Allied Health Interview 1: Myotherapy


As part of 2016 Allied Health Series we will talking to allied health professionals about how they would approach a particular condition (Achilles Tendinopathy). This is to highlight to similarities and differences between allied health professionals in an Evidence Based Medicine Society.

Achilles Tendinopathy Case Study

Gender: Female
AGE: 54years old
BMI = 22

L/Mid Portion Achilles pain which has been present for approximately 4months.
Recently a grandmother (3months) and baby sits 4 times a week.
Pain described as an ache most of the time with occasional sharp grab.
VAS: 6/10 most of the time,  9/10 at worst,     2/10 at best

Exercise:
Walk/Jog             x3           weekly
Pump Class         x3           weekly
Swimming           x1           weekly

No further information has been collected.

What is your qualification?
BAppSc (Exercise Science/Human Movement);

BHlthSc (Clinical Myotherapy)

Specialised or unique case history approach

Some further questioning that may be asked during the initial screen and questioning may include, how long it has been since flying, if at all in the last 4 months? Is there any pain anywhere else? If so, is it higher or lower of the mid portion Achilles pain. The exercise that she is doing may be contributing to her issue, continuing to probe for how she exercises including what sort of walking she does (power walking or leisurely ) and what sorts of movements are undertaken in the pump class may reveal how the initial injury progressed to a tendinopathy.

Continuing on from this looking at regions higher and lower than the affected area may be necessary. This may include looking at the feet to look for signs of extra wear including blisters or sores. Knees and hips should be screened also to ensure that the source of the problem is not coming from another of region of the body.

Lastly looking at her footwear for signs of wear. This may give an indication of over pronation in her walking stride and a referral to a podiatrist may be necessary.

Specialised or unique assessment procedures

While the patient still has their shoes on I would get them to undertake a number of movements including calf raises, toe taps and walking up and down a step. On removing the shoes standing from behind may reveal some over-pronation. You may also notice higher in the kinetic chain bowed Achilles tendons or internal knee rotation. When performing a dorsiflexion lunge test you would be expecting a score lower than 7cm from the wall due to the thickening and decreased range of movement.

With the patient in a prone position on the table I would begin to feel around the area of the Achilles. Feeling through the Gastrocnemius and Soleus gives me an indication of the integrity of the muscles. In most cases you would suspect a lot of tightness with limited dorsiflexion. As you progress lower in the Achilles tendon itself I would be feeling for a thickening of the tendon with limited lateral or medial movement. While holding the foot in dorsiflexion resisted movement into plantarflexion would create tenderness and pain for the patient.

Specialised or unique equipment for assessment and treatment

Hot packs and heated gels can be used when trying to heat the Gastrocnemius and Soleus muscles to increase blood flow, while cold therapies can be used to reduce inflammation. Although this may not be as effective as the tendon is now in the degenerative phase which is characterised by collagen degeneration and cell death.

Dry needling may be another modality that we may use. Dry needling can alleviate major trigger points within the muscle bellies of Gastrocnemius and Soleus. These tight areas in the muscle may be causing it to be tight leaving it with limited range of motion, being ineffective in its pull on the tendon and weak. Furthermore like the heat therapies the needles bring blood flow to the area to increase waste products being removed.

Stretching like the other therapies already mentioned, increases blood flow to the area. The other important benefit to stretching is increasing the muscle spindles metabolism, increasing the uptake of oxygen into the muscle therefore creating a relaxed muscle. Stretching also causes an overall increase in range of movement due to the stretch on tissues.

When takin the patient through take home exercises, the eccentric loading exercises would have to be the one of choice. This strengthens the tendon through increase motor behaviour increased cellular activity and hypertrophy of the musculotendinous junction.

Specialised or unique treatment types/approaches

See above

Treatment targets and criteria for prognosis, referral and management outcomes

Reduce pain is our main objective when treating a patient with an Achilles tendinopathy. When someone is pain free they are better able to participate in everyday activities. Increased range of movement can be measured also for the patient to get a sense of achievement and increase motivation. This would done through the weight-bearing dorsiflexion-lunge test. As the pain decreases and the range of movement increases an increase in pre-injury exercise activities can be achieved with management of load.

Referral to a podiatrist for closer examination of foot biomechanics would be advised and also some form of orthotic may be helpful in making a full recovery. Furthermore referral to an exercise physiologist may be advised to strengthen the lower limb.

SHOE REVIEW: SAUCONY GUIDE 8


Review:
Subjective review:
Creating a soft but responsive landing at ground contact the Guide 8 allows your legs to move seamlessly through the motions without feeling like you are working increasingly hard against an over cushioned shoe. The semi-straight last allows for orthotics to slip in easily and the mild-moderate support did not over correct my gait or noticeably increase pressures under foot.
The Guide 8 although noted as a standard D width does feel slightly wider than its counter-parts and would be suitable for someone who has trouble fitting into a most off the shelf runners.

External factors influence: Very little external factors affected my run, running on grass was slightly harder due to soft substance underfoot reducing rebound and responsiveness. The niggles disclosed in the subjective table was due to a sudden increase in barefoot gym training and not due to the shoes at all.

Does it meet claims?: Mostly yes, I would say the Saucony Guide 8 does meet the claims of the company as it does provide a plush feel under foot and a light to moderate support.

Why points lost:  The reason for points being lost is not necessarily a bad thing. In fact points being lost actually places Saucony’s own assessment of the shoe in-line with what had been found and that is that the shoe is responsive and not over-cushioned while providing mild-moderate support.

Who the shoe would suit best:  The Guide 8 would suit most mild- moderate pronators or those with a slightly wider foot. Additionally, placing a supinated foot type in this shoe is not such a stretch that they may be over-corrected. Furthermore, the sister shoe to the Guide 8, the Ride 8 is a neutral shoe with similar properties minus the EVA medial posting.
Runner Review Score Card

Technologies
Cushioning:         Plush
Support:               Dual density SSL EVA medial post
Last Shape:         semi-straight
Materials:            EVA, Blown Rubber, Carbon Rubber and Synthetics
Claims:                 ultimate training partner for runners seeking a plush feel with moderate support

Shoe Type: Traditional

Min———————|———————–Max

External Factors

Distance of runs 5km Terrain Weather My Mood Injuries/Niggles Subjective Run Score
Run One Road Overcast Relaxed Nil 9/10
Run Two Footpath Sunny Happy Slight foot pain 7.5/10
Run Three Road Sunny Happy Less foot pain 8/10
Run Four Road Overcast/humid Happy Nil 9/10
Run Five Grass Sunny Happy Stiff Shoulders 7/10

* Each section is completed with as accurate as possible subjective information.

Intrinsic factors

Distance of runs 5km Rearfoot Cushioning Forefoot Cushioning Rearfoot Support Energy Feedback/Ride Technology  Score
Run One 2 2.5 2.5 2 9
Run Two 1.5 2 2.5 2 8
Run Three 2 2 2.5 2 8.5
Run Four 2 2.5 2.5 2 9
Run Five 2 2.5 2.5 2 9

** Each section is completed with a score out of 2.5 for an overall score out of 10 per run.

A Thank you to the company and explanation that this is simply one person’s view on a shoe which may simply not been correct for their foot type ect

Smoking and the Foot


It’s one thing podiatrists seem to know and seem to know well, if your patient is a smoker they have either begun to feel the pinch of the effect, the addictive habit has on their feet and legs or they soon will. Like anyone with an addiction whether legal or illegal the individual will not be able to make the decision to quit until they are ready to quit. Many would say that they would like too, many would say that they have tried but those have been successful have tried too; once, twice, five times or ten but eventually they got there and not one of those who have ceased the lifestyle regrets their decision. Yes, they may miss the smell, the socialization or the escape but regret is not a word you will hear uttered from their mouth.
Today we look how smoking affects the circulatory system and therefore the foot in our patient and in many cases also those friends and family member whom we care about.

Circulatory System
The Venous and Arterial System are two parts of an interdependent circulatory system which supplies oxygenated blood to the body while at the same time helping to remove metabolic bi-products. Veins are responsible for the transport of deoxygenated blood back to the lungs where they can release carbon dioxide and become re-oxygenated once again. The movement of the blood flow through venous return is considerably slower than that of its counter- part, the arteries, which are supported by powerful pumps of heart. The arteries are the transport system for the delivery of oxygenated blood to the tissues of the body via the centrally situated aorta and left ventricle pump to the most outer reaches that the body has to offer (I).

Explaining PAD/PVD
Peripheral Vascular Disease is a development of atherosclerotic blood vessels in the smaller veins and arteries of the body, more commonly in the lower limb. Atherosclerosis within the blood vessels is the damaging of vessel walls and the build-up of fatty deposits. This can result in blockages which can reduce blood supply and potentially cause the development of clots within the vessels. The outcome of which can lead to a reduction in oxygen delivery to the body tissues, blood pooling and a build-up of metabolic products within the lower limb – manifesting into tissue death and significant pain.

Risk Factors
A number of risk factors have been identified throughout the literature regarding their influences of Peripheral Arterial Disease. By far the most significant is seen to be smoking causing 68% PAD in Males and 61% in females. Additionally, many lifestyle related health issues are seen to major contributors to this serious condition including; High Blood Pressure, Atherosclerosis, Diabetes, High Cholesterol, 60+ years of age and a Personal History of Vascular Disease.

quitline

Smoking and the Foot

  • 100 year association between smoking and peripheral vascular disease
  • Number one modifiable lifestyle risk for PVD
  • Doubles chances of PVD
  • The more cigarettes smoked the greater the risk of PVD


There has been a significant push over the last decade or more to reduce the impact of second hand smoke on non-smokers and more specifically children. A major reason for this is the finding that second hand smoke has shown to increase the risk of coronary heart disease in non-smokers and the risk of heart attack by 30% (H).

Symptoms
It has been found that many people with PAD and PVD do not display any symptoms at all. However, the most common symptom which does appear is an intermittent pain in the legs which many people associate with aging rather than a serious medical condition. The intense pain and leg cramping will generally come about with exercise and cease soon after rest has begun. – this is known as intermittent claudication and is one of the early signs of PAD.

As the disease progresses the pain can also appear at rest and in the evening, this is known as critical leg ischemia and should be significant worry to the patient. It is common at this stage of the disease that leg ulcers may develop due to significant restriction in blood supply.

Furthermore, other symptoms which may show with PAD are colour changes in skin colour, the temperature in one leg being lower than the other, as well as poor hair and nail growth.

Treatment
The primary goal of treatment of PAD is to reduce symptoms and progression of the disease by addressing the underlying causes of the condition. The prong in the attack is to make changes to the lifestyle of patients. The number one most important lifestyle change that can be made is the cessation of smoking.
Additionally, using a healthy eating plan, increasing exercise and reducing weight by having a health weight target is also extremely beneficial. These action alone do have the power to reduce the important and commonly high numbers associated with High Cholesterol, High Blood Pressure and Blood Glucose Levels.
However, sometime simple or in many cases large lifestyle changes are not enough to address the underlying health conditions. Smoking is an addictive habit which poses its very own problems, in addition to increasing exercise when a patient may already be in pain due to intermittent claudication. In this case medications are a great secondary prong of attack. Reducing leg pain will help patients begin to exercises (at least breaking down one of the barriers). Furthermore, blood clot prevention and specific medications used to lower the numbers of the conditions discussed above are of vital importance.

In some circumstances the best option is simply to undergo surgery. The invasive treatment can be used to restructure and bypass blood vessels to help increase blood supply to the peripheries of the limbs and reduce symptoms and progression to ischaemic limbs. Unfortunately, this too can be an overlooked option for too long and a decision may be made that surgical debridement (in case of wounds) or amputation may be the best option in saving the life of a patient.

Conclusion
It can be seen that the habit of smoking causes more than just lung cancer. In fact, it has been shown to have more effect on the vascular system than any other, significantly increasing the chances of Peripheral Arterial Disease, Peripheral Vascular Disease, Coronary Heart Disease and Stroke.
It is becoming more and more apparent that each of our lifestyle choices we participate in can have a large impact upon our health whether positively or negatively and that lifestyle based diseases are far outweighing those associated with pathogens. Next time you talk to your patient don’t let them “yeah yeah” your education of them away, challenge them and find out what’s holding them back.

 

Jackson McCosker
Director /Chief Editor