Kobes Achilles Rehab Process

A good read from Espn regarding Kobe Bryants Rehab protocol...

Even before an MRI Saturday confirmed a complete (Grade III) rupture of Kobe Bryant's left Achilles tendon, everyone, especially Bryant, already knew the extent of the injury. After all, Bryant had experienced the telltale symptom of a torn Achilles, saying after Friday night's game that he felt like he "had been kicked." If not literally, Bryant was at least figuratively struck by an injury that will force a premature end to his season and raise the question in everyone's minds as to what happens next.

As it turns out, Bryant didn't waste much time deliberating the future. On Saturday he underwent surgery to repair his Achilles with orthopedic surgeons Dr. Neal ElAttrache and Lakers team physician Stephen Lombardo, and in that moment began his road to recovery. All indications are that Bryant intends to play again, and while the rehabilitation process is lengthy and intense, there is reason to believe he will indeed see the court in the 2013-14 season.

Here are some of the key points to consider in recovering from an Achilles tendon repair:

1. Controlling swelling: The first few days following surgery are targeted at controlling swelling as much as possible and promoting healing of the wound (where the surgical incision was made). Guarding against infection is essential in moving the recovery forward. There is always a risk of infection with any surgical procedure, so close monitoring of the wound and controlling inflammation are imperative.

2. Protect the repair: The most important element in the early stages of recovery is protecting the Achilles repair. Specifically, it is critical not to overstretch the tendon, which would result in over-lengthening, which would then be impossible to reverse. Consider that the functionality of the tendon is dependent on energy and explosiveness that comes when pushing off the foot. If the tendon loses elasticity -- which would happen if it were to lengthen excessively -- the athlete would lose the ability to push off the foot effectively, a requisite skill for any sport,  especially basketball.

To guard against this, the tendon is protected in a shortened position in the early phase post-surgery. Bryant's ankle will be maintained in a slightly plantar-flexed position (toes pointing downward) with the assistance of a splint and he will not be allowed to bear weight initially. Even his early range-of-motion exercises will be limited to focusing on pointing the ankle down; there will be no stretching of the calf.

3. Progress to normal walking: Bryant will be transitioned from an immobilizing splint to a boot with extra heel support inside (again, to avoid overstretching the tendon) but will still be on crutches and bear only partial weight. Gradually he will progress off crutches while still in the boot, then eventually he will move to a normal (athletic) shoe with a heel support inside. The final step is moving the heel support out of the shoe and getting the foot to its normal resting (neutral) position. Throughout this time, Bryant will be working on range of motion, light strengthening and cardiovascular exercise (such as stationary bike).

4. Restore movement patterns: By approximately three months, Bryant should be approaching full range of motion. He will likely have incorporated walking on an Alter-G treadmill, which reduces total body weight so that there is less load on the healing tissue but still permits the athlete to restore normal movement patterns. It's important for the body's nervous system to relearn normal motion after that motion has been forcibly interrupted for a period of time. The sooner that process begins, the less likelihood of developing compensations which can lead to additional problems down the line.

5. Rebuild sports-specific skills, training: Once the repair has had the opportunity to heal and normal walking has been restored, then it's a matter of pushing the athlete's cardiovascular training, strength, balance and coordination. Agility and sports-specific drills are added later with an eventual return to basketball activity. Controlled time and exposure to contact progresses to increasing minutes and unrestricted contact.

For the first few months, the athlete has to be restrained from progressing too quickly in order to protect the repair. Once the repair has healed to the point where it is safe to resume more aggressive activity, the athlete then has to push himself hard to regain what he's lost during the protective period.

[+] Enlarge
Andrew D. Bernstein/NBAE/Getty ImagesBryant has a long six to nine months ahead of him.

If all goes well, the hope is that Bryant will be able to return to play within six to nine months, the timetable offered by the Lakers. It's worth noting that there isn't a large pool of comparables in the NBA when it comes to return to play following an Achilles tendon repair. Some have returned to play successfully (Dominique Wilkins) and others have retired in the wake of the injury (Isaiah Thomas). Chauncey Billups of the Los Angeles Clippers is perhaps the most recent example of an NBA player to return from a torn Achilles. After tearing his Achilles in February 2012, Billups returned to play in late November of the same year. However, he has been challenged by several other ailments (foot, back, groin) throughout the season.

The obvious and most routine demands on the Achilles of running up and down the court and jumping and landing repeatedly can be more easily overcome by the athlete. Perhaps the most challenging element of a basketball player's game to regain following this type of surgery, however, is sudden acceleration, the quickness off the foot necessary to make a sharp move around an opponent.

Athletes will often say that it is this explosiveness, this quickness that takes nearly a year to regain, perhaps long after returning to competition. Internally, the tendon continues to be shaped and modeled by the stress the athlete places on it as he returns to increasingly demanding activity. That internal adaptation is essential for the athlete to ultimately regain the feel of a "normal" leg, one that no longer feels different than the other. Simply put, it takes time.

Of course, Bryant is anything but normal even within the sphere of elite athletes. He has proved that he has the mental toughness and physical fortitude to push himself beyond what others around him might be doing. He will need to call on both, particularly in the later stages of his recovery from this Achilles repair, in order to return to the court this fall.

By then, Bryant might have everyone thinking back to the sight of him limping off the court in April and wondering whether there was ever really any doubt about what would happen next.

Dr. Joshua Brooks

Chiropractor Falls Church, VA 22046

Cervical Adjacent Level Degeneration, a Case Study

History

A 51-year-old man, who is a former professional lacrosse player status post C3-C7 laminectomy without fusion (10 years prior) and C5-C6 ACDF (5 years prior) for myelopathy, presents with right arm pain (mild to moderate) and severe right triceps weakness (2 out of 5 strength).

Examination

No evidence of myelopathy. Triceps strength 2/5, decreased triceps reflex 0.  Sensory deficit in C7 distribution.  Absent deep tendon reflex right triceps.

Prior Treatment

Prior surgery C3-C7 laminectomy without fusion (10 years prior).  C5-C6 ACDF 5 years prior.

Extensive PT (no improvement).  One C7 selective nerve root block (temporary relief).

Diagnosis

Right C7 herniated disc and C7 palsy

Case Discussion

Ronald A. Lehman, Jr., MD

Associate Professor of Surgery

Walter Reed Army Medical Center

This case highlights many of the issues that we face with adjacent level degeneration after cervical surgery.  This patient underwent a C3-C7 laminectomy in the past with subsequent C5-C6 ACDF.  The patient exhibits significant and recalcitrant C7 radiculopathy that is affecting his quality of life.  The MRI displays anterior compression cephalad at C4-C5 with some posterior scar or residual ligamentum flavum hypertrophy as well as a significant C6-C7 disc herniation that is commensurate with the C7 radiculopathy that the patient endorses in subjective questioning and objective examination.  Since the patient underwent a prior multilevel laminectomy and decompression, a revision posterior operation (even to perform a C6-C7 foraminotomy) can be fraught with potential complications, including dural tear, nerve root injury and likelihood of residual scar formation post-operatively.  The concept of a fusionless operation at C6-C7 is intriguing; however, with the patient being 50 years of age, the likelihood of his displaying facet arthrosis is significant and a relative contraindication for a disc replacement. (Comparison of magnetic resonance imaging and computed tomography in predicting facet arthrosis in the cervical spine. Lehman RA Jr, Helgeson MD, Keeler KA, Bunmaprasert T, Riew KD. Spine (Phila Pa 1976). 2009 Jan 1;34(1):65-8)

After obtaining pre-operative consultation with ENT to perform a direct laryngoscopy to assess the vocal cords after the previous anterior approach, a good option is to address this pathology from an anterior operation since that is the site of the compression.  Performing a discectomy from a posterior approach in the setting of previous laminectomy may lead to a higher complication rate.  Removal of the plate at C5-C6 and performance of a generous discectomy and foraminotmy with take down of the posterior longitudinal ligament (PLL) allows for adequate excision of the disc fragment and decompression of the posterior osteophytes. The other consideration is to properly evaluate the C4-C5 level to determine if there is a decreased threshold for symptoms at the C6-C7 level because of the compression at C4-C5.  This level could be contributing to the post-operative pain experienced by the patient and should be followed longitudinally for development of symptoms. I agree with the treatment of addressing the C6-C7 level from an anterior approach.  Continued follow up with particular attention to the C4-C5 level is warranted.

Dr. Joshua Brooks

Chiropractor Falls Church, VA 22046

Updated Concussion Guidelines, New Article

ABSTRACT

Objective: To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article.

Methods: We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations.

Results: Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.

Report of the Guideline Development Subcommittee of the American Academy of Neurology

1. Christopher C. Giza, MD*, 
2. Jeffrey S. Kutcher, MD*, 
3. Stephen Ashwal, MD, FAAN, 
4. Jeffrey Barth, PhD, 
5. Thomas S.D. Getchius, 
6. Gerard A. Gioia, PhD, 
7. Gary S. Gronseth, MD, FAAN, 
8. Kevin Guskiewicz, PhD, ATC, 
9. Steven Mandel, MD, FAAN, 
10. Geoffrey Manley, MD, PhD, 
11. Douglas B. McKeag, MD, MS, 
12. David J. Thurman, MD, FAAN and 
13. Ross Zafonte, DO

Dr. Joshua Brooks

Chiropractor, Falls Church VA 22046

Spinal Manipulation Effective for Acute Neck Pain

NIH study finds spinal manipulation more effective than medication for acute neck pain.

Spinal manipulation or home exercise was more effective than medication for treatment of acute to sub-acute neck pain, according to a recent NCCAM-funded study published in the Annals of Internal Medicine. Researchers from Northwestern Health Sciences University and the Minneapolis Medical Research Foundation randomly assigned 272 participants with neck pain, aged 18 to 65, to receive either spinal manipulation therapy, medication, or home exercise instruction.

In the study, spinal manipulation therapy consisted of various techniques, including spinal adjustments (low amplitude, high velocity) and mobilization (low velocity) of areas of the spine. Participants in the medication group received non-steroidal anti-inflammatory drugs, acetaminophen, or both; those who did not respond to these medications or could not tolerate them received narcotic medications. Home exercise with instruction focused on gentle self-controlled movement of the neck and shoulder joints, and participants were instructed to do the exercises six to eight times each day. In addition, participants in this group received two individualized hour-long sessions of one-on-one exercise instruction, as well as written directions for exercise at home.

The researchers observed significant short-term and long-term improvements in participant-rated pain in the spinal manipulation group compared with those receiving medication. At 12 weeks, 82 percent of participants in the spinal manipulation group (compared to 69 percent in the medication group) experienced reductions of pain of at least 50 percent. Similar findings occurred at 26 and 52 weeks. Additionally, the spinal manipulation group reported greater global improvement, participant satisfaction, and function than the medication group. Home exercise with instruction was just as effective as spinal manipulation at each time point.

Few studies exist to date on the management of neck pain with noninvasive methods, such as spinal manipulation, home exercise, or medications. According to the researchers, the findings from this study suggest that both spinal manipulation and home exercise may be viable treatment options for managing neck pain.

References

• Bronfort G, Evans R, Anderson AV, et al. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain. Annals of Internal Medicine. 

  2012

  ; 156(1):1–10.
  
  
  Dr. Joshua Brooks
  Chiropractor Falls Church VA 22046

Non Operative Treatment for Meniscus Tears

Study confirming successful non-operative treatments for meniscus tears...

The best available evidence from our search consisted of a retrospective review (1), a prospective clinical trial (2), and a randomized trial (3).

Lim et al performed a retrospective chart review among 30 mostly female patients who completed non-operative treatment for degenerative posterior root tear of the medial meniscus (1). Treatment consisted of supervised therapy, exercises, and NSAIDs for 8-12 wks (1). The authors concluded that clinical outcomes of self-reported pain and function improved during the follow-up period, an average of 36 mos (1). However, the study is limited in that the design did not allow for blinding of participants or a control group.

Rimington et al conducted a prospective trial among 26 patients with degenerative medial meniscus tear, comparing non-operative treatment consisting of NSAIDs to operative treatment (2). Almost half of patients improved with non-operative treatment, while remainder did not improve and chose to undergo operative treatment (2). At conclusion of treatment, subjects in both groups showed improved pain and function as assessed by questionnaire (2). Of note, a greater percentage of men elected surgery compared to women (72% vs 13%) (2). Limitations of this study include a lack of randomization, possibility of selection bias, and treatment until improvement was demonstrated on primary outcomes.

Herrlin et al randomized 90 middle-aged patients with degenerative medial meniscal tears to surgery followed by 8 wks of exercise or exercise alone, and found similar improvements in patient questionnaires for pain, function, symptoms, and activity (3). Limitations of this study include lack of blinding and no control group.

Based on this review, it can be concluded that non-operative management of meniscal tears shows promise in achieving successful clinical outcomes in a large percentage of the patients, and should be considered as the initial treatment approach. Sample exercises from VHI PC-Kits have been provided based on information from these articles.

Dr. Joshua Brooks

Chiropractor, Falls Church VA 22046

Exercise for Whiplash?

From VHI...

To answer this question, we performed a comprehensive search of the PubMed database (October 2011) for randomized, controlled trials and systematic reviews that addressed this specific research question. ¹

Four randomized controlled trials (1-4) and two literature reviews (5,6) were summarized.

Three studies evaluated the effect of physical therapy and/or exercise among patients with chronic (grades I-III) WAD, with two finding a significant benefit. Among 71 patients with WAD, Jull et al compared 10 wks of physical therapy (home exercise, manipulation and education) to self-management (home exercise and education), and found therapy resulted in significantly greater improvement in pain and function (1). Unfortunately, due to the study design, it is not clear which component of therapy is most effective for patients with WAD. Stewart et al also found a significant effect of 6 wks of exercise and advice compared to advice alone on improving pain and function among 134 patients with chronic WAD; however long term follow-up showed no effect of treatment (2). Of note, 15% and 23% of the exercise and advice groups, respectively, reported seeking outside treatment during the intervention (2). In contrast, among 213 patients with chronic WAD grade II, Vickne et al found no benefit of adding stabilizing exercises using a ceiling-mounted sling to 4 mos of physical therapy and home exercise; extending the home exercise to one yr also had a minimal effect (3). Limitations of this study included lack of compliance monitoring and the possible influence of subjects' unsettled compensation claims (3).

For acute whiplash injury (grades I-II), Vassiliou et al established that active exercises and physical therapy modalities (e.g., heat, massage) were more effective than standard treatment with a soft collar in reducing pain and disability after both 6 wks and 6 mos (4). A limitation of this study was a high dropout rate, particularly in the standard treatment group.

Based on this review, it can be concluded that exercise therapy improves outcomes for patients with whiplash injury; however, the specific type, frequency, and duration of exercise that is most effective is not yet clear. Sample exercises from VHI PC-Kits have been provided based on information from these studies.

Dr. Joshua Brooks

Chiropractor, Falls Church VA 22046