Category Archives: Rehabilitation

Benefits of Cold Therapy

As the team physician for all sports at a university for over twenty years, I had the opportunity to see athletic trainers perform.  They were very good at diagnosing injuries and knowing which ones could be managed with therapy and which ones needed additional studies and sometimes surgical treatment.  When injuries could be managed with therapy and modalities alone, they were able to accelerate recovery to bring athletes back to high levels of function at a rate that seemed magical.

 Among the most frequent modalities was cold therapy and they used it in multiple ways.  Naturally ice packs were a must on the sidelines and they always had them handy.  When someone was injured icing was begun immediately to reduce blood flow with bleeding into the tissues to try to keep the swelling to a minimum.

They also used cold therapy in accelerate recovery.  One of the favorite treatments was immersion of a limb in a bucket of ice-filled water.  They would then remove it and apply gentle heat, always being careful to not use cold too long or heat too high.  The hyperemic response to removal from cold also occurred without the application of heat.

Hyperemia is an increased blood flow that causes the skin to redden and ultimately warm.  You can see it in people’s faces when they come inside from the cold.  You can definitely see it when one removes ice packs from the skin.  So, not only do you get the benefit of cooling to reduce swelling but you also get the benefit of increased blood flow after removing the cooling device.

Our trainers made a convincing case for another benefit of this so-called “contrast” therapy.  They hypothesized that the change in reduced blood flow from cold followed by increased blood flow from warming caused the tissues to shrink and expand with a resulting pumping effect to help drive out swelling (edema).

A third benefit of cold therapy is pain relief.  Cold applied to an injured or painful area can reduce the pain.  That not only makes the person more comfortable but allows better rehabilitation by making it less painful to move an ankle or tighten a muscle.

In summary, the benefits of cold therapy are

  • Temporary reduction of blood flow to
    • Reduce bleeding to an area of acute injury
    • Possibly to transiently shrink tissues to help pump out edema
    • Hyperemia (representing increased blood flow) upon warming to help accelerate the healing process
    • Pain reduction

The biggest problem with cold therapy is inconvenience and risk of cold injury.

  • It’s not practical to carry around a bucket of ice slush so this sort of immersion therapy generally needs to be provided in a training room.
  • Ice packs alone are hard to keep in place and plastic bags of ice tend to leak and “sweat” wetting one’s clothing, etc.
  • Cold injury can occur if you treat with too much cold for too long.
  • Compression (another therapeutic modality for managing edema) is difficult to apply over ice packs.
  • Electrical cooling devices require (believe it or not) electricity, limiting mobility.

A convenient and useful way to provide both cold therapy and compression is provided with the ICE20 Compression Therapy Wraps.  You may click on ICE20 to see our list of their nice cold therapy devices.

 

James D. Hundley, MD; Orthopaedic Surgeon, Retired; Former Athletic Team Physician

Regaining Shoulder Range of Motion

July 11th, 2012 

 by James D. Hundley, MD

During my first year of residency, Dr. Charles Neer, a famous shoulder surgeon, was our visiting professor.  We learned a lot from Dr. Neer but the idea that stuck with me forever was his simple technique for regaining shoulder range of motion following surgery.

Dr. Frank Wilson, our training chief, was very influential with his description of the shoulder capsule as being analogous to the leaves of an accordion.  You had to tease them apart bit by bit.  Except in rare cases, he frowned on manipulation under anesthesia.

Keep in mind that this is about regaining functional use of the shoulder in average people after a fracture or other injury and surgery.  It is not about regaining strength other than in daily use of the limb and it’s certainly not about the definitive rehabilitation of athletes.

Naturally I must insert a disclaimer:  I am not your treating physician.  I am simply telling you what has worked for my patients for many years.  Your treating physician is the one you should listen to primarily.  Consider these ideas as supplementary or complimentary to what you’ve been told.

Here are some ideas to keep in mind:

  1. Neer
    1. Most use of the shoulder is to put the hands in front of the body so if you can reach up in front enough to get to a cabinet above eye level and reach down to your lap, you can do most of what you want to do.
    2. A simple way to accomplish this is to grasp your palms together and interlock your fingers.  Straighten the elbows.  Then use the normal arm to lift the hurt one.  It works better if you lie supine since once you get to 90 deg. of forward flexion, gravity will assist you rather than fight you.
  2. Wilson
    1. Steady, almost constant, gentle stretching is needed, is generally safe, and can be very effective.
    2. You need to move your shoulder often, not just once a day or so when a therapist is there to help you.
    3. Manipulation under anesthesia seems fast but carries the risk of muscle and tendon ruptures as well as fracture.  Furthermore, after a manipulation there is a tendency to quickly return to the pre-manipulation contractures
  1. Hundley
    1. Passive range of motion precedes active range of motion.  “Passive range of motion” means that something moves the affected limb other than the muscles of that limb.  In these techniques you are using your good arm to move your bad one.  “Active range of motion” may be contraindicated following some operations (rotator cuff repair for example) and fractures.  Listen to your surgeon about when you can start active motion.  Unless you regain passive range of motion, there is no chance of regaining active range of motion.
    2. Flexion to get the arm overhead also helps with external rotation.  Concentrate on flexion and don’t worry much about external rotation.  It will follow.
    3. It absolutely helps to lie supine to use gravity when using the Neer technique.  Otherwise, “gravity uses you”.
    4. If you will prop your arm away from your body (pillows or arm rest or arm over the back of a sofa when sitting, elbow on a table or desk), you can change your starting point from down by the side to a better place.  That gives you a head start and helps tease those sticky layers of capsule apart.
    5. Be innovative.  Figure out ways yourself to stretch your arm forward and upward.  Reach up to a tree limb, bar, door jamb, whatever it takes, and hold on to it for as long as possible.
    6. Internal rotation is another matter.  You have to make that happen.  The best way is to reach the bad arm as far behind your back as you can and grasp the wrist of the bad arm with the hand of your good arm.  Initially it will be just pulling to get it behind your body.  Ultimately you need to start lifting the hand up the back until you get it as high as the hand of the good one will go.
    7. Physical Therapists are very important in the rehabilitation process.  If you depend on them to do all of the work, however, you are missing many opportunities to help yourself do better.  They can treat you once every day or two.  You need to be moving your shoulder almost all of the time.
    8. Finally, here’s something to keep in mind about healing and my concept of “cumulative pain”.  The body is a remarkable organism and starts trying to heal things almost the instant it is injured.  That includes surgery.  Healing starts with bleeding followed by formation of scar tissue and so on.  If you wait until the pain of injury/surgery has subsided before you do any serious movement of a joint, I think that there is a 100% chance of it scarring down and never moving well.  Early motion is critical.  Cumulative Pain:  I’ve always told my patients that the pain of regaining motion in injured joints can be equated to the pain of walking barefooted across a bed of hot coals.  If you go slowly, I believe that you will hurt longer than if you push through the pain and go faster.  Thus, your ultimate pain burden will be less if you move on and get it over with.  That’s not to say that you can regain your motion in a day, but you probably do need to regain it in two or three weeks.  Once four to six weeks have passed, you have a big mountain to climb.

Summary

  1. You can and need to help yourself regain motion in your shoulder after injury or surgery.  Your therapist is important but cannot do it all for you.
  2. If you are doing your own pulling, you may cause pain but you are unlikely to harm yourself.
  3. Time is critical.  You cannot wait weeks and weeks to regain substantial range of motion.
  4. Forward flexion is the most important movement.  Do this by grasping the hands together and lifting the good arm with the bad.  This is easier when lying supine than when vertical.
  5. Prop your arm away from your body as often, as far, and for as long as you can.
  6. External rotation tends to improve along with forward flexion, so concentrate on forward flexion.
  7. Internal rotation needs special attention.  Regain that by pulling the wrist of the bad arm behind and then up the back with the good hand.
  8. Check with your physician/surgeon before doing these exercises and do not begin lifting the bad arm with its own muscles without your surgeon’s approval.

 Dr. Hundley is a retired orthopaedic surgeon and is the president of OrthopaedicLIST.com.

Using a Stationary Bicycle to Regain Knee Flexion

by James D. Hundley, MD

I have often recommended stationary bicycling as a conditioning exercise for people who had difficulty walking, had poor balance, etc.  It can be boring but watching a sporting event or exciting TV show makes it less so.

On the positive side, it’s convenient, effective, and safe.  You can do it in your own home whenever time permits, day or night, and you don’t have to worry about being run over by a careless driver.

When I had total knee replacement I was determined to practice what I’d been preaching.  The sooner you regain your range of motion, the better it will be and, on a cumulative basis, you’ll experience less pain.  My own surgery was complicated by a femoral DVT that required clot removal and aggressive anticoagulation, the latter resulting in my knee filling with blood making it harder to flex.  I had to get my knee going, so I started using my stationary bike.

At first I couldn’t make a complete revolution, even with the seat fully elevated.  I rocked the pedals back and forth to flex the knee as much as I could tolerate and held it at the forward and backward endpoints for a few seconds, back and forth, back and forth.  Ultimately I was able to make a full revolution, an exciting event for me.

Once I was able to make a complete revolution with the seat elevated, I would ride slowly for five minutes or so until I felt that the knee was “warmed up”.  Then I would lower the seat and push some more.  Over a week or so I was able to progressively lower the seat to its lowest position giving me as much flexion as the bicycle would allow.

This is not to say that I didn’t also have physical therapy and do other exercises, but I truly believe that the bicycle helped me regain my knee range of motion.  I now have 135 degrees of flexion and extension to neutral, and credit much of that to using the bike.

My wife recently had knee surgery and has been using a similar technique.  In her case, however, she is also using the Ortho Pedal, an “add-on” that effectively shortens the crank arm attached to the sprocket.  With this she has made some full revolutions and we’ll gradually adjust the Ortho Pedal to lengthen the crank arm to increase her knee flexion.

Click here to see the Ortho Pedal.  It was initially designed for those with fixed limitation of knee flexion that took them away from bicycling.  With the Ortho Pedal they could resume something that they loved.  I can see how it would work well for that but have also seen it useful in regaining knee range of motion in the acute postoperative stage.

Dr. Hundley is a retired orthopaedic surgeon and the president of OrthopaedicLIST.com.

Conservative Management of Carpal Tunnel Syndrome and Shoulder Stiffness

These innovative Rehab Products are designed to help individuals experiencing musculoskeletal disorders like shoulder impingement, hand pain or carpal tunnel syndrome.  The products are all based on sound biomechanical principles and can be seen by clicking on the following links:

The Arch Assist provides soothing, massage-like support to the arch of the hand without restricting normal movement.  This is a great product for anyone who uses a computer for long periods or experiences symptoms related to carpal tunnel syndrome.

The Carpal Correct program is the answer to the question:  “What can I do to help carpal tunnel syndrome at home.”  This low cost e manual provides stretches and massage techniques that are based on recent research

Shoulder “Pros” are physical and occupational therapists who work directly with shoulder problems. “  The Shoulder Pro enables you to move your shoulder in an arc, the way therapists mobilize the shoulder. If you are serious about improving your shoulder range of motion on your own, please consider the “Shoulder Pro”.

Regaining Shoulder Range of Motion

by James D. Hundley, MD

Way back in 1968 during my first year of orthopaedic residency at the UNC Hospitals, Dr. Charles Neer, a famous shoulder surgeon, was our visiting professor. We learned a lot from Dr. Neer but the idea that stuck with me forever was his simple technique for regaining shoulder range of motion following surgery.
Dr. Frank Wilson, our training chief, was very graphic with his description of the shoulder capsule as being analogous to the leaves of an accordion. You had to tease them apart bit by bit. Except in rare cases, he frowned on manipulation under anesthesia.
Keep in mind that this is about regaining functional use of the shoulder in average people after a fracture or other injury and surgery. It is not about regaining strength other than in daily use of the limb and it’s certainly not about the definitive rehabilitation of athletes.
Naturally I must insert a disclaimer: I am not your treating physician. I am simply telling you what has worked for my patients for many years. Your treating physician is the one you should listen to primarily. Consider these ideas as supplementary or complimentary to what you’ve been told.

Here are some ideas to keep in mind:

1. Neer
a. The most useful positions of the shoulder find the hands in front of the body so if you can reach up in front enough to get to a cabinet above eye level and reach down to your lap, you can do most of what you want to do.
b. A simple way to accomplish this is to grasp your palms together and interlock your fingers. Straighten the elbows. Then use the normal arm to lift the hurt one. It works better if you lie supine since once you get to 90 deg. of forward flexion, gravity will assist you rather than fight you.

2. Wilson
a. Steady, almost constant, gentle stretching is needed, is generally safe, and can be very effective.
b. You need to move your shoulder often, not just once a day or so when a therapist is there to help you.
c. Manipulation under anesthesia seems fast but carries the risk of muscle and tendon ruptures as well as fracture. Furthermore, after a manipulation there is a tendency to quickly return to the pre-manipulation contractures.

3. Hundley
a. Passive range of motion precedes active range of motion. “Passive range of motion” means that something moves the affected limb other than the muscles of that limb. In these techniques you are using your good arm to move your bad one. “Active range of motion” may be contraindicated (i.e. should not be done) following some operations (rotator cuff repair for example) and fractures. Listen to your surgeon about when you can start active motion. Unless you regain passive range of motion, there is no chance of regaining active range of motion.
b. Flexion to get the arm overhead also helps with external rotation. Concentrate on flexion and don’t worry much about external rotation. It will follow.
c. It really helps to lie supine to use gravity when using the Neer technique. Otherwise, “gravity uses you”.
d. If you will prop your arm away from your body (pillows or arm rest or arm over the back of a sofa when sitting, elbow on a table or desk), you can change your starting point from down by the side to a better place. That gives you a head start and helps tease those sticky layers of capsule apart.
e. Find ways to stretch your arm forward and upward. Reach up to a tree limb, bar, door jamb, whatever it takes, and hold on to it for as long as possible.
f. Internal rotation is another matter. You have to make that happen. The best way is to reach the bad arm as far behind your back as you can and grasp the wrist of the bad arm with the hand of your good arm. Initially it will be just pulling to get it behind your body. Ultimately you need to start lifting the hand up the back until you get it as high as the hand of the good one will go.
g. Physical Therapists are very important in the rehabilitation process. If you depend on them to do all of the work, however, you are missing many opportunities to help yourself do better. They can treat you once every day or two. You need to be moving your shoulder almost all of the time.
h. Finally, here’s something to keep in mind about healing and my concept of “cumulative pain”. The body is a remarkable organism and starts trying to heal things almost the instant it is injured. That includes surgery. Healing starts with bleeding followed by formation of scar tissue and so on. If you wait until the pain of injury/surgery has subsided before you do any serious movement of a joint, I think that there is a 100% chance of it scarring down and never moving well. Early motion is critical. Cumulative Pain: I’ve always told my patients that the pain of regaining motion in injured joints can be equated to the pain of walking barefooted across a bed of hot coals. If you go slowly, I believe that you will hurt longer than if you push through the pain and go faster. Thus, your ultimate pain burden will be less if you move on and get it over with. That’s not to say that you can regain your motion in a day, but you probably do need to regain it in two or three weeks. Once four to six weeks have passed, you have a big mountain to climb.

Summary
1. You can and need to help yourself regain motion in your shoulder after injury or surgery. Your therapist is important but cannot do it all for you.
2. If you are doing your own pulling, you may cause pain but you are unlikely to harm yourself.
3. Time is critical. You cannot wait weeks and weeks to regain substantial range of motion.
4. Forward flexion is the most important movement. Do this by grasping the hands together and lifting the good arm with the bad. This is easier when lying supine than when vertical.
5. Prop your arm away from your body as often, as far, and for as long as you can.
6. External rotation tends to improve along with forward flexion, so concentrate on forward flexion.
7. Internal rotation needs special attention. Regain that by pulling the wrist of the bad arm behind and then up the back with the good hand.
8. Check with your physician/surgeon before doing these exercises and do not begin lifting the bad arm with its own muscles without your surgeon’s approval.

Dr. Hundley is a retired orthopaedic surgeon and the president of OrthopaedicLIST.com.