Human beings by nature need structure. As a general rule we thrive with a set of rules and organization to live within. For example, we have set hours that we go to work for. We usually drive to work on the same route each day. Our meal times are pretty consistent.

With this in mind we like to plan our lifestyle as well. Some of us will plan the meals for the upcoming week. We set a schedule of meetings, kids’ activities, and social events. Especially as we age into adulthood and middle age, we schedule regular dentist visits, eye visits, and physicals with our doctor. Some of us meet regularly with our bank or financial planner to plot out our financial strategy.

We need structure.

When dealing with an injury or physical condition, structure is important for successful and timely recovery. Our philosophy at Donald Physiotherapy is to create a plan with you to map out what needs to be done to achieve success. Many of you will have created a written plan with your physiotherapist that outlines what you need to do as well as what the therapist needs to do. This team approach between physiotherapist and you creates the needed structure and expectations for both sides.

The successful plan depends on your WHY.

The end goal is different for everyone so it is imperative for us to work with you to clearly know what we are working towards.

Is to run 5km? Is it to play on the floor with grandkids? Is it work on the computer without back pain?

The successful plan has to have an end-goal.

And as physiotherapists, there is nothing more rewarding than seeing someone achieve that goal.

~ Trevor, Physiotherapist

With Family Day and the February break coming up, I am looking forward to some much-needed rest. Personally, I feel like the past few months have gone by so quickly that I haven’t had time to sit back and reflect on all that has happened. In the past three months, I graduated from university, took a whirlwind trip around Australia and New Zealand, started a new job and continued to provide medical coverage for sports teams around Saskatoon. It's safe to say it has been busy. During these three months, what I most often neglected was rest, and it has shown.  We often hear about the importance of exercise and physical activity on our mental and physical well-being, but what we don’t learn is how equally important rest and relaxation can be. In this blog post I am going to talk about how you can gain improvements in the gym and everyday life by taking some time to rest.

The purpose of training or physical activity is to overload the body in order to gain improvements in strength, endurance, muscle mass, etc. Most people think that exercise is when we build muscle and become stronger, but actually it is the complete opposite. When strength training (ex. Lifting weights, body weight exercises, banded exercise) we break down muscle, creating micro tears in the tissues. It isn’t until we rest that the body can repair, rebuild and strengthen those muscles – this is known as adaptation. If we don’t allow our body to rest and recover, we can actually do more harm to our body than good – in the exercise world this is known as under recovery.  What this means is that if we don’t give ourselves enough rest, our bodies will continue to break down, preventing adaptation and impacting our performance. Continually overloading the body without rest may lead to a decrease in training quality and the possibility for injury.

What are some signs of over-training?

• Decrease in performance
• Persistent fatigue – Constantly drained, lack of energy or motivation.
• Persistent mild muscle soreness
• Loss of appetite
• Poor sleep

What are some forms of recovery?

• Sleep – We should be aiming for at least 8 hours of sleep every night.
• Rest Day – Avoid further loading for physical and psychological recovery. Example: Binge watching your favourite Netflix series on a Sunday afternoon.
• Active Recovery – Low intensity exercise such as walking, cycling, swimming or yoga.  
• Proper Nutrition – What we eat plays an important role in how we train and recover. Be sure to talk to a Dietitian on how you can ensure you are getting proper nutrition to optimize your performance.

This idea of a proper work to rest ratio isn’t just for physical activity but can be applied to all aspects of life. Take school for example – as a student you often spend your entire day in class, frantically trying to take in as much information as you can. Once class is over, it is on to a late night at the library, cramming for those four midterms in one week, running only on energy drinks. Studying and going to class would be like training or working out. Staying up late and poor nutrition would interfere with your ability to rest. This cycle continues week after week and is what my classmates and I would call “surviving, not thriving”. In the end you continually stress and break down your body until it can’t function properly (ex. worsening test scores, persistent fatigue, sickness, etc.).

​This February break I challenge you to not only get active, but take time to rest and recover. For myself I plan to sleep in, spend time outside exploring our amazing city, and end up on the couch watching my favourite show on Netflix. Rest and recovery can take many forms, but if we don’t make it a priority, we may never reach our full potential.

~ Alex, Physiotherapist

Tendons are the strong connecting tissues that anchor our muscles into the bone during our daily activities. They are not truly separate from either tissue, gradually blending into the muscle and bone at either end. Tendons rely on highly structured collagen fibers to handle the heavy demands that are placed on them during our lives. The most common sites of injury include the Achilles tendon at the ankle, the patellar tendon at the front of the knee, and the rotator cuff tendons of the shoulder.
 
Injuries to tendons are common at all stages of life. There are a number of factors that can increase the risk of suffering a tendon injury including age, sex, genetics, concurrent diseases (i.e. diabetes, rheumatoid arthritis, smoking, obesity), and inadequate rest and recovery between bouts of exercise/work. Inactivity and lack of loading have a powerful effect on the maintenance of tendon health as well. 
 
Tendon injuries can occur for a wide variety of reasons and have three classifications that are commonly used:
 
Tendonitis - Characterized by inflammation. (covered below)
 
Tendonosis - Characterized by degenerative changes to the tendon structure. Repetitive strain that does not heal fully over a longer period of time.
 
Tendinopathy - An inclusive term that relates to the pain and reduced function of tendons during injury and recovery.
 
Injury to a tendon can be due to both to a single event or due to a repetitive stress over time. A single event could be an accident at high speeds, or a tissue under a heavy load. The other end of the scale is injury caused by repetitive stress that adds up over time, leading to a situation where the tendon fails to cope. This can lead to an increased risk of tendon injury during relatively normal daily activities.
 
There are two main types of collagen inside the tendon, referred to as Type 1 and Type 3 respectively. Type 1 is thicker and able to handle heavier forces. Type 3 collagen is thinner and helps to develop the framework for the tendon. Several theories exist as to what may actually cause the change in tendons that lead to injury, the most popular involves a lack of oxygen in the tissues and the effect that inflammation has when it occurs repeatedly over a longer period of time. This boils down to an inability for the tendon to maintain the balance between new collagen fibers and the natural loss and change that happens with age and activity. Over time, the structure will change in a way that makes the tendon less able to handle stress and load.
 
What is quite interesting is that these structural tendon problems are relatively common in the general population. Up to 13% of people in their 50s, 25% of people in their 60s, and 50% of people in their 80s will demonstrate a full thickness rotator cuff tear. More importantly, is that some of these people will have minimal or no symptoms at all. Ultrasound and imaging only tells ua a part of the story. Painful symptoms are poorly matched to Ultrasound findings, meaning that a high percentage of patients that show positive findings on imaging do not have any related pain or symptoms.
 
Typically, tendon healing will go through three different stages of recovery during the healing process.
 
Inflammation - Days. Immediately after acute injury, the body will release certain chemicals and molecules that bring immune cells to the injury site. Their first job is to remove any dead or damaged tissue that will not recover and to make room for the next phase of recovery. These chemicals have the unfortunate side effect of making the area tender and sore on average, but is necessary for our body to move forward.
 
Proliferation - Weeks. Once the body has completed the inflammatory phase, new cells will be laid down in the tendons to repair the damage. Depending on the extent of the injury this process can take up to several weeks. These new tissues will be immature and not yet used to the stresses of daily activity. During this time there may be some more sensitivity in the area as new blood vessels and nerve endings are developed as well.
 
Remodeling - Months to Years. Once the new tissues have been incorporated into the existing tendon, the remodeling process can begin in earnest. This period of time actually encompasses our whole lives as we are constantly changing our bodies as we grow, age, and engage in meaningful activities. From a healing perspective, this can take months or even years to fully develop the tendons that were a part of the injury. While this can seem daunting in its scale, it is also a huge source of optimism as even older injuries and complaints can often be improved with effort.
 
Despite the various options that exist to treat tendon injuries, they can sometimes result in reduced function and disability for months. Even with successful treatment, some will be left with a tendon that is weaker than previous and potentially more susceptible to injury in the future. While tendons have the ability to regenerate to a degree, the current thought is that the highly ordered structure that it began with will likely not return to preinjury levels after injury and recovery. After the healing process, tendons contain a higher concentration of the Type 3 collagen, which are typically thinner fibers, resulting in an overall weaker tendon. This can be changed to a degree over time by developing the strength of that tendon, but how much depends on the severity, location, and circumstances of the injury.
 
So what can be done about this then?
 
1.    Manage and guide the inflammatory process. Everyone will have different needs when it comes to this. Inflammation is a natural and necessary part of recovery. However, if this period is prolonged, it does not allow for transition into the later stages.
 
2.    Maintain movement and mobility. While immobilization has been demonstrated to be useful in post-surgical tendon recovery and for other types of tendon injuries, this must be balanced with keeping the affected area moving and functional.
 
3.    Develop structure and strength of the tendon. Once the tissues enter the remodeling stage it is important to introduce loads and activities that will help that tendon to grow and adapt to each person’s needs and environment. Muscle loading is necessary for the development and maintenance of tendon size and strength, but this needs to be done carefully at times.
 
I hope that this information will assist in the understanding of this very common condition. As always, if there are any questions or comments regarding this material, please feel free to contact our office directly.
 
-Trent, PT
 
References
 
●     Tendinopathy: injury, repair, and current exploration. Lipman, K et al. 2018. Drug Design, Development and Therapy.
●     Mechanisms of tendon injury and repair. Thomopoulos, S., Parks, W., Rifkin, D., Derwin, K. 2015. J Orthop Res.
●     Review: Emerging concepts in the pathogenesis of tendinopathy. Dean, B., Dakin, S., Millar, N., Carr, A. 2017. The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland.
●     Tendon Basic Science: Development, Repair, Regeneration, and Healing. Andarawis-Puri, N., Flatow, E., Soslowsky, L. 2015. J Orthop Res.

Why is it that some days are better than others? How many factors can play a part in the pain experience? The short answer is that nearly everything can play a role in what we feel in our bodies, but how can we picture that more easily? 

There is an excellent tool that has been developed by the Neuro Orthopedic Institute (NOIgroup) that strives to give people a better understanding of the many factors involved in their pain. It is called the Protectometer. More information about the NOIgroup can be found at their website http://www.noigroup.com, but we will go through the basics below.  

Please feel free to look at the previous posts regarding the topic of chronic pain if you would like more information on general concepts.  

Let’s begin with a refresher on a definition of pain. Pain is defined in the literature as - An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. 

In this context, pain can be understood as a defence mechanism or protector of our body, meant to alert us to an area or issue that requires attention or modification. For example, to move away from something too hot, or to remove our feet from the sharp stones underneath us.  

The Protectometer, otherwise known as a “danger meter”, is an idea that can help to explain the many factors that may influence the pain experience. Referring to the definition of pain above, we know that the perception of danger in a body tissue or area can be enough on its own to create a pain response, under the right conditions.  

Another way to visualize this is as a set of balance scales. With so many potential factors that can influence the positive and negative sides, it can be very difficult to decide which particular thing seemed to increase or decrease the painful symptoms. This helps to explain why sometimes it is very hard to pinpoint which one thing caused a problem when a combination of countless factors could be to blame. It can be very difficult to interpret all of the things that happen in a single day, let alone a week, or a month.  

The scale can have a protective OR amplifying effect on symptoms. People who have more positives on their scale are likely to be more resilient, while people who have the deck stacked against them are likely to have more difficulty overall. The brain, nerves, and tissues, add up all of the different factors to decide what we feel and how much of it we feel in any particular moment. All physical activity, and all mental activity can play a role in adjusting the scales. All the things we do in a day, plus the things that are said, heard, thought, and believed, can make a difference. Even the environment we are in can play a role in what we feel.  

Identifying the negative parts of the condition, environment, thoughts, activities, and feelings is an important step in determining what can change and how to go about it. This works in the reverse as well in that all of the positive things about feelings, activities, thoughts, environments, and support from others can help to balance the scales in our favour.  
This is a dynamic and ever-changing balancing act between the positives and negatives in the body. While there can certainly be habits and a leaning in one direction based off of history, we know that the system is always capable of some measure of change.  

So how do we tip the scales? We can add things to the positive aspect, or remove negative things from the other side. Now, not all of these things are changeable, but there are often a number of things that are. Everyone will have different things to consider and a different starting point, but that’s where we begin.  

Please feel free to leave a comment or reach out to our office if you have any questions. 

~ Trent, PT
​
References: 
·         Moseley, G. L., & Butler, D. S. (2017). Explain pain supercharged: The clinician's manual.

One of the more common things that people come into the clinic for is shoulder pain.  There are many issues that may occur with a shoulder that may cause pain, and this may include problems with the rotator cuff. 
What is the rotator cuff? It is a group of muscles that helps to hold the shoulder in its socket. They also work to lift the arm and rotate it inwards and outwards. The four muscles of the rotator cuff include the subscapularis, supraspinatus, infraspinatus and teres minor. There are other muscles that surround these four and influence how efficiently they work. And if these muscles do not work efficiently, they and the rotator cuff muscles can develop tendinopathy (thickening and tears).  
​
Tendinopathy can occur due to the following (1):

• Impingement of the shoulder muscles – when the muscles rub on each other or surrounding structures due to postural position or other bony changes such as shoulder or acromioclavicular (AC) joint arthritis
• Partial or full thickness tears due to chronic degeneration of tendons
• Partial or full thickness tears due to trauma, such as falling on an outstretched hand or trying to catch yourself on the way down 

What does rotator cuff tendinopathy feel like? Your shoulder can be sore, uncoordinated, and weak. You may have difficulty and/or pain with reaching overhead or behind you (especially if you have to reach quickly!), pain in your shoulder at night, and pain as you try to raise your arm up. There is a very high chance that you have a rotator cuff tear if you have two of the signs above and you are over the age of 60 years (1).  

So what can do you if you suspect that you have a rotator cuff tendon issue or tear? There are several factors that may lend to a more favourable recovery from a rotator cuff tendinopathy. Depending on your mechanism of injury, severity and location of a tear, age and level of function, you may be a candidate for surgery. But physical therapy has also been shown to be effective in the management of rotator cuff tendinopathy (1). Through consideration of each person’s level of function, daily activities and interests, a home exercise program that is best for that person an the issues that they are having can be recommended. Manual (hands on) therapy to help improve shoulder and muscular mobility (this can include massage therapy) is also helpful. Education on anatomy, the way the body moves and how it heals, and different movements to do or avoid is also very helpful with managing this kind of shoulder pain. 

Personally, as someone who has enjoyed playing a number of sports and still likes to do so, getting ahead of shoulder pain and potential tendinopathy is important for me, especially since I know that chronic degeneration can lead to tears. I try to keep my shoulders in shape for volleyball, carrying kids and, daily activities in the home and yard, and running with the dog. Some of my go-to exercises include yoga (weight bearing through the hands and shoulders), free weight exercises like rows and overhead press, and rotational resistance band exercises. I began doing these things after minor aches and pains began to affect some of the activities that I enjoy the most. I intend to continue to be active and keep my shoulders healthy, and I am passionate about helping my patients do the same. Please feel free to contact me or one of my colleagues if you have any questions about what you can do to prevent or manage your shoulder pain!

~ Kristyn, PT 

References:
1. Factor D, Dale B. Current Concepts of Rotator Cuff Tendinopathy. Int J Sports Phys Ther. 2014 Apr; 9(2): 274–288.
 
 
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Tinnitus is defined as the perception of sound without the accompanying external stimulus.  
Tinnitus, or ringing in the ears, affects a significant amount of the population at one time or another in their lives. While it is normal for someone to experience intermittent episodes of buzzing, ringing, or tonal sounds in the ear from time to time, some people experience a condition which is much more persistent and sometimes more bothersome. Prevalence is estimated between 5-42% of the population.  

The condition itself does not have one root cause or pathology associated with it. It can be caused by noise trauma, physical trauma, disease, aging, and as a side-effect of some medications. A number of different structures and conditions can contribute to the presentation and the symptoms that an individual experiences. This can include cardiovascular, neurological, mechanical, and inflammatory disease states. These factors will produce a sensitivity in the nervous system, leading to changes in the brain that can produce the phantom sound or make it increasingly difficult to shift our attention elsewhere.  

From a cardiovascular perspective, an increase in blood pressure can sometimes result in the ability to hear a thudding or pounding, drum-beat like sound. This can occur unilaterally or bilaterally. This can also be the result of inappropriate formation of small blood vessels in the inner ear and surrounding tissues which does not allow blood to flow through them smoothly in all situations. Anything that is of a vascular nature will require assessment and investigations as recommended by the appropriate physician and/or specialist and is outside the scope of physical therapy.  

From an inflammatory basis, a number of structures in the face, head, and ear can contribute to the perception of sound if they become irritated or sensitive. This include various nerves, the sinuses, eustachian tubes, and even the middle ear bones that conduct sound to the eardrum. The eardrum itself can be a source of irritation if it becomes inflamed or scarred as well. The treatment for this typically is medical in nature to try and reduce swelling/inflammation in the specific tissues.
 
The neurological mechanism is the most common pathway that relates to idiopathic tinnitus. Idiopathic referring to an onset of symptoms with no known injury or mechanism. This can be due to sensitization of the peripheral nervous system, central nervous system, or a combination of the two. This is typically treated through a combination of medication, education, and stress-reduction strategies.  

Mechanically, the upper cervical spine and jaw joints can contribute to a presentation of tinnitus in some cases through their connection into a cluster of nerves referred to as the trigeminocervical complex. Since the trigeminal nerve has connections to the other cranial nerves, overwhelming stimulus of these pathways can contribute to the intensity and frequency of symptom presentation. On the bright side, appropriate mechanical treatment and education surrounding these tissues can sometimes provide improvement in the tinnitus symptoms that are experienced. Not everyone has a mechanical presentation, but since treatment and therapy are non-invasive, it can be worthwhile to consider assessment by a trained healthcare practitioner.  

Another useful avenue of assessment for those suffering from tinnitus is a comprehensive hearing assessment through an Audiologist. This will assist with understanding the unique features of a patient’s presentation and help other practitioners determine an appropriate course of action. Audiologists also have the ability to treat some aspects of tinnitus with assistive devices that can create white noise, amplify normal hearing, and try to retrain the brain/nervous system to ignore the tinnitus itself.  

One of the most important things to note regarding tinnitus is that the amount of distress or the perceived volume of the sound does not relate to the severity of the condition. Louder tinnitus does not mean that someone is at greater risk of harm or injury/disease.  

~ Trent, PT

 References: 
Somatosensory tinnitus: Current evidence and future perspectives. Ralli, M. et al. Journal of International Medical Research. 2017.  

Maladaptive plasticity in tinnitus - triggers, mechanisms and treatment. Shore, S., Roberts, L., Langguth B. Nat Rev Neurol. 2016. 
​
Current insights in noise-induced hearing loss: a literature review of the underlying mechanism, pathophysiology, asymmetry, and management options. Le, T., Straatman, L., Lea, J., Westerberg, B. Journal of Otolaryngology - Head & Neck Surgery. 2017.
 

Following the holidays, which is always a busy time of year, I had the opportunity to go on vacation with my family. It was a lovely and refreshing time and I came home ready to do some prioritizing in life.  Naturally, this included getting back into the routine of exercise after the holidays. I think that this time of year often sparks the goal of developing some exercise habits for people. This is WONDERFUL news since I am often working with people to reduce aches and pains and include movements and mobility practices that will help them to reach their goals – whether these goals are to reduce pain so that they can function in life again, or if they are working towards performance goals for sports or leisure.

Personally, I am often looking for a consistent time to exercise in a routine way while balancing work and family life. I enjoy doing yoga at home because it is an easy way to get balanced exercise on my own time, no matter what mother nature has schemed up. I also like to go for walks or runs, play volleyball on the weekends and play games my toddlers dream up! It’s fun to play with them and then they gravitate to physical activity which helps them to burn energy (I wish I could bottle that)! I enjoy how playing with the kids helps them develop a love for the types of exercise that they enjoy. What types of exercise do you enjoy?

Movement is key for physical comfort and mobility. Of course sudden injuries happen, and there is nothing that a person can do to avoid that, but I do see that people who are more physically active or mobile before an injury occurs recover more quickly.  Frequent strengthening and stretching can also help someone to prevent injuries. For instance, maintaining back mobility and lower body strength and conditioning can help someone to shovel or rake without developing strain injuries during the seasons that require these activities. So findings something that you enjoy doing can make a big difference in not only how you move now, but how you recover from an injury.

There are a few exercises that I find that I go back to again and again for people. Not only to the help people recover from ailments, but I also give these ones to people wanting to do whole-body conditioning as options to maintain health and prevent issues.

Some of the exercises that I tend to use often include the following:
| Walking (Duration: 10+ mins; Frequency: daily as able)
| Posture Correction (Sitting tall) (Duration: 2+ mins; Frequency: every hour)
| Single Leg Balance (Duration: 30 sec each leg; Frequency: 2 times per day)
| Push Up (On the Wall or Floor) (Sets: 2; Reps: 10; Intensity: slow and controlled; Frequency: daily)
| Calf Raise |  Bilateral - Supported (Chair) (Sets: 2; Reps: 10-20; Intensity: slow and controlled; Frequency: daily)
| Squat (Chair) (Sets: 2; Reps: 10; Intensity: slow and controlled; Frequency: daily)
| Cat/Cow (Sets: 2; Reps: 10; Intensity: slow and controlled; Frequency: daily)
| Upper Trapezius Stretch (ear to shoulder) (Reps: 2 per side; Hold: 30 sec; Frequency: daily)
| Levator Scapulae Stretch (nose to arm pit) (Reps: 2 per side; Hold: 30 sec; Frequency: daily)
| Gastrocs Stretch (Wall) (Reps: 2 per side; Hold: 30 sec; Frequency: 1-2 times per day)
 
Of course an exercise program is tailored to each person’s abilities and needs, so some of these may be too challenging for people or they may not be challenging enough. I enjoy working with each person to find a form of movement that works for them and that they enjoy doing. Hopefully I will have given you a few ideas for things to try! And if you have any questions along the way, please feel free to give me a call.

​~ Kristyn, PT