percent of the cases can have these symptoms persist.
Diagnosis and Treatment for MTBI
As a profession, chiropractic is a important part of the rehabilitation for the concussion population as the post-traumatic patient typically presents to the average chiropractic practice. As chiropractors (along with all healthcare providers), even if you mix the history with the above symptoms inclusive of neurological, behavioral and cognitive traits, you then have the direction or “triage road map” of the way to conclusively differentially diagnose your individual, including what tests to consider conducting in order to do so. The first line of testing is to consider imaging to rule out bleeding and ensure the patient does not require an immediate consultation. Treating blindly can place your patient in risk that is possible.
Imaging of the brain requires either MRI or CAT scans, MRI being the more sensitive, and in the absence of bleeding, the diagnosis is limited to MTBI or concussion (used interchangeably). More recently, diffusion tensor imaging (DTI) has been a tool available to picture mTBI victims that uses tissue water diffusion speeds to determine bleeding at a very small level giving demonstrable evidence to brain injury. As reported by Soares, Marques, Alves, and Sousa, (2013), DTI has several issues to overcome to certify accuracy including, but not limited to, tissue type, integrity, barriers and quantitative diffusion rates that are required to infer molecular diffusion prices. DTI is a model based upon assumption with a outlook as a tool.
Historically, MTBI was exclusively diagnosed by an omission of advanced imaging findings and the presence and persistence of the neurology, cognitive and behavioral signs and symptoms. Today, brain-derived neurotrophic factors (BDNF) offer responses about carpal brain pathology that is both conclusive and reproducible. Based on Korley et al. (2015), brain-derived neurotrophic factors is a secreted autocrine (compound hormone or messenger in blood) which promotes the development, maintenance, survival, differentiation and regeneration of neurons. BDNF also is important for synaptic plasticity (strengthening of synapses over time) and memory processing. Germane to MTBI and concussion, BDNF has been implicated in decreasing brain injury, with elevations and restoring traumatic brain injury.
Korley went on to report that BDNF levels were the highest in the normal group with lower values in mTBI and even lower in traumatic brain injury (TBI) subjects. In addition BDNF values were associated with incomplete recovery of patients that were MTBI compared to moderate or severe TBI patients. Because of this, it has been ascertained that BDNF has for identifying associated sequelae at 6 23, a prognostic value.
Korley stated that BDNF is the most abundantly secreted brain neurotrophin and as a secreted protein and can be readily measured using well-established immune-assay methods, identifying it as a non-necrosis brain injury biomarker. This distinguishes BDNF from other biomarkers which are components of neurons and myelin based proteins among other structures. In order for structural fibers to be found in high abundance in circulation, adequate cellular necrosis and damage to the blood barrier membrane must be observed, however BDNF does not require cellular damage or necrosis to be observed in circulation enabling DDNF to be more plentiful in flow than structural proteins.
Following a traumatic brain event, BDNF supports synaptic reorganization and recovery during the brain circuitry “reconnection” phase. Therefore, a better prognosis is indicated by lowered values. In patients with a co-morbidity of BDNF of anxiety, depressive disorders and schizophrenia BDNF values on the day of injury predispose this population to incomplete recovery as a risk element. Korley et al.. Concluded that serum BDNF discriminates between MTBI and TBI cases. Also, diminished BDNF values are associated with recovery in identifying and useful symptoms 6-months post-trauma.
Conclusion
Simply put, a blood test could assist providers in concluding the existence and/or severity of traumatic brain injury or mild traumatic brain injury. An early diagnosis is afforded by the results so you can devise a treatment plan inclusive of changing activities of everyday living to prevent additional damage and optimize the repair procedure with minimizing further chemical, physical or emotional stressors.
Based upon interviews with leading neurologists and neurosurgeons who understand and have first-hand expertise of both receiving chiropractic care and handling and treating MTBI patients, it is strongly recommended that until the signs and symptoms of the neurologic, cognitive and behavioral abate that high-velocity rotational cervical adjustments be avoided to enable the brain to “repair and rewire” the connections without additional possibilities of and Coup/ Contrecoup energy to the mind. This is a recommendation which we agree while recognizing that chiropractic care should not be avoided adapted to allow the brain to heal.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
References:
1. Hartvigsen, J., Boyle, E., Cassidy, J. D., & Carroll, L. J. (2014). Mild traumatic brain injury after motor vehicle collision: What are the symptoms and who treats them? A population-based 1-year inception cohort study. Archives of Physical Medicine and Rehabilitation, 95(Suppl. 3), S286-S294.
2. Jeter, C. B., Hergenroeder, G. W., Hylin, M. J., Redell, J. B., Moore, A. N., & Dash, P. K. (2013). Biomarkers for the diagnosis and prognosis of mild traumatic brain injury/concussion. Journal of Neurotrauma, 30(8), 657-670.
3. British Journal of Sports Medicine. (2016). Sport concussion assessment tool 2. Retrieved from http://bjsm.bmj.com/content/43/Suppl_1/i85.full.pdf
4. Soares, J. M., Marques, P., Alves, V., & Sousa, N. (2013). A hitchhiker�s guide to diffusion tensor imaging. Frontiers in Neuroscience, 7(31), 1-14.
5. Korley, F. K., Diaz-Arrastia, R., Wu, A. H. B., Yue, J. K., Manley, G. T., Sair, H. I., Van Eyk, J., Everett, A. D., Okonkwo, D. O., Valadka, A. B., Gordon, W. A., Maas, A. I., Mukherjee, P., Yuh, E. L., Lingsma, H. F., Puccio, A. M., & Schnyer, D. M., (2015). Circulating brain-derived neurotrophic factor has diagnostic and prognostic value in traumatic brain injury. Journal of Neurotrauma, 32, 1-11.
Additional Topics: Weakened Ligaments After Whiplash
Whiplash is a commonly reported injury after an individual has been involved in an automobile accident. During an auto accident, the sheer force of the impact often causes the head and neck of the victim to jerk abruptly, back-and-forth, causing damage to the complex structures surrounding the cervical spine. Chiropractic care is a safe and effective, alternative treatment option utilized to help decrease the symptoms of whiplash.
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So as to advance through the six clarified stages, the athlete may undergo extensive physiotherapy, focusing on hip range of movement exercises, manual therapy and trigger point releases, active stretching, potentially deloaded activities like hydrotherapy or Alta G walking/ running and strong hip rotator and gluteal strengthening exercises. Much of this will be ‘controlled’ and led by the wishes of the surgeon as they will provide the framework on if and what happens concerning loading.
Hip Muscle Control
Summary
In this phase it’s anticipated that the athlete will remain relatively quiet for 2-3 weeks post surgery. This allows for full tissue recovery to happen, including scar tissue maturation. The athlete is allowed to completely mobilize in full weight-bearing; however care needs to be taken using any flexion and rotation motions and no lifting will be allowed.
Early Loading & Foundation
The primary feature of this phase is that the athlete can start early and low-load strength exercises focusing on muscle activation in a neutral spine position, along with a progressive selection of motion program to improve lumbar spine flexion, extension and rotation. In this stage that the physiotherapist will guide the athlete through safe and gentle stretches to your hip quadrant muscles like the hip flexors, gluteals, hamstrings and adductors. The athlete also lasts gentle neuro-mobilization exercises to advance the freedom of the sciatic nerve — an issue in this condition as neurological tethering is a chance as a result of scar tissue formation caused by the surgical procedure.
Progressive Loading
In this phase the athlete continues with a variety of movement progression along with the physiotherapist progresses manual therapy to the pelvis and lumbar spine. Neuro-mobilization techniques can also be progressed. The significant change in this phase is that the progression of load on many of the strength and muscle control exercises.�
Load Accumulation
This is the stage where the athlete begins to advance the load in strength-based exercises. Resistance is used in the form of barbell load and band resistance. Three exceptional exercises performed here are the ‘kneeling hip thruster’, ‘deadbug antirotation press’ and also the ‘quadruped walkout’ (Figures 6-8 — explained in detail in the online database of exercises).
The athlete also begins running drills at this phase and it might be expected that as well as building running Amount, the athlete should progress over four weeks to close to full sprint speeds. This is also the stage whereby they would initiate mild to moderate sports special skills drills. Another characteristic of this stage is that the athlete starts the ‘Sorensen test’ exercise (Figure 9) and it will be expected that they can maintain the position for no less than 90 seconds before advancing to the next phase.
