#fourpinespt

Concussions are a form of traumatic brain injury. Specifically, they are known as a subset of a mild traumatic brain injury and have become more of a focus with prevention, education, and screening in the medical community. They have been identified as a major health concern due to high rates of occurrence and potential for long-term effects.

According to the CDC, there are an estimated 1.6 to 3.8 million mild traumatic brain injuries that occur annually. Concussions are not only sports-related as well, but can occur with motor vehicle accidents, falls, and military injuries for example. 

Concussions can present with a loss of consciousness OR without a loss of consciousness and as a result can go unrecognized due to variation in symptoms and presentation. Overall prevention is key and parents, players, and coaches should be able to recognize signs and symptoms, especially in the first 48 hours.

SIGNS AND SYMPTOMS

Symptoms of concussions can include dizziness, nausea, impaired memory, poor concentration, noise and light sensitivity, confusion, blurred and double vision, and “not feeling right.”

Signs that can be observed include memory loss, unsure where they are, behavior/personality changes, clumsy, slow, and unclear responses, and loss of consciousness.

RED FLAGS

Red flags or emergency indicators that we watch for include spinal fractures, cervical myelopathy, upper cervical spine ligamentous instability, and vertebral artery insufficiency. 

Battle Sign: Bruising behind the ear and at the mastoid process.

Raccoon eyes: Darkening and bruising around eyes.

Increasing number of symptoms

WHAT TO DO IF YOU SUSPECT A CONCUSSION

If there is a suspected concussion, the individual needs to be monitored for the first 48 hours for worsening of symptoms. NSAIDs should be avoided, and physical activity should be limited. Sleep is essential, and avoiding screen time is recommended as well. 

While there can be a lot of concern with concussions, most individuals have their symptoms resolved 7-14 days post-injury. The concern comes into play further when as many as 5% to 58% have persistent symptoms that linger and affect daily function. 

Recovery can vary quite greatly, be complex, and be influenced by multiple factors. It has been found that typically females, youth, and individuals with a history of migraines and ADHD may experience longer recovery. Also, individuals can be more susceptible to a longer recovery if there are injury-related factors such as loss of consciousness, amnesia, and delayed removal from sport. Overall, a clear characterization of risks that may cause poor recovery remains unclear and needs further study and research.

For individuals with ongoing and lingering symptoms, a physical therapist with expertise in this area can help guide a safe return to normal function and a specialized treatment plan based on the limitations of the individual, as well as work with your physician for optimal recovery.

TREATMENT

Some treatments may include self-management and education, specific exercises building up to sport and work-specific tasks, eye and vision tasks, and balance and coordination training. 

Blood Flow Restriction Training 

Blood flow restriction training, or BFR, is far from a new discovery, however, its use in rehabilitation over the last decade has really come into culmination. The concept of blood flow restriction was initially discovered in 1966 by Yoshiaki Sato in Japan after he injured his lower leg and was placed in a cast for 6 weeks. He spent that time sitting cross-legged, as is common in Japanese culture, and essentially restricted blood flow to his lower leg. When the cast was removed 6 weeks later, he surprisingly had no atrophy. Fast forward to the early 90’s, and clinical units for blood flow restriction training started to enter the market, however, it wasn’t until around 2012 that this intervention really took off. 

Blood flow restriction training creates a hypoxic environment in the muscle, meaning an environment that lacks oxygen. This causes cellular swelling, activates protein synthesis, causes intramuscular anabolic signaling, increases growth hormone, and increases muscle fiber recruitment.1,2 Through these mechanisms, blood flow restriction training can elicit muscular hypertrophy and strength by using light external loads of 20-30% repetition maximum (RM).3 This is fundamental for creating adaptions in a tissue that may be load compromised or recovering from injury. For this reason, BFR has really gained popularity in the rehabilitation settings where the goal is to improve overall muscle hypertrophy and strength, even when you are dealing with the healing soft tissues and joint complexes.3 

The ability of a muscle to create force is going to be dependent on the balance between motor unit recruitment and development of muscular fatigue, due to the lack of oxygen delivery to the muscles.6 When lacking oxygen and under fatigue, the force producing capacity of exercising skeletal muscles are slightly altered.6 When exercising with BFR, there is a greater decline in the maximal voluntary isometric muscle contraction (see as a decrease in force production) compared to lower pressures or no BFR intervention at all.7 Especially under isometric conditions, the maximum voluntary contraction EMG amplitude is greatly reduced (72.5% vs. 46.3% of maximum EMG activity).4 However, in order to maintain force output levels during BFR when under accelerated fatigue, motor units of high threshold excitability are recruited, therefore a hypertrophic stimulus would be provided to a greater proposition of the muscle fibers creating an increased level of myoelectric activity in resistant exercise with BFR.8 The use of BFR targets the recruitment of Type II fast twitch muscle fibers4, the same type of muscle fiber that is first to atrophy. Furthermore, the addition of BFR has been shown to increase the neuromuscular activation and MVC (maximal voluntary contraction) of targeted muscles 15 minutes after BFR was applied.4,5 

BFR is an excellent tool across a variety of conditions and populations. BFR is great for individuals who have suffered from atrophy or are unable to train with heavy loads. It can be an essential tool following surgery where you may be non-weight bearing for several weeks or months. BFR with low loads is a safe and effective tool we utilize at Four Pines for musculoskeletal rehabilitation. Additionally, it can be used to build muscle hypertrophy and create adaptations in those already training but need to get in a strength/hypertrophy session without overloading their joints with heavy weights. Our clinicians are trained to utilize blood flow restriction training to meet your needs, goals, and personal aspirations. 

References: 

1. Scott BR, Slattery KM, Sculley D V., Dascombe BJ. Hypoxia and resistance exercise: a comparison of localized and systemic methods. Sports Med. 2014;44(8):1037-1054. doi:10.1007/S40279-014-0177-7

2. Yasuda T, Loenneke JP, Thiebaud RS, Abe T. Effects of blood flow restricted low-intensity concentric or eccentric training on muscle size and strength. PLoS One. 2012;7(12). doi:10.1371/JOURNAL.PONE.0052843

3. Patel S, Amirhekmat A, Le R, Williams III RJ, Wang D. Osteochondral Allograft Transplantation in Professional Athletes: Rehabilitation and Return to Play. Int J Sports Phys Ther. 16:2021. doi:10.26603/001c.22085

4. Lauber B, König D, Gollhofer A, Centner C. Isometric blood flow restriction exercise: acute physiological and neuromuscular responses. doi:10.1186/s13102-021-00239-7

5. Nie J, Dankel SJ, Laurentino GC, et al. Blood Flow Restriction During Futsal Training Increases Muscle Activation and Strength. 2019. doi:10.3389/fphys.2019.00614

6. Hammer SM, Alexander AM, Didier KD, Barstow TJ. The Journal of Physiology C 2020 The Authors. The Journal of Physiology C 2020 The Physiological Society. J Physiol. 2020;598:4293-4306. doi:10.1113/JP279925

7. Head P, Waldron M, Theis N, David Patterson S. Acute Neuromuscular Electrical Stimulation (NMES) With Blood Flow Restriction: The Effect of Restriction Pressures. J Sport Rehabil. 2020;30(3):375-383. doi:10.1123/JSR.2019-0505

“Prostate? I have heard the term; my doctor has talked about it... but what exactly does it do?”

A prostate is a reproductive organ in people born as males. It works with the testicles and fluids from other glands to make up semen/ allow for ejaculation. It is also important for the urinary continence system by providing pressure on the urethra.

 "How do I know something is wrong with my prostate?" 

Symptoms include:

Urinary leakage

Urinary retention

Slowed stream

Nocturia (getting up more than 1 time/night to pee)

Erectile dysfunction

Enlarged prostate

Pelvic pain

Elevated PSA levels

"Why would my prostate cause urinary problems"

Great question! A quick anatomy overview, your urethra (the tube that allows pee to flow out from your body into the toilet/woods/your chosen place to relieve yourself) runs right through your prostate, so if it becomes enlarged, it can squeeze on that urethral tube and can cause all the symptoms above. (insert photo of anatomical prostate with urethra)

"I am getting my prostate removed . . . now what!?"

Once you and your doctor have determined that getting a prostatectomy is the right fit for you, head to Physical Therapy! Pelvic Floor physical therapists will help set your expectations, answer questions, and create goals (along with your Physician) pre and post-prostatectomy. Physical therapists will teach you how to utilize your pelvic floor muscles appropriately to lessen your experience with incontinence postoperatively . . . yes everyone has a pelvic floor! Your Pelvic Floor PT may also teach you how to manage your penile tissue to prevent fibrosis that may cause Peyronie’s disease (painful bend of the erected penis due to fibrous plaque). Your PT will assess the muscle strength of the hips/legs/and pelvic floor muscles and teach you the best ways to strengthen prior to surgery to lead to a quicker recovery post-prostatectomy. 

Have you heard of a “Kegel” and think it is only for the ladies? Guess again, Kegels are for all. 

Urinary leakage is common right after surgery, but we want to prevent leakage as soon as possible. That is where PT’s come in to show you the tips and tricks for getting you back to your normal, healthy self that does not have to wear pads to enjoy your everyday outdoor activities. 

Dr. Erin Dougherty, PT, DPT

Oh My Hammy! 

Dr. Norene Christensen, PT, DSc, OCS

At some point in our athletic endeavors, we have experienced a high hamstring strain (at the base of the butt) or mid muscle strain.   Hamstring injuries may occur after accumulated repetitive microscopic trauma or in response to a single event exceeding the limits of the muscle-tendon unit.  This means that we can have a low-level chronic pain due to ongoing decline in tissue integrity from poor mechanics or poor training (ie running) or we can have a one-time event that tears the muscle or ruptures the tendon (waterskiing accident).  In sporting events, a common mechanism of hamstring injury is with sudden sprinting or kicking.  In daily life a common mechanics of injury is slipping (on loose dirt or ice) or falling forward and trying to catch oneself.  Unfortunately, a history of previous hamstring injury increases your risk of another hamstring injury by 2.7 times.

For chronic “base of butt” or mid hamstring pain, it is important to rule out other possible causes such as adductor muscle injury, lumbar spine radiculopathy or proximal hamstring tendinopathy.  For acute high hamstring injuries x-rays may be necessary to rule out avulsion fracture of the ischial tuberosity (where the hamstrings attach to the pelvis) or an MRI to evaluate tendon rupture(s) and retraction.

To best care for yourself after a hamstring injury can be multifactorial and dependent upon the mechanism of injury.

For high velocity injuries which result from sudden sprinting, hard kicking, falling forward skiing (or water skiing) or slipping on ice that results in a significant amount of pain at the base of your buttock.  Do not stretch as you will want to be evaluated by your orthopedist to rule out avulsion fracture and or avulsion of the hamstring tendon(s) which may require in surgery.  If you avulse 2 or more tendons and they retract more than 2 cm from the bone, it is best to have this repaired sooner or later for best functional outcomes.  From there you will see your favorite physical therapist to begin the rehabilitation process to return you to sport or the activities you love to do.  This rehab process can take up to 6 months depending on your post-surgical outcomes, pain levels and activity levels.

For chronic high hamstring pain with running or other activities, you may need to work on different areas of your body as well as your hamstring.  You may need to address loss of mobility and flexibility in your spine, hips and legs which may contribute to your hamstrings overworking.  Addressing strength imbalances or dysfunctional motor patterns that have developed over the years may help take some of the strain off the hamstrings.  The body is a beautiful compensator and sometimes you just don’t realize that you may be weak in key stabilizing muscles.  Have your running mechanics assessed by a professional that will video tape you and work with you to change your mechanics to improve efficiency and reduce microtrauma to the area.  Our hamstrings are important pelvic and core stabilizers so utilizing exercises geared towards stabilization in functional patterns will help tie the hamstrings into your core.  Finally, will need to train eccentrically for tendon health but also for the function of the hamstring during running, sprinting, and kicking (Askling L-Protocol and more).

For return to running or return to your sport it is wise to implement different running or movement drills into your rehab.  Lower-level drills can be implemented immediately as long as they are pain-free with advanced drills being performed as pain reduces.

As with most injuries, stretching may be done with a sensation of “strain” not “pain”.  Hamstring pain will dictate whether you can progress your program to the next level.  Once you can walk without pain you may begin a graded running program.  There are many programs out there to follow but an example of a return to running protocol accounts for greater acceleration distances and gradual intensity increases at high percentage of maximal velocity over time.  These programs include walking, at 50% max velocity, 80% max velocity towards 100% while varying distances and may be progressed if pain-free.

At Four Pines Physical Therapy, we have PTs that are certified in running rehabilitation and will take the time to properly rehab you back into your sport utilizing appropriate therapeutic techniques, exercises, video assessments and more.  Our PTs will help you with your return to a running program or general fitness program that achieves your goals.  

Hamstring injuries are common in runners and other athletes as well as the general community due to chronic stress to the tissues or due to a sudden high-speed injury.  Whether you have surgery to reattach tendons that have torn off and retracted or want to address the nagging pain with activity, the therapists of Four Pines Physical Therapy will develop the most appropriate treatment plan for you.

Call us for a free 20-minute consultation for more information on how we can help you.

Example of HS

Standing HS stretch with leg on bench

Supine hip flexion HS stretch

By Kaysha Heck  

ACL tears are one of the most common knee injuries sustained while skiing. With the heavy snow, good skiing, and epic power days this year, I’m sure there was no shortage of knee injuries. While I hope everyone had a safe and healthy season, I know some individuals’ ski seasons ended in a less than ideal manner.

If you tore your ACL this year, sometime in January or February, you are likely sitting right about 3-4 months out of surgery. My guess is you are finally starting to feel better, your knee is getting stronger, and you are longing for the snow to melt. You are anxious to get back to biking, hiking, and running.

Can’t blame you there!

However, when returning to running after an ACL reconstruction there are several things to consider for a safe, effective, and successful progression back.

1. Time

As rehab professionals, we look to return someone to running at right about 16 weeks. Yes, graft type, prior surgery, and other factors do make a difference, but overall 16 weeks is about what you’re looking at. Why so long? It takes (at least) this amount of time for your knee joint to start to normalize, re-establish homeostasis, and build back up protective strength.

In fact, recent studies are showing that it takes 2 years for all healing markers to return to normal and homeostasis to fully be re-established in the knee, but that’s another discussion.

Now, not to get too medical, there are some things to consider from a tissue healing standpoint before beginning a running program. After surgery, your graft goes through a process called ligamentization where the graft (usually from a hamstring, quad, or patellar tendon) becomes a ligament through revascularization, cellular regeneration, and remodeling of the tissue. Either end of the graft must become incorporated into the insertion sites and build tensile strength.

This process doesn’t fully occur until 12 weeks.

2. Normal Joint Motion 

Since day one you have likely been working on the range of motion and swelling in your knee. Working to re-establish normal motion and mechanics in the knee early on is essential for long term joint health.

Making sure you have full knee extension (all the way straight) and knee flexion (bent) equal to the other side is pivotal before beginning a running program.

Swelling is another key issue. While swelling after surgery is normal, constant swelling 16 weeks out indicates the joint is still irritated. Running will increase the forces through the knee joint and the last thing you want to do is pound on an already cranky joint.

3. Strength

Quad strength is the most important factor in protecting your knee and getting you back to functioning at full force. Don’t get me wrong, hamstrings (another huge protector of the ACL) and glutes are super important, but quads are key. The quads provide strength and stability to the knee, protect it, and take load off of the joint. Time and time again, research has shown quad strength matters… a lot. So how does this play into running?

Ideally at four months, your quad strength on the injured side should be 60% of the uninjured knee.

That is to say, if you can kick out 100lbs on a knee extension machine on your good side, you should be able to kick out 60lbs on your surgical side before we even consider letting you run. Why? This shows you have good enough protective strength in the knee to allow for initiation of a safe running program.

4. Balance 

 Along with quad strength, balance (specifically the neuromuscular control portion) is critical in prevention of future injury and overall joint health.

Several studies coming out recently have emphasized the importance of re-establishing complete motor control, balance, and stability for injury prevention.

There are several ways in which balance can be tested. One of my favorites and most researched in terms of ACL recovery is called the Y-balance. The test incorporates balancing on one leg while reaching the other leg into three different directions. Both legs are tested and the results compared. At four months, results on the surgical leg should be within 90% of the uninjured leg. This number has been shown to be an acceptable cutoff for reduced injury risk and assumption of a safe return to running program.

5. Progression 

If you are anything like me, once cleared to run, the most challenging part is not over doing it. However, it is extremely important to progress back slowly and only manipulate one variable at a time.

Usually after ACL injury, return to running programs begin with a 10-15 min easy run on flat, dry ground, three days per week. Each week, running time is progressed. Once 25-30 min of consistent running is obtained without any symptoms, another variable can be manipulated (speed, frequency, terrain, or intensity).

When progressing back into running some general guidelines to remember are:

1. Do not progress distance more than 10% per week

2. Take a rest day between runs when just starting back

3. Avoid over striding as this increases joint forces at the hip, knee, ankle, and low back. Try opting for a quicker cadence (step rate) at the same speed.

Running programs will vary and some will progress slower depending on the extent of the surgery, prior history, and training experience.

Not sure if you are ready?

By Dr. Morgan Kinnes

What do ACLs and Perineums have in common? Maybe more than you think. Both are commonly injured, there are up to 200,000 ACL injuries per year in the United States and 90% of women have some degree of perineal tearing while giving birth (this is almost 4 million perineal injuries every year), and both require rehabilitation. 

Let’s back up a little bit. The perineum is the area of tissue in between the vagina or base of the penis and the anus and is made up of skin, fat tissue, and the pelvic floor muscles and contains quite a few nerve endings. During vaginal birth, the perineal tissue stretches to allow the baby’s head to exit the vagina and this sometimes results in a tear. Perineal tears can lead to urinary or fecal incontinence and pelvic pain with sexual intercourse. 

There are four different degrees of tears indicating the severity of injury and tissues involved. 

First degree: Tearing of the skin

Second degree: Some tearing of pelvic floor muscles and skin

Third Degree: Tearing of skin, pelvic floor muscles, and partial tear of the anal sphincter 

Fourth Degree: Tearing of skin, pelvic floor muscles, and complete tear of the anal sphincter and into the lining of the bowel.

Sometimes mom’s position during labor or the use of an instrument (forceps or a vacuum) can increase the risk of tearing. The typical birthing position of mom lying on her back with her feet up in stirrups or laying as if in a recliner increases the risk of perineal tearing. There are many different options for laboring positions that can reduce the risk of tearing that you can discuss with your provider. Perineal massage is another way to decrease the risk of perineal tears. Perineal massage should be done 1-2 times per week beginning around 35 weeks.

There is good news for new moms. Just like ACL injuries, a physical therapist can help address symptoms following a perineal tear. Pelvic Health Physical Therapists have specialized training and are experts in treating urinary and fecal incontinence and pelvic pain. ACOG (American College of Obstetricians and Gynecologists) recommends every person who has given birth see a Pelvic Health PT to address any issues they are having and prevent any further issues.  

What is Blood Flow Restriction? 

A form of low intensity resistance training that can be used to enhance muscle growth, strength, and performance of the working muscles

A way to prevent muscle atrophy and build strength without increasing load on joints

How does Blood Flow Restriction work?

A specifically designed cuff is placed high up on the leg or arm

Individualized amounts of compression are applied to the working limb and a select 1-4 exercise are performed as determined by your therapist

The compression of the cuff causes a buildup of metabolic muscle byproducts that lead to enhanced muscle growth 

BFR can achieve similar results in muscle growth to high intensity interval training (HIIT)

Who is Blood Flow Restriction  for? 

Post-surgical clients (achilles tendon repair, ACL repair, meniscal repair, hip scope, or rotator cuff repair) with limitations in weight bearing or range of motion that prevents higher/heavier loads 

Clients with pain, arthritis, or degenerative issues that cannot handle higher/heavier loading to joints or tendons

Clients with healing tissues that cannot yet handle higher/heavier loads

High level athletes that need to maintain training intensity but cannot handle the high level of forces necessary to be competitive

What are the benefits of  Blood Flow Restriction?

BFR helps to prevents muscle atrophy

Allows for muscle strengthening without having to overload joints 

Excellent way to bridge the gap between low intensity and high intensity training 

Side effects? 

Some muscle soreness after BFR is expected 

Muscle fatigue during exercise and low levels of discomfort are normal

By Dr. Mouna Goyette

Strength training: Heading into ski season prepared with strong and balanced muscles is crucial to preventing injury. Although pre-season training is ideal, it’s never too late to start. A ski-specific program is best. A physical therapist who is specially trained in sports or ski injury prevention can address your individual needs. ACL injury prevention programs, such as SportsMetrics, have been proven to reduce knee ligamentous injuries in female athletes.  

Recovery: Whether you are a 100-day skier or a weekend warrior, you will need recovery strategies. Any repetitive activity can lead to overuse injuries or excessive tissue soreness. Having a holistic recovery program including a proper recovery exercise program, rest, nutrition, hydration, and sleep can significantly improve your performance on the slopes and make you feel better as a whole. 

Self-Care: The allure of a powder day can distract us from our most basic human needs. Try to keep up with your food and water during your ski day, so that you are fueled with the energy that skiing demands. Find a snack and water system that works for you. Address nagging injuries before they become unmanageable. A good physical therapist will have a better chance at keeping you involved in your sport the earlier the injured is addressed. Of course, helmets are strongly recommended. Concussions account for 20% of the ski injuries in North America each year. Severe brain injuries can be fatal and even mild concussion symptoms can last months or years.