Is your headache from neck pain or your neck pain from a headache?

Neck pain is very common in the U.S. with some estimates suggesting that 70% of the population will experience neck pain at some point.  Though not as common, 1 in 6 Americans are likely to suffer from severe headache or migraines. 

We commonly see clients who suffer from both neck pain and headaches.  It turns out that these two seem to go hand in hand.  Studies have shown that 90% of people with tension type headaches have neck pain, 75% of people with migraines have neck pain, and 84% of people with self reported sinus headaches have neck pain(1,2,3).

 None of the epidemiological studies referenced above chose to delve into the driver of the headache. Is the headache coming from the neck pain or is the neck pain being driven by the headache? The answer; it depends.

There have been numerous studies, based on the work of Janet Travel, that have looked at myofascial (muscular) origins of headaches. Similarly, there is research that links upper cervical joint dysfunction to headache symptoms(4).  Conversely, with the theory of central sensitization one could speculate that chronic migraines and headaches may eventually drive neck pain.

It’s not so easy, especially in a blog post, to be definitive of the origin of every headache or neck pain.  The best bet is to have a skilled PT perform a thorough evaluation to look for all possible contributing factors to your headaches.

The take home message is this: If you thought that there was nothing else you could do for your sinus headache, migraine, or tension type headache besides rest and medication, you were wrong.  A good physical therapist can find the cause or contributing factors to your headaches and help to ease your pain.

 

1.      Ashina, S., Bendtsen, L., Lyngberg, A. C., Lipton, R. B., Hajiyeva, N., & Jensen, R. (2015). Prevalence of neck pain in migraine and tension-type headache: A population study. Cephalalgia, 35(3), 211–219. https://doi.org/10.1177/0333102414535110

2.      Burch, R., Rizzoli, P., & Loder, E. (2018). The prevalence and impact of migraine and severe headach in the united states: Figures and trends from government health studies. Headache, 58(4), 496-505.

3.      Malo-Urries, M., Tricas-Moreno, JM., Estebanez-de-Miguel, E. et al. (2017). Immediate effects of upper cervical translatoric mobilization on cervical mobility and pressure pain threshold I patients with cervicogenic headache: A randomized controlled trial. Journal of Manipulative and Physiological Therapeutics, 40(9), 649-658.

4.      Shannon M. Petersen, Gwendolen A. Jull & Kenneth E. Learman (2019) Self-reported sinus headaches are associated with neck pain and cervical musculoskeletal dysfunction: a preliminary observational case control study, Journal of Manual & Manipulative Therapy, DOI: 10.1080/10669817.2019.1572987

 

Improving your core muscle coordination

Back pain is one of the leading reasons why people seek physical therapy care.  GOfit is no exception as we see many patients who experience back pain. There can be numerous causes of back pain from myofascial to spondylogenic and discogenic, just to name a few.  Regardless of the source of pain, there seems to be a similar response of the deep core stabilizer in the presence of pain; it shuts down. 

Well, “shuts down” may be a bit of an exaggeration. It doesn’t stop working altogether, but it does begin to atrophy and lose its coordination or muscle timing. Plenty of studies have shown that specific exercises can cause hypertrophy of this muscle but only a few have looked at how specific exercise effects the timing, or coordination of this muscle. As they say ‘timing is everything.’  Pure muscle bulk is great but muscles needed to be coordinated in their activity so they can activate at the right time to support the structure of the back.  A delay in activation of the transversus abdominis of even a few milliseconds could be the difference in pain free and painful functioning.

The authors of this study looked at the effect that specific exercise had on the timing of transversus abdominis activation.  Subjects of the study performed three exercises of increasing difficulty (abdominal drawing in maneuver, side planks, and bird dog) two times a week for four weeks. After four weeks muscle activation timing of the transversus abdominis was retested.  The authors found that muscle timing of the transversus abdominis improved significantly in the experimental group compared to controls.

So, what does this all mean? First, it means that we can improve the activation timing of one of our deep core stabilizers through some pretty simple exercises. Muscle timing is an important part of coordination. Having a coordinated and strong core will undoubtedly lead to reduced pain and improved daily functioning.

 

Selkow NM, Eck MR, Rivas S. Transversus abdominis activation and timing improves following core stability training: A randomized trial. Int J Sports Phys Ther. 2017;12(7):1048-1056.

Achilles tendinopathy treatment: What works and what doesn't?

Part 2

In the second installment of this series we want to review the most common courses of treatment for Achilles tendinopathy and discuss their current efficacy. There are a number of different approaches that one may encounter in the medical community. So, let’s review the effectiveness of those approaches.

What doesn’t work

NSAIDs: There is little scientific basis for the use of non-steroidal anti-inflammatory (NSAIDs) medications.  As we know from part 1 of this blog post, Achilles tendinopathy is NOT an inflammatory process. So, medications that work to reduce inflammation would add no value to your ability to heal. Unless you like unnecessary side effects from medication, stay away from the NSAIDs.

Corticosteriod Injections: Just like NSAIDs cortisone is an anti-inflammatory and has no medical rationale for it’s use on this condition. If that’s not enough, adverse effects were reported in 82% of corticosteroid trials that included further tendon atrophy, tendon rupture, and decreased tendon strength. This is a no brainer, cortisone has no business being in your Achilles tendon.

What might work

The jury, aka the scientific community, is still out on these interventions. Some studies have shown some success but there is still more research that needs to be done before the scientific community puts their seal of approval on these treatments.

Extracoporeal shockwave therapy: This is a treatment technique that uses high energy acoustic waves to deliver a mechanical force to the body’s tissues. The workings of this treatment are poorly understood but there have been recent clinical trials that show good results for those with chronic Achilles tendinopathy.  Unfortunately, there needs to be more high-level evidence and specific treatment parameters identified before this treatment moves up the list.

PRP: PRP is the injection of platelet-rich plasma (PRP) into a site of tendon injury. PRP stimulates healing through a number of growth factors in the plasma. There is a lot of good evidence out there that PRP can help tendon healing elsewhere in the body. Unfortunately, there is not a lot of evidence specific to the Achilles tendon.

Prolotherapy: Prolotherapy is the injection of hyperosmolar dextrose into the tendon. Clinical trials have demonstrated a reduction in pain, improvement in tendon strength and reduction in the size of intratendinous tears associated with the disorder. Although early research shows benefits with this procedure there still needs to be more high-level studies performed before this treatment is deemed truly effective.

Low level laser therapy: There is conflicting evidence to suggest low level laser therapy is beneficial to Achilles tendinopathy. There are randomized control trials that demonstrate improvement in tendon healing and elasticity. However other trials showed no effect on pain compared to controls. There is high level evidence to suggest that low level laser therapy may be an effective treatment but more studies are needed to confirm this.

Ultrasound: In animal studies ulatrsound has been shown to stimulate tissue growth and tendon healing. In the acute phases of tendon injury, it has been shown to reduce pain, swelling, and improve patient function. However there has not been a lot of new evidence to continue to demonstrate its efficacy and for this reason it stays in the “what might work” section of this post.

What does work

Eccentric Exercise: Eccentric exercise remains the gold standard for treating Achilles tendinopathy. There is good high-level evidence for the benefits of eccentric exercise in the management of Achilles tendinopathy. The mechanism behind the benefits of eccentric exercise are not well understood. Theoretically eccentric exercise produces rapid strengthening of the calf muscle, stiffening of the tendon, and lengthening of the tendon.  Studies have shown some adverse effects if proper form or insufficient rest between bouts of exercise occur so it is important that a physical therapist prescribe the correct dosage of exercise.  Most research recommends a course of 6 to 12 weeks of eccentric exercise.

Deep friction massage and tendon mobilization: Studies have demonstrated that deep friction massage combined with stretching can increase tendon healing, improve elasticity of the tendon, and reduce strain through the muscle-tendon unit.

There you have it, a quick review of the current treatment approaches to managing this frustrating condition.  Physical therapy can play an important role in the rehabilitative process of Achilles tendinopathy. We can have a very quick and positive affect on a number of biomechanical risk factors associated with the condition. Likewise we are the exercise experts and should be used to manage your exercise prescription as it relates to eccentric exercises.

Li H & Hua Y. Achilles tendinopathy: current concepts about the basic science and clinical treatments. BioMed Research International. 2016(6). https://dx.doi.org/10.1155/2016/6492597.

Chaudhry, F. Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review. Eur J Orthop Surg Traumatol. 2017(27). 441-448.

Achilles tendinopathy: What is it and how did it get there?

This is the first of two posts that will focus on a common foot problem: Achilles Tendinopathy. In this series we look to explain the process of Achilles tendinopathy, common risk factors, proven treatments, and new treatment ideas.

Achilles tendinopathy is one of the most common ankle overuse injuries. The disorder is more likely to be found in active individuals who participate in running and jumping sports. Achilles tendinopathy can be a frustrating condition because of the potential for pain to become persistent and significantly limit athletic participation and daily function. This blog post summarizes a review of the current concepts and treatment of Achilles tendinopathy. This is the first of two posts where we will delve into this often-frustrating condition.

First it is important to point out that we are using the term tendinopathy rather than tendinitis. Tendinitis had been used for decades but this is actually a bit of a misnomer. The term tendinitis implies that there is an inflammatory condition occurring. Recent studies however have found that tendon changes occur as a result of failed healing where inflammation and inflammatory cells are not found.  The tendon itself, like most tendons, has a relatively low blood supply. In the Achilles the area of the tendon that is least vascularized is approximately 2 to 6 cm above its insertion into the heel. This explains why this is the most likely area of the tendon to be injured. 

In normal tendon healing an injured tendon must go through the three phases of healing. The first phase, the inflammatory phase, typically lasts two to three days and is important in laying the ground work for healing to occur. After two to three days healing enters the proliferative phase where new fibrous like tissue is laid down in the area of injury. This typically occurs for 6 weeks until healing starts to enter the remodeling phase. In the remodeling phase new tissue starts to align itself in a direction that best absorbs the load through the tendon. This typically lasts another 4 weeks. Finally, if all goes well, after approximately 10 weeks the tendon will enter the final phase of healing, the maturation phase. In the maturation phase the new fibrous tissue gradually changes to scar tissue over the course of about a year. That means that if everything goes right it takes an injured tendon about a year to fully heal.

If everything doesn’t go right then you end up stuck in the proliferative phase of healing.  Being stuck in the proliferative phase leaves a tendon with too many cells responsible for breaking down the tendon, fibrous tissue that is disorganized, and a blood supply that has no business being there long term.  The tendon is now structurally weaker and painful.  This doesn’t sound like something anyone wants.

The first question one might want to ask is, how can someone avoid getting Achilles tendinopathy? That is best answered by looking at a list of risk factors associated with the disorder.  There are intrinsic factors associated with this disorder. Intrinsic factors include having a flat foot, a foot with too much arch, limited mobility of the subtalar joint (heel), and a leg length discrepancy. Systemic inflammatory conditions such as rheumatoid arthritis, hypertension, diabetes, obesity, hypertension, and certain medications can all increase the risk of developing Achilles tendinopathy. Extrinsic factors include excessive loading of the tendon through sport, training errors that include abrupt changes in frequency or intensity of training, change in training surface (hills or hard surfaces), poor shock absorption and uneven footwear may all contribute to Achilles tendinopathy.

There are a number of factors on this list that can be modified by training and lifestyle changes. Reducing your overall inflammatory lifestyle through diet could easily reduce the risk of developing Achilles tendinopathy. Likewise, smart exercise prescription including gradual progression of exercise and activity without huge jumps in training can significantly reduce your risk.  There are plenty of risk factors on this list that are within your own control!

In Part 2 of this post we will discuss ways that physical therapy can help restart the healing process and reduce the risk for setback and future injury.

Li H & Hua Y. Achilles tendinopathy: current concepts about the basic science and clinical treatments. BioMed Research International. 2016(6). https://dx.doi.org/10.1155/2016/6492597.

Chaudhry, F. Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review. Eur J Orthop Surg Traumatol. 2017(27). 441-448.

Free Screening at Fleet Feet Annapolis

Come to Fleet Feet Annapolis on October 11th between 4 and 7 pm for a free physical therapy screening by the GOfit team!

Bring all your musculoskeletal problems and questions!

We will provide a quick screen to assess the issues that you are having and provide you with some helpful tips and exercises to get you headed in the right direction!

Fleet Feet Annapolis is located in the Harbour Center at 2572 Solomons Island Road, Annapolis MD 21401.

Factors contributing to prolonged back pain

Green BN, Johnson CD, Haldeman S, Griffith E, Clay MB, et al. (2018) A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders. PLOS ONE 13(6): e0197987. https://doi.org/10.1371/journal.pone.0197987

This week’s blog post goes a little outside the normal topics covered on this blog. Usually we are concerned with mechanical issues or neuromuscular re-education strategies that we can directly influence and effect as physical therapists.  But looking at our client as a whole person, it is important to consider and acknowledge other factors that may be contributing to their pain or functional limitation.  These are factors that may be outside the scope of physical therapy practice, but it is important to recognize their potential contribution to our client’s complaints.

The authors of this paper were interested in determining risk factors, co-morbidities, and prognostic factors associated with the most common spinal disorders. As the authors point out spinal disorders contribute a significant burden on society and these problems have risen sharply in the past three decades. Spinal disorders are the leading cause for years lived with disability throughout the entire world. If spinal disorders have been getting worse and worse it certainly begs the questions, Why? What has changed in society that has led to this dramatic increase over the past 30 years.  The answer seems to be lifestyle.

The authors looked at a number of the most common spinal disorders including joint pain, myofascial pain, radicular pain, trauma, infection, arthritis, and congenital deformities to determine common risk factors associated with these groups of disorders.  The authors found that many of the risk factors associated with spinal disorders are completely modifiable and it all comes back to lifestyle.

Let’s start with the obvious. It is well known that living a sedentary lifestyle and over indulging in poor food can lead to numerous health problems, including spinal disorders. Those who had a higher body mass index and did not participate in regular exercise were at high risk for developing and sustaining spinal pain. What you put in your body, in terms of medication and tobacco, can increase your risk for developing a spinal disorder.  But it is not just diet and exercise.  Work life can be a risk factor for back pain.  A repetitive physically demanding job can increase your risk for back pain just as much as a stressful job or a sedentary job.  Work stress and other forms of psychological stress can increase the risk of developing or sustaining back pain.  There were too many specific risk factors to cover in this blog but it is important to know that the majority of risk factors described in the research are completely modifiable through lifestyle changes.

The take home message here is that there are psychological, nutritional, and physiological changes that we can all make to help reduce the risk of developing and contributing to back pain. We need to continue to champion healthy lifestyle practices that include regular exercise, proper nutrition, healthy work environments, and reduced psychological stress so that we can live healthy, happy, pain free lives.

Movement retraining for hip impingement part 2

Lewis C, Loverro K, Khuu A. Kinematic differences during single-leg step-down between individuals with femoroacetabular impingement syndrome and individuals without hip pain. J Orthop Sports Phys Ther. 2018;48(4). 270-279.

This week’s post is a close continuation of our last blog post. This post will hopefully drive home the message that movement retraining is a significantly important piece of rehabilitation.  The focus of this paper is on femoracetabular impingement (FAI). FAI is thought to occur when the femoral head (ball) prematurely contacts the acetabulum (socket).  When the ball part of the hip joint prematurely contacts the outer rim of the socket the tissue in between (labrum and cartilage) can become damaged and produce pain that is commonly felt in the groin.

As the authors point out there has been a lot of research on different hip joint shapes(morphology) and the relationship between hip joint morphology and the occurrence of FAI and groin pain. On the other hand, there has not been much research on altered movement patterns that may be associated or contributing to FAI. These authors wanted to change just that.

The purpose of this study was to determine if there were differences in movement patterns in those with FAI and those without. Participants ranged in age from 14 years old to 50 years old. Participants in the FAI group had to be diagnosed via physical examination, clinical presentation, and imaging with some form of CAM, pincer, or mixed hip joint morphology.  Individuals in the comparison group had to have no recent history of lower extremity pain and were picked as demographic matches.

3D motion analysis was used to measure various movement angles in the pelvis, hip, and knee while participants were instructed to perform a single leg step down. The authors believed the single leg step down would be challenging enough to identify movement discrepancies between groups of participants compared with other dual leg tasks such as the squat.

The results of the study were not completely surprising. The group with FAI had greater hip flexion and anterior pelvic tilt than the pain free group.  Increased hip flexion and anterior pelvic tilt would put someone in a position more likely to experience FAI. This suggests that FAI is not necessarily solely a structural issue of the hip joint and that movement patterns may be a modifiable contributor to their pain.  People with FAI may be able to retrain their movement patterns to avoid positions that cause impingement in the hip.  The authors also found that women had greater hip flexion, adduction, and anterior pelvic tilt which is not surprising given that women typically have greater pelvic width and are more likely to experience impingement symptoms. 

So it is likely that people who are experiencing FAI may have an underlying bony morphology but somewhere along the way they began moving in a way that set them up for impingement symptoms. There could be a number of reasons or causes for this altered movement, but it is important to note that movement patterns are changeable.

Movement retraining as a treatment for hip impingement

Harris-Hayes M, Steger-May K, Van Dillen L, Schootman M, Salsich G, Czuppon S et al. Reduced hip adduction is associated with improved function after movement-pattern training in young people with chronic hip joint pain. J Orthop Sports Phys Ther. 2018;48(4). 316-324.

The topics of hip impingement and hip pain are near and dear to our hearts here at GoFit and a clinical interest of ours. The article reviewed here uses the term hip joint pain to encompass a number of potential and often related diagnosis (femoracetabular impingment, developmental dysplasia, labral tears, and chondral lesions). 

Hip joint pain is a big problem. Especially for young, athletic women. Unfortunately, there isn't a great amount of high-quality research to suggest the best method of treatment. Despite this there has been a huge growth in the amount of surgeries to treat these various conditions. 

We talk a lot about manual therapy on the blog, likely because we are manual therapists and that is where our interests lie. But changing movement patterns is just as important in improving pain and function long term. This article is interesting because it looked at the effect movement retraining would have on individuals with chronic hip joint pain. 

The patients who participated in this study were between the ages of 18-40 years old, mostly women, who had deep hip pain or groin pain that had been present for at least 3 months. The pain had to be reproduced with a classic impingement test that brought the hip into flexion, adduction, and internal rotation. The authors used some pretty cool 3D kinematic technology to see how the effects of specific movement retraining would have on the person’s ability to correctly perform a single leg squat. They also looked at hip abductor strength and even looked to see if there were structural changes to the head of the femur w/ MRI imaging. 

Participants in the study had 6 one-hour sessions over a 6-week period. During these sessions a physical therapist provided instruction in movement of daily functional tasks and patient specific tasks with practice throughout. The patient was asked to perform the specific movements that they were deemed independent with as their home exercise program. 

The authors hypothesized that this specific movement retraining would reduce the amount of relative hip adduction the patient had during a single leg squat. This is important because increased hip adduction has been associated with "impingement'' type pain. They also believed that hip abductor strength would increase over the course of treatment.

This was a relatively complex study in the sense that there were a lot of moving parts. With this study, as with most studies, making generalizations can be difficult and results should be taken cautiously.  With that being said, there appears to be a couple of take home messages here. The first is that retraining movement during patient specific and functional tasks did work to reduce patient's hip adduction during specific movements. Those who had a greater reduction in hip adduction also had a greater improvement in pain and function assessed through patient specific scales.  Interestingly there was no change in hip abductor strength. This suggests that motor control and the timing of muscle activation may play a more important role in stabilizing the hip than pure strength. Also, of note the patients that reported a greater compliance to their home exercise program showed a greater reduction in hip adduction.  

 

Are you walking like Frankenstein's monster?

Falla D, Gizzi L, Parsa H, Dieterich A, Petzke F. People with chronic neck pain walk with a stiffer spine. J Orthop Sports Phys Ther. 2017;47(4):268-277. http://dx.doi.org/10.2519/jospt.2017.6768

Many people fall into the cycle of chronic neck pain.  They may not realize that not only are the effects of neck pain local, but they may also be remote.  Local changes include but are not limited to reduced neck range of motion in all directions, reduced smoothness of neck rotation, and reduced speed of neck motions (Falla et al.). It has also been found that individuals with neck pain have decreased proprioception (the body’s awareness in space) and increased swaying of the body during balance tasks (Falla et al.).

The aim of the study listed above was to assess spine kinematics (studying an object in motion) and walking characteristics in people with chronic neck pain.  The researchers hypothesized that changes in walking pattern would be present in those with chronic neck pain.  They believed this because it is thought that motor adaptations occur in response to pain.  They body attempts to protect itself from additional painful experiences once it has already experienced pain.  Therefore, it adapts to altered patterns of moving.

The study compared individuals with episodic chronic neck pain greater than 3 months with a pain-free control group.  Participants were asked to walk on a treadmill at 3 different speeds (two preselected by researchers and one self-selected by the participant) with the neck in three different positions (neutral and rotated to the right and left).  A custom-made helmet with markers and two laser pointers was worn by participants.  They were instructed to project the lasers to specific targets during the rotational portions of the experiment to verify each participant had the same amount of rotation.  Markers were also placed over the participant’s body to track motion throughout the body while walking. 

It was found that the group with neck pain demonstrated a shorter stride length and less trunk rotation than the control group.  The trunk rotation was decreased in the neck pain group versus the control group during slower speeds and the difference was even more pronounced at higher walking speeds and with the head rotated.  This is an interesting finding because at higher speeds of walking trunk rotation should increase in order to optimally transfer energy through the body.  If there is limited trunk rotation, this can cause increased stress to other areas of the body that are absorbing this energy or working harder to compensate for the lack of energy storage.  It can then lead to premature breakdown of certain areas of the body creating unnecessary injuries.

Additionally, the researchers hypothesize that a further reduction in trunk rotation is seen with the head rotated to the right or left possibly because of psychological factors.  They believe that because the head rotation is a more demanding situation that places the patient in disequilibrium, the patients have less trunk rotation as a guarding mechanism due to fear of movement or anxiety.

What can patients with chronic neck pain do to avoid this? In the simplest way, patients can work on rotating their trunk and swinging their arms during walking.  They can also work with a physical therapist to improve the mobility of their trunk through hands-on techniques as well as through stretching and exercise.  Performing neck range of motion exercises in pain-free ranges can build up confidence in the patient that they can move in pain-free patterns.  This will reduce overall guarding from movement patterns in the neck and elsewhere in the body.  This article reinforces the effects that a chronically dysfunctional area of the body can have elsewhere and the importance of addressing pain before it becomes chronic.

Harmless ankle sprain? Part 2

In the clinic we see it pretty often, the chronic ankle sprainer. Someone who comes in because they have sprained their ankle for the 3rd, 4th, 5th time. Or someone who has a history of chronic ankle sprains and is now presenting with knee, hip, or back pain on the same (or opposite) side.

This week’s blog post is a follow up to our post, “Harmless ankle sprain?”  In that post we reviewed and discussed the mechanisms behind chronic ankle instability. As we discussed it is altered proprioception, the body’s awareness of joint position in space, that effects feedback and feedforward mechanisms resulting in an elevated chance of spraining the ankle again. 

Traditionally it has been thought that the tissue damage to ligaments and tendons as a result of an ankle sprain has concurrently damaged the mechanoreceptors in those associated tissues. Mechanoreceptors are sensory organs thought to be responsible for generating the majority of proprioceptive input. So, if the mechanoreceptors are damaged, it would lead to altered proprioception and an increased likelihood of having another ankle sprain. This makes sense, except that the research on proprioceptive deficits following ankle sprain remain inconclusive. Some studies have shown deficits, while others have not. This means that there is likely proprioceptive input occurring by means beyond ligament, joint, and tendon receptors.

The updated view of joint proprioception is that proprioception is comprised of a network of tissues and receptors. The change in tension through this network of tissues (muscles, joint capsule, ligaments) during certain movements results in proprioception. In this updated view of proprioception, as the authors suggest, passive joint stiffness is likely important in the transmission of forces during movements and therefore important in the activation of proprioceptors.

The study’s purpose was to determine what the effect of an ankle sprain had on motion perception (proprioception) and passive ankle stiffness.  Motion perception was measured by hooking participants up to a machine that slowly moved their ankle. Participants were asked to press a button as soon as they perceived ankle motion. Passive ankle stiffness was measured by hooking participants up to the same machine and asking them to press a button when they began to perceive a stretch sensation. The authors expected that the group of individuals with history of an ankle sprain would have worse motion perception and worse passive ankle stiffness.

The results of the study confirmed that individuals with history of an ankle sprain have a worse sense of motion perception, or proprioception, than individuals with no history of an ankle sprain.  The surprise was that no significant difference in passive ankle stiffness was noted between those with a history of an ankle sprain and those without. However, the results did show that individuals with greater passive ankle stiffness had a greater sense of motion perception. This does suggest that there is a relationship between ankle stability and heightened proprioception.

In the blog post “Harmless ankle sprain?” we suggested balance exercises as a means for improving feedforward and feedback mechanisms in individuals with a history of chronic ankle sprains. It is also important to consider that altering the length-tension relationship of muscles surrounding the ankle joint may improve motion perception following ankle sprain.  Physical therapists have the means to do this through traditional strengthening exercises.  This may also mean that people with a history of chronic ankle sprains might consider avoiding over-stretching muscles around the ankle as this may have a negative effect on proprioception. 

Marinho HVR et al. Influence of passive joint stiffness on proprioceptive acuity in individuals with functional instability of the ankle. Journal of Orthopaedic & Sports Physical Therapy. 47(12); 899-905.

Direct access to physical therapy: good for your wallet and your health.

It never gets old hearing positive benefits of physical therapy.  It feels even better when research backs up what we all know to be true.  This week's blog highlights just that.

This week we are reviewing a study (cited below) that assessed the effects of physical therapy as the initial point of care for people experiencing neck and back pain. The study was coordinated between a large multi-clinic physical therapy practice and an insurance carrier in South Carolina. First let me say that it is absolutely amazing and commendable that they were able to get a large scale insurance carrier and physical therapy practice to work together. That in itself was an accomplishment and it gets even better. 

The researchers allowed patients with neck or back pain to choose their preferred access to care. Patients had a choice between either the traditional model (seeing a family care physician first, then following the chain of referrals) or direct access to physical therapy (seeing the physical therapist first).

This is an important issue, as the authors point out, because of the massive amounts of money spent and lost on spine related pain. The authors suggest that close to $85 billion dollars are spent yearly on spine related conditions with an additional $10 to $20 billion lost in productivity. Those are huge numbers and they have only gotten bigger. Aside from the huge monetary problems, neck and back pain effect a large part of the population, close to 25%. So it is important to understand how to best manage this group of people.

The results of the study were great for physical therapists.  First lets talk about the monetary benefits. The results showed that the group of patients that went directly to physical therapy saved over $1500 per patient on their cost of care compared to the group that chose to go the traditional route.  That equated to a total cost of savings of greater than $250,000 in the 171 patients that accessed physical therapy directly. This was due to reduced office visits to physicians, reduced imaging, reduced prescriptions, and reduced number of injections.  It should also be noted that the group that accessed physical therapy directly had fewer visits and less days in care, likely due to the value of early physical therapy care.

The second great result of this study was that the outcomes between the two groups were the same. There was a similar improvement in function and reduction in pain and disability between both groups.  That means there was no benefit of going through the traditional model.  Outcomes were just as good when care was initiated by physical therapy.

Lastly, and possibly the best part of the study showed that physical therapists are completely competent direct access providers.  When patients chose to see physical therapists first the research showed that there were no incidents of missed diagnosis or delays in care as a result of clinical decision making. Physical therapists are capable of finding red flags and determining patients that need to be referred out. This is significant as patient safety is often cited as a reason against direct access to physical therapy services.

Denninger T, Cook C, Chapman C, McHenry T, Thigpen C. The influence of patient choice of first provider on costs and outcomes: analysis from a physical therapy patient registry. Journal of Orthopaedic & Sports Physcal Therapy. 2018;48(2). 63-71.

 

 

Harmless ankle sprain?

Yen SC, Corkery M, Donohoe A, Grogan M, Wu YN. Feedback and feedforward control during walking in individuals with chronic ankle instability. J Orthop Sport Phys Ther. 2016. Vol 46 Issue 9, 775-783 DOI: 10.2519/jospt.2016.6403

How many of you have had an ankle sprain?  Maybe you’ve had more than one?  One reason for the chronic nature of ankle sprains may be related to altered feedback and feedforward mechanisms after the initial injury.

85% of ankle sprains are inversion injuries, meaning the injury occurred on the outside of the ankle with the foot rolled inwards.  Afterwards, it is possible for an individual to develop chronic ankle instability (CAI), which is defined as “repetitive bouts of lateral ankle instability resulting in numerous ankle sprains” (Yen et al.)

Why does this happen? The researchers of the study above believe that the feedback and feedforward mechanisms for motor control become altered, causing increased likelihood of individuals to sprain their ankle again.  This was shown in this study by monitoring the differences between individuals with and without chronic ankle sprains when an external weight (a small sandbag) was placed on top of the subject’s foot while walking.  Those with chronic ankle sprains showed different responses in ankle position during the adaptation (initial) and post adaptation (subsequent) periods after the weight was placed on the foot. The chronic ankle sprain group quickly reverted back to their normal walking pattern after the weight was placed on their foot, possibly making them more susceptible to another sprain.  The control group did not revert their walking pattern back to normal once the weight was placed on their foot, instead keeping their foot everted or turned out to accommodate the weight.  This suggests a change in the feedback control in the chronic ankle instability group.  Additionally after the weight was removed, the chronic ankle instability group did not maintain the altered positioning of the ankle to match the control group. This suggests altered feedforward control.

What contributes to feedback and feedforward motor control? Proprioception or the body’s awareness in space contributes to motor control.  Those with chronic ankle instability often have poor awareness of the position of their ankle and the motion occurring at their ankle. 

What does this mean for you? Individuals who have had one ankle sprain may have altered proprioception during normal activities and sport, making them more susceptible for a second sprain.

What can you do to prevent another sprain?  You can work with a physical therapist on improving your ankle proprioception through dynamic and static balance exercises, progressively challenging your ankle as your proprioception improves.

Iliotibial band syndrome (ITBS): regional interdependence at play.

This week’s post is for the gents, sorry ladies. That doesn’t necessarily mean that you can’t walk away with the take home message; regional interdependence is always at play. Regional interdependence is a fancy way of saying that one area of the body can have influence on the way another area moves and feels.

This week’s review is on the article listed below.

Noehren B, Schmitz A, Hempel R, Westlake C, Black W. Assessment of strength, flexibility, and running mechanics in men with iliotibial ban syndrome. Journal of Orthopaedic and Sports Physical Therapy. 44(3). 217-221.

This study was unique in that it was the first attempt at developing a “comprehensive injury profile,” as the authors put it, for male runners with iliotibial band syndrome (ITBS). ITBS is associated with pain on the outside portion of the knee, just above the knee joint. The pain is usually achy or burning in nature and typically grows in intensity the longer one does the offending activity, in this case running. Plenty of runners, both male and female, suffer from ITBS with some research putting the incidence as high as 14% among runners.  Regardless it has earned a reputation as one of the leading causes of lateral knee pain in runners.

The purpose of the study was to look at the similarities of the biomechanics, strength, and movement patterns between male runners with ITBS compared to pain free male runners. What the authors found was that the ITBS group of male runners had greater knee adduction and greater hip internal rotation angles during running as well as weaker hip external rotators compared to the pain free control group.  There is debate on the mechanisms that can cause these common characteristics but likely the cause or driving factor may be different for each runner.

There is plenty more that can be said in regards to regional interdependence and the influence of various joints and motor control on running mechanics and ITBS. The are studies out there that have shown a relationship between altered ankle/foot mechanics and ITBS. We could even say that lumbar spine and thoracic spine mechanics may have an influence on ITBS in runners. Regardless the take home message remains the same.  Different areas of the body can influence pain and performance in regions that are close or remote. So, the real culprit of your knee pain may not actually be your knee.

Manipulation: beneficial for low back pain

What is a manipulation?  A manipulation is a quick thrust (high acceleration, low amplitude thrust) applied to a specific joint in the body in order to increase the amount of motion at that joint.  The manipulation causes a neurophysiological response, helping to decrease local pain and muscle tone.

Who should receive manipulation? Individuals with a fixated or “stuck” joint.  A fixated joint is one that will not move in a certain direction and often leads to pain and dysfunction.  This fixated joint could be causing a problem locally or somewhere else along the kinetic chain. This individual must be cleared for all contraindications prior to manipulation.

How can this help me as a patient with back pain?  It has been shown that individuals with back pain can benefit greatly from manipulation immediately and several months after the intervention.  The results from the study below by Janette Morton indicate that patients who received manipulation in addition to an exercise program experienced less pain immediately and 3 months after treatment compared to the group that performed exercise only.  Not only did the group that received manipulation experience less back pain, they also demonstrated improved range of motion in their low back as well as improved ability to perform every day tasks.

Who can do this for me? Physical therapists are trained to perform these precise movements in a specific manner in order to produce the best benefit with little harm.  Some physical therapists are trained in more advanced methods of manipulation.  These therapists are considered manual therapists and should be certified.  The team members at GOfit are both certified manual physical therapists! 

Janette E. Morton (2013) Manipulation in the Treatment of Acute Low Back Pain, Journal of Manual & Manipulative Therapy, 7:4, 182-189, DOI: 10.1179/106698199790811546

How to treat the likely culprit of lateral hip pain; gluteal tendinopathy

In the last blog post, we discussed gluteal tendinopathy: why it happens, whom it affects, aggravating factors, and briefly how to treat it.  Today we will delve further into treatment strategies for gluteal tendinopathy as suggested by the authors: 

Grimaldi A, Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. J Orthop Sports Phys Ther. 2015;45(11):910-922. 

Ideas to reduce lateral hip pain:

1.     Reduce compression of the gluteus medius and minimus tendons; ie. avoid repetitively adducting the hip (bringing the hip close to the midline of the body) or maintaining it in this position. For example, avoid sitting with the legs crossed or lying on your side without a pillow between your legs. 

2.     Avoid hip stretches into hip adduction while the hip is flexed or extended. So lay off of your pigeon stretch or figure 4 stretch for the time being.

3.     Use dry needling or trigger point release techniques in lieu of stretches to address affected muscles

4.     Avoid aggravating activities for the time being such as excessive stair climbing or running hills during training.

Ideas to rehab: Exercise should be focused on slowly progressing tensile loads in non-aggravating positions.

1.     Start with sustained low intensity isometric contractions into hip abduction to activate the gluteus medius and minimus muscles for pain relief.  Resistance can be progressed as tolerance is improved.  This may be done on your back, standing, or side lying with a pillow between the legs and you can provide your own isometric resistance.

2.     Next, resisted exercises are employed for hypertrophy of the muscle and tendon remodeling.  This should be done 3 times per week and the workload should begin at a moderate level and progress if you are able to tolerate this well.  Weight-bearing exercise is key because it helps activate the gluteus medius better.  A good exercise would be side stepping with a resisted band tied around the legs.

3.     Physical therapists need to assess movement patterns and control of the pelvis during the aggravating task and retrain these motions.

4.     Physical therapists should assess the spine and knee for contributing factors and treat as needed.

Please call GoFit Physical Therapy to help treat your hip pain.  We are here to answer any questions you may have: (443)699-4771 info@gofit-pt.com

Trochanteric Bursitis? Probably not...

Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management. Grimaldi A, Mellor R, Hodges P, Bennell K, Wajswelner H, Vicenzino B. Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Med. 2015;45(8):1107-1119.

 

Today’s blog post highlights gluteal tendinopathy and it’s relationship to physical therapy.  Tendinopathy is defined as a disorder of a tendon, which is the tissue connecting the muscle to bone.  This post summarizes some key points directly from the article listed above.

Previously most lateral hip pain (pain on the outside portion of the hip) had been over diagnosed as trochanteric bursitis.  Now, it has been established that oftentimes lateral hip pain is not coming from the bursa, but instead from gluteus medius and minimus tendinopathy. These muscles are two of the three gluteal muscles and these two sit on the outer portion of the hip.  It is thought that the gluteal tendinopathy arises because of altered compression and tension to the tendons.  When the tendon is not provided with the correct amount of loading, whether it be too much or too little, the tendon begins to break down.  The gluteal muscles are then unable to function as they would normally, potentially leading to pain.

It is proposed that the positioning of the hip can lead to increased compression of the gluteal muscles.  If the hip is constantly in an adducted position (with the leg coming into a position closer to midline of the body), the gluteus medius and minimus tendons are continually compressed and placed on tension causing atrophy.  Additionally in this position, the gluteus medius and minimus muscles do not have a mechanical advantage to activate when needed, so other muscles take over.

Who typically suffers from this condition? Women > men, ages 40-80 years old

Aggravating factors: Crossing the legs when sitting, side-sleeping, walking, going up and down stairs, moving from sit to stand

How to treat it: Control the load placed on the gluteus medius and minimus tendons. Specifically avoid activities with high tensile and compressive loads, and work to modify movement patterns (ie. train the body to avoid adducted positioning of the hip). This can be done in physical therapy.  In fact, physical therapy has been shown to be more effective at improving this condition long term than corticosteroid injections.

Return to Sport after ACL repair - How many athletes are actually ready?

Young Athletes Cleared for Sports Participation After Anterior Cruciate Ligament Reconstruction: How Many Actually Meet Recommended Return-to-Sport Criterion Cutoffs? Toole, Ithurburn, Rauh, et al. Journal of Orthopeic & Sports Physical Therapy, 2017. 

This is an interesting article that highlights what we see often in sports; athletes returning too soon to their respective sport following an ACL tear. When athletes return to their sport too soon they are at a greater risk of a re-tear and are less likely to perform at their previous level. This study looked at how many young athletes actually met the recommended return to sport criteria when they were cleared to return by their surgeon and rehabilitation team. 

The authors had several tests that they used to determine return to sport readiness. These were quadriceps and hamstring strength at greater than or equally to 90% of the uninjured leg, single leg hop tests at greater than or equal to 90% of the uninvolved leg, and a self reported knee function scale. 

The outcomes are pretty staggering. Of the subjects in the study, only 13.9% of athletes that were cleared to return to sport by their surgeons and rehab team actually met the recommended criteria. The research also shows that those who returned to their sport without meeting the recommended criteria were less likely to maintain their level of participation.

So what does this mean? Unfortunately this means that a great majority of athletes are being cleared to return to their sport way earlier then they should be. This also means that most surgeons and physical therapists are likely not performing any reliable tests to determine if their patients met standards to return to sport. 

How GOfit can help: If you have had an ACL injury and you are still having pain and/or difficulty returning to the activity that you love, we have the ability to objectively evaluate your function and develop a treatment plan specifically for you.

The Future of the GOfit blog

The GOfit blog is heading in a new direction! 

Every week or so we will post an article review that is relevant to our practice and helpful to our clients.  

Here it goes!

Free Seminar at Athleta Annapolis Harbour Center

Come check out the GoFit therapists as they give a free seminar about trigger points and self trigger point release strategies this Sunday April 3rd, at 3pm!  Located inside Athleta at the Annapolis Harbour Center, 2510 Solomons Island Rd, Annapolis, MD 21401.

See you there!