Optimum DPT Blog #11 MEAT Not RICE!

In last week’s blog post we discussed that icing and following the RICE (rest, ice, elevation, and compression) protocol, while wildly popular, is not the best way to treat the pain and inflammation of an acute injury.  Icing or following RICE is very effective at providing pain relief; however, it is likely delaying your recovery.

So, what should you do?

To recover the fastest from acute injuries, it turns out an active recovery is the answer. 

So out with RICE and in with the MEAT! (Sorry vegetarians and vegans.)

MEAT stands for Movement, Exercise, Analgesia, and Treatment.  It has been proposed as the optimal approach for managing acute injuries. 1

So, lets break MEAT down like a low and slow smoked brisket…

Movement:

There’s a couple saying from the NOI group—“movement is medicine” and “motion is lotion”.  Instead of resting an injury, moving the damaged area through a full range of motion that is pain free.  First gentle movement generates a muscle contraction, this a propulsive force necessary to move lymph (swelling) throughout the body.  The lymphatic system largely mirrors the circulatory system; however, it does not have an active pump (the heart) to move fluid. It is passive and relies on contraction of the muscles or “muscle pumps” to function normally.  When you’re fully resting an area there’s no muscle pump and swelling more readily accumulates. Another benefit to movement, the pain-free movement (and later exercise) does some interesting things with the nervous system which decreases pain and the perceived threat surround the injury. Basically, the more you move it in a pain-free manner the better you’re going to feel, and the more you expect it to feel better… which makes you feel better.  It’s a nice positive feed back loop!

Exercise:

Gentle exercises should be the next progress.  It increases circulation to the area.  More blood equals more oxygen and nutrients to the injured tissue.  That equates to faster recovery.  Additionally, movement and exercises introduce a gentle amount of stress into the injured tissues.  That stress or load, helps trigger new tissue grow and ensure the new tissues are formed in an organized manner, increasing their strength along the direction of tension.  That equates to a better recovery.  A recent study on amateur athletes with severe muscle injuries found that those who started early therapeutic exercises (2 days after injury) recovered on average 3 weeks faster than those who vs delayed exercise (9 days after injury). 2

Analgesia:

Analgesia is a fancy word for pain relief.  Pain limits one’s ability to efficiently move an injured area through a full range of motion or engage in exercise, so addressing pain to allow as much movement as possible is key.  Pharmacologically, NSAIDs (nonsteroidal anti-inflammatory drugs) like Ibuprofen, Aleve or Advil, are commonly taken for pain management.  But NSAIDS alone do not expedite recovery and could be delaying it as they—by name-- disrupt the inflammation which is part of the body’s natural healing process. Tylenol is also commonly used.  Tylenol is not an NSAID and will not disrupt prostaglandin synthesis; however, Tylenol and the liver do not play nice with one another.  Additionally, both Tylenol and NSAIDS can cause gastrointestinal issues even if taken as recommended.  Therefore, it is always a good idea to discuss medication use with your physician!  But pain relief comes in many other forms.  Topical analgesics like biofreeze, Ben Gay, Tiger Balm, etc), massage therapy, and the application of heat are other good options for temporarily decreasing pain to allow you to better move an injured area and participation in exercise.

Treatment.  This is a broad category that consists of treating the individual injury using a variety of therapeutic approaches—e.g. physical therapy.  Specific prescribed therapeutic exercise and activities are the cornerstones of treatment for acute injury.  And there’s a myriad of complementary therapeutic interventions which relieve the pain of acute injuries, augment the therapeutic exercises, and expedite recovery: soft tissue mobilization, joint mobilization or manipulation, dry needling, electrical stimulation, H-Wave NMES, and blood flow restriction rehabilitation.

We’ll talk more about those in the coming weeks! But if you’d like to know more just give me a call at 231-881-9770!

So MEAT in summary is: do what you can to decrease the pain (but not ice), so you can begin moving the injured area as much as possible without causing pain, then begin exercises and therapy ASAP!

 References:

1.       Campbell, Ryan. (2013, December) Goodmed Direct Primary Care. Retrieved from https://goodmedclinic.com.

2.       (PDF) Early versus Delayed Rehabilitation after Acute Muscle Injury (researchgate.net)

Optimum DPT Blog #10 Should I Ice It?

A recent trip from a family member to the doctor’s office and being told to rest, ice, compress and elevate the injury prompted this blog post…

Should I Ice It?

It is one of the most frequently asked questions I’m asked at Optimum DPT.  A summertime hot take…

No.

But that’s heresy you charlatan! When I tweak something, I ice it.  Like my father before me and his father before him!

Roll an ankle: Ice it.

Tweak your back: Ice it.

Pull a hammy: Ice it. 

Yes, we’re icing folk round these parts and you’re kind isn’t welcome round here!

Hey, I get it. Icing a new injury was still gospel when I was in undergrad studying to be an athletic trainer and later physical therapy school (1999-2007). (Geez time flies.) And, if you or someone you know has played sports in the past 60 years, you’ve likely heard from every physician, therapist, trainer, and coach that icing all injuries is the way to go.  You may have even heard of the acronym RICE--Rest, Ice, Compression, Elevation-- is the best thing you can do for your injury. 

But why is that? 

Well studies from early 1940’s describe that surgeons would use ice to help control pain, lower infection rates, decrease the rate of dying on the operating table.1 This is because ice slows down cellular metabolism, and this allows surgeons to keep as much tissue alive as possible. While ice was intended to preserve lost limbs and decrease surgical complications, it would eventually sneak its way into being used for all injuries.

The key moment for this happened in 1962 when a 12-year-old boy was playing on some train tracks. (That never ends well.) He zigged when he should have zagged, and he lost an arm.  But then, for the first time in history, surgeons successfully reattach a whole limb.  To preserve the boy’s arm a lot of ice was used.2

This a was major medical milestone, and news story of the successful operation spread. People had lots of questions.  Medical jargon answers are hard to remember, but that doctors “iced” the boy’s injured tissue was easy to recall.  Public’s take away: any injury needs a good icing.  Seems legit. That logic combined with the fact that icing does provide significant pain relief was the foundation for our “ice every injury” mentality. 

Fast forward a little more than a decade to 1978.  Harvard physician Dr. Gabe Mirkin published the “Sportsmedicine Book” and in created the acronym “RICE” (Rest, Ice, Compression, and Elevation) which was considered the gold standard initial four activities for treating the pain and inflammation of an acute trauma.  RICE cemented the concept that icing is THE WAY to go to treat the pain and swelling of a new injury.3

As I said in 2007 icing and RICE was still considered the gold standard… but is it today?

No, we’ve cooled on icing injures (but not on bad puns). And, more come to accept that inflammation isn’t necessarily bad.4

In 2013, Gary Reinl published “Iced! The Illusionary Treatment Option.”  In which refuted the RICE protocol, citing numerous research that icing-- while it feels good-- is certainly not beneficial and likely detrimental to a person’s recovery.  “It’s actually the worst thing you can do.”

Evidence suggests that icing will:

• Prevent the natural flow of oxygen and nutrients via blood circulation.

• Trap metabolic waste in and around the injured area.

• Potentially cause additional damage to tissues and nerves.

• May delay recovery

For most people in pain, anything that takes away the pain (even temporarily) can feel like it’s helping.  Since icing can very effectively numb pain, many may think that it too is helping.  But in reality, it’s just putting a band-aid on the pain, it’s not actually fixing anything.” 5

Reinl’s argument and supporting evidence was so strong that in 2015 Dr. Mirkin recanted his position and advised people to abandon the RICE protocol he coined.

“Subsequent research shows that rest and ice can actually delay recovery. … the application of cold suppresses the immune responses that start and hasten recovery. Icing does help suppress pain, but athletes are usually far more interested in returning as quickly as possible to the playing field. So, today, RICE is not the preferred treatment for an acute athletic injury.” Reinl, G. (2013). Iced! The Illusionary Treatment Option, 2nd ed. United States of America: G. Reinl

Well, shoot. Now what?

Find out in the next post!

References

1.       Massie FM. Refrigeration anesthesia for amputation. Annals of Surgery. 1946;123(5):937-947

2.       May 23, 1962: Give That Kid a Hand! | WIRED

3.       The R.I.C.E Protocol is a MYTH: A Review and Recommendations – The Sport Journal

4.       The Use of Ice For Inflammation: A Prehistoric Approach That Should Be Discontinued

5.       An Interview with Dr. Kelly Starrett and Gary Reinl

Optimum DPT: Blog #8 Brain Warriors Fundraiser 5k Run Walk Roll

A non Optimum DPT post!  Early summer is a great time to get out and exercise, especially in northern Michigan.  So...

Do you love to run? 

Do you sorta of kind of like to jog? 

Do you at least not mind walking or moving in general? 

I'm glad you said yes, because here is a great opportunity for you:

The 1st annual Northern Michigan Brain Warriors 5K or 1 Mile Run, Walk or Roll.  

It fun time for all ages and goes to support and learn about brain injury.  This event's scenic route takes you along the beautiful fully paved, Little Traverse Wheelway in Petoskey, MI.

A brain injury can be sustained from any of the following activities: fall, concussion, cancer, auto accident, bike accident, military injury, and more.

Benefit proceeds will be donated to the Brain Injury Network of Northern Michigan ( http://braininjurynorth.com/ ) whose mission is to "...educate and empower members, providers and the community in the treatment and recovery from brain injuries."

I've already signed up (represent Optimum DPT and Therapy Solutions) and am planning on a strong showing by at least not taking last place for my age group!

Location:  Bayfront Park West, Petoskey

Date/Time Information:  Saturday, June 2, 9am to 11am Registration begins at 8:30 am

Contact Information:  Therapy Solutions (231) 487-0080

Interested in joining me?  Click HERE! 

Until Next Time,

Matthew Gaunt, DPT, ATC, Dip. Osteopractic, FAAOMPT

Optimum DPT: Blog #7 Pain Talk

Just a friendly announcement reminder!  I am doing a talk on Pain tomorrow at Pilates Midwest on M-119 at 1:00 PM.  If you or someone you know is suffering from pain there's a 100% chance you'll get something useful out of attending.  It's also free (minus your Saturday afternoon free time).

I hope to see you there!

Until Next Time,

Matthew Gaunt, DPT, ATC, Dip. Osteopractic, FAAOMPT

Optimum DPT: Blog #5 Rotator Cuff Tears... it's not over for your shoulder!

I was talking with a gentleman recently and the topic of shoulder pain came up.  His shoulder had been hurting for a few months, and he had been having trouble lifting and reaching over head as well as getting comfortable enough for good sleep.  So he went into see his physician and got some scans that showed a partial rotator cuff tear.  He was afraid that his shoulder was permanently damaged, and that he was going to need surgery.  I told him that he probably would not need surgery-- physical therapy and a few home exercises would most likely get him back to normal.

Let’s take a quick look at some of the current research.

First, rotator cuff tears are pretty darn common, affecting, very conservatively, 10% of those over the age of 60 or 5.7 million people in the United States.1-2 Other research suggests that rotator cuff tears are far more prevalent—about 35% of those in their 40s, 50% of those in their 60s and 80% of those in their 80s.3  

Interestingly, a rotator cuff tear can be completely pain free, with up to 96% of people being unaware that they even have an injury or abnormality!3-4 This is because most tears arise from slow, age-related changes overtime that your body adapts and gets used to.  No perceived threat or danger = no pain.5   

However, when the change to the rotator cuff happens suddenly (during a fall, car crash, etc.) your body has no time to adapt.  That’s when you really feel it!

Rotator cuff repairs are performed on between 75,000–250,000 patients per year in the United States.6,7However, rotator cuff repairs fail at a surprisingly high-- 25% to 90%.8  But here’s the real shocker… patient satisfaction and functional outcomes are the virtually identical regardless of the repair being intact or failing!9

How can that be?

Well, Kuhn et al, 2013 thought that the physical rehabilitation post-operatively may be the actual cause of the successful recovery in most people.  They looked at more than 400 patients with atraumatic full-thickness rotator cuff tears (completely ruptured tendons).  Instead of surgery these patients were treated by a physical therapist for 6 weeks (averaging 8 treatments) and given a good home program of therapeutic exercises.  At the 6-week follow up patients could declare themselves 1) cured, 2) improved or 3) in need of surgery. 

Only 9% felt that they needed surgery. 

Of those that indicated “improved” an additional 6 weeks of physical therapy (averaging 7 treatments) and home exercise were given.  Afterwards, only 6% felt they needed surgery—for a total of 59/399 or about 15%.

The physiotherapy stopped at this point, but patients could continue with the home exercises.  However, Kuhn et al then kept track of the patients.  At 1 year an additional 6% had opted for surgery.  After 2 years the numbers got a little murky with about 15% of the patients not responding, but only 5% more reported electing surgical repair sometime in that 2nd year-- for a grand total of 26%.

Meaning that somewhere between 74-79% of people got better and stayed better with just 8-15 treatments with a physical therapist over a 6-to 12-week period and some home exercises!

What that tells us is that just because someone has a rotator cuff tear it doesn’t mean they are doomed to a lifetime of pain or need surgery to get back to normal.  You might want to try some physical rehabilitation though! 

Your outcomes at Optimum DPT would likely be even more favorable as we are an advanced practice physical therapy clinic with Osteopractic-and Fellowship-trained physiotherapists, the only one in northern Michigan. 

First, Osteopractic Physical Therapy has been found to be 57% MORE effective for shoulder conditions compared to traditional physical therapy.10 Applied to Kuhn et al findings, this suggests that your odds of success with rehabilitation alone improves to about 89-91% when working with an osteopractic physiotherapist.  Incidentally, osteopractic physical therapy was also found to decrease total health care utilization by 60% and the cost of care by 35% compared to conventional physical therapy.10 (Who doesn’t like saving time and money?)

Second, fellowship-trained physical therapists (Fellows or FAAOMPTs) have been found to be more efficient at treating musculoskeletal conditions, like rotator cuff tears, and produced better functional outcomes than residency-trained and entry-level physical therapists.11 So if you have body ache or pain working with a physical therapist who is a Fellow or FAAOMPT is the way to go if there is one practicing in your area!

Finally, Optimum DPT is one of a two physical therapy clinics in Michigan (and the only one in northern Michigan) certified to provide Personalized Blood Flow Restriction Rehabilitation.11I already talked about Blood Flow Restriction Rehabilitation in an earlier blog post; but to recap, Blood Flow Restriction supercharges rehabilitation for the maximum strength and endurance gains, muscle growth and tissue healing possible, even if an injury (like a rotator cuff tear) has made you too weak to perform traditional strengthening exercises.12-13

Check out this excellent video on BFR by Performance Physical Therapy & Wellness.

Bottom line, compared to traditional physical therapy, at Optimum DPT you are going to get better, faster… and, with our unique direct physical therapy practice, save a lot of money doing it!

If you or someone you know has been dealing with a rotator cuff issue or some other shoulder condition have them contact our Petoskey office at 231-881-9770 today.

Until next time,

Matthew Gaunt, DPT, ATC, Dip. Osteopractic, FAAOMPT

References:  

1.       Reilly et al., 2006. https://www.ncbi.nlm.nih.gov/pubmed/16551396

2.       Werner, CA., 2011. (http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf)

3.       Milgrom et al., 1994. http://bjj.boneandjoint.org.uk/content/jbjsbr/77-B/2/296.full.pdf

4.       Girish et al., 2011. https://www.ncbi.nlm.nih.gov/pubmed/21940544

5.       Moseley, L., 2011. https://www.youtube.com/watch?v=gwd-wLdIHjs

6.       McCormick, H. Orthopaedic and Dental Industry News. Healthpoint Capital; NY, NY: Nov 22. 2004 ArthroCare closes opus medical acquisition

7.       Vitale et al., 2006. https://www.ncbi.nlm.nih.gov/pubmed/17399623

8.       Kuhn et al., 2013.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748251/

9.       Slabaugh et al., 2010. https://www.ncbi.nlm.nih.gov/pubmed/20206051

10.   Fleury & Perreault, 2015. https://osteopractor.wordpress.com/2015/04/29/osteopractic-physical-therapy-cost-effectiveness-compared-to-national-average/

11.   Rodeghero, et al., 2015. http://www.jospt.org/doi/pdf/10.2519/jospt.2015.5255

12.   http://www.owensrecoveryscience.com/certified-providers/

13.   Moore, Ciccone & Butts, 2017. https://osteopractor.wordpress.com/2017/08/16/the-science-and-evidence-blood-flow-restriction-training/

14.   Hughes et al., 2017. http://bjsm.bmj.com/content/51/13/1003.long

Optimum DPT: Blog #4 Blood Flow Restriction Rehabilitation

PTS Blood Flow Restriction Unit

Blood Flow Restriction Rehabilitation / Training (BFR) is, in my opinion, the most interesting treatment in conservative care today.  You may have seen it featured on ESPN recently as more and more professional sport teams and universities embrace the technology since it showed incredible results for wounded warriors.  There is a growing body of evidence supporting its use in physical therapy, especially for those too elderly, frail or injured to engage in traditional strength training exercises.  

One such study, Clarkson et al 2017, offers further evidence showing the incredible impact of incorporating BFR with general exercise.  

The authors had sedentary, elderly adults (men and women in their 60s & 70s) walk with and without BFR for 6 weeks (4 walks per week, 24 total walks).  The authors examined common functional measures of strength, mobility, balance and endurance: the timed-up and go test, the 6-minute walk test, the 30 second sit-stand test, and the modified Queens College Step Test at the start of the program, at 3-weeks and at the 6-week mark.  The BFR walking group saw a 2.5-to 4.5-fold greater improvement in their measures of physical function compared to the non-BFR walking group

A 250% to 450% greater gains in strength, endurance, balance and mobility just by adding Blood Flow Restriction to the walking.  

Just to be clear (if it wasn’t)… That. Is. Amazing.  

But if you are elderly or injured and the thought of walking seems too daunting, do not get discouraged.  Similar results have been found by adding BFR to simple, low weight resistance exercises as well as bike riding!

And the gains of BFR is not limited to just the sedentary elderly— it has been shown to be effective across almost all age groups and fitness levels.

Lower Extremity Blood Flow Restriction Exercise

Optimum DPT the Osteopractic Physiotherapy Specialists of Michigan is proud to be one of two clinics in Michigan certified to offer Blood Flow Restriction Rehabilitation and Training, and the only clinic in the northern half of the state to offer this amazing intervention to the public.

If you want to supercharge your therapeutic exercise, get back your independence, and return to work or play ASAP contact our Petoskey office today!

Until next time,

Matthew Gaunt, DPT, ATC, Dip. Osteopractic, FAAOMPT

Optimum DPT: Blog #3 A Runner With Lateral Foot Pain (Cuboid Sprain)

Brief Case Report: A Runner with Lateral Foot Pain

One of our Optimum DPT members, a 36-year-old Petoskey man presented with complaints of sharp, 5-6/10 pain on the outside of his left foot.  He woke with his pain after a 4-mile run down a gravel road the evening before.  He noted several missteps (slight ankle rolls) during the jog due to pot holes; however, he denied pain at the time and indicated that he was able to complete the run without difficulty.  He admitted to having had lateral ankle sprains (rolling his ankle) in his past during school sports, but otherwise had no history significant injury.

The gentleman could bear weight and walk, but he was limping.  He indicated coming up onto the balls of his feet to be very painful, and that hoping and jogging were too painful to attempt.  He presented with localized signs of inflammation--erythema (redness) and edema (swelling)-- at the lateral dorsal left foot but without ecchymosis (bruising).  The area was tender to touch but not exquisitely so-- and the most acute tenderness located over the cuboid bone.

An acute left cuboid sprain

As he was able to bear weight at the suspected time of injury and in clinic, did not have sharp tenderness over his navicular bone nor at the base of his 5th metatarsal, he did not meet the Ottawa foot rules for referral for diagnostic imaging to rule out fracture.1

Active range of motion assessment was grossly normal save for pain with eversion.  Strength assessment found mild loss of peroneal muscle strength and extensor strength of the lateral toes.  A dorsal-plantar cuboid shear test reproduced familiar symptoms, and glide of the left cuboid seemed limited vs the right side.

Given the history, patient reports and findings an impression of an acute cuboid sprain with subsequent cuboid syndrome was made.

Cuboid syndrome is documented but not fully understood.  Symptoms are believed to arise from the sprained cuboid impinging (pinching) the fibroadipose synovial folds surrounding the bone.  In this condition the cuboid is not “out” of place, but may not moving normally with the surrounding bones.  The sural, lateral plantar and other surrounding nerves may also be irritated by the sprain and/or subsequent inflammatory response.2

The condition has been found to respond favorably to manual therapy, specifically joint manipulation.2-4.  The patient agreed to proceed with a high velocity, low amplitude thrust manipulation.  A single cuboid manipulation was delivered, and an audible joint sound (pop) was felt and heard by both the patient and myself.  The patient noted an immediate improvement in his point tenderness and ability to walk.

A follow-up appointment was schedule the next day.  At that time the patient was walking normally, noting only trace discomfort, and had a marked reduction in the redness, swelling and point tenderness over his left cuboid.  Left cuboid glide was found to be grossly equal to his right side.

About 24 hours after a high-velocity, low amplitude cuboid manipulation to treat the sprain.

No further treatment was indicated.  The patient was advised to hold off running for week and return for further care if needed.  He was contacted two weeks out and reported being pain free and to have resumed his usual runs.

If you or someone you know is experiencing foot or heel pain like the runner above (or any ache/pain really) click here and do not hesitate to contact Optimum DPT Osteopractic Physical Therapy Specialists of Michigan to see if we can help get you back to moving the way you want to move and doing the things you want to do!  Click the link above or call our Petoskey office at 231-881-9770.

Until next time,

Matthew Gaunt, DPT, ATC, Dip. Osteopractic, FAAOMPT

References:

1.        http://www.ohri.ca/emerg/cdr/docs/cdr_ankle_poster.pdf

2.        Durall CJ. Examination and Treatment of Cuboid Syndrome: A Literature Review. Sports Health. 2011;3(6):514-519.

3.        Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle sprains a case series. J Orthop Sports Phys Ther. 2005;35(7):409-415

4.        Blakeslee TJ, Morris JL. Cuboid syndrome and the significance of midtarsal joint stability. J Am Podiatr Med Assoc. 1987;77(12):638-642

Optimum DPT: Blog #2 New Location

We are excited to announce a new practice location for Optimum DPT – Osteopractic Physical Therapy Specialists of Michigan.  We have moved to 2810 Charlevoix Avenue, Suite 105, Petoskey, MI 49770.  Our new location is in the west/left Arrowhead Commons building.  We are the second office down, between Joy Valley Counseling and Petoskey Gynecology & Infertility.  Optimum DPT is currently sharing a common entry and hallway with Petoskey Gynecology & Infertility, our office is on the left.

This new location offers expanded clinical space!  Once we are done with some light renovating we will have two examination & procedure rooms—one dedicated for osteopractic & orthopaedic manual physical therapy and the other for vestibular rehabilitation.  We will also have a dedicate exercise suite for personalized blood flow restriction rehabilitation (BFR).

Our phone number remains the same: 231-881-9770, call and schedule for appointments! 

Until next time,

Matthew Gaunt, DPT, ATC, Dip. Osteopractic, FAAOMPT