Arthroscopic shoulder decompression surgery (ASAD) is a surgery performed for patients with subacromial shoulder pain, or “shoulder impingement”, which accounts for up to 70% of all shoulder pain problems.
The first ASAD was performed in 1972, and it is now one of the most common surgical procedures in orthopaedics. The rationale behind the procedure is that the pain is caused by excessive compression of the rotator cuff (shoulder muscles) and its bursa between the acromion bone and humeral head when moving the arm. That is, the muscle is pinched/compressed between the two bones. The surgical procedure involves removing the coracoacromial ligament and shaving the bony arch of the acromion bone, which will reduce the compression, thereby reducing or eliminating symptoms.
A review in 2009 explored the scientific literature on sub-acromial shoulder pain, which showed that there was no difference between patients treated with surgery and those treated with non-surgical options. The review, however, noted that its findings were limited by the poor quality of the literature, and recommended that more high-quality trials are undertaken. To address this gap in the research literature, a very large clinical trial was more recently conducted, involving 313 patients and 51 surgeons at 32 hospitals, with the results published in the prestigious journal ‘The Lancet’ in 2018. The trial was titled ‘Can Shoulder Arthroscopy Work?’ and its aim was to investigate the effectiveness of ASAD (Beard et al. 2018).
The clinical trial compared three groups of patients with subacromial pain, who had not responded to conservative treatment (exercise and steroid injections). Patients were randomly assigned to one of three groups: (i) a control group which received no further treatment; (ii) a group which had investigational arthroscopy surgery acting as a placebo, as the essential surgical element (bone and soft tissue removal) was omitted; and finally (iii) a group which had standard arthroscopic shoulder decompression surgery. All patients had the same aftercare, and all patients and healthcare professionals involved in the trial were blind to the surgery performed.
The results showed that there was no significant difference between the two surgical groups, with both surgical groups only showing a small benefit compared to the “no treatment” group after six and twelve-month follow ups. The authors of the paper questioned whether the benefit that the surgical groups had over the “no treatment” group was due to a placebo effect from the surgical procedure. This trial strongly questions the continued use of ASAD in the management of subacromial pain.
Physiotherapy has been shown to be effective for reducing pain and improving function for patients with subacromial shoulder pain (Steuri e al. 2017). If you are suffering from shoulder pain, please call us on (02) 9232 5566 or click here to schedule a consultation with one of our Bend + Mend Sports Physios in Sydney’s CBD.
Steuri R, Sattelmayer M, Elsig S, et al Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs British Journal of Sports Medicine 2017;51:1340-1347.
Beard et al. 2018. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet. Volume 391, Issue 10118, P329 – 338.
An OASIS refers to the trauma of the Perinuem which occurs in vaginal delivery. It is where the Perinuem tears from the vagina down towards and into the anal sphincter and potentially the mucosa as well. It is commonly referred to as a third or fourth degree tear. This type of injury can commonly lead to anal incontinence.
Eason et al. 2002, Tin et al. 2010 and Johanessen et al. 2014 all looked at the prevalence of pregnant women who sustained an OASIS at birth of having anal incontinence and found that they were at a significantly increased risk. In addition, a study by Evers et al. 2012 found that women who sustained an OASIS were significantly more likely to still have anal incontinence 5-10 years post-partum.
How Common Is It?
Corton, McIntire, Twickler et al. 2013 showed that OASIS is more common than we are led to believe. They found that the rate of OASIS following vaginal delivery is approximately 18%!
Are Certain Women More Likely To Sustain An OASIS?
Research shows that there are certain women who are more likely to sustain an OASIS. Women who have a vaginal delivery where forceps are used are at a higher risk of OASIS (Heir, O’Connor, Higgins et al. 2013).
As maternal age increases, so does the risk of OASIS with vaginal births. In fact, women over 25 years of age are twice as likely to suffer from an OASIS than women under 25 years of age (Guiro-Urganci et al. 2013).
Perineal length has also been shown to be relevant in the prevalence of OASIS (Dua et al. 2009). Perineal length refers to the distance of the base of the vagina to the start of the anus. Geller et al. 2014 found that if a woman has a perineal length of less than 3cm then they are at a higher risk of OASIS. Aytan et al. 2005 found that when a mediolateral episiotomy was performed on women with a perineal length of less than 3cm, this significantly reduced the chance of OASIS.
Williams et al. 2019 found that race/ethnicity is a factor as well. This study found that Asian women had a higher rate of OASIS when compared to women of other backgrounds.
Landy et al. 2011 found that women with a lower BMI had a higher risk of OASIS than women with a higher BMI.
Lastly, Raisanen et al. 2013 and Gudmundsson et al. 2015 found that shorter women are at a higher risk of OASIS than taller women.
If you have any questions or concerns or you want to know more about what could help you be as informed as possible for childbirth then come and see Bonnie, our Women’s Health Physiotherapist at Bend + Mend Physiotherapy in Sydney’s CBD.
Firstly, before we discuss the UR-CHOICE study, it is important to note that life is unpredictable and as much as we can try and predict the potential complications that may or may not happen in childbirth, sometimes things are just out of our control. In saying this, I believe that it is extremely important that pre-natal women are as informed as possible so they can make the right decision for them and their baby. Factors such as the baby’s health must come into consideration and depending on other factors may supersede any pelvic floor risk factors discussed below.
The UR-CHOICE study by Wilson et al. 2014, set out to try and work out which pre-natal women are at a low, medium or high risk of certain complications in childbirth. If we could work this out then the goal would be that more women are making informed birth choices, less women are having significant childbirth complications and of the women who do have significant childbirth complications, they are understood better.
UR-CHOICE stands for?
U – Urinary incontinence before pregnancy
R – Race / Ethnicity
C – Childbearing started at what age?
H – Height (mother’s height)
O – Overweight (weight of mother, BMI)
I – Inheritance (family history)
C – Children (number of children desired)
E – Estimated fetal weight
All of the above factors have been researched and identified as predictors in pre-natal women for sustaining pelvic floor dysfunction. Wilson et al. 2014 stated: “We believe that the UR-CHOICE score should be estimated for every pregnant woman antenatally between 37 and 38 weeks to help with the prevention of pelvic floor dysfunction.”
Questions that are commonly asked to me in the clinic are:
“Why didn’t someone tell me before that this could have happened?”
“Could there have been a way to predict this before childbirth?”
“Could I have prevented this?”
I think as health professionals, we have a duty of care to our patients to provide as much information as possible for them to make as an informed decision as possible. It is my goal as a Women’s Health Physiotherapist to ensure that I help my patients make an informed choice and do what they believe is the best decision for them and their baby. If you have any questions or concerns or you want to know more about the UR-CHOICE predictive study then come and see Bonnie, our Women’s Health Physiotherapist at Bend + Mend Physiotherapy in Sydney’s CBD.
What’s the likelihood that something will go wrong during labour? This is a really tricky question that I am regularly asked by my patients. How can we predict something that’s so variable and somewhat out of our control?
In 2018, a study by Caudwell-Hall et al. looked at 483 women and wanted to know how many of these women had an atraumatic (without trauma), normal vaginal delivery. In this study, they found that 23% had a cesarean, 21% had operative delivery and 4% had Obstetric Anal Sphincter Injuries (OASI). This means that 51.9% of women had an atraumatic, normal vaginal delivery. That’s half of the women in this study.
However, this study did further testing using Ultrasound on the women who had an atraumatic, normal vaginal delivery (51.9%) and found that an extra 5.5% had a levator avulsion injury and an extra 6.4% had a sphincter injury. This brings our number of women who had an atraumatic, normal vaginal delivery down to 40%.
Then this study delved even deeper and found that of this 40%, an extra 7% of these women suffered microtrauma. This brings our final percentage of women who have an atraumatic, normal vaginal delivery to 33%! This study concluded therefore that only 33% of women will have an atraumatic, normal vaginal delivery. They also noted that the prevalence of potential issues in childbirth are higher than current assumptions. I don’t know about you but this statistic makes me cringe. It makes me think about what could potentially be done for women pre-natally to help increase the number of women who actually have an atraumatic, normal vaginal delivery.
However, once again, how can we predict something that’s so variable and somewhat out of our control? There is more and more research coming out that health professionals should be aware of and utilise when seeing pre-natal women. There are screening tools now that can be used to make women aware of the risks and likelihood of whether it is more or less likely that they may sustain certain complications during childbirth. In saying this, I don’t believe we will ever be able to firmly predict something so unpredictable as childbirth but if we can screen pre-natal women and be able to identify those who are at a high risk of complications with childbirth then hopefully we will be able to increase the number of women having an atraumatic, normal vaginal delivery. In addition, when these complications do occur, women are more informed and prepared to handle them.
My next blog will be discussing UR CHOICE, which is a screening tool that can be used to identify women who may be at a higher risk of complications during childbirth. If you have any questions or concerns or you want to know more then come and see Bonnie, our Women’s Health Physiotherapist at Bend + Mend Physiotherapy in Sydney’s CBD.
Depression is becoming more widely and acceptably spoken about, and while there is still lots we need to research to further understand the complexity of depression, there is an increasing understanding of the role exercise plays in its management. With over 100 studies conducted on the role of exercise in the management of depression there is an increasing awareness of the crossover of physiotherapy as an adjunct to managing the exercise component.
While there is no magic cure to depression, researchers have identified the chemical release in the brain during exercise can have an anti-depressant effect. Exercise helps improve mood, energy and general well being. One positive effect of exercise is the release of hormone and neurotransmitters which positively influence the effects of depression. These neurotransmitters can also help mitigate the effect of stressful events which cause depression, acting like a buffer.
In contrast to this, there is a common notion that having depression can act as a barrier to exercise. Yes mood plays a role, but physically there is no evidence to suggest that depression affects a persons ability to exercise.
How is this relevant to physiotherapy? The long answer involves a patient-centred approach. Physiotherapy is not just about restoration of movement from an injury, it’s about enabling movement and promoting function. There is more to an individual than just an injury, we all have our own stories and experiences of the world, and the same injury does not affect two individuals the same. Physiotherapists are specialists in getting people to move, which includes exercise prescription, goal setting, monitoring progression of programs and most injury prevention and rehabilitation. We are adept at adapting our approach according to the patient’s needs.
Systematic reviews of types of exercise interventions and duration of exercise programs are poorly understood. As you can guess there is no magic type of exercise that is better than any other, nor are you more likely to respond to a specific intensity. General consensus suggests however that a program should be based around the following points:
A minimum exercise program duration of 9 weeks
150 minutes per week of aerobic activity
Include 2-3 sessions of strength based training
Choosing an exercise modality that you enjoy increases adherence, Eg. team sports vs solo endeavours
While we are not a substitute for psychological, medical or pharmacological interventions, physiotherapists can add value in management of depression. If you would like assistance in improving function, advice on exercise prescription or setting exercise goals come in and see one of our friendly Physiotherapist’s at Bend + Mend in Sydney’s CBD.
Exercise progression is increasing the difficulty of an exercise so that you can continue to see improvements in that particular activity.
There are different ways in which an exercise can be progressed. One way is to increase the weight. For example, with heel raises using just your body weight adding a heavy backpack will increase the weight of the exercise.
Increasing the number of repetitions can also increase the difficulty of an exercise. However sometimes this can change the purpose of the exercise. Lower repetitions are generally more for muscle strength and higher repetitions works towards the endurance of a muscle.
You can also lengthen the duration. For example, increasing the time you are walking or running.
In general exercise progressions should only increase by 10% at a time. This sometimes can be hard to figure out. Exercise progressions guided by your Physiotherapist are the best way to ensure you are increasing the difficulty by the right amount. Sometimes making an exercise too hard can in fact worsen or re-injure your current symptoms.
Why do I need to progress my exercises?
Exercise progression is a key aspect of gaining muscle strength. Muscle adaptation occurs when an exercise becomes easy. This means your body is now no longer challenged by this activity and will plateau at that level. Your body needs to have increases in difficulty for you to continue to adapt and improve. Without exercise progression a patient won’t continue to see improvements in their rehabilitation.
When should I progress my exercises?
The time in which you should progress your exercise is different for every individual. Each person takes a different amount of time to adapt to an exercise. If you feel as though your exercise is easy and you are no longer being challenged by it then this can be a good indicator that you need a progression.
If you have an injury or need help with your current exercise regime, contact Bend + Mend to discuss this with one of our Physiotherapists today.
The Pilates Ring or sometimes known as the “magic circle” is an apparatus used in Bend + Mend’s Group Physio classes. The ring can be used in various ways to challenge your body. It can be used to assist with stretching or strengthening. This blog is going to discuss four different ways in which you can use the Pilates Ring.
Place the ring around the outside of your knees. Roll your spine up into the bridge with outwards pressure on the ring. Once at the top of the bridge, then slowly roll your spine down with continued outward pressure on the ring. Using the Pilates Ring with your bridges makes this exercise more challenging for your gluts than a standard bridge as you are engaging you glut muscles to apply the outward pressure on the ring.
Inner thigh squeezes
The ring is placed between your ankles and you are in a sidelying position. Support your head with your lower arm or a pillow. Engage your inner thighs and try to get the ring to touch. Then slowly release the ring, keeping in control of the pressure.
Lay on your back with the ring in your hands and feet towards the ceiling. Lift your chest from the floor by shortening the distance between your ribs and hip bones. Place the ring between your ankles and slowly lower your chest back down to the ground. The chest should be lowered slowly resisting gravity which wants to drop you back towards the ground. By slowly lowering you are challenging your abdominals throughout the entire exercise.
Laying on your back hook the ring over the arches of your feet. Hold onto the ring with an underhand grip and let your shoulders drop down towards the floor. Don’t worry if you can’t straighten your knees, your hamstrings will still be stretched. You may even feel a calf stretch here too.
If you would like some help incorporating these exercises into your routine, book in for an Initial Assessment with one of our experienced Bend + Mend Physiotherapists today.
The Spikey Ball can be both your friend and your enemy at times. We use this tool to help release trigger points as well as provide some self-massage to muscles. Generally, the firmer the ball the deeper the release will be. It also can be quite painful when the ball is firmer. I would start with a softer ball to ease yourself into the release techniques and then progress to a firm one if you feel its needed.
You can either use the spiky ball standing or lying on the ground depending on what you are trying to release. When you are lying on the ball on the ground this can be quite a firm release as your body weight is applying the pressure. If that feels too painful you can always try the same muscle group in a standing position, this way you can monitor the pressure more easily by not pushing into the ball as hard. Once the ball is in position you can either hold it there or roll it around if that feels better. Start with 30 seconds of release and as your tolerance improves you can continue to lengthen the time. Using the spiky ball whilst watching TV is a great way to distract yourself from the time and pain spent on the ball.
Some areas to release using the Spikey Ball are:
Upper trapezius mucsle
Front and side of hip muscles
If you would like some further help on how to use the spiky ball the Physio’s at Bend + Mend would be happy to assist you. If the spiky ball isn’t quite enough to fix your problem then you can come in for an assessment with one of our experienced Physiotherapists at Bend + Mend in Sydney’s CBD today.
As trends in exercise have changed, so too have routines that we find ourselves completing. Todays topic…Foam Rolling.
Foam rolling, although not a new concept, is one that we are increasingly learning more about in the scientific community, whether its benefiting functional performance, flexibility, or just generally feeling good. What was once thought of as a fad is here to stay. But what does it do? And how can it assist your workout?
Lets break this down into what effect foam rolling has on pre exercise, and what is does post exercise.
Pre exercise (before exercise)
A recent study (Su et al., 2017) compared the acute effects of static stretching, dynamic stretching and foam rolling used as part of a warm up on flexibility and muscle strength of knee flexion and extension. The results showed greater improvements in flexibility after foam rolling compared to static stretching and dynamic stretching. In regard to strength, knee extension improved after both dynamic stretching and foam rolling, but not after static stretching. From this we can see that foam rolling, as part of a warm up, can help improve flexibility without having a negative impact on strength.
Post exercise (after exercise)
Another study (Pearcey et al., 2015) compared the effect of foam rolling on quadricep delayed onset muscle soreness (DOMS). Participants performed 10 reps x 10 sets of weighted back squat at 60% of their 1-repetition max followed by either no foam rolling or 20 minutes of foam rolling immediately, 24 hours and 48 hours post exercise. The results showed a significant reduction in quadriceps tenderness in the days after fatigue in the foam rolling group compared to no foam rolling.
Below are a few helpful videos of how to foam roll your ITB, Quads and Calves!
Su, H., Chang, N., Wu, W., Guo, L. and Chu, I. (2017). Acute Effects of Foam Rolling, Static Stretching, and Dynamic Stretching During Warm-ups on Muscular Flexibility and Strength in Young Adults. Journal of Sport Rehabilitation, 26(6), pp.469-477.
Pearcey, G., Bradbury-Squires, D., Kawamoto, J., Drinkwater, E., Behm, D. and Button, D. (2015). Foam Rolling for Delayed-Onset Muscle Soreness and Recovery of Dynamic Performance Measures. Journal of Athletic Training, 50(1), pp.5-13.
Lisfranc injuries are notoriously difficult! They are often missed during diagnosis and can have a very slow recovery time.
Alice, one of our lovely physios, has written a blog previously describing in detail what a Lisfranc injury is. This blog will go over what a ‘typical’ rehabilitation program would like for someone who has undergone surgery.
As mentioned in our previous blog, a Lisfranc injury involves the Lisfranc ligament that attaches the second metatarsal to the medial cuneiform within the mid-foot. The severity of this can vary greatly from a mild sprain to full fracture dislocation. A Lisfranc injury is often caused by a direct injury, such as a car accident or fall, or indirectly where the foot in placed in dorsiflexion then rotated. For example, during a soccer games where a player is on their toes and suddenly twists.
Once a Lisfranc injury is diagnosed (typically by a weight-bearing x-ray) it will be determined whether the injury is stable or unstable. Stable Lisfranc injuries are often less severe and have no fractures or non-displaced fractures. These injuries are often managed conservatively within a boot. Unstable Lisfranc injuries result in displacement of some or all of the tarsometatarsal joints with associated ligament rupture and/or significant fractures. Unstable injures are commonly managed operatively where the bones are fixed with screws, pins, or k-wire to allow for the injury to heal in a stable position. Fusion of this joint is also another operative management option.
Below is an example for a Physiotherapy rehabilitation programme for a Lisfranc Injury following surgery. Each individual should be given a rehab protocol which may vary depending on their specialist and/or severity of injury.