Friday, February 8, 2019

Treating Back Pain: A Spine of the Times


by Jill Jonda, PT
You’re 34 years old with a 9-5 desk job, but you still regularly go to the gym and play a couple pick-up games of basketball a week. One day you wake up and have nagging, gnawing pain just to the right of your spine in the low back. You wait a couple days and it’s not getting any better: in fact it’s traveling into your right buttock. You think, “But I’m just 34 years old! What’s happening to me?”

Unfortunately, this is a pretty common internal dialogue. According to the NIH, about 8 of 10 adults will experience back pain at some point in their lives. Luckily, physical therapists are equally as used to diagnosing and treating back pain, and the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is a well-studied, noninvasive approach for diagnosing and treating pain of a mechanical origin (mechanical pain).  But what is “mechanical pain?” 

Mechanical pain is produced when a stress or force is placed on an anatomic structure and can be aggravated or relieved with greater or less deformation on those tissues. You can demonstrate this easily with just a finger: if you bend your index finger backward to the point of resistance, you’ll experience a strain. Initially, it’s uncomfortable but as you hold it there, pain – the brain’s way of saying to the body, “Stop doing that!” – starts to set in. Once you relieve the stretch on the finger, the pain should subside. The same is true of mechanical pain: many times it completely goes away once the mechanical stress is eliminated.


More often than not, back pain originates from mechanical stress. The spinal column consists of vertebrae and intervertebral discs, which sit between each vertebra. The disc is a very mobile structure consisting of 2 layers – an outer fibrotic layer and an inner gelatinous layer – kind of like a jelly donut. When we flex our spine (bending forward and rounding it), we put greater mechanical stress on the front portion of the disc. The disc becomes displaced backward to the area of least pressure. This generally isn’t a problem, but repeated force on the front portion of the disc can cause the back portion to weaken and start to bulge. The bulge can press on nerve and/or other tissues along the spine, causing pain in areas away from the spine, such as in the buttock or even into the leg (sciatica). Eventually, a bulged disc can lead to a herniation: the jelly center of the disc begins to squish out of the fried dough part, and that’s not ideal for donuts or spines.

As physical therapists, it’s our job to evaluate each of our patients and treat the not only the symptoms but also the cause of their pain, while also preventing similar pain to return in the future. I know my patients think I’m the “posture police,” but for those with pain originating from either the cervical or lumbar spine, I always recommend sitting with good lumbar support in a firm chair to promote a neutral spine. Sitting with slouched posture is bound to produce some sort of mechanical pain, either in the neck or low back, because of the stresses placed on the spine. Also, if sitting is bothersome, stand up and reverse the curvature in your spine by walking around for a few minutes.  Remember, you should see your PT or healthcare provider if your pain isn’t improving. We can help you stand (and sit) corrected!

Resources: 
Treat Your Own Back by Robin McKenzie

Friday, January 11, 2019

Thoracic Outlet Syndrome: A Pressing Matter

by Julia Glick, PT
 If you follow the NBA you have most likely heard that Markelle Fultz, the Philadelphia 76ers’ guard, has thoracic outlet syndrome (TOS). We most commonly hear of athletes from baseball developing this, but rarely basketball – in fact, basketball player Ben Uzoh wasn’t diagnosed until he retired, even though he had previously experienced TOS symptoms. It also took visits to more than 10 clinicians before Fultz was diagnosed with neurogenic TOS. But what does that mean and why was it so hard to diagnose? 
The thoracic outlet is the area between the first rib and collarbone, through which the majority of the nerves and arteries/veins that enter the arm pass. In TOS something in this space narrows and compromises either the nerves or vasculature (arteries/veins). A person with TOS usually has pain, temperature changes, or numbness/tingling at the neck, shoulder, arm, or hand.

Part of what makes it so difficult to diagnose is that there are no standard diagnostic criteria for TOS. There are also several presentations: neurogenic, vascular, and non-specific. With neurogenic TOS, the brachial plexus (nerves that pass through the thoracic outlet) are compressed and will usually cause pain and/or weakness. Features of vascular TOS tend to look more like coldness and numbness, as the arteries and veins are compressed. Regardless of presentation, these symptoms are often difficult to reproduce because they can change based on the position of the head, neck, shoulders and arms.

There are no specific causes for TOS, which often makes it even harder to diagnose. Past trauma or overuse, such as in overhead sports, could possibly increase the likelihood of developing TOS. Anatomically, someone is more at risk if they have an extra upper rib or have any type of tightness of fascia or muscle that decrease the amount of space of the thoracic outlet.

Presently, there are several treatment options for TOS: physical therapy, injection, and first rib removal surgery. In physical therapy, the goals are to restore full range of motion of the shoulder and neck, decrease any restrictions that are impinging on the nerves as they pass through the thoracic outlet, decreasing pain, and improving strength. Fultz has been attending physical therapy, and his agent has reported improvements: they hope he will return in the 2018-2019 season. Here’s hoping for a full recovery for Fultz! 

References: 
Baumann, M. (2018, December 4). What baseball can tell us about Markelle Fultz’s latest diagnosis. https://www.theringer.com/nba/2018/12/4/18126446/markelle-fultz-thoracic-outlet-syndrome 

Bell, S. (2018, December 10). What is thoracic outlet syndrome, and what does it mean for Markelle Fultz? http://www.espn.com/nba/story/_/id/25455660/what-thoracic-outlet-syndrome-does-mean-markelle-fultz

Povlsen B, Hansson T, Povlsen SD. Treatment for thoracic outlet syndrome. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD007218. DOI: 10.1002/14651858.CD007218.pub

Retrieved from: https://twitter.com/wojespn/status/1070074789409153024  

Retrieved from: https://twitter.com/ESPNNBA/status/1077668580706209792

Smith, J. (2018, December 4). Sixers announce Markelle Fultz out indefinitely, reveal plan for injury. https://sixerswire.usatoday.com/2018/12/04/sixers-markelle-fultz-out-indefinitely-shoulder-injury/ 

Wojnarowski, A. (2018, December 5). 76ers’ Markelle Fultz has thoracic outlet syndrome, to miss 3-6 weeks. http://www.espn.com/nba/story/_/id/25453907/markelle-fultz-philadelphia-76ers-expected-miss-3-6-weeks-shoulder-rehabilitation

Friday, December 7, 2018

The Home Stretch

by James Bansberg, PT
Some of the most common advice we receive when we complain about a newly discovered ache or pain is to just “stretch it out.” But what does that even mean? How long do I hold it? When should I do it? Do I just throw my leg up on a table for a couple of seconds and beg the pain to go away?

Most of what we know about stretching is either a myth or based heavily on outdated science. Worse yet, when speaking to various health professionals, their recommended duration for stretching can vary greatly, which can be confusing and sometimes discouraging for their clients. Luckily, a 2018 study by Thomas et. al has helped answer some of these questions. The study focused on most effective form of stretching for improving range of motion, as well ideal stretch duration and frequency.

Despite its vilification in recent media, the researchers found that static stretching was more effective than other forms of stretching for improving range of motion long term. This doesn’t mean that static stretching should be the only form of stretching utilized in a regular workout program, however. Other studies have discovered the benefits of other forms such as dynamic and ballistic stretching, especially prior to activity.

As for duration, there’s good news for the more impatient types: a 30-60 seconds hold was as beneficial as other, longer durations (60-120 seconds and over 120 seconds). Consistency, however, was key: the research showed stretching more than 5 times a week was more effective than 2-3. Interestingly, 7 days of stretching per week did not yield better results than 5 days, making the sweet spot between 5-7 days per week.

The final portion of the study looked at optimal time spent per week stretching to maximize mobility changes. Surprisingly, a minimum of 5 minutes was required for significant changes, with the ideal time being anywhere between 5-10 minutes.

Ultimately, some stretching is better than no stretching, and recent studies have found benefits to other forms of stretching as well as foam rolling. However, even stretching has a proper dosage, so it is important we utilize available evidence to guide our decision-making so that we are able to reap the greatest benefit. 

References: 
Thomas E., Bianco A., Paoli A., Palma A. The Relation between Stretching Typology and Stretching Duration: The Effects on Range of Motion. Int. J. Sports Med. 2018;39:243–254. doi: 10.1055/s-0044-101146.

Friday, November 9, 2018

Keeping Knees Healthy this Fall

by Constance Taras, PT
 As fall is now upon us, so too is the season of football. For a few unlucky players, however, the season is already over, with preseason injuries benching them for the rest of the season. In the NFL, an average of 23 ACL injuries occur before the first game of the season is even played, and it doesn’t stop there: according to the ACL Recovery Club, a total of 51 players tore their ACL during the 2017 season. The good news is that current evidence strongly supports the use of knee and ACL injury prevention programs to decrease the risk of injury and ensure a successful (and long) season for any athlete.

The knee joint is a hinge joint held together statically by 4 main ligaments: anterior cruciate
Side-by-side comparison of a normal knee (left) and a knee with a torn ACL (right)ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL). Although there are many, the main dynamic stabilizers of the knee consist of the quadriceps, hamstrings, calf, and gluteal muscles. The knee is meant to move in one plane of motion creating both flexion (knee bent) and extension (knee straight). It does, however, allow our bodies to move laterally, pivot, and change directions quickly when healthy. If the knee demonstrates decreased strength, muscle imbalance, range of motion, or flexibility in the surrounding tissues, it can be predisposed to injury.

To help prevent injury, the literature cites a combination of dynamic stretching, running drills, strength training, plyometric drills, and core exercises that should be included in knee injury prevention programs. These should be completed for at least 20 minutes several times a week, starting in the preseason and carrying through the regular season. Examples of each are outlined below.

Dynamic Stretching 
High knees, butt kicks, font/side leg swings, Frankenstein walk

Running Drills 
Forward running, backward running, zig zag cone drills, bounding

Strength Training
Double- and single-leg squats, banded hip strengthening, Nordic hamstring curls

Plyometric Drills 
Skater jumps, double leg and single leg hops, box jumps

Core Exercises
Front planks, side planks, bridges

Make sure to tailor your program to be sport-specific and elicit the help of your local physical therapist for ideas on your personalized knee injury prevention program!

Sources Cited:
“Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention” (J Orthop Sports Phys Ther. 2018;48(9):A1–A42.

JOSPT Perspective for Patients Knee Injury Prevention: Exercises to Kepp You From Getting Sidelined” published in Journal of Orthopaedic & Sports Physical Therapy, 2018 Volume:48 Issue:9 Pages:734–734 DOI:10.2519/jospt.2018.0509

Friday, October 12, 2018

Direct Access for Physical Therapy in Illinois!

by Lauren Sweeney, Office Manager
August 17 was a day like any other in our office: we treated patients, we answered billing questions, we scheduled future appointments for care. But it was unlike any other day in one very important regard: we no longer had to ask patients, “Do you have a prescription from your doctor?”

Up until last month, Illinois state law required patients to have a doctor’s prescription prior to seeking treatment from a licensed physical therapist. On August 16, however, Governor Bruce Rauner signed into law a bill that allows patients in the state of Illinois to have direct access to physical therapy treatment. Patients seeking physical therapy may now simply book an appointment to do so, no differently than they would with their GP or dentist.

This is hardly a revolutionary idea, either. Illinois was one of the last states in the nation to adopt the bill, which is expected to reduce the need for unnecessary X-rays, MRIs, and opioid prescriptions. According to a recent BlueCross BlueShield study, direct access to physical therapy led to a 31% reduction in total health care costs and a 90% reduction in opioid use.

Research also reveals that patients who visited a physical therapist directly for outpatient care had fewer visits, leading to lower overall costs. A study published by the Journal of Orthopedic and Sports Physical Therapy discovered that patients who decide to choose physical therapy as their first treatment option for spine management saved an average of $1543 in their overall care as compared to patients who chose the traditional medical referral route. Both groups showed similar clinical improvement in their symptoms. 

That said, the law does come with stipulations: a physical therapist must refer a patient to a health care professional if the patient does not demonstrate measurable or functional improvement after 10 visits or 15 business days, whichever occurs first. Additionally, this law does not affect Medicare patients, who are still required to have a prescription for physical therapy prior to treatment per federal law. Most patients, however, now have the ability to seek treatment that is safe, effective, non-addictive, and non-invasive for many painful conditions.

Our physical therapy community is confident that with fewer barriers, the patient can choose physical therapy as a first treatment option, leading to a speedy, safe and less expensive recovery.

Resources:
https://www.jospt.org/doi/abs/10.2519/jospt.2018.7423

Friday, September 21, 2018

Improving Fitness with a Good Night's Sleep

by Chase Irons, Personal Trainer
This month, we've invited LSF personal trainer Chase Irons to be our guest blogger.

In my 10 years of personal training I’ve heard all sorts of bizarre and unusual questions and comments about health and fitness. A question that I get far too often, however, is something along the lines of, "How little sleep can I get by with while still being able to function optimally?" It isn't a question limited to personal training, either: at one point or another, all of us have likely wished we didn’t have to sleep so we'd have more time in the day to get things done. More than that, there are even all kinds of products on the market that claim to be able to help us keep going longer on less sleep. 

Luckily, scientific research on sleep and its effects on the body are plentiful. In a 2010 study, researchers sought to determine whether a combination of sleep deprivation and a moderate caloric deficit would affect results in body composition. For 14 days 3 women and 7 men were instructed to stay in bed for either 8.5 hours or 5.5 hours per night, and their meals were standardized at about 1,450 calories per day. Three months later, the study was repeated for another 14 days with the same participants.

At the end of the study the researchers found that both groups had a nearly the same weight loss of around 6.6 pounds. However, the 8.5 hour group had lost equal amounts of muscle mass and fat mass, while 80% of the sleep-deprived group's loss was lean mass while only 20% was body fat. That means that with all other factors held the same, only a fifth of the sleep-deprived group's weight loss was actually from body fat.

So what exactly is going on in the body to cause this phenomenon? In sleep-deprived individuals there are a few hormones that get knocked out of balance: they produce less leptin, more ghrelin and more cortisol. Decreased production of leptin can make the stomach feel empty. Increased ghrelin production triggers the body's tendency to store fat, reduce the amount of calories it burns, and stimulate hunger. Cortisol is a stress hormone frequently associated with fat gain and muscle wasting, and it also makes us crave sugary and fatty foods. To successfully lose fat we need to optimize leptin, ghrelin and cortisol, but sleep deprivation will make that nearly impossible.

Even if we stick to our diets and hit the gym, sleep deprivation makes it so that the calories we burn come from more from stored energy and less from stored body fat. Because of the muscle-wasting cortisol and the increased hunger because of the lowered leptin and raised ghrelin, it's going to take that much longer to see a positive change in our bodies.

So make it easy on yourself! Get the sleep your body needs so that you aren't working against your goals.

Additional Resources:
Insuffient sleep undermines dietary efforts to reduce adiposity, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951287/

Impact of Five Nights of Sleep Restriction on Glucose Metabolism, Leptin and Testosterone in Young Adult Men
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0041218

Influence of partial sleep deprivation on energy balance and insulin sensitivity in healthy women.

Sleep loss results in an elevation of cortisol levels the next evening.

Sleep restriction for 1 week reduces insulin sensitivity in healthy men.

Monday, July 23, 2018

Postural Restoration

by Stephanie Korso, PT
Although the human body may look symmetrical to the naked eye, the right and left sides of our body are actually asymmetrical. For example, we have a heart on the left side of our body and a liver on the right side. Our right hemi-diaphragm is larger and more domed than the one on our left, putting it in a better position to function. The left side of our brain controls the right side of our body and vice versa. Since the left side of the brain is primarily responsible for motor planning, most people are right side dominant, regardless of hand dominance. These asymmetries are balanced through integration of system imbalances. If the asymmetries are not balanced, then postural patterns can emerge. These postural patterns may then contribute to weakness, instability, and various pain syndromes. 

So…what’s a postural pattern? This is when our body gets stuck in a certain position. But we’re not just talking about bony alignment and how we look when we stand up tall or sit at our desks: we are referring to our body at any given moment in time. Posture involves coordination of multiple systems, not just the musculoskeletal system, and is constantly changing. Ideal posture involves a homeostatic state when nothing is working harder than anything else and where our overall body system can shut down. In this state of neutrality, we efficiently balance our various asymmetries. 

The Postural Restoration Institute has developed three main stages to restore optimal posture:

  1. Reposition – this involves muscle inhibition
  2. Retrain – this involves muscle facilitation
  3. Restore – this involves restoring reciprocal and alternating function
Diaphragmatic breathing is often a key component in achieving a neutral posture. When learning to optimally use your diaphragm, fully exhale, ridding yourself of all the air in your lungs. Your exhale should last longer than your inhale. Then, attempt inhaling into your right chest wall and into your back without allowing the bottom of your rib cage to flare open. This full exhale allows your diaphragm to dome into its resting position so that it can efficiently work upon inhalation. 

Think you got it? Challenge your diaphragm by blowing up a balloon! 
Nail it? Then try a common repositioning technique developed by the Postural Restoration Institute! Click on the following video for instruction.



References:

Postural Restoration Institute. www.posturalrestoration.com