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There was an article in the New York Times recently entitled Sports Injuries: When to tough it out.

The part of the article that stood out involved diagnostic testing. Here is a quote from the article:

“Sometimes going to a doctor for a diagnostic workup can be precarious, with scans that can show all sorts of apparent abnormalities and injuries that are not causing any problems.

For example, in a study reported at a recent meeting of the American Orthopedic Society, Dr. Matthew Silvis, an orthopedist in Palmyra, Pa., did M.R.I.’s of the hips of 21 professional hockey players and 21 college players. They showed abnormalities in 70 percent of the athletes, even though these hockey players had no pain or only minimal discomfort that did not affect their playing. More than half had labral tears, rips in the cartilage that stabilizes the hip.”

“M.R.I.’s are so sensitive,” Dr. Musahl said. “They frequently show little tears or fraying everywhere. And it is very, very common to have a small labral tear in your hip — it doesn’t mean you have to have the particular symptoms.”

The same is true for rotator-cuff tears, rips in the tendons that help stabilize the shoulder. Studies have found that about half of all middle-age people with no shoulder pain have these tears, although they are unaware of them and have no symptoms.

Testing certainly has it’s place but it is important to understand that testing is only one piece of the puzzle. The assessment, symptomatology, mechanism of injury, and experience also play a critical role because:

  • Hockey players are going to have hip labral tears
  • Baseball players are going to have labral fraying
  • Middle aged people are going to have degenerative changes
  • Assembly line workers are going to have tests positive for carpal tunnel and rotator cuff tears
  • Individuals over the ages of 50-60 are going to present with lumbar spine pathology
  • And so on…

And all of these test results could appear in someone who is completely asymptomatic.

It gets interesting when the individual reaches threshold – when symptomatology now presents itself.

Here are a couple of examples to consider from several years ago – both involved individuals diagnosed with carpal tunnel syndrome.

  • One individual fell on their wrist and aggravated their wrist. Within about a week of developing symptoms, an EMG was done and the test came back positive for CTS. So…in 1-2 weeks someone is going to go from not having CTS to now having it???
  • A individual was having significant wrist and shoulder pain – a recent flare-up. They were previously diagnosed with CTS via EMG (chronic case). With the latest flare-up in symptoms, another EMG was ordered since it had been awhile from the previous EMG.  Here this individual was in pretty severe pain and the new EMG results were…EMG results were improved from previous testing and were now within the “normal” range. A person who is in pretty severe pain now is being told that they no longer have CTS???
  • Add your own story or example here.

Everything is fine when 2 and 2 equal 4. It starts to get dicey when things don’t add up as easily. Again, the assessment – the symptoms- mechanism of injury – and your experience as a clinician play a significant role in bringing together the full picture.

As a young athletic trainer, I was under the impression that MRI and other diagnostic testing were the final determinant regarding someone’s injury status. Years of experience, research, professional discussion, and lots of “huh??? This doesn’t make sense” moments have changed that thought process over the years.

Diagnostic testing does have it’s place but it is important to keep testing in the proper perspective. It is a piece of the puzzle and requires putting the other pieces together as well. Diagnostic testing does not slam the door on the case necessarily – plenty of detective work needs to be done so that the entire case can be properly evaluated.

What are your thoughts? Have you had similar experiences when diagnostic testing and reality weren’t quite meshing?

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As an athletic trainer, we are all familiar with the principle of the weakest link.

A related term that I have become more familiar with lately is the term energy leak.

Gray Cook, in his book Athletic Body in Balance, states that an energy leak occurs “when all of the energy generated to perform a certain task or movement does not go specifically into that task or movement.”

Mark Verstegen, in his book Core Performance Women, has this to say about energy leaks: “Energy leaks occur when your body tries to produce force, such as when your foot hits the ground while walking or running. The energy goes up your leg into the rest of the body and finds an area of instability, perhaps around a hip. There the energy dissipates or “leaks” into this unstable joint creating greater trauma on the joint and surrounding connective and muscular tissue.”

Interesting enough – energy leaks don’t necessarily scream out to the casual observer – “LOOK AT ME, I’M AN INJURY WAITING TO HAPPEN!!!.” Individuals can still perform “normally” with energy leaks.

A pitcher can still perform at a high level…an assembly line worker can still perform their job…an individual still can be an avid exercise enthusiast – and all have energy leaks.

Those energy leaks result in microtrauma that will eventually manifest themselves in the form of an injury.

We sometimes have this perception that pain and discomfort are the main markers of microtrauma and injury. We tend to use that as our chief identifier instead of trying to identify  mobility and stability deficits. (Similarly, we use the absence of pain as the chief identifier that the injury is “gone” – again, a flawed strategy.)

The body is incredibly adept at doing “what needs to be done” in order to accomplish a task. That may even include performing a task to the eventual detriment of the body. The body is a great compensator but these compensations lead to the energy leaks that cause problems down the road.

So the assignment for you – don’t wait for pain to manifest itself in order to identify an injury. Assess and evaluate in order to identify energy leaks before they land your athlete or industrial athlete in the training room.

Do you have any examples of energy leaks to share? What are your thoughts?

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A study was published in a 2006 issue of the Journal of Athletic Training that I found interesting back then and wanted to revisit again now. The study, entitled Cortisol Concentrations in Human Skeletal Muscle Tissue After Phonophoresis with 10% Hydrocortisone Gel, was of interest to me because I have performed many a phono treatment over my career and wanted to see “if this stuff really worked”. (Kind of backwards isn’t it but continual learning, that’s the point of all this right.)

Phonophoresis is a treatment that is commonly prescribed by physicians to treat musculoskeletal injuries and the goal of this study was to help determine if the technique really was able to deliver the hydrocortisone to the skeletal muscle tissue that was being targeted with the treatment.

The samples consisted of 6 individuals in the sham group and 6 in the phonophoresis group. Each leg of each subject was utilized for this study. One leg was chosen for treatment and the other was chosen as the control for each subject.

The study involved 12 indivduals who were split into the treatment and sham group. Treatments utilized 10% hyrdrocorisone for the medication and the region being treated was the vastus lateralis. The treatment protocol utilized ultrasound delivered at 1.0 MHz x 1.0 W/cm2 and at 7 minutes utilizing a continuous treatment setting.

After some prep work was done following the single treatment, a needle biopsy was performed in which a sample was extracted from the vastus lateralis muscle. The muscle biopsy was then examined for cortisol concentrations.

Now, the authors acknowledge that phonophoresis has been effective in the driving low-molecular-weight compounds through the dermal layer.  After that however, it is uncertain if the medication is able to make it to the targeted tissues. Hence, this study.

The results as reported by the authors showed no significant difference in cortisol concentration between the control limb and the treatment limb, in either the sham or phonophoresis samples. No significant differences were noted between the sham and phonophoresis groups. So the final conclusion resulting from this study was that 10% hydrocortisone based phonophoresis treatment (delivered at the said parameters) did not raise the concentration of cortisol in human skeletal muscle tissue following treatment.

As we try to base our treatment decisions upon sound evidence, I thought that this study would help give us some additional insight into this common treatment.

Here are some of my observations as well as some additional commentary and discussion added by the authors:

  1. First off, the subjects were better men and women than me. Offering to have some muscle extracted for the sake of science is quite admirable. As you read the study, you’ll think the same thing.
  2. The authors admit that the sample size is small and I would agree. I would have loved to see a much larger sample but going back to the first point, getting many more to commit to what these subjects did may have been a minor miracle in and of itself.
  3. Probably one of the more interesting points the authors brought up centered around treatment length and intensity. At first blush, my thought was that the intensity was probably too low and the treatment length could have been longer. (Treatment lengths for ultrasound will generally vary from 5-20 minutes). The authors did report however that studies with swine showed an increase in cortisol levels with prolonged treatment (17+ minutes) and with lower intensities. I found this very interesting. Treatments at .1 and .3 W/cm2 were more effective in the swine. I may have surmised that higher intensity coupled with longer treatment times would be more effective but previous studies indicate otherwise. How this translates to human studies remains to be seen but the authors do note that utilizing multiple treatment settings for the delivery of phonophoresis should be further investigated. I agree.
  4. Another point the authors brought up was regarding injured vs. uninjured tissue. All of the subjects in this study were of apparent good health. The authors noted that healthy tissue may be more resistant to pharmaceutical delivery. Some studies have also shown injured cells to be more amenable to pharmaceutical delivery. This is a very valid point and very well could have some merit.
  5. Another point the authors discuss revolves around thermal vs. non-thermal delivery. The authors site a reference that notes that non-thermal delivery played a significant role in transdermal drug delivery. This is a valid consideration as well. Does the thermal aspect of the treatment alter or hinder the delivery of the medication versus the mechanical delivery settings? Is a pulsed setting more appropriate in this type of treatment?
  6. The authors also discuss the delivery of the medication indirectly through the blood (once the drug is delivered subdermally, the medication is delivered to the muscle through its blood supply) as opposed to directly through delivery of the medication to the  muscle tissue itself. They discuss this possibility as unlikely but do address it for discussion purposes.

Overall, the study was very interesting and I commend the authors for venturing into this study. It is important to have research validate our methodology. There are a lot of variables that this study was unable to account for but I do think that we did discover some important findings as a result.

So what are some takeaways.
Well aside from the point regarding injured vs. non-injured tissue, the study stongly shows that trying to deliver phonophoresis using 10% hydrocortisone cream to deep muscle tissue at the settings demonstrated is largely ineffective. One would argue that using similar parameters as illustrated and expecting different results is not good practice.

Secondly, the medication is not cheap. I wouldn’t necessarily consider “wasting” this medication utilizing application settings that are ineffective as good practice either.

Does this study particular study discount the use of phonophoresis? At this point, I’d say no but it definitely helps us to start thinking more about what we are trying to accomplish with this treatment and what methods we may go about  in order to accomplish our goals. We really need to consider the area we are treating and the parameters that we are using. What are our goals for the treatment as well? This study should help us to be more specific with our treatment goals.

I think that the authors clearly point to the fact that more research needs to be done and I agree. The trick is to take what we learned through this study and apply it to our daily practice.

What are your thoughts? Do you have any additional observations? Do you know of additional studies that refute or validate these findings. Feel free to share your comments.

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Why do you do what you do when treating a patient? study-pic

Huh???

Okay, let me ask it this way: What is the rationale that you are using when implementing a treatment strategy?

In other words, are you letting experience and research and sound data/information determine your treatment approach or do you rely on what you have always done because that’s the way it has always been done?

Let me give you an example: In the articlCurrent Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature, Reinold, et al. discuss a variety of data that point to the efficacy for the use of exercise to target specific muscles in the shoulder complex.

One of the exercises they examine is the empty-can exercise to strengthen the supraspinatus. Their research validates that the exercise of choice for strengthening the supraspinatus is actually the full-can exercise and not the empty-can exercise. Can you you use the empty-can exercise to strengthen the supraspinatus?  Sure. But when you produce the same amount of EMG activity with the full-can exercise as the empty-can and provide an environment that results in less potential humeral head migration and less anterior and medial deltoid activation, why would you continue to use the empty-can exercise (unless there was an absolute specific result you were trying to create)?

Because that’s what we learned in college…that’s is what someone once taught us…I’ve used that exercise for patients for my whole career…that’s the way I’ve always done it…and you can add your rationale here.

I am of the opinion that just because that is the way something has always been done, it doesn’t mean it is right.

And that is one small example.

Another example is regarding phonophoresis. There was a study in the Journal of Athletic Training a few years back that reported that there was no increase in the level of cortisol in the skeletal tissue following phonophoresis treatment (I’ll try and review this in a later blog post). So…if my goal is to treat deep muscular tissue with phonophoresis in the hopes of driving this medication into the tissue, I quite possibly am laboring in vain since the research is contrary to the goal.

There are countless other examples.

Question yourself and your methods. Frequently review why it is that you do what you do.

It is okay to change course and go a direction that is better – this is patient care, not politics.  Flip-flopping is okay if it ultimately leads to better care for your patients.

So…keep learning and calling into question things you have always done. Review and research again and again. You’ll be a better clinician for it.

Photo Credit by xb3

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Have you recently considered if wrist positioning affects grip strength?

Well, in case you have, this post is going to discuss some facts related to grip strength and wrist positioning.

So lets go through this demonstration to see if wrist positioning does affect grip strength. Working in the industrial setting, this is a demonstration that I will use with patients and other individuals to stress the importance of a neutral grip whenever possible.

So let’s take a look at the first example of grip with the wrist held in the neutral position. A neutral grip was able to generate 105 pounds of force. The second example shows the wrist at approximately 30 degrees of wrist flexion. Pay attention to the grip strength that is generated. The grip strength generated in this position is 68 pounds of force. 35% less than in neutral grip. The grip strength generated near end-range of flexion is 39 pounds of force. This is 63% less strength than generated in neutral grip and 43% less grip strength than generated in ~30 degrees of wrist flexion.

The conclusion: Grip strength generated in the flexed position is significantly less than compared to grip in the neutral position. The greater degree of flexion, the less strength that is able to be generated.

So the answer to the question is yes, wrist positioning does affect grip strength. Now, let’s look at some related information. This is of particular interest with those who have or treat carpal tunnel syndrome.

Extremes of wrist flexion and wrist extension can cause compression of the carpal canal and negatively affect intraneural blood flow. In an average person, pressure within the carpal canal is approximately 2 mm Hg.

When pressures reach 20-30 mm Hg, venular blood flow is impacted. Axonal transport is affected at 30 mm Hg. Neurophysiologic changes such as motor and sensory dysfunction begins at 40 mm Hg. At 60-800 mm Hg, complete cessation of intraneural blood flow is noted. Average carpal canal pressure in carpal tunnel patients in neutral wrist position was 32 mm Hg as reported in the study: The carpal tunnel syndrome: A study of carpal canal pressures. The same study goes on to show that extreme ranges of wrist flexion and extension in those with carpal tunnel syndrome increased carpal canal pressure in excess of 90 mm Hg.

One more aside. In the study: Segmental Carpal Canal Pressure in Patients With Carpal Tunnel Syndrome, the greatest pressure in the carpal canal was found 10mm distal to the distal wrist crease.

So as we bring this to a conclusion. Grip performed in a neutral grip is the optimal position for strength and also presents an environment for minimal carpal canal pressure. Grip performed in the flexion and extension is a less efficient movement and does contribute to increased pressure within the carpal canal.

So this is some information that you can store and utilize the next time you encounter someone using inefficient technique for their task or perhaps someone with carpal tunnel syndrome.

What do you think? Any new information that you would like to share? Any similar experiences that you can speak about to the group.

Additional Source: Carpal Tunnel Syndrome by David A. Fuller, MD

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I came across an interesting study yesterday comparing the use of ultrasound vs. low level laser therapy in treating Carpal Tunnel Syndrome.  The study was published in 2004 and conducted by Amir H. Bakhtiary and Ali Rashidy-Pour, Rehabilitation Faculty in the Physiology Department at Semnan Medical Sciences University, Iran. The study, entitled Ultrasound and laser therapy in the treatment of carpal tunnel syndrome, was published in the Australian Journal of Physiotherapy.

5770147_aad5619c5f1It is important for continued research such as this to be done. Low level laser therapy and other forms of light therapy have burst onto the scene over the last several years, particularly in the United States and so continued study as to their efficacy is important. Furthermore, carpal tunnel syndrome can be a debilitating condition and further studies to help provide quality treatment for those with CTS is important.

This study is of particular interest to me because as an athletic trainer in the industrial setting, this is a condition I see plenty of. Secondly, this is of interest because I have extensively used both treatments in the past to treat carpal tunnel syndrome and I was interested to see the results. This particular study concluded:  “Our clinical trials showed that ultrasound treatment is more effective than low level laser treatment in patients with mild to moderate carpal tunnel syndrome.”

The study had a sample group of 50 patients and a total of 90 wrists were treated. Each wrist was treated exclusively with either ultrasound or laser treatment. Patients were treated daily over a three week period for a total of 15 treatments.

The part that I found most interesting however involved the treatment parameters and this is probably where I have the most questions with the study. Ultrasound was delivered at a dosage of 1.0 W/cm2 for a total of 15 minutes per treament. The low lever laser treatment on the other hand was delivered at a total of 9 Joules over 5 points along the median nerve. This dosage equates, according to the study, to 1.8 Joules per treatment point.

According to the study, the results overwhelmingly favored ultrasound as a superior treatment based upon pre and post-treatment measurements.

As someone who has treated CTS for over the last 15 years utilizing each of these modalities, I observed the following in regards to this study:

  • Ultrasound was delivered at an intensity of 1.0 W/cm2. This seems to be reasonable. I may tend to use a slightly higher intensity personally (1.25 W/cm2) but this is dependent upon several factors and for the sake of the study, this seems fair.
  • Ultrasound was delivered at a treatment time of 15 minutes per treatment. This treatment time seems to be on the excessive side. (Now, on the flip side – if this did have positive results, maybe we need to reexamine our treatment times regarding ultrasound – but that is for another discussion.) Typical treatment times for the administration of ultrasound is generally 5-10 minutes, wouldn’t you agree? So, using ultrasound for 15 minutes per treatment seems to be in excess of what would be considered normal.
  • According to the study, laser was delivered at 1.8 Joules x 5 treatment sites for a total of 9 Joules. While the treatment dosage of ultrasound may be excessive, the treatment dosage for the laser treatment seems to be extremely low. The laser that we use at our facility utilizes three infrared diodes that each deliver 1 Joule of energy per treatment cycle. So for every 33 second cycle that we administer treatment, 3 Joules of energy are delivered per site. We typically will treat each site with 3 treatments and then treat a total of 3-5 sites at the wrist and hand. (Treatment is based upon manufacturer’s recommendations). So each site will receive 9 Joules of energy and this would again be repeated at 3-5 sites. This is a significant contrast to the treatment dosages used in the study.

Studies in this vain are important and I applaud those who conducted this study. Having said that, I am not sure that you can make the conclusion that ultrasound is a more effective treatment in mild to moderate CTS cases based upon the above observations. I do find the results, particularly with the ultrasound, interesting and definitely worth more investigation. I am just not completely sure, based upon what I read in the study, that the treatment dosages were “equitable”.

Am I incorrect in my observations? What are your thoughts? I am interested to hear what you think.

Photo Credit,  mrebert

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This is supposed to be a joyous time of year and yet every time you turn around, the news just seems dismal. If you aren’t careful, all the doom and gloom just might bring you down. So I thought it was important to highlight some stories directly related to the field of Athletic Training that verify that what we do is important and positively affects the lives of those we serve every day. So take a look at these stories and testimonies and feel better about what you do – you are making a difference. Here’s the proof:

  1. While the story is born out of tragedy, I think that the implications speak to service that Athletic Trainers provide. Board members from the North Carolina High School Athletic Association have proposed that nine recommendations to improve the safety of student athletes be implemented. At the top of the list – every every high school have a Certified Athletic Trainer. Check out the story. While it is sad that it took tragedy to get people to finally act, we can take comfort in knowing that Certified Athletic Trainers are viewed as a huge part of the solution, they are valuable, and they help keep students safe.
  2. There is a four-page article in the December 2008 edition of HR Magazine written by Kathryn Tyler highlighting the benefits of Athletic Trainers in the workplace. Here are some excerpts from that article. ” In a 2003 survey report – the latest available – from the NATA, all 32 respondents, including HR professionals and safety managers, said their athletic trainers provide a positive return on investment of about $3 for each dollar spent, and almost all said the severity of employee injuries had decreased by at least 25 percent since they brought an athletic trainer on-site.” She goes on to highlight several success stories including this one. Gainesville, Fl. hired an ATC for their city employees. Steve Varvel, the city’s risk management director, reported that the return on investment “is a 300 percent direct return – $160,000 to $175,000 per year.” In the year after the full-time athletic trainer was hired, “the city reported a 20 percent reduction in the number of workers’ compensation claims and a $300,000 reduction in claim amounts.”
  3. Suzi Higgins, ATC is the Head Athletic Trainer at Case Western Reserve University. She has initiated an anti-tobacco campaign with any team needing an intervention. The program is three fold and includes 1) education; 2) tobacco alternatives utilizing sponsorship from David’s sunflower seeds and Quench gum; and 3) genuine care and concern. Through this program, Suzi knows of two coaches who were heavy tobacco users that stopped and that helped to lead the way for the kids to follow suit. Suzi says, “Knowing you potentially saved someone’s life, it’s a good thing.”

So when you start asking yourself – do I really make a difference? Is what I do really worth it? Hopefully you’ll catch a glimpse from these three quick examples that the answer is unequivocally – YES. Now go out and make a difference today!!!

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