Research focus: tendon healing and ibuprofen

Like a lot of research studies undertaken, this one is not based on findings from human subjects. The results do however make an interesting read. We’ll keep an eye out for other research in this area as it’s a topic we are often asked about. 

The detrimental effects of systemic Ibuprofen delivery on tendon healing are time-dependent

Brianne K Connizzo, Sarah M Yannascoli, Jennica J Tucker, Adam C Caro, Corinne N Riggin, Robert L Mauck, Louis J Soslowsky, David R Steinberg, Joseph Bernstein
Clinical Orthopaedics and related Research 2014, 472 (8): 2433-9

BACKGROUND: Current clinical treatment after tendon repairs often includes prescribing NSAIDs to limit pain and inflammation. The negative influence of NSAIDs on bone repair is well documented, but their effects on tendon healing are less clear. While NSAIDs may be detrimental to early tendon healing, some evidence suggests that they may improve healing if administered later in the repair process.

QUESTIONS/PURPOSES: We asked whether the biomechanical and histologic effects of systemic ibuprofen administration on tendon healing are influenced by either immediate or delayed drug administration.

METHODS: After bilateral supraspinatus detachment and repair surgeries, rats were divided into groups and given ibuprofen orally for either Days 0 to 7 (early) or Days 8 to 14 (delayed) after surgery; a control group did not receive ibuprofen. Healing was evaluated at 1, 2, and 4 weeks postsurgery through biomechanical testing and histologic assessment.

RESULTS: Biomechanical evaluation resulted in decreased stiffness and modulus at 4 weeks postsurgery for early ibuprofen delivery (mean ± SD [95% CI]: 10.8 ± 6.4 N/mm [6.7-14.8] and 8.9 ± 5.9 MPa [5.4-12.3]) when compared to control repair (20.4 ± 8.6 N/mm [16.3-24.5] and 15.7 ± 7.5 MPa [12.3-19.2]) (p = 0.003 and 0.013); however, there were no differences between the delayed ibuprofen group (18.1 ± 7.4 N/mm [14.2-22.1] and 11.5 ± 5.6 MPa [8.2-14.9]) and the control group. Histology confirmed mechanical results with reduced fiber reorganization over time in the early ibuprofen group.

CONCLUSIONS: Early administration of ibuprofen in the postoperative period was detrimental to tendon healing, while delayed administration did not affect tendon healing.

CLINICAL RELEVANCE: Historically, clinicians have often prescribed ibuprofen after tendon repair, but this study suggests that the timing of ibuprofen administration is critical to adequate tendon healing. This research necessitates future clinical studies investigating the use of ibuprofen for pain control after rotator cuff repair and other tendon injuries.

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Qualified Personal Trainer

Three years ago, when we first moved to Glossop, we wrote a business plan for Global Therapies. One thing that we were clear on was that we would be constantly learning. Body work, manual therapies, making people move and feel better are all areas which constantly need updating and whilst we don’t want to be CPD course collectors, there is a requirement to ourselves as professionals to keep our knowledge relevant and up to date.

Along the way our plans changed just a little bit – we didn’t originally think Tim would be qualifying as a Physiotherapist (or will be in about a years time). But with inspiration gained from his time working at the 2012 London Olympics he enrolled at Salford University and is fast approaching the final year of his Physiotherapy degree.

What we did have planned though was for me, Tim, or both of us to become personal trainers or strength & conditioning coaches.  You often see PT’s or coaches enhancing their skills by training in sports massage and injury management, we would just be doing this the opposite way around.

Last September I enrolled on two CYQ courses: Level 2 Gym Instructor and Level 3 Personal Trainer. “CYQ is one of the UK’s leading awarding organisations for physical activity, fitness and wellbeing“, more about CYQ on their website. Having a sound base in anatomy and physiology has certainly helped as there has been a vast amount of reading, distance learning and written assessments, as well as several weekends attending practical lessons and ongoing assessments.

We are pleased to announce that Lynne is now a qualified Level 2 Gym Instructor and Level 3 Personal Trainer.

Level 3 Personal Trainer certificate

Level 3 Personal Trainer certificate (the CYQ certificate is on the way)

My original motivation for getting the PT qualification was to add depth to my knowledge when giving advice on injury management. Being able to safely advise on strength training for improving muscle functioning and correcting imbalances was a key area I wanted to learn. Along the way my thoughts on this have developed.

Complimenting my Hill and Moorland Leaders Award, I recently qualified as a UK Athletics Fell Leader in Running Fitness and have been taking people out on guided fell runs around the Peak District. I love showing people the area, and also giving people a reason to improve their fitness without the need to slog away for hours in a gym. It’s in this area I want to develop the PT work – fun, fitness and fresh air.

We’ll post more information on our PT services soon, but if you want to get fitter, lose weight, gain self-confidence or work towards a specific fitness goal then get in touch with me (contact@globaltherapies.com).

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End of Year 2 – Physiotherapy

Well. It’s been quite a ride to get to this point so far. More than halfway through the degree, and it is astonishing just how fast time flies. Equally, it seems like an age away since we were at the Olympic Games and I decided that the academic path was a good idea.

This year started off with a lot of time in University, looking specifically at Neurological, Respiratory and Spinal physiotherapy. This was followed swiftly by post-Christmas exams, which messed up my fell racing schedule somewhat, but sacrifices have to be made somewhere… Happily, the marks I got were all in the region of where I am aiming for, so the revision and the brain seemed to be working ok at that point.

We then had a couple of months working in groups on a presentation, which was a fairly intense part of the course. It is funny how working in a group really ends up galvanizing the mind and makes you work in a particular way. The final presentation went well, apart from a technical glitch of the whole computer system freezing up partway through my section (not my fault, I must hasten to add). Apparently this was dealt with very well, and we were completely unfazed by the problem.

From there, placements began in earnest. My first one was in the Community setting over in Stockport, so I spent 6 weeks on a mobile unit with my Clinical Educator, seeing all manner of physiotherapy issues and visiting people in their homes. This was a very eye-opening experience to see quite how things work in the physiotherapy setting outside of hospitals.

After a fortnight off for Easter I was back into my second placement – Neurophysiotherapy – which has been the most challenging one to date. A truly fascinating area of physio, and one that is quite often neglected when people think about the profession as a whole.

Now that is over, I am sitting down to make sure my portfolio is up to date – it will be assessed at some point next year, so it is probably best to make sure it is in some kind of order now, rather than wait until the week before I need it, and spend 72 hours surrounded by myriad sheets of paper.

This summer will also have some time dedicated to research and looking through academic papers in anticipation for a literature review that will need to be done in the first semester of the 3rd year, taking time to relax a little, but still working as hard as ever with massage clients over the summer. At least I don’t have to juggle work with University over the next couple of months, but that is going to be something that I’m going to have to deal with again once it gets to September.

Can’t wait.

Taking time to read on a rest day in Snowdonia

Taking time to read on a rest day in Snowdonia

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Research focus: trigger point therapy for calf pain

We are constantly reading, researching and investigating issues relating to the work we do. In our recent research we’ve read an interesting research study looking at calf (triceps surae) dysfuntion and whether trigger point therapy is an effective treatment. Alongside the trigger point treatment that was administered, subjects were advised on home care using a programme of stretching and foam rollering.

The abstract from the paper is in the text below, if you want to have a look – the results show that following treatment to deactivate trigger points the subjects had better range of movement in the ankle, less pain and better function. If you’re interested in knowing more about this study pop round for a chat.

Myofascial trigger point therapy for triceps surae dysfunction:
A case series (Rob Grieve, Sue Barnett, Nikki Coghill, Fiona Cramp)

Abstract

Aims

The main aim of the case series was to inform further experimental research to determine the effectiveness of myofascial trigger point (MTrP) therapy for the treatment of triceps surae dysfunction.

Participants

Ten participants with triceps surae dysfunction were recruited (4 females and 6 males); mean age ± standard deviation = 43 ± 7.1 years.

Methods

Participants were screened for inclusion/exclusion criteria and the following outcomes measures were assessed at baseline and discharge; lower extremity functional scale (LEFS), verbal numerical rating scale (NRS), MTrP prevalence, ankle dorsiflexion range of movement (ROM) and pressure pain threshold (PPT). Intervention involved trigger point (TrP) pressure release, self MTrP release and a home stretching programme.

Results

There was a high prevalence of active/latent MTrPs and possible myofascial pain syndrome (MPS) for all 10 participants at baseline. Active MTrP prevalence decreased to 0%, while latent MTrPs were still present at discharge. There were positive changes in most outcome measures (LEFS, NRS, ROM and PPT) for all 10 participants. Short term to medium term treatment outcomes (6 week post discharge) showed an overall mean LEFS increase of 11 points from 61/80 at baseline to 72/80 at discharge.

Conclusion

This case series suggests that a brief course of multimodal MTrP therapy would be helpful for some patients with sub-acute or chronic calf pain. Important preliminary data was gathered, that will inform more rigorous research in this under investigated area.

Keywords

  • Case series
  • Triceps surae
  • Calf dysfunction
  • Myofascial trigger point therapy

Manual Therapy
Volume 18, Issue 6 , Pages 519-525, December 2013

 

NB. ‘triceps surae’ is the name given to two muscles in your calf, the gastrocnemius and soleus. If you’re confused by the ‘tri’ aspect, then rest assured there are three muscle heads involved as your gastrocnemius has two heads.

 

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End of physio placement 2

For the past 6 weeks I have been on my Neurophysiotherapy placement in Tameside General Hospital. Neuro is not a discipline that I found particularly easy or natural to learn, and the placement held a few fears for me.

To be honest, before I did it, I had visions of not learning all that much and finding myself out of my depth in terms of communication and background knowledge. However, my preconceptions were completely changed by my Clinical Educator and the general team over in Tameside General.

I know that Tameside hasn’t really got the greatest of reputations, and also, when you mention Neurophysiotherapy and Tameside in the same sentence you get a lot of funny looks – Salford is the place you go for that, surely?
Not so.

Tameside have an Acute Stroke unit and a very busy neuro outpatient workload as well. They take in pretty much anyone needing neurophysio in the area – quite uniquely – with no qualifying criteria. So anyone above 18 with a neurological issue – they see. Which makes for a varied and complex caseload.

From the moment that I entered the building on my first day, to the minute I left on my last, it was a veritable whirlwind of learning and giving treatments. Tea breaks? Don’t be ridiculous, no time for that. The attitude of my Clinical Educator was that if we are at work, there are people to help. If you are at a loose end, there is probably something you’re missing, so find out what it is and get on with it. Patients don’t get seen when we’re at home, so make the most of the contact time while we have it.

While there I worked with so many different people from different backgrounds, covering all manner of neurological issues, from acute stroke to MS, vestibular problems to Charcot Marie Tooth (an inherited sensorineural peripheral polyneuropathy). My Clinical Educator had an interesting remit that covered inpatients and outpatients, so my time was similarly split, as well as spending a once weekly session in the hydro-pool.
And I learned so much.

Not just about neurophysio as a separate entity, but more as an adjunct to what I do on a day-to-day basis as a soft tissue therapist. I have to say that the team at Tameside are fantastic, and have such a breadth and range of knowledge, coupled with such a great attitude that I couldn’t help but learn.

My time is now being spent sorting out my portfolio with all the evidence from this placement, putting final touches to reflections, ensuring all the paperwork is done, and then… well, research for my final year project…. Placement may have finished, but the work doesn’t.

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Sports Massage qualifications

There are a decent number of people out there with sports massage qualifications now. Or at least, a good number of people out there who are advertising sports massage as a service, though there are a confusing array of different qualifications that allow them to advertise themselves as such.

The main qualifications out there are under the BTEC banner. They start off at Level 3 and go to Level 5, but what is the difference, and what can you expect from a practitioner of each level?

BTEC Level 3
A one-weekend qualification, generally done as a continual professional development course for a Personal Trainer or as a foundation course before more in-depth study commences. This level is a general introduction to Sports Massage, the basic techniques, and fundamental principles. After completing this course, a practitioner is able to perform basic massage on non-injured areas, and is expected to be able to recognise when it would be dangerous to give massage, and should know enough about theory of massage not to create adverse effects from their treatment.

BTEC Level 4
This qualification is more in-depth, and generally gets covered in 15-20 days over a sustained period of time. The practitioner is required to pass an anatomy exam, a practical exam, and to have done 100 hours of practice before passing, and therefore, before they are able to charge for their services. If you are being charged for a massage and they still have not completed their 100 hours, they aren’t actually qualified yet. This level of practitioner has a greater knowledge of anatomy, contraindications and theory of massage than that of Level 3. They are also able to use a wider range of massage techniques and should be more versed in stretching techniques and ‘releases’.

BTEC Level 5
This qualification is much the same as Level 4 but with a greater emphasis on recognition of injury and analysis of what might be wrong and what can be done to help with the rehabilitation of it. This is done from both a soft tissue, and an exercise point of view, and hence why it’s called Sports & Remedial Massage. Again, these practitioners must have at least 100 practice hours under their belts. Their anatomy and physiology knowledge should be better than the lower levels, and can rival some physiotherapists. They should have the full array of massage techniques at their fingertips (so to speak) and should be able to recognise and suggest potential diagnosis of injury. This also gives them the knowledge to know when it is safe to give a treatment, and when someone should be referred to another professional such as a physiotherapist, osteopath or a medical specialist.

Level 5 qualifications

our Level 5 qualifications

Both Tim and Lynne hold a BTEC Level 5 Sports & Remedial qualification, studying this in 2010 at the London School of Sports Massage.

Qualifications & Regulation
If you see a therapist and they don’t publicise their qualifications, I tend to see this as slightly odd. Doctors tend to write a ridiculous number of letters after their names, this is because they worked hard to get them, and they mean a lot to the individual.

Physiotherapists always have something after their name when advertising – if only to say they are Chartered, and a member of an association. Equally, they worked hard for their qualification, and don’t mind being called out on it, or asked about what their qualification means.

Massage therapy is not yet as well regulated as physio, and certainly not as well regulated as being a doctor, but that doesn’t mean we aren’t qualified.

If someone doesn’t advertise their qualification, it is likely that they have a weekend qualification, or a less accredited course. If you see a therapist, and you don’t know how they qualified, ask them. They will either fudge around the subject, or they will be able to tell you about a year long course in nauseating detail.

I know which one I would prefer to entrust my body to.

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Reaquaint yourself with the floor

Having spent six weeks on placement in the NHS, it seems that a lot of problems that professionals face, both on the ward, and in the community is that of falls.

Falls to the ground, and then the difficulty in getting back up off it again.

I find this astonishing, but it really is the case. The evidence is out there. It was estimated that in 2002,  just under half of all hospital admissions in the UK were directly attributable to a fall (http://www.hassandlass.org.uk/reports/2002data.pdf). I’m sure there are some more up to date data around, but couldn’t find any after a cursory search. Either way, that is a lot of accidents – just about a million, from falling over, or off something.

The floor is what attaches us to the rest of the world, and as we get older and more frail, it becomes an enemy. The floor, always there, is something that people fear. Despite the fact that as children, it is our closest friend, it is where we spend most of the time falling over, crawling about, and generally messing about, as we get older, we lose that connection to it.

The floor is something we stand on, and not a lot more. It is a platform that we try to avoid at all costs.

This, I reckon, is to our detriment.

Tim doing Japanese tea ceremony

Tim doing Japanese tea ceremony

When I lived in Japan, I did the tea ceremony on a weekly basis with a group of septegenerians. They had no problems getting on and off the floor. To them, falling over and getting back up again would not have been an issue. The floor held no fear for them. Is this something that we should consider?

If, from a young age we can get onto and off the floor without even thinking about it, we evidently lose that ability as we get older. But, if we do it, day in, day out, if we practice getting to the floor – that may seem such a long, long way away, and practice getting back off it again, maybe, by the time we get old, by the time we get to the age where we really don’t want to be falling as we’re afraid we won’t get back up again, that fear will not materialise… why not? Simply because it is a matter of day-to-day life. It is part and parcel of who we are.

I’ve been trying to get my parents to practice getting on the floor and back up again. The more we do it. The more we engage with something that is part of us – the floor, the less we will be afraid of it in the future when we become older.

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