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Important Concussion Resources

In Ontario, over 150,000 people are diagnosed annually with concussion in emergency departments and by primary care physicians. In 2016 there were 15,736 concussions diagnosed in the Champlain LHIN. It remains evident that both healthcare providers and patients feel ill-prepared to effectively navigate the healthcare system with respect to concussion care and management of persistent concussion symptoms.

The Ontario Neurotrauma Foundation,ONF has been working to provide clarity and evidence-informed direction with respect to post-concussion care for healthcare providers and patients by releasing the Standards of Post-Concussion Care and the  3rd Edition Guideline for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms for Adults over 18 Years of Age. Providers can use the resources to learn about up-to-date evidence-informed practices and recommendations. ONF’s goal is to streamline visits with healthcare providers and provide direction to patients and families to increase confidence about how, what and when care should be provided.

“Tennis Elbow” Treatment Approaches

Treating Lateral Epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review

Morten Olaussen, Oeystein Holmedal, Morten Lindbaek, Soeren Brage, Hiroko Solvang

Lateral Epicondylitis is otherwise known as “Tennis Elbow” is an overuse injury of the extensor tendons that join the forearm muscles to the lateral epicondyle of the humerus. This overuse injury is thought to affect the extensor carpi radialis brevis (ECRB) specifically. This injury is seen in patients with either excessive repetitive flexion with subsequent extension of their wrist such as in tennis players, improper form and/or improper equipment or even with a daily profession that requires manual labour with their hands.

Lateral Epicondylitis is generally thought to be a self-limiting injury but can take a long time to resolve. Common treatments used by family physicians and doctors who deal with sports injuries include rest, NSAIDS, physical therapy, deep friction massage, braces, acupuncture, extracorporeal shockwave therapy, cortisone injections, surgery as well as more recently platelet-rich plasma injections.

This article looked at the benefits of two of these treatment modalities: lateral elbow cortisone injection and non-electrotherapeutic physiotherapy. The authors did a systematic review, which included 11 randomized controlled trials, representing 1161 patients of both sexes and all ages. All of these studies looked at least at one treatment group and one control group which included receiving anything from no treatment, to common treatments such as counselling, rest, or NSAIDS. Some of the measures used to evaluate the efficacy of the treatments were pain, grip strength and overall improvement effect at 4, 12, 26 and 52 weeks of follow-up.

Overall, the results showed that corticosteroid injection provided patients with a short-term reduction in pain versus control groups. However, more notably corticosteroid injections resulted in an increase in pain, reduction in grip strength and negative effect on the overall improvement at the intermediate stage of follow-up. Manipulation and exercise in comparison to control showed improvement at short-term follow-up, but no significant difference at intermediate or long-term follow-up.

In all, this study reveals that corticosteroid injections may have a significant negative effect on the intermediate follow-up likely outweighs any of the short-term benefits. Manipulation and exercise and exercise and stretching have a short-term effect, with some evidence of longer-term effect.

Dr. Mickey Moroz M.D.C.M. CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

 

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (CAC SEM), Dip Sport & Exercise Med

The Danger’s of Being a Weekend Warrior Hockey Player

Cardiovascular effects of strenuous exercise in adult recreational hockey: the Hockey Heart Study

Sanita Atwal, Jack Porter and Paul MacDonald

CMAJ February 05, 2002 166 (3) 303-307;

There is a well-known trend for adult hockey players of all skills to join recreational hockey leagues as they become too old to play in competitive leagues as they did in their youth. In Canada, there are more than 500 000 men who play in these leagues. The reality of these men’s leagues is that most of the players treat their one or two games a week as their only physical activity for the week. On top of this, they often only get about 2 minutes of light warm up as they get on the ice before the game.

This study recruited 113 male recreational league hockey players to see if this “weekend warrior” behavior had any negative cardiovascular effects on these types of players. In other words, to look at if doing high-intensity activity playing hockey once or twice a week without proper warm-up would cause a dangerous strain on these men’s cardiovascular systems. To do so, they looked at the baseline cardiac risk factors of the 113 volunteers (Table 1 below). As well, each one of the players underwent Holter electrocardiographic monitoring before, during and after at least one hockey game to assess the player’s heart rates, any occurrence of arrhythmias, ST-segment changes and for correlation with symptoms and other predictors of fitness.

When looking at the maximum heart rate the players reached in this study while playing, the mean maximum heart rate was 184 beats/min. General recommendations for healthy and safe physical activity in Canada recommends that the maximum heart rate that should be targeted during exercise to be between 65% to 85% of the age-predicted maximum heart rate (HRmax = heart rate of 220 – age in years). Studies have shown that anything of higher intensity causing the heart rate to go above this range can potentially to lead to an increase in frequency of cardiac events and sudden death. In this study, all of the players had a maximum attained heart rate higher than this suggested range of 65%-85% (Graph 1 below). Furthermore, the mean period for which these player’s heart rates exceeded 85% of the age-predicted maximum heart rate was 30 minutes. For 70.1 % of the player’s heart rates recovery was poor post-exercise. Non-sustained ventricular tachycardia was seen 2 Holter monitoring sessions, atrial fibrillation was seen in one subject and ST-segment depression in data from 15 sessions. However, of these patients with irregular heart rhythms, none had irregular follow-up cardiac stress work-ups.

This study suggests that the recreational hockey player faces an exercise intensity that can be dangerous to their health as seen in all the cases of this study. Even though each of the participants had higher than recommended maximum heart rates and some even had abnormal Holter findings there were no adverse events and no abnormal follow-up cardiac studies. Canadian exercise recommendations suggest at least 150 minutes of moderate to vigorous intensity aerobic physical activity per week, in bouts of 10 minutes or more. Studies have shown that engaging in 4 or more per week resulted in a reduced relative risk of myocardial infarction. Ideally, recreational ice hockey players as well as any high-intensity sports participant should be aware of these risks and should be advised by their primary care health providers to train their cardiovascular system gradually and regularly to be able to do this high-intensity exercise.  It is often noted that when we get older playing high-intensity sports is a privilege and not a right; to continue to have the privilege of playing hockey, these “weekend warriors” should be encouraged to integrate regular cardiovascular exercise into their weekly routine. When we are young and in competitive leagues, we practice on a regular basis to prepare for our games. As adult athletes, we must take the same approach of preparation for our games but with the focus on exercise tolerance as oppose to on performance as is the case when we are younger.

Effectiveness of Shockwave Treatment Combined with Eccentric Training for Patellar Tendinopathy

Effectiveness of Shockwave Treatment Combined With Eccentric Training for Patellar Tendinopathy: A Double-Blinded Randomized Study

Karin M. Thijs, Johannes Zwerver, Frank J. G. Backx, Victor Steeneken, Stephan Rayer, Petra Groenenboom, Maarten H. Moen.

Clinical Journal of Sport Medicine, Volume 27, No. 2, May 2017

Patellar tendinopathy is a common overuse injury that affects the origin of the patellar tendon at the inferior pole of the patella. Overload of the mechanism leads to pain and dysfunction, and this condition can become chronic and difficult to treat. While eccentric training has developed a standard role in the rehabilitation for patellar tendinopathy, the role of extracorporeal shockwave therapy (ESWT) is less understood. The goal of this study was to determine the effectiveness of a combined treatment of eccentric training and ESWT compared with eccentric training and sham shockwave (placebo) in participants with patellar tendinopathy over a 24-week follow-up period.

This multicenter randomized and placebo-controlled trial was conducted at sports medicine departments in a university hospital and general hospital in the Netherlands. Fifty-two physically active male and female participants (mean age 28.6 years, range 18-45) with a clinical diagnosis of patellar tendinopathy were randomly allocated to either eccentric exercises with ESWT (ESWT group), or eccentric exercises in combination with sham-shockwave therapy (placebo group). Extracorporeal shockwave therapy and sham shockwave were applied in 3 sessions at 1-week intervals with a piezoelectric device. All participants in the study were instructed to perform eccentric exercises on a decline board at home (3 sets of 15 repetitions, twice per day). To assess outcomes, the Victorian Insitute of Sport Assessment-Patella (VISA-P) scores, pain scores during functional knee loading tests, and Likert scores were registered at baseline, 6, 12, and 24 weeks after initiating the ESWT or sham-shockwave treatment.

 

The results of the study revealed that when comparing the ESWT group to the placebo group, there ware no significant differences found. While VISA-P and pain scores significantly improved over the study period, there was no treatment effect between the groups over time.

Despite being a double-blinded, randomized control trial study, the authors note several limitations in their work. The power analysis prior to the start of the study revealed that 56 patients were needed to detect a clinically significant difference in the VISA-P score of 15 points. Unfortunately, there was a large loss to follow-up (31.8% in the ESWT and 13.3% in the placebo groups respectively). Furthermore, the physical therapists that performed the treatments were unblinded (as they needed to adjust the shockwave device to “true” or “sham” treatment), and this could have influenced the results. With these limitations in mind, this study showed no additional benefit of 3 sessions of ESWT in patients with patellar tendinopathy.

Sean Mindra, MD, CCFP

PGY3 – Sport and Exercise Medicine, University of Ottawa

 

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

A Review of Running Shoes

We are often asked to comment on which shoes may be most suitable for a patient. While that answer is up for debate, an important step to answering that question is understanding what is available out there. Here we will briefly outline some of the characteristics of different categories of running shoes that you may encounter.

1.) Minimalistic shoes – attempt to approximate barefoot running

General Characteristics:

  • Reduced/minimal cushioning
  • thin soles, no heel lift (traditional shoes have 10-14mm heel lift)
  • no arch support
  • wide metatarsal area/toe box
  • very flexible, generally very light

Example brands:

  • Vibram Five Fingers.
  • vivobarefoot
  • Merrell Barefoot
  • New Balance Minimus
  • Nike Free

2.) Maximalist shoes – attempt to maximize cushioning and protection of foot

General Characteristics

  • Thick cushioning
  • Rigid sole
  • Slightly reduced heel lift compared to regular shoes
  • Wide base
  • Lightweight for its size

Example brands:

  • Hoka One One
  • Merrell All Out Peak
  • Mizuno Wave Sky
  • Skechers GOrun Ultra R
  • New Balance Fresh Foam 980 Boracay

3.) Zero-drop shoes – footwear where the heel is at the same height as the ball of the foot

General Characteristics

  • Often overlaps with minimalistic shoes
  • Variable structure, but the emphasis is that there is zero heel lift

Example Brands

  • Altra Torin 3.0
  • Merrell Vapor Glove 2
  • Nike Flex Fury 2
  • Vibram FiveFingers Bikila

There are many studies out there looking into the pros and cons of each type of shoewear and whether they are effective in reducing running injuries. The jury is still out but hopefully, this will cast some light on what your patients may be talking about!

 

Jim Niu MD, CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

The Efficacy of Sustained Heat Treatment on Delayed-Onset Muscle Soreness

Jerrold Petrofsky, Lee Berk, Gurinder Bains, Iman Akef Khowailed, Haneul Lee, Michael Laymon

Clinical Journal of Sport Medicine, Volume 27, No. 4, July 2017

Delayed-onset muscle soreness (DOMS) is a relatively common phenomenon experienced by people who are new to exercise, or essentially anyone who exceeds their normal workout intensity. DOMS can range from mild irritation to severe pain that can form a significant barrier inhibiting performance, or exercise participation altogether. Furthermore, previous research has shown that DOMS is greater in intensity and duration in older individuals and individuals with diabetes, which is a particularly important patient population within family medicine. This cross-sectional repeated measure design study was performed to assess the impact on DOMS of heat applied for 8 hours immediately or 24 hours after exercise.

60 subjects aged 20-40 who were physically inactive for 6 weeks and had BMI’s less than 40 were divided randomly into 3 groups (control, ThermaCare heat wraps applied immediately after exercise, and ThermaCare heat wraps applied 24 hours after exercise). To provoke DOMS, the subjects completed squats in 3, 5-minute bouts with 3 minutes of rest in-between each bout.  Visual analog pain scales, blood myoglobin, muscle strength, range of motion, and stiffness of the quads were the main outcome measures of the study.

The results revealed a significant reduction in soreness in the group that had the heap wraps applied immediately after exercise (P<0.01). This was corroborated by blood myoglobin, algometer and muscle stiffness data. In addition, there was some benefit to applying the heat 24 hours after exercise when compared to control.

In summary, low-level continuous heat wraps left for 8 hours after heavy exercise can reduce the effects of DOMS (assessed by both subjective and objective measures). Although cold therapy is commonly used after heavy exercise to reduce soreness, heat seems to have the added benefit of increasing flexibility of tissue and tissue blood flow. The authors note that for the purposes of reducing joint swelling, it is still probably better to use cold therapy.

 

Sean Mindra MD, CCFP

PGY3 – Sport and Exercise Medicine, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

The Noisy Knee

Song, S. J., Park, C. H., Liang, H., & Kim, S. J. (2018). Noise around the Knee. Clinics in orthopedic surgery, 10(1), 1-8.

A common MSK question patients ask is “is it normal that my knee makes this sound?” While this review focuses on the knee, the approach can be generalized to any shoulder. Noise in the knee is common, and often patients are worried the noise is pathological.

Noise around the knee can be separated into physiologic and pathologic causes. This is defined by whether the sound is associated with pain, swelling, and abnormal range of motion. There are also many different types of sounds which are more likely to describe one cause than another. Crepitus is a vague descriptor used to represent a sound during a joint’s range of movement. Popping is a sudden explosive and well perceived sound, usually associated with injury such as meniscal, cruciate, or collateral ligament tears. Clunking is a loud singular noise due to release against resistance, often suggestive of something that was subluxed and now relocated. Clicking is a tiny, singular noise that occurs during one cycle of knee extension and flexion, this can be associated with various causes. Grinding and grating are used to describe continuous scratching sounds and are more associated with degenerative OA and patellofemoral pain syndrome.

Physiologic Sounds:

Not associated with any history of trauma, swelling, or pain.

Tend to be sporadic in nature

No aggravation of sounds and combined symptoms

Causes include:

  • build up or bursting of tiny bubbles in the synovial fluid
  • snapping of ligaments
  • catching of the synovium or physiological plica
  • hypermobile or discoid meniscus.

One way to distinguish between these causes is whether the joint sound occurs repeated during range of motion. If it happens repeatedly, it is usually due to anatomic structures rubbing against each other, such as ligaments/tendons or plica over a bony prominence. One common is the bicep femoris tendon at the lateral aspect of the knee. If the crack has a refractory period, it is likely due to air build up in the joint, and subsequent changes in joint pressure during range of motion cause cavity formation which creates a popping sound.

Management of physiologic noise involves reassurance and stretching and strengthening of affected musculotendinous structures.

Pathologic Sounds:

Can have history of trauma or injury

Tend to be higher pitch/frequency

observed consistently, has gradual aggravation

Causes:

  • Degenerative changes
    • Structural cause such as bony spurs and cysts, meniscal tears…etc
  • Pathologic plica
    • If a plica gets irritated, it can cause synovitis and pain
  • Patellofemoral instability
    • Due to hypermobility of patella or subluxation of patella
  • Post-surgical
  • Pathologic snapping knee syndrome
    • Any extra or intra-articular structure that causes painful sounds, which can include ganglion cysts, lipoma, synovial nodules, fabella, osteochondromas, osteophytes

Management of these pathologic noises depends on the underlying cause.

Overall, noise around the knee is a common phenomenon, with one study suggesting 38.1% of women and 17.1% of men over 40. With this approach, careful evaluation of the noise can help prevent unnecessary diagnostic interventions and provide appropriate guidance for healthy patients experiencing physiologic noise.

 

Jim Niu MD, CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

Chronic Exertional Compartment Syndrome – An Introduction

We have all heard of compartment syndrome. This is a medical emergency where increased pressures within a compartment can lead to rapid ischemia, muscle damage, and even potential amputation after a trauma or injury.

How many of us have heard of chronic exertional compartment syndrome (CECS)?

CECS is a cause of chronic exertional leg pain. Most often seen in young runners and elite athletes, it is a relatively unknown and underdiagnosed condition. Its incidence and pathophysiology are not well understood. One theory suggests a noncompliant fascia that cannot accommodate the expansion of muscle volume during exercise, causing increased intracompartmental pressures.

Suspect CECS with athletes who present with chronic anterior/lateral leg pain that worsens with prolonged use and resolves shortly upon cessation of activity. Most cases will occur in the anterior or lateral compartments. Classically, these athletes will be able to tell you that a specific time, distance, or intensity will bring on the symptoms, characterized as burning, aching, cramping, or pressure. It usually resolves fairly shortly if they stop the activity unless they continue to push through the symptoms for longer durations. It is fairly common to be bilateral. They may have some numbness/tingling in the dermatomal distribution of the nerve that runs through the compartment and weakness of those muscle groups.

Physical exam is often normal at rest. Some people will have visible painless fascial herniations. On physical exam immediately after exercise, there may be pain on palpation of the muscles involved, pain with passive stretching of the muscles, and the compartments may be quite firm. No imaging is necessary but will commonly be done to rule out other diagnoses such as a stress fracture. The diagnosis of CECS can be made clinically but given its non-specific nature, it can be confirmed using immediate post-exercise intracompartmental pressure testing. If confirmed, a surgeon may be consulted for an ELECTIVE fasciotomy.

The differential diagnosis includes medial tibial stress syndrome (shin splints), stress fractures, fascial defects, nerve entrapment syndromes, popliteal artery entrapment syndrome, and vascular or neurogenic claudication.

It is important to note that shin splints present with pain on the medial border of the tibia. Shin splints are NEVER lateral! A high level of suspicion is required for the diagnosis of ant/lat CECS as all imaging will be reported as normal.

While uncomfortable, there is no evidence to suggest that the pain from CECS indicates any muscle damage or has long-lasting implications. Modified activity is a reasonable treatment option. People may choose to avoid continuous running and opt to bike, swim, skate or play shorter shifts. Hopefully, this brief introduction sheds some light on the subject.

Jim Niu MD, CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

First-Aid Treatment for Friction Blisters: “Walking Into the Right Direction?”

Lando Janssen, Nenltje A.E. Allard, Dominique S.M. ten Haaf, Cees P.P. van Romburgh, Thijs M.H. Eijsvogels, Maria T.E. Hopman. Clinical Journal of Sports Medicine, Vol 28, No. 1, January 2018.

Trauma-induced separation within the epidermis, or friction blisters, are frequently encountered by patients choosing to be physically active to improve their overall health and well-being. Although most blisters are benign entities, complications including antalgic gait patterns, exercise-related or overuse injuries, cellulitis or sepsis can result. Thus, from the primary care physician’s perspective, the goal of treatment remains to reduce pain, facilitate healing and prevent both infection and recurrence.

However, much of the advice provided to patients regarding this topic is not evidence-based. To date, very limited research has been conducted to examine different treatment regimens for friction blisters. Furthermore, each study on this topic is limited to studying a homogenous population (elite athletes, military personnel). The purpose of this study was to compare the efficacy of fixation dressing versus adhesive tape in the first-aid treatment of friction blisters. These 2 methods were evaluated based on 1) Time of treatment application, 2) effectiveness, 3) material satisfaction in a large group of participants of the Nijmegen Four Days Marches (4DM). In addition, this study included a 1 month follow-up period to evaluate blister healing and complications when comparing treatments with different blister-covering materials.

The major findings of this prospective observational cohort study were:

  • Time of treatment application was significantly lower in the wide area fixation dressing group (41.5min, SD = 21.6min) compared to the adhesive tape group (43.4min; SD = 25.5min; P = 0.02).
  • A significantly higher drop-out rate in the 4DM was observed in the fixation dressing group as compared with the adhesive tape group (11.7% vs. 4.0%, respectively, P = 0.048)
  • There was no difference in pain intensity scores, infection rates, and the need for additional medical treatments. However, there was delayed blister healing in fixation dressing group (51.9% vs. 35.3%; P = 0.02) and a trend towards decreased satisfaction (P = 0.054) when compared to the adhesive tape group.

The authors conclude that despite a small, but significant reduction in the time of treatment application with wide area fixation dressings, these dressings resulted in delayed blister healing, a trend towards lower satisfaction, and a higher drop-out rate of in the 4DM. For these reasons, they do not recommend the use of wide-area fixation dressings in routine first-aid treatment for friction blisters and rather support the use of adhesive tape for this purpose.

Sean Mindra, MD, CCFP                                                                                                                  PGY3 – Sport and Exercise Medicine, University of Ottawa                                                      Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

 

Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis

Enke, Oliver, et al. “Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis.” CMAJ 190.26 (2018): E786-E793.

Back pain is a common issue seen in the family medicine practice that can result in significant morbidity. There are many therapies and pharmacological options available for the treatment of back pain, but high-quality studies showing efficacy are lacking for many of these options. In 2012, a BMJ review showed treatment benefit of gabapentin for low back radicular pain based on one study, and a few although not all guidelines subsequently suggested a trial of anticonvulsants for patients with acute neuropathic pain. This has resulted in a significant increase in the use of anticonvulsants in the family practice setting for low back pain. This review examines the use of anticonvulsants (topiramate, gabapentin or pregabalin) to treat low back pain with or without radicular pain. 9 studies were examined for a total of 859 participants. Of note, however, this study was not able to perform any significant subgroup analysis, such as acute vs chronic low back pain.

  1. Low back pain with or without radiating leg pain
    1. Gabapentin
      1. No effect for pain in short term. High-quality evidence.
      2. No effect for pain in the intermediate term, low-quality evidence
    2. Topiramate
      1. Small clinically significant improvement pain in short-term, moderate evidence
      2. No effect on disability in short-term
    3. Lumbar radicular pain
      1. Gabapentin or pregabalin
        1. No effect on pain in intermediate term, high quality evidence
        2. No effect on disability in short, intermediate, and long term, moderate evidence
      2. Topiramate
        1. No effect on pain or disability in short term. Low quality evidence
      3. Adverse events
        1. Higher in anticonvulsants compared to placebo, high quality evidence
        2. Most common side effects: drowsiness, somnolence, dizziness, nausea

In summary, this review suggests that anticonvulsants do not appear to improve patients’ pain or disability with regards to back pain, with or without radicular pain. While there are many nuances, the key to treating back pain without red flags remains centred on patient education, exercise therapy, and getting a multidisciplinary treatment program involved whenever possible.

Jim Niu PGY3 Sport and Exercise Medicine Fellow

Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (SEM), Dip Sport Med