Physiotherapy News and Research

Patients Can Wear a Sling for 3 or 6 Weeks After Rotator Cuff Repair

How long should you wear a sling after shoulder surgery? This duration of sling use and shoulder immobilization after rotator cuff repair has been an area of controversy for a long time. If you immobilize too long, you may end may up with a stiff shoulder. If you start motion too early the thought is that patients have a higher risk of compromising the tendon repair. According to the newest randomized study conducted by Dr. Jenssen in Norway for small and medium sized tears, there no difference in quality of life or healing rates (determined by MRI) one year after surgery regardless whether a sling was worn (and hence shoulder was immobilized) for either 3 weeks or 6 weeks. So based on these findings both 3 and 6 weeks of immobilization in a simple sling can be safe and effective.

Icing and physical exercise are effective in preventing quadriceps muscle weakness after anterior cruciate ligament surgery

In a recent study published in the British Journal of Sports Medicine, a detailed review of the literature was performed to determine if there are any treatments that can prevent quadriceps (thigh) muscle inhibition (weakness) after ACL surgery. While many people recommend the use of modalities such as TENS (transcutaneous electrical nerve stimulation), ultrasound, vibration, and/or neuromuscular electrical stimulation, there is low or very low-quality evidence to support the use of these treatments.  Rather, this study found moderate-quality evidence for the use of cryotherapy (icing) and physical exercise to prevent or minimize quadriceps muscle inhibition.  Ultimately this means that an ice machine (i.e. cryocuff, gameready, etc) along with an effective exercise program (see our YouTube videofor quads activation) are the most practical, most readily available, and most effective things you can do to bounce back after ACL surgery.

The vast majority of people with rotator cuff tears just need physiotherapy.

In an award winning study published by the MOON shoulder group in the Journal of Shoulder and Elbow Surgery, surgeons from multiple centres across the United States followed over 400 patients with various types of atraumatic rotator cuff tears for two years.  All patients were initially treated with physiotherapy. It turns out that over this two year period less than 25% of patients with a rotator cuff tear actually needed surgery.  The strongest predictors of needing surgery were low patient expectations regarding physical therapy and higher activity level.  These findings suggest that in the setting of a non-traumatic or degenerative rotator cuff tear, all patients should undergo an initial period of physical therapy.  If pain or weakness persists surgery should then be considered. This approach avoids unnecessary surgical procedures and may be cost-effective for payers from a societal perspective.

In a recent randomized clinical trial published in the JAMA, investigators compared the effectiveness of inpatient rehabilitation followed by an eight week clinic/home hybrid physical therapy program versus home-based therapy alone. Mobility at 26 weeks following surgery was equivalent in the two groups and there were no differences with respect to function and quality of life. The authors concluded that after uncomplicated total knee arthroplasty, there is no role for inpatient rehabilitation. As the trend for increasing rates of outpatient arthroplasty continue across North America, the importance of home-based physical therapy will continue to increase and access to such services will be of paramount importance.

Torn meniscus in your knee? Physiotherapy is the treatment of choice.

Did you know that in most cases Physical Therapy is just as good as surgery for non-obstructive meniscal tears of the knee? If you have a tear in the meniscus of your knee that is not displaced and getting pinched causing severe lack of motion this meta-analysis of 6 high quality randomized controlled trials found that Physical Therapy had equivalent outcomes to arthroscopic surgery. Given the non-invasive nature of physical therapy it is clearly the choice for treatment of meniscal tears! See the publication, Arthoscopy May 2016 for more details.

Setting the stage for success prior to hip arthroscopy: HAPI Study.

In recent randomized pilot study published in the Journal of Hip Preservation Surgery, patients who were consented for hip arthroscopy were assigned to either a 8 week home exercise programme or the standard of care (i.e. no exercise instruction). Patients who completed this brief period of home prehab had improved knee extension strength, hip flexor strength, and health-related quality of life at baseline and post-operatively at three months.  This study shows that similar to other orthopaedic procedures (e.g. knee replacement, ACL surgery), prehabilitation is a powerful determinant of post-operative success.

Evidence-based medicine supports the use of home physiotherapy following total knee replacement

In a recent randomized clinical trial published in the JAMA, investigators compared the effectiveness of inpatient rehabilitation followed by an eight week clinic/home hybrid physical therapy program versus home-based therapy alone. Mobility at 26 weeks following surgery was equivalent in the two groups and there were no differences with respect to function and quality of life. The authors concluded that after uncomplicated total knee arthroplasty, there is no role for inpatient rehabilitation. As the trend for increasing rates of outpatient arthroplasty continue across North America, the importance of home-based physical therapy will continue to increase and access to such services will be of paramount importance.

Physiotherapists in Canada – Challenges and Opportunities

According to a press release by CNW, the growing demand for physiotherapy services has lead to a shortage of physiotherapists in non-urban centres.  “Demand is outstripping supply” in certain parts of the country and access to care is a real challenge for some Canadians. The Conference Board of Canada has published a report on the ‘role of physiotherapy in canada’ and emphasize that physiotherapists may be well positioned to shift the emphasis from acute care to upstream solutions – this means the focus should be on prevention and wellness, rather than just treatment. Furthermore it was stated that home-based programs are more cost-effective than in-patient treatment and in the context of joint replacement can reduce overall costs on the healthcare system. Despite the increasing workforce, there is a growing need for home services as well as in small cities across Canada. Therapia is well positioned to improve access to care for Canadians and we look forward to the challenge and opportunities that lie ahead!

The power of prehabilitation – Physical therapy BEFORE surgery.

There have a large number of clinical studies that have demonstrated that doing physiotherapy before elective surgery improves outcomes and success in the post-operative period.  Until recently, the long term effects of a structured and official prehabilitation program were not well understood. In a recent study published in the October 2016 issue of the American Journal of Sports Medicine (https://journals.sagepub.com/doi/full/10.1177/0363546516652594), the authors compared two ACL study populations.  The first cohort was comprised of patients from Delaware and Norway and this group underwent extended preoperative physiotherapy before ACL surgery.  The comparative group (which did not undergo extensive preoperative physiotherapy) was from the MOON study population with patients from across the United States.

Ultimately, patients in the Delaware-Oslo cohort had improved clinical outcomes and a higher return to preinjury sports.  This is a very well done study that clearly demonstrates the need for a preoperative rehabilitation program that emphasizes strengthening and neuromuscular training. “Going to the gym” is simply not enough. Engaging in the right care with a trained physiotherapist before surgery has been scientifically proven to improve outcomes in the long run following ACL surgery.

Technology and Physiotherapy

From wearable devices to virtual reality, there are many possibilities that lie ahead in how patients will interact with their physical therapist and carry out their prescribed rehabilitation protocols.  Here are a few of the major technological trends we think will make their way into the physiotherapy industry in the near future

While questions regarding cost, compliance, feasibility remain to be answered, the adoption of these technologies to make patients and physiotherapists more informed and connected is inevitable.

Scientific evidence for home physiotherapy after ACL surgery

In a randomized trial performed in Canada and published in the American Journal of Sports Medicine (https://journals.sagepub.com/doi/full/10.1177/0363546509359763), Dr. Mohtadi demonstrated that when comparing patients treated with home physiotherapy versus  standard clinic based physiotherapy following ACL surgery (specifically in the first three months),  patients treated with home physiotherapy had similar quality of life and function scores both in the short and long run.  Randomized trials are the highest level of clinical evidence and this study demonstrates that there is an important role for home physiotherapy following ACL reconstruction in recreational athletes.

Practically, this study shows that fewer treatments in the home are just as beneficial as a high volume of treatment sessions in a traditional clinic.  Manual physical therapy, implemented correctly based on sequential milestones by a qualified physiotherapist, does not require the use of extensive and unnecessary equipment one may see in a clinic. Doing the right things in a simple manner can have a tremendous impact on outcomes following ACL surgery!

If you have osteoarthritis, see a physiotherapist before signing up for surgery

At the University of Western Ontario, there has been a recent cost-effectiveness study which demonstrated that arthroscopy is not beneficial for knee osteoarthritis compared to optimized nonoperative care in the form of medication, injections and physical therapy (https://bmjopen.bmj.com/content/6/1/e009949.long). In addition, the effectiveness of a structured neuromuscular and strengthening rehabilitation program has been clearly demonstrated for treating knee osteoarthritis. While total knee replacement does have a significant role in managing this condition, it is best reserved for patients with end-stage disease for whom non-operative care has not worked well.  Based on this, Canadian scientists and researchers have created GLA:D™ Canada – an education and tailored neuromuscular exercise program for individuals experiencing symptoms of knee or hip osteoarthritis. A similar program initiated and studied in Denmark in 2012 demonstrated that a simple exercise program with the aforementioned principles can reduce symptoms by 32%. As such, before considering surgery, meet with a physiotherapist who is familiar with strengthening and neuromuscular rehab protocols specifically designed for osteoarthritis!

Scientific evidence for home physiotherapy after hip or knee joint replacement

In another randomized trial, performed at the University of Toronto, investigators compared outcomes among patients who had joint replacement surgery and were treated with either home-based rehabilitation or standard in-patient physiotherapy.  The results of this important study, published in the Journal of Bone and Joint Surgery, demonstrated that there were no differences in pain, function, or satisfaction between the two treatment groups. Ultimately, the authors recommended the use of home-based rehabilitation following elective total hip or knee replacement because this approach was also found to be more cost-effective.

Minimizing the risk of ACL injury following surgery – Be strong and wait 9 months!

In a recent joint study between the University of Delaware (Department of Physical Therapy) and Norwegian School of Sports Sciences, investigators looked at the relationship between re-injury following ACL surgery, determination of the timing for return to sports, and knee function.  There were 106 patients who were followed for two years after their ACL was reconstructed.

The authors determined that in order to minimize the rate of re-injury, participants should (i) wait at least nine months from surgery until participation in sports that involve jumping, pivoting and hard cutting; and (ii) have symmetrical quadriceps (thigh muscle) strength. Furthermore, return to sports that involve cutting and pivoting had a four-fold higher risk of knee re-injury compared to lower demand activities. The implications of this research are massive. Preventing secondary injury can minimize the rate of simultaneous cartilage and meniscus pathology and as a result limit the progression of osteoarthritis in the future.

From a practical standpoint, this research suggests that return to sports decision-making should be time based and function based.  Working with a physiotherapist to improve core strength, quadriceps strength, and eliminate swelling are essential to optimizing function and sport-specific readiness, especially in the context of pivoting and cutting activities.

This study was published in the British Journal of Sports Medicine in May 2016. For more information, please visit https://bjsm.bmj.com/content/50/13/804.full

Good Living with Osteoarthritis in Denmark (GLA:D)

The authors determined that in order to minimize the rate of re-injury, participants should (i) wait at least nine months from surgery until participation in sports that involve jumping, pivoting and hard cutting; and (ii) have symmetrical quadriceps (thigh muscle) strength. Furthermore, return to sports that involve cutting and pivoting had a four-fold higher risk of knee re-injury compared to lower demand activities. The implications of this research are massive. Preventing secondary injury can minimize the rate of simultaneous cartilage and meniscus pathology and as a result limit the progression of osteoarthritis in the future.