Temporomandibular Joint exercises

Following the previous article on TMJ dysfunction, here are a few examples of exercises you can do at home to help your symptoms.

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Working on your posture is key to release some muscular tension coming from the neck and shoulders. Also see the previous blog on scapular stability.

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You can also controlled active jaw movement, meaning that the focus is to avoid the jaw from shifting or clicking. All movements should be painfree.

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Following some painfree active jaw movement, you can also do the same exercises with a slight resistance using your hand.

For more question or guidance, don’t hesitate to contact our clinic to see our experienced physiotherapist.

Temporomandibular Joint (TMJ) Dysfunction

The TMJ is the ball and socket joint that connects the Mandible (jaw bone) and the Temporal bone (one of the bones of your skull). It’s the small joint located in front of your ear. There is a cartilage cushion in between the ball and socket, referred to as the Disc. The disc is supported by special Ligaments, which keep the disc in place. Movement problems of the disc can be responsible for creating many symptoms in the TMJ, such as clicking, crepitations, locking, muscle spasm, and pain. There are several muscles which support and control movements of the TMJ.

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You may or may not experience jaw pain or tenderness with TMJ dysfunction. The most common symptoms include:

  • jaw clicking

  • jaw popping 

  • grinding 

  • limited jaw opening, or jaw deviation while opening (which you can observe in a mirror)

  • an inability to fully clench your jaw.

TMD sufferers are often teeth grinders or clenchers.  TMD can cause jaw headaches, ear pain, dizziness and upper neck pain. Some TMJ patients report pain or inability to eat, talk or sing. Tinnitus or ear ringing can be associated with TMJ dysfunction. (Vierola et al 2012)

TMJ Disorder/Dysfunction, or TMJD/TMD, is seen more commonly in women than men. There is a 3:1 incidence in females to males, and can include one or both jaw joints. In most instances, the dysfunction is a result of an imbalance or change in the normal function of the bones, ligaments, muscles, disc, or nerve components of the TMJ complex.

What Causes Temporomandibular Disorder?

TMJ dysfunction is considered a multifaceted musculoskeletal disorder. 

The most common causes of TMD include:

  • Masticatory muscle dysfunction, 

  • Derangement/displacement of TMJ articular disc

  • Bruxism: nocturnal grinding of teeth leads to increased pressure in TMJ and asymmetrical movement.

  • Occlusal Problems: Poor bite, Asymmetrical or Retrognathic (underbite, overbite) .

Contributory factors include:

  • Mandibular malalignment secondary to occlusal appliance or orthodontic treatment.

  • Removal of wisdom teeth,

  • Prolonged mouth opening eg dental procedure, 

  • Poor cervical posture, 

  • Myofascial pain, 

  • Neuropsychological factors,

  • Stress, and 

  • Whiplash and other less common causes include: trauma (e.g., blow to the chin), infection, polyarthritic conditions, tumors, and anatomical abnormalities.

The TMJ specific muscles involved in myofascial pain dysfunction are the Temporalis and Masseter. The temporalis is a fan-shaped muscle that fills the temporal space, and inserts onto the mandible. Its function is to raise the mandible to close your jaw. The masseter is a thick and strong muscle attached at your cheekbone and runs to the angle of the mandible. Its function is to also raise the mandible to close your jaw. 

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Treatment of myofascial pain disorder is focused on desensitizing muscles through hands-on mobilization, restoration of normal functional movement pattern through exercise, and providing education regarding prognosis and self applied maintenance. Treatment may also include other muscle re-education techniques such as Intramuscular Stimulation (IMS). We look at other mechanical influences such as neck disorder and posture, to assist in maximizing treatment management. At times, we often work with your oral practitioner (dentist, orthodontist, oral surgeon), and other practitioners who deal with behavioural modification, to optimize results.



Scapular Stability, your shoulder core

When we think of the core, we usually refer to our abdominal muscles, but did you know the shoulder has its own core ??

To improve function, strength, posture and balance, we need all our muscle to do their job and at the right time. It all starts with the center, the stability muscles, which is considered the core.

The scapulothoracic joint relies on the coordinated dance of 17 muscles, as well as its mobility at three other joints — the acromioclavicular, sternoclavicular, and glenohumeral joints — to provide stability for the rest of the arm and shoulder.

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The shoulder requires both mobility and stability in order to support and stabilize the rest of the upper extremity.

Think of the scapulae as the foundation of your house. Your house is only as sturdy as its foundation. Similar to a house, upper body strength relies heavily on the stability provided by the scapular muscles, which ground the upper extremities and allow for greater distal strength.

Any weaknesses can provoque a change is the muscle balance, the larger muscles will start to overwork and compensate for the smaller ones that are not doing their job.

Poor biomechanics and weakness of the shoulder "core" can also lead to overuse of the smaller muscles of the extremities (tennis/golfer's elbow, De Quervain tenosynovitis, etc).

A well balanced exercise program is key to avoid injuries in the upper body. In order to know where to start with your exercises, your physiotherapist can give you a specific selection adapted to your needs. 

In the following blog, we will show you an example of scapular stability exercise program as a basic to start with. Stand by for more !

All you need to know about the current air quality in BC

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Currently, there are air quality advisories for BC, Alberta and parts of Saskatchewan due to the BC wildfires. Follow the necessary precautions to take care of what matters most and avoid illness or injury.

What are the risks?

Poor air quality can lead to allergy-like symptoms including:

  • Headaches and fatigue

  • Eye, nose and throat irritation

  • Wheezing and heightened effects of asthma, particularly for children and the elderly

 Photo by 9nong/iStock / Getty Images

Photo by 9nong/iStock / Getty Images

The risk of respiratory and cardiovascular issues increases over time with continued exposure. Some people may experience more severe symptoms, like shortness of breath, dizziness coughing, or chest pain. If it's an emergency, immediately dial 9‑1‑1. If you'd like advice, call HealthLink/HealthLine at 8‑1‑1 or talk to your doctor.

 

What should you do?

  1. Stay indoors as much as possible. Avoid exercising outside; instead, head to a mall or gym.

  2. Drive with the windows up. Use air conditioning if you have it and set it to recirculate.

  3. Entertain children inside. Limit the amount of time children spend playing outdoors; young lungs are sensitive.

  4. Check air advisories often. Don’t rely solely on what it looks like outside.

  5. Be vigilant with breathing-related medications. If you have asthma or a lung-related illness, stay on top of your medications. See your doctor if you need to discuss dosage.

  6. Invest in an air purifier. A good air purifier will reduce particle levels inside your home.

  7. Above all, make your health and safety a priority.

Here’s a few interesting comments from Medical professional through Global and CBC news:

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Dr. Bonnie Henry says there is a lot of “confusion” surrounding the impacts of the smoke, and wants to assure people there won’t be any major issues down the road.

“Despite the fact it has been going on for several weeks, we really do see this as a short-term exposure compared to the day in, day out exposures that others have,” said Henry. “So for the vast majority of people when the skies clear, these symptoms of irritation and shortness of breath are going to go away and most of us will be absolutely fine.”

Henry says the smoky air makes it harder to get oxygen into the blood, and normally-healthy people can have symptoms including eye irritation, sore throats, running nose, cough and wheezy breathing. There will be some people who will feel long-term effects from the smoke if it irritates underlying conditions.

Infants, pregnant women and those with underlying health conditions are being told it is recommended they stay inside.

According to the app “Sh**t! I Smoke,” the air quality in Vancouver today is equivalent to smoking 9.5 cigarettes a day. But Henry says the smoke produced by a wildfire is different than cigarette smoke or smoke produced in cities known for heavy air pollution.

“Wildfire smoke is different from other air pollution. So we have seen comparisons to cities like Beijing and Delhi. But air pollution is caused by vehicle exhaust and industrial emissions and has other components to it that are also harmful to human health,” said Henry. “While wildfire smoke does certainly has health effects, it is not the same as ongoing exposure to long term pollution like we do in some of these cities.”

Health officials are discouraging strenuous activity outdoors for everyone — be they athletes or not — while the air quality advisory remains in place.

"Heavier breathing will allow more air pollution to enter the lungs," said Hedieh Hafizi a clinical exercise physiologist at Copeman Healthcare.

"Inhaling carbon monoxide decreases the body's oxygen supply and can cause respiratory irritation such as shortness of breath, and it can also aggravate any preexisting medical conditions," Hafizi said.

 

 

 

To Stretch or no to Stretch...?

I was once told to stretch before my activity, and then i heard it is a must to stretch after. I used to think i was good for me, but now heard it might not... but really what should i do ?!?

And why do i even stretch ? Because it feels good, because it’s part of our pre-workout routine, because a muscle is stiff and we think stretching will fix it. But most of what we know about stretching are based on wishful thinking and outdated science. We’re stretching for all the wrong reasons.

Who never heard of the old school technique of static stretching before a soccer game? Static stretching being where you sit, lie or stand and hold stretches for 20-30 seconds each. It was always part of our phys-ed class and the teacher was telling us the importance of stretching the muscle to prevent injuries…the time has change people!

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There is a lot of research now to show that this type of static stretching prior to exercise does not reduce your injury risk, including several big systematic reviews (a high level of scientific evidence) that all show that static stretching as part of warm up does not reduce your risk of injury.

Static Stretching has also been shown to reduce peak power and force output in the muscle stretched. What this means is that after static stretching, your muscle is not able to produce quite as much force (strength) as it could prior to stretching. Stretching robs your power !!

Studies show a 2% to 7% reduced strength and short lasting after a stretching session, 15-30 min. It is important to know the fact so let’s not panic, stretching before an activity will not significantly reduce your power nor will it make a difference on your next day activity.

So does it mean i should never stretch before an activity ? Well… NO!

The current best practice recommendation for warm up prior to exercise is NOT  to perform static stretches, but instead perform dynamic warm up designed to prepare your body for the exercise to come.  This should include things like large amplitude, controlled dynamic movements (such as leg swings), activities to gradually increase blood flow to the areas needed for exercise and activation/preparatory movements relevant to the activity.

Static stretching is only one type of intervention, so it doesn’t mean all stretches are bad. You can do PNF(Proprioceptive Neuromuscular Facilitation), where we use muscle contraction and relaxation to affect muscle lengthening, joint mobilization, ballistic stretches, and self myofascial release (foam roller, spiky ball etc).

The nervous system controls our flexibility much more than we thought.  Part of the limits of our flexibility is how much our nerves “put the brakes on” to protect our tissues from damage by excessive length or tension. Neurodynamic testing can be done to evaluate if the nerve is the structure actually blocking your flexibility.

Once again, your physiotherapist is well trained to guide you through the proper warm-up/stretching/technique to use according to your own condition.

Proper Deadlift Technique

The deadlift is one of the exercises i see the most mistakes performed regarding form and technique.

The deadlift, if performed correctly, will target many important and large muscle groups, not only in your lower body but also in your upper body.

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It will work your strength, core, balance, coordination and posture which makes it an easy exercise to incorporate many muscle groups, who doesn’t want to save some time at the gym !

“Doing the deadlift with good form teaches you to activate the stabilizing muscles around your spine,” says study author Lars Berglund, Ph.D. “It also strengthens your glutes, which are often weak in people with back pain.”

But if done incorrectly even with a slight variation of the proper form you can quickly injure yourself, and often it can lead to long term, painful injuries.

Even when you use a relatively light weight, doing poor reps shift some of the stress to your delicate spine. Little by little, rep by rep, your spine breaks down until you potentially end up with serious back pain, according to Stuart McGill, Ph.D., professor of spine biomechanics at the University of Waterloo in Ontario and the author of Ultimate Back Fitness and Performance.

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One interesting fact about deadlifts is that the exercise you perform in the gym is actually a real movement that we use in our daily living, like lifting objects. So while you’re doing your routine at the gym, you are actually practicing how to use a common daily movement to prevent injuries.

In the same category, the squat is another beneficial exercise, while performed correctly, will help you protect you back and other structures from injuries caused simply by a picking up your shoe…

So now that we know a bit more about deadlifts, there is a test you can self-perform before starting your program at the gym to evaluate if your form is fit for this exercise.

Push your hips back, bend at your waist, and touch your toes. The catch: your back has to remain flat throughout. If you can’t touch your toes—or if you had to round your back to touch your toes—you lack the hip mobility to properly deadlift. You can either ask a friend to take a video, do the test in front of a mirror or ask your beloved physiotherapist to have a look !

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If you passed you are ready to do a deadlift! But wait ! It’s always a better idea to progress your way into it to prevent any injuries and making sure you keep the right form even with heavier weights.

You can start with a body weight deadlift, progress with a kettlebell and then a weight bar, from light to heavier weights. Starting to lift only  a few inches from the ground and progress your way up is another trick to make the smooth transition.

As you do your deadlift, just keep in mind to keep your feet flat on the floor, bend at the knees, hinge at the hip by keeping your low back straight.

Grab the bar with hands shoulder-width apart, keep your shoulders retracted and your neck tucked in. And BREATHE !!!!

 

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Stay tuned for different variations of deadlift you can do at the gym.

Cuboid Syndrome

Feeling pain on the outside edge of your foot (lateral foot pain) is usually the first thing people with cuboid syndrome notice. It’s a relatively common condition, but not always recognized since it can come on slowly over time.

Trauma to the foot, be it a sudden injury or gradually repetitive forces may damage the supporting soft tissues causing the cuboid bone to move out of its usual position.  It can then act like a block, limiting the movement of the surrounding bones in the foot.

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This may happen suddenly due to an injury such as an ankle sprain, or develop gradually over time from repetitive tension through the bone and surrounding structures.

The 3 main causes of the cuboid syndrome is from a injury (sprain most likely inversion), repetitive strain (overuse, running, jumping) or altered foot biomechanics (foot pronation or flat feet).

The symptoms related to a cuboid syndrome can be lateral foot pain, swelling around the cuboid area, decreased ankle mobility and increased pain in weight bearing.

It is strongly recommended to seek help from your physiotherapist as the cuboid syndrome will not appear on a xray, unless there is an actual fracture of the cuboid bone.

Your physiotherapist will assess the condition and evaluate what is causing the cuboid the shift out of alignment. The assessment will not only include the foot and lower leg but the whole lower quadrant (Low back, hip and knee) because as you know, it’s all connected !!

The peroneus longus muscle runs down the outer side of the lower leg attaching on to the outer side of the foot.  Tension placed through this muscle from repetitive activities usually locks the cuboid in the altered position causing sustained pain.

If you remember the previous article on the glutes, you will remember that the glute muscles help to stabilize your pelvis to avoid your knees to shift medially and cause your foot to pronate. By losing your  arch support, you keep the cuboid blocked in the injured position.

Your therapist will be able to mobilize the cuboid in the right alignment with manual therapy techniques, release the soft tissue in the lower leg and foot (peroneus longus mostly), tape the foot to support the cuboid in the corrected position, show individualized exercises to your condition.

If the exercises and other techniques are not sufficient to old your foot arch, orthotics can be needed to support the structures. Come and see Katie, physiotherapist at the clinic for custom orthotic fitting!

RICE (Rest, Ice, Compression and Elevation) is always a good start at home to help the inflammation process when you notice the pain.

The cuboid syndrome is fairly easy to treat if it’s recognized early!

Keep your eyes open on the blog for an example of exercise program to follow if you think you are experiencing pain from a cuboid syndrome.

Low back pain…make your glutes your best friend !

Low back pain is amongst the most common injuries seen in Physiotherapy.

Some of the causes can be directly located in your spine (disc, vertebrae, nerve, etc) but lets not forget that the spine movements are also influenced by your pelvis/hips.

When actions of the spine are not accompanied by correct movement in the rest of the body, the spine and its surrounding muscles have to take up the slack and may become overworked and injured.

The glutes (maximus, medius and minimus) are the primary controller of movements in our hips and thighs and also play an important role in the stabilisation of the pelvis and support of the low back.

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The Glute Medius and Minimus are in charge of the stabilization while the Glute Max is our powerhouse.

If you have lower back pain or your back feels tight frequently, then you are probably overusing your movers while your stabilizers are taking a break. It’s time to wake them up!


But wait…am i really using my stabilizers during a squat…?

Did you know your body can actually switch on the wrong muscles because the correct ones are weak or inactive?  This is most common in our glutes and can be the reason for lower back pain, muscle spasms, and even nerve pain.

If your glutes are weak or inactive they cannot hold your pelvis in the right position or help maintain correct alignment.

How to start your glute awakening:

The basic process requires you to re-establish and strengthen neural signalling pathways that will correctly route the signals from your brain to the target muscle, and cause it to activate or ‘fire’ as it is supposed to.

This means that in the following exercises you must perform quality repetitions over quantity. This can and will take a surprising amount of concentration – but take the time to set up and focus your mind before each repetition.

Who doesn’t like brain teasers !

Release

Make sure your glutes have the optimal environment to be activated.  Your hips and pelvis should be in a neutral position and the surrounding muscles should the relaxed to avoid excessive tension.

Start by releasing your hamstring, hip flexors and buttock.

You can use a foam roller or a trigger point ball lying on the ground or against the wall.

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Palpate, feel and visualize :

In the first stage of reactivating your glutes, you’ll be focusing on trying to feel the glute muscles working and actually getting them to fire correctly. This is also known as your mind-muscle connection.

From a standing position, place fingers on each side of your butt cheeks and attempt to contract the glutes by imaging squeezing your butt cheeks together (this may sound funny but picture yourself holding a fart or holding a pencil slotted between your butt cheeks !)

You should be able to feel a glute contraction without tucking your pelvis or locking your quadriceps/hamstrings into a straight leg.

Once you get more practiced with this exercise, try to increase your level of control to be able to activate one side of your glutes at a time.

Isolate :

Tried to recruit your glutes in a bridge position without contracting your hamstrings.

You should be able to recruit your core to stabilize the pelvis, squeeze your glutes, without any pelvic tilt, and then push through your heels to lift your buttock without gripping your legs (hamstring compensation).

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Integrate:

Now that you are able to activate, feel that your glutes are being recruited without any surrounding muscle, you are able to integrate them in your favorite glute exercises : bridge, squat, leg lift etc.

This can be very challenging, so don’t hesitate to book with one of our physiotherapist to guide you through the proper process of glute activation without cheating.

 Stay tuned for a full glute strength program. Work on activation first then build strength in the right place.

 

Exercises for Pre and Post Pregnancy Issues and Meet the Expert.

Following our educational piece on Women's Health and Peri Natal Care we have been asked about common exercises and where to reach out to for further help. So here are some common exercises for some of the previously mentioned issues. But please, if your issues are more complex consult before trying these.

 

Pelvic Floor Strengthening

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Strengthening Core with Diastasis

 

Core Strengthening

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Meet the Expert

Jacquie Williams

Physiotherapist - Walnut Grove

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Jacquie graduated from UBC with a Master’s degree in Physical Therapy. Providing evidence based techniques in manual therapy, exercise prescription, and education, Jacquie believes it is important to empower clients with the tools and knowledge for the most effective treatment of any injury.

Jacquie has work in private clinics throughout the Lower Mainland. She treats all orthopedic conditions with a strong focus on manual therapy techniques. Jacquie also specializes in Women’s Health Physiotherapy. This includes peri-natal care, pelvic floor dysfunction and incontinence, and pelvis organ prolapse. Jacquie is a Registered Yoga Teacher and a Level 1 Hypopressives instructor.

For questions or appointments with Jacquie call 604 881 2002 or go to our website at www.physiofocus.ca.

 

Women's Health and Peri-Natal Care. The Role of Physiotherapy.

 

Women’s Health Physiotherapy is a specialized area of treatment that aims to address issues caused by pregnancy and child delivery. During pregnancy and delivery the body undergoes huge changes and this causes muscles, ligaments and connective tissue to stretch and deactivate, creating a difficult situation for women to create stability around there spine and pelvic girdle and difficulty maintaining normal pelvic functions. 

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Several common problems occur:

  • Diastasis rectus abdominus - where the abdominals separate  in the midline. 
  • Deep Abdominal and Pelvic Floor Dysfunction - this results in low back, pelvis and pubic symphysis pain. 
  • Urinary Incontinence or Prolapse - often as a result of sports associated with mild impact such as running or jumping. This is generally a result of your pelvic floor and muscles supporting your pelvic floor being stretched or torn. 
  • peri-natal or postnatal related musculoskeletal changes/impairments - physiotherapy manual therapy techniques are used to treat a variety of muscle, joint, ligament and postural issues associated with changes during pregnancy and child delivery. 
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The human body is amazing at functioning with the changing forces on it at pregnancy progresses and coping with the stress of childbirth. There are however several situations where help is needed to restore normal function and help women return to a pain-free active lifestyle.

If you need help with any of the above issues call the clinic in Walnut Grove at 604 881 2002 and ask for our Womens Health Physiotherapists Jacquie Williams. If you want to know more about Jacquie visit our Website at www.physiofocus.ca

Exercises to Help with Vertigo and Meet our Vertigo Specialist Rosanne Molnar

We have had lots of questions following our last article on Vertigo. Mainly more ideas for exercises and asking who is the best person in our team to see for this condition. 

The common exercises used to treat Benign Paroxysmal Positional Vertigo (BPPV) are:

  • Epley Maneuver
  • Gaze Stabilization
  • Brandt Daroff
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If you are having any of these issues our Walnut Grove Physiotherapist Rosanne Molnar is a specialist in this area. Meet Rosanne.

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Rosanne Molnar graduated in 2009 from the University of Alberta with a Master of Science
in Physical Therapy after completing a Bachelor’s degree in Kinesiology in 2005 from the
University of the Fraser Valley. She has continued her education with courses that include
level I and level II (lower extremity) of her manual therapy qualifications with the
Canadian Orthopedic Division Diploma of Advanced Orthopedic Manual and Manipulative
Physiotherapy, Vestibular Therapy (BPPV) and Graded Motor Imagery. Rosanne is an avid
leaner who is constantly updating her skills.
She has experience treating clients following motor vehicle accidents (ICBC), work related
injuries (WSBC) as well as most orthopedic conditions (strains, sprains, post-fracture).
With a straight forward and positive approach, Rosanne uses a variety of treatments which
include soft tissue release, mobilizations and exercise to help you return to your optimal health.

To speak to Rosanne or book an appointment please call 604 881 2002 or go to our website at www.physiofocus.ca

Vertigo. Why do I think I'm Spinning and How Physiotherapy Can Help.

Vertigo is a a condition commonly characterized by dizziness or the sensation of objects spinning around you. 

By far the most common type of vertigo is Benign Paroxysmal Positional Vertigo (BPPV) which is a problem with the inner ear. In this condition intense short periods of dizziness are associated with changes to the position of the head. This is due to calcium deposits, that are dislodged from the inner ear, blocking the flow of fluid through the semicircular canals in the inner ear. The normal flow of fluid in the canals is responsible for balance, and when this flow is disrupted, dizziness and the sensation of the room spinning happens. 

 

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Although movement of the head causes dizziness, physiotherapist have techniques where the fast and specific movement of the head is used to quickly move the fluid through the canals and unblock the calcium deposits. 

There are several techniques used but the most common are:

  • Elpey Maneuver
  • Dix Hallpike Maneuver
  • Brandt Daroff
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It is important to consult with a physiotherapist with advanced training on dealing with vertigo or vestibular issues. Specialized testing of balance issues is important to rule out other causes of vertigo and get a treatment that is tailored to the patient. Physiofocus Walnut Grove is fortunate to have Physiotherapist Rosanne Molnar on our team who has a specialization in this area. 

Check out www.physiofocus.ca or call 604 881 2002 for more information on Rosanne and how you can book to get rid of your issues with vertigo or any other aches and pain you may have. 

Have a great day.

Do you have Bad Posture?.... Feel Better with these Exercises

Postural pain is extremely common but most people don't know how to go about treating there pain.

Postural dysfunction or “Poor” posture is defined as when our spine is positioned in unnatural positions, in which the curves, or lack of,  are emphasised. Therefore the joints, muscles and vertebrae being in stressful positions. Poor posture longterm results in a build up of pressure on these tissues, causing pain and lack of function.

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Common causes of postural pain

  • Lack of education or awareness of correct posture
  • Sedentary lifestyle
  • Occupational demands
  • Joint stiffness
  • Decreased fitness
  • Muscle weakness
  • Muscle tightness
  • Poor core stability
  • Poor ergonomic work-stations

Physiotherapy uses the following techniques to treat postural pain

  • Assessment of postural deficincies
  • Postural education and training
  • Manual therapy 
  • muscle release/ massage
  • Postural taping
  • Joint mobilisation
  • Exercises to treat muscle weakness and lengthen tight muscles

Here are some exercises for neck and thoracic spine postural pain. 

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If you need more specific help with these exercises or need hands on treatment to help alleviate your postural pain and get you on track please call us at Physiofocus, 604 881 2002, or book online at www.physiofocus.ca

Enjoy your day

Heel Pain....Do you have Plantar Fasciitis?

Plantar fasciitis is pain that occurs underneath the heel at the point where your plantar fascia connects onto your heel bone

The plantar fascia is a tough fascial tissue that runs under your foot and has several functions in the foot during walking and running such as load distribution and maintaining stability. 

People will commonly describe:

  • Pain under the heel of the foot usually described as “sharp and achy”
  • Difficulty walking long distances or running
  • Worse pain in the morning when taking the first few steps out of bed or after a long period of rest

Plantar fasciitis occurs in approximately 10% of people who run regularly. Those at most risk are:

  • People between the ages of 40 and 60,
  • Those with “flat feet”
  • Obesity
  • People who spend a prolonged time standing on hard surfaces
  • people with joint tightness issues in their feet

Exercise is one of the primary forms of treatment along with hands on physiotherapy for lengthen the plantar fascia and maintain normal movement on the feet. Here are some ideas on how to treat plantar fasciitis with exercise. If you need more help treating this problem please go to www.physiofocus to book an appointment.

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Do you have Osteoarthritis in your knees but not ready for a Knee Replacement?? Have you heard of Hyaluronic Acid??

Knees contain synovial fluid, which is responsible for

  • absorbing shock
  • lubricating the knee joint
  • anti inflammatory effect

Changes in synovial fluid and  joint degeneration can lead to Osteoarthritis in the knee joint.

Hyaluronic acid (synvisc, cingal, viscosupplements) is a major component of synovial fluid and can provide relief from OA knees with a single use injection. Combine this with physiotherapy, exercise prescription and lifestyle changes and osteoarthritis can be well managed. 

We can help....

Dr Rose Martel (sports medicine) is the person to ask.......

http://physiofocussquamish.com/physiotherapists/

 

 

 

 

Great Article on Return to Sport after ACL Repair in Young People

http://trustmephysiotherapy.com/return-sport-following-acl-reconstruction-young-athletes/

October 28, 2016

Return to Sport Following ACL Reconstruction in Young Athletes

Again a great blog by Mick Hughes about ACL rehabilitation! 
This time, he explains the research on the return to sport decision in young athletes under 20 years old.
Should we really wait for 2 years for our young athletes to return to sports?

Mick Hughes is the head Physiotherapist of the Collingwood Magpies Netball team and shares his time between Collingwood and The Melbourne Sports Medicine Centre.

He is a keen blogger and posts regularly on sports physio and strength and conditioning topics. You can check out his website, which you can find some of his previous blogs.
And he is very active on social media and can be found at Facebook , Twitter: @mickwhughes and Instagram: @mickhughesphysio.

 

I wrote a blog recently called When can I return to sport after ACL surgery?.
It summarised two recent articles by Grindem et al (2016) and Krytsis et al (2016) that both clearly showed a reduction in ACL re-injury risk in elite adult athletes who waited at least 9 months, and passed a battery of strength and functional tests prior to being cleared to return to sport (RTS). To reiterate the above literature; waiting at least 9 months, being within 10% of the uninjured limb on a number of different strength and hop tasks, performing an agility T-test under 11 seconds and performing sport-specific conditioning at training, significantly reduced the athlete’s risk of re-injuring their ACL upon RTS.

This blog however will be a little different as I wanted to explore some worrying trends in the literature that suggest we should be more conservative with our RTS planning in our younger athletes who have had ACL reconstructive surgery – specifically those athletes under the age of 20.

I recently attended the annual Sports Medicine Australia (SMA) Conference here in Melbourne and was lucky enough to sit down and listen to some world experts in the field of sports medicine and sports physiotherapy. Two people in particular, Tim Hewett and Kate Webster, really grabbed my attention with their research and insight into the world of ACL injury.

And unfortunately that world is very bleak…

 

I’ll cut straight to the chase.

One study they discussed showed that 30% of young people (mean age 17) who RTS following ACL reconstruction will sustain a 2nd ACL injury within 2 years (1). Of this 30%, females were 5x more likely to do so than males.

And before you say, “C’mon Mick, don’t jump at shadows. This is just one study”.

This research wasn’t alone…

In a further review of the literature I started to find a depressing trend:

  • 25% of subjects (n= 16, mean age 16 years) sustained a 2nd ACL injury within 12 months upon RTS following ACL surgery; with 14 (87%) being female and 12 (75%) sustaining a 2nd injury to the contra-lateral knee. The authors conclusion was that, in this cohort of young athletes, those that RTS were 15x more likely to sustain a 2nd ACL injury within 12 months (2).
  • 29% of patients under 20 years of age (32/110) sustained a 2nd ACL injury within 3 years (3). To put this in perspective, only 8% (35/451) of the subjects aged over 20 years of age in this study sustained a 2nd ACL injury within the 3 year follow up period.
  • 23% of subjects (13/56, mean age 16 years) sustained a 2nd ACL injury within 12 months following RTS (4).

With such a concerning trend of 2nd ACL injuries within the first 2-3 years following a RTS, it has lead some researchers, including Tim Hewett (Nagelli & Hewett, 2016) (6), to pose the question:

“Should we be waiting 2 years to allow our younger athletes (<20 years of age) to return to sport?”.

Nagelli & Hewett wrote their paper based on the current ACL literature and make some very valid points. If we are to look purely at biological and physiological healing, the research is telling us that it can take up to 2 years to achieve baseline knee health (ie. full maturation of the ACL graft, resolution of bone bruises), restoration of knee joint position sense (proprioception/balance), restoration of neuromuscular control and restoration of knee strength following ACL reconstruction.

 

Although Nagelli & Hewett make a very good argument to delay sport for 2 years, we are all going to have a very difficult time explaining to a 17 year old, their coach and their parents that we need to wait 2 years before we allow them to RTS. This would be an even more difficult discussion, especially if the young athlete is at a critical stage of their early sporting career and the opportunity for a professional sporting contract is on the horizon.

But what I feel often goes missing in the literature on 2nd ACL injuries are the 3 things that are critical to a successful RTS following ACL reconstruction:

1) Was the patient compliant to the ENTIRE rehab plan as set out by their physio, exercise physiologist or strength and conditioning coach?

2) Did the rehabilitation plan include a period of supervised jumping, landing, pivoting, unanticipated change of direction, unanticipated landing and sports specific conditioning?

3) Was the athlete cleared to RTS with strength tests and functional hop tests prior to stepping back on the field/court? And were these tests also passed in a fatigued state?

My gut instinct tells me that these 3 things are not frequently ticked off prior to the patient returning to sport, and I have no doubt that the absence of these 3 criteria plays a significantly role in the high rates of 2nd ACL injuries that we see in the literature.

And there was some preliminary research presented that supports my gut…

Jay Ebert and colleagues from Hollywood Functional Rehabilitation Clinic (Perth, WA) presented some nice (unpublished) data on post-op ACL rehabilitation in a community setting of non-elite athletes. They reported that of the 111 ACL reconstructed patients in their study, 9% DID NOT attend ANY supervised physiotherapy within 12 months, 45% did not attended supervised exercise after 3 months, and only 30% of patients actually performed jumping, landing and agility training as part of their rehab.

Furthermore, they also looked at the quality of rehab and it’s influence on functional outcome measures (the same quads/hamstring strength and hop tests that Grindem et al & Krytsis et al used).

They found that of the 55% of patients who conducted at least 6 months of supervised rehabilitation/physiotherapy, they were all able to achieve 90% or greater limb symmetry on strength and hop tests at the 12 month follow-up mark. Furthermore those that completed supervised training longer than 6 months and/or completed high level training drills such as jumping and landing, were all close to achieving full limb symmetry between operated and non-operated limbs. This lead the authors to conclude that the higher quality of the rehabilitation, resulted in superior post-operative functional outcomes.

 

 

Conclusion

I think 2 years may be an ultra-conservative RTS timeframe for young athletes, but the evidence for biological healing is very hard to ignore. What us health professionals really need to be explaining to our young patients who wish to return to sports that involve hard landing, cutting and pivoting, are the following key points:

  • Up to 30% of people under the age of 20 will go on to sustain a 2nd ACL injury within 2 years upon to RTS. We can’t shy away from the statistics, and we need to try as best as we can not to allow the patient sitting in front of us to become another statistic of 2nd ACL injury!!
  • Surgery is only 50% of the rehabilitation plan. Surgery only restores mechanical/anatomical stability of the knee. It does not restore functional deficits of the knee; some of which may have been present prior to the primary injury (ie. dynamic knee valgus, poor trunk control, abnormal quad to hamstrings ratio).
  • The better the quality rehabilitation (ie. one that includes regular jump, landing, agility training), the more likely the patient will achieve post-operative limb symmetry on strength, hop and agility tests. As a result, the patient will have a significantly reduced chance of 2nd ACL injury.
  • The decision to allow unrestricted training and RTS should be based on an orthopedic assessment, time (at least 9 months post-op) AND a battery of strength and functional tests. The tests must include quads and hamstrings strength tests, hop tests and agility tests and the athlete must achieve at least 90% symmetry between limbs on all tests prior to RTS clearance. In my very humble opinion, we should be aiming to get close to 100% on all tests in both fresh and fatigued states.
  • With the very high rates of contra-lateral injuries, as much as possible, rehabilitation drills need to be performed unilaterally.
  • For better functional outcomes in non-professional athletes, a supervised physiotherapy/strength and conditioning/sports-specific training plan needs to be conducted for at least 12 months prior to returning to sport.
  • Once back playing sport, the patient should be conducting at least 2x per week ACL injury prevention drills (ie. PEP, FIFA 11, KNEE) for the remainder of their sporting career to reduce the risk of 2nd ACL injury.

I hope you have enjoyed this summary of recent evidence. As always, please share this blog with colleagues, other health professionals, patients, coaches, parents, family and friends. The more people are on board with this evidence, I firmly believe that we will start to see declining ACL injury rates, 2nd ACL injury rates and an overall improvement in individual and team performances on the field.