Wednesday, May 25, 2011

Tenderpoints and IMS (Ottawa Physiotherapy)

Below is an article about IMS (intramuscular stimulation) from the Ottawa Physiotherapy and Sport Clinics.  We offer IMS at our Orleans physiotherapy, Barrhaven Physiotherapy and Westboro Physiotherapy locations.


Tenderness at Motor Points(Extract from an article that was printed in the Journal of Bone and Joint Surgery September 1976)

A DIAGNOSTIC AND PROGNOSTIC AID FOR LOW-BACK INJURY
BY CC GUNN, MA, MB, B.CHIR*, AND WE MILBRANDT, MD*,VANCOUVER, BRITISH COLUMBIA, CANADA

From the Workers’ Compensation Board, Rehabilitation Clinic, Vancouver

The following extract is included because it was the first physical sign we discovered that is related to neuropathy.

ABSTRACT: In patients with low-back injury the motor points of some muscles may be tender. Of fifty patients with low-back “strain”, twenty-six had tender motor points and twenty-four did not, while forty-nine of fifty patients with radicular signs and symptoms suggesting disc involvement had tender motor points, and the one without such tender points had a hamstring contusion which limited straight leg raising. Of fifty controls with no back disability, only seven had mild tender points after strenuous activity, while forty-six of another fifty controls with occasional back discomfort had mild motor-point tenderness. In all instances the tender motor points were located in the myotomes corresponding to the probable segmental levels of spinal injury and of root involvement, when present.

Patients with low-back strain and no tender motor points were disabled for an average of 6.9 weeks, while those with the same diagnosis but tender motor points were disabled for an average of 19.7 weeks, or almost as long as the patients with signs of radicular involvement, who were disabled for an average of 25.7 weeks. Tender motor points may therefore be of diagnostic and prognostic value, serving as sensitive localizers of radicular involvement and differentiating a simple mechanical low-back strain from one with neural involvement.

It is often difficult, if not impossible, to establish the cause of disability and to assess its degree in patients with low-back pain. While in some patients the diagnosis can be made with no difficulty on the basis of the clinical history and physical examination, in others additional diagnostic tests including myelography and electromyography may be required. As a general rule, however, such tests are reserved for patients whose diagnosis is not clinically apparent or who are expected to require surgery. There remain, therefore, many patients with no localizing physical findings for whom ancillary tests are not considered necessary. The injuries in these patients are conveniently labeled “low-back sprain”.

The physician, unable to make a firm diagnosis, may rightly or wrongly relate the pain to socio-economic and psychophysiological factors, or may even suspect malingering. Therefore, many patients with genuine discomfort may not be treated appropriately simply because there are no significant physical findings.
The Workers’ Compensation Board of British Columbia operates an Outpatient Rehabilitation Clinic to provide treatment after industrial injuries. So-called low-back sprain, a vague term encompassing a multitude of disorders, is one of the most common disabilities seen at the Clinic. In 1974, the total number of admissions for all types of injuries was almost 5,000, and 1,630 (33 per cent) of these were for injuries to the lumbar spine. Of these lumbar-spine injuries, 1,401 (86%) were given a working diagnosis of low-back sprain. The remainder were fractures and postoperative conditions after laminectomies and spine fusions 8.

While performing electromyographic examinations in this Clinic, we discovered that some patients had tenderness at the motor points. Initially, these tender areas were confirmed as being located at the motor points by showing that they were at sites where the minimum electrical stimulus evoked muscle twitches using a standard calibration-stable stimulator with variable control of outputs. These studies established that the motor points of certain muscles are frequently tender in patients with low-back pain. Electromyography also showed evidence of neuropathy in the nerves supplying these tender muscles, including increased insertion activity, more polyphasic action potentials, and prolongation of the mean duration of the motor-unit action potentials, their mean amplitude remaining normal or decreasing and a partial interference pattern being obtained even during maximum voluntary effort6,7.

Tenderness parallel the severity of the symptoms and varied from week to week and even from day to day. Localized tenderness was not found in patients having hysteria or malingering. Because of these findings, we had to revise many previous diagnoses. For example, a dull ache localized to a small area in the upper lateral quadrant of the buttock, which previously had been attributed to gluteal bursitis, was found to be a tender gluteus medius. Similarly, tenderness at the gluteus maximus had been mistaken for sciatic-nerve tenderness. Tenderness described as trochanteric bursitis was found to be located at the tensor fasciae latae motor point, while tenderness thought to be caused by “adductor strain” and “rider’s sprain” was found to be located at the motor points of the pectineus and adductor longus 3. Tenderness was rarely limited to one motor point and a search for other points in muscles of the same myotome usually revealed their presence.
Methods and MaterialExamination for Tender Motor Points

Representative muscles of the second through the fifth lumbar and the first two sacral myotomes are examined. Trauma to a nerve root causes irritation or degeneration of nerve fibers, or both. These lesions may be detected during electromyography as increased insertional activity, polyphasic action potentials,
fasciculation potentials, fibrillations, and positive sharp waves, or in the procedure described here as tender motor points. Examination of the paraspinal muscles innervated by the posterior primary rami is also necessary to confirm the pathological process involves the segmental nerve at the root level.

SEGMENTAL INNERVATION OF MUSCLES OF THE LOWER LIMB
TABLE I

Muscle (Segmental Innervation) Peripheral Nerve points of both heads of the gastrocnemius and of the soleus.

With a little practice, any tenderness at these motor points may be quickly elicited, although some points are
L2 Sartorius (L2, L3), Pectineus (L2. L3), Adductor longus (L.2, 1.3), L3 Quadriceps femoris (L2-L4) L4* Quadriceps femoris (L2-L4), Tensor fascise lame (L4, L5), Superior gluteal, Tibialis anterior (L4, L5), L5 Gluteus medius (L4-S1), Semimem>xanosus (L4-S1), Semitendinosus (L4-S1), Extensor hallucis longus (L4-S1) , S1 Gluteus maximus (L4-S2), Biceps femoris, short head (L5-S2), Semitendinosus (L4-S1), Medial gastrocnemius (S1, S2), Soleus (S1, S2) S2 Biceps femoris, long head (S1, S2), Lateral gastrocnemius (S1, S2), Soleus (S1, S2)

* Muscles receive innervation from more than one segment. The segments listed on the left are those generally accepted as the predominant source of innervation of the muscles in question. All are innervated by the anterior rami; the posterior rami go to corresponding levels of the erector spinae muscles, but there is extensive overlapping of the posterior rami.

In this prospective study, 100 patients and 100 control subjects were examined and followed. They were divided into four groups:

Patients with Low-Back Pain (Groups A and B)100 patients with low-back symptoms were selected from 147 consecutive patients. 47 patients were excluded with compression fractures, advanced degenerative osteoarthritic changes, and previous laminectomy or spine fusion.

All patients were managed with the standard Clinic regimen 8 including physiotherapy followed by graduated remedial exercises as well as occupational therapy or industrial activities as tolerance improved. Patients also received instruction in the care of the back and in proper bending and lifting techniques.
Control Subjects (Groups C and D)We decided to use 100 members of the lay staff of the Workers’ Compensation Board as controls. Their combined age and sex distributions were comparable to those of the patients in Groups A and B.

The control subjects were divided into two groups: Group C, fifty men and women who had no back disability; and Group D, fifty men and women who considered themselves normal, without back discomfort at the time although they had had occasional low-back discomfort after unusual activity.
Results

Group A - Low-Back SprainNo history of previous back surgery, no radicular symptoms, and no feeling of weakness, numbness, or paresthesia. No radicular signs, reflex changes, sensory changes, motor weakness, or muscle atrophy. Roentgenograms were normal or showed no more than minimum degenerative changes consistent with age or minor congenital abnormalities. No spondylolysis or spondylolisthesis. Of these fifty patients, there were twenty-six (52 per cent) who had tender motor points and twenty-four (48 per cent) who did not. These two subgroups were compared with respect to roentgenographic changes, mechanism of injury, and duration of disability. 15 of the 26 patients with tender motor points had roentgenographic abnormalities, while only two of the twenty-four without tender points had such findings.
The duration of disability ranged from 12 to 34 weeks (average, 19.7 weeks) in 25 of the 26 patients with tender motor points. In the 24 patients with no tender motor points, the disability period ranged from 3 to 13 weeks (average, 6.9 weeks).

Group B - Disc InvolvementThis Group had radicular symptoms and signs. All but one had tender motor points. The exception sustained a contusion of the hamstring muscles and this, rather than radicular involvement, was responsible for the limited straight leg raising. Although many of the patients with tender motor points had unilateral symptoms, as often as not their tender motor points were bilateral.
The duration of disability of the 49 patients in Group B with tender motor points ranged from 14 to 72 weeks (average, 25.7 weeks), while the one patient with no tender motor points was disabled for only 8 weeks.

Group C - No Back DisabilityThese subjects with no back disability showed no positive findings, developed Grade-1 tender motor points after unusual activity, such as jogging, or shoveling snow; their tenderness disappeared a few days later, only to recur whenever they increased their activities.

Group D - Occasional Back Discomfort

Physical examinations in Group-D subjects with occasional back pain were negative at the time of examination. But 46 (92%) had Grade-1 or Grade-2 tender motor points.
No correlations were evident between the locations, numbers, and grades of the tender points and the location of the degenerative changes visible on the roentgenograms.

Discussion

It is generally agreed that virtually everyone eventually has some degenerative joint disease in the low back, but that as a rule problems arise only when the degeneration has reached a certain degree and some incident, which may be minor, precipitates symptoms.
In this study it was found that an injury involving flexion combined with rotation of the lumbar spine is most likely to cause prolonged disability and that tender motor points may be useful in assessing back problems, particularly when no positive physical signs are detectable.
Tender motor points of a mild and transient nature may occasionally be found in asymptomatic individuals, especially after unusual activity. Moderately tender motor points are usually present in so-called vulnerable backs or lesser degrees of trauma. The presence of tender motor points might be significant in pre-employment medical examinations. Moderately to acutely tender motor points are almost constantly found in patients with disc degeneration. The degree of tenderness and the number of tender points tend to parallel the patient’s condition and may serve as indicators of progress.
An important finding was that low-back patients and no tender points were disabled for an average of 6.9 weeks, while those with tender points were disabled for an average of 19.7 weeks, almost as long as patients with radicular signs, who were disabled for an average of 25.7 weeks. Tender motor points, may, therefore, be a sensitive indicator of radicular involvement. Recovery time may be related to the degree of trauma sustained. Patients seen for the first time, who show no physical signs except tender motor points, deserve attention and continued surveillance.

Conclusions

Low-back pain without significant physical signs may present a diagnostic challenge. Tender motor points may be a clue under these circumstances.
This study suggests that muscle tenderness, maximum at motor points, can be elicited during the routine examination of the back and be a useful diagnostic and prognostic sign in this enigmatic group of low-back sprains.

Patients diagnosed as having simple low-back sprain but demonstrating acutely tender motor points will have a period of disability approaching that of patients with radicular signs, while patients with no tender motor points can be expected to do well.

References

1. Chusid, JG: Correlative Neuroanatomy and Functional Neurology. Ed. 15, pp. 236-237. Los Altos, California, Lange Medical Publications, 1973.2. Coers, C: Note sur une technique de prelevement des biopsies neuro-musculaires. Acta Neurol. Psychiat. Belgica, 53:759-765, 1953.3. Cyriax, JH: Textbook of Orthopaedic Medicine. Ed. 5, p. 646. London, BaiUierc, Tindall and Cassell, 1969.4. Denny-Brown, D, and Brenner, Charles: The Effect of Percussion of Nerve. J. Neurol•, Neurosurg., and Psychiat., 7: 76-95, 1944.5. Goodgold, Joseph, and Eberstein, Arthur: Electrodiagnosis of Neuromuscular Diseases, pp. 3 and 164. Baltimore, Williams and Wilkins, 1972.6. Gunn, CC, and Milbrandt, WE:Tennis Elbow and the Cervical Spine. Canadian Med. Assn, J., 114: 803-809, 1976.7. Gunn, CC, and Milbrandt, WE: Unpublished data.8. Milbrandt, WE, and Gunn, CC: A Comprehensive and Progressive Rehabilitation Programme for Low Back Strain as applied at the Workers’ Compensation Board of British Columbia. In Proceedings, International Symposium on the Rehabilitation of the Industrially Injured. Vancouver, British Columbia, Canada, April 1973.9. Nassim, Reginald and Burrows, HJ: Modern Trends in Diseases of the Vertebral Column, p. 268. London, Butterworths, 1959

IMS (intramuscular stimulation) from the Ottawa Physiotherapy and Sport Clinics

Wednesday, March 9, 2011

IMS and Chronic Low Back Pain





Intramuscular Stimulation (IMS) of Muscle Motor Points in the Treatment of Chronic Low Back Pain: A Randomized Clinical Trial
Here is another article discussing IMS an lower back pain.  FYI this is a service we offer at our Orleans physiotherapy, Barrhaven Physiotherapy and Westboro Physiotherapy locations.

Simple or mechanical low back pain, as defined by the Clinical Standards Advisory Group (CSAG 1994), is the commonest and most rapidly increasing cause of loss of work, demand for health care and need for state benefit in society today (Fordyce 1994).
In most recent population studies 36-37% of the adult population reported back pain in the last year and approximately 60% would report back pain at some time in their lives (CSAG 1994). The annual cost of this back pain to the NHS was estimated to be £480 million (This does not include private consultations or medicines outside the control of the NHS).
Tulder (1997) carried out a systematic review of RCT’s of the commonest forms of treatment in use for back pain, including Acupuncture (Dry-needling). This review concluded that the overall methodological quality of RCT’s on the efficacy of treatments for back pain was very poor. Acupuncture in particular appeared to have poorly designed trials to support its use in a clinical setting.
However, acupuncture still remains a common and a popular form of treatment for back pain and although described as being of poor quality some evidence does exist for its use. Gunn (1980) in a study of chronic low back pain found that patients treated with dry-needling had significantly better outcomes than controls with respect to return to work (P > 0.005). Garvey (1989) compared dry-needling to injection of local anaesthetic in patients with low back pain. Dry-needling resulted in a 63% improvement rate (P=0.09). The use of dry-needling as opposed to injection of trigger points is further supported in other studies (Hong 1994).
This study aims to address the lack of evidence and to support the use of acupuncture (Intramuscular Stimulation) in the clinical setting for the treatment of chronic low back pain. To achieve this a randomised controlled trail was conducted to test the hypothesis that: Dry-needling of muscle motor points for chronic low back pain in conjunction with a program of exercise produces superior outcomes to the use of an exercise program alone.
Patients who had simple, chronic low back pain, as defined by the CASG report (1994), were randomly selected from a total of 6 months of referrals made to the Physiotherapy Department at St. Leonards Hospital. These referrals were from the patients General Practitioners. A total of 45 subjects, 24 in the experimental and 21 in the control were recruited.
Once it was established that these subjects fit the study’s inclusion criteria and their written consent was obtained, they underwent the clinics standard back pain assessment, this was used to calculate a range of movement score (Stankovic and Johnell 1990). Subjects were also asked to complete two questionnaires as part of the study’s outcome measures,
• The McGill Pain Questionnaire.
• The Roland Morris Physical Disability Scale.
A further Questionnaire was used at initial assessment to rule out any obvious Depressive overlay.
• The Distress and Risk Assessment Method.
At this point an independent clinician randomly allocated each patient to either the experimental or the control group. The experimental group was treated with instruction in a home exercise program and also started on a course of Intramuscular Stimulation (IMS). This consisted of up to ten treatments.
The control group received similar instruction in a course of home exercise but received no treatment with IMS. At termination of treatment both groups were asked to complete the questionnaires again and receive a physical re-examination of the spine.
A follow up appointment for 3 months post discharge was then arranged to physically re-assess each patient and to complete the two outcome questionnaires. The results were analysed, using the non-parametric Mann-Whitney U test.
The results supported the hypothesis that intramuscular stimulation and an exercise programme are superior to an exercise programme in isolation. At the pre-treatment measurement stage there was no significant difference between either the experimental group or the control group at any of the three outcome measures.
At both the discharge and the three month follow up stage there was a significant difference noted in the Roland Morris scores (p = .005). Similarly, significant differences existed with the range of movement scores (p = .005) and the McGill pain questionnaire scores (p = .005).
This study proposes that the use Intramuscular Stimulation in the treatment of chronic low back pain be considered a serious alternative to other conventional therapies. Further studies with longer term follow up and larger numbers of patients are now needed to confirm this assumption.

Thursday, February 3, 2011

Intramuscular Stimulation

IMS and tennis elbow

Below is an article talking about intramuscular stimulation (IMS) which is a treatment offered at all three locations at the Ottawa Physiotherapy and Sport Clinics (Orleans physiotherapy, Barrhaven physiotherapy and Westboro physiotherapy sites).

Tennis Elbow and the Cervical Spine

C. Chan Gunn, MD
 
The exact cause of tennis elbow, a common condition, is still obscure. While the condition may well be entirely due to a local disorder at the elbow, the results of a study of 50 patients whose condition was resistant to 4 weeks of treatment directed to the elbow suggest that the underlying condition may have been (at least in these patients) a reflex localization of pain from radiculopathy at the cervical spine. Clinical, radiologic and electromyographic findings supported this suggestion. The pain was demonstrated to be muscular tenderness, which was maximal and specific at motor points. Treatment directed to the cervical spine appeared to give relief in the majority of patients. The more resistant the condition, the more severe were the radiologic and electromyographic findings in the cervical spine.
Tennis elbow, a common affliction, the exact cause of which is unknown, has been considered to be a self-limiting condition, seldom persisting for longer than 12 months, yet symptoms may continue longer despite all types of conservative treatment or even surgery.
This paper reports a new approach: in a series of 50 patients treatment was directed to the cervical spine after at least 4 weeks of treatment of the elbow had failed, and it was successful in most.
Patients and symptoms
The 50 patients with tennis elbow, 37 men and 13 women, were referred by attending physicians to the rehabilitation clinic of the Workers' Compensation Board of British Columbia for management. In many the condition had not responded to the usual conservative office measures, such as injections of steroids and local anesthetics, manipulation, ultrasound, friction massage and immobilization. Their age distribution was as follows: 21 to 30 years, 8 patients; 31 to 40 years, 10; 41 to 50 years, 13; 51 to 60 years, 15; and over 60 years, 4.
All were right-side-dominant, but three had only left-side complaints. Eleven had bilateral lateral epicondylar symptoms, 12 had concurrent medical epicondylar symptoms and 7 had bilateral medical and lateral epicondylar symptoms. The time lapse between onset of symptoms and referral to the clinic was 8 weeks or less in 24, 8 to 12 weeks in 11 and more than 12 weeks in 15.
The clinical types of tennis elbow, classified by onset and injury, were the following:
  1. Acute type, precipitated by indirect trauma (Cyriax's typeI) - - for example, probable avulsion due to acute pull of forearm extensor muscles at their origin (four patients).
  2. Subacute type, following indirect trauma (Cyriax's type II), from repeated and forcible extension movements at the wrist (six patients).
  3. Insidious onset (Cyriax's type III), with no specific single incident (11 patients).
  4. Acute onset following blunt trauma (Cyriax's type IV) (six patients).
  5. Associated with cervical "strain", with history of phyerextension or flexion injury to cervical spine or neck "strain" (13 patients).
  6. Associated with jolt or traction to shoulder (three patients).
  7. Not classified elsewhere - - for example, as part of multiple injuries, when exact mechanism is not determined (seven patients).
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Examination
In addition to eliciting the classic signs, the examiner palpated carefully the entire elbow region with a blunt point or the tip of a finger. Points of maximal tenderness found (usually four) were accurately determined and marked. These points seemed to correspond to the sites of muscle motor points in the region and were confirmed as such by electric stimulation. A motor point is defined as the site where a muscle twitch may be evoked in response to minimal electric stimulation. This point, a fixed anatomic site, lies close to where the motor nerve enters the muscle. Many of the motor points of the wrist extensor lie around the lateral epicondyle of the humerus, where there is also a rich supply of sensory nerve fibre endings (Fig I). Other upper-limb motor points where tenderness might be found were likewise examined (Figs. 2, 3 and 4). Since the tender muscles have common root derivations of their motor nerves (Table I), the cervical spine was also examined.
Electromyographic examination was performed in 42 patients, and in all patients with a history of acroparesthesia or in whom carpal tunnel syndrome or ulnar nerve tardiness was suspected, motor nerve conduction velocity tests were done to exclude such conditions.
Physical findings
The wrist extensor motor points generally found to be tender were those of the brachioradialis, extensor carpi radialis, supinator, extensor digitorum and extensor carpi ulnaris; these points are closely situated in an area of about 5 cm in diameter. Tenderness in other areas was of similar quality and often equal intensity; frequently both sides were involved. The frequency of tenderness at the various motor points is shown in Table II.
Eighteen patients showed slight limitation of lateral rotation or lateral tilting of the cervical spine to the affected side. On that side, in all patients, the apophyseal joints of involved levels were tender to digital pressure (commonly C5 and C6) when carefully examined showed resistance to passive motion.
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Table I - Spinal cord root derivations of motor nerves supplying arm and shoulder muscles.
Muscle

Infraspinatus, supraspinatus
Deltoid
Biceps
Brachioradialis
Pectoralis major
Triceps
Extensor carpi radialis
Flexor carpi radialis
Pronator quadratius
Flexor carpi ulnaris
Dorsal interossei
Motor nerve root derivation

C5,6
C5,6
C5,6
C5,6
C5-8, T1
C6-8, T1
C6-8
C6-8
C8, T1
C7,8, T1
C8, T1

Table II - - Frequency of tenderness at various motor points.
Muscle of tender motor point

Trapezius
Supraspinatus
Infraspinatus
Deltoid (any of three points)
Pectoralis major
Biceps branchialis
Extensor carpi radialis
Extensor carpi ulnaris
Extensor digitorum
Branchirradialis
Triceps (any of three points)
Adductor pollicis brevis
Flexor carpi ulnaris
Frequency* of tenderness

36
39
12
28
13
15
57
57
50
12
6
13
16

*Out of a possible 100 -- that is, 50 X patients X 2 sides.
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Muscle atrophy, especially of the trapezius, supraspinatus, triceps and deltoid, was noted in 15 patients, and partial loss of sensation to pinprick over the associated dermatome was detected in 1 patient.
In 10 patients an autonomic (pilomotor and sudomotor) reflex was elicited when the patient was exposed to cold air: the skin over the dermatome involved - generally C5,6 - showed "goose pimples" or an erector pili effect (cutis anserina). This reflex (sometimes accompanied by excessive perspiration in the axillae) could also be induced by digital frictional pressure over many of the tender motor points. Deep reflexes were always normal.

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Radiologic findings
Radiographs of the elbow invariably showed no significant findings, but radiographs of the cervical spine in 34 patients (average age, 47 years) showed changes commensurate with age.
Electromyographic findings
All 42 patients showed some abnormal electromyographic findings of early neuropathy or radiculopathy in affected myotomes. Discharge of action potentials due to mechanical excitation was often increased, and with voluntary activity the mean duration of the action potentials appeared prolonged, but the amplitude was normal or reduced. Typically, polyphasic potentials appeared in abnormal numbers. The interference pattern was reduced and in severe cases lost altogether. In some patients, action potentials of individual units could be identified even during maximum contraction.
Treatment
When first assessed, the condition of 23 of the 50 patients had not improved with at least 4 weeks of standard treatment measures. Two had had bilateral surgical procedures but pain had persisted. In view of the apparent relation of elbow symptoms to disorders of the cervical spine, our approach to relieving the symptoms in this group (group A) was directed immediately to the neck.
The other 27 patients (group B), who had not previously received local treatment of the elbow, were first given ultrasound, friction massage, ice and other therapy, and when symptoms persisted after 4 weeks, treatment was directed instead to the neck.
Treatment of the cervical spine included one or more of the following:
  1. Mobilization (Maitland's grades I to IV).
  2. Cervical traction.
  3. Isometric cervical exercises.
  4. Heat or ultrasound, or both, applied to apophyseal joints if excessive tenderness was spresent.
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Response to cervical treatment
Of the patients in group A the average duration of cervical treatment in the 22 who responded was 4.7 weeks; 1 patient still had symptoms on discharge after 9 weeks. Of the patients in group B the average total duration of treatment (elbow and neck) at the clinic in the 25 who responded was 11.1 weeks, and the average duration of neck treatment was 5.8 weeks; 2 patients still had symptoms on discharge after 18 to 20 weeks. The time lapse between onset of symptoms and beginning of treatment did not appear to influence duration or outcome of treatment.
Relation to electromyographic findings: Of the 42 patients who had an electromyographic examination the average duration of treatment in the 39 who responded was 5.3 weeks (4.7 weeks in the 20 with mild electromyographic abnormalities and 7.2 weeks in the 19 with moderate to severe abnormalities); 3 patients with moderate to severe abnormalities continued to have symptoms.
Relation to radiologic findings: The average duration of treatment was as follows: in the 16 patients with normal radiologic findings, 4.8 weeks; in the 19 patients with minor radiologic abnormalities (restricted motion, early degenerative changes), 4.7 weeks; and in the 12 patients with moderated to severe radiologic abnormalities (severe osteoarthrosis, narrowing of disc space, foramina encroachment), 7.31 weeks. The tree patients who continued to have symptoms had moderate to severe radiologic abnormalities.
Results on discharge from the clinic
  • Good: These 29 patients were able to resume their previous occupation.
  • Satisfactory: These 14 patients returned to light duties or changed to a suitable, nonaggravating occupation.
  • Fair: Four patients were discharged with residual discomfort. Some relief was obtained with a cervical traction apparatus used at home. All returned to a suitable, nonaggravating occupation.
  • Poor: Three patients, with severe radiologic and electromyographic abnormalities, continued to complain of symptoms on discharge.
Follow-up
Of the 47 patients who responded to treatment 44 were assessed at 3 and 6 months (time of writing) after discharge. They had had no further symptoms and had not sought further medical attention. Of the three who had symptoms on discharge, two were asymptomatic within 3 months and one, with severe cervical spondylosis, continued to have symptoms, even at a 1-year follow-up.
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Discussion
It is obviously not possible to draw definite conclusions from this small series because the condition of tennis elbow is often self-limiting, yet the findings challenge some current concepts.
For instance, women in this series were proportionately affected more than twice as often as men. Although the proportion of women affected was only 26% (13 patients), this is more than twice the usual proportion of women attending the clinic for other injuries - - 12% (598 of 4990 patients in 1974).
Bilateral and medial epicondylar symptoms are said to be unusual, yet 22% (11 patients) in this series had bilateral lateral epicondylar symptoms and 24 % (12 patients) had concurrent medial epicondylar symptoms; 14% (7 patients) had bilateral lateral and medial epicondylar symptoms.
In this study a force overload to the extensor muscles, direct or indirect, was found to be not the only precipitating factor; in 26% (13 patients) cervical "strain" was associated, and 84% (42 patients) showed some electromyographic evidence of cervical radiculopathy as well as physical signs in muscles of the myotomes involved.
While the pain may have presented at the bony epicondyle, maximum tenderness was more commonly found in the muscles at the several motor points that are close together and situated over bony prominences, where they are subjected to tension or pressure.
Other physical signs found, related to the cervical spine, were selective atrophy of muscles, especially the triceps and supraspinatus (15 patients), altered dermatomal sensation (1 patient) and presence of an autonomic reflex (10 patients).
These findings led us to conclude that, at least in this group of selected patients, the condition of tennis elbow was related to disorders of the cervical spine; therefore, when treatment to the elbow failed, neck treatment was tired - - with good results. It is probable that in many patients some degree of cervical degeneration preceded the elbow condition.
In this series, treatment of the cervical spine was followed by good or satisfactory relief of elbow symptoms in 86% (43 patients) in an average of 5.25 weeks. In four patients the continual use of a cervical traction apparatus at home provided relief. Tow of the three patients who had symptoms at the time of discharge subsequently improved within 12 weeks. Recovery time may be related to the degree of trauma sustained. Denny-Brown and Brenner have shown that mild percussive trauma to a nerve leads to swelling and local edema of the nerve, together with dissolution of the myelin, and recovery takes at least 4 to 5 weeks; however, if the trauma is sufficiently severe to lead to Wallerian degeneration, recovery takes at least 12 weeks. In the one patient in this series with persistent pain, treatment probably failed to relieve the causative factor (severe cervical spondylosis). The time lapse between onset of symptoms and beginning of treatment bore no relation to the outcome of treatment.
We are grateful to the commissioners of the Board and Dr. A.S. Little, director of medical services. Workers' Compensation Board of British Columbia, for their support and advice; and to Mr. G. Page, supervisor of the physiotherapy department. Miss C. Patterson. Mrs. J.E. Gunnyon and the other members of the staff for their cooperation and involvement in the project.

Wednesday, January 12, 2011

Best Time to Exercise

Best Time to Exercise to Make
Fat Burning Workouts Most Effective

When is the best time to exercise to get the benefits of physical exercise and make fat burning workouts the most effective? Finding time for exercise can be challenging – no matter when you do it, as long as you do your cardiovascular exercises for at least 30 minutes, you will burn the fat anyway. But to get the best possible result for investing your time and effort into your fat burning workout plan, you should get up early in the morning and do your cardio exercises such as running, walking, cycling, aerobics, etc before breakfast. Exercising in the morning has major advantages compared to exercising later in the day. So, why is the morning the best time to exercise? At our Barrhaven physiotherapy, Orleans physiotherapy and Westboro physiotherapy locations we have qualified health professionals that can create programs to reach your goals.

Best Time to Exercise and Burn Fat is in the Morning


Here are the reasons why:

In the morning, before breakfast when your blood sugar levels are low and it is ideal for fat burning exercises ,you will use up energy for exercising from fat stored in your body instead of energy from carbohydrates you have just eaten. If you exercise immediately after breakfast you will still burn the fat but only after you burn the calories from breakfast first. You can burn as much as 3 times more fat when cardio exercises are done on an empty stomach.
When you do your cardiovascular exercises in the morning, not only do you burn the fat during the session, but the fat burning process lasts for hours after the workout session. This is because speed training workouts boost metabolism naturally. If you exercise in the evening you still burn the fat during the workout but as soon as you go to sleep at night, your metabolism slows down rapidly - it is significantly lower than during any other time of the day, so you would not benefit from an evening workout as much as the morning.

The other reason why you should do your fat burning exercise in the morning is getting it out of the way early, especially if you consider it difficult and unpleasant. Putting it off as a chore will make you feel guilty, stressed and you are more likely to skip it if you had a busy day at work, tired or something more interesting came up. Maybe you are not a “morning person” and find it difficult to wake up early and have the motivation to exercise, but if you remember the time in your life when you challenged a difficult task and finished it and how great you felt afterwards!
After your morning cardiovascular exercises you will feel fantastic, not only because you accomplished a difficult task and can be proud of yourself but also because endorphins released in the body after a good workout plan will make you feel happy and euphoric as they create a natural “high”! Endorphins not only improve your mood and release stress but also relieve pain. Isn’t it a great start to the day?! Knowing that the most difficult part of the day is behind you, you can start your day and feel happy and satisfied for the rest of the day. So just get up in the morning and do it! The effort is well worth the result! Of course it will be difficult first, but after a few weeks you will become addicted to the feeling of the buzz you have after your exercise routine. Make a commitment to do it just for 1 month and cardio exercises will become your new habit before you know it, give a metabolism boost and making you feel great!
Whether you're trying to build muscle, burn fat, or increase your overall health, whey protein can certainly help. The best whey protein can increase your performance in the gym, and boost your lean body mass.


P.S. If you still insist after all, on exercising later in the day – the second best time to exercise (cardio exercises) will be after your weight training.

Lose Weight Walking

At all three of our locations which are the Orleans physiotherapy, Westboro physiotherapy and Barrhaven physiotherapy sites we get a lot of questions regarding how to loose weight.  

To lose weight walking is probably the easiest way to lose weight, the quickest way to lose weight and one of the simple ways to lose weight.


It is certainly the best exercise to burn fat especially at the start of your weight loss program if you are a beginner to fat burning workouts and your fitness level needs improving slowly.

Of course, the best way to burn fat is to perform exercises which will burn fat directly. How many calories burned walking? In average 2 to 3 calories burned by walking per minute, which is not a lot, but 80% of the total calories burned are from fat burned directly and only 20% from carbohydrates you consumed throughout the day. Walking is the best exercise to lose weight permanently. 

Health benefits of walking include boosting energy levels, increasing body fat burned, decreasing health risks which are associated with overweight conditions (such as high blood pressure, heart disease, stroke, etc.). Also, the benefits of walking – can be performed any where, any time, while talking with a friend or walking a dog, easy to start, no skills needed, no need of equipment.

Lose Weight Walking is a Good Start of Weight Loss Exercise Programs

Unfit people new to exercise have low fitness levels. This is because a lack of exercise leads to muscle loss and a loss of efficiency to fat burning. That is why many exercises will be too intense and too energy demanding to start a weight loss program. If exercises are too intense for you, your body will be taking energy from burning carbohydrates which came from food you have eaten rather then from fat stores in your body. That is why jogging and running to lose weight is not a good idea at the beginning, as you would not be able to prolong it for a long time to burn calories efficiently, and it will increase your appetite too. Many beginners are doing their best and push the limits to feel that they have done a proper job, as a result they are out of breath, their heart rate is too high, and have deficit of oxygen – not a good condition for burning fat. Once your fitness level improves, you would be able to utilise fat as energy even when running, but at the beginning walk to lose weight.
Fat burning mode requires steady workout with consistent pace and good oxygen supply to muscles, so even overweight or unfit people can achieve this during walking to lose weight.

Lose weight by walking is one of the fun ways to exercise: you can take your friend, child or dog with you, do shopping or window shopping just keep moving continuously to support your fat burning zone. What about other fun exercise ideas – a walking holiday - you can walk across your country discovering new places and attractions every day!

Lose weight walking is the best beginning to your weight loss program if your doctor approves it.