Custom Physical Therapy looking for a Physical Therapist.


Custom Physical Therapy is seeking an outdoorsy, mountain biking, hiking, Lake Tahoe loving, skiing, camping, life loving outpatient orthopedic physical therapist to join us in Reno, Nevada.


We love what we do and are expanding because of the experiences our patients have and the absolutely amazing people who work at Custom Physical Therapy. Yes, I am biased but it’s totally true.


If you are a PT or know of someone who is a PT or a new grad and may be interested in working with us, contact me at (775) 813-2332 or ameintjes@usphclinic.com.

I’d love to chat with you.

André

(Aka owner/physical therapist/chief goofball)

“Is this a model or is it the real thing?”


I had the pleasure of meeting with one of our local orthopedic surgeons, Dr. Benjamin Bjerke, and the Zimmer-Biomet rep, Christina Escobar, to talk Mobi-C Disc Replacement technology and surgical technique developed by Zimmer-Biomet. Incredibly interesting.

Seeing the prosthesis, my first question was, “Is this a model or the real thing you are showing me?” It was much smaller than I anticipated!

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Secondly, I found the specificity of the patient suitable for this intervention impressive – someone with neck pain and or radiculopathy (pain down the arm originating from nerve root compression in the neck) without much cervical spondylosis (degeneration of the discs and joints in the neck) and good vertebral alignment. The Mobi-C can replace discs at one or two levels of the cervical spine between the third and seventh cervical vertebrae.

So lets take a look in more detail.

Anatomy and Pathology of the Neck

  • The cervical spine has discs between each bone that provide cushioning for movements and body loads. The discs and bones in a healthy neck allow bending from side-to-side and front-to-back, and turning left-to-right. Disc problems can start from over-use, an accident, or just the wear and tear of daily life.  When a disc degenerates it becomes thinner and provides less padding to absorb movement.  Degenerated discs can also bulge (herniate) and pinch the spinal cord or nerves, which causes loss of feeling, weakness, pain, or tingling down the arms and hands. Below  you can see the normal cervical spine anatomy and adjacent is a graphic of what a spine with pathology may look like:

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Treatment Options

  • Before artificial discs were available, patients would traditionally receive an Anterior Cervical Discectomy and Fusion procedure to alleviate the pain from a herniated disc. In a fusion surgery, the disc is removed and either a bone spacer or a plastic implant is placed in the disc space to restore disc height and remove pressure on the pinched nerves or spinal cord.   A metal plate and screws is placed on the front of the vertebral column to hold the implant in place.  The result – a segment that no longer moves, or is “fused”.  The potential downside of a fusion procedure, in addition to the loss of motion, is that it can create additional stress on the spinal levels above and below it.  This can cause degeneration at those levels and potentially result in another future surgery.
  • An artificial disc like Mobi-C is an option instead of a fusion that will also be placed inside the disc space to restore height and remove pressure on the pinched nerves. However, the Mobi-C device is designed to allow the neck to maintain normal motion and thus limit adjacent levels from degenerating, possibly preventing future surgeries.

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Since Mobi-C cervical disc replacements are preferred over fusions because they preserve movement in the spine, lets take a look at this video to see what happens in the spine when a patient with the Mob- C implanted flexes and extends his/her neck versus a two level fusion:

Cervical disc replacement procedures are anticipated to experience rapid growth in the near future, due to multiple factors:

  • A growing library of clinical evidence demonstrating the long term safety and efficacy of cervical disc replacement.
  • Cervical disc replacement is being shown as a superior treatment to fusion for use at two cervical levels.
  • Better outcomes of cervical disc replacement over fusion such as reduced re-operation rates, reduced adjacent segment degeneration rates and surgeries, as well as a faster return to work.
  • Most patients return to work within six weeks of surgery. In the U.S. Mobi-C clinical trial, the return to work time was 20.9 days shorter for Mobi-C patients compared to fusion patients for two-level surgery and 7.5 days shorter for Mobi-C patients compared to fusion for one-level surgery.

What about physical therapy after the Mobi-C disc replacement?

  • Wear a neck collar to lessen neck movement for around a week after the surgery.
  • Avoid heavy lifting, repetitive bending, and prolonged or strenuous activity for up to 6 weeks after surgery.
  • When your surgeon releases you to start physical therapy the physical therapist will do a comprehensive evaluation to assess your cervical, scapular and shoulder range of motion as well as cervical, arm and trunk strength. Based on the data collected, you will be given specific exercises to address any deficits to ultimately improve your function. You may start of with cervical isometrics and progress to upper thoracic and arm strengthening exercises as well as neuromuscular reeducation of the deep neck muscles. The physical therapist will also utilize soft tissue mobilization techniques to limit scar formation and address any myofascial pain and muscle trigger points, present from inactivity. You will need to participate fully by being totally compliant with the home exercise program you are given by the physical therapist at your very first visit.

Successful outcomes are determined by multiple factors which include choosing the right surgical procedure done by a skilled surgeon, following post operative activity limitations and brace use as well as being totally compliant with physical therapy instructions and exercises. It is a 3 person team that makes your recovery work: you (and your home supporters), the surgeon (and their staff) and the physical therapist (and their clinical team members).

Thank you to Zimmer-Biomet for help with supplying me with information and photographs.

The Custom Physical Therapy Challenge Rules


If you dare ….. get fitter, stronger and healthier with the monthly Custom Physical Therapy Challenge.

Every month we will have a daily series of exercises to do for anyone and all who would like to join us. Employees, friends and family may join in.

Here are the rules:

  1. You complete all repetitions of each exercise every day and check it off the schedule of exercises.
  2. If you miss a day you may double up the next day – not advisable particularly towards the end of the series.
  3. It is purely the honor system.
  4. If you complete all exercises for the entire month you let us know by faxing the checked schedule to Custom Physical Therapy (775-331-1180) or emailing it to us with your name on it and contact number: customptchallenge@gmail.com
  5. Prize: $50-$75 gift certificate from a local business (Previously: Great Full Gardens Restaurant, 1 hour massage).

Exercise technique can be seen on our Youtube Custom Physical Therapy Challenge Channel. Here is the URL:

Let us know how you like it and what you would like to challenge in future months. For example, an arm challenge, butt challenge, core challenge, chest challenge, aerobic challenge, rope jump challenge.

If you have any concerns about doing the exercises and need help modifying them feel free to call us at the Sparks location: 775-331-1199. You can also email us with questions: customptchallenge@gmail.com

Have fun, be safe and get strong!

The Custom Physical Therapy Challenge Department

www.custom-pt.com

http://www.customphysicaltherapy.wordpress.com/

Reasons to Choose Custom Physical Therapy


Swelling and Knee Function


The most read post on this blog deals with “Swelling, Effusion, Edema and Bruising – What’s the difference?”.  I will take the concept one step further and discuss how knee swelling or joint effusions impact your ability to control your knee extension when you walk.

So, you injure your knee and develop swelling inside the joint.  You may notice your knee giving way.  That means when you transfer weight onto your injured leg the knee buckles.  This is due to the quadriceps (front of your thigh) not contracting efficiently and hence not controlling the knee in extension.  Knee extension is vital in walking because it stabilizes the leg to accept the transferred weight from the opposite leg when you are in stance phase of gait.  If the knee is unable to go fully straight while stepping onto it you have difficulty swinging the other leg through to take another step.

This happens because of the swelling (and possibly pain too) within the joint.  A neural reflex is set up by distension of the joint structures.  It passes through the spinal cord and back to inhibit the quadriceps.  It is then difficult to contract them at the right time and with sufficient speed during the gait cycle.  Hence, unsafe walking and difficulty going up and down stairs, for example.  You may notice immediate deterioration of your ability to contract the quadriceps following injury with a joint effusion.

To regain quadriceps function and hence to restore normal and safe walking you must control the swelling (see earlier post on this topic), avoid increasing it by careful activity modification and do specific exercises to regain normal quadriceps function.  Physical therapists will instruct you in specific neuromuscular reeducation exercises to restore the quadriceps recruitment pattern.  Such exercises may include seated quad sets, straight leg raises or short arc quad recruitment.  These may be done with neuromuscular electrical stimulation (not TENS – that’s for pain and totally different type of current form) to facilitate recruitment of the muscle.  In addition, you will be given terminal knee extension exercises in standing such as straightening the knee against a wall with a towel roll behind your knee against the wall or fully extending your knee against tension created by an elastic sports cord.

So, controlling swelling in a joint is necessary to regain function of the muscles moving that joint.  This process is used in all knee injuries that result in joint effusions as well as in all postoperative rehabilitation, for example, following ACL reconstruction, meniscus repairs and debridement as well as total knee replacements.

What have you found helpful in the past?

What worked for you?  What didn’t?

Post your comments here so other people can learn from your experiences.  We would love to here from you.

Hip pain – 21 months to diagnosis?


A study by Burnett et al in the Journal of Bone and Joint Surgery (2006) documented an average time from injury to accurate diagnosis for hip pain due to labral tears as 21 months.  People with this type of hip pain saw an average of 3.3 providers before definitive treatment was initiaited.  In 17% of their study group of 66 patients, surgery was recommended on a different anatomic site.  Once the correct diagnosis was made and the hip arthroscopy was performed, 89% of the patients were clinically better off than before surgery.  That is positive.

Hip pain can originate from a number of structures and as a result can be easily misdiagnosed.  Low back pain can refer pain to the hip area.  Sacroiliac joint dysfunction can too.  Hip pain can be due to bony problems such as impingement or due to damage to the cartilage structure around the socket, that is the labrum (similar to the shoulder – see an earlier post on this blog).  It can originate from strain or tearing of the lignaments around the hip joint as well as from all the many muscles which control the hip joint.  In addition, pain may originate from the pubic area where the abdominal muscles and the hip adductors attach, commonly called athletic pubalgia or a sports hernia.  Finally, hip pain can be a consequence of referred pain from the leg.

Hip pain is typically localized to the groin area.  It may also be felt laterally over the outside of the hip or in the buttock.  There may be clicking, popping and snapping in the hip joint associated with the pain.  Walking, running, ascending and descending stairs, putting shoes on (figure 4 sitting) and lying on the affected side may be challenging.

Your to do list:

  1. If you have back pain that radiates to the hip area (buttock, side of your leg, groin) ask your doctor or physical therapist to evaluate the hip.  At Custom Physical Therapy we check the hip with every low back pain patient so we do not miss the diagnosis.
  2. Educate yourself on the hip so you can ask questions of your doctor and physical therapist.  Do not let your hip pain get misdiagnosed and take 21 months to be correctly treated.
  3. Call us at Custom Physical Therapy if you have any questions regarding your hip pain.  Mention you are calling with specific questions regarding this post on hip pain.  We can answer your questions.
  4. There are some really top notch hip doctors in Reno, Nevada.  Call us if you want to know who they are.
  5. Please forward this on to your friends, family and coworkers via email, Facebook, Twitter or word of mouth.

Thank you for being part of Custom Physical Therapy.  Here’s to your healthy hips!

Physical therapy

Knee Pain! Osteoarthritis!


To my fellow Boomers out there ….. How are your knees doing?  We are an active sector of the population and we want to remain that way for the health benefits (and the fun!) thereof.  Knee pain due to osteoarthritis, whether one or both knees, has a dramatic impact on a person’s ability to continue with their chosen active lifestyle and, if it gets painful enough, may impact activities of daily living such as getting into and out of a car or a chair, cooking a meal or simply walking.

 WHY KNEE OSTEOARTHRITIS?

Osteoarthritis affects 25 million North Americans and is symptomatic in 13% of people aged 55 years and older.  It has been shown to be the most frequent cause of functional disability including being dependent on alternative forms of mobility due to the tremendous pain with walking.  Ouch!  The prevalence of osteoarthritis is rapidly increasing due to two main factors.  Firstly, the aging of the American population (that includes us!) is increasing the share numbers of people older than 55 years.  Secondly, the rapidly increasing obesity in our population is increasing the rate of joint degeneration.  One study reported 83% of males who had knee osteoarthritis were obese compared to 42% of males without it.  Wow!  Now there is a statistic that says a lot and leaves nothing to the imagination as to what we need to do to address the issue.

WHAT IS IT?

Osteoarthritis is the joints response to structural damage caused by mechanical problems.  It is the body’s attempt to repair a joint under unusual stress and often leads to a stable, pain free joint.  If this process fails (is insufficient for the magnitude of mechanical stress placed on the joint) the knee becomes symptomatic and hence functionally debilitating.

MECHANICAL STRESS YOU SAY?

Pathological mechanical stress of the knee joint may be due to:

  1. Increased overall load through the weight bearing joint surfaces (e.g. obesity).
  2. Reduced load bearing surface area thereby increasing the pressure (same force through a smaller area) exerted through the joint (e.g. misaligned joint: bandy or bow-legged).
  3. Repetitive impulsive loading of the joint (e.g. trauma, doing moguls).

Obesity increases the overall load through the joint and overwhelms the joint tissues resulting in osteoarthritis.  Being bandy or bow-legged reduces the weight bearing surface area in the knee joints (shifts it from throughout the knee to one side or the other of the joint) and results in excessive wear and tear of the joint on the outer or inner surfaces respectively.  Sustaining a serious injury to the knee in which ligaments are torn and the joint surfaces are banged together in the injury may initiate the osteoarthritic “repair” process as well.  Thus, when stress on the joint tissues exceeds their physiological tolerance breakdown ensues and osteoarthritis begins.

HOW CAN WE ADDRESS THE CAUSATIVE FACTORS?

Weight loss in an effort to attain a normal body weight for your frame is paramount in reducing the forces through the knees.  Walking results in a force through the knee equal to 3 – 4 times your body weight each step.  If you lose 20 – 50 pounds in an effort to attain your normal weight, you reduce the forces through your knees by 80 – 200 pounds each step you take!  Talk about happier knees!  An 11.2 pound weight loss over a 10 year period has been shown to reduce the likelihood of developing knee osteoarthritis by 50%.

For misaligned knee joints (those of you who are bandy or bow-legged) there are unloading braces to modify (increase) the load bearing surface and hence reduce stress to the one side of the affected knee.

In all osteoarthritic knee joints muscle weakness, joint stiffness and poor balance are factors.  Muscles around the knee joint serve to cause movement in bending and straightening the knee, can reduce mechanical stresses to the joint by absorbing loads applied to the limb (e.g. cushioning during landing a jump or when skiing) and stabilize the knee joint during daily tasks of walking, running, lifting and carrying to name a few.  Patients with knee osteoarthritis are 20% to 40% weaker in their quadriceps than people without the condition.  As the disease worsens the knee muscle activation patterns become less efficient and less specific and joint proprioception (the brain’s ability to know what is happening at the joint and react accordingly) is suppressed.  A well constructed, evidence-based physical therapy program will improve strength, range of motion and proprioception and result in improvements in physical function, pain and quality of life.  Modifying the mechanical problems causing the osteoarthritis together with addressing the inflammatory and pain aspects of the disease process through pharmacological intervention from your physician can result in an 86% success rate in improving your function.  Who would not like that!?

All our physical therapists at Custom Physical Therapy have undergone specialized training for treating osteoarthritis.  The therapists work as part of a team comprised of you the patient, your physician and the physical therapist.  Using physical therapy interventions to modify the mechanical factors impacting the progression of osteoarthritis together with the physician addressing the pharmacological aspects and the patient being compliant with an exercise and stretching program (see our very first post on this blog) as well as brace use, if prescribed, the team of patient-physical therapist-doctor minimizes the effect of the disease process on your function.

YOUR CALL TO ACTION!

  1. If you are overweight start a simple lifestyle change that entails weight loss (Call Joe Dibble, dietician at Sierra      Strength and Speed, for a consult.  He is really knowledgeable and practical.)
  2. Call Custom Physical Therapy so we can evaluate your      arthritic knees and set you up with appropriate treatment.
  3. Forward this post to someone you know who has sore      knees or you think may be interested in the information.

You are encouraged to call Custom Physical Therapy to talk to one of our accredited physical therapists about your knee pain.  You may be a candidate for this customized evidence-based program specifically developed to improve your function which deteriorated due to knee osteoarthritis.

Total Knee Replacement Season – What does the rehab look like?


Total joint replacements surgeries tend to increase towards the end of the year because insurance deductibles have been met and out-of-pocket expenses tend to be less.  An additional cost to the patient is the rehabilitation after the surgery, which also tends to impact insurance deductibles.

The most frequent type of joint replacement that needs the most rehabilitation is the total knee replacement, also known as total knee arthroplasty (TKA).  So what does the rehabilitation process involve?

The first thing to understand is that 50% of a successful outcome is the caliber of the surgery.  If you have done your due diligence by being an educated healthcare consumer (see my very first post on this blog) and asked the best surgeon to do your total knee arthroplasty, you should be pretty confident that the actual prosthesis is the right size and was put in correctly.  That is the easy part of the process; after all you slept through it!

Then you wake up and realize your knee hurts.  It is swollen, stiff, and the muscles in your thigh (both quadriceps in the front and hamstrings in the back) do not contract well despite you attempting to make them to work.  You have difficulty transferring from supine (lying on your back) to sitting and then to standing.  Now you have to walk with a walker, another foreign experience.   After 3-5 days, the doctor may send you home from the hospital.  Now you need to get into the car to be driven home.  This requires you to bend your new knee, another daunting thought.  Once home you need to do the right thing to keep your progress going and prevent complications such as deep vein thrombosis (DVT: a blood clot) in either one of your legs, arthrofibrosis (excessive scarring from the surgery) and infection.

HELP!

Physical therapists now become your best friends and should be for a number of weeks to months following the surgery.  You will be guided through a steady progression to return you to full function.

FIRST INPATIENT PHYSICAL THERAPY:

You will have inpatient physical therapy to get you ready for returning home i.e. avoid DVTs, know how to take care of your surgical wound and, you need to learn how to walk safely with a walker.  You will also need to ascend and descend stairs,  You should return home with enough active range of motion (AROM) to get into and out of the car and be instructed in transfers from supine to sitting to standing as well as how to get in and out of a chair.  Detailed instruction should be given regarding how to control the postoperative swelling.

Avoiding DVTs:  perform the embolic isometric contraction sequence of the calf, quadriceps and gluteus musculature (in that order).  Also, do ankle pumps.

Surgical wound care:  keep it dry, no showering – I have had one patient, 13 years ago, who decided to shower before the surgical wound was healed sufficiently.  The knee became infected and was never the same again.  Luckily it was not a TKA and the infection, therefore, did not enter the bone.  It is worthwhile doing it right and accepting you will be a little dirtier than usual!

Walking:  The majority of TKA patients start walking with a front wheel walker, day one or two after surgery.  The large base of support gives the individual more stability.  You must use an assistive device as your quadriceps (muscles comprising the front of the thigh) are not contracting efficiently.  This is because of the incision and the pain impacting the function of the extensor mechanism (quadriceps + patella + patella tendon).  As a result, you have difficulty straightening your knee and controlling it in full extension.  When you transfer weight to the leg, the knee will have a tendency to give way (knee buckles under the weight) and you may fall.

Negotiating stairs with your walker:  The inpatient physical therapist will teach you the correct technique for going up and down stairs with and without the walker.  All homes have at least one to three steps to ascend from the garage to the house or at the front door.  Just remember:  the nonsurgical leg does all the work so you lead with it up stairs and lower your surgical side down with it when going down stairs.

AROM:  Immediately you need to start working on getting your new knee straight (OUCH!) and getting it bending (OUCH!).  The inpatient physical therapist should show you simple but effective exercises such as passive knee extension, hamstring and calf stretching to get it straight.  They will also instruct you in heel slides to regain knee flexion.  If you leave the hospital with full knee extension (straight knee) and 90° of flexion, you will be ahead of the game.  With 90° of flexion you can get into and out of as well as sit in the car that will take you home.

Transfers:  Inpatient physical therapists are the gurus at instructing in transfers under a variety of circumstances, all in an effort to get you more functional and independent.  You should leave the hospital knowing exactly how to do a variety of transfers e.g. change positions in bed, sit to stand, in and out of a car, the commode,  avoiding low chairs like a couch.  You walker is your friend here to and you must focus on safety in all your mobility.

Control the swelling:  This is a vital component of regaining full range and quadriceps function and should be a major focus immediately following surgery. (read the second post on this blog which discussed this topic in detail).  Make sure you get iced in the hospital for 45 minutes at a time, all around your knee at least 4-6 times a day.  You, the patient, must be vocal about this to get it done.  You will be glad you followed this procedure.  Recognize you will have bandages around your knee so it will take a while for the cold to penetrate them.  Do not get the bandages wet (see paragraph above on infection!).  Once the bandages are removed (7 to 10 days after surgery) you will ice for 30 minutes.

Now you are home.  Feel better already, albeit a little beaten up I am sure.  Out patient physical therapy now takes over.  (if you are frail, you may get home health physical therapy but make sure they follow the following guidelines).

OUT PATIENT PHYSICAL THERAPY:

The other 50% of a good outcome is dependent on a good relationship between you and your physical therapists.  Here is where the hard work really starts and you must be dedicated.  Focus on the right things and you will get a great result.

Note: There is no need for the physical therapist to aggressively bend or straighten your knee.  This may inflame the joint and increase the likelihood of arthrofibrosis.  I typically set my patients specific goals to attain each week and it is their responsibility to achieve the range required.  I measure at the beginning of each physical therapy session to track progress.  If they struggle to improve at the agreed upon rate (typically 10° to 15° of active flexion per week), then I will step in and stretch their knee gently.

Rehabilitation is typically broken down into phases.  Transition from one phase to the next is dependent on specific criteria such as degree of pain and swelling.  Progression is not based purely on a timeline.

Phase 1:  Post op days 1-10

Goals:

  1. Understand the goals of the rehabilitation process.
  2. Good pain control (pain less than 5/10)
  3. Good control of swelling.
  4. Can contract your quadriceps.
  5. Can do a straight leg raise (SLR) with minimal lag (minimal loss of full knee extension when you raise your leg off the table while sitting).
  6. Full passive extension (straight knee).
  7. Active knee flexion 90°.
  8. Independent gait and transfers.

Phase 2: Weeks 2 – 12 post-op

Goals:

  1. AROM 0°-130° (we routinely are attaining 140° or more)
  2. Mild joint effusion (swelling within the joint).
  3. Can keep knee straight between physical therapy sessions.
  4. Full SLR.
  5. Normal gait pattern.
  6. Independent in a suitable gym and/or home program based on specific individual needs of the patient at discharge.

So, there is a lot of work to do in recovering from a total knee replacement.  It is not rocket science but it does require focused dedication.  Focus on the right things based on your discussion with the physical therapist and be dedicated with your home exercises as well as those in the physical therapy clinic.

Your call to action:

  1. If you are planning on a total knee replacement (or any other joint replacement) and have questions of any sort, call us at Custom Physical Therapy and a physical therapist will address your questions.  Call 775-331-1199.
  2. Forward this to a friend, family member or coworker who may be having a total knee replacement.
  3. Forward this post to your physician and have them post a comment.  It would be great to have their input too.
  4. If you have had a total knee arthroplasty, please post a comment.  People having knee replacements would benefit from hearing what worked and what challenges you faced during your recovery.
  5. Do something kind for a stranger today!

 Thanks for reading this.

 André

Swelling, Edema, Effusion, Echymosis, Bruising: What’s the difference?


If you sprain your ankle severely you may hear your doctor and physical therapist mention the words swelling, edema, effusion or bruising. If you have surgery on your knee for a meniscus tear or a ligament reconstruction you will hear similar terms (and see them too!). What is that bruising and swollen area in the muscles in front of your shin (tibia) when you ding your lower leg on the corner of a coffee table?

The Definitions (Dorland’s Medical Dictionary):

Swelling is defined as “a transient abnormal enlargement or increase in volume of a body part or area not caused by proliferation of cells.” The good thing is that it is transient so, as we have all experienced, swelling subsides over time (see below for hints on treatment).  It is due to some form of trauma to the body such as an ankle sprain (the ankle looks bigger) or a muscle tear (larger girth of your thigh with a hamstring tear) or a surgery (which is really a trauma to the tissue). Fluid accumulates – the enlargement is not a consequence of cell division (proliferation) such as may occur with an enlargement due to cancer in a tissue or the enlargement seen in a bone from a healed fracture.
Edema is “the presence of abnormally large amounts of fluid in the intercellular tissue spaces of the body.”  Here fluid accumulates between the cells (intercellular). This may be a consequence of tissue trauma, poor circulation resulting in lower leg edema, heart failure, blood clots, lymph node resection as happens with breast cancer, renal failure,  pregnancy and cirrhosis to mention a few causes.  In outpatient musculoskeletal physical therapy we mostly see patients who have edema due to surgeries (e.g. knee replacements) or an injury causing tissue trauma.  We may treat someone who has a comorbidity (co-existing condition) which has resulted in edema but if caused by a particular medical condition your doctor will be treating it, not us.
An effusion is “the escape of fluid into a part or tissue, as an exudation or a transudation.”  An exudation is “the escape of fluid, cells, or cellular debris, from the blood vessels and their deposition in or on the tissues, usually due to inflammation.”  Inflammation may occur due to trauma or surgery.  Blood vessel walls become more permeable or may be compromised. Fluid and cells can thus escape from the artery or vein into the surrounding area. Transudation refers to the passage of fluid across a membrane or tissue surface (e.g. the synovial lining of the knee joint), which may or may not be due to inflammation. In physical therapy, we commonly see a joint effusion where fluid has accumulated in the joint.  This may follow a knee or shoulder surgery or an ankle sprain, for example.
Ecchymosis refers to “a small hemorrhagic spot in skin or mucous membrane, forming a nonelevated, rounded or irregular, blue or purplish patch.” This is a medical term for  bruising which is defined as “a superficial injury produced by impact without laceration.” Both describe blood leaking into the surrounding tissue. You know this one!  Remember biting your cheek when you were chewing gum?  Your mucous membrane inside your mouth went blue.  Next time you do it tell who you are with that you have just created some ecchymosis in the mucous membrane of your cheek!

In summary, based on the above definitions, you can safely say that swelling refers to the enlargement of the body part involved and the swelling is due to fluid accumulation (edema, effusion) or blood accumulation (ecchymosis, bruising).

How do we treat swelling, edema, effusion, ecchymosis and/or bruising?

  1. Rest, Ice, Compression, Elevation:  “RICE” is what we know it as.  Rest refers to the need to limit activity so as not to create further trauma.  However, rest is relative.  That means you should move the affected area or tissue gently to keep it mobile and prevent stiffness during this phase but not so much that you increase the pain and swelling associated there with. There are times when movement is contraindicated … think broken bones! Ice for the first 48 to 72 hours after an injury with resultant swelling. The goal is to limit fluid accumulation in the injured area by reducing blood flow to the area. Cold temperatures result in blood vessel vasoconstriction reducing blood flow to the area which decreases the inflammatory exudate (see ‘exudation” described above) or bleeding into the involved tissue or joint. Remember this: ICE IS NICE! Compression refers to the use of an elastic wrap to compress the injured area and thereby limit swelling. The amount of compression should not be so much that blood supply is cut off or pain is increased. Elevation serves to decrease the hydrostatic pressure in the affected body part by raising it above heart level. The reduced pressure decreases the exudate and increases fluid removal from the area.  Add in gentle motion and you have a complete package.
  2. Heat: Use heat after 72 hours with the purpose of increasing blood flow to the injured area to flush out the accumulated fluid and inflammatory by-products. Heat also improves tissue flexibility thus making movement easier which is another method employed to reduce fluid accumulation in a joint or tissue.
  3. Movement? Yes, you should keep the injured area moving gently unless you have been told not to by your doctor or physical therapist. Movement of the injured joint (e.g. ankle sprain) or tissue (contracting the injured muscle) promotes pumping of the blood from the site as well as limits stiffness.  As mentioned above, movement may be contraindicated … think broken bones!
  4. Limit aggravating activities. After the initial shock of the injury due to pain, swelling and the limited function often associated with it, you may feel ready to increase your activity level. This is fine but must be closely monitored so as not to increase the already present fluid accumulation and pain. Limiting aggravating activities but still moving as normally as possible promotes healing of the injured tissue. For example, if you sprain your ankle and it is swollen and bruised but you can tolerate walking on it without limping for 10 minutes on level surfaces without increasing your pain and fluid accumulation then do so but stop before your symptoms are aggravated. Or, if you strain your hamstrings you may be able to walk with a normal gait pattern on level ground but not negotiate stairs without increasing the pain and worsening the gait pattern. Therefore, limit the use of stairs. Recall, we want normal movement early on following the injury to promote tissue healing.
  5. Lymphatic drainage. This is a manual technique used by physical therapists who have additional training specifically in lymphedema management. It involves very gentle massage techniques in specific areas of the body in a particular order to stimulate lymph drainage.  It is particularly effective for edema control. In addition to the massage techniques used, you are taught how to wrap the affected limb to promote drainage between massage sessions. You may also be taught how to massage yourself as a home program. If you need this type of treatment, make sure you ask the clinician you schedule with if they have specific training in this area. You can also look for a physical therapist who has this training via the National Lymphedema Network at http://lymphnet.org/.

In summary, swelling may encompass the terms of edema, effusion, ecchymosis and bruising as long as there is an increase in volume (size) of a body part or tissue due to fluid accumulation. RICE is the treatment of choice immediately after an injury/surgery but heat and controlled movement should not be avoided. If you have lymphedema you should consult with a physical therapist with specialty training in lymphedema management.

YOU CALL TO ACTION!

  1. What have you found most helpful in addressing the above symptoms?  Post your ideas on this blog for others to read.
  2. Invite a friend who has recently had an injury or surgery to read this and post their experiences.
  3. Call us at any of our three clinics if you have any questions regarding the specific application techniques to avoid ice or heat burns:

Sparks location: 775-331-1199

South Reno location: 775-853-9966

Northwest location: 775-746-9222