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Vertigo

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Vertigo

What is vertigo?

Vertigo is a broad term used to describe an illusionary sense of motion in the absence of true motion [1] Benign paroxysmal positional vertigo (BPPV) is a specific disorder of the inner ear which results in spinning sensations with changes in head position [1,2]. BPPV can be caused by head trauma/infection of a vestibular nerve (vestibular neuritis) and other complications in the inner ear related to illness or surgery, however, most cases of BPPV do not have a specific cause (idiopathic BPPV) [1,2]. The semicircular canals (anterior, posterior and lateral) in the inner ear which are filled with fluid (endolymph) that moves in response to rotation of the head which bends the cupula hair cells which stimulates vestibular nerves [1,2].

The two most common types of BPPV are BPPV of the posterior semicircular canal (posterior canal BPPV) or BPPV of the lateral semicircular (horizontal canal BPPV). The main mechanisms of BPPV are thought to be:

  1. Canalisthiasis – where free-floating debris in the semicircular canal causes continuous movement of the endolymph after movement has stopped which causes bending of the cupula and provokes vertigo [1-3]

  2. Cupulolithiasis – where abnormal debris attaches to the cupula making it more sensitive to gravity and provoking vertigo [1-3]

 

How is BPPV diagnosed from other causes of vertigo?

It is important that the specific cause of vertigo is identified to ensure effective treatment or management of symptoms. Other causes of vertigo include but are not limited to:

  • Other disorders related to the ear (otologic disorders) – e.g. Meniere’s disease [1]

  • Neurologic disorders – e.g. Demyelinating disease, central nervous system lesions, stroke [1]

  • Anxiety/panic disorders [1]

  • Cervicogenic vertigo (related to the neck) [1]

  • Side effects from medication [1]

  • Postural hypotension (low blood pressure) [1]

  • Other medical conditions – e.g. toxic, infectious or metabolic conditions [1]

There are specific criteria required to diagnose BPPV – these relate to both the patient’s history and the physical examination. 

 

Patient history

Patients with BPPV report episodes of vertigo associated with changes in head position relative to gravity [1,2] Common provoking activities include rolling over in bed, moving head to look upward and bending forward.1,2  

 

Physical examination

Physical manoeuvres are used to confirm presence of BPPV and identify the affected canal clinically. The Dix-Hallpike manoeuvre is used to confirm posterior canal BPPV [1-3]. During the Dix-Hallpike manoeuvre a patient is rapidly moved from sitting to lying position with the head tilted to 45 degrees below horizontal, 45 degrees to the side of the affected ear and downward [1]. The Roll test is used to diagnose lateral canal BPPV [1-3]. The Roll test is performed with the patient lying on their back with head starting in neutral position and turned rapidly to the right side, observing for symptoms, returning to face up position, and then turned rapidly to the left and observing for symptoms.1 In patients with BPPV these manoeuvres provoke vertigo and nystagmus (rapid, involuntary movement of the eyeball) [1-3]

How can BPPV be treated?

Surgery is not recommended or necessary unless it is to address a specific underlying cause (e.g. disease, illness), or there is the occurrence of severe, frequent, recurring episodes without any reduction or remission with other treatment options [1,2] Medication is also not necessary for treatment of BPPV but may be used to manage associated symptoms such as nausea or vomiting [1].

Although many cases of BPPV resolve spontaneously without treatment, some patients experience ongoing symptoms and may experience balance problems which can restrict activities and affect quality of life [1,2].

Current evidence supports the use of canalith repositioning (CRP) manoeuvres as initial treatment for BPPV [1-4]. CRP manoeuvres are performed on the patient and involve moving the patient’s head through a series of positions and using gravity to help move free-floating debris out of the affected semicircular canal [1,2]. CRP manoeuvres can be performed by any health professional in the outpatient setting, including physiotherapy [1,2]. The most commonly used and recognised CRP manoeuvre is the Epley’s manoeuvre which is effective in resolving symptoms in a small number of treatments (usually 1-3) [1,2].  Incorporation of vestibular rehabilitation with CRP manoeuvres is useful for long term management to promote functional recovery and/or as preventive measure [1,3,4]. Vestibular rehabilitation involved exercise- and movement-based interventions performed by the patient, they focus on challenging and promoting adaption of the nervous system to compensate for vestibular dysfunction [3].

 

If you have any questions regarding vertigo and dizziness, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

References

  1. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). J Otolaryngology – Head Neck Surgery. 2017;156(3_suppl):S1-S47.

     

  2. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews. 2014(12).

     

  3. Rodrigues DL, Ledesma ALL, de Oliveira CAP, Júnior FB. Physical Therapy for posterior and horizontal canal benign paroxysmal positional vertigo: Long-term effect and recurrence: A systematic review. J International archives of otorhinolaryngology. 2017.

     

  4. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews. 2015(1).

     

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Electrical stimulation: Does it serve a purpose, or does my physio just want to zap me?

Comment

Electrical stimulation: Does it serve a purpose, or does my physio just want to zap me?

Electrical stimulation (e-stim), most people are familiar with the term. It has become a mainstay in many physiotherapy practices, but what actually is it? Did you know there are actually many different types?

What is e-stim?

E-stim is an umbrella term for various different electrotherapy devices with different intervention goals. Of the most commonly used are Neuromuscular Electrical Stimulation (NMES), Transcutaneous Electrical Nerve Stimulation (TENS) and Inferential Stimulation (IFT). Despite these devices conducting electrical currents through the body via electrodes on the skin, they are in fact used to treat different things and thus their practical application varies [1].

 

NMES

NMES is used with the primary outcome to maintain strength and flexibility in order to restore, maintain and improve function [1,2]. Normally our brain sends messages to our muscles to initiate contractions. After muscular injuries, our muscle’s ability to activate becomes inhibited due to pain, swelling and/or trauma [1,2]. This leads to muscle wastage and poorly controlled muscle activation patterns, limiting the individual’s ability to properly recover during the healing process and placing them at an increased risk of future injury [2]. To prevent this, NMES is used to send an electrical current into the muscle to cause it to contract. In doing so, the muscle is being used and thus minimises muscle wastage; whilst also aiding to regain strength and restore correct movement patterns [1,2]. NMES has a wide practical application with research supporting its efficacy in chronic disease management [3],  post ACL repairs [2] and even in neurological injuries such as stroke [4]. The small battery-operated device is portable and thus can be used on essentially any type of land-based exercise whether that be in laying down or during a functional movement.  

 

TENS

TENS is similar to NMES, however where NMES is used for muscle activation, TENS is used for pain management [5,6]. The pulsed currents are sent through the muscle to help stimulate the release of various chemicals [5]. These chemicals help assist in reducing the sensitivity of the muscles and surrounding tissue by inhibiting neural pain pathways to the brain [5,7]. Current research demonstrates proven efficacy for TENS in decreasing pain compared to both placebo and anti-inflammatories [5]. TENS is often used for a multitude of different conditions including arthritis (both osteo and rheumatoid) [5], neuropathic (nerve related) [8] and even post- surgical pain [5]. It is a small portable battery-operated device, making it easily portable and usable regardless of whether you are at home, in the clinic or at work.

 

IFT

IFT is a form of TENS where rather than sending one frequency current, it utilises two alternating currents simultaneously [1]. These two currents become superimposed on each other where they intersect, enabling the ability to stimulate deeper within the targerted tissue [1]. This results in a reduction in pain in a similar underlying mechanism to TENS [9]. Compared to placebo, IFT has been found to have a positive effect on pain reduction [5]. IFT also can have positive effects on improving circulation and decreasing oedema by assisting in the removal of fluid in both the circulatory and lymph systems [1]. Unfortunately, unlike NMES and TENS, IFT is a larger stationary device and thus does not provide the portable convenience like the others.

 

Take home message

There is a variety of different e-stim devices all used for different purposes. Current research supports their use as an adjunct to therapy, meaning they aren’t a complete cure within themselves [1]. The use of e-stim is relatively safe with the most common side effects reported including pain, discomfort and skin irritation [10]. Several contraindications and precautions do come with the use of these devices [1], but your physio will assess you to clear these risks before starting the treatment to ensure your safety.

 

If you have any questions regarding e-stim or think you may benefit from its application, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

 

REFERENCES

  1. Brukner P. Brukner and Kahn’s Clinical Sports Medicine. 4th Editio. McGraw-Hill Australia; 2012.

  2. Kim K-M, Croy T, Hertel J, Saliba S. Effects of Neuromuscular Electrical Stimulation After Anterior Cruciate Ligament Reconstruction on Quadriceps Strength, Function, and Patient-Oriented Outcomes: A Systematic Review. J Orthop Sport Phys Ther. 2010;40(7):383-391. doi:10.2519/jospt.2010.3184

  3. Jones S, Man WD-C, Gao W, Higginson IJ, Wilcock A, Maddocks M. Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease. Cochrane Database Syst Rev. 2016;(10). doi:10.1002/14651858.CD009419.pub3

  4. Pomeroy VM, King LM, Pollock A, Baily-Hallam A, Langhorne P. Electrostimulation for promoting recovery of movement or functional ability after stroke. Cochrane Database Syst Rev. 2006;(2). doi:10.1002/14651858.CD003241.pub2

  5. Sluka KA (Kathleen A, International Association for the Study of Pain. Mechanisms and Management of Pain for the Physical Therapist. https://books.google.com.au/books?hl=en&lr=&id=ng2DCwAAQBAJ&oi=fnd&pg=PT22&dq=Mechanisms+and+management+of+Pain+for+Physical+therapists+&ots=QW8vap0AOC&sig=7v6EK-jAhIoZbjlXu--KnLykUvs#v=onepage&q=Mechanisms and management of Pain for Physical therapists&f=false. Accessed February 26, 2019.

  6. Gibson W, Wand BM, Meads C, Catley MJ, O’Connell NE. Transcutaneous electrical nerve stimulation (TENS) for chronic pain - an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2019;2:CD011890. doi:10.1002/14651858.CD011890.pub2

  7. Ahmed S, Haddad C, Subramaniam S, Khattab S, Kumbhare D. The Effect of Electric Stimulation Techniques on Pain and Tenderness at the Myofascial Trigger Point: A Systematic Review. Pain Med. January 2019. doi:10.1093/pm/pny278

  8. Gibson W, Wand BM, O’Connell NE. Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults. Cochrane Database Syst Rev. 2017;9:CD011976. doi:10.1002/14651858.CD011976.pub2

  9. Almeida CC de, Silva VZM da, Júnior GC, Liebano RE, Durigan JLQ. Transcutaneous electrical nerve stimulation and interferential current demonstrate similar effects in relieving acute and chronic pain: a systematic review with meta-analysis. Brazilian J Phys Ther. 2018;22(5):347-354. doi:10.1016/j.bjpt.2017.12.005

  10. Samuel SR, Maiya GA. Application of low frequency and medium frequency currents in the management of acute and chronic pain-a narrative review. Indian J Palliat Care. 2015;21(1):116-120. doi:10.4103/0973-1075.150203

Comment

What the Cup?

Comment

What the Cup?

What is cupping?

Cupping has been used since 3000 BCE, it originated in ancient Egypt where it was used to remove toxins from the body [1]. Since then cupping has spread throughout the world and been used in many cultures as a treatment for a variety diseases. Today cupping is mostly seen in traditional eastern medicine, where it is used to correct blockages and help the flow of Qi throughout the body [2]. It involves suctioning special cups to the skin of a patient, in the form of wet cupping or dry cupping. Wet Cupping is invasive and involves suctioning small amounts of blood through minor incisions made in the skin, this means it is usually not performed by physiotherapists in western practices [3].

What is dry cupping?

Dry cupping is non-invasive, as it doesn’t involve exposure to blood. It is mostly used to treat musculoskeletal pain in the chest, stomach, back and buttocks [4]. Smaller cups can also be used to treat regions on the arms and legs.

Cups vary from 38-50mm in diameter and are generally made of plastic or glass [3].

The cup is suctioned and held in place by heating the air in the cup then placing the rim of the cup on the skin so it is air tight, or by suctioning air out of the cup using an air pump after placing it on the skin [3]. This negative pressure inside the cup suctions the skin and feels like your skin and soft tissue underneath is being pulled or stretched. Then it is generally left in place for 5-20 minutes or can be moved around to cover a larger area using lubricant so that it can slide without interrupting the vacuum seal made between the skin and the cup [5].

 

How does dry cupping work?

The vacuum inside the cup creates a tensile force that stretches the skin, subcutaneous tissue and fascia lying beneath [2]. This also causes the small blood vessels in that area to expand. The larger the cup and more suction created the stronger it stretches the soft body tissues underneath, and the longer it is left in place the more blood that is drawn to that area [2].  

This means dry cupping has the potential to be used for a number of benefits such as:

  1.  Relieving muscle and surrounding fascia tightness [3]

  2. Aiding muscle and soft tissue healing [6]

  3. Increase blood circulation and aid removal of toxins from muscles [4]

  4. Improve immune function by aiding flow of lymph [6]

  5. Provide pain relief through stimulating pain inhibiting nerves [7]

  6. Promoting deep relaxation [7]

 

Is it safe?

Yes, provided it is performed by a suitably trained therapist. Patients may feel warmer and may sweat during a cupping treatment, this is just a result of blood vessels expanding and drawing more blood and heat to the skin [3]. Patients may also experience redness, swelling and bruising of areas of skin that have been cupped after a treatment, this is normal and should go away within a few days or weeks [4]. You should not having cupping therapy if you are pregnant, menstruating, have metastatic cancer or have cupping therapy over an area with a bone fracture, deep vein thrombosis, palpable pulse or skin irritation [8]. 

Complications to cupping are very rare and usually due to a lack of therapist training and incorrect practice, which have lead to only a few reports of skin burns, contamination and pressure wounds [9].

 

What does research say about the effectiveness of dry cupping?

There have been several studies investigating the treatment effects of dry cupping on a variety of musculoskeletal conditions. The findings of these studies are:

  • 2 weeks of cupping treatment significantly reduced chronic neck pain [10]

  • 2 weeks of pulsating cupping effectively relieved pain, improved function and quality of life in patients with chronic neck pain [11]

  • Cupping and exercise together is effective in improving neck pain and neck function, and better at improving pain than using a heating pack [12]

  • Patients with sub acute and chronic lower back pain felt less pain and improved flexibility in their lower back after 1 treatment [13]

  • Pulsating dry cupping is effective at relieving symptoms of knee osteoarthritis [14]

There is however a need for future studies to focus on confirming comparing these effects to standard treatments as well as understanding long lasting effects of dry cupping.

 

If you have any questions regarding treating your aches and pains or cupping therapy, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

 

References

  1. Nickel, J.C., Management of urinary tract infections: historical perspective and current strategies: part 1—before antibiotics. The Journal of urology, 2005. 173(1): p. 21-26.

  2. Tham, L., H. Lee, and C. Lu, Cupping: from a biomechanical perspective. Journal of biomechanics, 2006. 39(12): p. 2183-2193.

  3. Rozenfeld, E. and L. Kalichman, New is the well-forgotten old: The use of dry cupping in musculoskeletal medicine. Journal of bodywork and movement therapies, 2016. 20(1): p. 173-178.

  4. Yoo, S.S. and F. Tausk, Cupping: east meets west. International journal of dermatology, 2004. 43(9): p. 664-665.

  5. Turk, J. and E. Allen, Bleeding and cupping. Annals of the Royal College of Surgeons of England, 1983. 65(2): p. 128.

  6. Ahmadi, A., D.C. Schwebel, and M. Rezaei, The efficacy of wet-cupping in the treatment of tension and migraine headache. The American journal of Chinese medicine, 2008. 36(01): p. 37-44.

  7. Musial, F., D. Spohn, and R. Rolke, Naturopathic reflex therapies for the treatment of chronic back and neck pain-part 1: neurobiological foundations. Complementary Medicine Research, 2013. 20(3): p. 219-224.

  8. Chirali, I.Z., Traditional Chinese medicine: cupping therapy. 1999: Elsevier Health Sciences.

  9. Cao, H., X. Li, and J. Liu, An updated review of the efficacy of cupping therapy. PloS one, 2012. 7(2): p. e31793.

  10. Lauche, R., et al., The influence of a series of five dry cupping treatments on pain and mechanical thresholds in patients with chronic non-specific neck pain-a randomised controlled pilot study. BMC complementary and alternative medicine, 2011. 11(1): p. 63.

  11. Cramer, H., et al., Randomized controlled trial of pulsating cupping (pneumatic pulsation therapy) for chronic neck pain. Complementary Medicine Research, 2011. 18(6): p. 327-334.

  12. Kim, T.-H., et al., Cupping for treating neck pain in video display terminal (VDT) users: a randomized controlled pilot trial. Journal of occupational health, 2012. 54(6): p. 416-426.

  13. Markowski, A., et al., A pilot study analyzing the effects of Chinese cupping as an adjunct treatment for patients with subacute low back pain on relieving pain, improving range of motion, and improving function. The Journal of Alternative and Complementary Medicine, 2014. 20(2): p. 113-117.

  14. Teut, M., et al., Pulsatile dry cupping in patients with osteoarthritis of the knee–a randomized controlled exploratory trial. BMC complementary and alternative medicine, 2012. 12(1): p. 184.

Comment

Don’t run from the P.O.L.I.C.E.

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Don’t run from the P.O.L.I.C.E.

So, you rolled your ankle, you're thinking it will be fine, I’ll just walk it off. Little did you know as you continued to play the last 10 minutes of the game, the phases of healing have already begun. As you continue to run, your ankle throbs and feels unstable beneath your body. You feel sick as the pain won’t go away but continues to get worse. Thoughts race through your mind, what have I done? Should I see someone? Finally, you make the decision to come off the court, but what do you do now?

In the past, the process to assist with recovery was known as R.I.C.E.R. (Rest, Ice, Compression, Elevation and Referral). This has been proven to be effective, however, methods of management have changed to the P.O.L.I.C.E. protocol [1] :

P – Protection: this reminds individuals that a little bit of pain is okay but if the injury causes severe pain then the ankle should be protected using bandages, taping or crutches to off-load the ankle.

O – Optimal: the right amount of pain/discomfort (not too much but tolerable).

L – Loading: placing weight on the ankle (optimal-loading is advised).

I – Ice*: applied for 8-10 minutes at a time [2,3] alternating between 10 minutes on then 10 minutes off. This should be done as often as possible in the first 48 hours.

C – Compression: apply a compression bandage around the ankle, ensuring it is firm enough without cutting off circulation to the foot (Pinch test: squeeze toe, it should turn white then red again).

E – Elevation: raise leg above heart height to prevent pool of blood around the ankle due to gravity.

* Warning: any burning sensations in the region REMOVE the ice. Do not place ice directly on skin (apply a 1-2 cm cloth in between ice and skin). Never place ankle on top of the ice but rather the ice on top of the ankle.

 

Why this protocol?

Recent studies have shown that protecting the joint should be only as required as resting or offloading the joint could be detrimental causing changes as to how the tissue recovers [1, 4, 5]. These studies therefore promote optimal loading, where an individual can start placing body weight onto the ankle, as tolerable. This encourages correct fiber type and alignment to develop, early mobilisation and can facilitate accelerated recovery times [1, 4]. Further benefits of optimal loading are positive as changes to mechanical properties regarding load alter sensory feedback. This informs the brain that this painful feedback, which it was experiencing earlier on, is no long dangerous thus de-sensitizing the injury and reducing pain levels [4]. Previously the R.I.C.E. [6] method did not consider optimal loading and referral but rather focused on resting and went straight into management. Though icing is effective, studies have shown this has a limited effect depending on the duration and severity of the injury and should only be utilised in the acute phases [3]. Benefits of using ice should still be utilised as icing reduces the analgesic (pain) response and facilitates optimal healing by reducing swelling that would otherwise delay an individual’s rehabilitation process [7, 8].

So, when in doubt, don’t run, follow the P.O.L.I.C.E. protocol. If pain persists or worsens or you are unable to weight bare, contact your local physiotherapist and book an appointment.

 

What would a Physiotherapist do to help?

  • Perform a thorough movement examination of the lower body to provide education and understanding of the condition.
  • Provide tailored strategies and modifications to correct improper biomechanics of the ankle, i.e., taping, ergonomic assessment.
  • Design a personalised exercise program tailored to resolving muscle imbalances that would otherwise cause ankle instability.
  • Assist with improving range of movement and pain management strategies.
  • Provide education on self-management techniques.
  • Improve balance and retrain an individual back to pre-injury status.

 

If you have any questions regarding your acute injury, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

 

References

  1. Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE?. British Journal of Sports Medicine. 2011 Sep 7:bjsports-2011.
  2. Adie, Naylor, & Harris. (2010). Cryotherapy After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. The Journal of Arthroplasty,25(5), 709-715.
  3. Prins, J., Stubbe, J., Van Meeteren, N., Scheffers, F., & Van Dongen, M. (2011). Feasibility and preliminary effectiveness of ice therapy in patients with an acute tear in the gastrocnemius muscle: A pilot randomized controlled trial. Clinical Rehabilitation, 25(5), 433-41.
  4. Glasgow, P., Phillips, N., & Bleakley, C. (2015). Optimal loading: Key variables and mechanisms. British Journal of Sports Medicine, 49(5), 278-279.
  5. Bleakley, C., Dischiavi, S., Taylor, J., Doherty, C., & Delahunt, E. (2017). Rehabilitation reduces re-injury risk post ankle sprain, but there is no consensus on optimal exercise dose or content: A systematic review and meta-analysis. British Journal of Sports Medicine, 51(20), British Journal of Sports Medicine, Oct 15, 2017, Vol.51(20).
  6. Hing, Wayne, Lopes, Justin, Hume, Patria A., & Reid, Duncan A. (2011). Comparison of multimodal physiotherapy and "R.I.C.E." self-treatment for early management of ankle sprains. (RESEARCH REPORT)(Report). New Zealand Journal of Physiotherapy, 39(1), 13-19.
  7. MacAuley, D. (2010). Effect of accelerated rehabilitation on function after ankle sprain: Randomised controlled trial. BMJ. British Medical Journal (Clinical Research Ed.), 340(10), 1122.
  8. Bleakley CM, O'Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010; 340:1964.

Comment

Patello-Femoral Pain Syndrome

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Patello-Femoral Pain Syndrome

What is PFPS?

Patellofemoral pain syndrome (PFPS) is prevalent in approximately 25% of the athletic population and most commonly affects young adult females [1].  PFPS is characterised by anterior knee pain in and around the patella [2,3]. When bending at the knee joint, the patella should normally track in a lateral to medial direction before moving laterally again at full knee flexion. This motion is controlled by the quadriceps muscle group, particularly the vastus medialis oblique and vastus lateralis components. Poor coordination or weakness of these muscles can lead to inflammation of soft tissues (lateral retinaculum, infrapatellar synovium and fat pad) in addition to stress on cartilage and bone causing pain [3].

Presentation

  • Acute or gradual onset
  • Aggravated by increased on unaccustomed loads on the patellofemoral joint (e.g. higher training volume, increased running speed, hill/stair running and bounding)
  • Varied presentations including achy/sharp pain, poorly localised under or around the patella
  • Knee/s may feel like it is gives way or buckles [2,3]
  • Pain during squatting [4]
patellofemoral-pain-syndrome.jpg

Aetiology

  • Inadequate neuromuscular control or weakness of quadriceps muscles
  • Patella position (tilt/rotation)
  • Pronated foot type [1,2]
  • Increased knee valgus or femoral internal rotation
  • Reduced strength, coordination or range of motion of hip abductors causing increased stress on frontal and transverse forced around the knee [3]

Complications

May predispose to the development of patellofemoral osteoarthritis.

How can Physiotherapy help?

  • Provide education and advice about your condition and promote strategies to reduce your pain and symptoms
  • Provide an accurate and comprehensive assessment of your condition and address any underlying biomechanical factors contributing to your pain
  • Provide condition specific treatment including manual therapy, massage and stretches
  • Create an individualised exercise program to target muscular imbalances in the hip and/or knee and improve coordination of quadriceps muscles
  • Taping to correct abnormal positioning of the patella [2,5]

 

If you have any questions regarding your knee pain, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

 

References

  1. Nunes, G. S., Stapait, E. L., Kirsten, M. H., De Noronha, M., & Santos, G. M. (2013). Clinical test for diagnosis of patellofemoral pain syndrome: Systematic review with meta-analysis. Physical Therapy in Sport, 14(1), 54-59.
  2. Brukner, P. (2012). Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill. 4th Edition, 87. 725-726.
  3. Panken, A., Heymans, M., Van Oort, L., & Verhagen, A. (2015). Clinical prognostic factors for atients with aterior knee pain in physical therapy: A systematic review. International journal of sports physical therapy, 10(7), 929.
  4. Collado, H., & Fredericson, M. (2010). Patellofemoral pain syndrome. Clinics in sports medicine, 29(3), 379-398.
  5. Collins, N. J., Bisset, L. M., Crossley, K. M., & Vicenzino, B. (2012). Efficacy of nonsurgical interventions for anterior knee pain. Sports medicine, 42(1), 31-49.

Comment

Shoulder bursitis

Comment

Shoulder bursitis

What is shoulder bursitis?

The shoulder contains numerous structures (muscle, bone, ligaments, tendons and bursae) that work closely together to allow optimum functioning. Within each shoulder is two purse-like sacs that contain fluid: the sub-acromial and sub-deltoid bursae. These both help to reduce friction over adjacent surfaces (i.e. muscle on muscle, bone to muscle) [1]. When irritated, this leads to a thickening of the bursa causing a painful condition known as bursitis [2].


This is considered an active warning sign that the surrounding structures have undergone repeated trauma from overuse or have been involved in a single incident (i.e. collision) [1, 2, 3]. Poor body mechanics can also be a contributing factor to the onset of bursitis [2]. It has been commonly associated with chronic shoulder pain, rotator cuff tears and degenerative tendinitis of the rotator cuff [3].

Shoulder-Bursitis.png

Presentation?

  • Tender, swelling, painful when directly palpated
  • Pain when lying on shoulder
  • Pain when lifting shoulder
  • Limited range in all directions due to pain
  • Gradual onset of pain and limitations
  • Difficultly doing overhead activities

 

Complications – Septic Shoulder

Is a rare condition in which the bursa becomes infected. Sepsis is caused in the bursa because of direct contact piercing through the skin in the form of isotretinoin therapy and corticosteroid injections [4]. Individuals will feel the same symptoms as listed above, however, they may also become feverish, tired and sick. The shoulder may appear red and radiate heat [2, 4, 5]. Treatment should be sought from a medical practitioner to provide antibiotics to prevent the spread of the infection [2, 4, 5].

 

How can Physiotherapy help?

  • Perform a thorough postural and movement examination of the upper body to provide education and understanding into condition.
  • Provide tailored strategies and modifications to correct improper biomechanics of the shoulder, i.e. taping, ergonomic assessment.
  • Design a personalised exercise program tailored to resolving muscle imbalances that would otherwise cause shoulder bursitis.
  • Assist with improving range and pain management strategies.
  • Provide education on self-management techniques.

If you have any questions regarding your shoulder pain, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

References

  1. Lennard, T. (2011). Pain procedures in clinical practice / Ted A. Lennard ... [et al.]. (3rd ed.). Philadelphia: Saunders
  2. What is shoulder (subacromial) bursitis? (2013). https://www.arthritis-health.com/types/bursitis/shoulder-subacromial-bursitis
  3. Santavirta, S., Konttinen, Y., Antti-Poika, T., & Nordström, I. (1992). Inflammation of the subacromial bursa in chronic shoulder pain. Archives of Orthopaedic and Trauma Surgery,111(6), 336-340.
  4. Drezner, J., & Sennett, B. (2004). Subacromial/subdeltoid septic bursitis associated with isotretinoin therapy and corticosteroid injection. The Journal of the American Board of Family Practice, 17(4), 299-302.
  5. Khan, H., & Al-Tawil, K. (2013). Spontaneous Isolated Infection of the Subacromial Bursa. Case Reports in Orthopedics, 2013, 3

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Stress & Pain

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Stress & Pain

Do you often feel more pain during times of increased stress?

Pain is regulated by inputs from the brain, spinal cord and the environment and is influenced by multiple factors such as mood, thoughts, activity, sleep and stress [1]. These factors can influence the severity of pain and affect your prognosis. Often when the pressures of family, work and everyday life are weighing on you, not only do you experience an emotional impact but this can also increase your pain intensity and duration. Additionally, experiencing physical pain also makes people feel more stressed, thus creating a vicious cycle that may even lead to chronic injury. Therefore, managing stress is a significant factor to reduce pain and improve quality of life [1,2].

 

Effects of stress on the body

Psychological factors can contribute to increases in muscular tension and postural abnormalities that can accentuate the severity of physical injuries. These changes in muscle and posture can prevent muscles from functioning appropriately resulting in increased pain [1, 3].

For example, in patients following neck injuries, especially if the mechanism of injury was traumatic, they may experience increased muscle tension in the head, neck or upper limbs in addition to adapting abnormal postures that can heighten physical findings in the neck. The body’s response to stress and pain also varies widely among individuals, and these psychological factors could drive pain and take longer to resolve. Due to this variability, it is important to identify factors that may influence a patient’s recovery to potentially prevent re-occurrence [1].

Other effects of stress on your body and behaviour:

  • Fatigue
  • Sleep disturbances
  • Anxiety and/or depression
  • Lack of motivation or focus
  • Changes in mood/irritability
  • Social withdrawal
  • Reduced physical activity

 

What has research shown?

People suffering from psychological distress were shown to be five times more likely to suffer from chronic pain [4]. Current evidence supports the use of pain education for chronic musculoskeletal disorders in reducing pain, improving function, encouraging movement, lowering disability, and minimizing healthcare utilisation [5].

Research also demonstrated the effects of participating in regular exercise as an effective strategy for managing stress. Studies showed that post-exercise there was a significant impact on blood pressure responses to stress that may have implications for cardiovascular health [6,7].

Studies also recommended relaxation techniques such as deep breathing, yoga or meditation. These techniques encourage abdominal breathing which has been shown to promote stress reduction [3].

Overall, multidisciplinary biopsychosocial rehabilitation programs are recommended especially to those who suffer from chronic pain. These programs typically included pain education, pacing physical activities, and psychological treatment to address mood problems, sleep disturbances, unhelpful thoughts and behaviours in addition to medical management [2].

 

Coping strategies

Here are some tips to manage your stress:

  • Practice relaxation techniques such as deep breathing, yoga or meditation
  • Participate in regular exercise (at least twice a week for approximately 150-300 minutes of moderate intensity physical activity)
  • Ensure you have good quality sleep (between 7-9 hours)

 

How can physiotherapy help?

  • Complete a thorough assessment and physical examination of the individual and provide suitable recommendations on ways to improve posture and pain
  • Provide appropriate interventions to reduce muscle tension and pain with manual therapy techniques including massage
  • Create a individually tailored exercise program to increase physical activity and encourage self management
  • Provide education about your condition and help assist you locating appropriate resources to prevent re-occurrence

If you have any questions regarding whether we can help you manage your stress and pain better, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

 

References

  1. Brukner, P. (2012). Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill.41-52, 332-333.
  2. Kamper, S. J., Apeldoorn, A. T., Chiarotto, A., Smeets, R. J. E. M., Ostelo, R. W. J. G., Guzman, J., & van Tulder, M. W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. Bmj, 350, h444.
  3. Berger, B. G., & Owen, D. R. (1988). Stress reduction and mood enhancement in four exercise modes: Swimming, body conditioning, hatha yoga, and fencing. Research quarterly for exercise and sport, 59(2), 148-159.
  4. ABo, S. (2007). National survey of mental health and wellbeing 2007 (Cat. no. 4326.0). Canberra2007.
  5. Louw, A., Zimney, K., Puentedura, E. J., & Diener, I. (2016). The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy theory and practice, 32(5), 332-355.
  6. Hamer, M., Taylor, A., & Steptoe, A. (2006). The effect of acute aerobic exercise on stress related blood pressure responses: a systematic review and meta-analysis. Biological psychology, 71(2), 183-190.
  7. Hobson, M. L., & Rejeski, W. J. (1993). Does the dose of acute exercise mediate psychophysiological responses to mental stress?. Journal of Sport and Exercise Psychology, 15(1), 77-87

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Our First Handstand Workshop is here!!

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Our First Handstand Workshop is here!!

Want to learn how to do a handstand?  Or get your technique tweaked by the master?  Join our handstand workshop!!

 

WHO – Beginners to Intermediate Level.  Anyone looking to improve their handstands from the handstand master, Aleea Newton, former Australian Olympic Reserve Gymnast and current physiotherapist at Thornleigh Performance Physiotherapy.

 

WHAT -

Learning Objectives

-        Ideal shaping for a safe handstand

-        Common issues and difficulties

-        Tips and tricks for learning/progressing handstands without injury

-        Training Progressions for every level

 

WHERE – Thornleigh Performance Physiotherapy Gym

 

WHEN – Tuesday September 4th, 2018 7PM

 

HOW TO BOOK – As spaces are limited bookings are essential.  First 6 attendees are FREE (first in best dressed), thereafter $25 ($30 on the day). Register online at https://www.stickytickets.com.au/74405

Or email Tina tina@thornleighphysio.com.au

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Medial tibial stress syndrome

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Medial tibial stress syndrome

What is medial tibial stress syndrome?

Medial tibial stress syndrome (MTSS) is a common condition mostly affecting runners and recreational sports players. It is an overuse injury resulting from repetitive stress to the bone in the lower leg, the tibia. Stress reactions occur on the tibia and the surrounding muscles when the body is unable to heal properly, and with repetitive stress and inadequate healing, this creates an overuse condition. Tibialis posterior, a muscle in the back of the calf has been the main muscle responsible for this condition. However recent studies have identified that several muscles are involved, including flexor digitorum longus and the soleus, which are two muscles in the calf as well.

 

What are the symptoms?

The symptoms of MTSS include:

  • Vague diffuse pain in the lower leg near the shin bone
  • Pain that gets worse at the beginning of exercise but eventually subsides
  • Pain the following morning
  • As the condition worsens the pain may persist during activity

 

What are the risk factors?

The risk factors for MTSS is influenced by your individual biomechanics of movement, and the type of training you are performing. This means that the way your body moves and its positioning during walking and running can make you more susceptible to this condition. Some of these risk factors include:

  • Flat feet (excessive pronation)
  • Training errors
  • Sudden changes in physical activity e.g. sudden increase in intensity or duration
  • Shoe design
  • Surface type
  • Fatigue
  • Decreased flexibility
  • Muscle dysfunction

 

How do we treat it?

The foundation of treatment for medial tibial stress syndrome is based on identifying the risk factors involved, and treating the underlying pathology. This will ensure that we are treating the cause of the problem so it will not return in the future. Treatment begins with providing relief through rest and ice. In order to keep you active and still exercising you are able to completed pain free activities such as swimming or cycling.

Your physiotherapist will then begin a careful assessment of how your foot, knee and hip alignment are affecting your running and walking. Taping may be used to control your foot pronation (flat foot), and other techniques including strengthening and stretching of muscle imbalances, mobility exercises, motor control and stability exercises. Your physiotherapist will tailor these treatment options to your specific biomechanics which will reduce the stress placed on the tibia.

 

If you have any questions regarding shin pain, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

 

References

  1. Galbraith, M. Lavallee, M. 2009. Medial tibial Stress syndrome: conservative treatment options. Current Rev in Musculo Med. 2(3) 127-133.
  2. Batt, M. 2011. Medial Tibial Stress Syndrome. British Journal of Sports Medicine. 45(2)1-8.
  3. Franklyn, M. Oakes, B. 2015. Aetiology and mechanisms of injury in medial tibial stress syndrome: current and future development. World J of Ortho. 6(8) 577-589.

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Gua Sha

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Gua Sha

What is gua sha?

Gua sha is commonly known to be a traditional eastern medicine technique where a blunt tool, such as a ceramic soup spoon, is used to scrape the skin to improve blood circulation and oxygen supply to the soft tissue. A modern take on this technique is often referred to as instrument-assisted soft tissue mobilisation (IASTM).

 

What happens during tissue injury?

Inflammation usually occurs following an injury to generate new cells. The formation of scar tissue reduces elasticity of the injured tissue and results in adhesion. The scar tissue may also limit oxygen and nutrient supply and thus affect tissue regeneration. If left untreated, chronic inflammation may lead to tissue degeneration and contribute to chronic pain. These areas may also be more susceptible to re-injury.

 

How does gua sha work for injured tissue?

Adequate pressure and shear force applied during soft tissue mobilisation create micro-trauma in the affected area. This can facilitate the inflammatory response during the healing phase of the tissue. By using an instrument to assist, the clinician is able to deliver a greater force and stimulate adhesive points deeper within the tissue. Removing scar tissue and releasing adhesions help collagen synthesis and realignment. These in turn improve soft tissue function, range of motion, decrease pain and speed up healing.

 

Do I need gua sha?

Gua sha can be beneficial for conditions including but not limited to:

  • Tennis elbow
  • Patella tendon injury
  • Hamstring tendinopathy
  • Achilles tendinopathy
  • Partial muscle tears
  • Plantar fasciitis
  • Chronic neck pain
  • Chronic low back pain

 

What should I expect when receiving gua sha?

The clinician will typically start by rubbing lubricant such as cream to the skin before applying the instrument at a tolerable pressure onto the affected area. The clinician will perform smooth firm strokes over the affected area while feeling for restrictions or soft tissue irregularities. This process may take about 5-15 minutes depending on the affected area and condition.

In physiotherapy, gua sha may be used in conjunction with stretching and strengthening exercises depending on the type of injury and the stage of recovery. These exercises help restoration of function and prevent re-injury.

 

Are there any side effects with gua sha ?

Gua sha should not be painful during treatment. The rubbing and scraping may cause small blood capillaries near the surface of the skin to burst and result in redness, light bruising or soreness. These symptoms should resolve in a few days and can be managed with ice if necessary.

 

If you have any questions regarding whether gua sha can help, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

 

References

  1. Kim J, Sung DJ, Lee J. Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. J Exerc Rehabil. 2017;13(1):12-22.
  2. Lambert M, Hitchcock R, Lavallee K, et al. The effects of instrument-assisted soft tissue mobilization compared to other interventions on pain and function: a systematic review. Physical Therapy Reviews. 2017;22(1-2):76-85.

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Triangular Fibrocartilage Complex

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Triangular Fibrocartilage Complex

What is the TFCC?

The TFCC (triangular fibrocartilage complex) is a cartilage structure located on the small finger side of the wrist, it consists of ligaments and tendons. The function of this group of structures is to provide stability and smooth movement of the wrist joint. The TFCC keeps the forearm bones, the radius and ulna, stable when the hand grips objects or when the forearm rotates. An injury or tear to this structure can cause chronic wrist pain.

 

Types of TFCC injuries

There are two types of TFCC injuries:

  • Acute injuries: this is a traumatic tear. This can result from a fall onto the hand or from excessive arm rotation.
  • Chronic injuries: this is a degenerative tear or a tear that has lasted a long time. This can occur due to repetitive loading over a long period.

 

Symptoms

The symptoms of a TFCC tear include:

  • Pain at the base of the pinky side of the wrist
  • Pain worsens as the wrist is bent from side to side, and any activity that requires forearm rotation produces pain. For example: turning a doorknob or a key in the door, or lifting a heavy pan with one hand.
  • Tenderness over the back of the wrist
  • Reduced grip strength
  • Sometimes a clicking in the wrist

 

How is it diagnosed?

TFCC tears are diagnosed through careful assessment of the wrist and forearm. This involves your physiotherapist determining how your pain began, looking at the location of your pain, and how your pain is affecting the movements of your fingers, wrist and forearm. From here your physiotherapist is able to implement a treatment program.

 

How is it treated?

Throughout your assessment your physiotherapist would have determined the likely cause of your pain, which movements are painful and which movements are affected by your injury.

If the wrist is still stable, conservative treatment is taken. This involves beginning to decrease inflammation and pain around the area. You may be given a splint to wear for a short period of time to assist in pain reduction, and activity modifications will be applied to movements which cause pain such as heavy grasping and turning and twisting the wrist. Your physiotherapist will assess how you perform daily tasks, so these activity modifications can be manageable in your every day life.

Once pain and inflammation have been controlled, the focus of treatment will be on strength and mobility of the wrist and hand. Mobility will be addressed by improving the bending and straightening of the wrist, turning the palm up and then turning it back, along with making sure all of your fingers have proper mobility as well. Strength exercises will be prescribed to improve your grip strength, your ability to exert force when twisting the wrist, grabbing items, and bearing weight through the wrist. Additional exercises will be prescribed for you to be able to perform your activities of daily living with no pain.

Through mobility and strength exercises given by your physiotherapist you should be able to return to sport and return to normal activity.

 

If you have any questions regarding your wrist pain, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

 

Reference

Lubiatowski, P. Romanowski, L. Splawski, R. Manikowski, W. 2006. Treatment of injury of the Triangular Fibrocartilage Complex TFCC. Ortop Traumatol Rehabil. 30:8(3). 256-62.

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Extensor Tendinopathy

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Extensor Tendinopathy

History

A 53 year old female presented with gradual onset of pain to her right elbow localised to the lateral side of elbow and forearm.  She described her pain to worsen with gripping, reaching and lifting tasks, especially when attempting to use scissors at work. What can physiotherapy do to help?

 

Clinical examination

At rest, with her forearm relaxed on a pillow the patient had minimal to no symptoms. During active and passive range of motion examinations, pronation (inward rotation) of her forearm with the elbow extended and flexion of the wrist were the most provocative movements. Resisted extension of her wrist and 3rd finger also reproduced her symptoms and she was tender upon palpation over the lateral side of her right elbow and presented with painful and decreased grip strength. No reproduction of symptoms was evident following a screen of her right shoulder and neck, indicating a non-referral pain diagnosis.

Her mechanism of injury and clinical presentation indicate an extensor tendinopathy or commonly known as “tennis elbow”.

 

Management

A multimodal treatment incorporating education, unloading of the tendon from aggravating factors, pain relief and restoring tissue capacity and control was used to manage her extensor tendinopathy appropriately. Pulsed ultrasound was firstly used to promote the initial healing of soft tissue. She had active trigger point pain along her forearm muscle, that is a common occurrence in the presentation of extensor tendinopathy. The patient responded well with dry needling to her right forearm muscles which assisted in relieving muscle tension and forearm pain. She was provided with education regarding the use of ice as a form of pain management and unloading strategies. Isometric muscle activation exercises and stretches were also prescribed to be completed at home. She was also provided with a counterforce brace to be worn during working hours to assist her in gripping with reduced pain.

Over the next couple of weeks, the main focus was to restore the tissues capacity to withstand loads with minimal to no pain. This is achieved through appropriate rest and unloading of the tendon. Completing a progressive home strengthening exercise program with appropriate loads and tendon stretching. These strategies allowed time for the patient’s tendon to heal appropriately and reduce the symptoms the patient was experiencing. Manual therapy techniques and dry needling were used in conjunction to relieve any associated muscle tension. Following a couple weeks, she was able to return to full work duties with minimal to no issues.

 

If you have any questions regarding elbow pain, and need an assessment, please give us a call at (02) 8411 2050. Here at Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

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