A new study has shown the benefits of combining an injection with physiotherapy for the treatment of knee arthritis. Historically, injections alone have only provided a small level of relief for only a small percentage of patients suffering from knee osteoarthritis.
Common injections include cortisone (steroidal anti-inflammatory), hyaluronic acid (lubricating substance found in cartilage), dextrose (stimulates tissue healing) and stem cells.
The Knee Injection Study
The paper published this year (2023) was titled “Comparative Efficacy of Intra-Articular Injection, Physical Therapy, and Combined Treatments on Pain, Function, and Sarcopenia Indices in Knee Osteoarthritis: A Network Meta-Analysis of Randomized Controlled Trials.”
The paper was a Systematic Review comparing 3 different groups.
1) Physiotherapy only
2) Injection only
3) Injection combined with Physiotherapy
What were the results?
The authors found that for pain reduction, dextrose injection PLUS physiotherapy yielded the best results. For enhancing walking capacity, mesenchymal stem cell injection PLUS physiotherapy was the most effective.
Adding physiotherapy to any injections, yielded better results that the injection alone, so the recommendation is, regardless of what injection you may receive, the results will always be superior if some rehabilitation is undertaken in conjunction with the injection.
Effective physiotherapy treatment of knee osteoarthritis after you have had an injection should be designed to treat your assessable impairments. For example, if you are found to have reduced range of motion of your knee, then some hands on manual therapy may be useful to help restore your the flexiblity of your knee.
More of then not, we find their are weaknesses with strength testing of the quadriceps and hip abductor muscles so these will commonly be strengthened over an 8-12 week period.
The latest update on Physiotherapy and Headache management.
Back in 2016 Andrew wrote a great blog article on the role of physiotherapy in assessing and treating headache. Well with the headache that was 2020 behind us, I thought I would start the new year with the latest information and research on how physio can help that pain in your head.
What are the common headaches that physios see?
There are 3 common headache types that physios generally see:
Cervicogenic
Tension
Migraine
Cervicogenic (headache coming from the neck) are generally one sided, will start with neck pain and progress to the head. You may also find neck stiffness and checking your blind spot whilst driving to be difficult.
A cervicogenic headache is essentially referred pain from the neck that, due to a miscommunication of the nerves that supply the head and neck, the pain is perceived in the head, rather than the true source in the neck.
The pathophysiological basis for the referred pain is a “convergence” of nerves. To try to put it simply, the nerves that supply the head come into close proximity to the nerves that supply the neck. As the nerves from the neck make there way into the brain to communicate the message of neck dysfunction, they “converge” with the nerves that are carrying messages from the head. The end result is that the brain thinks the message is coming from the head, rather than the neck.
Tension headaches feel like you’re wearing a swimming cap that’s a little too tight! It will feel like a tightening pain around your whole head. You may also have neck pain related to this headache.
Migraine headaches are commonly one sided and intensely painful. Most people say they either feel sick in the stomach or don’t like bright lights/sound. Some people will also get an aura (seeing bright lights and colour) before their pain comes on. Neck pain can occur with Migraine however is less common.
Signs that your headache may be coming from you neck
1) Neck stiffness
2) Your headache changes when your turn your head i.e may be worse when trying to turn your head in one direction
3) Tenderness of the upper cervical region. It may be sore and sensitive to push on the muscles and joints at the top of your neck.
Does posture affect headaches?
How many times have you heard or thought ‘Wow I’ve got bad posture’. Well, all your worrying may be for nothing. There has been some great research into posture and headache, which has found that people with headaches have many different postures.
There was not one posture that made people more likely to suffer from headache.
Additionally, other factors such as stress, lack of sleep and reduced physical activity have a much larger effect on developing headaches.
So, is there a good posture? The best evidence we have suggests that changing posture, rather than having one specific posture, is the best approach to take.
Can physiotherapy help your headache?
Short answer…yes! There has been lots of research into physiotherapy and headache, which shows that we can help reduce the intensity, frequency and duration of headache.
How do we do this?
Hands on treatment of the joints and muscles in the neck can be very helpful to reduce headache pain and stiffness. However, the effects of these treatments don’t always treat the common, underlying muscle problem.
A study on 52 women in 2019 in the Journal of Orthopaedic & Sports Physical Therapy found that “Women with migraine demonstrated decreased neck flexor and extensor muscle endurance compared to women without migraine.”
We have found that improving the endurance of the neck muscles helps to improve the ability to do simple things like…reading, texting or even just sitting/standing long periods.
De Quervain’s Tenosynovitis is a painful condition which affects the thumb muscles including Abductor Pollicis Longus and Extensor Pollicis Brevis. A smaller muscle, called Abductor Pollicis Brevis can also be impacted.
Why does it happen and who is at risk?
Females are 4x more likely then men to develop Abductor Pollicis Brevis Pain. It is particularly prevalent in women who are in the post-natal phase. It is caused by a rapid increase in load on the thumb muscles and tendons. This over-load is usually caused from repetitive lifting of your new bub out of the cot and feeding positions with the wrist in a flexed position. It can also commonly occur in golfers, waiters and carpenters due to repetitive action of the wrist and thumb.
Tendons typically take an extended period to adapt to new loads and if we introduce new loads too quickly (same as when an Achilles tendon gets sore when you first start running training), they get a bit grumpy!
Signs and Symptoms of Abductor Pollicis Pain (De Quervain’s)
Symptoms will include swelling and local tenderness over the tendons on the thumb side of the wrist. You may experience a sudden sharp feeling when lifting your child or even lifting pots/pans etc. It can sometimes throb/ache for a while after aggravating it.
It won’t present with any nerve symptoms like pins and needles or numbness so if you do experience these symptoms, it is more likely there is a nerve impingement issue higher up in the elbow (posterior interosseous nerve) or in the neck.
Diagnosis
It is diagnosed by conducting a simple test called the Finkelstein test. The tests involve bending your thumb across the palm of your hand and then bending your fingers over the thumb. The wrist is then bent toward your little finger, called ulnar deviation. If this reproduces the same pain you experience and is not painful on your other, unaffected hand, it is likely De Quervains syndrome.
A physiotherapist will also conduct some tests on the joints around the thumb and wrist and some nerve tests to exclude them as a source of pain.
De Quervain’s Tenosynovitis Treatment
Splinting. Successful De Quervain’s treatment techniques include splinting/bracing of the wrist to off-load the thumb tendons, and then progressive weaning from the brace to reintroduce load in a monitored way. Splinting is normally started at night only, unless the symptoms are severe, in which case we recommend wearing it all day for at least 2 weeks initially. This simply gives the tendons a chance to rest and recover.
Gradual strengthening of the tendon is highly important as increasing the tendons tolerance to load is the fundamental component of rehab. As with any tendon strength program, load needs to be slowly introduced as a sudden increase in strength exercises can easily overload and aggravate the tendon. If bracing is left on for too long the tendon will become weaker and hence when you remove the brace the pain will come back.
Despite common belief, a corticosteroid injection is not the first-line treatment. An injection should only be considered if bracing and physiotherapy has failed over a 6-week period OR if the symptoms are severe enough to warrant an early.
If you start treatment early, your symptoms should improve over the next 4-6 weeks. If your symptoms start during or after pregnancy your symptoms are likely to resolve once breast feeding has stopped.
TOP TIPS:
ICE for pain relief
BRACE to off-load the tendon
STRENGTH to increase the tendons tolerance to load (likely the reason the thumb was sore in the first place).
CORTISONE injection only after 6 weeks if the above fails.
If you have any questions or if you think you may have De Quervain’s then please do not hesitate to get in touch with us here.
Headaches affect up to 50% of the population at some stage in their lives. At least 20% of all headaches and migraines can be attributed to the neck and some studies show this number may be significantly higher.
What is a cervicogenic headache?
A cervicogenic headache is essentially referred pain from the neck that, due to a miscommunication of the nerves that supply the head and neck, the pain is perceived in the head, rather than the true source in the neck. The pathophysiological basis for the referred pain isa “convergence” of nerves. To try to put it simply, the nerves that supply the head come into close proximity to the nerves that supply the neck. As the nerves from the neck make there way into the brain to communicate the message of neck dysfunction, they “converge” with the nerves that are carrying messages from the head and thus the end result is that the brain thinks the message is coming from the head, rather than the neck.
What can a physiotherapist do?
Our jobs, as physiotherapists, are to:
correctly identify headaches that are caused by a neck (cervical) dysfunction;
correctly identify what type of dysfunction it is and;
treat the underlying cause of the dysfunction to promote good, long-term outcomes.
How can we correctly identify a cervicogenic headache?
It can take 60-90mins to thoroughly assess and diagnose a headache as the symptoms and physical findings are complex and differ from patient to patient. The first step is to look at the history and symptoms. These typically include:
Gradual onset of symptoms (won’t come on sharply or suddenly)
Episodes are similar to each other i.e. symptoms do not worsen episode to episode
Location
Will generally by one-sided and will not shift sides within the same episode
Can be one of, or a combination of, neck, occipital (at the back), parietal (at the side) or orbital (around and behind the eye)
Can last anywhere from 1 hour to 1 week
Feels non-throbbing
Aggravated by neck movements or sustained postures
Other symptoms can include nausea, vomiting, visual disturbances and sensitivity to light and sound
If your symptoms fit the above criteria then the next step is to conduct a thorough musculoskeletal exam. This includes, but is not limited to,
Posture assessment
Ergonomic assessment if work seems to be an aggravating factor
Neck range of motion and strength testing
Shoulder and scapular range of motion
Thoracic range of motion
Palpation assessment, particularly looking for stiffness, position, tenderness and/or referred pain from the top 3 cervical joints
Cervical flexion rotation test (CFRT)
This test has been found to have good reliability in diagnosing cervicogenic headache (Hall et al, 2008)
If your symptoms still fit the criteria for a cervicogenic headache, we can then move on to addressing the findings from the physical assessment.
Treatment
Treatment will depend on the findings from the subjective history as well as the physical exam and can include, but are not limited to,
Neck and thoracic spine mobilisations
Thoracic manipulations
Ergonomic adjustments to workstation
Strengthening exercises for the deep neck stabilisers, neck and thoracic extensors and upper trapezius/shoulder girdle muscles.
Sustained Natural Apophyseal glides (SNAGs) for the C0- or C1-2segments (see video)
2 recent systematic reviews released in The European Spine Journal (Varatharajan et al, 2016) and the Journal of Manual Therapy (Gross et al 2016) both found that exercise combined with mobilisations is an effective treatment option for headache and can also decrease medication intake in the short and long term.
If the above signs and symptoms sound familiar, then please do yourself a favour and book an appointment with an experienced physiotherapist.
What is the best injection for knee arthritis?