Walking Up the Stairs

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If there is no handrail,

1. Use both crutches and lead with the good leg.
2. Stand close to the step and with your weight on the crutches, step up with the good leg.
3. Once your weight is on the good leg, bring the crutches up to the same step , followed by your weaker leg.
4. Check your balance before you proceed to the next step.

If there is a handrail,

1. Use the handrail for support.
2. Hold both crutches in one hand, hold the handrail with the other, and with all your weight through your arms, bring the good leg up one step.
3. Next bring the crutches up to that step, followed by the weaker leg.
4. Check you balance before you proceed to the next step.

Walking Down the Stairs

1. Start at the edge of the step, keeping your hips beneath you.
2. Place your crutches on the step below, your weaker leg should immediately follow the crutches to the step below. (Remember: "down with the bad")
3. Be sure to bend at the hips and knees to prevent leaning too far forward.
4. Finally, step down with the good leg.
5. Check your balance before you continue.

If there is a handrail, simply hold both crutches on one side and use the handrail for support.

Safety Considerations

• Ensure walking crutches are in good working condition, e.g rubber tips.
• Always wear proper non-slip footwear. Avoid socks and floppy slippers.
• Remove any loose rugs or obstacles from your path that can potentially trip you over.
• Always check with your doctor or physiotherapist on the type of walking aid that might work best for you.

-CT

Crutches are one of the many walking aids that people use to help them:

• reduce or totally relieve weight from the injured leg,
• relieve pain from the injured leg and,
• provide stability to the unstable injured leg during ambulation.

However, using crutches is not as easy as it looks. It takes some instruction, coordination and practice to get it right. In this first part series, we will show you how to fit your crutches and walk safely with your crutches during your recovery.

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How to fit your crutches

1. Fit the crutches while standing. You should wear your shoes when having the crutches fitted.
2. The crutches should be adjusted so that there is a space of 2 or 3 fingers width between the armpit and the top of the crutch.
3. The handgrip should be adjusted so that the elbow is bent approximately 30° when the hand is on the handgrip.
4. With your hands hanging relaxed, the handgrips should be at the level of your wrist.
5. Keep the leg of the crutch 6 inches away from the base of your foot.

Sit to Stand

1. Place both the crutches together and grasp the handgrips in one hand on the affected weak side.
2. Place your weight on your good leg and use the free hand on the seat and the other hand on the handgrips to help push yourself up to a standing position.
3. When you are stable, transfer one crutch to the good side and place both crutches beneath your armpit.

Stand to Sit

It is the reverse of "Sit to Stand".

Walking with crutches

1. To use your crutches, start by placing both crutches in front of you. Squeeze the crutches between your upper arm and ribs and take weight through your hands. Putting your crutches too far out in front of you may require you to lean on them too much, making you less stable and putting pressure on the nerves in your armpit. So until you are more experienced, take small steps.
2. Next, step forward with your weaker leg, putting as much weight as you are allowed it and taking the rest of the weight through your arms and hands. Your foot should line up with your crutches.
3. Finally, step forward with your good leg.
4. Repeat the three-step process (crutches -> weak leg -> good leg).

Walking with one crutch

1. Hold the crutch opposite to the weaker leg, i.e on the good side.
2. Place the crutch in front of you.
3. Next, step forward with the weaker leg.
4. Finally, step forward with your good leg.
5. Repeat the three-step process (crutch -> weak leg -> good leg).

Safety Considerations

• Ensure walking crutches are in good working condition, e.g rubber tips.
• Always wear proper non-slip footwear. Avoid socks and floppy slippers.
• Remove any loose rugs or obstacles from your path that can potentially trip you over.
• Always check with your doctor or physiotherapist on the type of walking aid that might work best for you.

In the next series, we will take a look on how to climb up and down the stairs safely with your crutches.

-CT

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Hypermobility or generalised joint laxity is defined as a condition in which most of an individual’s synovial joints have a range of motion beyond normal limits- i.e. excessive joint flexibility. Although hypermobile joints in certain sports such as gymnastics and ballet may provide a performance advantage, previous studies have revealed an increased incidence of musculoskeletal injuries such as joint dislocations and sprains in sportsmen with hypermobile joints. It is therefore prudent for schools and sporting associations to start identifying these hypermobile players to prevent such injuries from occurring.

The Beighton index for hypermobility is a validated test that can be used for assessing hypermobility. The Beighton score gives an overall composite score of 0-9 and can be categorised into three groups:

• 0-2 not hypermobile
• 3-4 moderately hypermobile
• 5-9 distinctly hypermobile

Identifying players with hypermobility could prompt for specific training techniques, aimed at stiffening and strengthening muscular support around susceptible joints. Educating on injury prevention and the use of strapping and supports to enhance mechanical support and proprioception of hypermobile joints could also help prevent future injuries for susceptible players - CG

Reference:

1. R Smith, A K Damodaran, S Swaminathan, R Campbell, L Barnsley. Hypermobility and sports injuries in junior netball player. British Journal of Sports Medicine. 2005; 39: 628-631

Give yourself 1 point for each of the simple tests that you can do, with the maximum score being 9 points. Most people score less than 2, and only three to four in a hundred healthy people score 4 points or more.

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• 0-2 points not hypermobile
• 3-4 points moderately hypermobile
• 5-9 points distinctly hypermobile

 -ct

If I have a knee pain, should I get it manipulated? - Alex, Singapore

Whether a not a knee pain should be manipulated or not, it depends on the cause of pain. However, as a rule of thumb, most manipulative physiotherapists will not manipulate the knee.

Anatomy of the Knee

The knee is a joint whose integrity is generally held by the strength of it’s ligaments, joint capsule and muscles due to the shape of the bones which make up the joint. The knee joint is 2 rounded condyles of the femur sitting on the flat plateau of the tibia (known as knee joint) with a ‘floating’ bone, known as the patella over the femur (known as Patellar-Femoral joint). The knee joint is similar to like putting 2 oranges on a flat plate, make it fairly unstable. Thus the stability of the knee comes from the 2 menisci, which acts to deepen the depth of the tibial plateau (to prevent sideway movements of the femur), the ligaments and joint capsule (to prevent excessive movements) and the muscles (to control the joint movement). There is a good animation of the knee and the ligament in an earlier post (knee-ligament-anatomy-animation)

Causes of Knee Pain

Due to the make-up of the knee, most causes of knee pain would be due to either strains of the ligaments, capsule or muscles or degeneration of the patellar. Manipulation is not warranted as manipulation is generally used for a ‘locked’ joint and not for strains. In most knee pain, mobilization, either accessory or physiological, is sufficient to decrease the pain together with strengthening and flexibility exercises.

However, in meniscus tears, where movement is blocked or limited and mobilization doesn’t work, a distraction manipulation might be done but with sever caution. Manipulation can also be used in a degenerated knee but would need to be done by an orthopedic surgeon - cs

"I suffered from inflammation in my right knee after running a marathon. What can I do to strengthen my legs and prevent the injury from occurring again?" -  LY, Singapore

Dear LY,

Knee pain is a common ailment amongst long distance runners. In most instances, knee injuries sustained from running stem from chronic overload and muscular imbalances and can result in knee inflammation.

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Examples include iliotibial band friction syndrome (ITBFS) and patellofemoral pain syndrome (PFPS). Stretching tight and shortened muscles and strengthening the appropriate weaker, inhibited muscles are key to rehabilitation of the knee and prevention of further injuries.

It is very common to find a weak glutes medius and tight ITB in runners with ITBFS or PFPS. To strengthen the gluteus medius, single leg bridging or single leg raises in quadruped position can be performed. For tight ITB, you can use a foam roller or a tennis ball placed under the ITB and roll up and down along it for 3- 5 minutes to release the ITB.

You may also want to consult a sports physician or physiotherapist for a gait analysis to determine the cause of your knee pain and to correct your running gait so as to prevent recurrence of the injury.

Recently, someone posed the same questions to Dr. Lewis Maharam, a leading running sports physician the same question at his blog. He posted up an excellent answer to the questions.

For a more detailed explaination on why you should wait at least 2-3 hours after your event for your sports massage, read Dr. Maharam’s post here.

When is surgery an option?

In general, surgery is recommended when a ruptured disc is pinching a spinal nerve root(s) and you have:

1. leg pain which limits your normal daily activities; or

2. weakness in your leg(s) or feet; or

3. numbness in your extremities; or

4. impaired bowel and/or bladder function

When is surgery NOT an option?

In general, surgery is not an option when:

1. your back and leg pain is not caused by a ruptured disc; or

2. you do not have leg symptoms;

3. there is a medical reason which prevents you from having surgery;

4. medication which reduces swelling or relieves pain would provide you with adequate relief; physical measures would improve your condition>

Surgical options

Laminectomy and disectomy

By definition, a disectomy means removal of disc, and laminectomy means removal of the lamina, which is a bone that is part of the vertebra.

A discectomy is performed under general anesthesia. In order to remove the fragment of herniated disc, your surgeon will make an incision over the center of your back. The incision is usually about 3 centimeters in length. Your surgeon then carefully dissects the muscles away from the bone of your spine. Using special instruments, your surgeon removes a small amount of bone and ligament from the back of the spine. This part of the procedure is called a laminectomy.

Once this bone and ligament is removed, your surgeon can see, and protect, the spinal nerves. Once the disc herniation is found, the herniated disc fragment is removed. Depending on the appearance and the condition of the remaining disc, more disc fragments may be removed in hopes of avoiding another fragment of disc from herniating in the future. Once the disc has been cleaned out from the area around the nerves, the incision is closed and a bandage is applied.

Microdisectomy

Newer techniques may allow your surgeon to perform a procedure called an endoscopic discectomy. In an endoscopic discectomy your surgeon uses special instruments and a camera to remove the herniated disc through very small incisions.

The endoscopic microdiscectomy is a procedure that accomplishes the same goal as a traditional open discectomy, removing the herniated disc, but uses a smaller incision. Instead of actually looking at the herniated disc fragment and removing it, your surgeon uses a small camera to find the fragment and special instruments to remove it. The procedure may not require general anesthesia, and is done through a smaller incision with less tissue dissection. Your surgeon uses x-ray and the camera to "see" where the disc herniation is, and special instruments to remove the fragment.

Endoscopic microdiscectomy is appropriate in some specific situations, but not in all. Many patients are better served with a traditional open discectomy. While the idea of a faster recovery is nice, it is more important that the surgery is properly performed. Therefore, if open discectomy is more appropriate in your situation, then the endoscopic procedure should not be done.

Chemonucleosis

Chemonucleosis involves the injection of an enzyme called chymopapain directly into the herniated disc to dissolve the protruding gelatinous substance. This can relieve the pain and other problems caused by the disc impinging on the nerve.

Before receiving chymopapain, you should discuss its use and the possibility of serious side effects, with your doctor as in very rare occasion, the use of chymopapain may cause paralysis of the legs or death. Another dangerous side effect of chymopapain injection is a severe allergic reaction called anaphylaxis. This side effect occurs in less than 1% of the patients receiving the medicine, but it occurs more often in women than in men.

Chymopapain injections are given only in a hospital, by your surgeon.

The sale and distribution of chymopapain was discontinued in the US in January 27, 2003.

Cross training refers to a training routine that uses different forms of exercise, apart from the normal drills commonly associated with a sport. Cross training is often utilized for many reasons, including weather changes, facility and equipment availability, and most commonly, for injury rehabilitation purposes.

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Cross training is a great way to condition different muscle groups, develop a new set of skills, and even challenge the body after hitting a fitness plateau. A fitness plateau is reached when there is no apparent improvement in performance even though the intensity of the practice remains the same. This usually results after months of the same exercises, allowing the body to be extremely efficient at performing those movements, and thus, limiting the amount of overall fitness achieved and actual conditioning obtained.

Cross training also allows you the ability to vary the stress placed on specific muscles hence reducing the risk of injury from repetitive strain or overuse.

Benefits of Cross Training

• Conditions the entire body, not just specific muscle groups - something you won’t get if you concentrate on just one type of activity.

• Exercising various muscle groups may help muscles adapt more easily to new activities.

• Flexibility in training regime (If weight bearing activities are restricted for some reason i.e. injury, non-weight bearing activities such as swimming is handy).

• Reduces exercise boredom - variety of activities to choose rather than the same drill.

• Reduces the risk of overuse injury by alternating the way muscles are used while allowing others to rest and recover.

• Improves your skill, agility and balance.

How does cross training prevent injuries?

Cross training can significantly reduce injuries caused by repetitive strain. Cross training gives the commonly used muscles in the sport some respite from the stresses exerted each day by reducing the amount of stress placed on weight bearing joints, muscles and tendons. The muscles may still be worked, even intensely, but without the normal impact or from a different angle. This allows the muscles to recover from the wear and tear built up over a season. This active rest is a much better recovery tool than total rest and forces the body to adapt to different stimuli. For example, in sports that depends heavily on running, swimming can be used as a cross training tool to reduce the stresses placed on the body, yet continuing to work the same muscles.

Cross training also helps to reduce or reverse muscle imbalances in the body that may result in injuries. A tennis player may develop muscle imbalances in the dominant side of his body especially in the shoulder of the serving arm. Thousands of serves over a season will cause the muscles in the playing arm to become stronger while supporting muscles and unaffected muscles will become weaker without training. Cross training can help to achieve balanced strength and stability of muscles in both the dominant and non-dominant sides. This balancing of strength and flexibility helps to prevent one muscle group, due to a strength imbalance, from pulling the body out of natural alignment. It also prevents muscle pulls and tears caused by one muscle exerting more force than the antagonist group can counter.

How to cross train?

Any exercise or activity can be used for cross training if it is not a skill associated with that particular sport. Weight training is a commonly used cross training tool. Other activities include, swimming, cycling and running.

A general fitness program has three components:

• Aerobic exercises (i.e. running, cycling, ball sports) help improve cardiovascular fitness

• Strength training (i.e. weight lifting) helps develop muscle bulk.

• Flexibility exercises (i.e. stretching, yoga) help keep muscles flexible.

These three components can be incorporated into your fitness routine for cross training. Firstly, check with your physician to make sure that it’s safe for you to begin a program. Some activities are not appropriate for people with certain physical limitations.

Consider the kind of activities that are readily available to you. Select activities that are convenient and enjoyable. With cross training, you can do one form of exercise each day, or more than one in a day. If you do both on the same day, you can change the order in which you do them. You can easily tailor cross-training to your needs and interests; mix and match you sports and change your routine on a regular basis. You should be doing at least 30 minutes of moderate activity on most days. You can break your exercise routine into short durations, so long as it adds up to at least of 30 minutes of physical activity daily. Remember to schedule rest days between days with intense workouts. Target different muscle groups on consecutive days to allow your body to recover between sessions.

A sample weekly cross training program might look like this:

• Three times a week: 30 minutes of aerobic exercises, alternating activities such as walking, swimming and stair climbing.

• Twice a week (not consecutive days): 30 minutes of strength training, working each major muscle group.

• Every day: 5 to 10 minutes of stretching. It’s also safe to walk every day.

Always start slowly and gradually increase the duration and intensity of your exercises. Try to follow the "10 percent rule": increase the frequency, duration, or intensity of an activity by no more than 10% each week.

Examples of cross training

• A cyclist may use swimming to build upper body strength and to maintain cardiovascular endurance.

• Swimmers may use free weight training to develop and maintain strength levels. They may incorporate rock climbing to keep upper body strength and endurance up.

• Runners may use mountain biking to target the legs from a slightly different approach. They can use deep water running to lessen the impact while still maintaining a conditioning schedule.

The key to a successful cross training program is that it must address the muscles used in the sport and also allow a break from sport specific activities. Training the same major muscle groups, but in a different way keeps the body conditioned but helps prevent overuse injuries. -CG

MCR: What are some of the key challenges facing someone with back problems?

Sylvia Ho: The first and perhaps largest hurdle is simply first understanding the problem. Back problems are extremely common. Statistics have shown at that any one point in time, some 20% of the population is having some form of back or neck pain within the past few weeks. Perhaps the fact that it is so common, people tend not to dwell on it. Of course until they experience it themselves.

Plus the fact that quite often, the pain resolves itself after some days of rest. The human body is quite an amazing machine that heals itself. Also, one rarely falls very ill from back pain, though there are certain cases where you can. But by far, back pain is not a life threatening disease though it can be life-limiting.

MCR: Why is understanding the problem important from a patient’s perspective?

SH: Understanding what’s causing your pain is very important with musculoskeletal conditions - that is problems with your muscles, joints, nerves and skeletal structures. A large of part of the treatment or recovery process requires very active participation from the client. Meaning there are things to do for the client.

Take for example when a problem is caused by some movement dysfunction caused by using the wrong set of muscles. This could happen because the correct set of muscles is not working too well or the nervous system is having problem getting them to respond. After finding out what’s wrong, we need the patient to begin to re-learn using the right set of muscles. And they have to continue doing so after they leave the clinic between their sessions. They need to know exactly what they need to do and what they must not do. This is what’s going to get them better in the long run. And they are only going to be able to do this if they understand what has happened, why the change is needed and what to do and change in their lifestyles. Understanding here is key.

Movement dysfunction can be as basic as not breathing right. There are quite a few ways to breathe using different sets of muscles. Using one particular set could affect muscle activation in your lower back. If the right set of muscles supporting your lower back doesn’t function properly, you will over time have lower back problems. Breathing using the right set of muscles and how that affects your low back pain is not generally intuitive for most people.

Sylvia Ho

Education Master of Physiotherapy, University of Melbourne 1999 Bachelor of Applied Science (Physiotherapy), University of Sydney, 1994 Professional Highlights Sylvia is a Principal Physiotherapist with Core Concepts. Her area of interest is the spine. Sylvia is a regular writer on health matters. She has been interviewed for articles by health magazines such as Shape, Ezyhealth, Her World and Female magazines.

MCR: What if they don’t understand?

SH: Well, firstly at our end we try to make it as simple as possible. At Core Concepts, we don’t throw out a lot of jargons. We make it a point to communicate clearly. If someone throws a lot of jargons at you, don’t get intimidated. Stop them and ask for simpler terms.

Don’t get thrown off by terms like ‘idiopathic scoliosis’. ‘Idopathic’ simply means ‘cause is not known’. Technical terms are important. They help professionals communicate faster and more precisely with each other. But often they don’t help patients to understand their conditions better.

Secondly, we layer the solution; working on the important bits first, before moving on so as not to overwhelm the client. Usually, we have one to two approaches for a particular problem and we will try to see which one works best for the client.

MCR: What about treatment that involves electrotherapy devices such as traction and short-wave diathermy?

SH: Our approach compared to using electrotherapy devices is fundamentally different. Most electrotherapy devices are focused on relieving the immediate pain symptoms. We obviously care about relieving your pain but also making sure that you stay pain-free. We do use such device usually at the early stages of acute pain before moving to use what is known as manual therapy.

A therapist that is more dependent on electrotherapy aides usually don’t need a high level of patient education on the client’s part. Very much like if you have a fever, you just take some medication. You don’t really need to know how the pills work but just that you need to take them at the prescribed times at the right amount. Pills are fixed quantities; it is harder to get them wrong.

With more a complicated disease like diabetes, you need to know more – about the symptoms, what to do when your blood sugars get too high or too low. If you just depend on the doctor handling your condition, you are going to run into problems at some point.

MCR: Based on your experience, what’s the level of patient education these days?

SH: Obviously, there is an entire spectrum of clients with different levels of patient education.

But overall, the level has certainly risen over the past few years. I believe that the internet has made a big impact in making more information available. There are also more health talks, magazines and newspaper articles today on health. We often find clients today asking us deeper and sharper questions. They have done their research before hand. We love these sorts of clients as we usually progress faster with their treatment.

But this is a double-edged sword. With more information out there, there is also more misleading information. Some are just plain wrong.

Massages are also another method of relieving pain. Increasingly, we see more massage ‘techniques’ appearing to solve more and more complicated problems. Often with conditions related to the muscles, joint and other supporting structures, muscles will get tight and tense. They will feel achy. Massage will help relieve that pain. But it does nothing to solve the underlying problem. If patients don’t understand this, they will walk thinking that their condition is better.

MCR: If someone is already suffering from pain, what can they do to help themselves?

SH: Seek help. Unresolved pain that lasts more than several weeks is not likely to get resolved on its own.

Find out more about your condition. Besides reading up on your own, asks lots of questions. A good doctor, physician or therapist will be more than happy to explain it to you.