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Guest Blog NMES: Case Study (Part 2)

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Guest Blog: Rich Griffin

Richard has been kind enough to share this case study with us. Be sure to check out his valuable tweets through twitter @Fitness_Griffin. Join in the discussion? What are your thoughts? Do you have any experience to share yourself? Click here for the forum..

Objective:  In gait the patient walks in an excessive supinated position throughout the gait cycle, on passive range of motion there is 10 degrees of dorsiflexion.

There is a 1.5 size difference in footwear common with talipes and signs of gastrocnemius/soleus wastage nmesanother symptom of talipes.  On encouraged eversion the patient could move the foot into a corrected position however in walking, fatigue or lack of innovation of peroneals was demonstrated immediately.  The overall aim at such a young age and this stage was to stimulate and encourage active firing of peroneals in function.

In a CPD session in 2011 a presentation was delivered on the use of Compex Neuromuscular stimulators (NEMS) in sports rehabilitation facility I was employed in.  Clinical reasoning would suggest this type of machine would benefit the patient with his rehabilitation. Contact was made with a former colleague in a clinic were the patient could be taken, this would allow a trial on the Compex NMES machine to see if it was a valid option.

Two small metal rods were placed in the approx area of peroneal’s origin and insertion then a electrical charge was sent through this area, immediately the foot moved into eversion and the peroneal muscle group carried out there functional action.

The electrode pads were then placed in the same area and the Compex NMES machine was used on a strength cycle set to a signal which would innovate the peroneals, the patient at such a young age was upset initially so distractions were used, once settled I then got the patient to walk around the clinic, the machine enabled the patient to produce small but definite improvements to the foot position during gait.

For 8/52 the NMES machine was used on the patient for 20 minutes each evening prior to putting boots and bar on before bed, increases in stimulation was made as the patient adjusted to the use of the NMES machine.  Often walking around the house with it on or favourite films/cartoons were used to distract the patient.

The surgeon reviewed the patient after using the NMES machine for 8 weeks and stated that he felt there was an improvement in the patients gait and active eversion. This appointment was purely coincidental regarding time frame of use of NMES machine.  Due to this a delay was put on surgery, the patient has another review in 3/12.

Only time will tell if further surgery will be required but at this stage the NMES protocol is assisting in the rehabilitation of talipes for this young patient.

Point of interest

In 19525 it was suggested the best age for tibialis transfer was between 3 and 6 years, as after the age of six years secondary changes in the soft tissues and bones prevent adequate correction.  In a follow up paper of patients with clubfeet treated with extensive soft tissue release, a correlation was found between the extent of the soft-tissue release and the degree of functional impairment. Repeated soft tissue releases can result in a stiff, painful and arthritic foot and significantly hinder quality of life.7

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References

  1. Miedzybrodzka Z, Congenital talipes equinovarus (clubfoot): a disorder of the foot but not the hand. 2003
  2. http://www.patient.co.uk/health/Talipes-Equinovarus-(Club-Foot).htm
  3. Morcuende J, Lori A, At El, Radical Reduction in the rate of extensive corrective surgery for clubfoot using the ponseti method. Pediatrics Vol.113. 2004.
  4. Dobbs M, Nunley R, Schoenecker M, Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. 2006.
  5. Critchley J, Taylor R, Transfer of the tibialis anterior tendon for relapsed club-foot. 1952.
  6. Haasbeek JF, Wright IG, A comparision of the long term results of posterior and comprehensive release in the treatment of club foot. J Pediatr Orthop, 17: 29-35. 1997
  7. Templeton P, Flowers M, Et Al, Factors predicting the outcome of primary clubfoot surgery. 2005.
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Pain and the Brain

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How you body produces its own pain medication!

Understanding pain read more….

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Lateral Epicondylalgia

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KEY POINTS

  • We should be using accurate terminology ‘tendonosis’ or tendinopathy
  • Few inflammatory cells in chronic tennis elbow ‘tendinitis’ is therefore NOT an accurate description. (Khan et al, 2002)
  • Choose treatments with fewer side effects where possible.
  • Choose treatments that target what we know about the disease process ie aim to improve tendon integrity through graded loading.
  • Limited evidence for use of topical NSAIDs (Hyldahl et al, 2010)
  • While corticosteroid injection has short term benefits, in the long term it is more likely to cause harm   (Dogramaci et al, 2009)

Find out more here ….

Do you know some good evidence that you want to share or disagree with the points above? Have your say here….

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Hamstring Strain: Prevention & Rehabilitation (Part 5)

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Guest blog by Paul Head

Paul holds a BSc Sports Therapy degree from University of Central Lancashire (UCLAN) and is a pre reg physiotherapy student. He received first Class Honours Classification (78% average) and  an award for Academic Excellence in the field of sports therapy / physiotherapy from DJO UK. Find out more about Paul here…

Physiowizz will continue to support and encourage CPD of students. If you feel your article is of good quality, evidence based and would be suitable for our public blog please send it to nicole@physiowizz.co.uk to help increase promotion of your personal blog.  Please include the following statement “I am happy for my blog to be reproduced on a physiotherapy learning site for educational purposes.”

‘The Glider’. The exercise is started from a position with upright trunk, one hand holding on to a support and legs slightly split. All the body weight should be on the heel of the injured leg with approximately 10–20° flexion in the knee. The motion is started by gliding backward on the other leg and stopped before pain is reached. The movement back to the starting position should be performed by the help of both arms, not using the injured leg. Once every third day, three sets with four repetitions       slider 3

‘The Glider’. The exercise is started from a position with
upright trunk, one hand holding on to a support and legs slightly split.
All the body weight should be on the heel of the injured leg
with approximately 10–20° flexion in the knee. The motion is started
by gliding backward on the other leg and stopped before pain is reached. The movement back to the starting position should be performed by the help of both arms, not using the
injured leg. Once every third day, three sets
with four repetitions

Hamstring curl on swiss ball  hamstring curl 2

Hamstring curl on swiss ball

Single leg glute bridge bridge 2

 Single leg glute bridge

 

bridge towel 2Eccentric knee extensions

Eccentric knee extensions

Brughelli and Cronin (2007) suggest alternative eccentric exercises to the Nordic hamstring exercise due it being an open chain exercise that is bilateral which could cause one leg to take more the strain than the other leading to asymmetries. Also that it is a single joint exercise whereas the hamstrings are bi-articulate that is stretched over the hip flexion and knee extension. It would be more specific to perform multi-joint eccentric exercises that involve more muscle groups working together. Brughelli et al (2009) showed the functional eccentric exercises below to be effective in returning an Australian rules football player who had three previous muscle strain injuries confirmed by MRI (grade II and III muscle strain injuries) to his right hamstring (long head of the biceps femoris) over the previous four years. Playing every game in the subsequent season injury free and the exercises also altered the optimum angle of peak torque of the knee flexors and extensors.

Malliaropoulos et al (2012) also recommend exercises that also incorporate both hip and knee concentric and eccentric actions due to the bi articular nature of the hamstring muscle group. Also active lengthening of the hamstring muscles may occur both in the late swing phase (open kinetic chain) and during late stance phase (closed kinetic chain) of sprinting. This suggests that open and closed kinetic chain exercise should be included in prevention programmes. The hamstrings lengthen under load from 45% to 90% of the gait cycle (swing) absorbing imposed mechanical energy, and then shorten under load from late swing through stance to reuse this energy. Therefore, they strongly advise to use of Stretch Shorten Cycle exercises and combine them with isolated eccentric exercises in open or closed kinetic chain in order to replicate hamstring function.

Eccentric Backward Box Drops   Eccentric loaded lunge drops: The trainee rises up onto his or her toes while taking a lunge stance, with or without resistance. He or she then quickly drops onto the ground with his or her feet landing flat and balanced. Then he or she will resist the downward forces into a deep lunge position while maintaining good posture

Single leg RDL with alternating toe touches

 Other exercises include double and single leg dead lifts and Romanian dead lifts, Eccentric split stance zerchers and eccentric leg curls.
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Hamstring Strain: Prevention & Rehabilitation (Part 4)

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Guest blog by Paul Head

Paul holds a BSc Sports Therapy degree from University of Central Lancashire (UCLAN) and is a pre reg physiotherapy student. He received first Class Honours Classification (78% average) and  an award for Academic Excellence in the field of sports therapy / physiotherapy from DJO UK. Find out more about Paul here…

Physiowizz will continue to support and encourage CPD of students. If you feel your article is of good quality, evidence based and would be suitable for our public blog please send it to nicole@physiowizz.co.uk to help increase promotion of your personal blog.  Please include the following statement “I am happy for my blog to be reproduced on a physiotherapy learning site for educational purposes.”

Hamstring Strain Rehabilitation

Soft Tissue Mobilisations

Hunter (2004; 2007) soft tissue mobilisations around the injured lesion and transverse glides across the healing tissue during passive and active movements of the muscle to promote collagen alignment and promote pliability of scar tissue formation. Rushdon and Spencer (2011) found that hamstring muscle extensibility and ROM improved greater when a static end range transverse medial glide technique was applied to the biceps femoris muscle for a period of 30 seconds along with a physiological stretch. When compared to a physiological stretch alone. A group of expert clinicians gathered together (Orchard et al, 2008) about their clinical expertise in dealing with muscle strain injuries. They agreed upon ice being very beneficial and early mobilising of the soft tissue and active movements within pain be commenced even <24 hours post injury. Ice applied for 20 mins after every rehabilitation session is also recommended.

Exercise 

In recent studies that have compared different rehabilitation protocols after acute hamstring strain injuries which showed good results in both time to return to play and re injury rates. Askling et al (2013) performed a study that compared two different rehabilitation protocols for acute hamstring strains. They used 75 male and female football players that had clinical signs of an acute hamstring injury. They separated the subjects into two different protocols. These were a L protocol which included exercises to put load onto the hamstrings during maximal dynamic lengthening. The exercises involved movements of the hip and knee with eccentric muscle actions. The C protocol consisted of conventional concentric and stretching rehabilitation exercises. Both protocols started 5 days post the injury with regular follow ups and progressions in load and speed of the exercises. Their results showed that the L protocol had a significantly shorter (28 days) return to play when compared with the C protocol (51 days). Also there was only one re injury between both groups which happened to a subject from the C protocol.

Slider et al (2013) also compared two different but heavily supported rehab programmes for hamstring strains. They separated 25 subjects who had a hamstring injury within 10 days and involved in sports, into a progressive agility and trunk stabilization (PATS) group and progressive running and eccentric strengthening (PRES) groups. They found both rehab protocols to be efficient in return to sport times and both had low re injury rates a year post return to sport participation with 2 in PATS group and 2 in the PRES group.

Sherry and Best (2004) also compared two different rehabilitation protocols. They had 24 athletes separated into: static stretching, isolated progressive hamstring resistance exercise and icing (STST) and progressive agility and trunk stabilization exercises and icing (PATS) groups. Their interventions lasted for 2 months on return to sport, with 3 sessions a week. The STST group had a 54% re injury rate whereas the PATS group had no re injuries within 16 days of returning to sport. With the STST group also showing a significant increase in re injury rates a year post returning to sport with 70% compared to 7.7% in the PATS group.

The exercises that were used in the most beneficial rehabilitation protocols were:

‘The Extender’. Stabilise the thigh of the injured leg with the hip flexed approximately 90° and then perform slow knee extensions to a point just before pain is felt. Twice every day, three sets with 12 repetitionsThe extender 2

The Extender’. Stabilise the thigh of the injured leg with the hip flexed approximately 90° and then perform slow knee extensions to a point just before pain is felt. Twice every day, three sets with 12

‘The Diver’. The exercise should be performed as a simulated dive, that is, as a hip flexion (from an upright trunk position) of the injured, standing leg and simultaneous stretching of the arms forward and attempting maximal hip extension of the lifted leg while keeping the pelvis horizontal. Once every other day, three sets with six repetitions.    ‘The Diver’. The exercise should be performed as a simulated dive, that is, as a hip flexion (from an upright trunk position) of the injured, standing leg and simultaneous stretching of the arms forward and attempting maximal hip extension of the lifted leg while keeping the pelvis horizontal. Once every other day, three sets with six repetitions.

‘The Diver’. The exercise should be performed as a
simulated dive, that is, as a hip flexion (from an upright trunk position)
of the injured, standing leg and simultaneous stretching of the arms
forward and attempting maximal hip extension of the lifted leg while
keeping the pelvis horizontal. Once every other day, three sets with six repetitions.

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Hamstring Strain: Prevention & Rehabilitation (Part 3)

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Guest blog by Paul Head

Paul holds a BSc Sports Therapy degree from University of Central Lancashire (UCLAN) and is a pre reg physiotherapy student. He received first Class Honours Classification (78% average) and  an award for Academic Excellence in the field of sports therapy / physiotherapy from DJO UK. Find out more about Paul here…

Physiowizz will continue to support and encourage CPD of students. If you feel your article is of good quality, evidence based and would be suitable for our public blog please send it to nicole@physiowizz.co.uk to help increase promotion of your personal blog.  Please include the following statement “I am happy for my blog to be reproduced on a physiotherapy learning site for educational purposes.”

Hamstring Strain Prevention

Nordic Hamstring exercise

In a recent study Peterson et al, (2011) added the Nordic hamstring exercise to conventional pre season soccer exercise programs and showed it to be beneficial in reducing injury rates in soccer. The Nordic hamstring exercise is a partner exercise. The athlete starts in a kneeling position, with his torso from the knees upward held rigid and straight. A training partner applies pressure to the athlete’s heels/lower legs to ensure that the feet stay in contact with the ground throughout the movement. The athlete then attempts to resist a forward-falling motion using his hamstring muscles to maximize loading in the eccentric phase. The participants were asked to brake the forward fall for as long as possible using the hamstrings. The athletes were asked to use their hands to buffer the fall, let the chest touch the surface, and immediately get back to the starting position by pushing with their hands to minimize loading in the concentric phase (Mjolsnes et al, 2004).

Nordic Hamstring Exercise Start     Nordic hamstring exercise End

Nordic Hamstring Exercise Start and  end positions.

Peterson et al (2011) used 942 soccer players who performed the Nordic hamstring exercise in a progressive 10 week program during pre season that was added to their conventional training program. They compared injury rates between players that performed the Nordic hamstring progressive exercise program (table below) and those that did not.

Week

Sessions

Sets

Reps

1

1

2

5

2

2

2

6

3

3

3

6-8

4

3

3

8-10

5-10

3

3

12-10-8

They found that injury rates were reduced by 85% when compared to the control group who did not perform the eccentric protocol. The 10 week protocol was made progressive to reduce the negative effect of delayed onset of muscle soreness (DOMS). This study showed that adding in the Nordic hamstring exercise alone to conventional pre season training programs reduced hamstring injury rates.

The most consistently thought of explanation for the beneficial role of eccentric exercises for the hamstring muscle group in preventing injury and re injury is that they cause a shift in the optimum angle for eccentric torque generation, to longer hamstring muscle lengths which can protect against hamstring injuries and re-injuries. Peak muscle-tendinous force and strain for the hamstring muscle group occurs during the terminal swing phase, just before ground contact, and it is suggested that it is in this period of the stride cycle that the bi-articular hamstrings are at the greatest risk of injury. It is therefore suggested that eccentric muscle strength training should be performed at longer muscle-tendinous lengths, mimicking movements and muscle length occurring at both the knee and the hip (Thorborg, 2012).

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Hamstring Strain: Prevention & Rehabilitation (Part 2)

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Guest blog by Paul Head

Paul holds a BSc Sports Therapy degree from University of Central Lancashire (UCLAN) and is a pre reg physiotherapy student. He received first Class Honours Classification (78% average) and  an award for Academic Excellence in the field of sports therapy / physiotherapy from DJO UK. Find out more about Paul here…

Physiowizz will continue to support and encourage CPD of students. If you feel your article is of good quality, evidence based and would be suitable for our public blog please send it to nicole@physiowizz.co.uk to help increase promotion of your personal blog.  Please include the following statement “I am happy for my blog to be reproduced on a physiotherapy learning site for educational purposes.”


Assessment

Subjective

They could feel a tear or a popping sensation at the back of their leg during high speed running, sprinting, change of direction, deceleration or kicking, overstretching activity. Sudden onset with pain and swelling on the posterior thigh.

Objective

Walking gait, functional tests

Clear joints above and below: Lumbar spine with active movements and passive overpressure if active is pain free. Pelvis and Ankle with active and passive range of motion

Active Range of Motion

Prone knee flexion; hip extension with the leg extended, will be painful, reduced strength

Straight leg raise (SLR); hip flexion with knee extension with internal and external rotation of the tibia, will show reduced ROM and pain

Passive Range of Motion

SLR with ankle in plantarflexion to limit neural involvement, will be painful, reduced ROM

Hip flexion with knee extension and internal / external tibial rotation

Manual Muscle Tests (MMT)

Knee flexion at 15 and 90 degrees of flexion with internal and external rotation of the tibia to help differentiate what muscle is injured

Hip extension with knee extended, could show reduced strength and pain

Palpation from ischial tuberosity down the muscle, most pain usually felt up to the musculotendinous junction and mid belly of the muscle.

Neurodynamics

This concept acknowledges the role that altered neural motion and physiology may have in the production of soft tissue dysfunction. During human motion the nervous system moves against adjacent tissue and is subjected to compressive and tensile forces. An alteration in the ability of the neural system to tolerate these forces has been suggested as a contributing factor in musculoskeletal dysfunction.

SLR

The patient lies supine and the clinician passively raises the patient’s leg, keeping the patient’s knee in extension. At the point of slight discomfort, the clinician adds in sensitising manoeuvres that further increase the mechanical and physiological stress on the neural tissue but which, theoretically, do not change the stress in the hamstring tissue.

These are: cervical flexion, internal rotation of the hip and ankle dorsiflexion.

Slump test

The patient sits on the edge of the couch. The clinician asks the patient to slump their spine whilst keeping their head up and looking forwards. The clinician then passively extends the patient’s knee to the point of mild discomfort. The clinician adds in sensitising manoeuvres that further increase the stress on the neural tissue but these are: cervical flexion, internal rotation of the hip and ankle dorsiflexion.

These two neurodynamic tests are important in trying to resolve the issue of whether a patient’s posterior thigh pain/hamstring pain is hamstring or neural in origin.

(Hunter and Speed, 2007)

Differential Diagnosis

Posterior thigh pain from sciatic nerve damage

Piriformis syndrome causing radicular posterior thigh pain

SIJ dysfunction

Adductor strain; due to adductor magnus having a hamstring portion that shares the same origin at the ischial tuberosity and nerve supply from the tibial nerve.

Isokinetic Testing can be helpful in quantifying reductions in strength and differences in strength between injured and non injured hamstrings and eccentric hamstring / quadriceps ratio

MRI and Diagnostic Ultrasound to help determine size of lesions and whether full healing has occurred prior to return to play.

Hamstring Strain Classification

According to the Munich consensus muscle strains can be categorized into functional and structural strains (Mueller-Wohlfahrt et al. 2013). Functional strains show no physical signs of muscle fibre damage on ultrasound or MRI scans but present with increased hamstring tone on palpation and the person reporting a feeling of tightness in the posterior thigh. This type of injury normally resolves in a week with treatment consisting of methods to decrease hypertonicity, decrease swelling and increase function. On the other hand structural strains show muscle fibre damage on MRI and ultrasound, pain on palpation and take longer to resolve.

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Hamstring Strain: Prevention & Rehabilitation (Part 1)

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Guest blog by Paul Head

Paul holds a BSc Sports Therapy degree from University of Central Lancashire (UCLAN) and is a pre reg physiotherapy student. He received first Class Honours Classification (78% average) and  an award for Academic Excellence in the field of sports therapy / physiotherapy from DJO UK. Find out more about Paul here…

Physiowizz will continue to support and encourage CPD of students. If you feel your article is of good quality, evidence based and would be suitable for our public blog please send it to nicole@physiowizz.co.uk to help increase promotion of your personal blog.  Please include the following statement “I am happy for my blog to be reproduced on a physiotherapy learning site for educational purposes.”

Hamstring strain injuries comprise a substantial percentage of acute musculoskeletal injuries incurred during sporting activities. They are the most prevalent muscle injuries reported in sport. Hamstring injuries account for between 6 and 29% of all injuries reported in Australian Rules football, rugby union, soccer, basketball, cricket and track sprinters (Mendiguchia and Brughelli, 2010). Participants in athletics, football and rugby are especially prone to this injury given the sprinting demands of these sports, while dancers have a similar susceptibility due, in part, to the extreme stretch incurred by the hamstring muscles.

Hamstring strain re injury rates have been shown to be 12-30% (Mendiguchia and Brughelli, 2010). With some of world’s most high profile sportsmen including Lionel Messi, LeBron James, Darren Clarke and Ashley Cole recently being sidelined due to hamstring injuries it is still a major problem today. This post will aim to go through how hamstring strains occur and hamstring exercises to improve prevention and rehabilitation. Part 1 goes through the anatomy, mechanism and assessment of hamstring strain injuries. Part 2 goes through the best evidence based exercises to prevent and rehabilitate hamstring strain injuries.

Anatomy

[Accessed from www.morphopedics.wikidot.com]

 

The hamstring muscle group consists of the semimembranosus, semitendinosus and bicep femoris muscles. All three muscles originate from the ischial tuberosity apart from the short head of bicep femoris which originates from the linea aspera and lateral supercondylar ridge of the femur. The semimembranosus inserts onto the medial condyle of the tibia. The semitendinosus inserts onto the superior medial surface of the tibia and the oblique popliteal ligament and both heads of the bicep femoris muscle insert onto the head of fibular. All 3 muscles are innervated by the tibial nerve with the short head of the bicep femoris being innervated by the common peroneal nerve. The hamstrings have a fascial connection to the peroneus brevis muscle linking to actions at the foot and the ankle, and the sacrotuberous ligament linking it with the pelvis and thoracolumbar fascia (Hoskins and Pollard, 2005).

[Accessed from www.morphopedics.wikidot.com]

Mechanism of Injury

The hamstrings can be injured by two main mechanisms, a sprinting type injury, that occurs at high-speed running and/or acceleration or by a stretching type injury that occurs during movements with large joint stretch moments that include; high kicking, split positions and glide tackling. The late swing phase of running is when the hamstrings are most prone to injury during. Yu et al. (2005) suggested that hamstring muscles were at risk from a strain injury during the late stance phase as well as during the late swing phase. However, hamstrings may have higher risk for strain injury during the late swing phase than during the late stance phase because the lengths of the hamstring muscles are significantly longer during the late swing phase than during the late stance phase.

The Bicep femoris muscle is the most commonly injured of the three hamstring muscles. It has two different nerve supplies and it reaches the greatest length and also greatest increase in length when eccentrically decelerating the anterior displacement of the lower leg during high speed running. It is the most commonly injured muscle in sprinting type mechanisms which is sometimes associated with a semitendinosus tear. The semimembranosus is the most commonly affected muscle in over stretching type mechanism hamstring strains.

Predisposing Factors

In a recent literature review it was found that the most significant and consistent predisposing factors for getting a hamstring strain were: age, weight and previous hamstring injury. With more research needed to identify other predisposing factors including: quadriceps peak torque, hamstring flexibility, weight, hip flexor flexibility, ankle dorsiflexion ROM, hamstring peak torque, previous sacroiliac joint dysfunction and lumbar spine injury to determine whether they correlate fully with hamstring strain injuries (Freckleton and Pizzari, 2010).

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Hamstring Strain: Prevention & Rehabilitation (Part 6)

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Guest blog by Paul Head

Paul holds a BSc Sports Therapy degree from University of Central Lancashire (UCLAN) and is a pre reg physiotherapy student. He received first Class Honours Classification (78% average) and  an award for Academic Excellence in the field of sports therapy / physiotherapy from DJO UK. Find out more about Paul here…

Physiowizz will continue to support and encourage CPD of students. If you feel your article is of good quality, evidence based and would be suitable for our public blog please send it to nicole@physiowizz.co.uk to help increase promotion of your personal blog.  Please include the following statement “I am happy for my blog to be reproduced on a physiotherapy learning site for educational purposes.”

Stretching

The results of intervention studies (Arnason et al., 2008; Askline et al, 2013; Sherry and Best, 2004) and one randomised controlled trial (van Mechelen et al., 1993) question whether flexibility reduces hamstring injuries. A non-randomised intervention involving contract-relax hamstring stretches in elite Scandinavian soccer teams failed to reduce injury rates which were statistically indistinguishable from those of teams that declined to follow the program (Arnason et al., 2008). In a randomised comparison of two rehabilitation programs, Sherry and Best (2004) compared a progressive agility and trunk stabilisation approach to one that involved isolated strengthening and stretching of injured muscles. The strengthening and stretching was particularly ineffective as it resulted in significantly more injuries in the 1 year follow-up period than the alternative program. In Askling et al (2013) study they found that there C protocol which included contract relax stretching showed increased re injury rates when compared to their L protocol that involved no static stretching.

However in Malliaropoulos et al (2004) study they investigated the effect of the stretching component of rehabilitation in 80 athletes who had sustained acute hamstring injury. Their study compared two rehabilitation programmes in which the only difference was the number of stretches performed. Each stretching session consisted of a static stretch to mild discomfort applied to the hamstrings for 30 seconds and repeated four times. One of the groups had one session per day while the other group had four stretching sessions per day. The results showed that the group that performed four stretching sessions per day regained their range of motion more quickly and had a shorter rehabilitation period, with both differences being statistically significant.

Castellote-Caballero et al (2012) showed that a neural mobilization slider technique on the sciatic nerve was effective in significantly improving passive SLR range of motion after only a week which included 3 sessions, in 14 football players. The subjects sat with their trunk in thoracic flexion (slump) and while maintaining that posture, they performed alternating movements of knee extension/ankle dorsiflexion with cervical extension, and knee flexion/ankle plantar flexion with cervical flexion. Subjects performed these active movements for approximately 60 s and repeated them 5 times.  Neurodynamic slider technique could perhaps be more effective at reducing injury rates than static stretching due to 16% of hamstring injuries showing no signs of muscle damage on MRI (Mendiguchia et al, 2012).

Return to Play

With signs of damage on MRI still being shown after full rehabilitation programs and no signs of symptoms on clinical examination it seems important to utilize progressive running sessions into rehab to assess how the hamstrings are functioning and also whether people are able to return to sport. Progressive running programs were utilized in Slider et al, (2013) study which is shown in the table below.

Level

Acceleration Distance (m)

Constant Speed 75% of Max (m)

Deceleration distance (m)

1

40

20

40

2

35

20

35

3

25

20

25

4

20

20

20

5

15

20

15

6

10

20

10

When the subjects were able to complete a level 3 times pain free they were progressed to the next level. This programme tests out the hamstrings when they are most vulnerable to injury during acceleration and deceleration in high speed running.

Another way of doing this could be to the subject run 90 metres with the first 30 m being acceleration, middle 30 m being constant speed and final 30 m to deceleration. The acceleration and deceleration distances can then be reduced and constant speed distance being increased keeping the exercise to 90m long to progress the exercise, this is utilized by THFC.

A test devised by Askling called the Askling H test involves performing a SLR with the knee kept in full extension and ballistic hip flexion is performed. If the subject showed signs of pain or lack of subjective confidence when performing the test it was positive. It was utilized in their 2013 study where if the test was positive rehab was continued for another 5 days. This could have contributed to their low re injury rates, which could suggest that this test should be utilized when determining whether a player is fully able to return to sport.

Conclusion

Hamstring strains are still very prevalent and a massive problem to people participating in sport. However in recent years promising research has been shown to be effective in reducing hamstring strain injury and re injury rates. It seems to suggest that the most effective rehabilitation and prevention protocols include eccentric training with trunk musculature training included instead of concentric and stretching training. In this piece I’ve included some of the exercises that were in the most successful protocols along with progressive running drills and a progressive nordic hamstring exercise protocol for the prevention of hamstring strains.  I hope you have enjoyed reading this and comments about your experiences with hamstring strains and rehab protocols would be very welcome. With thanks to Tim Campkin: @timcampkin89 for being my model in the pictures and Paul Starrs: @starrs89 for his input.

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Reference List

Arnason, A., Andersen, T.E., Holme, I., Engebretsen, L. and Bahr, R. 2008. Prevention of hamstring strains inelite soccer: an intervention study. Scand J Med Sci Sports, 18(1):40–8.

Askling, C.M., Tengvar, M. and Thorstensson, A. 2013. Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med, 00:1–8.

Brughelli, M. and Cronin, J. 2008. Preventing Hamstring Injuries in Sport. Strength and Conditioning Journal, 30 (1), 55-64.

Brughelli, M., Nosaka, K. and Cronin, J. Application of eccentric exercise on an Australian Rules football player with recurrent hamstring injuries. Physical Therapy in Sport10, 75–80.

Castellote-Caballero, Y., Valenza, M.C., Martín, L.M., Martos, I.C., Puentedura, E.J. and Fernández-de-las-Peñas, C. 2012. Effects of a neurodynamic sliding technique on hamstring flexibility in healthy male soccer players. A pilot study. Physical therapy in sport, 1 (7).

Malliaropoulos, N., Papalexandris, S. and Papalada, A. 2004. The role of stretching in rehabilitation of hamstring injuries: 80 athletes follow up. Medicine Science Sports and Exercise36:756-759.

Mjølsnes, R., Arnason, A. and Østhagen, T. 2004. A 10-week randomized trial comparing eccentric vs. concentric hamstring strength training in welltrained soccer players. Scand J Med Sci Sports, 14:311–17.

Mueller-Wohlfahrt, H.W., Haensel, L., Mithoefer, K., Ekstrand, J., English, B., McNally, S., Orchard, J., van Dijk, C.N., Kerkhoffs, G.M., Schamasch, P., Blottner, D., Swaerd, L., Goedhart, E. and Ueblacker, P. 2013. Terminology and classification of muscle injuries in sport: The munich consensus statement. Br J Sports Med,  47(6):342-50.

Petersen, J., Thorborg, K. and Nielsen, M.B. Preventive effect of eccentric training on acute hamstring injuries in men’s soccer: a cluster randomized controlled trial. Am J Sports Med39:2296–303.

Sherry, M.A. and Best, T.M. 2004. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J Orthop Sports Phys Ther34(3):116–25.

Slider, A., Sherry, M.A., Sanfilippo, J., Tuite, M.J., Hetzel, S.J. and Heiderscheit, B.C. 2013. Clinical and Morphological Changes Following 2 Rehabilitation Programs for Acute Hamstring Strain Injuries: A Randomized Clinical Trial.

Thorborg, K. 2012. Why hamstring eccentrics are hamstring essentials. Br J Sports Med46, 7.

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Total Knee Replacements: A little look at the research

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Total Knee Replacements: A little look at the research

 

Mobilisation

There is research to suggest that total knee arthroplasty improves health related quality of life in 90% of patients (NIH, 2003) however functional ability 1 year following surgery remains lower than that of an age matched healthy adult (Woodhouse et al, 1998).

Researchers found they had 18% slower walking speed51% slower stair-climbing speed, and deficits of nearly 40% in quadriceps strength at 1 year post TKR compared to controls (Woodhouse, 1998).

With the continuing cuts in the NHS it is important for all of us to back up our thoughts with evidence and educate people on our worth in not only improving quality of life and improving long term results of surgery but to educate people on the core values of physiotherapy in promoting health, self management and empowering those to take responsibility for their health.

 Fast facts

An interesting study by Bade et al (2011) investigated the use of a high intensity rehabilitation and its effects on functional outcomes.  Participants in the high intensity rehab followed a protocol and attended physio 2-3 x per week for 12 weeks. In total they attended 25 visits over the 12 weeks compared to 16 visits over 8 weeks in the control group.

The high-intensity rehabilitation program described in this cohort study demonstrated significantly greater short-term and long-term strength and functional performance increases compared to a lower intensity rehabilitation program (Bade et al, 2011). Major weaknesses of the study were its small sample size, lack of randomisation and blinding but it does offer a stepping stone for one to consider when treating these patients.

Got some evidence to add? Please post in our forum

Now I don’t know about you but in my local PCT some patients are not even offered post op physio?! With increased strain on the NHS it is important that we are educating patients on evidence which may help improve compliance with their home exercises ie.

“Research suggests that if you follow this program 3 times weekly under our guidance (be sure to give them a copy) you are likely to have improved long term function.”

It is also important that patients know that they can seek  additionally physio privately if  there is not suitable funding within the NHS. The age-old rivalry between private practice and NHS needs to be left behind so that we can work together to offer optimum patient care.

Here is a copy of the program used which is publically and freely available here

Figure 1.  (Bade et al, 2011)

Appendix

High-Intensity Rehabilitation Program

Phase 1 (Weeks 0–2)

  • Supine knee flexion (heel slides)
  • Short-arc knee extensions
  • Standing bilateral squats
  • Sidelying hip external rotation, with hips flexed to 45° and knees flexed to 90° (clams)
  • Sidelying hip adduction
  • Supine ankle plantar flexion and dorsiflexion (ankle pumps)

 

Progression:

  • When able to complete 2 × 8 repetitions without fatigue; NPRS at rest, <5/10; ROM, >15°–80°

Phase 2 (Weeks 0–4)

  • Seated single-leg knee extension*
  • Straight leg raise*
  • Standing hamstring curls*
  • Sidelying hip adduction*
  • Sidelying hip abduction*
  • Standing bilateral calf raises
  • Repeated sit-to-stand transfers
  • Marching or single-limb stance
  • Multidirectional stepping

 

Progression:

  • When able to complete 2 × 8 reps without fatigue; NPRS at rest, <5/10; ROM, >15°–90°

Phase 3 (Weeks 2–12)

  • Seated single-leg knee extension*
  • Seated single-leg knee flexion*
  • Single-leg press*
  • Single-leg calf press*
  • Standing hip extension, flexion, abduction, and adduction*
  • Step-ups, side step-ups, step-downs
  • Forward lunging
  • Single-limb stance progression (shoe to sock to foam, with eyes open, then with eyes closed)
  • Tilt board squats
  • Wall slides to 90° of knee flexion
  • Stability ball supine hip extension

 

Progression:

  • When able to complete 2 × 8 repetitions without fatigue; NPRS at rest, <3/10; ROM, >10°–100°

Phase 4 (Weeks 6–12)

  • Seated single-leg knee extension (eccentric)*
  • Seated single-leg knee flexion (eccentric)*
  • Single-leg press (eccentric)*
  • Single-leg calf press (eccentric)*
  • Standing hip extension, flexion, abduction, and adduction*
  • Step-ups, side step-ups, step-downs
  • Multidirectional lunging
  • Star excursion balance reaching
  • Wall slides with 5- to 10-second endurance holds at 90°
  • Stability ball supine combined hip extension with knee flexion
  • Agility exercises: side-shuffle, backward walking, and braiding
  • Single-limb stance progression

Read More: http://www.jospt.org/doi/full/10.2519/jospt.2011.3734#.UsgpLGRdVek

References

Bade MJ , Stevens-Lapsley JE . Early high-intensity rehabilitation following total knee arthroplasty improves outcomes . J Orthop Sports Phys Ther . 2011;41:932–941

Mizner RL, Petterson SC, Stevens JE, Vandenborne K, Snyder-Mackler L. Early quadriceps strength loss after total knee arthroplasty. The contributions of muscle atrophy and failure of voluntary muscle activation. J Bone Joint Surg Am. 2005;87:1047–1053.

National Institutes of Health. NIH Consensus Statement on total knee replacement. NIH Consens State Sci Statements. 2003;20:1–34.

Walsh M, Woodhouse LJ, Thomas SG, Finch E. Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects. Phys Ther. 1998:78:248–258.

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