Wednesday, April 1, 2020
Wednesday, February 26, 2020
|by Constance Taras Karwandyar, PT|
When we talk about injuries, we often hear of primary care physicians and orthopedic specialists performing imaging in order to assist patients in treating musculoskeletal pain. Imaging can include, but is not limited to, MRIs, X-rays, or CT scans. Although these tests may help feed our curiosity to “look under the hood,” they may not always be the best place to start.
In a world today looking to decrease healthcare costs, imaging can be a large line item: a study done by Parker et al estimates that musculoskeletal imaging costs are projected to reach $3.6 billion dollars in 2020. While the cost might be worth the peace of mind brought by the imaging results, studies have found that imaging does not actually ease fear and worry about the cause of pain. Once being labeled with “degenerative disc disease” or “knee arthritis,” patients tend to define themselves in terms of these issues. Additionally, abnormal findings are not always directly related to the pain a person is feeling. A patient with severe knee pain may have an MRI that reveals no abnormalities, or a patient with acute but mild back pain will have an MRI showing severe degenerative changes of their discs and two herniated discs.
In particular, non-coordinated findings can be very frustrating for a patient and leave them feeling confused as to the next best step to take. To make matters even more confusing, the literature indicates that positive imaging findings are common and may not be the best guide for future care decisions. A 2020 study performed by Horga et al on 115 asymptomatic (without any pain) adults revealed that 97% showed abnormalities in their knee MRIs. These findings included meniscal tears (30%), cartilage abnormalities of the patellofemoral joint (57%), and moderate tendon lesions (21%). Similar findings are present in low back pain: Brinjikhi et al performed a systematic review gathering information about positive low back imaging findings on asymptomatic adults. Data gathered on over 3,000 people revealed that by age 20, there was a 27% prevalence of degenerative disc findings and by age 50, that number rose to 80%. According to their findings, it is more common to have degenerative changes beginning at age 30 than to not - and this was in an entire population of people without back pain!
|Prevalence of abnormal MRI finding in the low back for 3,110 asymptomatic individuals (Brinkikji et al).|
It is important to understand that imaging has its place in healthcare and can be very helpful and necessary in certain situations. The American College of Physicians and the American Pain Society published a joint clinic practice guideline regarding the diagnosis and management of low back pain in 2007. According to this guideline, clinicians are recommended to only perform diagnostic imaging if: severe or progressive neurologic deficits are present, serious underlying pathology is suspected or the patient is a potential candidate for surgery or epidural steroid injections. The guidelines also suggest that clinicians should not perform imaging for patients with nonspecific low back pain.
In summary, imaging can be helpful to rule out serious pathology, be diagnostic when surgical intervention is indicated, or guide a physician when epidural steroid injections are indicated. Routine use of imaging, however may be causing more fear, more confusion, and more cost than necessary.
If you are confused about your recent imaging findings or have pain but are unsure if you need imaging in the first place, stop by Lakeshore Physical Therapy to discuss it with one of our experienced therapists. We offer complimentary injury screens to decide what is the right next step for you. We want you to feel confident in your healthcare decisions and clear on your road to recovery!
Flynn, T.W., Smith, B., Chou, R. Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder That Unnecessary Imaging May Do as Much Harm as Good. Journal of Orthopedic and Sports Medicine. Nov 2011, 41 (11) 838 – 846.
Horga, L.M., Hirschmann, A.C., Henckel, J. et al. Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal Radiol (2020).
Lewis, J.S., Cook, C.E, Hoffman, T.C., O’Sullivan, P., The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice. Journal of Orthopedic and Sports Medicine. Jan 2020, 50 (1) 1-4.
Thursday, January 16, 2020
|by Jill Jonda, PT|
According to Dutton, neurodynamics is “the study of the mechanics and physiology of the nervous system.” The nervous system is comprised of the central system (brain and spinal cord) and peripheral system (spinal nerves and cranial nerves). Peripheral nerves, the nerves that trigger parts of the body to work, can get “stuck” and develop dysfunction along their pathways. As these nerves exit the spinal cord and travel to their target tissue, they must be able to adapt to movement in relationship to their surrounding tissue, which would allow for normal neurodynamics.1 If tissue is compromised anywhere along a nerve, such as injury creating adhesions or inflammation, it can produce more stretch on tissue, yielding potential nerve related symptoms (tightness, numbness, tingling, pain, or even muscle spasm).
Here are some actions and activities that can result in abnormal neurodynamics:
|A diagram of the nervous system. |
It is impossible to move any joint without also moving a nerve
- Sustained postures. Holding a position for prolonged periods of time can cause adaptive shortening of connective tissue around nerve. This could include sitting at your desk at work for 6-8hours with rounded shoulders, a forward head, and rounded low back.
- Direct trauma, such as orthopedic injuries, yielding either primary nerve injury or secondary due to damage of surrounding tissues. For example, if a golfer takes a stroke that hits more of the ground instead of the ball, it might jar the arm and injure muscle around the elbow. The muscle may become inflamed and compress the nerves, which pass through and around the elbow.
- Extremes in motion, which put excessive traction on the nerve. An example would be a “stinger,” which places excessive traction on the brachial plexus (a network of nerves which exit the neck).
- Electrical injury.
- Compression, such as a disc bulge in the lumbar spine that places compression on nerve as it exits the spine.
In the clinic, we perform different tests and measures to determine whether or not neural tissue is tight or if it’s just muscle tension. Here are 2 tests we use to rule in nerve tension.
For leg symptoms: Straight Leg Raise
- Lying on your back, raise one leg up toward the ceiling.
- Pull your toes back and point the opposite direction, pumping your ankle. If this produces tightness in the back of the thigh, it’s a positive test for neural tension, as pulling the toes back puts the nerve on a stretch.
- Another way to “sensitize” nerve tissue would be to bend the neck, drawing the chin toward the chest with the leg raised in a neutral position. Pain in the back of the leg produced upon neck flexion would be a positive test for abnormal neurodynamics.
For arm symptoms: Upper Limb Tension Test
- Pull your shoulder blades down and back.
- Raise one arm out to the side with the elbow bent at a right angle.
- Next, rotate the palm up then begin straightening the elbow, wrist and fingers. The combination of these joint movements places the nerves that exit the spine at the neck on stretch.
- Tilt your head away from the arm being tested to stretch the nerves even more. Tilt the opposite way to put the nerves on “slack.” Slack is placed on the tissue by bending the wrist/fingers. Pain in the arm with neck or wrist motion would indicate the presence of nerve tension.
If you try either of these tests and feel nerve tension after the first few steps, no need to sound alarms quite yet! It’s normal to experience a degree of nerve tension: you’re putting the nerves that pass from your spinal cord down the leg or arm in their most stretched position. This sensation can sometimes be confused with muscle tightness or trigger point tenderness. If you’re experiencing tightness in your limbs and it’s accompanied by other nerve symptoms, specific muscle stretches may not alleviate your discomfort.
If you have nerve symptoms that aren’t going away, consider making an appointment with your physical therapist to help improve your neurodynamics!
1. Dutton, Mark. “Neurodynamic Mobility and Mobilizations: Chapter 11.” Dutton's Orthopedic Examination, Evaluation, and Intervention, edited by Joe Morita and and Brian Kearns 3rd ed., McGraw-Hill, 2012, p. 406.
2. Dutton, Mark. “Improving Range of Motion: Chapter 13.” Dutton's Orthopedic Examination, Evaluation, and Intervention, edited by Joe Morita and and Brian Kearns 3rd ed., McGraw-Hill, 2012, p. 444.
Friday, December 20, 2019
|by Sally Fansler, PT|
As discussed in one of our previous blogs, Illinois is now a direct access state, which allows patients to attend physical therapy without a referral from a doctor. This access allows for greater autonomy for both patients and therapists in our state. Since this legislation is only a little over a year old, however, word travels slowly, and many of our patients are not aware of the choices they have when seeking medical care.
Prior to this advancement in 2018, restrictions on direct access proved to delay the healing process for patients and increase medical expenses by requiring a separate consultation and often additional testing. Patients would often be delayed weeks in beginning their treatment due to the need to schedule an appointment with their primary care physician, and patients who did not have a primary care physician would have to navigate the process of finding someone and becoming a new patient. By making physical therapy more accessible to patients, direct access allows physical therapists to treat patients immediately, leading to more expedient improvement.
Furthermore, multiple research studies have agreed on the benefits of direct access. A study from Georgetown and Johns Hopkins University found that the total paid averaged $2236 for “physician referral” episodes of physical therapy as compared to $1004 for “direct access” episodes of physical therapy. Additionally, the physician referral episodes were 65% longer in duration than the direct access episodes. A similar study from the Journal of Health Services Research analyzed patients with low back pain. Those who saw a physical therapist at the first point of care had an 89% lower probability of having an opioid prescription and a 28% lower probability of having any advanced imaging services. The pattern is clear - lower cost, quicker improvement, and positive outcomes.
Direct access for physical therapy in Illinois has been a long time in the making, and has only been made possible through the expense, time, energy and effort on the part of physical therapists and physical therapy advocates throughout the U.S.to finally allow consumers (like you!) prompt access to physical therapy services. We are confident that, with fewer barriers, our patients will choose P.T. first!
Call to Action:
Spread the word!
At Lakeshore Physical Therapy, we are honored when our patients exercise their right to direct access care from our experienced physical therapists that are fully invested in their progress.
Denniger T. et al. (2017). The Influence of Patient Choice of First Provider on Costs and Outcomes: Analysis From a Physical Therapy Patient Registry. Journal of Orthopaedic & Sports Physical Therapy, 2017, Volume:48 Issue:2 Pages:63-71 doi: 10.2519/jospt.2018.7423
Mitchell J. (1997). A Comparison of Resource Use and Cost in Direct Access Versus Physician Referral Episodes of Physical Therapy. Physical Therapy, Volume 77, Issue 1, 1 January 1997, Pages 10–18, doi.org/10.1093/pti/77.1.10
Frogner B. (2018). Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Health Services Research, 2018 Dec;53(6):4629-4646. doi: 10.1111/1475-6773.12984. Epub 2018 May 23.
Tuesday, October 8, 2019
Tuesday, August 27, 2019
|by Sally Fansler, PT|
Move over, tennis and golf – here comes pickleball! A new favorite pastime among Baby Boomers, this sport combines elements of badminton, tennis and ping-pong. In recent years, it has become popular with older adults because of the smaller court, lower net, and slower ball speed. The rules are fairly straightforward and easy to learn, so pickleball easily becomes a fun social activity. It can be played indoors or out, in singles or doubles.
Over the past decade, however, the pickleball craze is taking hold at all age levels. Teenagers often play it in their physical education classes, and it is showing up as an intramural sport on college campuses. According to the USA Pickleball Association (USAPA), the sport has seen a 650% increase in numbers over the past six years. On-site pickleball courts are now being built not only at many retirement communities, but also as part of community park districts. The equipment – wooden paddles and plastic, whiffle-type balls – is also affordable, making it accessible to be enjoyed by a wide range of people.
Here is the pickleball rule overview:
- The serve must be underhand and below the waist—and it must be made at least one foot behind the baseline, struck diagonally crosscourt. Only one serve attempt is allowed.
- Only the team serving the ball is able to score points, which take place when the opposite side fails to return the ball or commits other faults, such as hitting the ball out of bounds.
- When the ball is served, the receiving team must let it bounce before returning, and then the serving team must let it bounce before returning, thus two bounces.
- After the ball has bounced once in each team’s court, both teams may either volley the ball (hit the ball before it bounces) or play it off a bounce (ground stroke).
- The two-bounce rule eliminates the serve and volley advantage and extends rallies.
- With doubles, both players on the serving team have the opportunity to serve and score points until they commit a fault
- Games normally go to 11 points, with the leading team needing to be 2 points ahead to win
Lakeshore Sport & Fitness in Chicago is planning an intro to pickleball class on Sundays in the fall of 2019. Please contact LPRacquet@LakeshoreSF.com for more information. The Chicago Park District is also growing their program and information on additional places to play can be found here: https://www.chicagoparkdistrict.com/taxonomy/term/2210
Tuesday, July 23, 2019
|by Constance Taras, PT|
|Picture A: Herniated disc Picture B: Piriformis spasm|
For nerves to stay happy, they have to have enough of three main elements: movement, blood flow, and space. Addressing these factors help guide our treatment of nerve pain.
- Increasing Movement: Nerves don’t really stretch, but we can perform glides to slide them along their track and keep them from adhering to surrounding tissues.
- Increasing Blood Flow: Heat increases blood flow and is typically a good line of treatment for nerve injuries to promote healing.
- Increasing Space: We want to ensure there aren’t any structures compressing the nerve such as a bulging disc, a muscle in spasm, or narrowed vertebral foramen (bony space where the nerve exits the spinal column). A variety of manual techniques and self-stretches and exercises may be prescribed to improve the space around the nerve.
In more chronic or extreme cases, irritation or compression of a nerve can cause weakness to the affected muscle as nerves also innervate (or give “electrical power” to) muscles. The muscles most commonly affected by sciatic nerve injury are the hamstrings (which bend the knee), anterior tibialis (which can result in foot drop), calf, and other ankle/foot muscles. Weakness in any of these groups can result in decreased balance, difficulty with stairs and prolonged walking, and feeling like your leg is going to give out on you.
Understanding where your pain is coming from is the first step to recovery – then having it properly treated by a physical therapist is the next best step. At Lakeshore Physical Therapy we treat these type of injuries and pathologies all of the time. We feel confident that we can identify the source of your sciatica and quickly get you pain-free!
Check out our recent Instagram post @lakeshorephysicaltherapy to see videos of some suggested exercises to treat your nerve pain!