Educational Materials

Regulating the functions of human body

An Introduction to Physical Medicine & Rehabilitation

If I said that you should consult a physiatrist for a medical problem, would you have any idea what I was talking about? What if I said to see a specialist in Physical Medicine & Rehabilitation? If you have no clue what I am talking about, don’t worry……these terms have little to no meaning for the majority of persons here in Barbados and even in the English-speaking Caribbean.

This specialty was first officially recognized in the US in 1947 and has grown tremendously since then. There are more than 9000 rehabilitation physicians in the United States while in the entire English-speaking Caribbean, there are less than ten of us.

A specialist in Physical Medicine & Rehabilitation, known as a physiatrist, is a medical doctor whose concern is optimizing the physical function of individuals. This may entail helping a person who suffered a decline in function due to illness or disease or maintaining the function of someone whose function has already been restored to the maximum possible level. The aim in each instance is to keep physical function as close to 100% as possible and quality of life the best it can be.

How is this done? The physiatrist does a thorough evaluation of each patient, diagnoses any deficiencies in physical function he/she has and creates the appropriate treatment plan to manage or compensate for those deficits to optimize physical function. This treatment plan may include tests, therapy, medications, bracing and different types of injections.

What type of patients can benefit from the services of a physiatrist? Patients of all ages and with a broad variety of conditions as listed below:

  • Amputees
  • Patients with different types of arthritis
  • Patients with brain injury- stroke, traumatic brain injury, tumours, multiple sclerosis
  • Cardiac patients with impaired quality of life due to heart attack, angina or heart failure
  • Geriatric patients who may be at risk of falls
  • Musculoskeletal pain- joint pains of all areas of the body, back pain, neck pain
  • Nerve conditions- carpal tunnel syndrome, diabetic nerve pain, pinched nerves in the back or neck
  • Pediatric patients with impaired development- such as cerebral palsy
  • Spinal cord injuries- traumatic or due to diseases such as multiple sclerosis
  • Sports injuries
  • Work-related injuries
  • Patients with spasticity- abnormal muscle tone due to prior damage to the brain or spinal cord
  • All patients with impaired function after an accident, surgery, prolonged illness or hospitalization

Doctors in our specialty usually work as part of a team with other health care workers including other medical specialists, physiotherapists, occupational therapists, speech therapists, nurses and social workers. Often, we take the role of “team leaders” who coordinate all aspects of care that patients may require. We may work in hospitals, in outpatient clinics or offices or sometimes both. Some of us have special interests such as pain management or sports medicine and restrict the types of patients seen in our practice. A number of us treat all possible conditions we can, especially in places where there are very few of us, as is the case here in the Caribbean.

In terms of testing, in addition to the usual tests other doctors may order, most of us perform nerve tests and some of us perform ultrasound scanning of joints, tendons and ligaments. Various types of injections can be performed, if necessary, to accelerate pain relief and return of function and quality of life.

I hope that this introduction to this specialty has stimulated your appetite for more knowledge. In subsequent columns, we will look at common conditions treated by physiatrists.

Amputation and Rehabilitation

By Dr. Shane Drakes

Let’s talk about missing limbs. Some persons are born without an entire limb or part of a limb (congenital limb deficiency) or we may lose part of a limb or an entire limb during later life due to an amputation.

Amputations are more common in the lower limb than the upper limb and there are multiple conditions which may lead to an amputation. The prevalence of these conditions varies among different age groups and also varies depending on whether the amputation is in the upper limb or lower limb.

In children, acquired amputations are more common than congenital limb deficiencies. The two causes of acquired amputations in children are trauma (the more common cause) and amputation related to disease (most commonly cancer). Congenital limb deficiencies have multiple possible causes including genetic abnormalities, maternal influences which include smoking, gestational diabetes or exposure to toxic medications or chemicals and vascular problems affecting the limb while in the womb. However, the cause of most congenital limb deficiencies is unknown. In adults, trauma is the most common cause of upper limb amputations and all amputations in those under 50 years of age while vascular disease (poor circulation) is the most common cause in lower limb amputations and in those over 50 years of age.

Hypertension, diabetes, elevated cholesterol, smoking and lack of physical activity all increase the risk of vascular disease and possible amputation. These are the same risk factors for strokes and heart attacks- these conditions contribute to atherosclerosis (narrowing of the blood vessels) which occurs throughout the body. In diabetic persons, nerve damage (which leads to decreased sensation in the feet) and increased susceptibility to infection increase the risk of the need for amputation. Here in Barbados, we have had a high amputation rate for many years due to the factors mentioned above.

After an amputation, the individual will need to undergo interdisciplinary rehabilitation to maximize his/her physical function, independence and quality of life. The rehabilitation specialist is a key person in this process as he will coordinate the rehabilitation program, monitor the patient’s progress, assist in management of pain and be a strong advocate for the patient to ensure that he/she receives all necessary resources to have a satisfactory reintegration into the community. Education of the patient and family of the process required to obtain and satisfactorily use a prosthesis and avoid possible complications after amputation is also crucial. Use of a prosthesis decreases the energy required by the amputee to walk compared to use of crutches and provides more independence than using a wheelchair. The ideal time for the rehabilitation specialist to begin working with the patient is prior to the amputation to educate him/her on what to expect and get therapy started to prepare the person for walking with crutches after the amputation. Unfortunately, this is not always possible.

An amputation can be seen as a reconstructive operation which cures infection, relieves pain and with the addition of a properly selected prosthesis for an appropriate patient, can allow some patients to function better than they did before the amputation. Individuals can walk, work, drive and even play sports after an amputation if they have an appropriate prosthesis and adequate care. Some of these individuals will be on show later this year in Rio de Janeiro at the 15th Summer Paralympics. Although they would have all taken different paths to reach that point, they all refused to allow an amputation to stop them achieving maximum independence and a satisfactory quality of life.

Cerebral Palsy and Rehabilitation

By Dr. Shane Drakes

Today, let’s look at a disorder which affects children. Cerebral palsy is a disorder of movement and posture and results from a disturbance or injury to an immature brain. There can also be some cognitive and sensory problems associated with this disorder in some patients. The injury to the brain that is responsible for cerebral palsy is non-progressive (doesn’t worsen over time). This disorder is the leading cause of chronic childhood disability worldwide. It affects 2-3 out of every 1000 children who are alive at birth.

The brain injury responsible for cerebral palsy can occur in the prenatal period (before birth), the perinatal period (around the time of birth) or in the postnatal period (within the first 3 years of life). The majority of cases occur in the prenatal period. There are multiple risk factors for the development of cerebral palsy and they differ according to the timing of the brain injury. Some of these risk factors are shown in the table.

Prenatal Risk FactorsPerinatal Risk FactorsPostnatal Risk Factors
Bleeding in the brainPrematurity – birth at less than 32 weeks, birthweight below 2500 gramsTrauma- accidents, falls or child abuse
Complications with the placentaAbnormalities of the placentaToxins
ToxinsDisorders leading to jaundice in the babyStroke
Structural abnormality of the brain or blood vesselsDifficult/traumatic deliveryInfection
Infections passed on by the motherInfectionsTumour

The symptoms of a child with cerebral palsy depend on the extent of the injury to the brain. Common symptoms include:

  • Weakness of the limbs and sometimes of the face
  • Difficulty walking
  • Visual problems
  • Cognitive problems
  • Abnormally increased muscle tone
  • Involuntary movements

Associated problems include hearing impairment, speech impairment, behavioural disorders, feeding problems, gastrointestinal problems and bowel and bladder dysfunction.

Children with cerebral palsy need to be followed by a team of healthcare professionals including a paediatrician, therapists and a rehabilitation specialist. They may also need care from a neurologist, neurosurgeon or orthopedic surgeon. In the United States, Early Intervention is a national program which ensures that therapists begin working with all children who are identified as having developmental delays. Here in Barbados, the Albert Cecil Graham Development Center provides significant support to children affected by cerebral palsy. The rehabilitation specialist will usually assist in the coordination of therapy and also ensure that the family gets any medical equipment that is necessary. We also prescribe braces to assist the child with walking if necessary and also treat the abnormal muscle tone which in some cases can be a hindrance to walking or proper positioning or achieving good hygiene. The increased muscle tone can also lead to significant pain. Some children may need surgery to treat the increased muscle tone or to manage soft tissue problems which limit range of motion or mobility. The rehabilitation specialist will also coordinate with the appropriate surgeons to have these procedures done if necessary.

Although we normal associate cerebral palsy with persons who need a lot of assistance, some of these persons are quite capable of living almost independently, have jobs and will be in action later this year in Rio at the Paralympic Games. As persons who have cerebral palsy transition into adulthood, the rehabilitation specialist can still play a major role in ensuring that they achieve and maintain optimal physical performance.

Carpal Tunnel Syndrome

By Dr. Shane Drakes

Today, we will discuss carpal tunnel syndrome (CTS). This is a condition caused by compression of the median nerve in the carpal tunnel at the wrist. The median nerve is a major nerve of the upper limb which supplies sensation to most of the fingers and also supplies power to muscles which move the thumb. Compression leads to dysfunction of this nerve causing symptoms which reflect the severity of the nerve injury.

The carpal tunnel is a passage in the wrist which allows the median nerve and the tendons of muscles which flex (bend) the fingers to pass from the forearm into the hand. The sides and floor of this passage consist of the wrist bones and the roof is formed by a ligament. Abnormalities of the tunnel or of the structures within the tunnel can increase the pressure within the tunnel leading to compression of the nerve. The presence of structures within the tunnel that are not normally found there can also have the same result.

CTS is the most common compressive nerve injury and affects person between 40 and 60 years of age more than any other age group. It affects women more than men and it is the most common repetitive trauma disorder with some job related factors such as high levels of use of vibrating tools, prolonged work with a flexed or extended wrist and highly repetitive and strenuous use of the wrists and hands. In most cases, the cause is unknown but some medical conditions increase the risk of developing CTS. These include:

  • Diabetes
  • Hypothyroidism
  • Chronic kidney failure
  • Pregnancy

Symptoms of CTS include:

  • Aching wrist and hand pain
  • Numbness, tingling or “pins and needles” in the thumb, index finger, middle finger and possibly the ring finger
  • Pain may radiate up into the forearm or in rare cases, up to the shoulder
  • Improvement with shaking the hand
  • Some clumsiness when using the affected hand

These symptoms tend to be worse at night and may wake the individual out of his/her sleep and usually affect the dominant hand. In advanced cases, an affected individual may notice wasting of the muscles around the thumb and have weakness of the thumb.

CTS can usually be diagnosed by taking a good history and performing a proper physical examination. However, any person who is suspected of having CTS should have nerve conduction studies and possibly electromyography performed. Nerve conduction studies (NCS) check the function of the nerve and electromyography (EMG) checks the electrical activity of the muscles. These tests can diagnose nerve injury and are recommended to confirm the diagnosis of CTS and rule out the presence of any other condition which may cause similar symptoms. A newer test used in some patients to diagnose CTS is musculoskeletal ultrasound but NCS/EMG remains the gold standard.

How does the Rehabilitation Specialist help in the evaluation and management of CTS? Persons in my field evaluate patients and determine the likelihood of the diagnosis being CTS, perform NCS/EMG and in some instances, musculoskeletal ultrasound to confirm the diagnosis. We also educate affected patients on the condition, refer them to occupational therapy, prescribe splints for the wrist, perform steroid injections if appropriate to control symptoms and refer patients for surgery if necessary.

CTS is a condition which can be bothersome and if not managed appropriately, can lead to altered hand function. If you have CTS or suspect you may have it, ensure you seek out an appropriate evaluation and management so you can maintain optimal hand function.

Management of Neck Pain

By Dr. Shane Drakes

Neck pain is very common and I’m sure that all of us have suffered from this condition at least once in the past. The neck functions to support and stabilize the head and allows motion of the head in different directions. The foundation of the neck’s complex anatomy is the cervical spine and associated ligaments. The cervical spine is made up of seven vertebrae (bones) and the intervertebral discs which are situated between consecutive vertebrae (except C1 and C2). The spine protects the spinal cord, nerve roots and spinal nerves and vertebral arteries. The spinal nerves originating in the cervical spine supply sensation to the back of the head, neck and upper limbs (shoulder to hand) and power to the muscles of the upper limb. The vertebral arteries supply blood to the brainstem and parts of the brain. There are multiple muscles around the neck which act to produce motion of the neck and the head.

There are multiple causes of neck pain but we will discuss the three most common causes today. These causes are:

  • Strains (muscle injury) and sprains (ligament injury)
  • Cervical facet joint mediated pain
  • Cervical radiculopathy (pinched nerve root in the neck)

Cervical strains have different causes such as sustained abnormal postures (hunched forward or leaning to the side), sleeping in a bad position or carrying a heavy object on one side of the body. Trauma which impacts the neck, such as whiplash in a car accident, can also cause strains as well as sprains. Such injuries typically cause pain in the neck and possibly shoulder muscles as well as neck stiffness. Symptoms typically resolve within a few days with appropriate management but in the case of whiplash, symptoms may persist for much longer and require more intensive and prolonged treatment.

The facet joints are the joints between consecutive vertebrae in the spine. Pain originating from these joints may be a result of osteoarthritis or post-traumatic in origin (such as from whiplash). It can therefore have a gradual onset or a sudden onset. The symptoms experienced depend on the level of the joint affected- in addition to neck pain, patients may have headaches and pain in the area of the posterior shoulder and around the shoulder blades. This condition is more challenging to treat and in the case of osteoarthritis, the pain may recur in the future.

Cervical nerve roots exit the cervical spine through the neural foramina (passages between the vertebrae) and join each other to form networks which divide into peripheral nerves that supply sensation and motor power to the upper limbs. Cervical radiculopathy refers to dysfunction of a nerve root caused by compression by a herniated intervertebral disc or osteoarthritic changes. Symptoms include neck pain which radiates into the upper limb, sensory disturbances (numbness, tingling or burning sensation) and weakness in the upper limb. This condition can be challenging to treat and needs urgent attention, especially if there is weakness of the upper limb.

The physiatrist plays an important role in the management of neck pain. A thorough history and proper physical examination are crucial to making the correct diagnosis of the cause of the pain. Investigations may also need to be ordered to help make the diagnosis- these include cervical x-rays and/or MRI and possibly nerve conduction studies and EMG. Appropriate treatment will be instituted by the physiatrist in a timely fashion as required by the urgency of the underlying cause of the neck pain. Treatment will include medications to control pain and muscle spasms, physical therapy for almost all patients and soft tissue or spinal injections as needed. Some patients with cervical radiculopathy and those who have spinal cord compression of the spinal cord will require surgery to decompress the cervical spine. These patients would be referred to the spine surgeon as soon as the physiatrist makes the diagnosis.

Any person with neck pain lasting more than a few days or with other associated symptoms should seek to have a thorough evaluation done so appropriate treatment can be started. This will lead to improved pain and restore function.

Dr. Shane Drakes is a Specialist in Physical Medicine &Rehabilitation and Sports Medicine. He can be contacted at sdoptimalfunctioning@gmail.com.

Management of Elbow Pain

By Dr. Shane Drakes

The elbow is the joint which connects the arm to the forearm. Three different bones come together to form the bony parts of the elbow joint. The humerus (arm bone) meets the ulna (inner forearm bone) and the radius (outer forearm bone) to form a hinge type of joint which allows flexion (bending) and extension (straightening) of the arm. The ulna and radius also meet in the elbow to allow for supination (rotating the palm upward) and pronation (rotating the palm downward) of the forearm. The bony parts that make up the elbow are stabilized by multiple strong ligaments. The elbow region is also the origin of many of the muscles in the forearm which then act to flex or extend the wrist and fingers. The elbow is very important in the performance of activities of daily living and participation in many different sports.

There are multiple possible causes of elbow pain. An individual’s prior medical history, history of trauma (whether on a single occasion or repetitively) and history of repetitive use of the elbow for work-related or sporting activities are all useful indicators of the likely cause of his/her elbow pain. Today, we will discuss a few of the more common conditions affecting the elbow:

  • Lateral epicondylitis (tennis elbow)
  • Medical epicondylitis (golfer’s elbow)
  • Ligament sprains
  • Osteoarthritis

Lateral epicondylitis refers to degenerative changes in the origin of the tendon of one of the muscles which extends the wrist. This condition usually has a gradual onset and is characterized by pain and tenderness on the outer part of the elbow. It was first described in tennis players but it can affect persons in other sports and can also be caused by repetitive wrist extension in some occupations such as mechanics, carpenters and plumbers. In sportspersons it is usually the result of equipment issues or faulty technique.

Medial epicondylitis has similar degenerative changes as lateral epicondylitis but these occur in tendons on the inner part of the elbow. These tendons are responsible for pronation or wrist flexion. The onset is gradual and there is pain and tenderness on the inner part of the elbow. Pain can be worsened by making a tight fist or activities requiring repetitive wrist flexion. It is a common injury in golf, baseball and occupations requiring repetitive use of tools such as carpentry.

There are multiple ligaments around the elbow which help to provide stability to the joint. Ligament sprains can occur as a result of trauma to the elbow or repeated stress. The ligament may be stretched, partially torn or completely torn. The most common ligament injured in the elbow is the ulnar collateral ligament. This can be injured by a single traumatic incident or more commonly, as a result of repetitive stress caused by throwing such as in baseball. Symptoms of a ligament sprain include pain and swelling over the affected area, instability if the injury is severe enough and sometimes an audible “pop” if the ligament tears completely.

Primary osteoarthritis (OA) in the elbow is uncommon but OA can occur secondary to trauma or medical conditions such as rheumatoid arthritis. Symptoms include pain, swelling, decreased range of motion, locking of the joint and possible instability. Bone spurs from OA may also compress nerves in the region of the elbow and cause neurologic symptoms such as numbness, tingling, weakness and muscle wasting in severe cases.

The rehabilitation specialist has an important role to play in management of elbow pain. A thorough evaluation will suggest the cause of the elbow pain in most patients. Where necessary, imaging such as x-rays, ultrasound or MRI will be ordered to confirm the diagnosis. The treatment plan can then be created for each patient. Oral medications or steroid injections will be used for pain control and occupational therapy will have an important role in recovery. Sportspersons will be counselled on correcting techniques and replacing faulty equipment and workers educated on ergonomic adjustments to help prevent recurrences. Medial and lateral epicondylitis can both benefit from the use of braces. Surgery may be required in cases of epicondylitis not responding to conservative treatment as well as in complete ligament tears and severe OA and in these cases, patients will be referred to an experienced orthopaedic surgeon.

If you have elbow pain which is not resolving in a short period of time, a thorough evaluation is the first step to regaining optimal physical function.

Multiple Sclerosis and Rehabilitation

By Dr. Shane Drakes

Multiple Sclerosis (MS) is a condition where the body’s immune system attacks and destroys the myelin around nerve cells in the central nervous system (brain and spinal cord). Myelin is an insulating layer which surrounds nerve cells and allows for rapid transmission of signals along nerves. The destruction of myelin and nerve cells in the brain and/or spinal cord causes disruption of impulse transmission along affected nerves and leads to the appearance of neurologic symptoms. After an episode of MS, new myelin can be laid down around the nerve cells leading to a remission (improvement in symptoms) or there can be scarring which leads to residual and permanent damage.

MS usually occurs in the 20-50 year age group, is twice as common in women as it is in men, significantly more common in Whites than Blacks and is much more common in northern/temperate climates than in tropical/southern climates. The prevalence here in Barbados is not precisely known but it is low compared to that in temperate climates. The exact cause of multiple sclerosis is unknown but both genetic factors and environmental factors seem to play a role. About 20% of patients with MS have an affected relative and migration to a temperate climate before age 15 has also been found to be a risk factor for developing MS.

Common symptoms include visual problems, bladder and bowel dysfunction, weakness, impaired sensation, increased muscle tone (spasticity), fatigue, pain, altered balance, difficulty swallowing, altered speech and cognitive deficits. The condition is worsened by heat- very important to consider in our climate.

MS has several different patterns as shown in the table below:

Pattern%of MS PatientsCharacteristics
Clinically Isolated SyndromeNot yet diagnosedFirst episode of neurologic symptoms suggestive of MS- patient may or may not later develop MS
Relapsing-Remitting85%Most common pattern of MS. Characterized by clearly defined attacks of new or worsening neurologic symptoms (relapses) followed by partial or complete recovery (remissions)
Secondary Progressive50% within 10 years of diagnosis
Eventually almost 85%
Patients initially showed relapsing-remitting pattern but then transition to progressive course of worsening of neurologic function
Primary Progressive10%Worsening neurologic function from the onset of symptoms, without early relapses or remissions
Progressive Relapsing5%Steady worsening of disability with occasional relapses

Factors that lead to a better prognosis in MS patients include:

  • Young age at onset
  • Female gender
  • Relapsing remitting course rather than primary progressive
  • First symptoms only affecting one region of the brain or spinal cord
  • Good recovery from the first MS episode
  • Longer interval between relapses
  • Low number of relapses in the first 2 years

Appropriate treatment of MS requires an interdisciplinary approach. The diagnosis is made by a neurologist who will also prescribe medications to manage the condition. The involvement of the rehab specialist is important because rehabilitation is crucial to minimize disability. Prescribing appropriate therapy and education of patients and family members/caregivers are crucial. Other important aspects of care include prescribing assistive devices for mobility (canes, walkers or wheelchairs) and activities of daily living. Management of pain and spasticity is also very important. Spasticity can be managed through the use of medications or injection procedures such as Botox injections or alcohol nerve blocks. Unfortunately there is no cure for MS but regular evaluation and prevention or swift management of complications can help ensure optimal physical function and the best possible quality of life for patients with MS.

Management of Shoulder Pain

By Dr. Shane Drakes

The shoulder is a complex area which allows significant mobility of the upper limb. This is important for completion of activities of daily living as well as participation in several types of sporting activities. The shoulder consists of two separate joints- the acromioclavicular (AC) joint and the glenohumeral (GH) joint. Shoulder motion occurs at the GH joint in multiple directions- this great mobility comes at the price of decreased stability of the glenohumeral joint when compared to some other joints in the body such as the knee or hip. Multiple ligaments and the joint capsules act as static (stationary) stabilizers of the joints of the shoulder while the four rotator cuff muscles act as dynamic (moving) stabilizers of the GH joint. The scapulothoracic joint is the position of the scapula (shoulder blade) on the back of the rib cage. Movement at this joint is important for normal shoulder movement and it is stabilized in a good position by several muscles.

There are multiple possible causes of shoulder pain. The likely cause of a person’s shoulder pain can be influenced by age, medical conditions, trauma to the shoulder and a history of repetitive upper limb use for work-related or sporting activities. Today we will discuss 3 of the most common conditions:

  • Rotator cuff disorders
  • Adhesive capsulitis (frozen shoulder)
  • Osteoarthritis

The rotator cuff consists of 4 muscles which originate on the scapula and attach to the head of the humerus (arm bone) and help maintain its position in the glenoid fossa (shoulder socket). These muscles are the supraspinatus, infraspinatus, teres minor and subscapularis. The tendon of the supraspinatus is the most common part of the rotator cuff that is injured. Tendinopathy (tendon disease) can involve inflammation, a chronic degenerative process or a tear of the tendon. Tendinopathy can result from trauma to the shoulder (such as a fall) or from chronic impingement (compression) of the tendon between two bony parts. Rotator cuff disorders are most common after 40 years of age but can occur in younger sportspersons who have chronic impingement. In many cases of tendinopathy, there is an associated inflammation of the subacromial-subdeltoid bursa. Symptoms include pain on the side of the shoulder, decreased range of motion, trouble sleeping on the affected shoulder and weakness of shoulder movement.

Adhesive capsulitis is a condition in which the synovial tissue of the capsule of the GH joint becomes adherent to itself as a result of the development of adhesions within the joint. This leads to progressive loss of range of motion of the shoulder. Symptoms include shoulder pain with significantly reduced range of motion. There is usually a progression from a painful stage to a stage of freezing/stiffening and then to the thawing stage. It can last up to 2 years without treatment. This disorder is associated with several conditions:

  • Diabetes
  • Hypothyroidism
  • Parkinson’s disease
  • Stroke
  • Immobilization

Osteoarthritis of the shoulder can affect either the AC or GH joint. The cause of the arthritis may be unknown or it may occur after trauma, infection or inflammatory disorders. Symptoms include shoulder pain, decreased range of motion, crepitus (creaking or cracking) when moving the shoulder. Examination may show obvious deformity if the AC joint is affected and tenderness over the affected joint.

The rehabilitation specialist can play a very important role in the management of shoulder pain. Taking a thorough history and performing a good physical examination will provide the physician with the correct diagnosis in most cases. When necessary, imaging studies such as x-rays, musculoskeletal ultrasound or MRI will be ordered to help make the diagnosis. An appropriate treatment plan can then be designed for each patient. The treatment plan will include a corticosteroid injection or oral medications for pain control and physical therapy followed by a home exercise program. In some cases of rotator cuff tendinopathy and osteoarthritis, surgery may be needed and adhesive capsulitis may require manipulation under anesthesia. In these cases, the patient would be referred to an orthopaedic surgeon for treatment.

If you have shoulder pain which has not responded to treatment after 1-2 weeks, an adequate evaluation is the first step towards regaining optimal physical function.

Dr. Shane Drakes is a Specialist in Physical Medicine &Rehabilitation and Sports Medicine. He can be contacted at sdoptimalfunctioning@gmail.com.

Spinal Cord Injury and Rehabilitation

By Dr Shane Drakes

Our topic this time will be Spinal Cord Injury (SCI). Firstly, what is the spinal cord? The spinal cord is a cylindrical bundle of nerves and supporting tissues connecting the brain to the rest of the body. It transmits electrical signals from the brain to the rest of the body. These electrical signals include motor information travelling from the brain to the limbs and trunk so we can move and sensory information from the body to the brain so we can appreciate touch, temperature and pain among other sensations. This allows us to respond to stimuli from inside or outside our bodies. The spinal cord is protected by our vertebrae (spinal bones). Damage to the nerves in the spinal cord prevents the transmission of signals through the damaged area in either direction.

A spinal cord injury can be caused by trauma (accidents, falls, assault) or non-traumatic causes such as spinal arthritis, infection, tumors, blood vessel damage or radiation. Motor vehicle accidents are the most common cause of SCI, followed by falls, acts of violence (most commonly gunshots) and sports injuries (most commonly diving). Traumatic SCI most commonly occurs in young males between 15 and 35 years of age. In persons over 60 years of age, falls are the most common cause of SCI.

Symptoms after a spinal cord injury include weakness/inability to move the limbs, altered or no sensation, bowel and bladder problems, spasticity (increased muscle tone) and sexual dysfunction. The presence and severity of symptoms will depend on the level at which the spinal cord is damaged and the completeness of the injury. The primary component of the injury (damage to the nerves and blood vessels of the cord) occurs at the time of the initial trauma. The secondary component of the injury includes inflammation, altered blood flow and release of dangerous chemicals. This occurs later and causes further tissue damage.

SCI is associated with complications involving every organ system. Harmful effects of this multisystem involvement include:

  • Breathing difficulty which may require ventilator use in those with high level neck injuries
  • Pneumonia
  • Urinary tract infections
  • Constipation
  • Low blood pressure, decreased fitness and coronary artery disease
  • Osteoporosis
  • Change in body composition predisposing the individual to diabetes and high cholesterol
  • Pain from overuse of the arms in wheelchair users
  • Sexual dysfunction and decreased fertility in males

How can a physiatrist help a person who suffered a spinal cord injury? After medical and possibly surgical treatment after the injury, intensive interdisciplinary rehabilitation is needed to maximize physical function. The team will need to include physical and occupational therapists, nursing staff, social workers and vocational therapists. The physiatrist can coordinate the rehabilitation process and educate the patient and family about potential medical complications and how these can be avoided and managed. During the inpatient rehabilitation stay, the patient will begin to learn routines that they will likely have to perform for the rest of their lives. These include management of bowel and bladder dysfunction.

A spinal cord injury is a devastating injury but it doesn’t have to mean that an injured patient’s life is no longer worthwhile. Some of these individuals are able to live independently and drive a vehicle with adapted controls. They also participate in sports including those at the Summer and Winter Paralympic Games which are held immediately after the respective Olympic Games for able-bodied persons. These competitors can potentially have all the medical complications that may affect an individual with spinal cord injury but they are at greater risk of upper limb injuries due to overuse. Patients with spinal cord injuries need life-long follow-up to ensure maximum function is maintained and complications are avoided or treated appropriately and in a timely fashion if they occur. The rehabilitation specialist has a major role to play in management of these patients and ensuring their physical function is optimized.

Osteoarthritis and Management

By Dr. Shane Drakes

I’m sure we all know someone who has been diagnosed with “arthritis”. In most instances, the condition that individual has is osteoarthritis (OA). This is a progressive disorder of the joints which leads to deterioration of the cartilage and new bone formation at the surface and margins of the joints. OA can be distinguished from other forms of arthritis such as rheumatoid arthritis due to the lack of inflammation and no involvement of parts of the body other than the joints.

OA is the most common form of arthritis and the prevalence of it increases with age – more than 50% of adults over 65 years of age will have OA. It is present equally in males and females up to age 55 but subsequently becomes more frequent in females. Any joint can be affected but the most common ones are in the knees, hands, feet, hips and the spine (neck and lower back). OA is associated with significant pain, loss of function and disability.

There are many possible causes of OA but in most cases, there is no underlying cause other than aging. This is usually referred to as primary or idiopathic OA. Conditions which may lead to secondary OA include:

  • Acute or chronic trauma
  • Prior infection
  • Obesity
  • Abnormal joint alignment (bow-legged or knock-kneed posture)
  • Abnormal joint formation from childhood
  • Joint disorders in childhood
  • Metabolic disorders
  • Crystals deposited into the joint such as in gout
  • Episodes of bleeding into the joint such as in hemophilia

OA has also been found to be associated with some genetic factors so a family history may increase your risk of developing it.

Symptoms of OA include joint pain, swelling, difficulty moving the joint and impaired function. Affected persons may also notice stiffness that improves with movement as well as crepitus (creaking or cracking) when moving the affected joint. Your doctor may notice swelling around your joint, tenderness with palpation of the joint and crepitus. The joint may also be seen to be enlarged as a result of new abnormal bone growth at the joint margins.

The severity and pattern of your symptoms as well as findings on x-rays of the affected joint will allow your doctor to figure out the severity of your osteoarthritis. OA is usually graded as mild, moderate or severe. This is important to know as it will dictate the treatment you should be offered and the likely response to treatment.

The rehabilitation specialist plays an important role in managing a person with joint pain. The first and most crucial step is to determine whether the pain is originating from the joint or soft tissues surrounding the joint (tendons, ligaments or bursae). This is important because the treatment required may be quite different. Depending on the most likely diagnosis, appropriate imaging may be ordered or performed. This may be an x-ray, ultrasound or MRI.

In a person who is confirmed to have OA, the severity determines the initial treatment offered by the rehabilitation specialist. Possible treatments include prescription of pain medications, prescription of braces or use of shoe orthotics. Use of a mobility aid such as a cane may also be recommended. Physical or occupational therapy should be a part of management of any person with OA as it is crucial to build strength in the muscles surrounding the affected joint. In a person who has a lot of swelling due to OA, aspiration of the fluid (removal using a needle and syringe) may lead to improved function and this is usually followed by a steroid injection into the joint. Another type of injection that has been used in recent times is hyaluronic acid. This medication is injected into the knee joint to provide lubrication and reduce pain. In a person with severe OA or someone who has a poor response to conservative treatments, referral to an orthopedic surgeon for surgery will be necessary.

If you suspect you have OA, a proper medical evaluation is the first start to reducing your pain and optimizing your physical function.

Traumatic Brain Injury and Rehabilitation

Traumatic brain injury has been in the news recently. Most of us have heard the story of the teenager from the USA who recently suffered a brain injury due to an accident here in Barbados. Let us discuss this condition and the care that these persons need after such an event.

Traumatic brain injury (TBI) is disruption of the function of the brain due to an external blow to the head. Falls account for the majority of TBI cases (especially in children and the elderly) with other common causes including motor vehicle accidents and assaults. In recent times, blast injuries during war or in terrorist attacks have also become an important cause of TBI. This condition predominantly affects persons 16-25 years of age, significantly more males than females and many times is associated with alcohol use. In the USA, it is reported that there are 1.7 million cases of TBI every year reporting to emergency departments throughout the country, with about 1.36 million of those cases not requiring hospitalization. The exact incidence of TBI is not known as many persons may not seek medical attention.

Symptoms and signs of TBI include decreased level of consciousness, memory loss for events before or after the injury, altered mental status and neurologic deficits. TBI can also be fatal. Depending on the cause of the injury, the individual may also have other injuries such as fractures sustained in a motor vehicle accident. The symptoms a TBI patient will have depend on the area of the brain affected and also the type of injury to the brain. Injuries to the brain can be described as primary (direct damage to brain tissue) or secondary (due to swelling, poor blood flow or metabolic disturbances). Injuries can also be focal (localized to one area) or diffuse (widespread brain injury).

An individual with a traumatic brain injury should seek immediate medical attention so that the appropriate treatment can be quickly implemented. The doctors will grade the injury as mild, moderate or severe after assessing the patient and the appropriate treatment will be given. Patients with mild injuries usually do not need to be hospitalized. Many of us would have heard about concussions in sportspersons over the last few years – this condition falls into the category of mild TBI. Persons with localized injuries to the brain such as bleeds/clots often require surgery to improve their condition and prevent worsening.

After the individual with TBI has been appropriately treated and is medically stable, the process of recovery will need to start. The rehab team is crucial in this process. In developed countries, persons with TBI will be discharged to a rehab center after hospitalization before they go back into the community. This is important as it allows the individual to start working on his/her deficits with the therapists and it also allows the team to start treating some of the complications of TBI before the person returns home. These include seizures, ongoing neurologic deficits, posttraumatic agitation, cognitive deficits, blood clots, endocrine disorders, urinary dysfunction and spasticity (abnormal muscle tone). The rehab progress of the patient will be followed as an outpatient after they are discharged from the rehab unit and complications will be looked for and treated at every visit.

The prognosis after TBI depends on the severity of the injury, duration of the coma and posttraumatic amnesia, the age of the patient and the effectiveness of the rehab process. Management of deficits and complications will also play a significant role in determining the person’s ability to be resume the life they had before the injury. In order for the injured person to regain maximal function, independence and quality of life, a quality interdisciplinary rehabilitation program is essential. The physiatrist has an important role to play in this team that assists the patient in reaching his/her goals.

Written by Dr. Shane Drakes

Strokes and Rehabilitation

Most of us either personally know someone or have encountered someone who had a stroke. Here in Barbados, in 2013, there were approximately 58 strokes per month. Let us look at what a stroke is and what medical professionals can do to help in such a situation.

A stroke is the abrupt onset of brain dysfunction caused by disruption of blood flow to an area of the brain. A stroke can be ischaemic (caused by blockage of a blood vessel) or hemorrhagic (caused by rupture of a blood vessel) in nature. The result is the same: irreversible damage to a part of the brain, leading to neurologic problems.

Who is at risk for a stroke? Risk factors can be thought of as modifiable (those that can be altered by medication or lifestyle changes) or nonmodifiable (those we can’t change). The nonmodifiable factors include age, gender, race and family history of a stroke. The greatest modifiable risk factor is hypertension but others include diabetes, heart disease, high cholesterol, smoking and obesity.

The symptoms of a stroke depend on the area of the brain that is damaged. There are multiple possible symptoms of a stroke, including weakness of the limbs or face, numbness of the limbs and face, difficulty speaking, altered consciousness, poor coordination and difficulty swallowing. Anyone who develops such symptoms should be taken for immediate medical assessment and treatment. In some patients, thrombolytic (“clot-busting”) medications can be given to limit the damage caused by the clot in the blood vessel. The development of great early medical care has been able to save the lives of many persons afflicted by a stroke over the years.

After emergency care and medical stabilization of an individual who had a stroke, early and ongoing rehabilitation is crucial to restore maximum physical functioning. In developed countries, there are inpatient rehabilitation units where stroke survivors participate in intensive early rehabilitation. In this setting, the physiatrist will take the role of a leader of an interdisciplinary team which works to achieve the best possible outcome for each patient during the stay on the unit. This team will include physical therapists, occupational therapists, speech therapists, nurses and social workers. The physiatrist also monitors the progress of rehabilitation, manages complications after stroke, advocates for the best possible care and coordinates the rehabilitation process. He/She will continue to perform these important roles in the outpatient setting after the patient is discharged from the rehabilitation unit. Prior to discharge home, mobility aids such as canes or wheelchairs are prescribed along with other required medical equipment such as shower chairs and commodes (bedside toilet).

Some post-stroke complications that the physiatrist may have to manage include shoulder pain (which may be caused by several different conditions) and spasticity (abnormally increased muscle tone). These conditions may require further therapy or injections to assist with pain relief and return to maximum physical function. A brace for the leg may be prescribed to assist with achieving a more normal and energy efficient gait.

We can see that rehabilitation after a stroke is crucial to restoring maximal physical function and ensuring the best quality of life. The physiatrist plays a very important role during this process and should be involved in the care of all stroke patients at an early stage in order for these patients to have the best possible outcome.

Management of Wrist and Hand Pain

By Dr. Shane Drakes

The wrist connects the forearm and the hand. It is a complex region containing many different bones and ligaments. The arrangement of the bones and ligaments allows the hand to have significant mobility while maintaining stability. The hand also is made of several bones and ligaments which are arranged as individual digits (the fingers). The position and mobility of the first digit (thumb) is crucial to normal hand function which is essential for performance of the activities of daily living and participation in many sports. The bones of the fingers also serve as points of origin for small muscles in the hand and points of insertion for the tendons of the muscles which flex (bend) or extend (straighten) the wrist and fingers. Important nerves and blood vessels also pass through the wrist on the way to the fingers.

There are many possible causes to consider in a person who has wrist or hand pain. The complexity of the areas means that pinpointing the exact cause of the patient’s pain is not always straightforward. A proper history must be obtained as this will contribute significantly to the physician’s ability to make to make the correct diagnosis. Factors that must be considered include the past medical history, history of a single episode or repetitive trauma and a job or participation in a sport that requires repetitive use of the wrist and hand. Today, we will discuss a few conditions which may lead to pain in these regions of the body:

  • Dequervain’s tenosynovitis
  • Carpometacarpal (CMC) osteoarthritis (OA)
  • Stenosing tenosynovitis (Trigger finger)

The tendons of the muscles which extend the wrist and fingers pass over the back of the wrist on their way to their insertions on the bones of the fingers. The tendons are surrounded by coverings known as synovial sheaths which help to prevent friction from the bones or ligaments in the area. The tendons pass over the wrist in six groups called compartments. Persons who do activities involving repetitive wrist or thumb motion may get swelling of two tendons which attach to the thumb. This condition is called Dequervain’s tenosynovitis. It causes pain in the area of the base of the thumb on the back of the wrist, along with swelling and tenderness. These symptoms can be worsened with thumb movement or ulnar deviation of the wrist (moving the hand toward the inner forearm bone).

CMC osteoarthritis refers to arthritis at the base of the thumb. This has the same causes as osteoarthritis in other areas of the body. The initial symptom is usually pain in the area when gripping objects or using the thumb forcefully. Other symptoms include swelling, stiffness and tenderness in the area as well as decreased range of motion and grip strength. These symptoms can make it very challenging to complete activities of daily living. The base of the thumb can appear deformed as bony enlargement occurs in the late stages of the disease.

In trigger finger, the flexed (bent) finger remains stuck in a flexed position when trying to extend (straighten) it. It may then extend spontaneously with a snap (like a trigger being pulled and released) or the individual may need to use the other hand to straighten it. Repetitive trauma causes inflammation in the sheath surrounding the tendons that flex the finger. This leads to a nodule (swelling) developing in the tendon. This nodule prevents normal movement of the tendon and causes the sticking and triggering when trying to extend the finger. Apart from the triggering, there may be pain in the area of the nodule. This condition is more common in persons with diabetes.

The rehabilitation specialist has an important role to play in management of wrist and hand pain. A thorough evaluation will suggest the cause of the pain in most patients. Where necessary, imaging such as x-rays, ultrasound or MRI will be ordered to confirm the diagnosis. The treatment plan can be designed once the correct diagnosis has been made and will usually include occupational therapy. Pain control and education of the patient about the diagnosis are other cornerstones of management of wrist and hand conditions. Pain control may require use of oral medications or a steroid injection into the appropriate area. A thumb spica splint will be useful in patients with Dequervain’s tenosynovitis and CMC OA. In patients who have severe injuries, fractures or conditions which are not responding to appropriate conservative treatments, referral to an orthopedic surgeon will be provided for an evaluation for surgical treatment of the disorder.

If you have severe wrist or hand pain or your pain is not resolving within a short period of time, a thorough evaluation is the first step to regaining optimal physical function.

Dr. Shane Drakes is a Specialist in Physical Medicine &Rehabilitation and Sports Medicine. He can be contacted at sdoptimalfunctioning@gmail.com.

Keeping Youth Athletes in the Game

By Dr. Shane Drakes

We previously discussed the preparticipation physical evaluation (PPE) which should be completed prior to participation in competitive sports. After making sure that our young sportspersons can safely participate in sports, we need to do all we can to ensure that they remain able to practice and compete as much as possible. In order to do this, we have to tackle the most common reasons which cause youth athletes to miss practice and competition, including:

  • Acute injuries
  • Overuse injuries
  • Overtraining syndrome (previously called “burnout”)

football-injured

Acute injuries in youth sports can affect any part of the body and can range from something as simple as a muscle strain to serious injuries such as fractures and concussions. Factors which may contribute to the occurrence of acute injuries in youth athletes include:

  • Gender- girls have been found to have higher incidence of knee injuries than boys
  • Previous injury
  • Rapid growth
  • Poor dynamic balance
  • Muscle weakness
  • Poor flexibility
  • Heavier weight or higher body mass index (BMI)

doctor121_sporting-injuries

Interventions to reduce the incidence of acute injuries include performing a warm-up before activity, balance training and possibly stretching. Qualified coaches, proper sports technique, safe and well-maintained sporting environments and the use of proper protective sporting equipment during practice and competitions also reduce the incidence of acute injuries in youth athletes. A well-designed preparticipation physical evaluation can identify some risk factors for injury and recommendations can be made to minimize the effects of these factors.

Overuse injuries can occur in all age groups but in the youth athlete overuse leads to unique injury patterns. This occurs as a result of the differences in the structure of growing bone compared to adult bone. Whereas adults get injuries of their tendons, youth athletes get injuries to the apophyses (sites where tendons attach to the bones). This occurs because these attachment sites are weakly attached by to the main bone by cartilage. Some overuse injuries also lead to injuries to the physes/growth plates (areas which contribute to the lengthening of bone). Risk factors for overuse injuries are similar to those for acute injuries as well as poor coaching and technique. These injuries can affect many different areas of the body. The pain from an overuse injury can progress as follows:

  1. After physical activity
  2. During the activity, with normal performance
  3. During the activity with impaired performance
  4. Chronic, persistent pain even at rest

growing-bone
physeal-injury

Recognition of these injury patterns in different areas of the musculoskeletal system in youth athletes and correlation with specific activities has led to development of guidelines for activity participation in youth sports in several developed countries. These include pitch counts in baseball and directives pertaining to fast bowling in youth cricket. Adherence to these guidelines can prevent the occurrence of overuse injuries in young sportspersons and keep them in the game.

In order to improve sporting performance, training needs to be undertaken and it should get progressively tougher. When training progresses appropriately in a healthy athlete who has an adequate recovery period, there is adaptation to the training stress resulting in improved performance. Inappropriately rapid or tough training progression and inadequate recovery periods can lead to the development of overtraining syndrome (sometimes called burnout). The initial symptoms of this disorder are fatigue and impaired sporting performance but multiple systems in the body are affected leading to other symptoms in addition to the overuse injuries that will likely occur as a result of excessive training. Single sport specialization (intensive year-round training in a single sport at the exclusion of all other sports) has become more common in young athletes who demonstrate prowess in a particular sport at an early age. This phenomenon contributes to the overtraining syndrome which may require a prolonged recovery period and can lead to some youth athletes quitting their sports.

The preparticipation physical evaluation provides a good start towards preventing injuries and the overtraining syndrome. In addition to prior injuries, important information that can be elicited includes the amount of time spent in training and competition, parental pressure, athlete happiness and coach involvement. Recommendations can be made to manage any risk factors that can lead to injury and management of injuries can be done in a timely fashion.

Recommendations to avoid overuse and the overtraining syndrome can also be made. These include limiting sport participation to a maximum of five days per week, at least 7 hours sleep each night and taking at least 2-3 months off competitive sports to rest, manage injuries and undergo strength and conditioning. If an injury or decreased performance occurs, a consultation with a qualified sports medicine professional should be arranged.

overtraining-symptoms

Parents, coaches, athletes and any other persons involved in youth sports should be aware of these issues so that our athletes can continue to perform at their best.

Dr. Shane Drakes is Specialist in Physical Medicine & Rehabilitation and Sports Medicine. He can be contacted at sdoptimalfunctioning@gmail.com.

Managing Low Back Pain

By Dr. Shane Drakes

Low back pain is an extremely common condition with some studies showing that 80% of people have had at least one episode of low back pain during their lifetime. While most episodes of pain eventually resolve, in a small percentage of people, it becomes chronic. This is a major cause of disability and lost productivity and has significant costs to the society.

The lumbar spine is made up of five vertebrae separated from each other by the intervertebral discs which act as shock absorbers. The vertebrae are joined by the zygapophyseal (facet) joints formed by the articular processes of adjacent vertebrae. The arrangement of the vertebrae forms the spinal canal which houses the spinal cord and the nerve roots. The neural foramina are also formed by the arrangement of the vertebrae and these provide passage for the nerve roots which supply muscle power and sensation to the back and lower limbs. The arrangement of the facet joints allows flexion and extension of the lumbar spine but limits rotation and this limits rotational stress on the discs. Ligaments assist in providing stability to the lumbar spine and the muscles of the lower back extend the spine. The actions of these muscles, coordinated with the actions of muscles in the abdomen, hip girdle and pelvic stabilizers contribute greatly to core stability, which plays a great role in protecting the spine from excess loads.

spinal-anatomy

There are many causes of low back pain but some of the more common ones include:

  • Mechanical low back pain
  • Facet arthropathy
  • Discogenic pain
  • Spondylolysis

Mechanical low back pain is the diagnosis that best suits the majority of persons who present with low back pain. In these patients, there are likely multiple possible factors contributing to the pain such as:

  • Poor core muscle strength
  • Poor flexibility
  • Habitual poor posture
  • Degenerative spinal changes as a result of aging or injury

Discogenic back pain arises from the intervertebral disc and occurs as a result of degeneration of the disc due to repetitive microtrauma. Tears in the disc may lead to internal disc disruption where the nucleus pulposus (gelatinous center of the disc) breaks down. This causes loss of disc height which leads to spinal instability and increases the likelihood of nerve root compression. It also leads to instability of the facet joints which can result in or worsen OA. The nucleus pulposus may also be squeezed out of the disc in a process called disc herniation. This may cause irritation of the nearby nerve root by direct pressure or from release of irritant chemicals. Dysfunction of the nerve root may occur as a result and this is known as a radiculopathy (nerve root damage). This results in leg pain more so than back pain, possible weakness and abnormal sensation in the leg.

disc-problems

Experts believe that abnormal movement patterns and alignment of the segments of the spine leads to minor stress on the spine which later leads to major stress and degeneration of the spine, leading to pain.

Facet arthropathy is the presence of changes associated with osteoarthritis (OA) in the joints of the lumbar spine. The degenerative process follows a similar pattern as that described for OA and is a result of aging and repetitive microtrauma. It results in an enlarged joint which is a source of low back pain. The enlarged joint can also make the passages for the spinal cord and nerve roots narrow and potentially compress these structures, leading to other problems.

Spondylolysis is a common cause of low back pain in young sportspersons. It is caused by a stress fracture of the pars interarticularis due to repetitive hyperextension of the spine, especially if combined with rotation. It is common in gymnasts, tennis players and young fast bowlers among others. The pain is worsened with spinal extension and alleviated by rest.

Proper management of low back pain requires a thorough evaluation so that an accurate diagnosis can be made. The foundation of back pain treatment is physical therapy with particular focus on core stabilization and this may be all that is needed for mechanical low back pain. Pain control with oral medications, modalities, local muscle injections or acupuncture may also prove helpful. However, someone with facet arthropathy or spondylolysis will likely need modifications to their exercise program so extension can be limited as it would worsen the pain during therapy. Persons with leg pain being more problematic than back pain likely have nerve compression and may need investigations such as an MRI or nerve testing. Other measures may be needed to manage the problem and these may include spinal steroid injections or surgery in some cases.

spondylolysis

Low back pain which doesn’t resolve within 2 weeks should be properly evaluated so you can get on the road to regaining optimal physical function.

core-stability

Dr. Shane Drakes is Specialist in Physical Medicine & Rehabilitation and Sports Medicine. He can be contacted at sdoptimalfunctioning@gmail.com.

Management of Buttock Pain

By Dr. Shane Drakes

Pain in the buttock region may not be as common as in other areas of the musculoskeletal system but in some cases it can be severe enough to affect sitting, walking or running and negatively affect a person’s quality of life.

The buttock region extends from the iliac crest (the top of the pelvic bones) to the gluteal folds (the where the buttock ends and the back of the thigh begins). As with all other areas of the musculoskeletal system, the buttock is made up of bones and joints, ligaments which assist with stability, muscles which allow for movement and nerves which provide power to the muscles and sensation to the skin. The bones of the buttock region are the pelvic bones and the sacrum and coccyx which form the lower segment of the spine. The sacrum is joined to the pelvic bones on each side at the sacroiliac (SI) joints. The stability of the SI joint is maintained by strong ligaments in the region. The muscles of the buttock include the three gluteal muscles which are closer to the surface and the deeper muscles which rotate the thigh outwards and help to keep the hip joint stable. The tendons of the hamstring muscles are also attached to the pelvis. The sciatic nerve is a major nerve in the lower limb and this passes through the buttock on the way to the thigh, leg and foot.

gluteal-muscles

si-joint-anatomy

Common causes of buttock pain include:

  • SI joint dysfunction
  • Hamstring tendon origin pain
  • Piriformis conditions
  • Referred pain from the lumbar spine

SI joint dysfunction refers to either restricted or excessive mobility of the joint. This causes stress on the surrounding structures. Risk factors for development of this condition include:

  • Muscle imbalance around the hip
  • Leg length discrepancy (one leg longer than the other)
  • Biomechanical abnormalities in the lower limbs

Patients with this condition have buttock pain that feels deep, possibly pain with ascending/descending stairs and tenderness over the joint. The pain can travel down into the thigh in some cases. Pregnant women are at increased risk of SI joint dysfunction as a result of hormones causing the surrounding ligaments to relax.

The hamstrings originate from the ischial tuberosity and this is a possible source of pain. In adults, an injury to the tendon at the origin may occur after an acute tear or as a result of overuse. The severity can range from minor tendon tears to the tendon being torn from the bone. In adolescents, a similar injury can result in an avulsion fracture (piece of bone being pulled off) if severe. This occurs because the bones are not fully fused in this age group and the tendon is stronger than the bone. An injury at this site results in buttock pain which may extend into the back of the upper thigh, with worsening with sitting, standing or attempting to walk.

hamstring-tendon-rupture

The piriformis muscle starts at the sacrum and attaches to outer part of the upper femur (thighbone). It rotates the thigh outward and helps to maintain hip joint stability. It can be affected by trauma, overuse in repetitive, vigorous activities such as long-distance running and prolonged sitting. Conditions affecting this muscle include strain and piriformis syndrome. In the latter condition, other symptoms include numbness, tingling or a burning sensation in the back of the thigh and leg. These symptoms occur as a result of compression of the sciatic nerve by the piriformis, as a result of an enlarged muscle or abnormal path travelled by the nerve.

piriformis-syndrome

In some patients, buttock pain is a result of pain referred from the lumbar spine. The source may be the joints in the lower spine or a herniated disc which may be pushing on a nerve root. In such a case, there will also likely be other symptoms such as back pain, numbness, tingling or burning pain in the leg or weakness of the leg. These other symptoms may be made worse by adopting particular postures.

Appropriate management of buttock pain requires a thorough evaluation to diagnose the cause of the pain. This includes a good history and proper physical examination. In some patients, imaging studies such as x-rays, ultrasound or MRI may be required to help confirm the diagnosis. In patients who have a herniated disc with nerve damage, nerve conduction studies and electromyography will be needed to confirm the presence and severity of the nerve damage. The rehabilitation specialist possesses the knowledge and skills to accurately diagnose the source of the pain and arrange appropriate treatment. This will usually include physical therapy/therapeutic exercises and pain management using oral or injected medications. Patients with herniated discs causing nerve compression or patients with severe hamstring injuries may require referral for surgery.

Get evaluated if you have buttock pain that is not resolving so you can start your journey back to optimal physical function.

Dr. Shane Drakes is Specialist in Physical Medicine & Rehabilitation and Sports Medicine. He can be contacted at sdoptimalfunctioning@gmail.com.

Hip Pain

By Dr. Shane Drakes

Pain in the hip region is quite common and can affect any age group. The presence of conditions leading to such pain can negatively affect mobility, participation in sporting activities and quality of life.

The hip transmits loads between the upper body, trunk and lower limb, allows mobility of the lower limb and provides a stable base when standing.

The hip joint is formed between the acetabulum (socket) of the pelvis and the head (ball) of the femur (thighbone). These areas of contact in the joint are covered with cartilage. The labrum is a ring made of a stiffer type of cartilage and connective tissue which is attached to the rim of the acetabulum. The labrum deepens the acetabulum and distributes the stress between the two bones over a larger area. The arrangement of the bones of the hip allows for movement along three different paths. Stability is provided by multiple strong ligaments as well as multiple muscles. These muscles, along with others, are responsible for movement of the hip.

hip-joint-and-ligaments

hip-muscles

In general, causes of hip-related pain can be classified as anterior (in the front) or lateral (on the side of the thigh). A few common ones include:

  • Osteoarthritis (OA)
  • Femoroacetabular impingement (FAI)
  • Tendon injuries
  • Greater trochanteric pain syndrome (GTPS)

OA is a progressive disorder of the joints which leads to deterioration of the cartilage and new bone formation at the surface and margins of the joints. There is no inflammation in this disorder. Risk factors for OA in the hip include age, genetics, joint disorders in childhood, metabolic disorders and prior trauma.

Symptoms of hip OA include pain in the groin, stiffness, difficulty walking and increased pain with some activities such as getting into/out of a vehicle or sitting on the toilet.

hip-arthritis

FAI is a condition resulting from the presence of bone in abnormal areas on either the femoral head or acetabulum or both. The abnormal areas of bone make contact with other areas during specific movements, leading to pain and restricted range of motion. The labrum and cartilage can be damaged when this process occurs repetitively and can possibly lead to OA of the hip. Symptoms of this condition include groin pain, a locking or clicking sensation, stiffness and decreased range of motion.

Common tendons injured around the hip include the adductor group (work to close the legs) and the iliopsoas (lifts up the lower limb). The adductors are usually injured in a “groin strain” in a sportsperson. Symptoms of injury of one of these tendons include groin pain which is worse with activity, possible decreased range of motion and decreased muscle strength.

On the lateral aspect of the hip, there are tendons of the gluteal muscles as well as bursae (small sacs of fluid) which protect the tendons and muscles from friction caused by rubbing on the greater trochanter (bony prominence). Any of these structures (or a combination of structures) can be affected and cause pain on the side of the upper thigh. This condition is known as greater trochanteric pain syndrome (GTPS). This pain can extend down the side of the thigh and worsen while lying on the affected side or after walking or running. Weakness of the affected muscles may also be present on examination. Risk factors for this condition include:

  • Trauma
  • Prolonged pressure to the hip area
  • Repetitive movements (walking/running)
  • Commencing unaccustomed vigorous exercise
  • Standing on one leg for long periods

The rehab doctor can play a significant role in the management of hip related pain. A thorough evaluation (history and physical examination) leads to an accurate diagnosis. The diagnosis can be confirmed with tests such as x-rays, ultrasound or MRI. In the case of OA, x-ray can also assist with judging the severity of the condition. Management of hip-related pain requires pain management using oral or injected medications, a properly planned and executed rehabilitation program for the diagnosed condition. In cases of severe OA or other indicated conditions, a referral to an orthopedic surgeon will be made so that restoration of function can occur.

trochanteric-bursa

If you have hip-related pain which is not resolved after 2 weeks, you should have a thorough evaluation as your first step towards regaining optimal physical function.

Dr. Shane Drakes is Specialist in Physical Medicine & Rehabilitation and Sports Medicine. He can be contacted at sdoptimalfunctioning@gmail.com.

Common Knee Problems

By Dr. Shane Drakes

Pain in the knee is a very common complaint and can affect any age group. The knee is one of the largest and most complex joints in the human body and impaired knee function results in limited mobility, difficulty in performing activities of daily living and reduces participation in sports.

The knee joins the thigh to the leg and is essential for normal movement. The knee joint has two components- the tibiofemoral joint (articulation between the thighbone and shinbone) and the patellofemoral joint (articulation between the kneecap and the thighbone). These joints get stability from multiple ligaments with additional stability provided by the surrounding muscles. The tibiofemoral portion also has a meniscus on each side and these menisci act as shock absorbers, help to stabilize the knee and protect the cartilage from damage.

There are multiple possible causes of knee pain but the acute (sudden onset) knee injuries are those which are feared most by sportsmen. These injuries may be traumatic or non-traumatic in origin and can involve ligament, meniscus or tendon tears, joint dislocations, cartilage injury or fractures. These injuries can end sporting careers and put the sportsperson at risk of early onset of arthritis in the knee.

Common causes of non-acute knee pain include:

  • Osteoarthritis (OA)
  • Patellofemoral pain syndrome
  • Tendinopathy
  • Osgood-Schlatter disease in adolescents

OA is a progressive disorder of the joints which leads to degeneration of the cartilage and new bone formation at the surface and margins of the joints. Risk factors for OA in the knee include age, genetics, joint disorders in childhood, metabolic disorders, prior injury and obesity. Symptoms of knee OA include pain with activity, stiffness after resting and impaired mobility. As the condition progresses, deformity of the knee is usually noted.

Patellofemoral pain syndrome refers to pain in and around the patella (kneecap). The patella moves within the trochlea (groove) of the femur when the knee is flexed (bent). This movement is controlled by the muscles of the quadriceps attach to the upper part of the patella. Activities such as climbing stairs can increase the force acting on the patellofemoral joint to as high as 8 times bodyweight. Factors which increase the force or affect how this force is distributed can lead to the patellofemoral pain syndrome. These include repetitive activities, biomechanical abnormalities of the femur, knee, tibia or foot, abnormal patella position, abnormally tight or loose stretched soft tissues, poor flexibility and poor muscle control. In addition to pain felt around the patella, other symptoms include aggravation by running, climbing stairs or prolonged sitting and cracking/creaking under the patella when moving the knee.

There are multiple tendons around the knee which can be affected by overuse, especially if combined with poor sporting technique. Patellar tendinopathy (jumper’s knee) is one of the most common tendinopathies in the knee and results from repetitive jumping activities and causes pain at the lower part of the patella. Other activities that result in other tendons being affected include repetitive acceleration and deceleration (as can occur in cycling and running) and repetitive downhill running.

Osgood-Schlatter disease affects the tibial tuberosity (bony prominence below the patella) in growing adolescents. The patellar tendon exerts a powerful pull on this bony area which has not yet fused to the tibia and leads to pain. Some children who are highly active during the period of rapid growth which occurs when puberty starts may suffer from this condition. The pain is localized to the affected area and is worsened by activity which leads to activity restriction- this varies from case to case.

The rehabilitation/sports medicine physician plays a vital role in the management of knee pain. This begins with a comprehensive evaluation (including history-taking and physical examination) to diagnose the cause of the pain. In some cases, imaging such as x-rays, ultrasound or MRI may be needed to confirm the diagnosis. Once the condition is diagnosed, patient education can begin and the individualized treatment plan can be created. This will usually include an exercise program which may be led by a physical therapist or by the patient. Pain control is essential and this would be achieved by avoiding aggravating activities and use of oral or injected medications as necessary. In cases of severe OA or if otherwise indicated, a referral for surgery would be made.

Knee pain which is not improving after a short period of relative rest and pain medications or which is worsening should be evaluated. This will help accelerate the process of returning to optimal physical function.

Common Ankle Conditions

By Dr. Shane Drakes

Pain in the ankle is a common complaint which can affect persons at any stage of life. Ankle pain and impaired knee function result in limited mobility, difficulty in performing activities of daily living and reduces the ability to participate in sports.

The ankle connects the leg to the foot and is a complex region which is essential for normal mobility. The ankle consists of three different joints which have different contributions to ankle function:

  • The tibiotalar (true ankle) joint- formed between the tibia (shinbone) and the talus. Dorsiflexion (bending the foot upwards) and plantarflexion (bending the foot downwards) occur at this joint.
  • The inferior tibiofibular joint- formed by the lower parts of the tibia and fibula (calf bone). This joint is important for normal ankle function, despite the minimal movement there.
  • The subtalar joint- formed between the talus and calcaneus (heel bone). It provides shock absorption, allows the foot to adjust to uneven ground and allows inversion and eversion (turning the foot inward and outward).

Ankle stability is achieved by the anatomical configuration of the bones as well as multiple ligaments which help to provide extra stability. Multiple tendons pass through the ankle region and attach to bones in the foot.

Common causes of ankle pain include:

  • Ankle sprains
  • Tendinopathy (tendon disease)
  • Retrocalcaneal bursitis
  • Sever’s disease in adolescents

An ankle sprain involves damage to the ligaments which provide stability to the ankle joint. The ligaments are found on the medial (inside) or lateral (outside) sides of the ankle. The lateral ligaments are more often involved in sprains as they are weaker than those on the medial side. The injury is most often caused by the foot suddenly turning inwards. The severity of the sprain can range from damage of one ligament, causing limited impairment, to damage to multiple ligaments, leading to ankle dislocation and requiring surgery. Symptoms of an ankle sprain include ankle pain, swelling, tenderness, possible skin discolouration and difficulty standing or walking.

There are multiple tendons passing through the ankle region to attach to bones in the foot. On the lateral side, there are the peroneal tendons, the tibialis posterior tendon is the major one on the medial side and the Achilles tendon on the posterior (back) aspect of the ankle. There are multiple tendons on the front of the ankle but these are much less commonly involved. Tendinopathy can range from simple inflammation of the tendon to complete rupture of the tendon. Biomechanical abnormalities and overuse are the most common causes of tendinopathy. Symptoms include pain, swelling of the affected area, tenderness and weakness of ankle/foot movement.

The retrocalcaneal bursa is a cushion of fluid found between the Achilles tendon and the calcaneus. Repetitive trauma or overuse can lead to inflammation of the bursa which is aggravated by pressure, such as from tight shoes. In some cases, the inflammation is caused by the bursa being squeezed between the Achilles tendon and an abnormally prominent calcaneus (pump bump). Symptoms include pain, swelling, tenderness and difficulty walking.

In growing children, the calcaneus is not fully fused together and the Achilles tendon can pull on the area where it attaches and lead to significant pain. This condition is called Sever’s disease (calcaneal apophysitis) and is the result of overuse in very active growing children. Symptoms include pain with activity, localized swelling and tenderness.

The rehabilitation/sports medicine physician plays a vital role in the management of ankle pain. This begins with a comprehensive evaluation (including history-taking and physical examination) to diagnose the cause of the pain. In some cases, imaging such as x-rays, ultrasound or MRI may be needed to confirm the diagnosis. Once the condition is diagnosed, patient education can begin and the individualized treatment plan can be created. This will usually include an exercise program which may be led by a physical therapist or by the patient. Pain control is essential and this is achieved by avoiding aggravating activities and use of oral or injected medications as necessary. The use of heel lifts or change of footwear may be required. In cases where indicated, a referral for surgery is made.

Ankle pain which is not improving after a short period of relative rest and pain medications or which is worsening should be evaluated. This will help accelerate the process of returning to optimal physical function.

Dr. Shane Drakes is Specialist in Physical Medicine & Rehabilitation and Sports Medicine. He can be contacted at sdoptimalfunctioning@gmail.com.

Common Foot Conditions

By Dr. Shane Drakes

Foot pain is a very common complaint especially in older persons. It is a significant cause of limited mobility, making it difficult to perform activities of daily living and hindering sports participation.

The foot is a complex region which is important for bearing the weight of the body and for locomotion. Multiple bones (tarsals, metatarsals and phalanges) and joints give the foot its shape and multiple ligaments help to maintain the stability of the foot. The muscles and tendons in the foot are crucial for movement. The tendons also assist the ligaments with maintenance of the arches of the foot. The foot is divided into three distinct regions- rear foot, midfoot and forefoot.

There are multiple causes of foot pain and we will consider some of the common ones according to the anatomical region involved:

  • Rear foot- plantar fasciitis
  • Midfoot- midfoot joint impingement/arthritis
  • Forefoot- disorders of the region of the hallux (big toe)

The plantar fascia originates on the calcaneus (heel bone) and attaches to the toes and is a very important structure. It provides support for the arch of the foot and plays a role in shock absorption while walking and running. Overuse can initiate a degenerative process at the attachment of the plantar fascia to the calcaneus. This causes gradual onset of pain in the heel, initially worst in the morning and getting better with activity. As the condition worsens, pain may be more constant and worsen with activity. Risk factors for this condition include:

  • Flat feet or high arches
  • Repetitive sporting activities
  • Abnormal lower limb biomechanics
  • Excessive walking
  • Inappropriate footwear
  • Obesity

The midfoot forms the top of the arch of the foot and is susceptible to problems if the arch sags or collapses. If the arch collapses, the normal relationship of the bones is lost and there is abnormal contact between them (impingement). If this happens repeatedly over a period of years, joint damage occurs and leads to arthritis in that region. Symptoms would include pain with walking, running, or other weight-bearing activities which generally grows worse throughout the day. The pain can be felt on the outside or inside of the midfoot initially and later may be present across the entire region. Swelling may also be present in the affected area. Risk factors for these problems include:

  • Age
  • Overweight
  • Tight calf muscles
  • History of tendinopathy contributing to a collapsed arch
  • Overuse
  • Poor footwear

Many of the causes of forefoot pain affect the region of the hallux, especially the area of the 1st metatarsophalangeal (MTP) joint. These are mostly caused by overuse except for 1st MTP joint sprain (“turf toe”) which is caused by forced hyperextension at the joint. This leads to pain, swelling and tenderness and painful or restricted range of motion at the joint. Other causes of pain in this area include hallux limitus and hallux valgus (bunion). In hallux limitus, there is restriction of dorsiflexion (bending upward) at the 1st MTP joint due to development of osteoarthritis. This leads to gait abnormality and the condition may progress to “hallux rigidus” where there is complete restriction of movement. Hallux valgus refers to deviation of the big toe towards the other toes. Osteoarthritic changes occur over time and may become severe enough to restrict joint range of motion. There is also pain over the 1st MTP joint with pressure from shoes. Risk factors for these 2 conditions include:

  • Trauma
  • Biomechanical abnormalities
  • Tight shoes (hallux valgus)

The rehabilitation/sports medicine physician plays a vital role in the management of foot pain. This begins with a comprehensive evaluation to diagnose the cause of the pain. In some cases, imaging such as x-rays, ultrasound or MRI may be needed to confirm the diagnosis. Once the condition is diagnosed, patient education can begin and the individualized treatment plan can be created. This will usually include an exercise program which may be led by a physical therapist or by the patient. Pain control is essential and this is achieved by avoiding aggravating activities and use of oral or injected medications as necessary. The use of heel lifts, heel cups, orthotics or change of footwear may be required. In cases where indicated, a referral for surgery is made.

Foot pain which is not improving after a short period of relative rest and pain medications or which is worsening should be evaluated. This will help accelerate the process of returning to optimal physical function.

The Dangers of High Heels

By Dr. Shane Drakes

Common causes of ankle and foot pain were discussed previously but one very important cause of these problems was omitted- HIGH HEEL SHOES. This article will focus on the possible dangers of excessive use of high heels and what can be done to help prevent such consequences.

Why do women wear high heels? There are multiple reasons including

  • Trying to look more professional at work
  • Making the legs look longer
  • Accentuating an outfit
  • Trying to appear taller
  • Trying to appear more attractive
  • Improved self-esteem and confidence

Unfortunately, the potential consequences of long term excessive use of high heels can significantly outweigh the short-term benefits that may be gained. Significant pain and deformity may result and in some cases, may require corrective surgery which can be costly and associated with a long recovery. Some of these include:

  • Corns and calluses
  • Making bunions worse
  • Ingrown toenails
  • Low back pain
  • Joint pains in the lower limb
  • Shortened Achilles tendon

The development of corns, calluses and ingrown toenails is related to the height of the heel of the shoe and the width of the toe box. The higher the heels, the greater the slope between the ball of the foot and the heel. Increasing the slope increases the tendency for the foot to slide forward and strike the front and sides of the shoe, corns and ingrown toenails. A higher slope also increases the pressure on the ball of the foot resulting in calluses being formed. A narrow toe box, which is common in pointy toe high heels increases the likelihood of these conditions and can contribute to the development of or worsening of bunions. A bunion can lead to pain and difficulty in wearing some footwear due to pressure over the area.

Increased pressure on the balls of the feet when wearing high heels leads to the pelvis tilting forward. The body compensates by increasing the arch in the lower back to keep upright. This puts abnormal strain on the spine and can also cause muscle overuse. These factors can cause back pain or worsen an existing back problem.

High heels lack shock absorption and prevent the natural rotation of the foot which occurs while walking. These factors mean that the ankles and knees act as shock absorbers and this can cause pain or worsen preexisting arthritis symptoms. Wearing heels also means that your ankle supports most of the weight of the body and causes impaired balance, leading to sprained ankles and possibly falls. Prolonged increased pressure on the balls of the feet decreases the padding in that area and causes significant pain.

The calf muscles attach to the heel bone via the Achilles tendon. Excessive use of high heels can lead to shortening of these structures which impairs ankle joint mobility. The body compensates by causing abnormal movement at other joints. One of these compensations, midfoot pronation, causes flattening of the arch of the foot, pain in that area and possibly midfoot arthritis in the future. Some injuries that can result from the shortened calf structures include:

  • Achilles Tendinitis/ tendon tear
  • Calf strain
  • Ankle sprain
  • Runner’s Knee
  • Plantar Fasciitis

What can be done to prevent the harmful consequences of wearing high heel shoes? There are some measures that can be tried:

  • Avoid wearing high heels for prolonged periods
  • Stretch the calf muscles regularly
  • Limit the height of the heels
  • Avoid pointy toe heels
  • Buy shoes in the afternoon when feet are at their largest
  • Shoes with leather insoles stop feet from sliding forward
  • Vary your shoe choices

For persons who may have already developed complications, seeing the appropriate specialist is important to guide care. Ingrown toenails, corns and calluses are treated best by a podiatrist. Back and joint pains can be managed by a rehabilitation specialist who may also be able to provide strategies to manage a shortened Achilles tendon. Any corrective surgeries would have to be carried out by an orthopedic surgeon with expertise in performing foot surgery. Of course, all efforts will be in vain if you keep wearing those high heels!

Dr. Shane Drakes is a Specialist in Physical Medicine & Rehabilitation and Sports Medicine. He can be contacted at sdoptimalfunctioning@gmail.com. You can see more educational articles at www.optimalfunctions.com

Common Track and Field Injuries

By Dr. Shane Drakes

This is the term for track and field or “sports term”. Each school will have their Track and Field Championships, there will be several weekend meets and everyone looks forward to NAPSAC, BSSAC and the Carifta Games. Unfortunately, every year, some promising athlete has his or her quest for glory halted by injury. Let’s discuss some of the injuries which can affect our athletes and what can be done to reduce the risk of such injuries.

In runners, the injuries will be in the lower limbs and the types of injuries sustained depend on the type of runner you are. Sprinters and hurdlers usually tend to have injuries which occur more suddenly (acute injuries) and involve strained muscles or tendons- most commonly the hamstrings. Other muscle groups which may be affected by acute injuries are the quads, adductors (groin area) and the calves. Groin and calf injuries in these types of runners may also occur gradually due to overuse. Hurdlers may also get acute injuries due to hitting the hurdles or falls and some of these include ligament damage at the ankle or the knee.

Distance runners tend to have more overuse injuries than acute injuries because they are not using the explosive movements of the sprinters and hurdlers. Two very common injuries are Achilles tendonitis and medial tibial stress syndrome (shin splints). Inflammation involving the muscle, tendon and bone surface causes shin splints which can progress to a stress fracture if not treated adequately. In some instances, stress fractures can occur in the feet or hip of distance runners due to overuse and other factors.

Jumpers may have acute injuries at take-off or landing (long jump or triple jump) and these include ankle or knee sprains or muscle strains. Much less commonly, more serious injuries such as tendon ruptures, joint dislocations or fractures may occur. Tendon injuries due to repetitive stress may also occur in the knee (patella tendon) and ankle (Achilles tendon). In high jump, similar injuries may occur but there can also be injury to the spine from repetitive spinal hyperextension.

In throwers, most injuries occur in the shoulder and include rotator cuff tendon injury and labral injury. Javelin throwers who use poor technique may also exert excessive force across the elbow of the throwing arm and damage the ligament on the inside region of the elbow (ulnar collateral ligament). Throwers do use their legs (javelin throwers most of all) and therefore may be vulnerable to injuries such as ankle sprains when they plant their feet before throwing the implement.

What can be done to reduce the likelihood of the injuries discussed? Firstly, all track and field athletes or those interested in becoming competitive athletes should have a preparticipation physical evaluation done prior to the start of training. This is important to ensure the athlete can participate in sporting activity safely and make sure there are no inadequately treated injuries. Screening can also be done for correctable risk factors for injuries such as poor flexibility and strength. It is crucial that coaches devise a proper training program for athletes such that improvement in performance can be made while ensuring proper technique, proper strength, conditioning and flexibility while avoiding overuse. Poor core strength can lead to abnormal compensatory body mechanics in athletes and increase the risk of injury so that should be addressed. Parents must also be involved in that process to make sure overuse is avoided- limiting extracurricular activity to a maximum of 5 days a week on average may be useful. Extra caution should be taken with children and younger adolescents as they may get injuries around the growth plates in the knee, ankle, shoulder or elbow and these lead to more serious problems. Athletes should report any injuries early so that appropriate treatment can be started early.

Track and field is an exciting sport and participation can be very rewarding. However, avoiding injury requires a team effort and should be high on the list of priorities of everyone involved.

Dr. Shane Drakes is a Specialist in Physical Medicine & Rehabilitation and Sports Medicine. He can be contacted at sdoptimalfunctioning@gmail.com. You can see more educational articles at www.optimalfunctions.com

Adding Exercise to Your Life

By Dr. Shane Drakes

Happy New Year to all! During this month, many persons will be seeking to add a regular exercise routine to their lifestyles. Regular exercise is beneficial for persons of all ages, levels of fitness and is also important for those who are known to have health challenges. Many of the benefits of exercise are mentioned regularly but we will discuss these in this article as well as some guidelines for an exercise routine.

Over the past few years it has been reported that the percentage of our citizens who are overweight or obese has been increasing. This trend has also affected the children- figures of 32% overweight and 14% obese were recently reported. Several publicized sudden deaths occurring in public spaces caused concern last year and these were thought to be the result of chronic, non-communicable diseases (NCDs) such as cardiovascular disease (heart attacks) and cerebrovascular disease (stroke). Inadequate physical activity has been linked to twenty-two harmful health conditions, including obesity, hypertension, type 2 diabetes, stroke, heart attack and cancer. A group of Australian researchers calculated the global cost of physical inactivity based on data on 5 diseases from 142 countries at $67.5 billion US. It is likely that the overall global cost of physical inactivity could be 3 to 4 times that amount.

There are multiple benefits of exercise including:

  • Improved cardiovascular health, strength and muscular endurance
  • Increased resistance to fatigue
  • Decreased risk of developing type 2 diabetes
  • Helps control hypertension, diabetes and elevated cholesterol
  • Reduced cancer risk
  • Decreased risk of osteoporosis
  • Along with dietary changes, assists with weight loss
  • Decreased anxiety, depression and stress

A good exercise program has several components:

  • Cardiorespiratory (aerobic)- walking, running, treadmill, cycling, elliptical, swimming
  • Resistance (strength training)- free weights, resistance bands, weight machines
  • Flexibility – stretching
  • Neuromotor- balance, coordination and agility

The American College of Sports Medicine has published guidelines for physical activity for persons of all ages. Children and adolescents should participate in 60 minutes of moderate to vigorous aerobic activity daily. These activities should be age appropriate, offer variety and be enjoyable. Adults should participate in 150 minutes of moderate aerobic exercise or 75 minutes of vigorous exercise weekly. All persons should do muscle strengthening activities at least 2-3 days per week. For young children, such activities can include climbing, jumping, tumbling and gymnastics while older children and adolescents can participate in supervised strength training programs with emphasis placed on using good technique. Flexibility and neuromotor exercises should be performed at least 2-3 days per week in all age groups. Neuromotor exercises are particularly helpful for the elderly to help reduce the risk of falls. Tai chi and yoga are good examples sources of neuromotor exercise. Persons unable to meet the requirements can still obtain benefit from whatever exercise they can tolerate.

How do you know if you are exercising at the correct intensity?

  • Light- you can easily sing while exercising and under most circumstances, you won’t break a sweat
  • Moderate- you can talk while exercising but not sing
  • Abnormal lower limb biomechanics
  • Vigorous- you will be breathing very rapidly and you will find it hard to talk while exercising

The Borg Scale (Rating of Perceived Exertion Scale) can also help you gauge how hard you are exercising.

Some persons will need a medical evaluation before starting a new exercise program. These include men over 45 and women over 55, those with known cardiovascular, pulmonary or metabolic diseases and those with more than 2 cardiovascular risk factors. Further testing may be necessary in some cases. Exercise is beneficial in those who suffered heart attacks and strokes once it is initiated under medical supervision. It can reduce the risk of another event, improve endurance, strength and physical function. Persons with joint pains should be evaluated and treatment started prior to beginning an exercise program. Consider a medical evaluation if any of these scenarios apply to you.

If you are planning to start an exercise program, the principles discussed in this article will be useful. If you need help, get a reputable, certified personal trainer for individual or group sessions and obtain great guidance in designing your exercise routine. You can get healthy, have fun and work towards optimal physical function.

Dr. Shane Drakes is Specialist in Physical Medicine & Rehabilitation and Sports Medicine. He can be contacted at sdoptimalfunctioning@gmail.com. You can see more educational articles at www.optimalfunctions.com.

The Truth About Steroids

By Dr. Shane Drakes

Steroid injections are a great option for pain relief. There seems to be a common misconception that all steroids in any form in any dosage given for any duration will cause unwanted complications. Nothing could be further from the truth.
There is NO danger in a properly administered steroid injection for pain relief as long as your doctor has discussed all possible risks with you and used all means possible to reduce those risks. Your doctor also looks out for your best interest in ensuring the injection is accurate by using ULTRASOUND GUIDANCE.

What are steroids? These compounds occur naturally in the body and are made from cholesterol. They fall into two categories:

  • Corticosteroids- cortisol and aldosterone
  • Sex hormones- testosterone, estrogen and progesterone

The corticosteroids and small amounts of the sex hormones are made in the adrenal cortex (outer part of the adrenal gland) while most testosterone and estrogen is made in the testicles and ovaries, respectively. Cortisol controls glucose metabolism, immune system function, cognitive factors such as attention and memory and normal development of the lungs and brain in babies in the womb. Aldosterone maintains the salt and water balance in the body and the sex hormones are necessary for reproductive function and secondary sexual characteristics.

Steroids are manufactured for medical purposes to treat persons with symptoms related to deficiency of the respective hormone. Glucocorticoids (cortisol and related compounds) are also used to treat various autoimmune and inflammatory conditions including asthma, lupus, rheumatoid arthritis and many others. They are also used to prevent rejection after organ transplant and are commonly used to treat joint, tendon, ligament and nerve pain. Administration is usually oral but may be inhaled for asthma and topical for some skin conditions.

The possible adverse effects of steroid INJECTIONS for pain include:

  • Infection
  • Bleeding
  • Elevated blood glucose in diabetics
  • Fat atrophy
  • Skin hypopigmentation (skin in the area turns white)
  • Flare reaction (sudden worsening of pain)
  • Tendon rupture

Elevated blood glucose levels usually return to normal within 5 days. Close monitoring and possibly increased medication for a few days (under medical supervision) is usually sufficient to manage this problem if it occurs. The flare reaction can result from the crystals in the steroid and can be managed by using an anti-inflammatory medicine. The other problems can be avoided by finding out if the patient is on any blood thinners, using sterile injection technique and ensuring accuracy. Fat pad atrophy in the heel or tendon rupture will produce more disability than what existed before the injection. The use of ULTRASOUND GUIDANCE minimizes the risk of these complications, ensures accuracy and safety and improves efficacy and possibly cost effectiveness.

Unwanted systemic (throughout the body) side effects do NOT occur with a single INJECTION but may occur if MULTIPLE INJECTIONS are done over a LONG PERIOD. When used ORALLY, HIGH DOSES or PROLONGED use increase the risk of:

  • Weight gain
  • Fluid retention
  • Increased blood glucose
  • High blood pressure
  • Puffiness of the face
  • Thinning of the skin
  • Cataracts or glaucoma
  • Insomnia
  • Mood swings
  • Stomach ulcers
  • Menstrual irregularities
  • Buffalo hump- caused by deposition of fat in the upper back between the shoulders
  • Osteoporosis (brittle bones)

Testosterone is also given to boys with delayed puberty or persons with low muscle mass due to severe illness such as cancer or AIDS. Because testosterone and other androgenic-anabolic build muscle and strength, they are also used to illegally boost sporting performance. The World Anti-Doping Agency (WADA) prohibits the use of these substances and testing positive for any of them will result in suspension from the sport.
Side effects of androgenic-anabolic steroids include:

  • Bad acne
  • Stunted growth and height in teens
  • Altered mood, irritability or increased aggression

Women may have menstrual irregularities, deeper voice, facial hair growth and baldness. In men, long term use can shut off natural testosterone and cause shrinking of the testicles, low sperm count, infertility and breast enlargement. Heart, liver and kidney damage can occur and elevated “bad” cholesterol levels increase the risk of heart attack and stroke. Athletes and any person without a medical reason to take these compounds should stay far away from them.
Once again, there is NO danger in a properly administered steroid injection for pain relief. Remember, the steroid injection should be only one part of your treatment. Targeted exercise is crucial for your recovery and you should ensure that your doctor provides you with access to that as well.

Dr. Shane Drakes is a Specialist in Physical Medicine & Rehabilitation and Sports Medicine. He can be contacted at sdoptimalfunctioning@gmail.com. You can see more educational articles at www.optimalfunctions.com