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How do excellent physiotherapists use Evidence Based Practice for better results?

All physiotherapists want the best for their patients and we aim to provide the most effective treatment for each and every person on the Northern Beaches that walks through our doors. But how do we know that our physiotherapy is making a difference and that it is the best care for every individual’s circumstances?

Everybody and every body is different, which means there are going to be nearly an infinite number of ways to treat individuals suffering from chronic pain, musculoskeletal disorders and muscular or ligament injuries. It is up to physiotherapists to identify the best methods for each individual client and implement them in a broader strategy to meet their goals. This is where utilising evidence based practice techniques and taking a results based approach to treatment and injury management can shave weeks from your recovery period and result in less pain and a decreased risk of suffering a re-injury.

What is evidence based practice?

Evidence based practice (EBP for short) isn’t a new concept, it has been utilised in the medical world for a number of years now and has become a popular method of treatment for physiotherapists around the world over the last decade.

EBP utilises ‘the integration of best research evidence with clinical expertise and patient values’[1] in order to shape the treatment of patients and include them in the processes of treatment in order to prevent pain and injury in the future.

The goals of evidence based practice are:

  • To improve the care for clients, resulting in more effective treatment and injury recurrence
  • To use evidence from high quality sources to help shape physiotherapy practice
  • To challenge treatment views based on anecdotal evidence
  • To integrate patient preferences into the treatment and decision making processes
  • To take the guess work out of treatments, using education to shape future activities

What are the 5 steps of evidence based practice?

Because evidence based practice relies on consistency and clinical fact in order to make diagnoses and frame the best treatment, a framework of steps has been outlined in order to help physiotherapists design and implement and evidence based approach to treating musculoskeletal conditions.

Step 1 – Ask an answerable and measurable question

One of the fundamental skills needed by musculoskeletal physiotherapists in designing an evidence based program is the asking of to the point clinical questions. By asking the right questions you can focus your efforts specifically on the areas needed, instead of non-important matters.

Step 2 – Acquire relevant research evidence

With the easy part out of the way, your physiotherapist will move onto extrapolating the answers to their questions in order to find relevant, recent and scientifically proven methods for treating your specific condition. Physiotherapists will use a combination of their own data collected over years of practicing in the field and scientific studies located in databases specifically designed to provide a workflow in order to come to the right conclusions.

Step 3 – Analyse the evidence

This is where the expertise and experience of your physiotherapist is really going to come in handy. For example, a Titled Musculoskeletal Physiotherapist has likely spent over a decade studying and practicing in the field and has gained an advanced insight into what evidence is important and what evidence may not be supported by clinical practice and other data. By critically analysing the scientific data your physio is already piecing together your treatment plan in their head and focusing on your goals in relation to the evidence for treatment techniques.

Step 4 – Implementation of the evidence

Now that your physio has conducted their full body assessment, questionnaire and compared data with high quality evidentiary sources, the real fun is ready to begin. Physiotherapists will implement their treatment plans usually by combining the best available evidence with their clinical expertise and their patient’s values and goals. During the implementation phase, your physio will be documenting and assessing your treatment and recovery in order to make any adjustments to your program and to ensure your recovery is progressing. Implementation isn’t a single process; it is the sum of all their experience and knowledge that can be altered and updated to suit your progress.

Step 5 – Evaluate the outcome

If your original treatment plan isn’t getting results, this is where your physio has the knowledge and flexibility to alter what’s required to get you back to 100% health. By documenting your progress and implementing evidence based methods, your physio is able to alter your treatment based on results and at the end of the day, that’s exactly why you see a physio in the first place. To get results. If it’s not working, fix it.

Evidence based practice in physiotherapy is a constantly evolving concept and allows for a flexible and science based approach to combating common musculoskeletal problems. Find yourself a Northern Beaches physio with the expertise and experience to create and implement an evidence based, patient-centred and results focussed program and you’ll be on the right track to a pain free future.

 

[1]  Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2

Soccer-knee-injury

ACL injuries: surgery, recovery and prevention

Australians in general and those of us on Northern Beaches especially are an active bunch. Unfortunately, activities that are great for the waistline can spell trouble for the musculoskeletal system when injuries occur. More people are playing sports, running or participating in some kind of physical activity than ever and that means more injuries. Aussies are world leaders in most sports and unfortunately we’re also world leaders in ACL injuries and that rate has been climbing consistently.[1]

Between 2000 and 2015 nearly 200,000 ACL reconstructions were performed in Australia with men aged 20 to 24 years and women aged 15 to 19 years the most common patients, but the fastest growing demographic was 5–14-year-old children.[2] Apart from being painful and ongoing, ACL repair can also be painful to the back pocket, costing on average over $8000 including hospital fees.

What, if anything can physiotherapists do to help prevent ACL injuries, and how do we make sure that a full recovery after ACL surgery occurs?

What is an ACL, what does it do and how are they injured?

Ligaments are strong bands of tissue connecting bone to bone and are among the most commonly injured part of the musculoskeletal system. Your anterior cruciate ligament or ACL for short is one of the four ligaments in your knee that keep your knee joint stable. Your medial and lateral collateral ligaments stop your knee from moving side to side, while your anterior and posterior cruciate ligaments keep the knee from sliding front to back.

ACL injuries can occur at some pretty random and innocuous times but usually are a result of rapid changes in direction at speed, typically in non-contact sports or events. ACL tears also commonly occur during sports that involve sudden stops, jumping and landing such as soccer, AFL, basketball and netball.

It’s common to hear a “pop” in the knee when an ACL injury occurs accompanied by some pretty rapid swelling, instability and an unbearable pain that won’t let you put weight on it. Depending on the severity of your ACL injury, treatment is likely to include a good chunk of time on the sidelines and probably some surgery.

What does ACL surgery involve?

A surgeon chops out a piece of another tendon (usually the hamstring), removes your damaged ACL (because it can’t heal itself) and replaces it with the new tendon. Your new replacement tissue is called a graft which will be attached to your bones with screws (airport security just got more fun) or other fixation devices and serves as the point where new ligament tissue can grow. Fun fact, if the tissue is taken from you, it’s called an autograft but if it was donated by another person it is known as an allograft.

How long until I can play sport after ACL surgery?

The recovery period after ACL reconstruction surgery varies from one person to the next and there are many factors that determine how quickly and adequately you will recover and how low it will take until you can get back into the full swing of things.

One of the biggest factors influencing how long ACL surgery recovery takes is whether you have an orthopaedic pre-habilitation and rehabilitation plan and you stick to it. A well designed pre ACL surgery body strengthening regime can shave weeks and pain off your post-surgical recovery. The physical shape your affected area is in is one of the strongest predictors of the chances of a fully successful recovery. It is likely that you have pain and weakness operating in tandem leading up to surgery, but you’re going to need every ounce of strength you’ve got to recover fully. In prehab your local physio will help you build strength and stability where you need it most to ensure you get the most out of your rehabilitation.

Your surgeon and musculoskeletal physio will be able to advise you when you’re good to go for most activities, but this is usually only once you have adequate flexibility, strength and fitness.

Can physiotherapy prevent an ACL injury occurring?

Because ACL injuries have been becoming increasingly common, more time and research is being devoted to understanding the mechanisms behind ACL injuries and what steps can be taken to reduce the possibility of an ACL tear happening. Prevention is much better and less painful than a cure.

Over the last two decades multiple randomised controlled trials have shown that anywhere between 50–80% of ACL injuries can be prevented by regular neuromuscular agility training programmes.[3] A number of these studies have shown that many ACL injuries are caused by faulty mechanics during dynamic movements performed under fatigue.[4]

These prevention programs include various modes of exercise such as plyometrics, neuromuscular training, and strength training designed to teach the body to perform movements deliberately and with precision even under fatigue. A trained musculoskeletal physiotherapist will be able to observe your technique and address the faulty movement patterns in a personalised injury prevention program.

 

[1] Janssen KW, Orchard JW, Driscoll TR, et al. High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003–2004 to 2007–2008: time for an anterior cruciate ligament register by Scandinavian model? Scand J Med Sci Sports 2012;22:495–501.

[2] Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015 David Zbrojkiewicz, Christopher Vertullo and Jane E Grayson Med J Aust 2018; 208 (8): 354-358. || doi: 10.5694/mja17.00974

[3] Caraffa A, Cerulli G, Projetti M, et al. Prevention of anterior cruciate ligament injuries in soccer. A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc 1996

[4] Mandelbaum BR, Silvers HJ, Watanabe DS. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 2005;33:1003–10

runner-stretching-muscles

Understanding the difference between an injury and pain

Whether you’re a novice runner or a seasoned veteran, chances are you’re well acquainted with pain. Right from the get-go we’re taught to run through the pain to push through it to get to that next PB. When you’re new to running long distances it’s normal for your body to take some time to adjust and being a regular runner is all about dealing with those niggling aches and pains. My right knee certainly lets me know all about it for a few days if I run too many stairs between Manly and Dee Why.

But how much pain does it take to gain and when does pain point to an injury? While pain and injuries go hand in hand, pain doesn’t necessarily mean you’ve got an injury and there are plenty of injuries that sneak by without causing pain where you’d expect it. Minor running “injuries” can be treated with a bit of good old fashioned R’n’R but more chronic or serious injuries require the expert guidance of a musculoskeletal physiotherapist.

Assessing pain: am I sore, or am I injured?

Before you can get to the treatment stage for those aches and pains, we’ve got to work out what we’re dealing with. At an initial consultation with a physio they will usually ask you a number of questions regarding your pain/injury to get a better idea of its causes and how best to treat it.

  1. Did the pain start abruptly or come on over time?

It is normal for your body to feel sore after a big run or a workout; delayed muscles soreness (DOMS) is a common occurrence and normally improves after a few days, whereas an injury will likely cause you pain for weeks or more at a time. If you heard a pop or snap and felt a twinge or an abrupt sensation of pain during your run, chances are you have suffered an injury. Around 70% of all running injuries are caused due to overuse, but they often show themselves in a straw breaking the camel’s back fashion.

  1. Is the pain persistent or does it only come on during certain activities?

Unfortunately, what your pain is trying to tell you isn’t always clear cut and chronic or persistent pain is notoriously difficult to pinpoint and treat. That being said, when muscle or joint soreness hangs around for longer than a few days, is accompanied by sharp pains or aches and is persistent even when not engaging in a physical activity it’s likely you’ve done yourself an injury.

  1. Is the area swollen, sore to the touch or bruised?

When you tear a ligament or cause substantial soft tissue damage, the body usually (not always) reacts by causing some pretty obvious external symptoms. It may not happen immediately, but swelling and bruising commonly accompany major injuries and can be more easily diagnosed by comparing one side to the other and checking for differences.

  1. Is there a loss of function?

Loss of function tests are one of the most common methods musculoskeletal physiotherapists use to identify the nature of pain. One of the biggest indicators of an injury as opposed to regular pain is the presence of a loss of function independent of any sensation of pain or an inability to complete certain movements due to severe pain.

Preparation is the first step to avoiding a running injury

  • See a physio to identify potential musculoskeletal and health problems that may contribute to injury
  • Always warm up and cool down by jogging slowly
  • Injured runners should consult a professional about how to prevent re-injuries
  • Hydrate prior to running and consider taking water on longer runs
  • Get a running assessment if niggles persist

Use the R.I.C.E method to treat running soreness

If you’re suffering from the DOMS or you’ve just pushed yourself a little hard and feeling it, you can’t go wrong erring on the side of caution and giving your body a bit of a recovery pamper session.

Rest properly and resist the temptation to down a number of celebratory alcoholic beverages. If you must go out, keep hydrating, don’t party too hard and let your body recover.

Ice – this will help constrict the blood flow to sore areas and help to reduce inflammation and soreness. If you feel up to it, you can always take your second ice bath as you likely already took your first one during the race.

Compression of the legs and arms will help flush out the lactic acid that has accumulated. Wearing compression gear will work great for this. Pairing compression and icing will ensure they work symbiotically and will shorten your recovery period.

Elevate your legs as you lie in bed thinking about how awesome and tough you looked covered in mud, running through electroshock stations, carrying logs and kicking butt.

If you have a persistent ache or pain whether it be the result of running or another physical activity, it needs to be identified and addressed. Nobody likes being injured, but allowing something as simple as shin splints to go untreated with continued overtraining, can cause tibial stress fractures, which will put you on your butt for at least 6 weeks. The moral of the story is from little things, big things grow; this includes injuries.

Visit a pain and injury clinic on the Northern Beaches for more information on identifying the difference between pain and injury and how to treat those niggling aches and pains before they progress to something more serious.