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A common fear for patients when discussing pain is the idea that their symptoms are ‘all in their head’ or that they won’t be believed either by friends, family, therapists or workplace. This fear can be worse when there appears to be no obvious cause for their pain or it has been present for a long time.
What is pain?
Many of the models used in the past to explain pain lead us to believe that the intensity of pain will always be proportional to the severity of an injury. The experience of pain is always real and usually distressing. However, pain is a warning system used by our nervous system to alert us to danger, not a direct indicator of damage done. This is a subtle, yet important distinction meaning that the experience of pain can be influenced by many different factors and not exclusively tissue damage.
How can stress impact pain?
Part of the role of your nervous system is to sort through a huge amount of sensory input and interpret it in a meaningful way. When pain is considered to be a serious threat to the body, the intensity of the pain will be worse.
This can happen in many situations, for example:
-The source of the pain is not well understood, leading to fear that the pain might be something very serious.
-The nervous system is in a state of hyper-arousal, such as when you are stressed or tired.
-The pain or injury could have a significant impact on your quality of life, career, relationships or hobbies.
-The injury occurred through a traumatic event such as a car accident.
What does this mean for my treatment?
Along with all our more traditional treatments, we also know that stress reduction strategies, mindfulness and addressing any emotional trauma associated with pain can all help to aid recovery and improve quality of life. Your physiotherapist is a great person to speak to about pain management strategies so you can get the most out of your life while dealing with long-term pain.
None of the information in this article is a replacement for proper medical advice. Always see a medical professional for advice on your individual injury.
Many common wrist injuries occur due to a fall on an outstretched hand.
This mechanism can cause numerous types of injuries including fractures, ligament sprains and cartilage injuries. One of the most important types of injuries to diagnose is a scaphoid fracture. Scaphoid injuries make up 15% of acute wrist injuries and 60% of all carpal fractures. These can be difficult to differentiate to a distal radius fracture but are important to diagnose, due to the possible severe implications of a missed diagnosis.
The scaphoid is the largest proximal row of carpal bones and forms the radial portion of the carpal tunnel. The scaphoid has a poor blood supply even without injury. Therefore, if not managed appropriately with a specific immobilising cast or brace, they can result in avascular necrosis – a condition where the bone does not receive enough blood to heal correctly, resulting in non-union and possible death of the fractured areas of bone.
There are also numerous ligaments which attach onto the scaphoid bone to provide intrinsic support for the wrist. A scaphoid fracture can also cause damage to these ligaments, which can cause scapholunate instability or dissociation. Without appropriate treatment this can result in long-term wrist instability, loss of range and strength and decreased function.
There are certain clinical tests physiotherapists use to determine if a scaphoid fracture has occurred, such as palpation of the scaphoid and the scaphoid compression test. If a scaphoid fracture is a potential diagnosis, a referral will be made for a CT scan to confirm the injury, as these injuries are often missed on a standard wrist X-Ray.
Management can be non-surgical or surgical. Non-surgical management is used for stable scaphoid fractures, and involves cast immobilisation, using a specific short-arm cast. Surgical management is typically only required for unstable and displaced fractures and involves insertion of a screw or pin to stabilise the fractured area.
Most high-level and elite athletes understand the need to ensure they get adequate recovery each training week to compliment the load in which they are currently training at. However, those of us who compete or play in more recreational sport often miss out on that optimal recovery period.
Recovery is becoming an increasingly important aspect of many sports in a bid to reduce fatigue and enhance performance. An adequate balance between stressors (including training, competition load and other life demands) and recovery is essential for any athlete (elite or recreational) to continue to perform at a high level.
Taking the time to recover during the season does not mean loss of skill or fitness. Recovery can come in many forms and does not always have to be physical. For example, you can break down aspects of recovery into passive, active and proactive approaches.
Passive may include external methods such as physiotherapy for any ongoing niggles or any maintenance, this implements a state of rest characterised by inactivity.
Active recovery such as cooling down after training or partaking in light activities such as swimming or bike riding.
Finally proactive recovery (e.g. social activities such as a yoga class or a bike ride with friends) ensures that you take the time to choose activities that are personally suited to you as an individual.
As we all know majority of winter sports have resumed for the year. As the training load increases and games are a weekly occurrence it’s important that athletes prioritise recovery and incorporate it as part of their training week.
The team here at Enhance Physiotherapy are highly skilled professionals who are able to assist you with any concerns related to your recovery throughout the winter sporting season. We also have float tank and hyperbaric chamber facilities which are readily available and can be used as part of your recovery processes. For more information regarding these you can read about them via the links below or call the clinic for more information.
What is BPPV?
Benign paroxysmal positional vertigo also known as BPPV is a common cause of vertigo which usually gives the brief sensation of spinning or dizziness associated with moving the head.
BPPV is a mechanical problem in the inner ear. It occurs when some of the calcium carbonate crystals called “otoconia” that are normally embedded in a gel like substance in the utricle become dislodged and move into one or more of the 3 fluid filled semi-circular canals, where they are not supposed to be. When enough of these accumulate in one of the canals they interfere with the normal fluid movement that these canals use to sense head motion, causing stimulation of the nerves that detect head movement sending abnormal stimulation to the vestibular system causing dizziness, spinning, nausea and nystagmus (fast eye movements) .
Are there different types of BPPV?
There are two types of BPPV, one is where the loose crystals (otoconia) can move freely into the fluid of the canal this is called “canalithiasis”. The second type and more rarely experienced type of BPPV is where the crystals are thought to be ‘hung up’ or adhering on the bundle of nerves that sense the fluid movement, this is called “cupulolithiasis”. With the first type of BPPV “canalithiasis”, it takes less than a minute for the crystals to stop moving after a particular change in head position has triggered a spin. Once the crystals stop moving, the fluid movement settles and the nystagmus (fast eye movement) and vertigo symptoms will stop. With the second type of BPPV “cupulolithiasis”, the crystals (otoconia) become adhered on the bundle of sensory nerves which makes the symptoms last longer.
How is BPPV diagnosed & treated?
BPPV is diagnosed through a subjective and objective examination by a trained practitioner which involves tests like the Dix-Hallpike, side lying test & roll test.
The right Dix-Hallpike position used to elicit nystagmus and vertigo symptoms for diagnosis. The patient is moved from a seated position to laying on their back with their head turned 45 degrees to the right and held for 30 seconds with the eyes open and physiotherapist watching all eye movement.
The nystagmus (fast eye movement) will have different characteristics that allow a trained practitioner to identify which ear the displaced crystals are in, and which of the 3 canal(s) they have moved into. Tests like the Dix-Hallpike or Roll Tests involve moving the head into specific orientations, which allow gravity to move the dislodged crystals and trigger the vertigo while the practitioner watches for the movements and determines the direction and timing of the nystagmus (eye movement).
Once your physiotherapist has diagnosed which canal(s) the crystals are in, and whether it is canalithiasis or cupulolithiasis, then they can take you through the appropriate treatment maneuver for you.
The maneuvers make use of gravity to guide the crystals back to the chamber where they are supposed to be via a very specific series of head movements.
Studies and research have shown that precision of the maneuver is the key to successful treatment and therefore it is recommended that this are completed by a trained professional.
Additionally, there is a screening tool completed by your trained practitioner prior to performing testing such as neurological examination and neck screening, along with other safety-related investigations to determine if certain elements of the procedure need to be modified or avoided.
How long does it take to treat?
Studies have shown that effectiveness of BPPV treatment is well into 90% improvement by 1-3 treatments by a trained professional. The “Cuplulolithiasis” “hung up” type can take a few more sessions as can BPPV as a result of trauma/head injuries. Once the crystals (otoconia) are back in the correct place and the symptoms have stopped, people can often feel some mild residual sensitivity to motion and unsteadiness. If is important that you follow up with your vestibular therapist so that they can evaluate this and provide home exercise techniques that can assist with correcting this.
Which symptoms BPPV doesn’t cause?
Please be aware BPPV will not give you constant dizziness that is not able to be changed or reproduced by a movement or change of position. It does not cause hearing loss, fainting, headaches or neurological symptoms. IF you have any of these symptoms, you must tell your health care provider immediately as other vestibular disorders can be misdiagnosed as BPPV.
With so much public education about the dangers of sun damage, the last thing you’ll be expecting to hear is that you’re not getting enough sunshine. However, in some countries up to 30% of the population have inadequate vitamin D status, increasing to more than 50% in women during winter and spring.
What does vitamin D have to do with sunshine?
Also known as the “sunshine vitamin”, vitamin D is essential for your health. With a typical western diet, most people will get about 10% of their daily vitamin intake through food and the other 90% is processed by the body through exposure to sunshine.
Why is it important?
Vitamin D is essential to maintain bone health and muscle function. Deficiencies in children can cause rickets, and over time it can cause osteoporosis in adults. It is also a predictor of falls, due to reduced muscle strength, which coupled with osteoporosis can lead to complicated fractures. Depression has also been linked to vitamin D deficiency.
Vitamin D has also been shown to have a significant role in preventing respiratory disorders and even reducing their severity. This has been a suggested mechanism for why people with darker skin are more susceptible to COVID infections and suffer more severe infections.
Think you get enough sunshine?
You might be surprised at how much sun exposure you need to make enough vitamin D. Unfortunately the answer isn’t straightforward. During winter you’ll need to be in the sun for longer, and the further from the equator you are, the more sun you’ll need. Fair-skinned people are better adapted to process vitamin D and as such need to spend less time outside.
People who tend to avoid the sun or dress very modestly might be surprised to find that they are vitamin D deficient, along with office workers and those who spend a lot of time indoors, particularly the elderly who are in care.
Being overweight can also put you at risk of being vitamin D deficient as fat cells absorb vitamin D and prevent it from being released in a way that can be used by the body.
Why are workplace injuries so common?
The nature of work is that we are often required to complete the same task for hours. We can also find ourselves faced with time constraints and deadlines that lead to lazy postures and taking shortcuts, simply to get the job done.
How can they be prevented?
Workplace injuries can happen suddenly, through an accident like a fall or by lifting something too heavy, however, the vast majority of workplace injuries occur over time due to repetitive tasks. Often these conditions begin slowly and take many months to resolve. Here are a few tips to keep yourself pain free in the workplace.
It’s important to assess the risk before you start. Do you need to ask for help or use an assistive device? Your legs are the strongest part of your body and ideally, you should use them to power the movement, rather than your arms or back.
Bending and twisting when lifting is also a common mechanism for injury. It is much safer to lift, then step to turn before putting an object down again. Pushing is a much more efficient movement than pulling and is always preferable if you have a choice. Try to push at waist height and keep forces as close to your body as possible.
Overuse injuries can occur by using the same side of your body rather than alternating sides. Practise using both left and right hands for taking phone calls and mouse work.
Be aware of your posture. Good posture isn’t having a rigid and upright spine. It’s about being able to let your spine sit comfortably in its natural curves and be able to move in and out of this easily. Stretching can help to counteract positions you find yourself in for long periods.
Your physiotherapist is a great person to speak to about preventing injuries in your workplace.
High ankle sprains involve a ligamentous injury slightly above the ankle joint. There are two long bones, tibia and fibula, that together form a stable surface connection for which the ankle can move on. The stability of this joint is crucial for the function of the ankle and its ability to withstand weightbearing activities.
This injury can appear similar to the more common lateral ankle sprain. However, it is more of an external rotation movement of the foot when it is planted which commonly leads to a high ankle sprain. With enough force, these injuries can also cause fractures or dislocations. It is important to distinguish a high ankle sprain from a lateral ankle sprain since the appropriate treatment will be different. Delayed treatment can cause complications in the future if not addressed and managed effectively.
Symptoms generally include pain and swelling in front of the ankle, a sensation of instability, difficultly with or unable to walk, or unable to perform a single leg heel raise.
Depending on the severity of the injury, it may either need conservative treatment or surgery with follow-up rehabilitation. One of the critical factors will be if the distal tibiofibular joint is stable or unstable which can be confirmed with imaging investigations.
It is important to determine the correct diagnosis early on to establish an appropriate recovery plan.
Walking aids vary from a walking stick, crutches or frames also known as walkers, this ranges from the least support to the most support making them more stable. They come in all different shapes and sizes so are guaranteed to find one that suits you and your mobility needs.
Walking aids assist with keeping you mobile and participating in your everyday daily activities. Their aim is to assist people with improving their balance, walking pattern and safety while mobilising independently. They also help to transfer weight from the upper limb to the aid to reduce weight bearing through the lower limbs this is especially important post surgery.
Who uses walking aids? Typically it is people with an injury or health condition, people with disabilities, older adults at risk of falling, or people post–surgery who are recovering and need assistance.
About half of Australians living with disabilities and around 93% of people living in residential aged care facilities use mobility aids (ABS 2015).
The benefits of walking aids are immense! Here are a few benefits that influence people both physically and mentally:
If you or someone you know would benefit from a walking aid, booking in with a physiotherapist is the first step. We can prescribe you with the correct aid to suit your walking needs.
We focus our assessment to look at your everyday needs. We first look at your walking, balance, muscle strength, cognition, and then the cardiovascular, neurological and musculoskeletal systems, and ask about any comorbidities and the setup at home.
We provide education and training on how to use the walking aid, the benefits of the aid (as mentioned above), proper prescription and fitting the aid to suit your needs.
Ice has been a common initial injury technique used among many when an injury first appears. When someone rolls their ankle, most of us instinctively grab an ice pack. When we see professional athletes get injured, they’re wrapped in ice before they’ve even made it off the field. But the question lies should we be applying ice immediately after sustaining an injury or not?
The earliest documentation of ice as part of the acute injury management protocol dates back to 1978 with the term RICE (Rest, Ice, Compression, Elevation). The intention behind using ice was to minimise the inflammatory response to accelerate healing (1).
However, based on new research it identified that by resting the injured site, the lack of movement is detrimental to recovery and delaying the recovery process. A study in 2014 (3) found that using ICE and rest may in fact delay initial healing, instead of helping. By applying ice immediately to the injury, it is preventing the body’s natural release of inflammatory cells, which then delays the initiation of healing (2).
Therefore, early optimal loading aids in recovery to the injured site for a quicker recovery.
In 2019 the latest and most comprehensive acute injury management technique is PEACE & LOVE (Protection, Elevation, Avoid Anti-Inflammatory Drugs, Compression, Education & Load, Optimism, Vascularisation and Exercise). This moves from resting the injury, to instead now encouraging early optimal loading to aid in the recovery through cell regeneration by light mechanical loading in the early stages (3)
With all of this new-found evidence on the negatives of icing injuries, it begs the question:
‘If ice delays healing, even if it can temporarily numb pain, should we still be using it?’
There is certainly a consensus throughout the literature that ice acts as a pain numbing agent by cooling the skin’s temperature. However, the impact on underlying muscles is non-existent, as muscle temperature remains unchanged. The only exception to this rule would be when injuries are severe and in circumstances where swelling will likely be the limiting factor for recovery such a severe joint sprain (ankle sprain) where it is limiting range of movement- then application of ice is warranted (4).
Otherwise, for now, based on current research keep the ice in the freezer as we now understand ice is less important than we once thought (5).
What is the AC joint?
The AC joint is a plane synovial joint formed between the acromion of the scapula (shoulder blade) and the distal end of the clavicle (collarbone), on top of the shoulder.
The joint is stabilised by the acromioclavicular (AC) ligaments, coracoclavicular (CC) ligaments and the coracoacromial (CA) ligament (Kiel & Kaiser, 2020). This joint is small but contributes to achieving full shoulder range of motion.
AC injuries are common in sports such as football, rugby league and rugby union. They may account for up to 40% of all shoulder injuries and nearly 10% of all injuries in collision sports (Kiel & Kaiser, 2020).
Mechanism of injury
The AC joint is often damaged by a fall onto the point of the shoulder, or a direct blow to the shoulder (ie a hip and shoulder bump in footy). This compresses the AC joint and can damage the ligaments which stabilise the joint (Brukner & Khan, 2017).
Diagnosis is made on a number of features:
Grades of AC joint injury – grading is based on the Rockwood classification system (see photo below)
It is important to see a healthcare professional to rule out other possible injuries. Some other key things to rule out in an acute shoulder injury include:
Rehabilitation timeframes will depend on the severity of the AC joint injury. All injuries will progress through a series of phases which will involve:
Brukner, P., & Khan, K. (2017). Clinical Sports Medicine. Elsevier.
Kiel, J., & Kaiser, K. (2020). Acromioclavicular Joint Injury. StatPearls.