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May 21, 2012 | 0 Comments

The Number of Reps Do Matter

About once a week an injured client will ask me what Orthopedic doctor would I recommend in town. Since there are plenty of Orthopedic Surgeons in Durango CO  they would like help narrowing down the field. I always ask about the clients history, what the condition is and what type of tests have been done. The client will always have a preconceived notion about one doctor or another because their friend went to Dr. X and had a good outcome from some surgery. But frequently the problem is not your normal Durango injury such as a Rotator Cuff Strain or an ACL tear. When this happens, I don’t recommend anyone specific but I tell them to call around and see which Dr. has the most experience with this issue. I also tell them to ask specifically how many procedures of this type the Dr. has performed.
Why would you go through all that trouble when there are plenty of competent surgeons in town? What it comes down to is repetitions. In Malcolm Gladwell’s book “Outliers” he talks about the 10,000 hour rule. Basically it takes about 10,000 hours of practice for someone to become an expert in a certain area. During this time one can learn from experience and see how different directions cause different effects. For normal knees and shoulders you can hardly go wrong in Durango, the Docs here have their 10,000 hours.  But for some complicated cases you may want to look elsewhere. I recently recommended that a client seek a second opinion in Vail for a complicated elbow case. She came back and reported that the Surgeon had performed over 17,000 procedures and he was only 45 years old. This is huge volume and with it comes a wealth of experience. In those 17,000 he had performed hundreds of the same procedures that he was recommending. You may be put off by the factory type atmosphere happening at some medical facilities, but those Docs are getting the reps. They are experts in fixing unusual problems.
So ask the question before you agree to a doctor or a procedure. How many of these exact procedures have you done?  If the answer is a few or a dozen you may want to look elsewhere. This is not meant to insult any of our Surgeons in town, but our  limited population can only provide a fraction of the number of complicated cases that occur in Denver or other large metro areas. It’s your health, you should be involved in the decisions and make informed choices.

Dr. Luke Angel

www.quantifiedperformance.com

May 11, 2012 | 0 Comments

New Back Treatment available in Durango

Ashlie demonstrates the ATM2

In our goal to be the most technologically advanced physical therapy clinic we have added another advanced treatment for back pain called the ATM2.  This equipment uses the most current concepts in core stability to get the deep muscles of the spine firing normally. Unlike some of our other treatments such as the ARPwave and Trigger Point Dry Needling this technique is pain free and has the additional benefit of immediate improvement in function after the first session.

After researching Back Pain for the past 5 years there were 2 things that stood out and led us to invest in the ATM2.

1. Exact Diagnosis of Back Pain is extremely difficult. Determining the exact cause of Back Pain even with an MRI is a guessing game. You have pain, you get an MRI, the MRI shows a bulging disc as L5: presto the L5 Disc is the cause of your pain. Not so fast. 80% of people over 40 years old without pain have abnormal findings on MRI. The cause of your pain could be chemical inflammation, facet joint injury, nerve irritation, muscle spasm or a host of others that do not show up directly on the MRI. Clients always come in and say the Doctor diagnosed a bulging disc on an MRI. That is not a diagnosis, that is a statement kind of like saying someone has a headache. It does not tell you what is the cause of the pain just tells you some information. So over the years Physical Therapist have attempted to determine a cluster of symptoms and physical findings that respond to certain treatments. These findings do not tell you exactly what is wrong but they do tell you how to treat the area. With this in the research, Physical Therapists show positive trending in treating Back Pain. The ATM2 does not require an exact diagnosis to be effective only that you have movement based back pain.

2. Previous concepts of Core Stability and Core Exercises are flawed. A lot of the concepts of specifically training Transverse Abdominus and attempting to train specific firing patterns do not work. Pulling your belly button to your spine while attempting movement is not normal. The body works reflexively as a whole. Attempting to consciously turn on one muscle more than others does not work. Strengthening movement patterns on the other hand does work. This allows the body to function normally and strengthen movements not specific muscles. The ATM2 allows us to strengthen patterns without pain. This allows normal muscle firing and improved lasting function reflexively without over thinking the process.

When I read about the ATM2 and how it addresses the above issues I was immediately sold and the results we have seen have been outstanding. You can try the ATM2 risk free to see if it will help your back pain with our guarantee. If it does not work you do not pay for session. Are any insurance based Physical Therapy clinics giving you the same offer? I don’t think so.

Dr. Luke Angel

www.quantifiedperformance.com

March 22, 2012 | 0 Comments

Scientific Injury Risk Assessment

What weaknesses in your body will cause you to get injured?  This question has been debated among physical therapists for 40 years. Depending on how the therapist was trained, depends on what they tested and what they considered important. Some believe muscle tightness, others believe muscle weakness and others look for asymmetries in the pelvis and leg length as causes and predictors of injury. The research shows that none of these variables can predict if you are more likely to be injured and may have little to do with recovery from an injury. Gray Cook and his group at Functional Movement Systems saw this problem and developed a movement screen that has been proven in multiple studies to predict injury risk. The Functional Movement Screen is a series of 7 movements that are judged for a score of 1 to 3. If you do not meet certain criteria you are at increased risk for injury. This screen is used in the NFL prior to multi million dollar contracts. From the screen, exercises can be prescribed to work on deficiencies and lower your risk of injury. These exercises require minimal equipment and can be performed on your own. This can be accomplished in as little as one visit every one to two weeks to advance your program and instruct you on new exercises to correct problem areas. If you are over 30 and athletic, the time is now to start corrective exercises that may prevent you getting sidelined for long period. Give us a call to get screened and get started on a prevention program. A little time and effort invested now can pay dividends to keep you moving in the future.

Dr. Luke Angel

www.quantifiedperfomance.com

February 27, 2012 | 0 Comments

Nerve complications following surgery

In the past few months I have treated 3 patients who have suffered nerve damage as a complication from orthopedic surgeries. While this is relatively uncommon, it is a risk that you should consider prior to deciding on a surgery. The first case is a young woman with chronic hip pain who had a labral repair. After the surgery her hip pain was better but she developed a radiating pain into her buttock and hamstring that was not present prior to the surgery. After attempting to treat the hamstring without success it was determined to be a nerve root traction injury. These type of nerve injuries not only are a cause of pain but also tend to inhibit muscle activation in the motor units they innervate. This presented as a Gluteal weakness which was not able to be strengthened through normal exercise. We were able to get some muscles activated through the ARPwave but only had mediocre results because various activities continued to stress the nerve. The second case was a client who had an ACL reconstruction who presented with numbness and muscle atrophy in the VMO due to the tourniquet compressing the Femoral Nerve. The VMO       ( the inside muscle of the quad) was extremely inhibited and the client could barely demonstrate a contraction after 8 months. This lead to knee instability and limited function. We treated this patient with the ARPwave which increased muscle contraction and allowed for her to be able to advance her current exercise program with an excellent result.  The third case was a Radial nerve compression after hardware had been put in to fix a broken humerus. This case was so severe we could not get a contraction using the ARPwave. We did not see any improvement in a few sessions and the patient discontinued therapy.
For all three of these cases the Doctors advised a wait and see approach. Nerve dysfunctions can take a long time (months to years) to resolve and if there is no visible compression on an MRI then there are few surgical remedies. Prior to starting Quantified Performance we were very limited in ways to treat the nerve. Now we use ARPwave, Laser, Frequency Specific Microcurrent and ASTYM to treat the affected area. While it is not proven that we are directly affecting the nerve with these treatments, it is proven that we are decreasing pain and inflammation and stimulating muscle activation in the area. All of this creates an optimal environment for the nerve to heal. I also utilize Neurodynamic testing and treatments to pinpoint areas where nerves are not mobile and attempt manual techniques to improve the situation. I have seen all of these treatments help with various nerve dysfunctions and sometimes they cause very dramatic results, but in a lot of cases they take months to resolve. It may be tough to buy into a therapy where there are not immediate gains, but I would rather be proactive with treating the nerve than to wait and see.  Even with advanced technology clients must be very patient with nerve issues and have to be aware that this is a real risk with surgical procedures.

Dr Luke Angel

www.quantifiedperformance.com

February 20, 2012 | 0 Comments

Recognizing Myofascial Pain

Last week we had a client come in from Park City to be treated for mid back pain that was radiating down her arm. This debilitating pain had come on suddenly after a massage and she ended up in the ER a day later. After an X-ray, an MRI, treatment from a Chiropractor, Physical Therapist and Pain management Doctor in Park City she found little relief. A friend from Durango suggested she give us a call. After a short phone consultation I was confident that the cause was myofascial pain or pain caused by the muscular system that can refer from its original spot. The original injury was a spot on her mid back where a massage therapist had pressed too hard. The Chiropractor attributed it to a rotated Thoracic vertebrae which he manipulated and made it worse. The PT attributed it to a dysfunctional rib which he applied significant direct pressure to and made it worse. The MD saw some bulging discs in the neck on the MRI and even though the pain emanated from a spot in the mid thoracic spine blamed it on that. The pain doctor injected the area with a medication that provided some relief not really giving an explanation for the injections. Why was this so hard to figure out? Medical professionals like to look at specific structures as the cause of pain. The bone is out of alignment, the nerve is getting pinched, the disc is protruding; these are nice easy explanations for a clients pain. Myofascial pain is a little more difficult to diagnose since there are few proven valid tests for it. One of the best tests is just to apply direct pressure to a muscle, look for a “jump sign” and see if it refers pain out. You can not see myofascial pain on an X-ray or an MRI so a lot of professionals do not see it as legitimate and certainly do not know how to manage it.
Travell and Simons wrote the first books on Trigger Points and myofascial pain in the 1980s in which they mapped out pain referral patterns by injecting irritating substances into the points and recording subjects description of where they felt pain. These maps demonstrated that these points, when irritated, can cause far reaching distal symptoms that were different from nerve patterns. Since then, many therapists such as Jones and Chaitow have developed manual treatment methods to eliminate trigger points. These methods while effective are somewhat difficult and time consuming. What has worked well for me over the past three years in the diagnosis and treatment of Myofascial Pain is Trigger Point Dry Needling. First I try to rule out everything else in the way of nerve, vertebrae and structural instabilities around the area. Next I look for hypertonus in specific muscle groups that correspond to the pain pattern. Finally I use Trigger Point Dry Needling and Laser as the treatment and the confirming tests. If the client has a significant change within 24 hours and/or within 3 treatments a significant part of the cause is Myofascial. If not, I look elsewhere. With experience, Myofascial pain has become easier to recognize as pain that does not fit the typical nerve or joint patterns but a problem that can be affected quickly by the right treatment.
If you are experiencing pain that is difficult to describe, pin point or correlate to a certain injury; you may have Myofascial Pain. The only way to treat it, is to recognize it first. By the way, the Park City client came down for 3 days of treatment and we made a significant decrease in her pain by correctly diagnosing and then treating the myofascial problem.

Dr. Luke Angel

www.quantifiedperformance.com

February 7, 2012 | 0 Comments

How much is 10 weeks worth to you?

We recently worked with a Crossfit athlete who had his Sternal Clavicular joint surgically fixated after a mountain biking accident caused a shoulder injury and a complete (Grade III) SC separation. The initial response from one MD was to wait and see; avoid stress to the area, let it heal over the next 6 months and then we’ll see what type of function you have. Knowing that this client wanted to return to Olympic lifts, pull ups, plyos and other stressful activities, we looked for other alternatives. A quick internet search found an expert in Vail who was able to performed the complex surgery that included 4 other procedures to the damaged shoulder joint. Four weeks after the surgery we started ARPwave, Laser, and Microcurrent at Quantified Performance. His function and range of motion quickly increased and by the time he was allowed to strengthen 2 weeks later, he had achieved 95% range of motion and full muscle  activation around his rotator cuff. By using the ARPwave, he continued to progress quickly with strength, stability, and normal movement patterns. 10 weeks after the initial visit to physical therapy the Surgeon released him with no restrictions.  He is free to return to Olympic lifts, pull ups, push ups and other upper body plyos.
Let’s review the time line because that’s the amazing part. 14 weeks after major shoulder surgery and Sternal Clavicular reconstruction this athlete has been cleared by the surgeon for EVERYTHING! Before using this advanced technology, it was common to see Rotator Cuff repairs in a sling for 6 weeks working on range of motion, then start strengthening at 10 weeks, then continue working on everything for the next 3 months with a total rehab time of 20 weeks and then another few months to slowly return to all activities. 14 weeks vs 24 weeks; what could you do with this time? You could train for the Iron Horse, get ready and be in shape for mountain biking season, get ready for boating season, go skiing or return to a physically demanding job.  Basically he has just gained a whole season of activity by accelerating the rehab process. 10 weeks can make or break your training and fitness for the year. A lot of clients report that they can not afford technologically advanced physical therapy, but you really have to decide how much your time is worth.

Dr. Luke Angel

www.quantifiedperformance.com

January 24, 2012 | 0 Comments

Getting Gronkowski back for the Super Bowl

While watching the AFC championship game we witnessed what looked like a significant eversion ankle injury to Patriots Tight End Rob Gronkowski. I was asked for my professional opinion (by fellow TV viewers) as to what the extent of the injury would be and how to best treat it. It looked liked an ankle subluxation or fracture due to the angulation of the ankle which would involve complete tearing of some of the ankle ligaments. This would also involve joint compression that would injure the cartilage to lateral side of ankle mortise and a possible avulsion fraction at either malleolus. When an ankle injury is severe enough, it ends up damaging both sides of the ankle due to tension on one side and compression on the opposite side. Either way there definitely is a combination of soft tissue (muscle, ligament and tendon) injury as well as injury to the bony and cartilage structures such as a bone bruise or fracture.
So for the treatment: 1. Immediate Microcurrent to decrease pain and swelling after the game with immobilization for protection. This would include constant treatment including sleeping with device on for 48 hours to prevent a large inflammatory response.  2. Start Laser therapy to improve ATP production in the area again to decrease swelling and improving healing potential. 3. ARPwave therapy to retrain the muscles that were affected by the violent movement. 4. Once the initial inflammatory response is controlled we would use all the above therapies to increase circulation and to help increase fibrous production in the area. 5. Once motion and weight bearing was started on day 3 or 4, I would use Dry Needling to release any Trigger Points that formed due to the injury or compensation. 6. The next step would be to increase muscle function with the ARPwave without exacerbating the injury.
This is true Sports Medicine; pushing the boundaries of physiology so the athlete can return in minimal time. Most Physical Therapists do not get a chance to practice this due to the high risk of re-injury for the athlete, so it is not used in a normal outpatient setting. I have experienced with this at the University of Michigan and with USA Hockey and this has helped me in treating all types of athletes over the years.  In combining this experience with advanced technologies and techniques, I have seen how far we have come from the era of ice, compression and ultrasound to treat acute injuries.
To my surprise Gronkowski returned a few plays later, which happens with a combination of determination, adrenaline, pharmaceuticals and a great tape job from the athletic trainer. This is a great sign and I have no doubt that the training staff is using some or all of the above mentioned techniques to get Gronkowski ready for the SuperBowl. Luckily  for those of you who live in or near Durango, you have access to all of these treatments at Quantified Performance Physical Therapy any time you need them.

Dr. Luke Angel

www.quantifiedperformance.com

January 12, 2012 | 0 Comments

ACL Surgery: Is it necessary to get it done quickly?

A recent 2010 study published in the New England Journal of Medicine by Frobel et al. has brought some questions to the trend of immediate reconstruction for ACL tears. This study looked 121 young active adults with a randomized controlled study design. This is one of the highest levels of research design available because the subjects are randomly assigned to each treatment group so they can be compared. The study compared subjects who had early ACL reconstruction with rehabilitation and another group who had rehabilitation with the option of later ACL reconstruction. The authors looked at various outcome measures, following the subjects for 2 years, with one of the main outcomes looking at return to sports and recreation. The results show that there was no difference in the patients reported functional return to sports and recreation whether they had early surgery or were in the rehabilitation group plus optional surgery later. 36 (32%) of the subjects avoided surgery all together and were just as functional as the surgical group.

How could this be? Returning to full function with an ACL tear? Again this is proof that the muscles are in control of preventing injuries by absorbing force and being able to move the body properly. If we rehab the muscles correctly by eliminating compensations and providing a strong base to protect an injured area the body can heal itself. We have seen this now with 4 patients who have returned to full function after suffering meniscus tears. At Quantified Performance physical therapy we use ARPwave technology to stimulate muscle contractions while performing functional movements. With this system we have seen improvements in many acute injuries and chronic conditions. It is becoming clearer that with technology we can get muscles functioning normally which helps all types of conditions.  We can not guarantee that you can avoid surgery, but at a fraction of the cost, it is well worth a try.

Dr. Luke Angel

www.quantifiedperformance.com

December 20, 2011 | 0 Comments

Last Run part 2

I wanted to continue thoughts on injury risk and apply them to a workout scenario. Lets take a workout that includes deadlifts then follows with Russian (jump) Lunges.  Both of these exercises are great for strength and explosive power. (I am not trying to pick on certain exercises, in fact the deadlift is a staple in our physical therapy practice.) Let’s remember from the last blog that muscle fatigue decreases the amount of motor units that are able to contract; when you are tired your muscles lose the ability to do work. This is because of energy stores in the system, neurochemical mechanisms, how well your system can clear waste products, loss of mental focus and a host of other physiological aspects. Now lets look at the 2 exercises. The deadlift is mostly a concentric lifting exercise, you lift the weight from the ground then drop it at the top so you are not lowing the weight to the ground.  When you are doing concentric exercises and your muscles fatigue you simply cannot lift the weight. Normally this will not cause an injury because you just can not perform the movement. The Russian Lunge is an explosive movement in which you catch your body weight in the lunge position also known as a plyometric exercise. This is an eccentric movement of controlling weight so you don’t collapse to the ground. It takes more muscle fibers to slow the momentum of your body to the ground in a plyometric action than with a concentric action. If your muscle can not control your body weight and momentum, the force will go some where else. So if you were to fatigue your hamstrings and gluts with deadlifts first then attempt to control an explosive movement with a smaller percentage of your available muscles; something in your body will have to absorb the force. The result will eventually be a torn hamstring. So think about this with all your plyometric exercises where you are controlling body weight with momentum. Don’t fatigue your muscle first concentrically then expect it to be able to control a plyometric exercise. Avoid injury by using strict form with plyometrics and don’t push through fatigue.

Dr. Luke Angel

www.quantifiedperformance.com

December 5, 2011 | 0 Comments

Why does the last run of the day cause the injury?

Ski season has just arrived in Durango, CO and one of the most common stories I hear in the physical therapy clinic is that ” I injuried my knee on the last run of the day”. Why is this such a common scenario? This is because of the interaction between motor unit recruitment and fatigue. Look at the picture of how the muscle fibers are made and envision this as your Quad muscle. On the first few runs your nervous system is recruiting a combination of slow twitch and fast twitch muscles to get you down the mountain. During the first 8 runs you may use 50% of your available muscle when making explosive turns leaving a 50% reserve. As the muscles fatigue some of the original fibers shut down (say 20%) and your body starts moving into using whats left. Now you have available 80% and you still need 50% to make it down the run. You still have a 30% reserve to draw from.  But you will reach a limit in fatigue where you only have 40% available to make a 50% movement. This can happen very quickly from numerous complex physiological and neurological reasons which are not fully understood. This is when the muscle stops absorbing force and transfers it your ACL, MCL, Patellar tendon, hip, low back or whatever is a weak link causing your ski ending injury. The key is to recognize signs when you are starting to fatigue and call it a day, so you can ski again tomorrow.

Dr. Luke Angel

www.quantifiedperformance.com

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