Showing posts with label sports. Show all posts
Showing posts with label sports. Show all posts

Monday, 15 February 2016

My Louisville-age Fellowship in Physiotherapy Pilgrimage: An unusual realization

With my US mentor, Dr. John Nyland, 
Director of Athletic Training Program, Spalding University, 
President of Board of Directors, JOSPT

Someone has rightly said that we all are students for our whole life and that life itself is the best teacher. And what a wonderful teacher life really is! It gives us multiple opportunities to learn, grow and progress with all its unique and practical based experiences.

It has been 12 years now that I am facilitating Physiotherapy education at this wonderful institute. And these 12 years too have been unique learning experiences from seniors, colleagues and students alike. But one of my wonderful learning opportunities was recently presented to me when I got to do my fellowship in Physiotherapy in the US. But the process for this had already started more than 2 years back when my boss and mentor Dr. Parag Sancheti had invited Dr. John Nyland for a Continuous Physiotherapy Education (CPE) session right here at Sancheti Institute College of Physiotherapy around in 2013 when even I had an opportunity to take a session on Virtual Reality Training in Sports. Our interaction and the constant support by Dr. Parag finally led to the invitation by Dr. Nyland for my visit to the US for an advanced learning experience in Orthopedics and Sports Physical Therapy.
Kosair Charities College of Health and Natural Sciences, 
Spalding University, Louisville, KY, USA

But this, by itself, was not an easy step as my pre-preparation included multiple short certificate exams on HIPAA, Blood – borne pathogens, Fire safety, workplace emergencies etc. Also the tests and shots of Influenza, Montoux, MMR, and DPT were just amazingly painful. Not to mention that previous passport expired in Feb 2015 and I woke up only in July 2015 to get new passport issues. Fortunately (and surprisingly) the US visa issuance turned out as the quickest and hassle-free process. Well, everything seemed to be finally set. My fellowship dates were from 18th October to 7th November 2015, a whole 3 weeks. But going to US on tourist visa and no tour? That’s when the Niagara Falls trip just dropped in like a bomb. But hey, we aren’t talking about the Niagara and the helicopter ride and the awesome wonderful experience. Right now, it’s purely my fellowship!!




Orthopedic and Sports Physical Therapy, Louisville, KY



Advanced Orthopedic Physical Therapy, Louisville, KY

So finally I took off to look forth for a wonderful 3 weeks’ vacation (oops), 3 weeks of enhanced learning experience on 17th Oct from Mumbai to reach Louisville. Dr. Nyland was extremely gracious to receive me on the airport. My learning started immediately from the next day and continued for the next 2 weeks. I got a chance to learn and observe eminent physical therapists like Dr. Bradley Wheeldon and Dr. Alex Kent from specialty clinics like the Orthopedics and Sports Physical Therapy, Dr. Julie Snowden, Dr. Robin McNeill and Dr. Katie Elder at the Advanced Orthopedics Physical Therapy and Dr. Janelle Caudill at the Kentucky Orthopedics Rehabilitation Team clinics. The purpose of the visit was not only to learn the advances in orthopedics and sports physical therapy but also to learn the aspects of PT department functioning, administrative responsibilities and to understand their perspective and rationale of Patient treatment approach and working on the needs and necessities of the PT department functioning. 


Kentucky Orthopedics Rehabilitation Team, Louisville, KY

My clinical learning also included 2 days each with Dr. David Caborn who is a Knee and Foot Surgeon at Kentucky One Health Jewish Hospital and with Dr. Ryan Krupp who is a Shoulder surgeon at Norton Brownsboro Hospital. And last but not the least, got to see Dr. John Nyland in action at his Return to Sports clinic at Spalding University as well as assist him in Inter-university Soccer matches for Men and women. 


Dr. Nyland Return to Sports Clinic, Spalding University


Inter-University Soccer Matches

My visit also comprised of giving an interactive lecture to the DPT students at Bellarmine University and to the MSAT students at Spalding University on my favorite topic of ‘Using Suryanamaskar (Sun-Salutation) as a Yogic way for a Community Based Exercise Program – A Physical Therapists Perspective’ which was a chance to represent my Institute, University, Culture and finally my Country and was highly appreciated by the students and the faculties at both the Universities.

Lecture on Suryanamaskar (Sun Salutation)

Practical Demo of Suryanamaskar with students and Faculty of Spalding

With Dr. Patricia Gillette, School of Physical Therapy, 
Bellarmine University, Louisville, KY, USA

Many of my friends and my colleagues have asked me about the different or new things I got to learn over there. Well, to start with, I would say that Physical Therapy education in India is in every way equivalent in standards to that in the US. Infact, our current education system has 4 years of Bachelors and 2-3 years of Masters Program in Physical Therapy while US has a general bachelors program and directly a 3 years DPT program. Ofcourse every education system has their own pros and cons and I definitely am not criticizing any one of it. What I feel is that we need to make special efforts at individual level to learn the best of every system. Even in India, we are very active in clinical research which will help our profession progress and grow. But we all yet need to take research publications more seriously. One basic learning part would be the multi-planar motions training, sports specific rehabilitation and the advanced functional rehabilitation concepts which I learned over there, probably due to the increased demands of their clients for a faster rehab to meet and match their active sports specific lifestyle. Also got to learn the utilisation and applicability of some different equipments like the 'Game-ready' and the 'Hivamat' which we typically do not use over here.
Game Ready Cryo Compress Packs

Hivamat Stimulator




But what I really liked and learned over there is their attitude and positivity. During my visits to the clinics or my lectures in Bellarmine and Spalding, I had asked Dr. Nyland about what were their expectations from me. His answer was simple. He just said, “Apurv, I want you to enjoy there. If you enjoy, people around you will enjoy and only then will you and others work more productively.” I was in love with this statement of his. We all are so much used to work under pressures that we know how to perform, but not how to excel. There, people laugh, play, joke and enjoy in their work also. This helps in creating a bonding between associates as well as your start liking what you do. Infact people want to be at work as it is not a place of stress, but a place to live your life too. (I am sure we know that US is amongst the most productive country in the world). 



Second, have a family life as well. We tend to work for our family and on this pretext get so much busy in that process that we don’t have any time left for our family. The next best thing I learned over there is their support system. Everyone has their own set of tasks and duties. But everyone is always eager and supportive towards their colleagues as well. This helps in building an extremely good team character and also facilitates a positive environment. We Indians are definitely extremely hardworking and intelligent breed of people and have the potential of exceeding in every aspect. I am sure, some change in our behavior and approach will get us far ahead. And it isn’t difficult either. Keeping the roads and our environment clean, following traffic laws and rules, loving and respecting others also is not so difficult. 


And most important what I learned is how to value people. Everyone around made me feel extremely special and cared for. Even in the public transport systems, hotel, and especially in the clinics I visited. We say “Atithi Deva Bhava” (Guests are Gods). I experienced it there. Ofcourse, staying away from my family for 3 weeks was painful. But I found another family over there in all the friends that I made. And that is how finally culminated my “Louisville Combined-Service Orthopaedic Surgery and Physiotherapy Fellowship”

Sunday, 28 September 2014

Pre and Post-Operative Physiotherapy in Knee Arthroscopy Surgeries




Knee arthroscopy from a physios perspective
¢  Young patient
¢  Active lifestyle
¢  Traumatic injury
¢  Athlete
¢  Functional Goal Setting: Patient may need to attain functional independence in BADL’s and also in relation to work demands and rarely to attain the sports activities being played.

Indications for Arthroscopic Repair/ Reconstruction:
¢  Injured ligament (different healing capabilities)
¢  Location & size of lesion
¢  Degree of instability experienced by patient
¢  Other associated injury – meniscal tear, articular damage etc
¢  Patients desired level of function
¢  Risk of re-injury
¢  Prevention of future impairment

Arthroscopy – Physiotherapist’s consideration
Indication for ligament surgery –
            Failed conservative management, early degenerative changes seen, pain/ loss of function.
Type of ligament surgery:
            Intra articular, extra articular, combined procedures
Grafts used:
            Autograft, allograft, synthetic, area of harvesting etc.

Pre-operative physiotherapy
¢  Deficits in pre-operative quadriceps strength influence function 6 months after ACL reconstruction
            David Logerstedt et al, The Knee, 2013

Pre-operative management & goals
‘Injuries around the Knee’ Symposium: Sancheti Parag et al, Br J Sports Med, 2010
¢  Oedema Control
¢  Minimize muscular atrophy
¢  Maintain ROM as much possible
¢  Protected ambulation
¢  Patient education
¢  Restoration of joint stability & motion
¢  Pain free & stable weight bearing
¢  Sufficient post-operative strength & endurance to meet functional demands
¢  Ability to return to pre injury activities
           
Post-operative management
  1. Maximum protection phase  – Weeks 1 – 4
  2. Moderate protection phase – Weeks 4 – 8
  3. Minimum Protection phase – Weeks 8 & beyond

Maximum protection phase – weeks 1 – 4
            TREATMENT GOALS:
¢  Protect healing tissues
¢  Prevent reflex inhibition of muscles
¢  Reduce joint effusion
¢  ROM 0 – 110°
¢  Active control of ROM
¢  Weight bearing 75% to tolerance (depends on specificity of tissue repaired)
¢  Early controlled weight bearing does not compromise knee joint stability and provides a better outcome in terms of VMO function
            Tyler TF Clin Orthop Relat Res, 1998

Intervention
Early: Days 1 – 14

¢  RICE
¢  Gait training – crutches PWB
¢  Passive to active ROM (with range limiting braces if required)
¢  Using CPM for ROM does not offer any additional benefits
Rosen MA Am J Sports Med, 1992
¢  Patellar mobilization
¢  Muscle setting exercises – Quads, hams, adductors at multiple angles
¢  Assisted SLR in supine (with brace when needed)
¢  Ankle pumps


Late: weeks 2 – 4
¢  Continue previous exercises
¢  Full weight bearing & closed chain exercises for hip & knee muscles (with permission)
            (Not in meniscal injuries)
¢  Low resistance PRE in open chain activities
¢  Core stabilisation exercises
¢  Aerobic conditioning – static cycles
¢  Physiotherapy is equally effective as arthroscopic partial menisectomy for meniscal tears and OA knees
            Katz et al. Engl J Med. 2013
¢  In a RCT, home exercise program alone was better versus arthroscopy in addition to home exercise program for chronic patello-femoral pain syndrome
            Kettunen et al Br J Sports Med. 2012
¢  Post-operative physical therapy accelerated rehab in arthroscopic partial menisectomy: Systemic Review with Metanalysis
            Dias et al J Orthop Sports Phys Ther 2013
¢  Electromyographic feedback along with conventional exercise therapy speeds up the rehab process
            Akkaya N et al Clin Rehabil. 2012
      
     
BRACING
¢  Using a functional brace or a neoprene sleeve post arthroscopic repair helps in improving joint position sense in early rehab phase
            Beynnon BD, J Orthop Sports Phys Ther, 2002;
                Brandson S et al Scand J Med Sci Sports, 2001

Moderate protection phase weeks 4 – 10
TREATMENT GOALS:
¢  Full pain free ROM
¢  Strength Gr. 4/5
¢  Dynamic joint (knee) control
¢  Improved kinaesthetic awareness
¢  Normalise gait pattern & ADL function
¢  Home exercises program

Intervention
            Early – weeks 5 – 6:
¢  Multiple angle isometrics
¢  Advanced closed chain strengthening & PRE
¢  Stretching exercises
¢  Endurance training
¢  Proprioceptive training – single leg, tilt board
¢  Stabilization exercises with elastic bands


Proprioceptive training and core strengthening
¢  Both form important aspects of phase 2 rehabilitation.
            Lephart SM Am J Sports Med, 1997
¢  Lack of core strengthening and proprioceptive training post arthroscopic cruciate reconstruction have been found to be associated with reduced stability and performance in patients
            Cinar-Medeni O, Am J Phys Med Rehabil, 2014

Intervention
            Late – weeks 7 – 10:
¢  Continue with previous exercises
¢  Advance strengthening (PNF patterns)
¢  Endurance & flexibility training
¢  Advanced proprioceptive training
¢  Walking/ jogging
¢  Initiate plyometric training (with permission in athletes)



Minimum protection phase weeks 11 - 24:
TREATMENT GOALS:
¢  Increase strength, power & endurance
¢  Improve neuromuscular control, dynamic stability & balance
¢  Improve cardio pulmonary fitness

Joint stability achieved by neuro musculoskeletal system


Intervention
¢  Continue stretching program
¢  Advanced PRE. Initiate isokinetic training if desired.
¢  Advanced close chain exercises & plyometric drills.
¢  Advanced proprioceptive training.
¢  Progressive agility drills (fig of 8, specific drills)
¢  Progress running program



Return to activity phase – 6 months & beyond
TREATMENT GOALS:
¢  Increase strength, power & endurance
¢  Regain ability to function at highest desired level
¢  Maintenance program
¢  Reduce risk of re-injury

Balance and Proprioceptive Training

Plyometric Training (Sports Specific)


Intervention
¢  Progress PRE & flexibility exercises
¢  Advanced agility drills
¢  Sports or occupation specific drills
¢  Need of protective bracing prior to return to work or sports.



Current trends in rehabilitation
¢  Shift towards individually tailored/ modified programs depending on functional requirement of the individual
¢  Functional training programs – exercises similar to ADL’s of the individual
¢  Limited Use of CPM machines
¢  Cryotherapy pre-op/ post-op beneficial to control pain and swelling
¢  Functional Testing to assess joint stability
¢  Emphasis on Proprioceptive Training
¢  Patient Perceived joint stability most important criteria for Prognosis
¢  Time not a major factor in determining treatment progression
¢  ROM, muscle strength and patient perceived joint stability most important criteria for exercise progression
¢  Delayed Surgery – faster strength recovery
            Wasilewski  et al 1993 , Shelbourne and Foulk 1995

Things to remember!
¢  No fixed Protocol for rehab
¢  Modify Exercises by regular patient evaluation
¢  Task Specific and Functional Exercises more effective
¢  Rehabilitation greatly influenced by level of motivation of the patient and compliance to the exercise program

Dr. Parag Sancheti
Dr. Apurv Shimpi (PT)
Dr. Anand Gangwal (PT)