Four Pines Physical Therapy

We want YOU to be a partner in YOUR rehabilitative care.

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Concussions are a form of traumatic brain injury. Specifically, they are known as a subset of a mild traumatic brain injury and have become more of a focus with prevention, education, and screening in the medical community. They have been identified as a major health concern due to high rates of occurrence and potential for long-term effects.

According to the CDC, there are an estimated 1.6 to 3.8 million mild traumatic brain injuries that occur annually. Concussions are not only sports-related as well, but can occur with motor vehicle accidents, falls, and military injuries for example. 

Concussions can present with a loss of consciousness OR without a loss of consciousness and as a result can go unrecognized due to variation in symptoms and presentation. Overall prevention is key and parents, players, and coaches should be able to recognize signs and symptoms, especially in the first 48 hours.

SIGNS AND SYMPTOMS

Symptoms of concussions can include dizziness, nausea, impaired memory, poor concentration, noise and light sensitivity, confusion, blurred and double vision, and “not feeling right.”

Signs that can be observed include memory loss, unsure where they are, behavior/personality changes, clumsy, slow, and unclear responses, and loss of consciousness.

RED FLAGS

Red flags or emergency indicators that we watch for include spinal fractures, cervical myelopathy, upper cervical spine ligamentous instability, and vertebral artery insufficiency. 

Battle Sign: Bruising behind the ear and at the mastoid process.

Raccoon eyes: Darkening and bruising around eyes.

Increasing number of symptoms

WHAT TO DO IF YOU SUSPECT A CONCUSSION

If there is a suspected concussion, the individual needs to be monitored for the first 48 hours for worsening of symptoms. NSAIDs should be avoided, and physical activity should be limited. Sleep is essential, and avoiding screen time is recommended as well. 

While there can be a lot of concern with concussions, most individuals have their symptoms resolved 7-14 days post-injury. The concern comes into play further when as many as 5% to 58% have persistent symptoms that linger and affect daily function. 

Recovery can vary quite greatly, be complex, and be influenced by multiple factors. It has been found that typically females, youth, and individuals with a history of migraines and ADHD may experience longer recovery. Also, individuals can be more susceptible to a longer recovery if there are injury-related factors such as loss of consciousness, amnesia, and delayed removal from sport. Overall, a clear characterization of risks that may cause poor recovery remains unclear and needs further study and research.

For individuals with ongoing and lingering symptoms, a physical therapist with expertise in this area can help guide a safe return to normal function and a specialized treatment plan based on the limitations of the individual, as well as work with your physician for optimal recovery.

TREATMENT

Some treatments may include self-management and education, specific exercises building up to sport and work-specific tasks, eye and vision tasks, and balance and coordination training. 

Concussions can be confusing and intimidating at first glance, but we can help guide you or your loved one back to their everyday activities and rediscover adventure!

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Blood Flow Restriction Training

Blood Flow Restriction Training 

Blood flow restriction training, or BFR, is far from a new discovery, however, its use in rehabilitation over the last decade has really come into culmination. The concept of blood flow restriction was initially discovered in 1966 by Yoshiaki Sato in Japan after he injured his lower leg and was placed in a cast for 6 weeks. He spent that time sitting cross-legged, as is common in Japanese culture, and essentially restricted blood flow to his lower leg. When the cast was removed 6 weeks later, he surprisingly had no atrophy. Fast forward to the early 90’s, and clinical units for blood flow restriction training started to enter the market, however, it wasn’t until around 2012 that this intervention really took off. 

Blood flow restriction training creates a hypoxic environment in the muscle, meaning an environment that lacks oxygen. This causes cellular swelling, activates protein synthesis, causes intramuscular anabolic signaling, increases growth hormone, and increases muscle fiber recruitment.1,2 Through these mechanisms, blood flow restriction training can elicit muscular hypertrophy and strength by using light external loads of 20-30% repetition maximum (RM).3 This is fundamental for creating adaptions in a tissue that may be load compromised or recovering from injury. For this reason, BFR has really gained popularity in the rehabilitation settings where the goal is to improve overall muscle hypertrophy and strength, even when you are dealing with the healing soft tissues and joint complexes.3 

The ability of a muscle to create force is going to be dependent on the balance between motor unit recruitment and development of muscular fatigue, due to the lack of oxygen delivery to the muscles.6 When lacking oxygen and under fatigue, the force producing capacity of exercising skeletal muscles are slightly altered.6 When exercising with BFR, there is a greater decline in the maximal voluntary isometric muscle contraction (see as a decrease in force production) compared to lower pressures or no BFR intervention at all.7 Especially under isometric conditions, the maximum voluntary contraction EMG amplitude is greatly reduced (72.5% vs. 46.3% of maximum EMG activity).4 However, in order to maintain force output levels during BFR when under accelerated fatigue, motor units of high threshold excitability are recruited, therefore a hypertrophic stimulus would be provided to a greater proposition of the muscle fibers creating an increased level of myoelectric activity in resistant exercise with BFR.8 The use of BFR targets the recruitment of Type II fast twitch muscle fibers4, the same type of muscle fiber that is first to atrophy. Furthermore, the addition of BFR has been shown to increase the neuromuscular activation and MVC (maximal voluntary contraction) of targeted muscles 15 minutes after BFR was applied.4,5 

BFR is an excellent tool across a variety of conditions and populations. BFR is great for individuals who have suffered from atrophy or are unable to train with heavy loads. It can be an essential tool following surgery where you may be non-weight bearing for several weeks or months. BFR with low loads is a safe and effective tool we utilize at Four Pines for musculoskeletal rehabilitation. Additionally, it can be used to build muscle hypertrophy and create adaptations in those already training but need to get in a strength/hypertrophy session without overloading their joints with heavy weights. Our clinicians are trained to utilize blood flow restriction training to meet your needs, goals, and personal aspirations. 

References: 

1. Scott BR, Slattery KM, Sculley D V., Dascombe BJ. Hypoxia and resistance exercise: a comparison of localized and systemic methods. Sports Med. 2014;44(8):1037-1054. doi:10.1007/S40279-014-0177-7

2. Yasuda T, Loenneke JP, Thiebaud RS, Abe T. Effects of blood flow restricted low-intensity concentric or eccentric training on muscle size and strength. PLoS One. 2012;7(12). doi:10.1371/JOURNAL.PONE.0052843

3. Patel S, Amirhekmat A, Le R, Williams III RJ, Wang D. Osteochondral Allograft Transplantation in Professional Athletes: Rehabilitation and Return to Play. Int J Sports Phys Ther. 16:2021. doi:10.26603/001c.22085

4. Lauber B, König D, Gollhofer A, Centner C. Isometric blood flow restriction exercise: acute physiological and neuromuscular responses. doi:10.1186/s13102-021-00239-7

5. Nie J, Dankel SJ, Laurentino GC, et al. Blood Flow Restriction During Futsal Training Increases Muscle Activation and Strength. 2019. doi:10.3389/fphys.2019.00614

6. Hammer SM, Alexander AM, Didier KD, Barstow TJ. The Journal of Physiology C 2020 The Authors. The Journal of Physiology C 2020 The Physiological Society. J Physiol. 2020;598:4293-4306. doi:10.1113/JP279925

7. Head P, Waldron M, Theis N, David Patterson S. Acute Neuromuscular Electrical Stimulation (NMES) With Blood Flow Restriction: The Effect of Restriction Pressures. J Sport Rehabil. 2020;30(3):375-383. doi:10.1123/JSR.2019-0505

8. de Queiros VS, de França IM, Trybulski R, et al. Myoelectric Activity and Fatigue in Low-Load Resistance Exercise With Different Pressure of Blood Flow Restriction: A Systematic Review and Meta-Analysis. Front Physiol. 2021;12:786752. doi:10.3389/FPHYS.2021.786752/FULL

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Biofeedback & Physical Therapy

Biofeedback is a tool used that uses myoelectrical signals to help retrain muscles. It can be used to either increase or reduce muscle activity depending on the goal and injury. Over the last decade, several studies have supported the use of biofeedback for musculoskeletal and neurological rehabilitation. Although research originally focused on the quadriceps and knee, evidence has since expanded to include the use of biofeedback for other orthopedic conditions and injuries. Let’s look at some ways biofeedback is used in physical therapy rehabilitation to address different injuries and conditions.

 KNEE:

After knee surgery, quad weakness and loss of neuromuscular firing are very common, sometimes for over 6 months.1 After menisectomy, several studies have addressed the benefit of biofeedback on recovery. Akkaya et al. found EMG-biofeedback to be effective at reducing time on crutches, increasing quadriceps recruitment, and speeding up the rehabilitation process.2 Kirnap et all found improvements in range of motion (ROM), overall function, and max quadricep recruitment with biofeedback.3 After meniscus repair, biofeedback was shown to help improve muscular control, coordination, and function during activities.4 Benefits were even seen after total knee arthroscopy in gait and quality of life when biofeedback interventions were included in rehab.5–7

The most recent addition to the knee literature has been the support of EMG biofeedback for patellar femoral pain. The use of real time visual biofeedback was shown to improve the relative contraction strength of both vastus lateralis (VL) and vastus medialis obliques (VMO) muscles subsequently enhancing activation during daily activities.8 In a study by Alonazi et al, after just four weeks of a biofeedback guided rehabilitation program, young males with patellar femoral pain had less pain, improved strength, and long-term function.9 

HIP:

More recently, studies on the hip have yielded promising results for the use of EMG biofeedback after total hip arthroscopy. In 2019, Doctors Soni and Samuel demonstrated a conventional rehabilitation program with the use of biofeedback produced superior outcomes compared to a conventional rehab programs alone.10 Following hip arthroscopy, the use of biofeedback can be essential in helping to regain stability and improve overall athletic function following FAI and labral surgery.

SHOULDER:

Studies published on the shoulder have supported the effects of EMG biofeedback for muscle patterning and rotator cuff activation for conditions such as shoulder instability, impingement, and rotator cuff repairs. For instance, Lim et al found the use of visual EMG biofeedback to be a clinically effective training tool for increasing activation and strength of the infraspinatus muscle during specific exercises while reducing the use (substitution) of the posterior deltoid.11 Scapular dyskinesis, or poor motor patterning, is an issue with many shoulder pathologies and a focus of all scapular strengthening programs. Recently in 2020, Du et al. demonstrated that the use of visual biofeedback can help improve muscle activation and control during overhead shoulder elevation.12 Similarly, Huang et al. showed this improved scapular muscular balance during rehab exercise was beneficial for improving symptoms associated with shoulder impingement. 13 Furthermore, the use of biofeedback has evolved to incorporate interventions that work to reduce activation or down regulate an overactive muscle group that often causes pain and dysfunction, particularly the upper traps when discussing the shoulder. 

ANKLE/FOOT:

The main focus of biofeedback use in the ankle and foot has typically pertained to gait and stroke recovery. In this arena, it has been shown to improve strength, balance, and gait patterning.14 Additionally, a recent study by Kim and Uhm showed the effectiveness of biofeedback for improving balance and lower limb muscle in athletes with functional ankle instability.15 

SUMMARY:

Visual biofeedback as an adjunct for physical therapy intervention has really been transformed and modernized over the last several years. The use of visual biofeedback has demonstrated greater increases in muscle activation and greater improvements in exercise form compared to verbal and audio feedback. 3 When muscle activation is minimal, simply being able to see changes in muscle activation levels is a huge motivating factor for patients. Furthermore, it gives them a goal, purpose, and intention to their training that they are likely missing.  For one study, real time visual biofeedback on quad muscle activation was provided to assist participant’s in maintaining a sustained quadriceps contraction. 4

sEMG biofeedback is a low-risk intervention, with high levels of versatility and the ability to customize treatment to achieve functional goals faster. New evidence and studies encourage the use of EMG biofeedback as an effective and innovative treatment intervention for physical therapy. 

References 

1. Glatthorn JF, Berendts AM, Bizzini M, Munzinger U, Maffiuletti NA. Neuromuscular function after arthroscopic partial meniscectomy. Clin Orthop Relat Res. 2010;468(5):1336-1343. doi:10.1007/S11999-009-1172-4

2. Akkaya N, Ardic F, Ozgen M, Akkaya S, Sahin F, Kilic A. Efficacy of electromyographic biofeedback and electrical stimulation following arthroscopic partial meniscectomy: a randomized controlled trial: http://dx.doi.org/101177/0269215511419382. 2011;26(3):224-236. doi:10.1177/0269215511419382

3. Kirnap M, Calis M, Turgut AO, Halici M, Tuncel M. The efficacy of EMG-biofeedback training on quadriceps muscle strength in patients after arthroscopic meniscectomy. 1224;118:1224.

4. Oravitan M, Avram C. The Effectiveness of Electromyographic Biofeedback as Part of a Meniscal Repair Rehabilitation Programme. ©Journal Sport Sci Med. 2013;12:526-532. http://www.jssm.org. Accessed November 4, 2021.

5. Nakandala N. EMG-Biofeedback Therapy in Knee Rehabilitation: A Review. 2019.

6. Zeni J, Abujaber S, Flowers P, Pozzi F, Snyder-Mackler L. Biofeedback to promote movement symmetry after total knee arthroplasty: A feasibility study. J Orthop Sports Phys Ther. 2013;43(10):715-726. doi:10.2519/JOSPT.2013.4657

7. Levinger P, Zeina D, Teshome AK, Skinner E, Begg R, Abbott JH. A real time biofeedback using Kinect and Wii to improve gait for post-total knee replacement rehabilitation: A case study report. Disabil Rehabil Assist Technol. 2016;11(3):251-262. doi:10.3109/17483107.2015.1080767

8. Ng GYF, Zhang AQ, Li CK. Biofeedback exercise improved the EMG activity ratio of the medial and lateral vasti muscles in subjects with patellofemoral pain syndrome. J Electromyogr Kinesiol. 2008;18(1):128-133. doi:10.1016/J.JELEKIN.2006.08.010

9. Alonazi A, Hasan S, Anwer S, et al. Efficacy of Electromyographic-Biofeedback Supplementation Training with Patellar Taping on Quadriceps Strengthening in Patellofemoral Pain Syndrome among Young Adult Male Athletes. Int J Environ Res Public Health. 2021;18(9):4514. doi:10.3390/IJERPH18094514

10. Krupa D, Soni MM. To compare the effectiveness of Neuromuscular electrical stimulation and Electromyography biofeedback in individuals following Total Hip arthroplasty. 2019;07. doi:10.18535/jmscr/v7i10.06

11. Lim O, Kim J, Song S, Cynn H, Yi C. Effect of Selective Muscle Training Using Visual EMG Biofeedback on Infraspinatus and Posterior Deltoid. J Hum Kinet. 2014;44(1):83. doi:10.2478/HUKIN-2014-0113

12. Du WY, Huang TS, Chiu YC, et al. Single-session video and electromyography feedback in overhead athletes with scapular dyskinesis and impingement syndrome. J Athl Train. 2020;55(3):265-273. doi:10.4085/1062-6050-490-18

13. Huang HY, Lin JJ, Guo YL, Wang WTJ, Chen YJ. EMG biofeedback effectiveness to alter muscle activity pattern and scapular kinematics in subjects with and without shoulder impingement. J Electromyogr Kinesiol. 2013;23(1):267-274. doi:10.1016/J.JELEKIN.2012.09.007

14. Aiello E, Gates DH, Patritti BL, et al. Visual EMG biofeedback to improve ankle function in hemiparetic gait. Annu Int Conf IEEE Eng Med Biol - Proc. 2005;7 VOLS:7703-7706. doi:10.1109/IEMBS.2005.1616297

15. Kim J-H, Uhm Y-H. Effect of Ankle Stabilization Training Using Biofeedback on Balance Ability and Lower Limb Muscle Activity in Football Players with Functional Ankle Instability. J Korean Phys Ther. 2016;28(3):189-194. doi:10.18857/JKPT.2016.28.3.189

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Incontinence and Men's Health

When we think about urinary and fecal incontinence, often we think of someone who has given birth and is dealing with incontinence postpartum. The reality is that anyone can be affected by bowel or bladder incontinence and around 50% of men over 65 are dealing with urinary incontinence and 3-8% of men over 60 are dealing with fecal incontinence.  Incontinence is defined as any unwanted leakage of any amount of urine, fecal matter, gas, or diarrhea. There are several types of incontinence including stress urinary incontinence, urge urinary incontinence, mixed urinary incontinence, and fecal incontinence. Urgency and frequency of bowel and/or bladder are also common complaints among men.

Incontinence affects many aspects of a person’s life, their mental health, their physical health, and their wallet. Incontinence is linked to a higher incidence of depression and anxiety. it can also lead to an increased incidence of UTIs. Products that help with Incontinence can cost over $100 a month.

Urinary incontinence in men often occurs after treatment for prostate cancer. When the prostate is removed the tissue that aids incontinence is also removed making it difficult to hold back urine. Fecal incontinence can be caused by a variety of things including colorectal cancer, diet, and nerve dysfunction.

Incontinence is often attributed to “old age” and is thought to be something you just have to deal with. Neither is true and incontinence is often easily treatable by a pelvic floor physical therapist. Luckily the muscles of the pelvic floor also aid incontinence. Strengthening and retraining of the pelvic floor muscles can decrease urinary incontinence in men. Strengthening the pelvic floor muscles alone isn’t always the best way to address incontinence. The treatment approach includes bladder and/or bowel retraining, managing fluid intake and diet, managing constipation, increasing joint mobility in the pelvis, spine, and hips, strengthening of muscles around the hips and spine, and nerve mobility. Pelvic floor physical therapists receive specialized training to treat men with urinary and fecal incontinence and work with their clients to devise an individualized treatment plan to address concerns.

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Pre & Post Prostatectomy and Physical Therapy

“Prostate? I have heard the term; my doctor has talked about it... but what exactly does it do?”

A prostate is a reproductive organ in people born as males. It works with the testicles and fluids from other glands to make up semen/ allow for ejaculation. It is also important for the urinary continence system by providing pressure on the urethra.

 "How do I know something is wrong with my prostate?" 

Symptoms include:

Urinary leakage

Urinary retention

Slowed stream

Nocturia (getting up more than 1 time/night to pee)

Erectile dysfunction

Enlarged prostate

Pelvic pain

Elevated PSA levels

"Why would my prostate cause urinary problems"

Great question! A quick anatomy overview, your urethra (the tube that allows pee to flow out from your body into the toilet/woods/your chosen place to relieve yourself) runs right through your prostate, so if it becomes enlarged, it can squeeze on that urethral tube and can cause all the symptoms above. (insert photo of anatomical prostate with urethra)

"I am getting my prostate removed . . . now what!?"

Once you and your doctor have determined that getting a prostatectomy is the right fit for you, head to Physical Therapy! Pelvic Floor physical therapists will help set your expectations, answer questions, and create goals (along with your Physician) pre and post-prostatectomy. Physical therapists will teach you how to utilize your pelvic floor muscles appropriately to lessen your experience with incontinence postoperatively . . . yes everyone has a pelvic floor! Your Pelvic Floor PT may also teach you how to manage your penile tissue to prevent fibrosis that may cause Peyronie’s disease (painful bend of the erected penis due to fibrous plaque). Your PT will assess the muscle strength of the hips/legs/and pelvic floor muscles and teach you the best ways to strengthen prior to surgery to lead to a quicker recovery post-prostatectomy. 

Have you heard of a “Kegel” and think it is only for the ladies? Guess again, Kegels are for all. 

Urinary leakage is common right after surgery, but we want to prevent leakage as soon as possible. That is where PT’s come in to show you the tips and tricks for getting you back to your normal, healthy self that does not have to wear pads to enjoy your everyday outdoor activities. 

Dr. Erin Dougherty, PT, DPT

Pelvic Health PT is inclusive for all genders

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Pediatric Developmental Physical Therapy

What is a Pediatric Physical Therapist: A Pediatric Physical Therapist provides services and support for children and their families, from birth to age 18.  They work with kids who have developmental delays or disabilities aiding in development, restoring function, and improving mobility.  They identify and treat conditions that may lead to movement, cognitive, and even social challenges.  They work with families to create treatment plans that increase the child’s strength, restore movement, improve coordination, and address deformities that may have occurred. 

What To Expect: Kids learn through play and exploration.  Thus, a Pediatric physical therapist will guide your child through a series of specifically designed play and sensory experiences. These will assist in development of your child’s ability to learn and move their bodies how and when they want to, giving your child the ability to make every day experiences and activities easier.

Common Conditions Treated: Developmental delays and missing milestones Muscle weakness or imbalance Torticollis, scoliosis and plagiocephaly Impaired coordination or motor planning Nerve and muscle conditions such as Cerebral Palsy (CP) or Periventricular Leukomalacia (PVL) Children who are small for gestational age or born prematurely Toe walking Sensory processing and integration challenges Genetic disorders or syndromes Traumatic or hypoxic injuries Children exposed to drugs or toxic substances Bed wetting, daytime accidents, chronic constipation or bowel and bladder incontinence

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Oh My Hammy!

Oh My Hammy! 

Dr. Norene Christensen, PT, DSc, OCS

At some point in our athletic endeavors, we have experienced a high hamstring strain (at the base of the butt) or mid muscle strain.   Hamstring injuries may occur after accumulated repetitive microscopic trauma or in response to a single event exceeding the limits of the muscle-tendon unit.  This means that we can have a low-level chronic pain due to ongoing decline in tissue integrity from poor mechanics or poor training (ie running) or we can have a one-time event that tears the muscle or ruptures the tendon (waterskiing accident).  In sporting events, a common mechanism of hamstring injury is with sudden sprinting or kicking.  In daily life a common mechanics of injury is slipping (on loose dirt or ice) or falling forward and trying to catch oneself.  Unfortunately, a history of previous hamstring injury increases your risk of another hamstring injury by 2.7 times.

For chronic “base of butt” or mid hamstring pain, it is important to rule out other possible causes such as adductor muscle injury, lumbar spine radiculopathy or proximal hamstring tendinopathy.  For acute high hamstring injuries x-rays may be necessary to rule out avulsion fracture of the ischial tuberosity (where the hamstrings attach to the pelvis) or an MRI to evaluate tendon rupture(s) and retraction.

To best care for yourself after a hamstring injury can be multifactorial and dependent upon the mechanism of injury.

For high velocity injuries which result from sudden sprinting, hard kicking, falling forward skiing (or water skiing) or slipping on ice that results in a significant amount of pain at the base of your buttock.  Do not stretch as you will want to be evaluated by your orthopedist to rule out avulsion fracture and or avulsion of the hamstring tendon(s) which may require in surgery.  If you avulse 2 or more tendons and they retract more than 2 cm from the bone, it is best to have this repaired sooner or later for best functional outcomes.  From there you will see your favorite physical therapist to begin the rehabilitation process to return you to sport or the activities you love to do.  This rehab process can take up to 6 months depending on your post-surgical outcomes, pain levels and activity levels.

For chronic high hamstring pain with running or other activities, you may need to work on different areas of your body as well as your hamstring.  You may need to address loss of mobility and flexibility in your spine, hips and legs which may contribute to your hamstrings overworking.  Addressing strength imbalances or dysfunctional motor patterns that have developed over the years may help take some of the strain off the hamstrings.  The body is a beautiful compensator and sometimes you just don’t realize that you may be weak in key stabilizing muscles.  Have your running mechanics assessed by a professional that will video tape you and work with you to change your mechanics to improve efficiency and reduce microtrauma to the area.  Our hamstrings are important pelvic and core stabilizers so utilizing exercises geared towards stabilization in functional patterns will help tie the hamstrings into your core.  Finally, will need to train eccentrically for tendon health but also for the function of the hamstring during running, sprinting, and kicking (Askling L-Protocol and more).

For return to running or return to your sport it is wise to implement different running or movement drills into your rehab.  Lower-level drills can be implemented immediately as long as they are pain-free with advanced drills being performed as pain reduces.

As with most injuries, stretching may be done with a sensation of “strain” not “pain”.  Hamstring pain will dictate whether you can progress your program to the next level.  Once you can walk without pain you may begin a graded running program.  There are many programs out there to follow but an example of a return to running protocol accounts for greater acceleration distances and gradual intensity increases at high percentage of maximal velocity over time.  These programs include walking, at 50% max velocity, 80% max velocity towards 100% while varying distances and may be progressed if pain-free.

At Four Pines Physical Therapy, we have PTs that are certified in running rehabilitation and will take the time to properly rehab you back into your sport utilizing appropriate therapeutic techniques, exercises, video assessments and more.  Our PTs will help you with your return to a running program or general fitness program that achieves your goals.  

Hamstring injuries are common in runners and other athletes as well as the general community due to chronic stress to the tissues or due to a sudden high-speed injury.  Whether you have surgery to reattach tendons that have torn off and retracted or want to address the nagging pain with activity, the therapists of Four Pines Physical Therapy will develop the most appropriate treatment plan for you.

Call us for a free 20-minute consultation for more information on how we can help you.

Example of HS

Standing HS stretch with leg on bench

Supine hip flexion HS stretch

Eccentric Exercises – supine tband, Nordic hamcurls, reachers, glider

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Rock Climbing Injury Prevention

Climbing can be a very fun and rewarding sport. Here are some tips and tricks to prevent musculoskeletal injuries while climbing.  

1) Warm-up! 

Your climbing warm-up should involve dynamic movements at both the upper and lower extremities that are sport-specific. This means mimicking the types of movements used in climbing and moving the joints through their full range of motion. Dynamic stretches will help increase the blood flow to muscles and tendons and can help reduce the risk of injury. For the lower body, this may include repetitions of standing hip openers, high stepping movements, and flagging movements. For the upper body, this may include overhead movements for the shoulders, wrist flexion and extension, and flexing and extending the fingers. After completing dynamic stretches, start your climbing session with 2-3 easier routes to complete your warm-up. 

2)  Mobility 

Climbing requires a wide range of movements and movement patterns. Achieving and maintaining the full range of motion throughout your joints, in particular the shoulders, hips, and ankles will allow for more optimal movement. Static stretches (holding a stretch for 30-60 seconds) are not advised as a warm-up prior to climbing but are useful when combined with dynamic movements to maintain or increase flexibility. A foam roll is a great tool for working on stretching and mobility of the upper body. Recommended movements include "angel arms" (laying on the foam roll and gently moving both arms as if you are making a snow angel). From this position you can transition into pec stretches in low, mid, and overhead positions. Open book stretches can be completed without a foam roll either laying on your back or in half-kneeling against a wall to promote thoracic spine mobility. 

3) Strength Training of the antagonist muscles 

Agonist muscles are the primary movers and antagonist muscles work in the opposite direction of the agonist muscles to complete an action. When an agonist muscle contracts, the antagonist muscle relaxes and rests while the movement of the agonist is performed. Incorporating antagonist strengthening specific to climbing into your strength program can help reduce the risk of injuries. This may include exercises such as resisted finger extensions (opening the hand against the resistance of a rubber band, for example), training of the wrist extensors (performed with a weighted dowel or flexbar), resisted shoulder external rotation at 90 degrees, shoulder horizontal abduction ("T's) and shoulder overhead scaption ("Y's"). 

4) Core Strength 

In order to effectively perform the variety of movement patterns necessary in climbing, it is important to build strong trunk musculature. Core strengthening for climbing should focus on trunk stability as well as include exercises that challenge trunk stability by adding arm, leg or a combination of arm and leg movements in movement patterns similar to those frequently used in climbing. Start with planks and side planks and add in arm and/or leg movements. This may include planking while moving your leg in and out of a flagging position, or moving your leg in and out of a high knee position touching the inside or outside of your elbow with your knee. With your arms, you could perform a cone reach to cones placed at different angles around you. 

5) Movement training 

Having a friend film you while climbing can provide helpful feedback to allow you to identify deficits in your climbing technique. Performing climbing drills to address the specific deficits in your climbing technique can help promote more efficient and optimized movement patterns and can help reduce the risk of an overuse injury. Several small adjustments in climbing technique that are beneficial in reducing the risk of overuse injury include engaging your shoulder blades, using a neutral (vs flexed) wrist position when grasping holds, avoiding overreaching at the shoulder during overhead movements, avoiding hyperextension of the elbows, climbing with good posture at your upper back, avoiding climbing with elbows kept in a flexed position, and using footwork and weightshifting effectively to avoid unnecessary overstraining of the arms. 

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Tips for those hard winter shoveling months

By Dr. V. Norene Christensen

Well you know the ol’ saying in our area – nine months of winter…three months of road construction! That being said, it is time for us to bunker down and prepare to dig ourselves out of our homes and barns while trying to stay vertical at the same time!

Here are some tips to keep you safe!

Shoveling Takes Time…Don’t Lift Heavy Snow Loads Just Trying To Get It Done…You May End Up In The Snow Yourself!

Warm Up! Have a good warm drink, move around, bend forwards/backwards/side to side, squat and stretch to prepare your muscles for some hard work.

Use a light weight plastic shovel to help take some of the weight off the load

Know Your Lifting Limits!

Use good form – try to push rather than lift and throw the snow

Use your arms and legs – not your back

Keep your knees bent and keep a safe wide base of support to keep you stable

Keep loads close, do not reach out especially under load

Scoop and lift small amounts of snow upwards and forward to throw

Pivot your whole body to throw the snow (if you must throw it to the side) rather than twisting just your back

REST WHEN YOU ARE TIRED

Prevent Slipping And Falling While Shoveling… Don’t Wear Your Slippers....It’s Another Way To End Up In The Snow Yourself!

Wear good soled shoes for traction

Use some type of ice cleat (i.e. Yaktraks, MICROspikes) to prevent slipping on ice

Take smaller steps

Slow Down

You Have A Snow Blower!... Great News….Now Let’s Stay Out From Underneath It!

Read Above for preventing slips and falls

Wear good gloves that will not slip and ear protection

Follow the snow blower instructions on use – do not pull to back up while the rotor is moving….great way to only need one shoe

Do not manhandle the snow blower to get into tight corners – that’s for shovels

With the snow blower off, safely clean the rotors to ease the use of the machine and its efficiency to clear snow

Four Pines Physical Therapy Wishes You A Safe and Fun Winter!

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Returning to running after ACL Surgery

By Kaysha Heck  

ACL tears are one of the most common knee injuries sustained while skiing. With the heavy snow, good skiing, and epic power days this year, I’m sure there was no shortage of knee injuries. While I hope everyone had a safe and healthy season, I know some individuals’ ski seasons ended in a less than ideal manner.

If you tore your ACL this year, sometime in January or February, you are likely sitting right about 3-4 months out of surgery. My guess is you are finally starting to feel better, your knee is getting stronger, and you are longing for the snow to melt. You are anxious to get back to biking, hiking, and running.

Can’t blame you there!

However, when returning to running after an ACL reconstruction there are several things to consider for a safe, effective, and successful progression back.

1. Time

As rehab professionals, we look to return someone to running at right about 16 weeks. Yes, graft type, prior surgery, and other factors do make a difference, but overall 16 weeks is about what you’re looking at. Why so long? It takes (at least) this amount of time for your knee joint to start to normalize, re-establish homeostasis, and build back up protective strength.

In fact, recent studies are showing that it takes 2 years for all healing markers to return to normal and homeostasis to fully be re-established in the knee, but that’s another discussion.

Now, not to get too medical, there are some things to consider from a tissue healing standpoint before beginning a running program. After surgery, your graft goes through a process called ligamentization where the graft (usually from a hamstring, quad, or patellar tendon) becomes a ligament through revascularization, cellular regeneration, and remodeling of the tissue. Either end of the graft must become incorporated into the insertion sites and build tensile strength.

This process doesn’t fully occur until 12 weeks.

2. Normal Joint Motion 

Since day one you have likely been working on the range of motion and swelling in your knee. Working to re-establish normal motion and mechanics in the knee early on is essential for long term joint health.

Making sure you have full knee extension (all the way straight) and knee flexion (bent) equal to the other side is pivotal before beginning a running program.

Swelling is another key issue. While swelling after surgery is normal, constant swelling 16 weeks out indicates the joint is still irritated. Running will increase the forces through the knee joint and the last thing you want to do is pound on an already cranky joint.

3. Strength

Quad strength is the most important factor in protecting your knee and getting you back to functioning at full force. Don’t get me wrong, hamstrings (another huge protector of the ACL) and glutes are super important, but quads are key. The quads provide strength and stability to the knee, protect it, and take load off of the joint. Time and time again, research has shown quad strength matters… a lot. So how does this play into running?

Ideally at four months, your quad strength on the injured side should be 60% of the uninjured knee.

That is to say, if you can kick out 100lbs on a knee extension machine on your good side, you should be able to kick out 60lbs on your surgical side before we even consider letting you run. Why? This shows you have good enough protective strength in the knee to allow for initiation of a safe running program.

4. Balance 

 Along with quad strength, balance (specifically the neuromuscular control portion) is critical in prevention of future injury and overall joint health.

Several studies coming out recently have emphasized the importance of re-establishing complete motor control, balance, and stability for injury prevention.

There are several ways in which balance can be tested. One of my favorites and most researched in terms of ACL recovery is called the Y-balance. The test incorporates balancing on one leg while reaching the other leg into three different directions. Both legs are tested and the results compared. At four months, results on the surgical leg should be within 90% of the uninjured leg. This number has been shown to be an acceptable cutoff for reduced injury risk and assumption of a safe return to running program.

5. Progression 

If you are anything like me, once cleared to run, the most challenging part is not over doing it. However, it is extremely important to progress back slowly and only manipulate one variable at a time.

Usually after ACL injury, return to running programs begin with a 10-15 min easy run on flat, dry ground, three days per week. Each week, running time is progressed. Once 25-30 min of consistent running is obtained without any symptoms, another variable can be manipulated (speed, frequency, terrain, or intensity).

When progressing back into running some general guidelines to remember are:

1. Do not progress distance more than 10% per week

2. Take a rest day between runs when just starting back

3. Avoid over striding as this increases joint forces at the hip, knee, ankle, and low back. Try opting for a quicker cadence (step rate) at the same speed.

Running programs will vary and some will progress slower depending on the extent of the surgery, prior history, and training experience.

Not sure if you are ready?

Contact us for a Running Assessment or a Functional Movement Assessment in either the Alpine or Jackson location and we’ll be sure to get you off on the right foot!

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Being Thankful Can Improve Your Health!

By Dr. V. Norene Christensen

Have you ever considered how being thankful can influence your health? If you really stop and think about it, it makes sense.

We’ve all been around the person who complains all the time, views every situation with a glass is half-empty approach, or just has a flat low-energy negative personality.

You are probably picturing the face of someone now and immediately your posture sags. How different do you feel when someone smiles in your direction, shares an encouraging word, or gives you a thumbs-up?

How thankful are you when the constant complainer is replaced by the cheery sunshine person with a bubbly personality? Gratitude is a lot like that. The more thankful you are, the happier you are.

According to Harvard Health, “Gratitude is strongly and consistently associated with greater happiness. Gratitude helps people feel more positive emotions, relish good experiences, improve their health, deal with adversity, and build strong relationships.”

How cool is that? So Cool, that before every staff meeting at Four Pines Physical Therapy, we go around and name 3 things/people/experiences that we are grateful for.

Being Thankful Improves Health.

I am thankful for my husband, daughters, family, and friends who encourage me and just do life with me – I am not alone in my journey.

I am grateful that my strength and attitude flies at a much higher altitude than my stature.

I am thankful for the opportunity to serve people and help them feel better, so they can get back to doing what they love.

I am thankful for the adversities in my life that have given me opportunities to grow and learn more about myself… and trust me, I’ve had my fair share of learning lessons!

I am thankful to those who have picked me up when I have failed to only try and try again until I succeed.

I am thankful for the strength and determination to persevere and triumph.

Gratitude Improves Health.

Who are you thankful for?

What are you thankful for?

What experiences are you thankful for?

I encourage you to take a moment each day and answer just one of these questions. Being thankful improves health. Be filled with gratitude…the quality of your life depends on it.

Happy Thanksgiving!

The Staff of Four Pines Physical Therapy hopes that you will fully enjoy your family and friends and be grateful for such love and support in your life.

Resources: https://www.health.harvard.edu/healthbeat/giving-thanks-can-make-you-happier

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4 Types of Perineal Tears

By Dr. Morgan Kinnes

What do ACLs and Perineums have in common? Maybe more than you think. Both are commonly injured, there are up to 200,000 ACL injuries per year in the United States and 90% of women have some degree of perineal tearing while giving birth (this is almost 4 million perineal injuries every year), and both require rehabilitation. 

Let’s back up a little bit. The perineum is the area of tissue in between the vagina or base of the penis and the anus and is made up of skin, fat tissue, and the pelvic floor muscles and contains quite a few nerve endings. During vaginal birth, the perineal tissue stretches to allow the baby’s head to exit the vagina and this sometimes results in a tear. Perineal tears can lead to urinary or fecal incontinence and pelvic pain with sexual intercourse. 

There are four different degrees of tears indicating the severity of injury and tissues involved. 

First degree: Tearing of the skin

Second degree: Some tearing of pelvic floor muscles and skin

Third Degree: Tearing of skin, pelvic floor muscles, and partial tear of the anal sphincter 

Fourth Degree: Tearing of skin, pelvic floor muscles, and complete tear of the anal sphincter and into the lining of the bowel.

Sometimes mom’s position during labor or the use of an instrument (forceps or a vacuum) can increase the risk of tearing. The typical birthing position of mom lying on her back with her feet up in stirrups or laying as if in a recliner increases the risk of perineal tearing. There are many different options for laboring positions that can reduce the risk of tearing that you can discuss with your provider. Perineal massage is another way to decrease the risk of perineal tears. Perineal massage should be done 1-2 times per week beginning around 35 weeks.

There is good news for new moms. Just like ACL injuries, a physical therapist can help address symptoms following a perineal tear. Pelvic Health Physical Therapists have specialized training and are experts in treating urinary and fecal incontinence and pelvic pain. ACOG (American College of Obstetricians and Gynecologists) recommends every person who has given birth see a Pelvic Health PT to address any issues they are having and prevent any further issues.  

Reach out to Four Pines Physical Therapy in the Jackson & Alpine, Wyoming area to develop a personalized care plan today! We have the best physical therapists in Wyoming! If you are not in the Jackson or Alpine, Wyoming area look for a physical therapist near me in your area online. 

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Blood Flow Restriction Training

What is Blood Flow Restriction? 

A form of low intensity resistance training that can be used to enhance muscle growth, strength, and performance of the working muscles

A way to prevent muscle atrophy and build strength without increasing load on joints

How does Blood Flow Restriction work?

A specifically designed cuff is placed high up on the leg or arm

Individualized amounts of compression are applied to the working limb and a select 1-4 exercise are performed as determined by your therapist

The compression of the cuff causes a buildup of metabolic muscle byproducts that lead to enhanced muscle growth 

BFR can achieve similar results in muscle growth to high intensity interval training (HIIT)

Who is Blood Flow Restriction  for? 

Post-surgical clients (achilles tendon repair, ACL repair, meniscal repair, hip scope, or rotator cuff repair) with limitations in weight bearing or range of motion that prevents higher/heavier loads 

Clients with pain, arthritis, or degenerative issues that cannot handle higher/heavier loading to joints or tendons

Clients with healing tissues that cannot yet handle higher/heavier loads

High level athletes that need to maintain training intensity but cannot handle the high level of forces necessary to be competitive

What are the benefits of  Blood Flow Restriction?

BFR helps to prevents muscle atrophy

Allows for muscle strengthening without having to overload joints 

Excellent way to bridge the gap between low intensity and high intensity training 

Side effects? 

Some muscle soreness after BFR is expected 

Muscle fatigue during exercise and low levels of discomfort are normal

*Consult your doctor before beginning BFR if you have a history of deep vein thrombosis, varicose veins, high blood pressure, cardiac disease, or may be pregnant.

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4 Tips To A Successful Backcountry Ski Season

By Dr. Mouna Goyette

Fitness: Backcountry skiing requires a special type of fitness. You need the endurance to make it to the top of your climb with enough energy reserve and strength left over to ski down safely. We need to train both uphill and downhill muscles for this type of activity. Working with a physical therapist who specializes in ski touring and endurance sports can be helpful to gain insight into your specific needs.  

Technique: Training goes out of the window if you do not have proper ski touring techniques. Climbing up mountains is hard work. Improper technique is inefficient and can zap your energy or leave you soaked in sweat. This can lead to a very unenjoyable and potentially dangerous situation. A little technique goes a long way. Proper fueling and hydration technique are also imperative to sustain the energy needed for your outing.

Gear: In the backcountry, you carry your amenities in your own backpack! Having the appropriate tools, organized in an efficient system is key. Knowing how to work your gear is imperative. Take the time to research, read manuals, take an “intro to backcountry class,” watch instructional videos, and seek mentorship. Proper clothing and layering are critical to maintaining a safe body temperature. Your layering system will change depending on the day’s weather. Practice your uphill travel skills at a local ski hill and test all of your gear/clothing options before you head into remote terrain.  

Education: Avalanche education is a must if you are traveling in avalanche terrain or even plan to avoid it. With global warming, avalanches are less predictable. With more people skiing in the backcountry than ever, it’s crucial to have solid terrain management skills. Formal avalanche classes are most comprehensive, however, there are some great books out there to introduce concepts to beginners. An avalanche rescue course and regular practice are also strongly recommended. A wilderness first aid class also goes a long way to help ensure backcountry safety and preparedness. 

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4 Tips to a Successful Ski Season

By Dr. Mouna Goyette

Strength training: Heading into ski season prepared with strong and balanced muscles is crucial to preventing injury. Although pre-season training is ideal, it’s never too late to start. A ski-specific program is best. A physical therapist who is specially trained in sports or ski injury prevention can address your individual needs. ACL injury prevention programs, such as SportsMetrics, have been proven to reduce knee ligamentous injuries in female athletes.  

Recovery: Whether you are a 100-day skier or a weekend warrior, you will need recovery strategies. Any repetitive activity can lead to overuse injuries or excessive tissue soreness. Having a holistic recovery program including a proper recovery exercise program, rest, nutrition, hydration, and sleep can significantly improve your performance on the slopes and make you feel better as a whole. 

Self-Care: The allure of a powder day can distract us from our most basic human needs. Try to keep up with your food and water during your ski day, so that you are fueled with the energy that skiing demands. Find a snack and water system that works for you. Address nagging injuries before they become unmanageable. A good physical therapist will have a better chance at keeping you involved in your sport the earlier the injured is addressed. Of course, helmets are strongly recommended. Concussions account for 20% of the ski injuries in North America each year. Severe brain injuries can be fatal and even mild concussion symptoms can last months or years. 

Mindfulness: It may be obvious that skiing in control is the best practice, however, keep in mind that a lot of folks are discovering the great outdoors for the first time this year. A polite “on your left” when passing may not resonate with someone who is new to the sport. Take the time to kindly educate others, to help keep the mountain safer for everyone. Learn to understand terrain, conditions, and lighting to help you prevent an unexpected fall. Keep constant and honest self-communication about your limitations. Most ski injuries happen at the end of the day when fatigue sets in. Know when you need a rest or when you need to call it a day! 

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8 Great Things to Do in Wyoming During Winter If you Didn’t Have To Worry About Back Pain

By Dr. V. Norene Christensen

80% of Americans will experience back pain at least once in their lifetime. If you are living with back pain, then you might also feel pain in your butt and down your leg (sciatica). Back pain can limit your ability to sit, stand, walk, and sleep. It can also stop you from doing the things that you love to do because you hurt or that you are afraid that it will make you hurt.

But what if you didn’t have to live with back pain? Can you picture it? You Could Be:

1) Enjoying the great outdoors while dog sledding with an outfitter

Without the achy soreness of back pain, you could be sitting in the sled or better yet, driving the dogs up to Granite Hot Springs for a hot soak or up on Togwotee Mountain to Brooks Lake Lodge for a wonderful lunch and relaxation in the beautiful lodge.

2) Snow machining into the National Forest ripping powder turns

Without sciatica that increases with sitting and the sharp pain that occurs when you are jarred, you could be ripping donuts, jumping cornices and slalom through the trees with your friends getting great face shots and vistas.

3) Snowshoeing with Friends

Without sharp, burning back pain that makes your face contort with every step, you could be experiencing the fun and adventure along a lake or deep in the woods with a group of like-minded playful friends and canines.

4) Downhill Skiing

Just think how easy putting on ski boots could be if your back didn’t hurt every time you bent over then twisted to buckle your boots.  You could be out catching face shots in the powder bowls, cruising the bump runs and sitting on the chair lift with your friends recounting the awesome run you just did.

5) Elk Refuge Sleigh Ride

If you back didn’t prevent you from sitting for less than ten minutes, you could be sitting in a horse drawn sleigh being taken through the elk herd, watching the bulls and birds of prey with your grandchildren.

6) Tubing and the Mountain Coaster at Snow King

Without having difficulty going from sit to stand due to sharp back pain or sciatica, you could be sitting on a tube with your child and go careening down Snow King Mountain only to jump right up and do it again!  Then run over and ride the Mountain Coaster down the side of Snow King Mountain and be able to get out of the coaster without any problems at all.

7) Snow Coach Tour into Yellowstone National Park

If your back pain didn’t limit how long you could sit, you would be able to enjoy a Snow Coach ride to Old Faithful in Yellowstone National Park.

8) Art Gallery Walks and Museums

Without nagging back pain or sciatica, you could be walking through some amazing art galleries as well as museums including the National Museum of Wildlife Art and Buffalo Bill Center of the West.

There you go – 8 Great Things you could be doing in Wyoming if your nagging back pain wasn’t getting in your way of living an active life with your family and friends.

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Taking an active approach to recovery after an injury

By Kaysha Heck

RICE vs. PEACE & LOVE

For a long time, RICE (rest, ice, compression, elevation) has been the standard of care after an injury. However, more recently, icing has come under fire with claims that icing actually impedes the healing process. Hence the new acronym, “PEACE & LOVE”. Like most things the answer isn’t black and white. Before you jump to a conclusion, let’s see what the research has to say.

One of the main reasons ice is used after an acute injury is to reduce swelling. Not to start the healing process. Inflammation is not the same as swelling and edema and will happen regardless after an injury. It is both essential and necessary for the healing process to occur. Ice has been shown to be effective for the first 48hrs after an injury to reduce swelling, with dismissing returns after that. Ice helps to reduce pain, muscle spasms, muscle guarding, and allows for early mobility. After an injury, being able to move around a little bit allows new blood and macronutrients to get to the injured area, which is essential for healing. Despite the current trend, there is no solid research showing that icing actually impedes the healing process. Studies claiming such are based on false logic and provide inconclusive results.  

The idea behind PEACE & LOVE is this. After an injury, you need to protect the injured area from further injury. Elevating will keep the swelling down. Compression is designed to neuromodulation pain and further reduce swelling which allows for early mobility. The faster you can start moving after an injury, the faster the body is able to mobilize nutrients, healing factors, and ultimately begin the recovery process. 

Often overlooked after an injury is the gradual progression of loading. This is where the “LOVE” comes in. Gradually returning to normal activities after an injury allows for a safe and optimal return of strength, mobility, and balance to the injured site. This helps to build resiliency and optimizes the repairing tissues. 

The biggest take away between RICE and PEACE & LOVE is the importance of taking an active approach to recovery after an injury. RICE calls for a more passive approach to recovery which we now know is not beneficial. At the end of the day being dramatically on one side of the fence isn’t useful. Icing won’t “fix” an injury but if it allows you to move sooner that will help you to heal faster. The faster you are able to reduce pain, begin moving, and progressively loading after an injury, the sooner you will be back on the field. 

Meeting with a physical therapist can help you develop a personalized plan to get you moving appropriately, managing your pain, and on the ideal road to recovery after an injury. Reach out to Four Pines Physical Therapy in the Jackson & Alpine, Wyoming area to develop a personalized care plan today!