Compex doesn’t have to be complex

compex

I should probably start by acknowledging that there are other muscle stimulation devices available… but I’m not employed by Compex, I just have some very good experiences using their product. This blog was borne out of frustration of seeing Compex machines gathering dust in treatment rooms or being used ineffectively as passive, plinth based modalities. I think a lot of people are missing the trick, you need movement!

While I am an advocate of its use clinically, I  want to disclose that using a Compex will not make a bad exercise good. It is a bolt-on to a rehab program and is something that can make a good exercise great. That is key. The clinical reasoning, exercise selection and placement of the stimulation all underpins an effective application, so before rolling it out to all athletes or patients make sure you can reason why it has a place in your practice.

Its all about progress

Like with any intervention, the clinical reasoning behind the application of muscle stimulation can influence its use at different stages of injury and rehabilitation. In the acute stages, it is believed that muscle stimulation may modulate pain. For an interesting read on the use of electricity and pain throughout the centuries, click here. However, as we understand more about optimal loading and mechanotherapy, we probably need to limit the time an athlete sits on the plinth watching the latest Mannequin Challenge on their smart phone while their quad twitches. It is worth considering that a Compex placed on a dead body would still cause it to twitch. The key is to get them moving and use the Compex to either facilitate movement or provide an external load. Interesting that we can use the same machine and the same settings to either regress or progress an exercise… the key is in the exercise selection.

Consider the tissues

Muscle injury: It should be pretty obvious that placing a muscle stimulation device, designed to promote contraction of muscle, on a contractile tissue with a tear or micro-damage could have negative consequences. For a second, lets forget the Compex. Respect the pathology and consider if you really need to lengthen or contract that muscle to load it. Is there a way you can work that tissue as a synergist perhaps? If the hamstring was injured in the sagital plane, can we move through coronal (frontal) planes and still load the hamstring? This could possibly be a slight progression on an isometric exercise and shouldn’t change the length of the muscle that may cause pain or further damage. Certainly more beneficial than sitting on the treatment bed though. So now consider how muscle stim may benefit this stage of injury. It could possibly help with any inhibition due to swelling or pain, perhaps be used to add an increased load to unaffected tissues that you may not be able to load otherwise.

As the healing progresses and the level of activity increases, it is quite common that we see some deficits in muscle function, especially after a long acute phase (if that isn’t a paradox?! Think post surgery or fixation). A good example is post ankle reconstruction, where you have worked on regaining plantar / dorsi flexion but when you ask the athlete to do a heel raise, it’s quite an effort. It may be appropriate to use the Compex here as a little crutch to facilitate movement and contraction. But the key thing here is it is not our cadaver that we causing a contraction in, the athlete is consciously initiating the movement. (Previous blog on internal and external cues here).

csjjpmaw8aefyb4
Now promise me if the Compex hurts, you will turn it down. OK?
Progressions by all definition, progress. So after working through isometric and concentric exercises, the program may require some eccentric load. This is worth trying yourself before asking a patient to do it, because a very simple exercise like a TRX squat that may have been cleared earlier in the program can dramatically increase in work with the addition of Compex. Consider a quad injury. The Compex has two phases of a cycle, a fasciculation phase that causes visible twitch and a long contraction phase (depending on the setting, the length and intensity of the contraction change). After one or two cycles for familiarisation, instruct the athlete to work against the contraction – so when the Compex wants to promote knee extension via a quad contraction, sit back and encourage knee flexion. Try this yourself for 6-8 reps and feel the fatigue induced, it usually surprises people. Again, make sure you can reason WHY you are doing this. This is usually a good bridge for someone who needs to step up their program but maybe can’t tolerate external load (confounding injuries, instability of joints, lack of technique etc etc.)

Joint Injuries: In comparison to a muscle injury, your application of Compex may be more aggressive. Because you are unlikely to affect a non-contractile tissue with the stimulation, you may use the eccentric reasoning to help reduce atrophy rates following a intracapsular injury like an ACL. Ensure you know the available range first of course.

With these injuries, the external stimulation may help with inhibition, improve proprioception lost by the ligament or capsule or it may provide stability to the joint by increasing the available contraction. Again, there will be a time and a place and it requires the clinician to reason through the application, but this may be a great addition to a program that is becoming stale.

Tendon injuries: The use of the Compex to enhance an isometric contraction or to create an eccentric contraction may be a great addition for an in-season tendinopathy as a way of managing load. The timed contraction allows clinicians to monitor Time Under Tension (TUT) which is essential for tendon management. If considering a High-Medium-Low frequency through the week, a pain free exercise that is used on a Medium day can become a High load exercise with the addition of an externally generated contraction. But consider the two things that aggravate a tendon, compression and shear. Appropriate exercise selection and range is going to be crucial, that being said, it may be that the addition of stimulation to the quads actually reduces shear through the patella tendon by changing the fulcrum of the patella (no research to back this up, just my musings).

musing
I really like Geckos. I found this Gecko a musing
Conclusion:

I think there are many options out there to enhance rehabilitation by considering the diversity of muscle stimulation. But I want to repeat for the hundredth time, it is the exercise selection that is key. The addition of a Compex will only amplify that choice.  For the patient, it adds a bit of variety to a rehabilitation program and for the clinician it is another tool to help with optimal loading of a healing tissue or structure. I am a big fan of weight training (don’t let my chicken legs fool you) but there are injuries or athletes that for one reason or another are unable to tolerate weights. This is one tool in a very large and overused metaphorical tool-box that may bridge that gap between body weight exercises and weighted exercises. I also believe there is great benefit when complimenting this with Blood-Flow Restriction Exercise or Occlusion training… but that’s another blog.

As always, thoughts and opinions are welcome.

 

Yours in sport,

Sam

Case Study: working through the pain with Nick Atkins

Nicks 30/30 challenge

A bit of an unusual blog from us, but I hope its as popular as our previous ones due to the message it contains. A very good friend of mine is undergoing a year-long series challenges to help raise money for a cause very close to his heart.

Below is a summary of the 30 challenges that Nick Atkins is doing, having turned 30 this year.

image
Nick Atkins 30 / 30 challenges

I’m sure a lot of people will question the management of some of his injuries I’m detailing here because I’ll admit its not how I would typically manage these problems, so let me explain quickly why rest is not an option here:

Nick, along with his sister Jen & brother Jon, very sadly lost their mum, Judith Atkins, to pancreatic cancer in 2013. Pancreatic cancer has the lowest survival rate of any cancer. Doctors believe there is a period of remission around 5 years that if reached, the risk of the cancer returning is negligible. Judith was a few months short of this milestone before the pancreatic cancer aggressively returned. While we are generally winning the fight against cancer, pancreatic cancer remains the outlier and part of Nicks aim is to not only raise money for research, but also awareness. (Nicks justgiving page here). For this reason, he is displaying an incredible amount of grit and determination to complete these challenges, despite his body saying otherwise.

251232_10150326777859126_3449228_n
Nick, certified drinking athlete. Pre-challenge training

A quick background into Nick, he is what his friendship circle would describe as a “drinking athlete” and certainly not a runner. So while some endurance junkies out there may do physical challenges like these regularly, Nicks starting position was certainly not one built on endurance.

Nicks injuries to date:

 

Untitled
Disclaimer – I have permission from Nick to share these details regarding his injuries.

 

The nature of Nicks challenges meant the timeframes were dictated by inflexible dates, making it very hard to periodize any training. So load management became critical, forecasting time periods where we could off-load but maintain a crucial level of fitness.

The first problematic injury(ies) was the bilateral plantafascia pain with right sided calcaneal fat pad irritation. This was the first time we had to make decisions about the program. Previous aches and pains in the lower limbs and back were manageable and its not in Nicks nature to complain. But this pain in his foot was affecting ADL’s as well as training. Typically inflammatory in nature and progressively increasing pain, it took him to the point where he couldn’t weight bear through his heel – but was still completing physical challenges.

Controlling the controllables:

Dropping or moving a challenge was not an option, so we had to sacrifice road running training and hockey for a period of two weeks. Nick maintained fitness via swimming and cycling (a lot) in the mean time we addressed some biomechanical issues in the foot. I say this very tentatively, because in fact it was a lack of biomechanical issues that we had to address. Nick was prescribed some permanent orthotics when he was about 16 for “collapsed arches” – in fact these orthotics were probably causing more problems than solving. Nick had good active control of the medial and longitudinal arches in both feet, so no evidence of a collapsed arch. These orthotics were encouraging him to laterally weight bear via some high density medial posting of the calcaneus & preventing any medial rocking after heel-strike. We removed these, added some gel heel cushions to his work shoes to help offload the fat pad and temporarily reduced running training, which seemed to resolve the pain after two weeks. Instead, nick ramped up the swimming and cycling as part of his triathlon training.

10419593_715296375221508_4475737449468001641_n

 

Nature of the beast:

There have been times recently however where we can’t modify load. Nick is currently running with right sided Achilles pain and in the last week has developed sharp pain in his left groin which is present following a rest at the end of a long run. This presented us with a problem; a month of 10k’s, with half marathons immanent and full marathons on the near horizon. Nick can’t afford to rest.

Typical management of tendon problems would be modifying load along with addressing strength. There was a dramatic difference with single leg heel raise between left & right. Temptation would be to add some exercises here to address this, but we need to acknowledge the accumulative load and consider if there would be any benefit. We decided that the back to back events could in themselves serve to maintain fitness, so we could drop a training session during the week.

The other consideration is where & when Nick is getting the pain. The Achilles pain is only present with compression, so with full plantaflexion – recreated both actively and passively, which makes me suspect a retrocalcaneal bursa involvement. We know that tendons don’t like compression but the absence of any Haglunds deformity and with adequate, well fitting running shoes there is reason to think the tendon may not be a source of symptoms. (See my previous tendon blog here with references).

The pain has stayed at the same level for over 4 weeks now, so we have identified an upcoming gap in events as a window to unload and reassess. In the mean time we can achieve short term relief with soft tissue massage to the gastrocs and some tib-fib, talocrural and subtalar mobilisations.

The groin on the other hand presents like a classic tendinopathy and we were able to exclude any pubic synthesis involvement via a series of tests. This injury was a lot more acute in nature compared to the Achilles. We tried some isometric adduction through different ranges of hip flexion and achieved some short term reductions in pain. Once again, we had to sacrifice some hockey training to try and reduce load and cutting actions in the groin, but in place of this we added isometric groin squeezes into Nicks program.

What’s next?

10372589_10152460747776425_6767386341239402965_n
Nick & his wife Cat, who has done every challenge with him so far & ironically is conducting her PhD in tendon pathology.

At the time of writing, I have my fingers crossed as Nick is running a “True Grit” obstacle course with his dedicated wife, Cat, who has done every challenge with him so far! (Except the 100 different beers in a year).

With some half marathons and marathons coming up, along with long distance treks I’m anticipating an update to this blog in the summer. Like I said, the plan now is to highlight a window of relative rest where we’ll do some detailed analysis of the right leg in particular. Overall though, I’m incredibly impressed that someone with no endurance running experience has had so little problems. It wont be typical management that’s for sure – while there are long term goals to be met, performance is not the main driver. I’m used to managing similar problems with a view of being pain free, able to perform at high level and minimising the risk of re-injury. So some of this management may not appease the purists, I understand.

For Nick, however,  there are no specific performance targets to be met, it is just essential that he finishes. He’ll do that without my help because of the level of determination he has, but my job is to try and keep a lid on the severity of injury (he insists 90 days without a hot drink is harder than any marathon or combination of marathons).

But the description of Nicks injuries & management are secondary to the fact that hopefully I’ve helped promote Nicks challenges and ultimately an awareness of Pancreatic Cancer. For that reason, if you’ve read this far please help share Nicks challenge.

1897674_715301338554345_7029664882965157963_n
Nick & his mum, Judith.

https://www.justgiving.com/nicks3030challenge/

On behalf of Nick, yours in sport

Sam

ps – the 30th challenge is yet to be decided, Nick wants to make it something special so please send us your suggestions!!

 

Cryotherapy: Therapeutic but is it clinically relevant?

Ice
ACPSEM members can access PRICE guidelines here

Try thinking of a title about Ice and avoid the temptation to put “Baby” in it!

 

The thing that I love about physiotherapy is that nothing is ever black & white. Things will come in and out of fashion and our understanding about interventions and treatment modalities will continuously evolve. One of the great debates is about the use of ice following injury. How long should we apply it? In what form should we apply it? Should we use it all?

I recently skimmed through the Physical Therapy in Sport journal under “Articles In Press” and saw two papers within that category alone that discussed the use of cryotherapy. (For anyone that is a geek like me and hasn’t got the Health Advance App by Elsevier, get it! ACPSEM members can access all the content for free here http://bit.ly/PTISaccess).

The first paper was a systematic review (Martimbianco et al 2014), which instantly lost my attention, from my point of view they combine the conclusions of a multitude of papers and varying methodologies (all with their own unique methodological flaws) to create a super-conclusion that most of the time isn’t clinically relevant or is very noncommittal. Essentially, systematic reviews are literature stereotyping. In this case, said paper based a lot of its findings on papers from in the early 1990’s. It concluded that there was not enough evidence to draw a definitive conclusion on the use of cryotherapy following ACL reconstruction.

The second paper however, provoked a bit more thought. This study was by Phil Glasgow, Roisin Ferris and Chris Bleakley – with Glasgow and Bleakley from the recent POLICE guidelines fame – who better to critique the use of ice?
Glasgows paper was a randomised trial looking at the effects of cold water immersion (CWI) comparing different temperatures and durations of immersion on Delayed Onset Muscle Soreness (DOMS). It was this paper that inspired the forthcoming discussion…

 

What do we think we know about cryotherapy?

 

The first thing to distinguish is the method of cryotherapy; in what form should ice / cold be applied? Cryotherapy comes in forms of crushed ice to blocks of ice, buckets of cold water to cold water baths, compression devices to good old-fashioned ice spray on the side of the pitch. In any form, the proposed clinical benefits encourage a pumping effect on vascular system to encourage blood flow, nutrient and waste transportation (Wilcock, Cronin & Hing 2006). Then there are psychological benefits of feeling more “awake” and less fatigued (Wilcock et al 2006). A recent Cochran review (Bleakely et al 2012) found that CWI is superior to passive intervention at reducing muscle soreness. (I know, I slate systematic reviews then use them to my advantage). The point I’m getting at is that of all the proposed benefits of cryotherapy, the most weight is behind the subjective benefits. Take Glasgows recent paper; The control groups scores of VAS pain following eccentric hamstring exercises were 20% higher than one of the intervention groups that underwent 10 minutes immersion at 6ºC (see image below source). The results were not statistically significant but they do look clinically relevant. These percentage differences do not have to be statistically significant for them to have a major benefit in elite sport, where marginal gains has now become a specialised role in itself thanks to Dave Brailsford and the British Cycling team. Everyone is looking for that extra percent to enhance performance & results.

Image

 

Where does ice fit in the treatment room?

 

If we return to the basic scientific theory underpinning cryotherapy, we think that it decreases metabolic activity and therefore limiting secondary hypoxic damage – essentially reducing risk of secondary injury. The injury has happened, there is nothing we can do about that, but we can prevent it worsening. Secondary hypoxic damage not only weakens affected tissues, but the associated swelling can effect surrounding tissues. In steps the counter argument…

It has been found that tissue temperatures below the subcutaneous layers are very difficult to influence due to the highly sophisticated homeostatic systems in place. Bleakley, Glasgow & Webb (2012) found the changes in tissue temperature are not enough to influence metabolic activity. However we do know that CWI will reduce skin temperature, even if it doesn’t affect tissues below (Algafly & George 2007). We also know how important the skin is in feeding information back to the CNS. It plays a huge role in proprioception and nociception.

 

In our treatment room, we still advocate the use of ice despite the emergence of this new understanding. What has changed in recent years is our thought process behind what is happening as a result of the ice. Instead of using cryotherapy in isolation to limit swelling, we now combine it with compression (which is proven to assist with swelling and decreasing CK levels etc) to reduce pain. For more proximal soft tissues injuries, we have the luxury of a Game Ready machine to compress and cool affected areas. However for more distal injuries, e.g. Following an ankle sprain, we will encourage the player to submerge their foot in a bucket of 1/3 ice and 2/3 water. As soon as the foot goes numb, we begin some appropriate movements (cryokinetics) depending on injury location, structures involved etc. By doing this, we believe the hydrostatic pressure of the water will act as local compression while the ice provides appropriate analgesia. The analgesia then allows us to begin some loading of damaged structures – thinking back to the POLICE guidelines that advocate Optimal Load. Every stage of this treatment is clinically reasoned. The movements undertaken should not exceed normal ranges of movement and must be pain-free.

 

Lets wrap it up…

At the moment, cold water immersion is commonly used as a recovery modality from exercise, especially exercises that elicit DOMS, but with very little empirical evidence to support this. Despite this, we have subjective improvements in pain following any ice interventions. If we can accept that and build that into our clinical reasoning, then we have a way of removing pain from our limiting factors and enabling us to introduce movement to an injured structure. So, although we can’t clinically justify the use of cryotherapy as a recovery modality, I would advocate it as part of a treatment & rehabilitation program.

 

Yours in Sport,

 

Sam

 

Image
Game ready professionally photographed in my kitchen