Why Manual Therapy could be just what the Doctor Ordered

At Elite Sport Performance and the Knee Clinic, the key to successful outcomes is our three-pronged approach to treatment: treat the problem, strengthen the area, and avoid or modify offending activities. These three components are broad and can encompass a wide variety of decisions and actions. If we zoom in on the first component, ‘treat the problem’, we may encounter a number of treatment options for the problem we are endeavoring to manage, but how do we know what’s best for each patient? The principles of evidence-based medicine would dictate that that the related research, the practitioner’s clinical experience, and the patient’s values all need to be considered when determining the best course of action.

When it comes to joint pain, we often think of injections or surgery as our only options, however, it is important to understand that the bio-mechanics of a joint, or the way a joint functions is heavily dependent on structures that are adjacent to it. Think of the muscles, tendons, ligaments, and nerves that relay messages to and from the brain about that joint. Knowing this, it is not surprising that the related research around managing many musculoskeletal conditions is to employ what is known as a ‘multi-modal’ approach to treatment. This means that the best outcomes are achieved by utilizing a variety of treatment options, including addressing changes to fascia, muscles, and tendons surrounding a joint, in addition to working through an individualized strengthening program to re-calibrate or rehabilitate the function of that joint, and perhaps even protecting it from further damage with a brace.

Whether due to trauma or degenerative changes over time, cellular scar tissue, or fibrosis can accumulate and disrupt optimal function of a joint or tissue, and can even be a cause of pain. Using a variety of clinically-derived manual, or hands-on treatment protocols such as Active Release Techniques, Graston Technique, and other similar approaches, practitioners can improve the rate and quality of healing as well as aid in restoring optimal function to a joint or tissue.  This ‘hands-on work’ will often be prescribed as part of a patient’s individualized plan of management, and would fall under the ‘treat the problem’ component.

A Guide to Custom Knee Braces

Knee braces are used for a plethora of different clinical indications.  Being that we are the only private knee clinic in Alberta, we are intimately knowledgeable on these different braces and their appropriateness for various clinical conditions.

 

Patellar Stabilization Knee Braces

Knee braces can range from off the shelf to fully custom, can range in size from really quite small to relatively onerous, light weight to cumbersome, flexible to stiff.  The smallest and simplest knee brace that we offer in our clinic is a patellar stabilization brace called a Knee-O-Tracker.  This small neoprene brace has a buttress on one side that can be tightened or loosened in order to create stability to either the medial or lateral side of the kneecap, depending on which way the kneecap is prone to subluxing or even dislocating.  Relatively comfortable and able to be worn underneath most pants, it does a good job of decreasing the chances of recurrent subluxation or dislocation but is not strong enough to truly stop the dislocation incident, if appropriate forces are applied.

 

Mechanoreceptive Knee Braces

Next in the line of brace control is something called a GenuTrain by Bauerfeind.  This German company creates a woven, soft knee sleeve that is elastic in certain planes of motion and non-elastic in other planes of motion.  It is excellent at stimulating what are known as the mechanoreceptors, small sensors in the skin that make your brain more cognizant of the position of your knee relative to the rest of your body.  While they do not create true knee control, they do wake up the muscles in the area to a statistically significant degree and give people a greater sense of confidence during activities of daily living.  GenuTrain knee braces also come in a new osteoarthritic unloader version.  This unloader version takes the mechano-receptive fabric brace and adds BOA adjustable straps to it in order to create mechanical unloading to the medial or lateral compartment of the knee, depending on which way you wear the brace.  This brace is not custom but comes in six different sizes and so can be made to fit quite snugly.  A very comfortable brace, it again helps the patient feel more confident in their day-to-day activities.

 

Custom Meniscal / Cartilage Unloader Knee Braces

Moving up the scale of unloading control, we get to a brace made by Ossur called a Rebound Cartilage Unloader.  This unloader knee brace is custom made and is very svelte.  It can be designed to either unload the medial or lateral compartment and begins to unload from a 45-degree flexion knee bend, making it unique amongst unloader braces, which typically unload from 30 degrees of flexion to full extension. Its light weight and low profile make it an excellent option for thin or lean patients who have either acute or subacute meniscal damage postoperative meniscal repair or early degenerative changes.

 

Custom Osteoarthritis Unloader Knee Braces

The most common brace utilized in our clinic is the custom OA Unloader One made by Ossur.  This brace is the gold standard for medial or lateral compartment unloading.  It is thin, light weight, and custom fit down to the millimetre.  It is very comfortable and single-handedly has helped thousands of our patients either get back to or continue with activities that they are passionate about that they were not able to do without this brace.  In cases of bone bruises or impaction fractures, this brace helps to alleviate symptoms remarkably well and quickly.

 

 

Custom Ligament Knee Braces

In our opinion, the best and lightest custom ligament brace on the market is the CTI made by Ossur.  CTI originally stood for carbon and titanium, the materials with which this knee brace was comprised.  Both materials are vaunted for their strong mechanical characteristics and exceptional light weight.  Over the years, the CTI has undergone revision after revision and has become progressively better.  It is now a very light weight, preimpregnanted carbon fibre that is exceptionally strong.  Measured with attention to detail, it is accurate down to the millimetre, and consequently is very comfortable for the patient and exceptionally good at stopping any extraneous motions medially, laterally, anteriorly, or posteriorly of the shin relative to the femur.  It also stops any excessive varus and valgus loads, but it cannot stop internal torque.

 

A different version of the CTI is the CTI OA.  This particular custom brace has all the same features of CTI but can be built with a degree of unloading incorporated either laterally or medially depending on the particulars of the patient’s case.  Where the degree of unloading is adjustable in something like a rebound cartilage or Unloader One, in a CTI OA the degree of unloading is predetermined at the time of manufacture.

 

Insurance Coverage

Most people’s insurance companies will have coverage for non-custom knee braces and most insurance companies have a separate, distinct provision for coverage of custom knee braces.  Following a comprehensive history, physical examination and review of any appropriate imaging at our Knee Clinic, we are able when clinically indicated to write you a prescription that you can submit to your insurance in order to be reimbursed, often for 100% of the cost of the knee brace.  Some of these knee braces carry a one-year fit warranty so that if the patient’s changes, the laboratory will remake the brace from scratch for free.  Both Bauerfeind and Ossur have excellent reputations for standing behind their work and although they very rarely have manufacturing issues, if ever there is something that arises, they stand behind their products remarkably well, as do we.

 

Should you have any questions about your own knee or if you would like to bring in your current knee brace to see if it still fits, or needs adjusting, or perhaps needs to be replaced, please phone us at (403) 457-5633.

Our Approach to Knee Injections

Joint injections and musculoskeletal (MSK) injections are increasingly common in Calgary and indeed, across North America.  At both Elite Sport Performance as well as our private Knee Clinic, we utilize various injections when clinically indicated.  Joint and musculoskeletal injections can be done either blind or with the benefit of image guidance.  Various studies purport that blind injections into a joint have an accuracy of somewhere around 63% to 75%, while image-guided joint injections enjoy an accuracy of between 95% and 99%.  Unsurprisingly then, the popularity of image-guided joint injections is increasing.  There are still some ‘old-school’ physicians who claim to be able to do a blind injection with a high degree of accuracy, but the statistics do not support this approach.

 

When performing an image guided injection, the practitioner has the option of using a diagnostic ultrasound or a much more expensive piece of equipment called a fluoroscope.  A fluoroscope is effectively a live x-ray exposing the patient to a not-insignificant degree of radiation.  Diagnostic ultrasound, on the other hand, is non-irradiating.  With respect to fluoroscope-guided procedures, a small amount of dye is typically injected so that the physician can confirm that the needle placement is correct.  This is in part necessary because the fluoroscope does not show in great detail the soft tissues in the area in question.  Diagnostic ultrasound, on the other hand, does not require any dye injection and shows in considerable detail the soft tissues surrounding the target to the injective.

 

There is another less palatable reason for a doctor to use a fluoroscope for image guidance rather than a diagnostic ultrasound, and that is the ability to bill Alberta Health Services for a ‘surgical procedure’ for even the most basic injection.  This billing code allows the physician to bill Alberta Health Services over $600 for simply turning on the fluoroscope when a much less expensive, less dangerous ultrasound option exists.  Diagnostic ultrasound procedures are billed at a dramatically lower rate to Alberta Health and can also be utilized within a truly private clinic.  Compounding the disparity between these two procedures is the timeliness with which they can be done.  Image-guided joint injection by a physician using a fluoroscope currently is accompanied by a wait of weeks to months within the city of Calgary.  The same image-guided joint injection using a diagnostic ultrasound can often be done within one or two days.  This represents a significant cost-savings of time for a patient looking to have a procedure done sooner rather than later.  This timeliness, along with the different ethical approach in billing Alberta Health Services so much money for a simple procedure, is why there is quite a difference in pricing for certain injections within the city.

 

Ultimately, it is the patient’s prerogative which route they choose to take,  but consider asking the clinic which method of image guidance they use and ask yourself if costing the public system more than $600 extra really represents good value for you, your family, or your community.  Paying a little bit extra to have the procedure done privately in a timely fashion, using a non-irradiating guidance such as diagnostic ultrasound, can allow you to feel better both physically and morally.  For more information regarding this topic or to learn more about any of the injections that we offer within our clinic, please reach out at (403) 689-9889 or reception@kneeclinic.ca.

Low Back Pain and Disability

Did you know that low back pain causes more disability than any other condition globally? As such, the development, or ‘pathogenesis’, of low back pain has long been investigated by research groups and programs. Most recently, the esteemed Drs. Injeyan, Injeyan, and Triano compared differences in inflammatory markers in the blood between asymptomatic individuals, and patients with non-specific acute or chronic low back pain. While there are limitations to every study, their results highlighted a distinct increase in pro-inflammatory mediators and a marked decrease in anti-inflammatory mediators in both groups of symptomatic patients when compared to asymptomatic individuals. Interestingly, a separate group in 2016 looked at the various effects of spinal manipulation and found that this technique may in fact activate naturally-produced anti-inflammatory mediators.

Inflammation and Diet

Did you know that localized inflammation in response to musculoskeletal injury is not only natural, but is essential to promote healing?  Damaged cells release chemicals within the inflammation which signals the body to initiate the repair process.  While some level of local inflammation is necessary, uncontrolled or persistent inflammation can cause more harm than benefit, resulting in additional tissue damage and prolonged recovery.  Substantial evidence now suggests that what we eat can influence the inflammatory response to both acute and chronic conditions.  Both pro-inflammatory and anti-inflammatory foods have been shown to affect the inflammatory response of the immune system to injury.  Limiting consumption of pro-inflammatory foods such as saturated and trans fats, refined sugars and carbohydrates, and processed foods, and increasing consumption of anti-inflammatory foods such as omega-3 fatty acids, colourful fruits and vegetables, olive and flax seed oils, and nuts, may not only help keep the inflammatory response in check, but may also protect healthy cells from inflammation caused damage.

 

References:

Minihane, A., et al. (2015). Low-grade inflammation, diet composition and health: current research evidence and its translation. British Journal of Nutrition114(7), 999-1012.Tidball, J. (2005). Inflammatory processes in muscle injury and repair. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology288(2), R345-R353.

Inflammation and OA

Osteoarthritis (OA) was previously considered non-inflammatory. It is now well recognized that inflammatory mediators are produced and can be measured in joint fluids of patients with OA. This inflammation is a major risk factor in cartilage loss, pain, swelling, and stiffness. When management and treatment of OA consists of anti-inflammatory components, patients can improve their function and decrease pain levels. Platelet-rich plasma (PRP) is a cell therapy, that uses one’s own blood through joint injections, to reduce inflammation. Platelets are a high source of concentrated growth factors and inflammatory mediators. Platelets in PRP release many types of anti-inflammatory proteins that signal cells that lead to suppression of inflammation in OA.

 

Goldring and Otero. Inflammation in Osteoarthritis. Curr Opin Rheumatol. 2011; 23

Xie et al. Biology of platelet-rich plasma and its clinical application in cartilage repair. Arthritis Res Ther. 2014; 16

What is Cupping and why does Michael Phelps swear by it?

What is Cupping?

Cupping is a therapy in which glass jars or cups are suctioned onto the skins surface with negative pressure. Traditionally, cupping has been used in Chinese medicine for 1000s of years to open up meridian pathways to allow Qi to flow through. When Qi flows freely throughout the body one enjoys good physical, mental and emotional wellbeing.

Cupping uses suction and negative pressure to drain excess fluids, stimulate the parasympathetic nervous system (relaxation) and increase blood flow to muscles and skin. It can be used along Meridians and acupuncture points to clear colds and flus and stimulate specific organs, it can also be used along fascial lines across the body to specifically treat fascia and muscles

Why treat fascia? Fascia is connective tissue (has an appearance like a spider web) that covers everything within our bodies – muscles, bone, nerve, organs etc. – it is the 3D glue that holds everything together.  It is what allows our muscles to slide/glide efficiently.  A fascial dysfunction can restrict range of motion, decrease blood flow to an area, and cause pain and toxin build up.

Cupping is different than most manual therapy in that the majority of other techniques use compression, whereas Cupping decompresses (lifts, separates and stretches) tissue to release adhesions and break down existing scar tissue, relax muscle spasms, and decrease trigger point pain. It has also been shown to decrease tissue changes (scar tissue formation) and inflammation following trauma.

What are the marks left by cupping?

The circular marks left behind from a treatment are not bruises and are rarely sensitive to the touch. They are static blood, lymph, cellular debris and toxins being released from deeper tissue layers. Marks can vary in pattern and color and can last anywhere from 3 days to 2 weeks.

So who can benefit from Cupping?

The short answer is anyone, but especially those with joint or muscle pain/tension, headaches, frequent colds or flu that are not getting the relief they need from regular massage therapy. Cupping is historically very effective in treating chronic overuse injuries such as bursitis, tendonitis and other myofascial pain syndromes such as runner’s knee, tennis elbow, and low back pain.

 

Platelet Rich Plasma (PRP): How does it work?

Platelet rich plasma, commonly called PRP, has been promoted widely as a potential treatment for helping injured musculoskeletal tissues to heal.  Platelet rich plasma contains high concentrations of several growth factors.   Platelet rich plasma has been used worldwide for multiple indications of knee pain, most commonly accelerate ligament healing or to augment tissue repair.  The mechanism of action of PRP is well understood, with ongoing research being done to further refine when and how PRP injections can be performed for maximal efficacy.  There are myriad ways in which PRP can help joint osteoarthritis, including the anabolic effects of the growth factors found within PRP.  There is a well-documented anti-inflammatory effect as well as cell proliferation and scaffolding to help create tissue remodeling.  PRP has also been found to improve tissue stiffness, making cartilage more resilient to future wear and tear.

The philosophy behind using platelet rich plasma to augment tissue healing is based upon growth factors that are present in an individual’s own blood.  Platelets naturally gravitate toward an injured area of the body and the alpha granules, which contain the growth factors, are released by the platelets.  For platelet rich plasma, blood is drawn from a patient and the platelets are spun down with a centrifuge to much higher levels than are normally seen in a person’s own blood.  These concentrated platelets are then injected into the injured or surgically repaired area.

Over the last few years, platelet rich plasma has emerged as an accessible and relatively inexpensive source of growth factors to treat musculoskeletal injuries.  PRP contains growth factors that are very important for musculoskeletal healing, such as TGF-beta, platelet-derived growth factor (PDGF) insulin-like growth factor (IGF-I) in fibroblast growth factor (FGF).  The growth factor concentration in platelets, coupled with the normal platelets that are present in blood, are sufficient to yield increases of measurable growth factors in the blood to help reduce knee pain.  Laboratory studies have confirmed that PRP has beneficial effects on ligament fibroblast migration and the differentiation and production of collagen.  This means that it assists with healing knee pain.  In addition to the effects of the growth factors directly on healing, platelet rich plasma has also been reported to enhance the gene expression of important healing factors.

The future of PRP is encouraging.  Using the patient’s own growth factors and platelets is cost effective and research does indicate that it facilitates repairs in both basic science and animal models.  While ongoing studies are still required, it is widely believed that the use of biologic agents to enhance healing is the next major breakthrough in sports medicine for treating knee pain.

(Source: Steadman Phillipon Research Institute via drrobertlaprademd.com website).

Inflammation- Understanding the Fire

Inflammation is a normal action of the immune system when it encounters injured tissue, infection, allergen or toxin. The whole point of inflammation is as a transient process whereby the immune system is stimulated to deal with an offending situation…a knee injury or virus for example. So in and of itself inflammation is not a bad thing yet can be if it’s left on for too long. That’s where lifestyle habits can come in. Eating foods that the body cannot digest well or might be sensitive to, not providing the body with the daily nutrition it needs to function properly, chronic stress, not getting enough sleep, repetitive movements at work or in sports, to start, all act as constant triggers of inflammation. Repeating even one of these triggers daily can maintain an inflammatory reaction in the body that effectively goes unchecked.

Ongoing inflammation doesn’t allow the body to fully heal itself or focus energy on day-to-day maintenance. If maintained long enough, a chronic inflammatory reaction will irritate the nervous system leading to chronic pain syndromes, contribute to hormone imbalances, worsen allergic reactions or make us more susceptible to infections. Sometimes we cannot get away from this reaction if we’ve sustained certain injuries or surgeries that damage our tissues yet for most if use, there’s much we can do to settle the fire of inflammation should we choose.

Do you really need a knee replacement?

Joint replacement surgery is a booming industry as our ageing population faces the degenerative processes that come with getting older.  Surgical techniques and hardware continue to improve, but wait times continue to worsen.  In the Calgary Health Region alone there are thousands of patients on the waiting list for hip or knee replacement, with wait times for a mere consult often over one year.  The reality is that only a small proportion of these people actually NEED a joint replacement.

Medicine is not immune to the powers of marketing, and joint replacement surgery is no exception.  Knee and hip replacements are BIG business in the developed world, and family doctors are indoctrinated early on to refer directly to a surgeon whenever a patient presents with some knee or hip osteoarthritis.  The reality is that only some joints require replacement; the rest can be managed very well with conservative measures.  Reason would suggest that a patient with an osteoarthritic joint should start with the most conservative treatment options first, progressing on to more and more invasive options as needed, with total joint replacement as the final intervention once all others have failed.  Outlined below is a sample continuum that a patient can take on their journey through hip or knee osteoarthritis.

Get a weight bearing X-ray.

Proper positioning and select views in a weight bearing position can help to clarify exactly how much degenerative change has occurred to the joint in question.  Ask your doctor for weight bearing (standing) views to best ascertain the extent of wear.

Get a diagnostic ultrasound or and MRI.

An MRI is not always required, but it behooves the doctor and patient to get a clear picture not only of the boney deterioration of the joint but also the soft tissue and cartilage damage.  Remember that osteoarthritis (OA) is a degenerative joint process involving the soft tissues of the joint as well as the bone.  One does not exist in isolation from the other.

Correlate imaging findings with a thorough, hands-on clinical exam.

Too often I hear stories of doctors conducting a physical examination of a patient without ever putting their hands on the patient.  There is often a poor correlation between imaging findings and clinical symptoms, so it is vitally important to have a thorough, hands on examination of the joint in question to help complete the clinical picture.

Follow the clinical triad:

  1. Treat the actual problem
  2. Strengthen the area
  3. Avoid making it worse

Get stronger.

With increased strength comes increased stability, and instability within an arthritic joint is very often a considerable pain generator.  Beginning a strength program in an already painful joint can be agonizing, but there really is no alternative. Pushing through the first month of exercise-exacerbated pain will be worth it, and study after study suggest that resistance training and loading of an arthritic joint does not cause the joint to wear down faster, but rather helps to prolong the viability of that joint.

Get a custom unloader knee brace

One of the most effective, least invasive interventions that can be done is the use of a truly custom, unloading brace.  Made for both knee and hip osteoarthritis, a custom brace is often the single most effective intervention, and represents ‘the most bang for your buck’.  Custom knee braces in particular can offload the exact region of the knee that is most painful, allowing you to carry on with the activities that you are passionate about with considerably less discomfort.  By reducing the magnitude of impact on the arthritic joint with each step these braces also help to slow the rate of further progression.  They are lightweight, slim and can be worn under ‘most’ day to day clothing.  Custom unloader braces are often covered 100% by your private health insurance with a doctor’s prescription.

Consider a guided lubricant injection.

Viscosupplementation is the name for a type of hyaluronic acid injection that can serve to lubricate the internals of an osteoarthritic joint.  Brand names include Synvisc, Monovisc, Durolane, Cingal, Neovisc, Orthovisc, Synolis and others. Any of them can be beneficial in creating some hydraulic cushioning with the joint and defraying mechanical compressive load on to worn down cartilage.  These injections typically take about one month to begin working and can last for 10 – 12 months.  Some research suggests that repeating these injections once per year for three years (think of it as an annual oil change) can further slow the rate of wear of the joint.  These injections should be done under image guidance (ultrasound or fluoroscopy) to improve the accuracy of the injecting doctor.  Contraindications for viscosupplementation include very severe arthritis (it works best in mild to moderate OA), significant leg deformity (bow legged or knock kneed) and morbid obesity.

Consider Platelet Rich Plasma (PRP) injections

Platelet Rich Plasma is derived from a small fraction of your blood.  Drawn from your arm in the same fashion as having regular blood work done, the blood is spun in a special centrifuge to separate out the growth factors of your blood.  Reinjected into an arthritic joint twice over a six-week span, PRP can help to stimulate the development of new blood vessels and consequently allow for some new tissue regeneration.  With the exclusion of stem cell injections, PRP is the primary regenerative medicine that we have available to us in the management of joint osteoarthritis.  The benefits of PRP can often be felt after about six weeks, and can continue to have a positive effect on joint health for several years thereafter.  The injected joint is often sore for two to three days post injection, and it is important to know that you are not allowed to take anti-inflammatory medication for one week leading up to the procedure

Stay away from repeated cortisone injections

Cortisone (corticosteroid) injections are a very effective way to diminish inflammation within a joint.  The problem is that osteoarthritis, despite its name, is not truly an inflammatory process.  Rather, osteoarthritis is degenerative joint disease, and while you may get some symptom relief from a single cortisone injection as it wipes out any residual inflammation that is present in the joint, it is not a clinically appropriate intervention to repeat.  Why put an anti-inflammatory into something that isn’t truly inflamed?

With any combination of the measures outlined above, patients can expect to have at least some improvement in their symptoms.  Sticking to the clinical triad (treat it, strengthen it, don’t make it worse) helps to keep patients focused on what’s important in the management of an arthritic joint, and will reduce the likelihood of truly needing a knee replacement.  In our clinic we hedge our bets by making the surgical referral on the assumption that it will take about one year to get to the surgeon.  During that year we work diligently with the patient using the interventions listed above.  Most of the time we are able to improve the patient’s symptoms and quality of life so much that they take themselves off the surgical list.  Check out our testimonials page to read some of the success stories.