• Internal fixation (compared to hemiarthroplasty) had a faster surgical time and less blood loss and lower infection rate.
• A second (revision) surgery was more common after internal fixation (40 per cent compared to only five percent with hemiarthroplasty).
• Deaths from either internal fixation or hemiarthroplasty were about the same.
• Complication rates were lower and hip function higher among the patients with a total hip replacement (compared to internal fixation).
• All things considered, cemented implants seems to be the preferred technique. Outcomes are better with less pain, faster recovery, and improved function.
• It was difficult to separate results using type of surgical approach as the variable from type of implant and postoperative care provided. No strong recommendations could be made in this area.In summary, there isn’t a cut and dried approach to femoral hip fractures in the elderly. The best available evidence does not strongly support one treatment method over another. For displaced femoral neck fractures, hemiarthroplasty seems to win out over internal fixation. Many variables and factors are taken into consideration when proposing a plan of care. The surgeon must examine each patient on a case-by-case basis.

The thigh bone, or femur is the longest and strongest bone of the body. It takes a lot of force to break the femur in an adult so it is often accompanied by other injuries. The fracture is a disabling problem, severely limiting mobility until it is stabilized.

Until recently the most common way to treat a fractured femur was to apply traction, the source of a thousand cartoons and jokes. Fortunately, modern treatment usually stabilizes the bone quite early on and allows you to move around on crutches.

This guide will help you understand:

• what structures are involved
• what the symptoms are
• what can cause these fractures
• how health care professionals diagnose these fractures
• what the treatment options are
• what First Choice Physical Therapy’s approach to rehabilitation is

What structures are most commonly injured?

The femur extends from the hip to the knee and represents one fourth of the height of the average adult. You can feel the lower end of the femur at the knee. The upper end is deeply buried in the muscles at the hip, but you can feel the bony bump of the greater trochanter on the outer side of the hip.

The shaft of the bone is a hollow tube with dense strong compact bone on the outside and fatty tissue with no structural strength inside. The shaft breaks when impact, bending, twisting or compression stresses the bone.

How do fractures of the femur commonly occur?

Femur shaft fractures occur in high energy traumas such as motor vehicle accidents and falls from a height. Gunshot and blast injuries also cause severe open fractures of this area. Lower energy accidents which may cause a fracture of the thigh bone include collisions in sports, skiing injuries and twisting injuries.

Impact against the thigh causes a bending force that compresses one side of the bone and stretches the other. This may result in a short oblique fracture or a three-part fracture with a short triangular fragment.

A twisting force can be applied to the thigh bone when the foot or lower leg is trapped and the weight of the upper body is rotating. This causes a spiral fracture of the bone.

Compression along the line of the bone causes a transverse fracture. This may occur in a car accident when the knee strikes the dashboard and the force is transmitted up the bone.

The bone injury is only a part of the total picture when a fracture occurs. Injury to the muscles, tendons, ligaments, skin, blood vessels and nerves may be more important than the broken bone. This is particularly true of femur fractures. The force needed to break the thigh bone often causes a lot of damage to the other structures in the thigh. An open fracture in which the bone comes out through the skin is an especially severe problem.

What symptoms do femur fractures cause?

The main immediate symptom from the injury is pain in the thigh and inability to use the leg. It is very rare for anyone to be able to walk on a broken thigh bone and it shouldn’t be attempted. The leg is often unstable and does not move as one. Usually, the fractured leg will be shorter than the other one and distorted. There will be swelling and tenderness at the site of the fracture. There may be loss of sensation and movement of the foot if the nerve or blood supply has been affected. If the bone has come through the skin the wound will be obvious. Internal bleeding from a broken femur can be significant causing rapid heart rate and low blood pressure leading to shock.

Pain will continue to be significant for several weeks as the thigh bone heals but this will be lessened if the bone is stabilized by surgical fixation. Swelling, tenderness and massive bruising are also symptoms that often last for weeks.

How will my fracture be evaluated?

First aid evaluation at the scene of the accident will include questions about the nature of the accident, site of pain and ability to move the leg. The shock status of the patient will also be evaluated. The leg will be assessed for wounds, sensation and blood supply. Usually the leg will need to be splinted prior to transport to the hospital. The patient should be kept warm and still.

In the Emergency Room the patient will be further assessed for shock and blood loss as this can be significant. The patient will be checked carefully for other injuries especially in the case of a high energy accident with its potential to cause multiple traumas. The vascular and nerve supply of the limb will be carefully checked. The limb will be stabilized with splints, sandbags or skin traction. Careful palpation of the leg, paying attention to the knee and shin as well as the thigh and hip, may give an indication of other injuries. Routine tests are done to evaluate blood loss and general body biochemistry prior to an anesthetic.

X-rays of the thigh are a vital part of the evaluation of this injury. CT or MRI scanning is not usually needed for these fractures.

The standard x-ray views are an anteroposterior (AP) view of the whole thigh bone from hip to knee and a lateral view of the shaft. It is extremely important to get satisfactory x-rays of the hip and knee joint to make sure these regions are not also fractured. Even with good X-rays a small number of hip fractures are not discovered at the initial evaluation.

What treatments should I consider?

Surgery

A few years ago this type of fracture was most commonly treated in traction. However, in North America the majority of patients with a broken thigh bone are now treated by surgery. This surgery consists of straightening (reducing) the fracture and stabilizing it with a metal rod passed inside the bone and fixed to the bone at the top and bottom to prevent shortening and rotation.

Traction may be recommended in some cases where the risks of a more major operation seem too great. A metal pin is passed through the bone either just above or just below the knee. Slings and splints support the leg, and 15-25 lbs or 7-11kg of weights are attached by cords and pulleys to the pin. The principle behind using traction is that pulling on the bone both straightens it and keeps it still.

The traction must be maintained until the healing process is advanced to the point where the fracture will not move when the traction is removed. This usually takes six to eight weeks in an adult. Following this period in traction the fracture must still be protected in a body cast, otherwise it is liable to shorten, angulate or rotate. The body cast, from chest to ankle is maintained for some months until the fracture is united. If the fracture has a very stable pattern it may be possible to treat it in a cast brace after the initial period in traction.

Apart from the significant inconvenience of prolonged bed rest for traction, prolonged immobilization, and a body cast, this way of treating the fracture was found to cause a number of problems such as malunion, nonunion, stiffness, weakness and poor functional recovery from the injury.

Thus the reason for treating a fractured femur by surgery is because the results of non-operative treatment are not consistently good. Surgery is done under general or spinal anesthetic. The bone is straightened and kept straight by traction. A small hole is then made at the top of the thigh bone and a thin wire is passed down inside the bone, crossing over the fracture and into the lower fragment. The inside of the bone may be reamed (cleared out) to ensure a snug fit. Next an Intramedullary Rod (IM Rod or IM Nail) is passed over the guide wire inside the femur and is secured with screws at either end.

With some fracture patterns or with open fractures, an external fixation device may be used. To apply an external fixator, the bone is straightened and large threaded pins are passed into the bone fragments above and below the fracture. These pins are attached to a rigid framework outside the thigh, which holds the fragments in position while the healing process takes place.

When the fracture extends far down the shaft towards the knee a plate may be used. The greatest advantage of operative treatment of a fractured femur is that it allows the patient freedom to move, to walk on crutches very soon after the surgery and to leave the hospital early. The bone is not healed by the surgery, but it is held still to improve the chances of healing. The quicker recovery of normal movement of the hip and knee prevents future problems of stiffness and weakness.

Implants are often removed after the bone is healed. The external fixators are always removed. Plates are also removed quite frequently as they may give the patient some symptoms and can often be felt through the skin. Removal of IM Rods is done only when they cause symptoms. The removal operation is relatively simple and recovery is usually quite rapid (six weeks) however, the bone may need some time to regain full strength after the hardware has been removed.

When there are no symptoms attributed to it, removal of the hardware is controversial. Some surgeons advocate it because the presence of a plate or a rod may weaken the bone long term; others leave the hardware in and point to the small but significant incidence of re-fracture in the three months after the implant is taken out.

What happens as I recover from surgery?

The normal uncomplicated process of bone healing takes six weeks to obtain 50 percent of eventual bone strength, three months to reach 80 percent bone strength and consolidation and remodeling of the fracture site may continue for 18 months. The consequences of this timetable are that the fracture needs protection for the first three months. Early on this means using crutches and not putting much weight through the injured leg otherwise the fixation will fail.

In order to determine when more weight can be put through the thigh your orthopaedic surgeon will monitor the healing with x-rays at intervals. When new bone formation (callus) is evident bridging across the fracture, you may be encouraged to put more weight on the leg.  Even though actual bone healing may be at 50 or 80%, overall recovery from the fracture and surgery also requires adequate muscle strength and endurance as well as joint range of motion and control. Physical Therapy at First Choice Physical Therapy can help you achieve this.

Rehabilitation at First Choice Physical Therapy will begin as soon as your surgeon recommends it. Sometimes therapy will be recommended even before you are allowed to fully weight bear. In other cases, rehabilitation will not be recommended until full or nearly full weight bearing begins. Each surgeon will set his own specific restrictions based on the type of fracture, surgical procedure used, personal experience, and whether the fracture is healing as expected.

Even if Physical Therapy for the injured leg has not yet begun, at First Choice Physical Therapy we highly recommend maintaining the rest of your body’s fitness with regular exercise.  You can use an upper body bike if you are non-weight bearing or may even be advised to do non-weight bearing exercises in a pool. A stationary bike is often the best cardiovascular activity once weight bearing begins. Weights for the upper extremities and other leg are also strongly encouraged. Your Physical Therapist at First Choice Physical Therapy can provide a program for you to maintain your general fitness while you recover from your surgery.

If you are still using crutches by the time we first see you at First Choice Physical Therapy, your Physical Therapist will ensure you are using them safely, properly, and confidently and that you are abiding by your weight bearing restrictions. We will also ensure that you can safely use your crutches on stairs. If you are no longer using crutches, or once you no longer need them, your Physical Therapist will focus on normal gait re-education. Until you are able to walk without a significant limp, we recommend that you continue to use your crutches, or at least one crutch or a cane/walking stick. Improper gait can lead to a host of other pains in the knee, hip and back so it is prudent to use a walking aid until near normal walking can be achieved. Your First Choice Physical Therapy Physical Therapist will advise you regarding the appropriate time for you to be walking without any walking aid at all.

Patients may experience pain when they initially start to put weight through their leg. This pain can be from not using the joints and muscles regularly or it may be from concurrent soft tissue injury that occurred when you fractured your thigh. During your first few appointments at First Choice Physical Therapy your Physical Therapist will focus on relieving your pain. We may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the surgical site or anywhere down the extremity. In addition, your Physical Therapist may massage your leg and ankle to improve circulation and help decrease your pain.

The next part of our treatment will focus on regaining the range of motion and strength in your entire lower limb. Your extremity will look and feel quite weak after not using it for an extended period. Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program. We will focus particularly on gaining range of motion in your knee as the knee can easily become stiff if early motion is not encouraged. In regards to strength we will focus on the muscles of your hip and thigh but may even give you exercises for areas such as your ankle or back as these areas help to support the lower limb when you are weight bearing. An electrical muscle stimulator may be used to assist your muscles in contracting as you do your exercises, which will assist you in more rapidly gaining your strength back. Exercises may also include stationary cycling and the use of Theraband or weights to provide some resistance for your lower leg.

If necessary your Physical Therapist will mobilize your joints. This hands-on technique encourages the stiff joints of your hip, knee, ankle and foot to move gradually into their normal range of motion. Mobilization of the joints may be combined with assisted stretching of any tight muscles around the surgical site. Fortunately, the initial phases of gaining range of motion and strength after a femur fracture go quickly. You will notice improvements in the functioning of your whole leg even after just a few treatments with your Physical Therapist at First Choice Physical Therapy. As your range of motion and strength improve, we will advance your exercises to ensure your rehabilitation is progressing as quickly as your body allows.

As a result of any injury, the receptors in your joints and ligaments that assist with balance and proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobility and reduced weight bearing will add to this decline. If your balance and proprioception has declined, your joints and your limb as a whole will not be as efficient in its functioning and the decline may also contribute to a potential injury in the future. As a final component of our treatment your Physical Therapist at First Choice Physical Therapy will prescribe exercises for you to regain balance and proprioception. These exercises might include activities such as standing on one foot or balancing on an unstable surface such as a wobble board or a soft plastic disc. Advanced exercises will include agility type exercises such as hopping, jumping or moving side to side.  Eventually we will encourage exercises that mimic the quick motions of the sports or activities that you enjoy participating in.

Once the fracture shows x-ray signs of consolidation you can use the leg more normally and return to heavier activities and sports. This stage is usually between three and 18 months post-injury and depends just as much on the recovery of muscle strength and endurance as it does on the recovery of the bone. The fact that the healing process may go on for 18 months means that the symptoms of aching, throbbing, swelling and weakness may continue for a long time after the bone appears ‘healed’ on x-ray but should gradually decline and then disappear.

Generally, the strength and stiffness one experiences after surgery to repair a femur fracture responds very well to the Physical Therapy we provide at First Choice Physical Therapy, however, if your pain continues longer than it should or therapy is not progressing as your Physical Therapist at First Choice Physical Therapy would expect, we will ask you to follow-up with your surgeon to confirm that the surgical site is tolerating the rehabilitation well and ensure that there are no hardware issues or complications that may be impeding your recovery.

Overall the prognosis for full recovery from a fractured thigh bone is encouraging. Most people’s bones heal in a good position and they recover near normal function. Most of those who do not recover full function have had the injury or its treatment complicated by one or more of the problems discussed in the next section.

A fracture of the shaft of the thigh bone is a serious injury with the potential for severe long term problems. It is also commonly associated with other injuries. Modern treatment with IM rod fixation fixes the fracture in a good position and allows early mobilization, pain relief and discharge from hospital. Complications from this type of treatment are relatively rare and it is normal to return to full activity however full recovery can take up to 18 months.

Bones are living tissue, and like all living tissues they rely on blood vessels to bring blood to keep them alive. Most living tissues have blood vessels that come from many directions into the tissue. If one blood vessel is damaged it may not cause problems, since there may be a backup blood supply coming in from a different direction. Certain joints of the body, however, have only a few blood vessels that bring in blood. One of these joints is the hip. This document will describe what happens when this blood supply is damaged and results in what is called avascular necrosis (AVN) of the hip. Another name for this condition is osteonecrosis (which means “bone death”).

This guide will help you understand:

• how AVN develops
• how health care professionals diagnose this condition
• what treatments are available
• what First Choice Physical Therapy’s approach to rehabilitation is

 

Where does AVN develop?

The hip joint is one of the true ball-and-socket joints of the body. The hip socket is called the acetabulum and forms a deep cup that surrounds the ball of the upper thighbone. The thighbone itself is called the femur, and the ball on the end is the femoral head. The ball and socket arrangement gives the hip the large amount of motion needed for daily activities such as walking, squatting, and climbing stairs.  Thick muscles of the buttock at the back and the thigh in the front surround the hip.

The surface of the femoral head and the inside of the acetabulum are covered with articular cartilage. This material is about one-quarter of an inch thick in most large joints. Articular cartilage is a tough, slick material that allows the surfaces to slide against one another without damage.

 

All of the blood supply comes into the ball that forms the hip joint through the neck of the femur (the femoral neck), a thinner area of bone that connects the ball to the shaft. If this blood supply is damaged, there is no backup.  Damage to the blood supply can cause death of the bone that makes up the ball portion of the femur.  Once this occurs, the bone is no longer able to maintain itself.

 

Living bone is always changing. To maintain a bone’s strength, bone cells are constantly repairing the wear and tear that affects the bone tissue. If this process stops the bone can begin to weaken, just like rust can affect the metal structure of a bridge. Eventually, just like a rusty bridge, the bone structure begins to collapse.

When AVN occurs in the hip joint, the top of the femoral head (the ball portion) collapses and begins to flatten. This occurs because this area is where most of the weight is concentrated. The flattening creates a situation where the ball no longer fits perfectly inside the socket. Like two parts of a mismatched piece of machinery, the joint begins to wear itself out. This leads to pain in the hip joint and eventually to osteoarthritis of the joint.

Why do I have this problem?

There are many causes of AVN. Anything that damages the blood supply to the hip can cause AVN.

Injury to the hip itself can damage the blood vessels. Fractures of the femoral neck (the area connecting the ball of the hip joint) can damage the blood vessels. A dislocation of the hip out of the socket can tear the blood vessels. It usually takes several months for AVN to show up, and it can even become a problem up to two years following this type of injury.

Some medications are also known to cause AVN. Corticosteroids (cortisone) such as prednisone or methylprednisolone are the most common drugs known to lead to AVN. This is usually only a problem in patients who must take cortisone every day due to other diseases, such as advanced arthritis or to prevent rejection of an organ transplant.
Sometimes there is no choice, and cortisone has to be prescribed to treat a condition, knowing full well that AVN may occur.  Local injection with cortisone, such as one or two injections into joints to treat arthritis or bursitis, has not been proven to cause AVN but some patients have developed AVN within the first month of taking these drugs orally (pills by mouth). Patients taking both corticosteroids and statin drugs (cholesterol-lowering medications) seem to have the greatest risk for developing AVN of the femoral head.

A clear link exists between AVN and lifestyle choices such as smoking and alcohol abuse. Smoking causes blood vessels to constrict or narrow thereby limiting the amount of blood flow to an area such as the hip with its already limited backup supply. Excessive alcohol intake somehow damages the blood vessels and can lead to AVN. Deep sea divers and miners who work under great atmospheric pressures are also at risk for damage to the blood vessels. The increased pressure at such depths causes tiny bubbles to form in the blood stream, which can block the blood vessels to the hip, damaging the blood supply.
There is a long list of other diseases and conditions that are associated with an increased incidence of femoral head osteonecrosis. These conditions are referred to as nontraumatic causes. For example, there is a link between osteonecrosis and problems like gout (hyperuricemia,) leukemia, sickle cell diseases, and HIV infection as well as a link with less well-known diseases such as Gaucher disease, and Caisson’s disease.

What does AVN feel like?

The first symptom of AVN is pain when weight is placed on the hip. The pain can be felt in the groin area, the buttock area, and down the front of the thigh. As the problem progresses, the symptoms include development of a limp when walking and stiffness in the hip joint. Eventually, the pain will also be present at rest and may even interfere with sleep.

How do health care professionals identify this condition?

Diagnosis begins at First Choice Physical Therapy with a complete history and physical examination.

Your Physical Therapist will ask questions about where precisely your pain is, when the pain began, what you were doing when the pain started, and what movements aggravate or ease the pain. They will also want to know about your occupation, what other medical problems you have, and your medication use.  In addition, if AVN is suspected, they may inquire about whether you drink alcohol or smoke.

Next your Physical Therapist will do a physical examination to determine exactly where your pain is, to assess how much stiffness you have in your hip joint, to determine if your hip is weak, and to assess whether or not you are walking with a limp.  Your therapist will palpate, or touch, around the hip joint, including the buttocks and back areas, to determine where most of your pain is located.  Your therapist will also move your hip into different positions to determine which motions cause or ease your discomfort. Finally, they will want to look at your foot position and alignment when you stand, and may ask you to walk or squat so alignment can be determined during these activities as well.  If AVN is suspected your Physical Therapist will likely encourage X-rays to be done.

X-rays will usually show AVN if it has been present for an extended period of time. In the very early stages, it may not show up on X-rays even though you are having pain. In the advanced stages, the hip joint will be very arthritic, and it may be hard to tell whether the main problem is AVN or advanced osteoarthritis of the hip. Either way, the treatment is basically the same.

If the X-rays fail to show AVN, you may need to have a bone scan done to determine if the pain in your hip is coming from early AVN. A bone scan involves injecting tracers into your blood stream firstly and then several hours later using a large camera to take a picture of the bone around the hip joint. If there is no blood supply to the femoral head, the picture will show a blank spot where the femoral head should be outlined on the film.

With today’s technology becoming more advanced, often these days a magnetic resonance image (MRI) is done instead of a bone scan. The MRI scan is probably the most common test used to look for AVN of the hip. The MRI scanner uses magnetic waves instead of radiation. Multiple pictures of the hip bones are taken by the MRI scanner. The images look like slices of the bones. The MRI scan is very sensitive and can show even small areas of damage to the blood supply of the hip, even just hours after the damage has occurred.
Your doctor or surgeon will use these imaging studies in order to plan the best treatment approach for you. He or she will look at where the damage has occurred, the size of any lesions, whether or not there has been any collapse of the bone, and determine if any arthritic changes have developed. Based on these findings, the condition will be classified as either mild, moderate, or sever

What can be done for the condition?

Once AVN has occurred, the treatment choices are determined by how far along the problem is and your symptoms. Other factors that guide treatment decisions include your age, activity level, general health including any specific health problems present, and your life expectancy. For example, patients with other serious health problems or with a limited life expectancy might be treated with nonoperative care. While the symptoms may be reduced with pain medications and anti-inflammatory medications, no medical treatments will restore the blood supply to the femoral head and reverse the AVN.

Nonsurgical Treatment

If AVN is caught early, non-surgical treatment may be an option.  Nonsurgical treatment involves using medication as well as doing Physical Therapy at First Choice Physical Therapy.

In regards to medication, anti-inflammatories are often used to ease pain. Bisphosphonates are another group of medications that can be helpful. One particular bisphosphonate, Fosamax, which is normally used for the treatment of osteoporosis, has been shown effective in reducing the risk of femoral head collapse in patients with avascular necrosis. In some cases, surgeons also prescribe biophysical treatment modalities such as electrical stimulation or shock wave therapy in an attempt to get the bone to heal. Sometimes these measures may help delay the need for surgery, but they rarely reverse the problem.

Physical Therapy can be very effective in treating AVN of the femoral head if it is detected early. It can help to ease your pain and prevent further damage but again, treatment is not aimed to reverse the problem of damage has already been done.  Early detection and treatment with Physical Therapy is the key to nonsurgical management of AVN.

During your first visit to First Choice Physical Therapy your Physical Therapist will take some baseline measurements in regards to your pain level, hip mobility, and your ability to do certain activities so that any improvement or regression over time can be measured.  The first few treatments will focus on decreasing any pain or inflammation you may have.  Ice is a very useful modality to reduce pain, however, many patients find heat to be more soothing and pain relieving in the case of the deep hip joint.  Either one is appropriate depending on the relief it provides in your individual case.  Your Physical Therapist may also use electrical modalities such as ultrasound or interferential current to decrease the pain and inflammation. Massage, particularly for the buttocks, back, or anterior and lateral hip muscles, may also be helpful.

Decreasing the load that the hip joint bears can be very effective in allowing the bone to heal as well as managing pain. This decreased load is achieved by having you use crutches or a walker instead of putting weight through your affected leg. If bearing no weight on the leg is too difficult, or deemed not completely necessary by your Physical Therapist, putting some weight through the leg, but bearing less than full body weight on that side can still be effective in giving the hip a chance to heal and in reducing your pain.  Your Physical Therapist will teach you how to safely use the crutches or a walker.  If you have stairs at home, they will also show you how to use the crutches on stairs to ensure that you are as mobile as possible while using them.  Using the walking aid appropriately will avoid other problems in associated joints later on.  Although helpful for your hip, unfortunately, putting no or only some weight on your leg and using a walking aid for too long, however, can have a detrimental effect on your muscles and joints, and will also cause compensatory problems elsewhere in the body, such as in your ankle, shoulders or back. The optimal amount of time to use a walking aid in order to positively affect AVN healing will be determined by your Physical Therapist in conjunction with advice from your doctor or surgeon.

Once you are no longer required to use a walking aid, your Physical Therapist will educate you on proper gait.  We all take thousands of steps per day simply to walk around, so it is imperative that each step you take is done properly, without putting any excessive pressure through your healing hip joint.  If you are unable to walk without a limp, your Physical Therapist may suggest that you continue to use a walking aid such as one crutch or a cane/stick, for a longer period of time.

In addition to pain relief, the main goals of Physical Therapy treatment at First Choice Physical Therapy are to avoid losing range of motion, to keep your hip and associated muscles strong, to avoid further injury, as well as to keep you doing as many of your regular functional activities as possible.

In order to achieve the range of motion goal your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching exercises that you will practice in the clinic and also do as part of a home exercise program.  Maintaining range of motion is crucial to avoid further wear and tear on the hip joint. If the joint is not moving well into all ranges of motion, the joint surface does not get its required nutrition and more easily breaks down leading to early osteoarthritis.  Moving the joint also helps to move any swelling that may be present, and gets fresh blood to the healing areas. Only mild discomfort at the very end ranges of motion during these stretching exercises, however, is permissible. Any sharp or moderate discomfort should be heeded as it means that too much pressure is being put on the delicate healing bone. An exercise bike can be very useful in order to gain range of motion.  Even if you are unable to fully rotate the pedals of the bike, the forwards and backwards motion still assists the joint nutrition and aids in gaining range of motion.  Stretches for your knee, ankle and calf may also be necessary as these areas can become tight with the use of a walking aid.

If necessary, and as healing allows, your Physical Therapist may mobilize your hip joint. This hands-on technique encourages the hip to move gradually into its normal range of motion. Mobilization of the hip may be combined with assisted stretching of any tight muscles around the joint.  Again, the healing bone of the hip joint is delicate therefore anything more than mild discomfort at end ranges of motion should be strictly heeded.

Next your therapist will prescribe strengthening exercises. These exercises will focus on the muscles of your hip and thigh but will also include exercises for your back and core area as they play a large supporting role for your hips.  Due to compensatory walking and movement patterns while you are in pain it is common to develop a muscular weakness in certain muscles around the hip, and an overall muscular imbalance.

Exercises that involve the entire lower limb, such as squats on both legs at the same time or just one leg, will be prescribed. Exercises that work the muscles while in standing most effectively assist with daily activities such as walking and stair climbing, however they also put the most amount of stress through the hip joint. Other exercises in sitting or lying, for this reason, may also be prescribed. Exercises in these non-weightbearing positions are excellent as they allow you to target specific muscles around the hip, such as the gluteals, even if you are not weightbearing on that side. Your therapist may use an electrical muscle stimulator to assist your muscles in contracting as you do your exercises; this will help you to more rapidly gain your strength back. Exercises may also include the use of Theraband or weights to provide some added resistance for your hip and lower extremity. If you have access to a pool, your therapist may suggest you go into the pool to do your exercises. The buoyancy and hydrostatic properties of the water along with the warmth of the water (provided it is a heated pool) can assist greatly in providing comfort to the hip joint and often allows you to exercise through greater ranges of motion and with less discomfort.

As a result of any injury the receptors in your joints and ligaments that assist with balance and proprioception (the ability to know where your body is without looking at it) decline in function. A period of decreased mobility and reduced weight bearing will add to this decline. When balance and proprioception is declined, your joints and your limb as a whole will not function as efficiently and the decline may contribute to further injury in the future. For this reason a final component of our treatment at First Choice Physical Therapy will be to prescribe exercises for you to regain balance and proprioception. These exercises might include activities such as standing on one foot or balancing on an unstable surface such as a soft mat, or a soft plastic disc. More advanced exercises may involve side to side motions or even light hopping and jumping if your hip is healed enough to tolerate these activities.

During all of your exercises your Physical Therapist at First Choice Physical Therapy will pay particular attention to your exercise technique to ensure that you are not using any compensatory patterns or are developing bad habits in regards to how you use your hip and lower extremity.  If you do not pay close attention to how you use your joint and limb once your pain has settled inefficient patterns that developed due to pain can become habitual, and compensatory pain can develop either in your hip or back, or another joint.  In addition, poor movement patterns lead to faster wearing down of the hip joint socket, namely early osteoarthritis. Your Physical Therapist at First Choice Physical Therapy will be crucial to providing you with feedback regarding correcting old habitual patterns and developing new, efficient patterns during your daily activities.

As your range of motion, strength, and proprioception improve, your therapist will advance your exercises to ensure your rehabilitation is progressing as quickly as your body allows, and to incorporate exercises that simulate your specific everyday activities of daily living and any recreational activities that you may want to return to.
Asides from directly rehabilitating your hip, at First Choice Physical Therapy we also highly recommend maintaining the rest of your body’s fitness with regular exercise while your hip is improving.  This exercise can be done simultaneously to your specific hip rehabilitation.  You can use an upper body bike if you are unable to use a normal stationary cycle, or it may be permissible to do gentle aerobic exercises in a pool. A stationary bike is often the best cardiovascular activity once your range of motion and pain levels allow it.  Weights for the upper extremities and other leg are also strongly encouraged.  Advanced exercises such as the stepper or elliptical machines may be used once your hip has recovered to an acceptable level.  Your Physical Therapist at First Choice Physical Therapy can provide a program and advice for you to maintain your general fitness while rehabilitating your hip.

When you are well under way, regular visits to our clinic will end. Your Physical Therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

As mentioned above, rehabilitation at First Choice Physical Therapy can assist a hip with AVN if the process isn’t too far advanced.  If, however, your pain continues longer than it should or your therapy is not progressing as your Physical Therapist would expect, a surgical treatment option may be required.

 

If the femoral head has not begun to collapse, your surgeon may suggest an operation to try to increase the blood supply to the femoral head. Several operations have been designed to do this.

Decompressing the Femoral Head

The simplest operation is to drill one or several holes through the femoral neck and into the femoral head, trying to reach the area that lacks blood supply. The drill bores out a plug of bone within the femoral head. This operation is thought to do two things: (1) it creates a channel for new blood vessels to quickly form into the area that lacks blood supply, and (2) it relieves some of the pressure inside the bone of the femoral head. Relieving this pressure seems to help decrease the pain patients experience from AVN.
Decompression is often accompanied by the use of bone grafts with or without growth factors, a procedure designed to stimulate bone growth at the site of the defect. The donated bone comes from the patient (taken from the pelvic bone or lower leg). The bone is crushed up into tiny pieces and applied to the hole or defect caused by the necrotic process.

The decompression operation (with or without bone grafting) is done through a very small incision in the side of the thigh. The surgeon watches on a type of X-ray that shows the bones on a TV screen, called a fluoroscope, as a drill is used.  The surgeon uses the fluoroscope to guide the drill where it needs to go. This operation is usually done as an outpatient procedure, and you will be able to go home with crutches the same day.

Fibular Bone Graft

A more complicated procedure to try to increase the blood supply to the femoral head is a vascularized fibular bone graft procedure. This is actually a tissue transplant rather than a classic bone graft. With this procedure the graft is taken from the fibula, which is the thin bone that runs next to the shin bone.  The surgeon removes a piece of the small bone from the fibula along with the blood vessels to the bone. The surgeon then drills a hole through the side of the femur and into the femoral head. The surgeon attaches the blood vessels from the fibula to one of the blood vessels around the hip. This creates instant blood flow into the bone graft and into the head of the femur. This operation does two things: (1) it brings blood flow to the femoral head through the bone graft, and (2) because the fibular bone graft is strong, it keeps the femoral head from collapsing as the bone heals itself. Being that the graft supports the femoral head, the graft is also referred to as a strut graft.  This procedure is an inpatient procedure and will require you to stay in the hospital for several days.  It is a very complicated operation and is not commonly done. It is not always successful because the blood supply to the graft is fragile and may not form completely.

Rotational Osteotomy

In cases of small lesions involving less than one-third of the surface of the femoral head, performing a rotational osteotomy has been very successful. This procedure involves making a cut through the bone and turning the head of the femur so that the necrotic bone is no longer bearing any weight.

Artificial Hip Replacement

When AVN is in the advanced stages, the condition is no different from osteoarthritis of the hip joint. Your surgeon will probably recommend replacing the hip with an artificial hip joint. For those patients with a limited bone defect that only affects the femoral head and does not extend into the hip socket, a resurfacing procedure might be considered. Hip resurfacing arthroplasty is a type of hip replacement that replaces the arthritic surface of the joint but removes far less bone than the traditional total hip replacement.

 

The rehabilitation you will need after surgery for AVN depends entirely on what surgical procedure was performed.  Obviously those procedures that are more complicated will require more intensive therapy at First Choice Physical Therapy for a longer period of time. You may even need to be seen by an inpatient Physical Therapist so you can start some exercises while you are still in the hospital.

After being discharged from the hospital you should begin Physical Therapy at First Choice Physical Therapy as soon as your surgeon allows.  Some surgeons will recommend that you begin rehabilitation immediately, whereas others prefer that you wait until you are able to put a sufficient amount of weight through your surgical side.

After surgery for AVN you will be required to use a walking aid such as a walker or crutches.  After a drilling operation, you will probably use the walker or crutches for six weeks or so. Due to the drill holes weakening the bone around the hip, fracturing the hip by putting too much weight on it is possible. Using a walking aid allows pressure to be taken off the bone while it heals and reduces the risk of fracturing your hip while the bone is healing. Patients who have had bone and blood vessels grafted are required to limit how much weight they place on the hip for up to six months.

If you are still using a walker or crutches by the time we first see you at First Choice Physical Therapy, your Physical Therapist will ensure you are using them safely, properly, and confidently while abiding by your weight bearing restrictions. With crutches we will ensure that you can safely use them on stairs. If you are no longer using a walking aid, or once you no longer need one, your Physical Therapist will focus on normal gait re-education to ensure that you are putting only the necessary forces through the surgical side with each step, and are not compensating in any way. Until you are able to walk without a significant limp, we recommend that you continue to use a walking aid, such as your crutches, or a cane/stick. Improper gait can lead to a host of other pains in the knee, hip and back so it is prudent to use a walking aid until virtually normal walking can be achieved. Your First Choice Physical Therapy Physical Therapist will advise you, in conjunction with your surgeon’s protocol, regarding the appropriate time for you to be ambulating without any walking aid at all.

During your first few appointments at First Choice Physical Therapy your Physical Therapist will focus on relieving any pain and/or inflammation you may still have from the surgical procedure. They may use modalities such as ice, heat, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the surgical site or anywhere down the extremity. In addition, your Physical Therapist may massage your hip, back, leg or ankle to improve circulation and help decrease your pain.

The next part of our treatment will focus on regaining the range of motion in your hip.  Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching exercises that you will practice in the clinic and also do as part of a home exercise program.  You may experience a small amount of discomfort at the end ranges of motion initially, but despite this it is important to perform the range of motion exercises as prescribed because moving the joint also helps to move the swelling, get fresh blood to the healing areas, and provides nutrition to the joint. Only mild discomfort, however, is permissible. Any sharp or moderate discomfort should be heeded. An exercise bike at this stage of recovery can be very useful. Even if you are unable to fully rotate the pedals of the bike, the forwards and backwards motion still assists the joint nutrition and aids in gaining range of motion.  Stretches for your knee, ankle and calf may also be necessary as these areas can become tight with the use of a walking aid.

If necessary, and as time and healing allows, your Physical Therapist may mobilize your hip joint. This hands-on technique encourages the hip to move gradually into its normal range of motion. Mobilization of the hip may be combined with assisted stretching of any tight muscles around the surgical site.

Strengthening exercises are another important component of your post-surgical rehabilitation.  Due to compensatory walking and movement patterns in response to pain it is common to develop a muscular weakness in certain muscles around the hip, and an overall muscular imbalance.  Exercises will focus mainly on the muscles of your hip and thigh but your therapist will also include exercises for your back and core areas as they play a large supporting role for your hips.  Exercises that involve the entire lower limb, such as squats on both legs at the same time, or just on one leg, will be prescribed. Exercises that work the muscles while in standing are most effective for improving daily activities such as walking and stair climbing. Other exercises in sitting or lying, however, may also be prescribed. Exercises in these non-weightbearing positions are excellent as they allow you to target specific muscles around the hip, such as the gluteals, even if you are not weightbearing on that side. Your therapist may use an electrical muscle stimulator to assist your muscles in contracting as you do your exercises; this will help you to more rapidly gain your strength back. Exercises may also include the use of Theraband or weights to provide some added resistance for your hip and lower extremity. If you have access to a pool, your therapist may suggest you go to the pool to do your exercises. As mentioned above, the buoyancy and hydrostatic properties of the water along with the warmth of the water (provided it is a heated pool) can assist greatly in providing comfort to the hip joint and often allows you to exercise within a greater range of motion.

As a result of any injury or surgery, the receptors in your joints and ligaments that assist with balance and proprioception (the ability to know where your body is without looking at it) decline in function. A period of decreased mobility and reduced weight bearing will add to this decline. When balance and proprioception has declined, your joints and your limb as a whole do not function as efficiently, and the decline may contribute to further injury in the future. Once you are able to put full weight onto your surgical side a final component of our treatment at First Choice Physical Therapy will be to prescribe exercises for you to regain this balance and proprioception. These exercises might include activities such as standing on one foot or balancing on an unstable surface such as a soft mat, or a soft plastic disc.

During all of your exercises your Physical Therapist at First Choice Physical Therapy will pay particular attention to your exercise technique to ensure that you are not using any compensatory patterns or are developing bad habits in regards to how you use your hip and lower extremity.  If you do not pay close attention to how you use your joint and limb post-surgically inefficient patterns that developed due to pain even prior to surgery can remain as habits and compensatory pain can develop either in your hip or back, or another joint.  In addition, poor movement patterns lead to faster wearing down of the hip joint socket, namely early osteoarthritis. Your Physical Therapist at First Choice Physical Therapy will be crucial to providing you with feedback regarding correcting poor movement patterns and developing new, efficient patterns during your daily activities.
As your range of motion, strength, and proprioception improve, your therapist will advance your exercises to ensure your rehabilitation is progressing as quickly as your body allows, and to incorporate exercises that simulate your specific everyday activities of daily living and any recreational activities that you may want to return to.  If you are still very active, heavy sports that require running, jumping, quick stopping and starting, and cutting may need to be limited depending on the state of your hip joint, and which surgical procedure has been performed.  Your surgeon will advise you regarding which activities in your individual case are discouraged or not at all permissible.

Asides from directly rehabilitating the hip after surgery, at First Choice Physical Therapy we also highly recommend maintaining the rest of your body’s fitness with regular exercise while your hip is recovering.  This exercise can begin very early post-surgically.  You can use an upper body bike if you are not yet able to use a normal stationary cycle, or you may even be allowed to do gentle aerobic exercises in a pool. A stationary bike is often the best cardiovascular activity once your range of motion and pain levels allow it.  Weights for the upper extremities and other leg are also strongly encouraged.  Advanced exercises such as the stepper or elliptical machines may be used once your hip has recovered to an acceptable level.  Your Physical Therapist at First Choice Physical Therapy can provide a program and advice for you to maintain your general fitness while you recover from your surgery

When you are well under way, regular visits to our clinic will end. Your Physical Therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Generally the rehabilitation after surgery for AVN responds very well to the Physical Therapy we provide at First Choice Physical Therapy.  If for some reason, however, your pain continues longer than it should or your therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the hip is tolerating the rehabilitation well and to ensure that there are no complications that may be impeding your recovery.

Femoroacetabular impingement (FAI) occurs in the hip joint. Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. Femoroacetabular tells us the impingement is occurring where the femur (thigh bone) meets the acetabulum (hip socket). There are two different types of impingement. They differ slightly depending on what gets pinched and where the impingement occurs.

This guide will help you understand:

• what parts of the hip are involved
• how the problem develops
  how health care professionals diagnose the condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What part of the body is affected?

Femoroacetabular refers to the place in the hip where the round head of the femur (thigh bone) comes in contact with the acetabulum or hip socket. Two types of impingement are known to cause pinching of the soft tissues in this area:  The first is called cam-type impingement. This occurs when the round head of the femur isn’t as round as it should be. It’s more of a pistol grip shape.

It’s even referred to as a pistol grip deformity. The femoral head isn’t round enough on one side (and it’s too round on the other side) to move properly inside the socket.
  The result is a shearing force on the labrum and the articular cartilage, which is located next to the labrum. The labrum is a dense ring of fibrocartilage firmly attached around the acetabulum (socket). It provides depth and stability to the hip socket. The articular cartilage is the protective covering over the hip joint surface.

Sometimes cam-type impingement occurs as a result of some other hip problem (e.g. Legg-Calve-Perthes disease, slipped capital femoral epiphysis,) but most of the time, it occurs by itself and is the main problem. Men are affected by cam-type impingement more often than women.

The second type of impingement is called pincer-type impingement (more common in women). In this type, the socket covers too much of the femoral head. As the hip moves, the labrum comes in contact with the femoral neck just below the femoral head. Pincer-type impingement is usually caused by some other problem. It could be as a result of 1) hip dysplasia, 2) a complication after osteotomy surgery (cutting away bone) to correct hip dysplasia, or 3) an abnormal position of the acetabulum called retroversion. Hip dysplasia is a deformity of the hip (either of the femoral head or the acetabulum, or both) that can lead to hip dislocation.

What causes this problem?

The cause of the problem has been under considerable debate for a long time. Now with better imaging studies, we know that some subtle changes in the shape of the femoral head may be the cause of FAI. Other anatomical changes in the angle of the hip may also contribute to this problem. 
The basic problem is that the head of the femur butts up against the cartilage rim around the acetabulum and pinches it. An alternate type of femoral acetabular impingement causes abnormal jamming of the head-neck junction.

Normally, the femoral head moves smoothly inside the hip socket. The socket is just the right size to hold the head in place. If the acetabulum is too shallow or too small, the hip can dislocate. In the case of FAI, the socket may be too deep. The rim of the cartilage hangs too far over the head. When the femur flexes (bends) and internally rotates, the cartilage gets pinched. Over time, this pinching or impingement of the labrum can cause fraying and tearing of the edges and/or osteoarthritic changes at the impingement site. 
At the same time, with changes in the shape and structure of the hip, there are changes in normal hip movement. There may be too much hip adduction and internal rotation. Hip adduction refers to movement of the leg toward the body. Muscle weakness of the hip abductor muscles, hip extensors, and hip external rotators add to the problem. Hip abduction is moving the leg away from the body. With the combined effects of anatomic changes in the hip and the resultant muscle imbalances, repetitive motions can create mini-traumas to the hip joint. The result can be an additional problem: partial or complete labral tears. A complete rupture is referred to as an avulsion which indicates that the labrum is separated from the acetabular cartilage where it normally attaches.

What does this condition feel like?

The first noticeable symptom of femoroacetabular impingement is often deep groin pain with activities that stress hip motion. Prolonged walking is especially difficult. Although the condition is often present on both sides, the symptoms are usually only felt on one side. In some cases, the groin pain doesn’t start until the person has been sitting and starts to stand up. There is often a slight limp because of pain and limited motion. Groin pain associated with femoroacetabular impingement can be accompanied by clicking, locking, or catching when chronic impingement has resulted in a labral tear. When femoroacetabular impingement and a labral tear are both present, symptoms get worse with long periods of standing, sitting, or walking. Pivoting on the involved leg also reproduces the pain. Some patients have a positive Trendelenburg sign (hip drops down on the right side when standing on the left leg and vice versa).

As is often the case, one problem can lead to others. With femoroacetabular impingement, hip bursitis can develop. The gluteal (buttock) muscles may be extra tender or sore from trying to compensate and correct the problem. The pain can be constant and severe enough to limit all recreational activities and sports participation.

How do health care professionals diagnose the problem?


Diagnosis begins with a complete history of your injury. Your Physical Therapist at First Choice Physical Therapy will ask questions about where precisely the pain is, when the pain began, if there was a specific injury that occurred or whether the pain gradually developed over time, and what movements aggravate or ease the pain.  They will inquire about any previous injuries to the hip, low back, knee or even ankle, which may have contributed to the hip or groin pain you are feeling now. Your therapist will also ask about any swelling, clicking, catching, or weakness in the hip or groin area.

Next they will do a physical examination. Your Physical Therapist will first look at your posture and alignment in standing. They may also check to see if you have a leg length discrepancy that is contributing to your injury or dropped arches that can also change your entire lower limb alignment.  Next they will palpate all around your low back, pelvis, groin, and also the side and back part of your hip including into your buttocks muscles in order to determine your most tender point. After determining your most sore point they will check the range of movement in your hip by passively moving your hip into many different ranges of motion.  Motion in your pelvis and low back may also need to be checked.  With FAI often the range of movement of the involved hip is not the same as the normal hip.  Depending on the cause of the FAI the range of motion may appear to be restricted or may even appear to be overly mobile, particularly in one direction.  In addition the muscles both at the front and back of the hip joint may be tighter than they should be.

The strength of your muscles around your groin and hip as well as your knee and core will be assessed next. Your therapist will ask you to resist certain movements while checking for pain as well as strength deficits. Often with FAI the gluteal muscles are weak on the affected side, which creates a muscular imbalance affecting the biomechanics at the hip. Your therapist may also want to watch you do things such as walk, jog, mini squat on one leg, or hop in order to assess your overall biomechanics.

Other specific tests may be done to provoke your symptoms and test for excess or restricted movement at the hip joint. In one common test done for FAI the patient lies on the table on his or her back. Your Physical Therapist then bends your leg up, internally rotates the hip, and presses the knee toward the other leg. This position puts the hip in such a position that impingement occurs and often reproduces the painful symptoms.  If you have an inflamed bursa at the front of the hip, this position will also be irritating for it.

Several imaging tests can be done to identify what’s going on including X-rays, magnetic resonance images (MRI), and computed tomography (CT) scans. X-rays show the presence of any extra bone build up as well as the position and alignment of the bones and joint. X-rays also show the shape of the femoral head. 
Any asymmetries (i.e., where the head is not an even round shape compared to the other side) are also visible on X-rays as well as indications for a retroverted hip, which is, in simple terms, a hip bone that is angled backwards.  
MRIs can show any damage to the labrum but not necessarily any changes to the surface of the hip joint. The presence of edema (swelling) under the bone may show up and requires further evaluation to decide if it is from femoroacetabular impingement or some other cause (e.g., cyst, tumor, stress fracture). Using MRI with a dye injected into the joint (called magnetic resonance arthrography or MRA) provides greater detail of the joint surface and may be needed.
 CT scans help show the exact shape of the bone and reveal any abnormalities in the bone structure. CT scans might be the most helpful when arthroscopic surgery is planned as they give the surgeon a better idea of what needs to be done to reshape the bone. If the procedure is going to be done with an open incision, then the CT scan isn’t necessary, as the surgeon will see everything once the area is opened up.

What can be done for this condition?

Once all the test results are available, a course of action is determined. This may be conservative care (nonoperative) with anti-inflammatories and Physical Therapy or it may be surgery.  Generally patients undergo a trial of conservative care before doing any surgery but in some cases, surgery is recommended right away.

Nonsurgical Rehabilitation

Physical Therapy at First Choice Physical Therapy can be very helpful for FAI. The goals of conservative management are to relieve pain, improve function by correcting muscle strength imbalances and alignment, and prevent future issues with the hip.

During your first few appointments at First Choice Physical Therapy your Physical Therapist will focus on relieving your pain and inflammation simply to settle the hip down. They may use modalities such as ice, heat, ultrasound, or electrical current. In addition, your Physical Therapist may massage your hip or leg to improve circulation and help decrease your pain.  Another crucial step to settling your pain down is activity modification.  Your therapist will discuss this with you. It is nearly impossible to give the hip a complete rest but avoiding activities such as pivoting on the involved leg when there is a labral tear or irritation, and avoiding long periods of sitting can give the hip a chance to calm down. All sports should also be avoided in these initial stages as should prolonged walking.  Sometimes it is necessary to reduce your normal activity in some respect for up to six months in order to let the tissues around the hip joint heal. Your Physical Therapist will closely guide you regarding activity modification and will give suggestions for maintaining physical fitness while dealing with this injury.

Based on your individual assessment findings your therapist will design a program of stretches and strengthening exercises specifically for you to help improve the biomechanical function of the hip, the range of motion of the hip, and alter any muscle imbalances that may be present.

Tight muscles around the hip can contribute to pinching between the femoral head and acetabulum in certain positions. Your Physical Therapist will give you stretches for both the front and back parts of your hip which includes, in particular, the hip flexors and the external rotators and abductor muscles (deep gluteals) of the hip. They may also ask you to do groin or knee stretches depending on their assessment findings. A program of flexibility for the joint and stretching exercises won’t change any bony abnormalities present but can help lengthen the muscles, correct muscle imbalances, and reduce bony contact and subsequent impingement in the hip.  If completing your exercises is difficult, your therapist may suggest you initially go into a hydrotherapy pool where the warmth and hydrostatic properties of the water can assist your discomfort. As soon as you are able, however, your Physical Therapist will encourage you to start completing your exercises on land to more closely simulate regular activities of daily living.

Strengthening exercises will focus on correcting any muscle imbalances that have developed as a result of your injury. It is most common that the gluteal muscles, which are the major supporters of the hip as well as rotators, abductors and extensors of the hip, are weak in comparison to other muscles around the hip. This can contribute to the impingement at the hip.  Exercises for the gluteals as well as other areas such as the groin, anterior hip, and core area may be prescribed based on your individual assessment findings. Exercise bands, weights or weight machines may be used to add extra resistance and help to build up strength and endurance.

Your therapist will discuss your lower limb alignment, overall posture, and any abnormal movement patterns you may have developed. Sometimes even small changes in your posturing particularly as you walk, such as changing your foot or knee position, can make a significant difference in the pain you feel and how quickly your hip improves.  In some cases orthotics to improve arch alignment or a heel lift to correct a leg length discrepancy can make a difference.

When both legs have nearly equal strength, it is possible to gradually resume a full and normal level of all activities (so long as there is no pain during any of those movements or activities). For the young or active adult, this includes activities of daily living as well as recreational and competitive sports participation. Older adults experiencing labral tears associated with the impingement problem may expect to be able to resume normal daily functions but may still find it necessary to limit prolonged sitting or standing positions. Your Physical Therapist will closely guide your activity levels during your return to activity in order to ensure you don’t overdo any aspect and to ensure that you avoid re-injuring the hip. You Physical Therapist at First Choice Physical Therapy will liaise with your doctor regarding your progress with rehabilitation. While undergoing Physical Therapy treatment some patients may also benefit from intra-articular injection from a doctor.  This injection combines a numbing agent with an anti-inflammatory (steroid) medication in order to calm the hip down and allow you to strengthen and stretch the hip.

If conservative care does not relieve your problem, surgery may be required.  It should be noted, however, that anyone needing surgery will also benefit from Physical Therapy prior to the surgical procedure in order to address any muscle imbalances and abnormal movement patterns that may have contributed to the FAI.

Surgery is advised when there is persistent pain despite a good effort at conservative care and when there are obvious structural abnormalities of the hip. Early diagnosis and surgical correction may be able to restore normal hip motion. Delaying surgery is possible for some patients but the long-term effects of putting surgery off have not been determined.  Once it has been decided that surgery is the way to go, the surgeon has three choices: 1) full open incision and correction of the problem, 2) arthroscopic surgery, and 3) osteotomy (cutting the bone to reshape the socket.)

With the fully open surgical procedure, the head of the femur is dislocated from the socket to make the changes and corrections and reshape it. With arthroscopic surgery, hip dislocation is not required. Osteotomy is done for pincer-type impingement. Whenever possible, the surgeon tries to save the hip. When there is extensive damage to the cartilage, hip resurfacing or total joint replacement may be needed. There are many factors to consider when making the decision whether or not to do a hip replacement. These factors include the patient’s age, findings on imaging studies, type and severity of deformity, as well as the presence of arthritic changes.

If there is a labral tear, surgery is usually done arthroscopically, whenever possible, to repair the damage. The surgeon trims the acetabular rim and then reattaches the torn labrum. This procedure is called labral refixation. Each layer of tissue is sewn back together and reattached as closely as possible to its original position (called the footprint) along the acetabular rim. When repair is not possible, then debridement (shaving or removing) the torn tissue or pieces of tissue may be necessary.

Correction of the problem can result in improved function and pain relief. The hope is that early treatment can prevent arthritic changes but long-term studies have not been done to prove this idea. After surgery, patients will be restricted to a partial weight-bearing status. The exact weight bearing recommendations will depend on the amount of bone removed and whether or not the labrum was torn and repaired.

What should I expect after surgery?

Rehabilitation at First Choice Physical Therapy following surgery for FAI should begin as soon as your surgeon allows it. Each surgeon will set his own specific restrictions based on what was done during the surgical procedure, their personal experience, and whether your tissues are healing as expected. Generally speaking, the more complex the surgery the more involved and prolonged your rehabilitation program will be. In any case, activity restriction is important for the first few weeks after surgery in order to avoid fatiguing or overloading the hip muscles.

If you are still using crutches by the time we first see you at First Choice Physical Therapy, your Physical Therapist will ensure you are using the crutches safely, properly, and confidently and that you are abiding by your weight bearing restrictions. We will also ensure that you can safely use your crutches on stairs. If you are no longer using crutches, or once you no longer need them, your Physical Therapist will focus on normal gait re-education so you are putting only the necessary forces through the surgical side with each step, and are not compensating in any way. Until you are able to walk without a significant limp, we recommend that you continue to use your crutches, or at least one crutch or a cane/walking stick. Improper gait can lead to a host of other pains in the knee, hip and back so it is prudent to use a walking aid until near normal walking can be achieved. Your Physical Therapist at First Choice Physical Therapy will advise you, along with recommendations from your surgeon, regarding the appropriate time for you to be walking without any walking aid at all.

During your first few appointments at First Choice Physical Therapy your Physical Therapist will focus on relieving any pain and inflammation you may still have from the surgical procedure itself. We may use modalities such as ice, heat, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the surgical site or anywhere down the limb. In addition, your Physical Therapist may massage your hip, leg or ankle to improve circulation and help decrease your pain.

The next part of our treatment will focus on regaining normal range of motion in your hip.  Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of a home exercise program. Range of motion in the hip generally comes back very quickly after surgery, but it still depends on what your surgeon has done inside your joint as well as the state of your joint prior to surgery.  Rehabilitation will focus not only on regaining range of motion that may have been restricted due to the surgical process, but will particularly focus on improving flexibility and correcting imbalances that may have contributed to the impingement in the first place now that the anatomical issues have been corrected by the surgical procedure.  Stretches for the front and back of your hip, particularly the hip flexors and the hip external rotators and abductors (deep gluteals) will be prescribed. An exercise bike at this stage is very useful to assist in gaining back the hip flexion and extension range of motion as long as the bike seat is kept high enough to avoid pinching of the hip during the flexion portion of the pedal cycle. Even if you are unable to fully rotate the pedals of the bike this activity it is still encouraged; performing the back and forth motion forces fluid through the joint and greatly assists the healing process.

If necessary your Physical Therapist will mobilize your hip joint. This hands-on technique encourages the hip to move gradually into its normal range of motion. Mobilization of the hip may be combined with assisted stretching of any tight muscles around the surgical site.  Particular attention will be taken such that the healing structures of the hip are not impinged at all during mobilizations of the area.

At First Choice Physical Therapy we also highly recommend maintaining the rest of your body’s fitness with regular exercise while your hip is healing.  This can begin very early post-surgically.  You can use an upper body bike if you are non-weight bearing or may even be allowed to do aerobic exercises in a pool as long as it doesn’t compromise the hip. A stationary bike is often the best cardiovascular activity once the surgical structures have healed enough and you can put some weight through your foot. Weights for the upper extremities and other leg are also strongly encouraged. Your Physical Therapist at First Choice Physical Therapy can provide a program for you to maintain your general fitness while you recover from your surgery.

As soon as possible your therapist will prescribe strengthening exercises specifically for your surgical hip. These exercises will focus on restoring any muscle imbalances that have either been contributing to the impingement or that have developed due to the impingement. The deep gluteal muscles, in particular, will require specific attention as they are the major supporters of your hip joint, and also play a major role in controlling the position of your lower limb in standing.  Exercises for your core area are also important and will be prescribed.  Strengthening exercises that work the muscles while in standing most effectively assist with daily activities such as walking and stair climbing, however other very effective exercises for your gluteals in a lying position can be prescribed for the period while you are partial weight bearing.  Your therapist may use an electrical muscle stimulator to assist your muscles in contracting as you do your exercises; this will help you to more rapidly gain your strength back. Exercises may also include the use of exercise bands or weights to provide added resistance for your hip and lower extremity. If you have access to a pool, your Physical Therapist may suggest you go into the pool to do your exercises. The buoyancy of the water along with the warmth and hydrostatic properties can assist greatly in providing comfort to the hip joint and often allows your exercises to be done more easily with less discomfort. As soon as you are able, however, it is important to start land-based exercises as these more closely simulate your normal everyday activities.

As a result of any injury, the receptors in your joints and ligaments that assist with balance and proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobility and reduced weight bearing will add to this decline. If your balance and proprioception has declined, your hip joint and your limb as a whole will not be as efficient in its functioning and this may contribute to injury in the future. As a final component of our treatment your Physical Therapist at First Choice Physical Therapy will prescribe exercises for you to regain balance and proprioception. These exercises might include activities such as standing on one foot or balancing on an unstable surface such as a wobbly board or a soft plastic disc. Advanced exercises will include agility type drills such as light hopping or moving side to side.

As your range of motion, strength, and proprioception improve, your Physical Therapist will advance your exercises to ensure your rehabilitation is progressing as quickly as your body allows. As soon as it is safe to do so, your therapist will add more aggressive exercises such as jumping, hopping, and running, or exercises that mimic the sports or recreational activities that you enjoy participating in.  During all of your exercises you Physical Therapist will pay particular attention to your technique to ensure that you are not using any compensatory patterns or are developing bad habits in regard to how you use your hip and lower extremity. Enduring pain in your hip for years, months, or sometimes even just weeks usually causes you to use your hip and lower extremity in a pattern that avoids or limits your pain, but that is not efficient for a normal hip.  If you do not pay close attention to how you use your joint and limb post-surgically these patterns often continue to occur once the source of your pain has been eliminated by surgery.  Further hip impingement can occur. Your Physical Therapist at First Choice Physical Therapy will be crucial to providing you with feedback regarding correcting these patterns and developing new, efficient patterns during your daily activities.

Approximately five to six months after surgery your Physical Therapist will guide you back to full activities including your sporting activities. Many patients report continued improvements in their symptoms even up to the end of the first year after surgery.
Generally the rehabilitation after surgery for FAI responds very well to the Physical Therapy we provide at First Choice Physical Therapy.  If for some reason, however, your pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the hip is tolerating the rehabilitation well and to ensure that there are no complications that may be impeding your recovery.

Anatomy

Causes

Symptoms

Diagnosis

Treatment

Surgery

Post-surgical Rehabilitation

The hip joint is a true ball-and-socket joint. This arrangement gives the hip a large amount of motion needed for daily activities like walking, squatting, and stair-climbing.

Understanding how the different layers of the hip are built and connected can help you understand how the hip works, how it can be injured, and how challenging recovery can be when this joint is injured. The deepest layer of the hip includes the bones and the joints. The next layer is made up of the ligaments of the joint capsule. The tendons and the muscles come next.

This guide will help you understand:

The important structures of the hip can be divided into several categories. These include:

• bones and joints
• ligaments and tendons
• muscles
• nerves
• blood vessels
• bursae

Bones and Joints

The bones of the hip are the femur (the thighbone) and the pelvis. The top end of the femur is shaped like a ball. This ball is called the femoral head. The femoral head fits into a round socket on the side of the pelvis. This socket is called the acetabulum.

The femoral head is attached to the rest of the femur by a short section of bone called the femoral neck. A large bump juts outward from the top of the femur, next to the femoral neck. This bump, called the greater trochanter, can be felt along the side of your hip. Large and important muscles connect to the greater trochanter. One muscle is the gluteus medius. It is a key muscle for keeping the pelvis level as you walk.

Articular cartilage is the material that covers the ends of the bones of any joint. Articular cartilage is about one-quarter of an inch thick in the large, weight-bearing joints like the hip. Articular cartilage is white and shiny and has a rubbery consistency. It is slippery, which allows the joint surfaces to slide against one another without causing any damage. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to make motion easier. We have articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate.

Articular Cartilage

In the hip, articular cartilage covers the end of the femur and the socket portion of the acetabulum in the pelvis. The cartilage is especially thick in the back part of the socket, as this is where most of the force occurs during walking and running.

Ligaments and Tendons

There are several important ligaments in the hip. Ligaments are soft tissue structures that connect bones to bones. A joint capsule is a watertight sac that surrounds a joint. In the hip, the joint capsule is formed by a group of three strong ligaments that connect the femoral head to the acetabulum. These ligaments are the main source of stability for the hip. They help hold the hip in place.

A small ligament connects the very tip of the femoral head to the acetabulum. This ligament, called the ligametnum teres, doesn’t play a role in controlling hip movement like the main hip ligaments. It does, however, have a small artery within the ligament that brings a very small blood supply to part of the femoral head.

A long tendon band runs alongside the femur from the hip to the knee. This is the iliotibial band. It gives a connecting point for several hip muscles. A tight iliotibial band can cause hip and knee problems.

Iliotibial Band

A special type of ligament forms a unique structure inside the hip called the labrum. The labrum is attached almost completely around the edge of the acetabulum. The shape and the way the labrum is attached create a deeper cup for the acetabulum socket. This small rim of cartilage can be injured and cause pain and clicking in the hip.

Muscles

The hip is surrounded by thick muscles. The gluteals make up the muscles of the buttocks on the back of the hip. The inner thigh is formed by the adductor muscles . The main action of the adductors is to pull the leg inward toward the other leg.

Adductor Muscles

The muscles that flex the hip are in front of the hip joint. These include the iliopsoas muscle. This deep muscle begins in the low back and pelvis and connects on the inside edge of the upper femur. Another large hip flexor is the rectus femoris. The rectus femoris is one of the quadriceps muscles, the largest group of muscles on the front of the thigh. Smaller muscles going from the pelvis to the hip help to stabilize and rotate the hip.

Finally, the hamstring muscles that run down the back of the thigh start on the bottom of the pelvis. Because the hamstrings cross the back of the hip joint on their way to the knee, they help to extend the hip, pulling it backwards.

Nerves

All of the nerves that travel down the thigh pass by the hip. The main nerves are the femoral nerve in front and the sciatic nerve in back of the hip. A smaller nerve, called the obturator nerve, also goes to the hip.

These nerves carry the signals from the brain to the muscles that move the hip. The nerves also carry signals back to the brain about sensations such as touch, pain, and temperature.

Blood Vessels

Traveling along with the nerves are the large vessels that supply the lower limb with blood. The large femoral artery begins deep within the pelvis. It passes by the front of the hip area and goes down toward the inner edge of the knee. If you place your hand on the front of your upper thigh you may be able to feel the pulsing of this large artery.

The femoral artery has a deep branch, called the profunda femoris (profunda means deep). The profunda femoris sends two vessels that go through the hip joint capsule. These vessels are the main blood supply for the femoral head. As mentioned earlier, the ligamentum teres contains a small blood vessel that gives a very small supply of blood to the top of the femoral head.

Other small vessels form within the pelvis and supply the back portion of the buttocks and hip.

Bursae

Where friction occurs between muscles, tendons, and bones there is usually a structure called a bursa. A bursa is a thin sac of tissue that contains fluid to lubricate the area and reduce friction. The bursa is a normal structure. The body will even produce a bursa in response to friction.

Think of a bursa like this. If you press your hands together and slide them against one another, you produce some friction. In fact, when your hands are cold you may rub them together briskly to create heat from the friction. Now imagine that you hold in your hands a small plastic sack that contains a few drops of salad oil. This sack would let your hands glide freely against each other without a lot of friction.

A bursa that sometimes causes problems in the hip is sandwiched between the bump on the outer hip (the greater trochanter) and the muscles and tendons that cross over the bump. This bursa, called the greater trochanteric bursa, can get irritated if the iliotibial band (discussed earlier) is tight. Another bursa sits between the iliopsoas muscle where it passes in front of the hip joint. Bursitis here is called iliopsoas bursitis. A third bursa is over the ischial tuberosity, the bump of bone in your buttocks that you sit on.

As you can see, the hip is complex with a design that provides a good amount of stability. It allows good mobility and range of motion for doing a wide range of daily activities. Many powerful muscles connect to and cross by the hip joint, making it possible for us to accelerate quickly during actions like running and jumping.

This guide will help you understand:

• the anatomy of the temporomandibular joint
• what causes a temporomandibular joint disorder
• what the common symptoms are
• how the problem is diagnosed
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

The temporomandibular joint, commonly called the TMJ, is your jaw joint. There are two temporomandibular joints, one on each side of your head, just in front of your ears. If you place your fingertips on top of the skin in front of your ears and open your mouth so your jaw drops you will feel the joint moving under your fingers.

The TMJ is a hinge joint that is made up of two bony parts. One part is located on the temple bone of the skull (which is denoted by the ‘temporo’ part of the joint’s name).  This part of the joint is shaped like a shallow hollowing and is called the TMJ fossa. The second bony component of the joint comes from the lower jawbone, which is also called the mandible bone (‘mandibular’ part of the joint’s name). This portion of the joint is round and knob-like and is called the condyle. The condyle fits into the fossa of the temporal bone.  Movement of the TMJ allows us to open and close our mouths in order to do a variety of things such as sing, speak, yawn and chew. If you place the tips of your fingers in front of your ears and open and close your mouth, you will feel the condyles as they move in the fossa under your fingers.

An extremely important part of the anatomy of the TMJ is the articular disc within the joint, which sits between the bony fossa of the temporal bone and the bony condyle of the mandibular bone.  The disc, which is made up soft malleable fibers, follows the motion of the condyle and acts as a deformable pad that allows the condyle to move forwards and backwards on the temporal fossa as the jaw opens and closes.  Any disturbed motion of the disc or wear down of the anatomical structures of the disc can quickly lead to pain and dysfunction in the joint.

There are numerous ligaments and muscles that attach to the bones of the TMJ.  These ligaments and muscles both create stability of the joint and also allow motion at the joint.  A stable joint means that the bones remain in the correct anatomical position at rest and while in motion and this allows the joint to function as it is designed to do.

Ligaments attach bones to other bones and their primary responsibility is to maintain stability of the joint (keep the joint in place).  The most prominent ligaments of the TMJ include the temporomandibular ligament, which attaches straight from the temple bone to the mandible bone, and covers directly over the joint itself.  The stylomandibular and sphenomandibular ligaments are other large ligaments that attach from bones of the skull to the mandible. Other smaller ligaments around the TMJ also assist in stability of the joint and allow the joint to function properly. In addition, a thick portion of tissue, called the joint capsule, covers over the TMJ joint and also provides considerable stability.

In addition to ligaments, there are several muscles that not only help to the stabilize the joint, but also act to move the TMJ (and subsequently the lower jaw) so that we can carry out the variety of movements we do with our mouths. The two largest muscles involved in jaw motion are the temporalis muscle and the masseter muscle. Both muscles can be felt when you clench your jaw; the temporalis muscle can be palpated in the area over the temples and the masseter muscle can be felt bulging near the jaw angle.

The medial and lateral pterygoid muscles are a set of muscles on each side of the jaw that lie deep along the TMJ joint.  The medial pterygoid has two portions, both originate from the deep skull bones and then come together to insert into the mandible bone. The muscle can be felt if you wrap your thumb under the angle of your jaw and press up and inwards toward the bone.  It can also be felt within your mouth as you palpate near the same area, under the base of your teeth, beneath the gums.

The lateral pterygoid muscle also has two portions and also originates from within the skull. One portion of the muscle inserts into the TMJ’s articular disc and the other portion inserts into the mandible bone.  The lateral pterygoid muscle is more difficult to palpate for untrained fingers, however if you slightly open your mouth and press your fingers into the small indentation made near the TMJ you will be pressing on one portion of the lateral pterygoid. From the inside of the mouth you can run your fingers along the upper teeth until you hit the gums at the back of the mouth, between the upper and lower teeth. Pressing on the lateral pterygoid in this location is often painful.

The medial and lateral pterygoids are extremely important muscles in the movement of the jaw. The medial pterygoid assists in moving the jaw in several motions but one of its main functions is to close the jaw, and it does this by working in conjunction with the large masseter muscle.

The lateral pterygoid’s main function is to move the jaw to one side.  If the lateral pterygoids on each side work together at the same time, they can assist in opening the jaw.

Other small muscles, which attach to the tongue, skull and lower jaw also aid in movement of both the jaw and tongue.

The innervation, or nerve supply, of the TMJ, gives both sensation to the joint, and also provides the muscles of the joint with the necessary nerve input in order to work. The TMJ innervation comes from a combination of nerves, including a portion of one of the deep cranial nerves called the trigeminal nerve (cranial nerve V).

A single specific cause of TMJ pain can often be difficult to discern as it is frequently due to a combination of factors affecting the joint.

Congenital jaw anatomy

Congenital jaw anatomy means the anatomy that you were born with.  The unique variations in jaw size, jaw resting position, and the position of your teeth once they grow in (including the adult wisdom teeth) can affect the wear and tear on the TMJ. In most cases anatomy alone does not cause TMJ issues but rather your individual anatomy in combination with other mitigating factors, can results in TMJ pain.

Trauma

Trauma can be in the form of a single macrotrauma to the joint (or related anatomy) or many little microtraumas to the TMJ.  Macrotrauma to the TMJ may include injuries such as a punch to the jaw, a jaw fracture, a dislocation of the jaw, or even a motor vehicle accident.  Microtrauma, such as prolonged opening of the mouth while receiving repetitive dental treatment, or repetitive gum, nail or pen chewing over time can also lead to TMJ pain. Trauma, both macro and micro, can disturb the normal alignment of the TMJ, cause tension in the muscles controlling the joint, and lead to abnormal wear on the articular disc.

Bruxism (Teeth Clenching & Grinding)

Clenching and/or grinding of the teeth are also considered forms of microtrauma to the TMJ. Many people clench their jaw as a habit, particularly when stressed. Repetitive chewing such as on gum, a pen, or on your nails is also a form of repetitive clenching. Clenching causes recurring stress on the ligaments and disc and also increases tension in the muscles of the TMJ, all of which can lead to pain in the joint.

Teeth grinding is most often a habit that occurs at night.  In some cases, the grinding is so intense that it heard by others sleeping in the same room.  Intense grinding can cause wear down of the teeth and in severe cases can actually break teeth, fillings or crowns.  Some cases of grinding may be mild and not cause any notable symptoms at all in the TMJ.  As with repetitive clenching, the excess force creates undesirable stress on the TMJ.  Often TMJ pain that is worse upon waking leads your Physical Therapist to the suspicion that you are clenching or grinding your teeth in the night.

Degeneration

All joints wear down over time due to the natural process of aging, and the TMJ is no exception.  In some cases, this wear and tear (osteoarthritis) occurs earlier than normal or is amplified by trauma, other biological factors, or inflammatory disease processes. Wear and tear can lead to pain in the joint.

Posture

Prolonged poor neck (cervical) posture can directly affect the TMJ due to the close anatomical proximity of the two areas.  The most common posturing fault that is seen in relation to the neck is a forward head position. Normally when the neck is in good posture and in line with the rest of the spine, a plumb line seen from the side of the body falls through the ear lobes and the middle of the shoulder joints.  Many people, however, naturally rest their head with their chin poking forward.  This results in the plumb line from the ear lobe falling out in front of the shoulders, and the weight of the head falling in front of the body. Computer or desk workers commonly display this neck posture. This forward head posture not only increases the stress on the neck, but also affects the position of the TMJ by dragging the lower jaw forward and in effect creating a constant shear and pressure of the TMJ condyle and articular disc towards the front of the joint.

Other Causes

Other non-orthopaedic problems can cause or contribute to TMJ pain.  Patients suffering from chronic pain disorders such as fibromyalgia or systemic disorders such as rheumatoid arthritis commonly feel pain in their TMJ.  Psychological stress alone can also lead to TMJ pain, as can other more sinister problems such as tumours.  In addition some ear, nose and throat problems can also manifest in TMJ pain, therefore a thorough examination is required to determine any contributing factors and also to rule out any serious issues.

Common symptoms related to TMJ disorders are:

• Pain or aching in the jaw bone, jaw muscles, head, neck, face, or ear (often in front of or below the ear) or other muscles surrounding the jaw area. Pain is sometimes worse in the morning, which can indicate nighttime bruxism.
• Clicking, popping, grinding or grating sounds when moving the jaw. Injury to the joint structures causes abnormal motion, leading to joint sounds.  It should be noted that many people experience sounds coming from their TMJ but have no associated pain or problems.
• Difficulty opening/closing the mouth or moving the jaw. It is often particularly difficult to open the mouth wide.
• locked jaw. The jaw either gets stuck in one position, (more commonly the open position but can also be in the closed position). Generally this is due to abnormal functioning of the structures of the joint and a portion of the articular disc getting stuck within the joint.
• Swelling over the TMJ.
• Difficulty chewing, biting, yawning or moving the mouth with ease.
• A feeling of change in your bite position (occlusion).
• Headaches.
• Dizziness.
• Ringing in the ear (tinnitus).
• A feeling of fullness in the ear.

Your Physical Therapist at First Choice Physical Therapy will take a detailed history of your symptoms in order to diagnose your pain.  They will ask about how long you have had your symptoms, and if there are any factors that aggravate your symptoms such as eating certain foods or performing specific movements such as yawning, chewing, or closing your mouth.  They will also want to know if anything in particular eases your symptoms such as ice, heat, or massaging over the joint.  Your therapist will want to know exactly where your pain is, if it radiates anywhere, and if you are taking any medication to ease your discomfort.  They will also ask you about any dental problems or work you may recently have had done.  Your therapist will inquire about whether your jaw ever gets locked into a position and will also inquire about how comfortable your bite feels or if you have noticed a recent change in your bite. As mentioned above, many other problems can produce similar pain as a TMJ disorder does, so your therapist will also need to ask you questions about your general health and will want to know if you have had any other recent illnesses, muscle aches, pains, or related symptoms.

Next your therapist will do a physical examination of your TMJ. They will ask you to open and close your mouth and move your jaw side to side in order to determine how much range of motion you have.  During this motion they will also assess how well coordinated the movement of both TMJs are together. Your therapist will also want to watch you clench your jaw and examine your teeth while doing this in order to take a general look at your bite occlusion. They may also ask to look inside your mouth to see if there is any notable wear and tear on your teeth.  While you are performing any of these motions your therapist may place their fingers over your TMJ to feel the motion of the joint. They will also be feeling and listening for any clicking or popping in the joint.  If the articular disc in the joint does not move smoothly and in coordination on each side of your jaw then the opening or closing of your mouth will be affected. One side may open or close slower, quicker or more or less widely than the other. This abnormal motion wears the joint down and can eventually lead to pain.

In addition to palpating your TMJ your therapist will also assess the tension in the muscles that control your jaw, including the large temporalis and masseter muscles on your lateral skull and jaw.  The smaller TMJ muscles such as the pterygoids will be assessed externally by feeling your jaw, but may also require an intra-oral examination.  This requires your therapist to don a glove and feel the muscles, as well as the motion of your TMJ from inside your mouth.

Your therapist will also assess the motion in your neck joints in order to determine if stiffness or laxity in these joints is affecting your TMJ. They will also want to assess your posture in both sitting and standing and will look closely at the resting position of your head, neck, jaw, face and shoulders. Any other muscles of the neck, shoulders or upper back that affect the TMJ will also be assessed in order to determine their strength, flexibility, and control.

Your Physical Therapist, in conjunction with your doctor or dentist, may request that you obtain an investigation of your jaw or neck. X-rays or an MRI are the most common forms of investigations used to aid in the diagnosis of TMJ problems. X-rays assess the status of the bones and joint cartilage and an MRI can assess the other soft tissue structures of the joint such as the articular disc and the ligaments.  Bite impressions by your dentist can be another investigation needed in order to assist in determining the cause of your TMJ pain. Imaging is rarely a first approach with TMJ pain, it is usually done when conservative care has failed to change the symptoms.

Treatment of TMJ problems can vary greatly depending on the cause of the problem, as well as the type and severity of symptoms you are complaining of. Physical Therapy treatment at First Choice Physical Therapy can be very useful in managing your TMJ problem or alleviating your problem all together. Often our treatment also involves the conjoined effort of your doctor, and your dentist (or orthodontic specialist).  Medications prescribed by your doctor can be very useful as a pain relieving adjunct to our treatment at First Choice Physical Therapy. In more chronic or extreme cases your doctor may even choose to do a joint injection of an anti-inflammatory or pain relieving medication into your TMJ. If required, your Physical Therapist may also work with your dentist or orthodontic specialist to determine if a mouth splint or dental work is needed in order to assist with your TMJ issues.

Physical Therapy treatment at First Choice Physical Therapy can be very useful to manage your TMJ symptoms or alleviate them completely.

Your therapist will use a variety of techniques and modalities to alleviate your pain and avoid future TMJ problems. They will also provide education in order to help you better manage your TMJ problem on your own.

Firstly, your therapist will provide hands-on treatment such as massage or other techniques to alleviate the tension in the muscles that control your TMJ, including the large temporalis muscle near your temple, and the strong masseter muscle at the angle of your jaw.  The other smaller muscles such as the pterygoids may be massaged externally around your jaw, or your therapist may don a glove and work on these muscles from inside your mouth.  Muscles in your neck, shoulders, or upper back may also require tension-relieving techniques. Other hands-on work will include your therapist mobilizing your TMJ joint if needed (externally or intra-orally) as well as mobilizing any stiff joints in your neck or upper back.  Massage can be extremely effective in relieving pain originating from your TMJ as well as relieving stress, which increases muscle tension. For this reason your therapist will also teach you self-massage techniques that you can use for relief when you are at home on your own.  These techniques may include massage of the muscles outside or inside of your mouth.  General relaxation techniques can also be useful to decrease overall stress and subsequently the tension in the muscles around the TMJ.

Several Physical Therapy modalities can be useful in decreasing your pain.  Your therapist may use ultrasound, laser, transcutaneous nerve stimulation (TENS), or other electrical modalities. In addition, ice or heat are simple but effective ways to provide relief both while you are at First Choice Physical Therapy and while you are at home. Acupuncture has also been shown to be an effective method of pain relief.

The position of your TMJ is largely affected by the position of your lower jaw, head, and neck as well as your upper and lower back.  Your therapist will teach you the correct posturing to manage your individual TMJ problem and will provide strengthening exercises for your jaw, neck, and torso.  Your therapist will ensure you have the strength in the postural and core muscles related to the TMJ such that you can maintain good posture throughout your day.

Your therapist will provide practical advice on a number of items that can assist you in managing or eliminating your TMJ pain. They will promote sleeping positions that do not add pressure onto your TMJ as well as remind you to not lean or rest your jaw into your hand while sitting or thinking.  Your therapist will encourage you to avoid chewing hard foods such as apples, carrots, or hard/chewy candies.  Chewing gum, nail biting or chewing on the ends of pens out of habit should also be avoided.  In addition, foods that require you to open your mouth widely, such as burgers or large sandwiches should also be avoided or cut into smaller pieces. Your therapist will teach you how to yawn while blocking your chin from opening too wide to ensure the jaw does not overextend or get locked into an open position. TMJ positioning, stabilization, and coordination exercises will also be taught.  These exercises will teach your muscles to control your TMJ so that it can function within a pain free range of motion and can do so without adding extra stress to the joint. Often the use of a mirror while you do these exercises is extremely helpful to provide feedback on whether or not your mouth and jaw are in a proper position.

In severe intractable cases of TMJ pain and dysfunction, surgery may be suggested.

The TMJ is an important joint for basic actions such as speaking, yawning, and chewing. A disorder of the joint can be very debilitating but Physical Therapy at First Choice Physical Therapy can assist you in alleviating your pain and managing your TMJ problem.

This guide will help you understand:

• • what causes vertigo

• • what tests your healthcare professional will do to diagnose it

• • what First Choice Physical Therapy’s approach to rehabilitation is

The anatomy and physiology underlying the human body’s sensation of balance is complex.  Many systems are involved including the brain, the spinal cord, the eyes, the ears and the receptors in the skin, joints and muscles.  Disruption to any of these areas through injury or disease can affect one’s feeling of being balanced.  Vertigo is the chief complaint of patients when there is dysfunction or disease within the inner ear portion of the balance pathway or along the inner ears’ connections to the brain.

The inner ear, which is also called the labyrinth of the ear, is made up of three primary structures which moderate balance and equilibrium; the semicircular canals along with the saccule and utricle. Collectively this system of the inner ear is termed the vestibular system or vestibular apparatus. The inner ear also contains the cochlea, which is the main structure involved in hearing.

The three semicircular canals work to detect rotational motion of the head. The canals are positioned at 90-degree angles to one another and are filled with fluid called endolymph. Hair cells are located at the base of each canal and project up into the endolymph.  Movement of the head causes movement of the endolymph within the canals, which in turn causes the hair follicles to move accordingly and emit impulses about the position of the head in space. Hair follicles in the saccule and utricle add to the balance information by providing feedback about the position of the head in reference to gravity (vertical orientation) as well as detecting linear motion of the head.

Sensory information from the inner ear is relayed to the brain via the vestibular portion of the eighth cranial nerve (CNVIII), which is also called the vestibulocochlear nerve.  The cochlear portion of the nerve transmits information about hearing. Specific areas of the brain, in particular the cerebellum and brain stem as well as portions of the cortex, process the inner ear sensory information. When both the right and left inner ears are sending the same information, the brain processes that the body is balanced. When the body or head moves, the sensory input from the ears is not identical so the brain perceives motion and the body adjusts accordingly.

The ears work in close relation with the eyes in order to maintain equilibrium and balance. The vestibulo-ocular reflex is an automatic function of the eyes, which stabilizes images on the retina in response to the vestibular sensory input from the ears. This reflex causes the eyes to move in the opposite direction to the movement of the head in order for the eyes to remain fixed on a target. Thus, accurate vestibular input from the ears affects how the eyes adjust, and to one’s sense of being balanced.  The accurate relay of information from the eyes along the cranial nerve called the optic nerve (CN II) to the brain is also required.

For the healthcare professional, assessing reflexive eye motion is important in order to determine whether the vestibular system is working properly.  If one inner ear is affected by disease or injury then the sensory input being sent to the brain will falsely indicate movement from that vestibular system.  In this case the eyes will adjust accordingly and move opposite to the perceived motion despite the head actually being still.  An involuntary back and forth movement of the eyes results. This movement of the eyes is called nystagmus.  Nystagmus can be caused by several reasons other than vestibular problems, however in the case of accompanying vertigo, nystagmus leads the health care professional to the suspicion that the vestibular system is the culprit.

The brain amalgamates the vestibular information from the inner ears with sensory information from the eyes as well as the information coming from the receptors in the muscles and joints to provide the body with its overall sense of balance within its environment.

Disruption along any portion of the anatomical pathway described above can affect one’s perception of balance or equilibrium.  A problem with the inner ear portion of the pathway or the sensory information being relayed to the brain via the vestibulocochlear nerve is termed a peripheral vestibular disorder.  If the problem affecting one’s balance is due to damage of a structure within the brain itself, which then affects the reception and integration of balance information, it is termed a central vestibular disorder.

Peripheral or central vestibular disorders can both cause vertigo.  Some cases of vertigo may be due to both peripheral and central vestibular disorders.

The most common peripheral vestibular disorders causing vertigo are benign paroxysmal positional vertigo, Meniere’s disease, and vestibular neuronitis/neuritis or labyrinthitis. Other causes that will be discussed in this guide are migraine associated vertigo, acoustic neuroma, and vertigo as a symptom of Multiple Sclerosis.

Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is a common clinical disorder of balance, which is characterized by recurrent vertigo spells that are brief in nature (usually 10-60 seconds) and are most often triggered by certain head positions.  Benign, in medical terms, means it is not threatening to life. Paroxysmal means it comes with a rapid and sudden onset or increase in symptoms.

BPPV is the most common cause of recurrent vertigo.  The cause of BPPV is proposed to be calcium carbonate crystals (called otoconia or otoliths), which are sometimes termed ‘ear rocks’ within the semicircular canals of the inner ear. Usually these crystals are located within the utricle and saccule of the ear. It is thought that these crystals dislodge and migrate to the semicircular canals of the ear.  The cause of this dislodgement is postulated to be a number of possible reasons such as an ear or head injury, an ear infection or surgery, or from natural degeneration of the inner ear structures.  Often a direct cause cannot be identified.

The otoconia settle in one spot in the canal when the head is still.  The most common canal for settlement in is the posterior semicircular canal. A sudden change in head position, often brought on by activities such as rolling over in bed, getting out of bed, bending over, or looking upwards, causes the crystals to shift. This shift in turn sends false signals to the brain about equilibrium, and triggers the vertigo.

Vertigo due to BPPV can be severe and accompanied by nausea. The attacks can occur seemingly for no reason and then disappear for weeks or months before returning again. Generally BPPV affects only one ear and although it can occur at any age it is often seen in patients over the age of 60 and more often in women.  Nystagmus is usually present.

Vestibular Neuronitis or Labyrinthitis

Vestibular neuronitis or labyrinthitis is an inflammation of the inner ear or its associated nerve (the vestibular portion of the vestibulocochlear nerve), which causes vertigo.  Hearing may also be affected if the infection affects both portions of the vestibulocochlear nerve.

The vertigo caused by vestibular neuronitis or labyrinthitis is of a sudden onset and can be mild or extremely severe. Nausea, vomiting, unsteadiness, decreased concentration, nystagmus and impaired vision may also accompany the vertigo. Most often the infections that cause inflammation of the inner ear or the vestibulocochlear nerve are viral in nature as opposed to bacterial. Proper diagnosis of the cause is important in order to provide the most effective and appropriate treatment.

Meniere’s Disease

Meniere’s disease is a chronic incurable vestibular disorder characterized by symptoms of episodic severe vertigo, fluctuating hearing loss, ear ‘fullness’ and/or ringing in the ear (tinnitus), and nystagmus.

This disease derives its name from a French physician, Prosper Meniere, who theorized in the late 1800’s about the cause of this repertoire of symptoms, which he noted in many of his patients.

Early-stage acute attacks of Meniere’s disease vary in their length anywhere from 20 minutes to 24 hours. The attacks can occur regularly within a week or may be separated by weeks or months. Other symptoms may coincide with the attack such as anxiety, diarrhea, trembling, blurry vision, nausea and vomiting, cold sweats, and a rapid pulse or heart palpitations.  Following the attacks patients often feel extreme tiredness, which requires many hours of rest to recover.  For some patients time between attacks may be symptom free but other patients report ongoing related symptoms even between attacks.

The exact cause of Meniere’s disease is still not certain but it is theorized that it is due to an abnormal amount of endolymph fluid collecting in the inner ear and/or an abnormal buildup of potassium in the inner ear.

Migraine Associated Vertigo

Some patients who suffer from migraines (approximately 25-35%) experience migraine associated vertigo (MAV).  MAV, (also called a vestibular migraine), may also be accompanied by nausea or vomiting and may last a few seconds or a few days. Other vestibular symptoms may also be noted in association such as motion intolerance, sensitivity to head movement, dizziness, a feeling of pressure in the ears, imbalance and spatial disorientation.  With MAV the symptom of vertigo may precede the onset of the migraine or may appear as the headache pain develops.  Vertigo may also occur during a headache-free time frame.  Some patients will also present with a true BPPV after the migraine event has ceased.

Acoustic Neuroma

An acoustic neuroma is a benign (non-cancerous) tumour on the vestibulocochlear nerve. Early symptoms are related to loss of hearing in the affected ear, ringing in the ear (tinnitus), dizziness, and a feeling of fullness in the ear. The tumour is slow growing so symptoms come on gradually and may be easily overlooked in the early stages. As the tumour grows it may push on other nerves in the area and symptoms such as headaches or pain and numbness in the face may appear.  Vertigo or other balance issues may arise with growth of the tumour.

Vertigo as a symptom of Multiple Sclerosis

Multiple Sclerosis (MS), which causes a demylenation of nerves, primarily attacks the cerebellum of the brain, as well as the brain stem (including the cranial nerves such as the vestibulocochlear nerve), and the spinal cord. The cerebellum is particularly important in regards to balance as it helps to integrate information received by the brain in order to both maintain balance and arrange coordinated movements. Damage to either the cerebellum and/or the vestibulocochlear nerve due to MS can cause vertigo.

Approximately 20% of MS sufferers will experience vertigo as a symptom. The vertigo attacks associated with MS can be short-lived or last for days or weeks at a time. A much more common symptom of MS sufferers rather than vertigo is general dizziness or lightheadedness.

Other causes of Vertigo

Although most cases of vertigo are related to peripheral or central vestibular disorders, other causes of vertigo may be identified such as alcohol intoxication, metabolic disorders, bacterial or viral infections, side-effects from medications, or side effects from overexposure to specific chemicals (ototoxicity).  Even severe emotional issues causing anxiety can manifest in vertigo. In some rare cases, however, a cause for the symptom of vertigo goes unknown.

Vertigo is rarely experienced independent of other symptoms.  Depending on the cause of the vertigo the following symptoms may accompany a vertigo attack or be experienced in close proximity, either before or after the attack, or as a result of the vertigo attack itself:

• dizziness
• headaches
• nausea and/or vomiting
• cold sweats
• ringing in the ears (tinnitus)
• fatigue
• hearing loss
• twitching eyes
• nystagmus
• ear pressure
• panic attacks
• a feeling of being pulled to or leaning to one side
• fear of falling
• increased risk of falls
• anxiety
• depression
• work difficulties
• decreased engagement in social activities
• decreased motion of the neck or body or avoidance of certain movements in order to avoid onset of an attack or limit symptoms.

A detailed history of your problem is the most crucial information needed by your healthcare professional in order to diagnosis true vertigo from general dizziness, to determine a cause for the vertigo, and then to implement appropriate treatment.

Your healthcare professional will ask you to describe your symptoms in detail.  As explained above, true vertigo is more than just a general feeling of dizziness or lightheadedness, but rather a false sensation of spinning or rotating within your environment or your environment spinning or rotating around you.

Your healthcare professional will want to know when the first episode of your vertigo occurred, how long it lasted, and if it was associated with any other events such as a car accident, head trauma, or an illness or infection.

They will also want to know how often you have experienced the vertigo since the first episode, and the general pattern of symptom frequency.  Your healthcare professional will ask if anything in particular triggers your symptoms such as moving your head in a certain direction or getting out of bed.  They will also inquire about any other related symptoms such as nausea, vomiting, falls, visual disturbances, feelings of fullness or pressure in the ear, ringing in the ear, hearing loss, headaches or if you have a history of migraines.  Your healthcare professional will also want to know if there is anything that makes your symptoms better, if you are taking any medications, or if you have a family history of any inner ear disorders or central nervous disorders.

Your healthcare professional will then perform a physical examination.  They will look in your eyes to note any nystagmus and may do a basic examination of your ears by looking into them. A general examination of your balance will be completed and they may ask you to lie down and then get up from the lying position in order to determine if it brings on your symptoms.  A general examination of the joints of your neck will also be completed to rule out any symptoms coming from the neck region.  Other general physical examinations such as blood pressure in both lying and standing may also be assessed.

Dix-Hallpike’s manoeuvre

Dix-Hallpike’s manoeuvre is a test that can be done by your healthcare professional in their clinical setting.  This tests helps to determine if certain head movements are the cause of your vertigo. If positive this test can also determine which ear is the problem.

During this test your healthcare professional turns your head to one direction then assists you to quickly lie back while maintaining your head position and also hanging your head over the edge of the bed. Your healthcare professional watches your eyes for whether nystagmus occurs and also assesses the direction and quality of it.

After you sit upright for a few minutes to allow recovery, the same test is done with the head turned to the opposite direction.

The tests that can be done in your healthcare professional’s clinic in order to definitively determine the cause of your vertigo are limited.  Depending on what your health care professional finds on their initial examination they may send you for a battery of other tests to further determine the cause of your vertigo.

Electronystagmography

Nystagmus, as previously explained, is an involuntary movement of the eyes.  Nystagmus can indicate a problem with your balance system, particularly the nerve that runs from your ear to your brain (vestibulocochlear nerve) or the nerve that runs from your eyes to your brain (optic nerve).
Electronystagmography (ENG) is a commonly used test to check for signs of nystagmus in more detail.

To conduct this test electrodes are placed around the eye and the movements of the eye are recorded as you are asked to follow certain moving targets or while your head is positioned in different directions.  A related test is one in which the eye movements are video recorded by wearing goggles rather than electrodes (videonystagmography).

Caloric testing

During this test, which is a subtest of electronystagmography, cool and warm water or air is administered to each ear, one at a time. The change in temperature stimulates the balance organ in the ear and in normal circumstances your eyes reflexively move in a specific direction depending on whether cool or warm water is administered.  Absence of this movement indicates a vestibular problem.

Rotation Tests

Normally each time your head moves one way your eyes move in the opposite direction.  During rotation tests electrodes or goggles are used to record how the eyes move while the head is moving at differing speeds.  You may be asked to move your head while looking at a fixed target, or a computerized chair may be used to rotate your head while it is restrained.

Simple rotation tests may be administered by your healthcare professional in their clinical setting. For these tests they will observe your eyes while they move your head or rotate you on a swivel chair.

Vestibular evoked myogenic potential (VEMP)

This test is used to confirm whether or not the saccule and part of the vestibular nerve are functioning properly.
During this test headphones are used along with electrodes over the neck muscles. For this test the saccule, which also responds to sound, is stimulated via loud clicks into the headphones rather than via head movements. The response of the neck muscles to the clicks is recorded and indicates whether the sensory impulses are being transmitted properly.
Posturography

Sometimes called computerized dynamic posturography, this test provides information about motor control and balance function during varying unstable conditions.  Rather than providing specific information about the vestibular portion of the ear or brain, this test focuses on the feedback needed by the receptors in one’s joints, muscles, and skin (proprioception) in order to maintain one’s balance.

During this test you are required to stand on a moveable platform and you are asked to focus on a specific target. The platform or the target is then moved while pressure gauges under the platform record and map your body’s sway in relation to a neutral standing position.

Scans

In some cases a magnetic resonance imaging (MRI) scan or a computerized tomography (CT) scan of the brain may be done. An MRI scan uses a strong magnetic field and radio waves in order to produce a detailed image.  A CT scan uses a series of detailed X-rays to create an image.

These scans can identify abnormal growths affecting the ear (tumors both benign or malignant) or lesions such as those seen in MS.

Hearing Tests

Standard hearing tests are often carried out when delineating the cause of vertigo due to the close relation between the hearing and balance organs and nerves of the ear.

Treatment of vertigo is dependent upon the underlying cause of the vertigo. General forms of treatment can be categorized into canal repositioning manoeuvers, dietary adjustments, medications, vestibular rehabilitation exercises, and surgery.

Canal Repositioning Manoeuvers

In cases of vertigo where the cause is determined to be an otoconia that has settled in one of the semicircular canals, such as with BPPV, canal repositioning manoeuvers are often successful in eliminating or decreasing symptoms. During these manoeuvers the head and trunk is moved in an specific way in order to reposition the displaced particles.  Repositioning the particles stops the false signals being sent to the brain regarding head position and therefore eliminates the vertigo. Success of these procedures may depend, however, on where the otoconia are located in each specific case. The two main manoeuvers used are the Epley Manoeuver and the Semont-Liberatory manoeuver.  A healthcare professional trained specifically in these manoeuvers should administer them in order to get the most effective results.

Dietary Adjustments

Dietary adjustments may assist in decreasing vertigo depending on the original cause of the vertigo.  For migraine sufferers, specific foods or drinks can bring on the headaches and associated symptoms therefore limiting these items can potentially decrease symptoms. For those suffering from Meniere’s disease, a change in the body’s fluid levels can affect the physiology of the disease process in the inner ear.  For this reason monitoring one’s body fluids may make a difference to the overall symptoms including vertigo. Other substances such as food or medication that indirectly affect fluid loss or absorption should also be monitored.

A thorough discussion with your doctor and/or a dietician about your specific symptoms and situation can help you make any possible dietary adjustments to decrease your vertigo.

Medications

Some medications may assist in dealing with your symptoms or may be required to deal with the initial cause of your vertigo ie: an inner ear infection. Your doctor can discuss your specific situation with you and decide whether there are any medications that may be useful in decreasing your vertigo or any secondary symptoms such as nausea and vomiting.

Vestibular Rehabilitation Exercises

Vestibular Rehabilitation Therapy (VRT) is a set of exercises designed specifically for you by a Physical Therapist that encourage the brain and spinal cord to compensate for any deficits that may be present due to inner ear disease or abnormality.

Patients with vestibular problems often stop relying on the signals coming from the inner ear because their brain has learned that they may not be a true representation of their balance and equilibrium. Patients often start to rely more on the input from their eyes as well as the proprioceptive input from their muscles and joints.  In relying more on the eyes and muscles and joints patients frequently overcompensate and develop abnormal head or body movements in order to avoid the movements that bring on their symptoms. VRT addresses these compensatory patterns and works to desensitize the patient’s vestibular system so the patient can decrease or eliminate their vertigo and start moving normally again.

In some cases when non-invasive treatment is unable to effectively control the symptoms of vertigo, surgical intervention may be an option.  The type of surgical intervention depends on what has been deemed the cause of your vertigo. For example, surgical intervention may be required to remove a growth within the ear, or may be aimed at treating any secondary damage done within the ear due to an underlying disease process.

If your healthcare professional feels that surgery may be an option that needs to be explored in order to deal with your vertigo they will refer you to the appropriate surgical specialist in your area.

Vertigo can be an extremely debilitating problem and its cause is sometimes difficult to delineate.  Fortunately, in the majority of cases a specific cause can be identified, which allows a treatment and management plan to be implemented, and keeps the vertigo under control.

Luckily, most of us go about our daily lives without any regard for the complexity of our body’s systems that keep us upright and balanced.  It is not only until one experiences a disruption of their balance that they are reminded how vitally important it is to simple, everyday tasks.

Vestibular rehabilitation therapy (VRT) consists of a set of exercises that encourage the brain and spinal cord to make up for balance or equilibrium deficits, which are present due to inner ear or central nervous system disease or abnormality.  VRT exercises are designed specifically for you by a Physical Therapist at First Choice Physical Therapy who has specialized knowledge in this area.  VRT is also referred to as balance retraining therapy.

This guide will help you understand:

• the anatomy of the vestibular system
• why VRT is needed
• which disorders VRT is commonly used for
• what First Choice Physical Therapy’s approach to VRT is

The anatomy and physiology underlying the human body’s sensation of balance is complex.  Many systems are involved including the brain, the spinal cord, the eyes, the ears and the receptors in the skin, joints and muscles.  Disruption to any of these areas through injury or disease can affect one’s feeling of being balanced.

The inner ear, which is also called the labyrinth of the ear, is made up of three primary structures which moderate balance and equilibrium; the semicircular canals along with the saccule and utricle. Collectively this system of the inner ear is termed the vestibular system or vestibular apparatus. The inner ear also contains the cochlea, which is the main structure involved in hearing.

The three semicircular canals work to detect rotational motion of the head. The canals are positioned at 90-degree angles to one another and are filled with fluid called endolymph. Hair cells are located at the base of each canal and project up into the endolymph.  Movement of the head causes movement of the endolymph within the canals, which in turn causes the hair follicles to move accordingly and emit impulses about balance. Hair follicles in the saccule and utricle add to the balance information by providing feedback about the position of the head in reference to gravity (vertical orientation), as well as detecting linear motion of the head.

Sensory information from the inner ear is relayed to the brain via the vestibular portion of the eighth cranial nerve (CNVIII), which is also called the vestibulocochlear nerve.  The cochlear portion of the nerve transmits information about hearing. Specific areas of the brain, in particular the cerebellum and brain stem as well as portions of the cortex, process sensory information coming from the inner ear. When both the right and left inner ears are sending the same information, the brain processes that the body is balanced. When the body or head moves, the sensory input from the ears is not identical so the brain perceives motion and the body adjusts accordingly.

The ears work in close relation with the eyes in order to maintain equilibrium and balance. The vestibulo-ocular reflex (VOR) is an automatic function of the eyes, which stabilizes images on the retina in response to the vestibular sensory input from the ears. This reflex causes the eyes to move in the opposite direction to the movement of the head in order for the eyes to remain fixed on a target. Thus, accurate vestibular input from the ears affects how the eyes adjust and to one’s sense of being balanced.  The accurate relay of information from the eyes along the optic cranial nerve (CN II) to the brain is also required.

If one inner ear is affected by disease or injury then the sensory input being sent to the brain will falsely indicate movement from that vestibular system.  In this case the eyes will adjust accordingly and move opposite to the perceived motion despite the head actually being still.  An involuntary back and forth movement of the eyes results. This movement of the eyes is called nystagmus and when present, leads any health care professional to suspect a vestibular problem.

Two other reflexes, the vestibulocollic reflex and the vestibulospinal reflex also work to help the body maintain its balance and sense of equilibrium. The vestibulocollic reflex (sometimes called the vestibular-neck reflex) works in conjunction with the vestibular input and the neck muscles in order to stabilize the head. The job of the vestibulospinal reflex is to create compensatory body movements in response to the vestibular input in order to maintain one’s balance and avoid falling over.

The brain amalgamates the vestibular information from the inner ears with sensory information from the eyes, as well as the information coming from the receptors in the muscles and joints of the neck and the rest of the body to provide the body with its overall sense of balance within its environment.

Disruption along any portion of the anatomical pathway described above can affect one’s perception of balance or equilibrium.  A problem with the inner ear portion of the pathway or the sensory information being relayed to the brain via the vestibulocochlear nerve is termed a peripheral vestibular disorder.  If the problem affecting one’s balance is due to damage of a structure within the brain itself, which then affects the reception and integration of balance information, it is termed a central vestibular disorder.

The most common peripheral vestibular disorders that are treated by VRT are benign paroxysmal positional vertigo (BPPV), and any injury or disease that results in a reduced inner ear function. This reduced function may be associated with disorders such as Ménière’s disease, vestibular labyrinthitis or neuritis, or an acoustic neuroma.  The term unilateral or bilateral vestibular hypofunction may be used in describing the reduced function of the vestibular system in one (unilateral) or both (bilateral) ears due to disease or injury.

Clinically, any peripheral dysfunction in the vestibular system, which affects one’s balance can potentially be treated with VRT, however the effectiveness of the treatment will depend on the exact cause of the vestibular issues.

Central vestibular disorders such as Multiple Sclerosis or stroke may also respond to VRT, although generally peripheral vestibular disorders tend to respond better.

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is a common clinical disorder of balance, which is characterized by recurrent vertigo spells that are brief in nature (usually 10-60 seconds) and are most often triggered by certain head positions.  Benign, in medical terms, means it is not threatening to life. Paroxysmal means it comes with a rapid and sudden onset or increase in symptoms.

BPPV is the most common cause of recurrent vertigo.  The cause of BPPV is proposed to be calcium carbonate crystals (termed otoconia, otoliths, canaliths or ‘ear rocks’) within the semicircular canals of the inner ear. In normal circumstances these crystals are located within the utricle and saccule of the ear but in BPPV it is thought that these crystals dislodge and migrate to the semicircular canals of the ear.  The cause of this dislodgement is postulated to be a number of possible reasons such as an ear or head injury, an ear infection or surgery, or from natural degeneration of the inner ear structures.  Often, however, a direct cause cannot be identified.

The otoconia settle in one spot in the canal when the head is still.  The most common canal for settlement is in the posterior semicircular canal. A sudden change in head position, often brought on by activities such as rolling over in bed, getting out of bed, bending over, or looking upwards, causes the crystals to shift. This shift in turn sends false signals to the brain about equilibrium, and triggers the vertigo.

Vertigo due to BPPV can be severe and accompanied by nausea. The attacks can occur seemingly for no reason and then disappear for weeks or months before returning again. Generally BPPV affects only one ear and although it can occur at any age it is often seen in patients over the age of 60 and more often in women. Nystagmus is usually present.

Meniere’s Disease

Meniere’s disease is a chronic incurable vestibular disorder characterized by symptoms of episodic severe vertigo, fluctuating hearing loss, ear ‘fullness’ and/or ringing in the ear (tinnitus), and nystagmus.

This disease derives its name from a French Physician, Prosper Meniere, who theorized in the late 1800’s about the cause of this repertoire of symptoms, which he noted in many of his patients.

The exact cause of Meniere’s disease is still not certain but it is theorized that it is due to an abnormal amount of endolymph fluid collecting in the inner ear and/or an abnormal buildup of potassium in the inner ear.

Early-stage acute attacks of Meniere’s disease vary in their length anywhere from 20 minutes to 24 hours. The attacks can occur regularly within a week or may be separated by weeks or months. Other symptoms may coincide with the attack such as anxiety, diarrhea, trembling, blurry vision, nausea and vomiting, cold sweats, and a rapid pulse or heart palpitations.  Following the attacks patients often feel extreme tiredness, which requires many hours of rest to recover.  For some patients time between attacks may be symptom free but other patients report ongoing related symptoms even between attacks.

Vestibular Labyrinthitis or Neuronitis

Vestibular labyrinthitis or neuronitis is an inflammation of the inner ear or its associated nerve (the vestibular portion of the vestibulocochlear nerve), which causes vertigo.  Hearing may also be affected if the inflammation also affects the cochlear portion of the nerve.

The vertigo caused by vestibular neuronitis or labyrinthitis is of a sudden onset and can be mild or extremely severe. Nausea, vomiting, unsteadiness, decreased concentration, nystagmus and impaired vision may also occur. Most often the infections that cause inflammation of the inner ear or the vestibulocochlear nerve are viral in nature as opposed to bacterial. Proper diagnosis in regards to it being viral or bacterial is important in order to provide the most effective and appropriate treatment.

Acoustic Neuroma

An acoustic neuroma is a benign (non-cancerous) tumour on the vestibulocochlear nerve. Early symptoms are related to loss of hearing in the affected ear, ringing in the ear (tinnitus), dizziness, and a feeling of fullness in the ear. The tumour is slow growing so symptoms come on gradually and may be easily overlooked in the early stages. As the tumour grows it may push on other nerves in the area and symptoms such as headaches or pain and numbness in the face may appear.  Vertigo or other balance issues may arise with growth of the tumour.

Peripheral or central vestibular disorders can result in a number of varying symptoms. VRT can potentially alleviate or resolve any symptoms associated with the vestibular disorder. Common symptoms include:

• dizziness
• vertigo
• blurried vision
• fatigue
• anxiety
• headaches
• nausea and/or vomiting
• cold sweats
• ringing in the ears (tinnitus)
• hearing loss
• twitching eyes
• nystagmus
• ear pressure
• panic attacks
• a feeling of being pulled to or leaning to one side
• fear of falling
• increased risk of falls
• impaired balance
• unsteady walking
• anxiety
• depression

A detailed history of your problem is the most crucial information needed by your Physical Therapist in order to diagnose the cause of your vestibular disorder and then to implement the appropriate VRT.

Your Physical Therapist will ask you to describe your vestibular symptoms in detail. Any symptoms listed above that you experience, or others, should be mentioned. Your Physical Therapist will want to know when the first episode of your symptoms occurred, how long they lasted, and if they were associated with any other events such as a car accident, head trauma, or an illness or infection.  They will also want to know how often you have experienced your symptoms since the first episode, and the general pattern of symptom frequency.  Your Physical Therapist will ask if anything in particular triggers your symptoms such as moving your head in a certain direction or getting out of bed. In regards to dizziness your therapist will inquire about the nature of what you feel, and whether or not you experience episodes of true vertigo, where you have a sensation of spinning or rotating. Your Physical Therapist will also want to know if there is anything that makes your symptoms better, what makes your symptoms the worst, and if you are taking any medications, or if you have a family history of any inner ear disorders or central nervous disorders. They may ask you to rate the intensity of some of your symptoms on an objective scale.  Lastly, they will inquire about all the daily activities that are affected by your vestibular problem such as your walking ability, your driving ability, your work activities, and even your home activities such as getting dressed, bathing, showering, and housekeeping.  They will also want to know if you have had any falls or almost-falls.

After taking a detailed history your Physical Therapist will then perform a physical examination. A general examination of your balance will be completed. They may ask you to stand on one foot or stand with your eyes closed.  You may also be asked to lie down and then get up from the lying position in order to determine if this motion brings on your symptoms.  They will also want to observe your resting head and neck posture as well as how you walk to assess for any compensatory changes or strategies.

Your Physical Therapist will look in your eyes to note any abnormalities of your eye gaze.  For any health care professional, assessing reflexive eye motion is important in order to determine whether the vestibular system is working properly.  As explained above, if one inner ear is affected by disease or injury then the sensory input being sent to the brain will falsely indicate movement from that vestibular system.  In this case the eyes will adjust accordingly and move opposite to the perceived motion despite the head actually being still.  An involuntary back and forth movement of the eyes, called nystagmus, results.

There are a number of tests that your Physical Therapist may perform in the clinic in order to determine whether or not nystagmus or irregular eye movement is present.  These tests may involve lying you down on the bed while they hold your head still, shaking or rolling your head gently, or positioning your head in specific ways in sitting or lying. In some cases, your Physical Therapist may ask you to wear specialized glasses, which enable them to better assess your eye motion. Nystagmus can be caused by several reasons other than vestibular problems, however in the case of accompanying dizziness or vertigo, nystagmus leads your Physical Therapist to the suspicion that the vestibular system is the culprit.

Your Physical Therapist may also assess the tracking of your eyes by asking you to follow certain objects with your eyes or asking you to move your head while maintaining your focus on a specific target.

A general examination of the joints of your neck will also be completed to determine if any of your symptoms could be coming from the neck region.  Other general physical examinations such as blood pressure in both lying and standing may also be assessed.

Finally, your Physical Therapist may ask you to fill in a questionnaire that asks you about the intensity of your vestibular symptoms and what provokes them in order to give them a better idea of when your symptoms are at their best and worst.

Depending on what your Physical Therapist finds on their initial examination they may send you for a series of other tests to further determine the cause of your vestibular symptoms.

Advanced Testing

Electronystagmography

Electronystagmography (ENG) is a commonly used test to check for signs of nystagmus in more detail.

To conduct this test electrodes are placed around the eyes and the motion of the eyes is recorded as you are asked to follow certain moving targets or while your head is positioned in different directions.  A related test is one in which the eye movements are video recorded by wearing goggles rather than electrodes (videonystagmography.)

Caloric testing

During this test, which is a subtest of electronystagmography, cool and warm water or air is administered to each ear, one at a time. The change in temperature stimulates the balance organ in the ear and in normal circumstances your eyes reflexively move in a specific direction depending on whether cool or warm water is administered.  Absence of this movement indicates a vestibular problem.

Rotation Tests

Normally each time your head moves one way your eyes move in the opposite direction.  During rotation tests electrodes or goggles are used to record how the eyes move while the head is moving at differing speeds.  You may be asked to move your head while looking at a fixed target, or a computerized chair may be used to rotate your head while it is restrained.

Simple rotation tests may be administered by your healthcare professional in their clinical setting. For these tests they will observe your eyes while they move your head or rotate you on a swivel chair.

Vestibular evoked myogenic potential (VEMP)

This test is used to confirm whether or not the saccule and part of the vestibular nerve are functioning properly.
During this test headphones are used along with electrodes over the neck muscles. For this test the saccule, which also responds to sound, is stimulated via loud clicks into the headphones rather than via head movements. The response of the neck muscles to the clicks is recorded and indicates whether the sensory impulses are being transmitted properly.

Posturography

Sometimes called computerized dynamic posturography, this test provides information about motor control and balance function during varying unstable conditions.  Rather than providing specific information about the vestibular portion of the ear or brain, this test focuses on the feedback needed by the receptors in one’s joints, muscles, and skin (proprioception) in order to maintain one’s balance.

During this test you are required to stand on a moveable platform and you are asked to focus on a specific target. The platform or the target is then moved while pressure gauges under the platform record and map your body’s sway in relation to a neutral standing position.

Scans

In some cases a magnetic resonance imaging (MRI) scan or a computerized tomography (CT) scan of the brain may be done. An MRI scan uses a strong magnetic field and radio waves in order to produce a detailed image.  A CT scan uses a series of detailed X-rays to create an image.

These scans can identify abnormal growths affecting the ear (tumors both benign or malignant) or lesions such as those seen in MS.

Hearing Tests

Standard hearing tests are often carried out when delineating the cause of vertigo due to the close relation between the hearing and balance organs and nerves of the ear.

Vestibular Rehabilitation Therapy Exercises

As indicated above, a wide variety of disorders that cause dizziness or imbalance can be treated with VRT.  Virtually any disorder that is due to a vestibular dysfunction, and is not being well compensated for, can be treated with VRT.  Effectiveness of VRT depends on a proper diagnosis of the cause of the imbalance, the skill/training of the therapist designing and administering the treatment, and the adherence to the exercise program prescribed.

As explained previously, the aim of VRT exercises is to encourage the brain and spinal cord to make up for any balance or equilibrium deficits that are present due to inner ear or central nervous system disease or abnormality.  In other words, patients teach their vestibular system to do one of several things; adapt to stimuli that is presented, substitute other sensory pathways, or get used to the change in the vestibular signals sent to their brain such that they can manage their vestibular disorder and maintain a normal functioning life despite possible ongoing symptoms. In some cases, VRT can eliminate vestibular symptoms. Unfortunately, however, this is not always the case therefore minimizing symptoms or frequency of symptom recurrence is considered a successful outcome of VRT.

Research on VRT indicates that generally VRT exercises are effective in ameliorating many vestibular disorder symptoms and that the improvements can often be maintained for months following the therapy.  The effectiveness of the therapy often heavily depends, however, on what exactly is causing the vestibular symptoms in the first place and the use of customized exercises rather than just a standard exercise protocol. VRT, however, is not universally effective for all vestibular problems.  There are even some vestibular problems where exercise is not considered appropriate, therefore a proper diagnosis of the cause of symptoms is useful.

VRT Exercises

If your Physical Therapist feels that VRT is appropriate for you after your assessment is complete, they will prescribe a number of individualized exercises for you to regularly perform. These exercises will address your specific vestibular problem and the related symptoms. In addition, the exercises prescribed for you will focus on any everyday issues you are facing as a result of your symptoms.  Some exercises will be performed with your Physical Therapist at First Choice Physical Therapy and others will be taught to you such that you can complete them independently as part of a home exercise program.  Medications to treat your symptoms can be an adjunct to VRT and should be discussed with your physician.

The types of exercises used in VRT can be divided into the following categories:

Adaptation Exercises

These exercises work to force the vestibulo-ocular reflex (VOR) to adapt to movement of the head. In a way it is encouraging the eye-ear-brain connection to ‘reset’ itself.

A commonly used protocol of exercises which are based on this principle of getting the VOR to adapt to progressively more advanced motions of the head are Cawthorne-Cooksey Exercises.  This protocol of exercises has been around since WWII when two doctors, Terence Cawthorne & Harold Cooksey, noted that soldiers with balance disorders due to head injuries improved more quickly if they were forced to be active rather than bedridden. Examples include doing eye and head movements in sitting, and once these have been mastered these movements are then done while standing. Cawthorne-Cooksey Exercises are most effective when used in combination with other individualized vestibular exercises prescribed by your Physical Therapist.

Substitution Exercises

The purpose of these exercises is to use visual cues and those coming from the joints and muscles, to make up for the loss in vestibular sensory cues.  These exercises work to improve gaze stability and postural stability.

Gaze stability exercises improve one’s vision while the head is moving. For example, a patient may be asked to focus on a target, keep it in focus, and then move their head side to side, all the while maintaining focus of the target. Specific exercises, which vary the speed of the head motion and the position of the head, such as those done when lying, sitting or walking, will also need to be trained.

An example of an exercise that challenges postural stability would be one where you are standing on a soft mat and trying to balance.  To advance this exercise, the exercise would first be done with eyes open and then eyes closed.

Habituation Exercises

These exercises work to decrease the magnitude of the vestibular symptoms one feels by repetitively exposing the system to stimuli that bring on the symptoms.  These exercises attempt to fatigue the vestibular response to the stimuli such that symptoms decrease over time.  An example is putting your head down towards your knees in sitting and then back up. This exercise is repeated several times a day. The severity and duration of the dizziness felt after the exercise should be recorded.

Compensation Exercises

These types of VRT exercises encourage other systems and mechanisms associated with balance in the body to work harder in order to counteract the diseased vestibular system.  They can include substitution type exercises but also include more generalized central nervous system based strategies.  Often patients have already developed their own compensatory strategies by the time they have visited one of our Physical Therapists. It is the job of your Physical Therapist to help identify which strategies are in use and to assist you to use these strategies more effectively to manage your disease and symptoms.

Canalith-Repositioning Maneuver or Exercises

These exercises are used when otoconia (also called canalith) have settled in the semicircular canals and are causing vertigo and other symptoms.  The treatment of BPPV is often successful with this type of VRT.  Common maneuvers your Physical Therapist may use are called the Epley Maneuver or the Semont Maneuver (also called the Liberatory maneuver.) Both maneuvers involve your Physical Therapist holding your head into a certain position and then lying you down onto your back or side. If successful this motion dislodges the canalith and moves it into the inner ear area where it no longer causes symptoms. When these maneuvers work to treat BPPV, they often work quickly, even in just one treatment session.

Your Physical Therapist may also prescribe a set of exercises for you to do at home, which is similar to the canalith-repositioning maneuver that they perform with you in the clinic.  The most commonly used set of exercises are called Brandt-Daroff exercises.  These home exercises are generally used to treat BPPV but may also be prescribed for other vestibular disorders.

Machine-based Exercises

There are several machines that have been developed to challenge the vestibular system and therefore may be used in VRT if available. Examples include virtual-reality type simulators and moveable standing platforms. The benefit of these types of exercises is that the parameters of the exercise can be objectively set and measured, which allows objective improvement to also be measured.  In addition, with some machines, once the program is set up, less direct therapist supervision may be required which allows more patient independence.  With most types of VRT machines feedback is also provided, which enhances the learning ability. Home videos have also been developed for similar purposes.

Gait Retraining

These types of exercises work specifically on how you walk. Many people with vestibular issues develop an inefficient gait pattern. Your Physical Therapist will assess your walking pattern and will prescribe specific exercises to address any issues you may have developed to compensate for your vestibular symptoms.

General Exercise

Many patients with a significant or chronic vestibular disorder avoid activity due to it bringing on their symptoms. These patients, particularly if of an elderly age, quickly become deconditioned.   For these patients a general exercise regime aimed at improving cardiovascular health will be prescribed by your Physical Therapist.  The initial activity recommended is generally regular walking on even terrain, which should be done in a quiet and calm environment.  As general cardiovascular health improves and normal walking is tolerated by the vestibular system then walking on uneven terrain and/or on a busy street where increased head movement is required can be initiated.  Other general recreational activities such as golf, bowling, swimming or any other activity that you may enjoy can be discussed with your Physical Therapist and added at their discretion.

Manual Neck Treatment

Some patients who experience dizziness or balance issues have a concurrent orthopaedic problem with their neck, which is causing or adding to their symptoms.  In some cases this may be the original problem and in other cases a problem in the neck may have developed due to an existing chronic vestibular problem which in turn causes decreased voluntary head and neck movement. In these cases your Physical Therapist at First Choice Physical Therapy may also do some hands-on treatment for your neck in combination with the other VRT exercises described above.

Education

Secondary injuries due to vestibular problems can easily occur due to frequent falls or near-miss falls.  As part of your VRT your Physical Therapist will ensure you are well educated regarding simple strategies that can minimize your risk for secondary injuries. For example, the use of a walking aid when you are tired or in a particularly busy environment, such as a grocery store, may be advised. Motion lights or night lights for during the evening hours or nighttime near the entry doors may be encouraged.

VRT can be extremely useful to decrease or eliminate any vestibular symptoms you may be experiencing, which are present due to inner ear or central nervous system disease or abnormality. These exercises will show the best results if prescribed specifically for you by one of our Physical Therapists at First Choice Physical Therapy.

The brain is an extremely sensitive organ and is the control centre of our body.  When reflecting on common injuries resulting from sport or daily activities, injuries occurring to the brain are often overlooked.  Injuries to the brain are extremely common, particularly if you partake in sport, and even more so if you partake in a contact sport.  You don’t need to participate in a sport to cause injury to your brain.  Non-sport related injuries to the brain can occur during activities such as falls or motor vehicle accidents.  Injury to the brain from these or similar causes is termed a concussion.  A concussion in the medical world is considered a mild head injury or mild traumatic brain injury (TBI).  Due to the injury the brain cannot function the way it normally does. Your ability to perform your normal activities with the same speed, reaction time, and precision as prior to the injury can be significantly altered.

Fortunately the symptoms of a concussion in most cases are temporary and resolve over time.  With each concussion, however, there is a small chance that permanent brain damage can occur, so proper treatment and sound medical advice regarding management of this injury is crucial.

This guide will help you understand:

• how the condition develops
• how health care professionals diagnose the condition
• what treatment approaches are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What is the anatomy of the brain?

The brain is a soft organ that sits in the hard skull for protection. It is cushioned by cerebrospinal fluid that fills in the space between the skull and the brain.  The cerebrospinal fluid acts like packing foam that protects your fragile items from both the sides of the hard moving box itself and from the rapid or sudden motions that the box may endure.

The brain is the control centre for all of the body’s activities. Damaging the brain can alter your ability to perform tasks both mentally and physically.

What causes a concussion?

Any force that causes the brain to move rapidly within the skull and bang against the inside of the skull can cause a concussion.  In layman’s terms, a concussion can be caused by anything that ‘rattles the brain.’

Typically concussions are thought to be caused by direct blows to the head, such as in boxing or bar fighting, or by hitting your head on the ground during a fall, but indirect forces to the head are also common causes of concussions. For example, a fall onto your buttocks or onto any other part of your body can transmit a force strong enough to your brain to cause a concussion, even if you do not hit your head during the fall.  Similarly, a blow to your neck, face or any other area of your body that is severe enough to transmit the force to your head can cause a concussion.

Motor vehicle accidents often similarly cause concussions due to the whiplash motion of your neck which subsequently forces your brain to rapidly hit the inside of your skull. Shaken baby syndrome is another example of this indirect mechanism of brain injury, as are explosions where your body is rapidly thrown back.

What are the symptoms of a concussion?

Signs and symptoms of a concussion can vary extremely between people.  It is not always obvious that someone has a concussion, so if the mechanism of injury for a concussion was present, a concussion should always be suspected and thoroughly investigated.

You do not need to lose consciousness to suffer a concussion, and in most cases there is no loss of consciousness.  If you do lose consciousness, however, you have most certainly sustained a concussion.  Any loss of consciousness should be taken seriously, and any bouts lasting more than approximately a minute are considered severe.

Signs and symptoms of a concussion can vary extremely between individuals and can last days, weeks, months, or even longer in some cases.  Fortunately, however, in the majority of cases symptoms usually resolve within 7-10 days.

One of the most common symptoms of a concussion is a headache.  Confusion is another common sign. This sign can easily be overlooked by the examiner unless the patient is moderately to severely confused, so ruling out a concussion should not be based on the fact that the patient ‘did not appear confused.’

Other signs and symptoms of a concussion that may be present on their own or in combination are concentration difficulties, decreased attention, difficulty with mental tasks, memory problems, difficulties with judgment, a decrease in balance and coordination, a feeling of disorientation, a feeling of being ‘dazed,’ fatigue, blurred vision, light and/or sound sensitivity, difficulty sleeping or sleeping more than usual, being overly emotional, being irritable or sad, neck pain, a feeling of ‘not being right’, and ringing in the ears.  Amnesia may be another symptom.  Two types of amnesia can occur: Retrograde amnesia which is forgetting events that happened before or during the concussion event, or anterograde amnesia, which is when you do not form new memories about events that occurred after the concussion. In severe concussions, a change in personality may even occur.  If a patient shows even one sign or symptom listed above this should be indicative of a concussion occurring and a full concussion evaluation should proceed.

Signs and symptoms that are even more severe after an injury to the head, such as recurrent vomiting, a change in pupil size, blood or fluid coming from the ears or nose, seizures, or obvious physical coordination or mental difficulties indicate a severe brain injury and require immediate emergency attention.

In most cases signs and symptoms appear immediately after the concussion has occurred, however in some cases the signs and symptoms can be delayed by a few hours or possibly even days.  For this reason if the mechanism of injury suggests a concussion despite a lack of obvious symptoms being immediately present, the patient needs to be thoroughly examined for latent development of concussion signs or symptoms over a reasonable time frame, and a concussion must be thoroughly ruled out before returning to activity.

How do health care professionals diagnose a concussion?

Diagnosing a concussion can be easy in cases where there was an obvious mechanism of injury involving a blow to the head, and when there are immediate signs and symptoms to indicate the brain has suffered an injury.

In many cases, however, a concussion can be overlooked when the mechanism of injury does not directly involve a blow to the head, the signs and symptoms are not obvious, or the signs and symptoms are delayed in their onset.  The patient may initially ‘appear fine.’

Diagnosis of a concussion begins with a complete history of the mechanism of injury. As stated above, any blow to the head or force through the body that is strong enough to transmit a force to the head will lead your health care professional to the suspicion of a concussion.  At a sporting event, often the sideline health care professional is privy to having seen the mechanism of injury, which aids in diagnosing a concussion. Included in the history will be questions regarding any previous concussions that the patient may have incurred.  The more concussions you incur, the higher your chances of sustaining another concussion, and it can more easily occur with decreased force.

Thorough questioning regarding the patient’s symptoms is the next step to diagnosing a concussion.  With sporting events, immediate symptom evaluation should occur on the sidelines by a health care professional or a coach well educated in concussion signs and symptoms.  If neither is available, immediate referral to a doctor should occur.

As symptoms can appear immediately or can be delayed, monitoring of symptoms from the time of concussion for at least a few hours is necessary.  As mentioned above, symptoms may even be delayed a few days so if the mechanism of injury indicates a potential for a concussion, the development of symptoms needs to be monitored for a few days after the injury, and during this time, the patient should not be allowed to participate in sport or challenging cognitive activities. It is important to monitor for not only the initial emergence of any concussion signs or symptoms, but also for the worsening of any existing symptoms, or any decline at all in the patient’s ability to perform physical or cognitive tasks.

The evaluation of cognitive function should occur when initially diagnosing a concussion.  General questions regarding orientation that have traditionally been used such as ‘who are you?’, ‘where are you?’, and ‘what time is it?’, have not been shown to be sensitive enough to pick up a decline in cognitive function.  For this reason diagnosis of a concussion should not be ruled in or out based solely on these general questions.  More advanced questioning can be useful in helping to determine a decline in cognitive function indicating injury to the brain. For instance, at a sporting event questions such as ‘who scored the last goal?’, ‘which team was played last week?’, or ‘how far into the game is it?’ can help to delineate a concussive state.  More advanced sideline concussive cognitive tests are also available and are useful in sports where concussions are common.  Outside of sport, more in-depth questioning such as the exact location of a street, or questions regarding the full date and time of day may assist in determining the patient’s cognitive status.

Whether on field, at the emergency department, or in the medical clinic a thorough physical examination will need to be completed.  This examination is to look for signs such as pain in the neck, which may indicate a concurrent cervical spine injury, amnesia, or soft tissue injury to the skull.

Following the physical examination a clinical neurological examination is completed including tests for strength and sensation, reflexes, coordination, visual and auditory disturbances, and cognitive impairment including deficits to memory or concentration.  A thorough examination of the patient’s balance and gait will also be completed.  Impairment in balance can often be seen as a clinical sign of reduced motor function when a patient suffers a concussion. Balance that is not disturbed, however, does not exclude the diagnosis of a concussion having occurred.

A concussion is a functional injury to the brain rather than a structural injury.  This means that damage to the brain tissue generally cannot be physically seen.  For this reason, neuroimaging tests such as computerized tomography (CT) scans or magnetic resonance images (MRI) that look at brain structure are not needed to diagnose a concussion.  Normal findings are common when imaging is completed in patients who show clinical signs of a concussion. In other words, you can still have a concussion, even a severe one, despite CT scans or MRI results being normal.  For this reason, neuroimaging is not routinely ordered if a concussion is diagnosed, unless true structural damage to the brain is suspected.  X-rays of the skull may be considered to rule out bony injury to the skull itself if the mechanism of injury warrants it.

If structural damage to the brain is suspected a CT scan or MRI is necessary as these are currently the best neuroimages readily available to view the structure of the brain.  Structural damage may be suspected when concussion signs or symptoms are severe.  For example if there has been a significant loss of consciousness (greater than one minute), significant memory loss, a change in pupil size, repetitive vomiting, seizures, or rapidly worsening levels of cognition or physical ability.  Even if the concussion symptoms are not severe, but the mechanism of injury involved enough obvious force to cause structural damage then a neuroimage of the brain is indicated.  For example, concussions due to falling from a height or from a high-speed motor vehicle accident would warrant a neuroimaging test.  Neuroimages may also be more routinely ordered in adolescents or children due to the fragility of their developing brains.

Currently there are no neuroimaging tests used routinely that can identify the changes in the brain that relate directly to the clinical signs and symptoms seen with a concussion.  New MRI neuroimaging testing which is sensitive to brain electrical activity (functional MRIs also knows as fMRI) and MRIs that are more sensitive to minute structural damage (perfusion and diffusion tensor imaging), as well as other types of new imaging technologies are currently being trialed and extensively researched.  These tests show hope in potentially creating a gold standard neuroimage test that identifies a concussive state.  Some major hospitals or clinics may already have these tests available, and if so, these tests add valuable information to diagnosing a concussion and analyzing clinical symptoms.  At this stage, however, not enough research has been completed on these tests to warrant their use as a standard procedure in the diagnosis of a concussion.

What is the treatment for a concussion?

The basis of treatment for all concussions is rest until signs and symptoms resolve.  Once signs and symptoms have resolved then a graduated increase in both cognitive and physical activity is implemented while monitoring symptoms.  Once graduated activity is implemented and tolerated then a graduated return to sport or work schedule can be considered. Rest for a concussion means both a physical rest but also a cognitive rest. This means not only will sporting activities or manual work activities be excluded, but also mental activities requiring attention and concentration such as television watching, computer work, reading, texting, or doing schoolwork.  The brain simply needs time to heal, as with any other injury to the body.  The eyes and ears can be particularly sensitive to sound and light after a concussion and even normal lights and sound can precipitate symptoms so any stimulus of this sort needs to be avoided or limited.

If a concussion is suspected during a sporting event the player should be immediately removed from the game and not be allowed to return to play that day under any circumstance.  Serious injury to the cervical spine should be ruled out and then a full concussion examination should proceed.  An ice pack can be applied to the neck or head if pain is present in either of these areas.  If it is unclear whether a concussion may be present, it is recommended to err on the side of caution and assume a concussion is present until thoroughly ruled out.  The common sporting cliché of “when in doubt, sit them out” should be applied.  In the event of an injury occurring outside of sport that involves significant impact or force, such as a motor vehicle accident or fall from a height, one should assume that a concussion has occurred until this has been thoroughly ruled out.

Immediately after a concussion a patient should not be left alone and should be monitored for any development of new signs and symptoms or any deterioration in existing signs and symptoms over a period of a few hours. If the patient does not exhibit any signs or symptoms indicating a severe concussion and they have not deteriorated over several hours of monitoring them, it is fine to let them sleep, as this will aid their recovery. They do not need to be awoken every few hours unless a doctor has examined them and has specifically suggested that this be done.  In severe cases, some concussed patients may be kept in the hospital for monitoring overnight.

Fortunately the majority of concussions (80-90%) resolve in a short period of 7-10 days.  Several factors, however, may lengthen recovery times and will require typical management of a concussion to be modified.  Severe concussions or those concussions where the symptoms last longer than expected will require a longer recovery period.  Patients who have had a loss of consciousness of greater than one minute also generally require a longer recovery period, as do children and adolescents whose brains are still developing and are therefore more sensitive to injury.  Repetitive concussions create cumulative injury to the brain and therefore generally require a longer period to recover after each time they occur.  There is also a thought that females may incur more severe concussions due to their lesser neck musculature compared to males. The increased male musculature may help to absorb some of the forces that the body (including the brain) endure which may decrease the severity of a concussion.  For this reason females may require a longer recovery period before returning to work or play. Interestingly, patients who suffer from migraines, mental disorders, depression, sleep disorders or attention deficit syndrome may also require a longer period to recover and these factors should be considered when planning return to activity protocols.

Neurocognitive testing (testing one’s ability to think) can be useful as an objective measure of a patient’s cognitive abilities, reaction time, and overall mental processing abilities as they recover from a concussion.  It is not uncommon for a patient to ‘feel fine’ after a concussion, including having their physical symptoms resolve, but for their cognitive abilities to still be deficient.  For many high level sports teams, a baseline neurocognitive test is done pre-season so that if a concussion occurs, test results post-concussion can be compared and used as an evaluation of whether the player is back to pre-concussion status before returning to play.  There are several neurocognitive tests being used and there is not one gold standard test yet identified.  Most tests consist of computer-generated tasks that measure reaction time and cognitive ability.  Tests are available in a variety of languages and normative value ranges are available if a pre-test has not been completed.  Neurocognitive testing should not, however, be used as a sole predictor of return to activity timelines.  All physical symptoms must still be considered, a full medical clearance completed, and then a graduated return to play protocol implemented.

Examples of these tests include The Axon Sports Computerized Cognitive Assessment Tool (CCAT) and The ImPACT test (Immediate Post-Concussion and Cognitive Test.)  Other tests that are designed to be administered once a concussion has occurred, such as the SCAT3, can also be administered pre-season in order to establish baseline information about each individual, however they are not as encompassing as the neurocognitive computerized tests available, therefore when available, a baseline computerized neurocognitive test should be carried out. Post-concussion neurocognitive testing should not, however, be used as a sole predictor of return to activity timelines.  All physical symptoms must still be considered, a full medical clearance completed, and then a graduated return to play and return to learn protocol implemented.

The best treatment for a concussion is prevention.  Regarding concussions from sport, protective equipment such as helmets and mouth guards should be worn to absorb forces, and equipment should be the latest in technology where feasible.  New equipment such as helmets and other protective pieces are continually being researched and tested in order to improve their shock absorbing ability and decrease the severity of concussive forces sent to the brain.

Athletes and non-athletes should maintain their body strength and physical fitness as there is the possibility that stronger musculature might protect against forces transmitted through the body and also better control any abhorrent forces transmitted to the head and neck. This musculature may decrease the severity of any injury sustained.

Patients are also encouraged to decrease risk-taking behavior in their sport or everyday lives and take preventative action against injuries to their head.  Seat belts should be worn at all times when in a vehicle.  Helmets should be worn for biking and hard hats during manual labor tasks.  Ladders should be well secured to avoid falling from a height.  Unnecessary hits during sport and overall sporting risk-taking behaviors should be minimized or avoided.  In addition, athletes should stay well hydrated while partaking in their sport so that their cognitive awareness for injury-causing situations is at peak performance throughout their game.  Even something as simple as removing or securing throw rugs in your home can assist in decreasing the risk of a fall and a resultant concussion.

Can medications help me after a concussion?

Immediately after sustaining a concussion medications should be avoided until a full assessment of the concussion signs and symptoms can be reviewed. Even over-the-counter drugs such as ibuprofen, nurofen, paracetamol, or acetaminophen should not be taken after a concussion until a doctor is consulted.

Once reviewed by a doctor, if medication is prescribed its aim is for one of two reasons:  Firstly, medication may be prescribed to treat the concussion injury itself in an attempt to decrease initial symptoms or duration of symptoms.  Secondly, medication may be used to deal with the symptoms arising from the concussion such as sleep deprivation, or emotional lability.  Many doctors choose not to medicate at all when treating a concussion in order to not mask any symptoms.  If medication is prescribed the doctor who prescribes it should closely monitor the patient and all health care professionals involved in the patient’s care should be aware of how the medication may affect the symptoms of the concussion.

Alcohol and illicit drugs should be strictly avoided when recovering from a concussion.

What will I do to rehabilitate from a concussion?

Returning to sport, work or everyday activities after a concussion requires a specific return to activity plan that is closely monitored for the re-appearance of concussion signs and/or symptoms.  Your Physical Therapist at First Choice Physical Therapy, along with consultation from your treating doctor, can create, implement, and monitor your return to activity plan. If you are a student, it is recommended that your health care professional contact your school to ensure they are aware of the recent concussion and to also ensure they are on-board with Return to Learn and Return to Activity guidelines.  It is pertinent that all involved in the care of a concussed patient follow the same conservative guidelines in order to optimize recovery.

The backbone of rehabilitating from a concussion is rest until symptoms subside, then a graduated return to cognitive and physical activity without creating any symptoms.

Returning to work or sport following a concussion proceeds through a basic sequential process.  Your Physical Therapist will specifically guide you regarding the amount of activity you should engage in and will closely monitor you for signs or symptoms to ensure the healing brain is ready for each progressive level of physical or cognitive activity.

As a general guideline, the steps in this sequential process are:

1. No activity, complete cognitive and physical rest
2. Light aerobic activity; exercise such as walking or stationary cycling and/or light cognitive activity such as reading or computer work for a short period
3. Sport-specific training such as running and/or work/school specific tasks such as working on spreadsheets, solving math problems, or engaging in more mentally challenging tasks
4. Non-contact training drills for athletes, more intensive or longer duration physical activity for non-athletes (longer walks) and mental activities of longer duration or combined mental activities such as reading with the television on
5. Once cleared by a doctor, athletes begin with full-contact training.  Non-athletes are medically cleared to begin back to some regular everyday activity
6. Return to competition for athletes at a graduated level (ie: athlete returns to play in one quarter or only on certain offensive/defensive plays.) Non-athletes return to work/school gradually (ie: half days to start or fewer cognitive tasks during a full day).

Each of the 6 stages of the general return to activity plan will occur over a 24-hour period, which means that for athletes suffering a concussion, full return to sport will not occur earlier than approximately 6-7 days after the initial injury.  If at any stage during rehabilitation signs or symptoms arise, your Physical Therapist will ask you to cease the current activity and return to resting for a minimum of 24-hours, or until all symptoms have resolved.  Activity will begin again once all symptoms have subsided.

Cognitive and physical tasks should begin again at the same level where no symptoms occurred (it is not necessary to return all the way back to stage one unless it is the progression to step two that has caused the symptoms) and proceed then to the next level only once the task at hand has been completed without generating signs or symptoms.  Each step can be progressed if it is undertaken without any symptoms arising during or after the exertion, and your Physical Therapist is content with all aspects of your exertion ability and your physical response to this exertion.  It is worth mentioning again that no step should be progressed earlier than 24-hours after the previous step.  Latent signs and symptoms may appear within this time frame so it is important to allow sufficient time for these to emerge, but also to give the brain time to recover from the exertion it has endured during the rehabilitation process itself.

By following a progressive sequence of increased physical and mental exertion you will be allowed (and encouraged) to exert yourself during rehabilitation as long as this exertion does not bring on signs or symptoms.  In other words, exertion both physically and mentally during rehabilitation should be sub-maximal and below a symptom threshold.  As mentioned above, in some cases a longer rehabilitation with a longer return to activity plan may be necessary; such as when loss of consciousness was greater than one minute, or in patients who have had repetitive concussions.  In these cases, patients may find that they must continue doing activity at one threshold for longer than the 24-hour period while the brain heals.  Allowing an athlete to exercise sub-maximally while recovering from a concussion (rather than not exercising at all) is very beneficial to maintain their fitness and psychological state while sitting out with an injury.

While engaging in your rehabilitation plan, it is important to remember that any additional physical or cognitive activity outside of this plan adds to the stress that the healing brain must endure.  Going to the movies, completing your taxes, or walking around the shopping centre for the day will all add stress to your healing brain.  It is best to report all extracurricular activity that you anticipate engaging in, or need to engage in, to your Physical Therapist so they can take this into account when developing and modifying your rehabilitation plan.

Your Physical Therapist at First Choice Physical Therapy will be fundamental in guiding your rehabilitation and return to activity plan after a concussion.  They will provide you with criteria regarding the levels of physical and mental exercise to work towards, and will also monitor physical exertion signs, such as your heart and breathing rate, in order to appropriately progress your physical exertion levels from light through to heavy.  Your symptoms will be documented in order to monitor for any changes with increasing levels of exertion.  Special tests for balance and physical coordination may be used to give your therapist an indication of your physical ability as you recover.  Your Physical Therapist will also analyze your individual circumstances and specifically tailor your return to activity to incorporate any special circumstances that may apply to you.  For instance, if you are returning to a sport, such as soccer, where the risk of a second concussion is high, your Physical Therapist may delay your return to play for a longer period than if you are returning to a sport such as tennis, or not returning to any sport, but rather a work or scholastic situation where your risk for a second concussion is low or none at all.  Factors such as your gender, your predisposition to migraines, learning disabilities, and any previous concussions sustained will also be taken into consideration when tailoring your individual rehabilitation plan.

If you received any concurrent injuries when you sustained your concussion, such as a soft tissue injury to your neck or any other injury, your Physical Therapist at First Choice Physical Therapy will simultaneously treat this injury.  Your therapist will ensure that not only your brain is ready and prepared to return to your regular activity, but that the rest of your body is also ready to begin.  Manual therapy, massage, electrical modalities and specific exercises may be used to treat your neck.  It should be noted that in some cases hands-on treatment to the neck area after a concussion can bring symptoms on.  Your therapist will closely monitor for this, and treatment will be modified accordingly.

Each patient is unique in both their concussion signs and symptoms, as well as in the sport or job they need to return to, therefore close and frequent monitoring of your return to activity plan by your Physical Therapist is necessary.  Your Physical Therapist at First Choice Physical Therapy will be in close consultation with your doctor and any other health care professionals that have been involved in the care of your concussion injury to ensure you are returning to your regular activity as quickly but also as safely as possible.  Medical clearance from your doctor will be needed before certain levels of activity are undertaken.  For those returning to sport, your therapist may also consult with your coach to discuss implementing a gradual return to activity within your practices and matches.

It is worth mentioning again that full recovery from a concussion involves the ability to both physically as well as cognitively handle complex tasks without creating any symptoms.  Decreased cognitive function is more easily overlooked than physical symptoms and therefore special attention will be paid by your Physical Therapist to your cognitive function as you recover.  Your therapist may use neurocognitive testing to get an objective measure of where your reaction time is at, or to ensure that mentally challenging tasks do not provoke symptoms.

Variables such as stress in a job or the stress of an important sporting event can add to the cognitive demands of any task at hand so these variables will be taken into consideration by your Physical Therapist when your return to activity plan is being implemented.  Other variables such as noise and lights can easily aggravate symptoms so will also be taken into account when in the final stages of returning to full activity.  For instance, the music and lights during a dance/stage performance, the bright lights of a nighttime playoff game, a match within a large busy stadium, or an office/classroom that is lit with fluorescent lighting can aggravate symptoms.  Where possible, your Physical Therapist will attempt to incorporate your regular sporting or work environment into your return to activity plan to ensure the activities you engage in are as similar as possible to those you will incur in your normal environment once you are fully back into action.

If even mild signs or symptoms resulting from the concussion are lingering it is absolutely critical that you do not return to regular activity or sport, particularly where the possibility of incurring another concussion is present.  If you do return to activity, the risk of sustaining a second and more damaging concussion is increased as your lagging cognitive function and reduced reaction time leaves you more vulnerable to a second injury. This is termed Second Impact Syndrome.

Second Impact Syndrome

Second-impact syndrome (SIS) is a condition that occurs when a patient incurs a second concussion before full recovery has occurred from an initial concussion.  The second blow does not need to be forceful in order to cause SIS.  SIS is considered rare but is a very serious condition and can result in death or severe brain damage as the brain rapidly swells and/or bleeds following the second blow.  SIS occurs most often in young athletes under the age of approximately 25 and when it does occur has a high fatality rate among these athletes.  Due to the real possibility of SIS a conservative rather than aggressive return to activity protocol should be implemented following a concussion.

Post Concussion Syndrome

Post concussion syndrome (PCS) is the presence of symptoms from a concussion, which last much longer than expected.  Symptoms may last weeks, months, or occasionally even years.  Symptoms are varied but can be physical, such as a headache or dizziness, or may be cognitive such as difficulty concentrating or performing mental tasks.  Other symptoms such as light sensitivity, or emotional irritability may also occur.

The cause of PCS is unclear.  One belief is that structural damage to the brain causes the ongoing symptoms.  Others believe, however, that the symptoms develop due to a psychological or emotional reaction to the initial injury.  In any case it is considered abnormal and a complication of a concussion.

Fortunately in most cases PCS symptoms resolve in approximately 3 months.

Depression

Depression has been reported as being a potential long-term consequence of concussion and when present, may be considered a symptom of PCS.

Further research is needed to accurately link concussions to a depressed state, however trends in research are focusing on the possibility that the greater the number of concussions sustained, the greater your risk for depression.

The brain is a delicate, sensitive, and complex organ.  Injury to the brain has the potential to affect aspects of both physical and cognitive functioning in activities of daily living as well as during activities of sport and work.  Most signs and symptoms of a concussion resolve relatively quickly, but in some cases signs and symptoms can last longer than anticipated and continue to affect a patient’s ability to function.

The best treatment for concussion is prevention.  When a concussion does occur, however, the seriousness of the event needs to be acknowledged by the patient, the health care professional, and any other caregiver involved.  A prudent and cautious attitude to treatment, recovery, and return-to-activity must be implemented.