Nervous About Flexibility

by Jill Jonda, PT

Do you stretch frequently and still seem to feel tight? Are you concerned you can’t touch your toes or can’t get your pecs to loosen up? When this happens, we usually talk about flexibility - the amount of mobility around a joint or multiple joints – but muscle tension isn’t always the cause of the sensation of “tightness:” in fact, neural tissue (tissue which makes up the nervous system) tension can provide a very similar sensation. Let’s take a look at how neurodynamics can affect the body.

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).

A diagram of the nervous system. 
It is impossible to move any joint without also moving a nerve

Here are some actions and activities that can result in abnormal neurodynamics:

• 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

1. Lying on your back, raise one leg up toward the ceiling.
2. 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.
3. 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

1. Pull your shoulder blades down and back.
2. Raise one arm out to the side with the elbow bent at a right angle. 
3. 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. 
4. 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!

References:

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.

Direct Access = Direct Improvement

by Sally Fansler, PT

Did you know that you can schedule an appointment with a physical therapist...without the need for a referral from your doctor?

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.

Resources:

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.

Ice versus Heat: A Hot (or Cold) Topic

by Constance Taras, PT

One of the questions we most commonly field when patients have first sustained an injury is “Should I ice it, or would heat be better?” Both heat and ice are conservative, beneficial modalities, but to better understand the benefits of either, let’s first look at the physiological effects of each:
 

Typically, the more traditional approach is to apply ice to musculoskeletal injuries, but the type of musculoskeletal injury is important. For acute injuries that are swollen, warm, and painful (such as ankle sprains), ice can temporarily numb the area and decrease pain signals from the nerves, therefore decreasing pain. Ice also constricts the surrounding blood vessels so that less fluid and fewer cells arrive at the injured area. While this could theoretically slow down healing to the area as it does restrict the flow of healing mediator cells (leukocytes) to the area, it also means that less swelling is present. Less pressure on all the surrounding structures could mean less pain and improved range of motion.

However, what if we are dealing with a more chronic injury? Chronic injuries often suffer from decreased blood flow to the injured area, and as a result have a harder time healing. Application of heat, therefore, is the more beneficial modality, as it increases the rate that blood and repairing cells reach the injured site to improve the overall healing process. We also tend to recommend heat over ice in the case of a muscle in spasm or a tight muscle: the improved tissue extensibility provided by heat helps to relax shortened and tensed muscles in order to decrease spam and ultimately pain. Heat also allows improved stretching and increased range of motion, whereas ice could cause the muscle to tighten further, decreasing range of motion at a joint.

But an equally important factor to consider is how heat or ice makes you feel! If ice makes your pain worse or vice versa then it may not be the best option for you, even if clinically it makes more sense (unless it is contraindicated by other health conditions, such as diabetes, Raynaud’s disease or hypertension). If you are unsure what is the best modality for you and your specific injury, reach out to a Lakeshore physical therapist to help you build a customized plan!

References:

Malanga et. al. Mechanisms and efficacy of heat and cold therapies for musculoskelatal injury. Postgrad Med 2015; Early Online 1-9.

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

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

Tape on Me: Kinesiology Tape and Physical Therapy

by Jill McCormick, PT

If you’ve watched sporting events recently, you may have noticed professional athletes sporting cool-looking tape on their shoulders or knees. It’s not some obscure form of body modification – it’s kinesiology tape. Believe it or not, kinesiology tape has become so mainstream lately that you may have even seen someone standing next to you in line at the grocery store with this unique-looking application.

Unlike the old-school athletic tape, kinesiology tape has both stretch and memory. This allows for unlimited movement of the joint or limb while keeping it in place. It is designed to stay on for days at a time, even in the shower or pool. While you may remember first seeing it on the US Women’s Volleyball player Kerri Walsh, t’s not just for athletes or sports injuries. This tape is used in physical therapy to treat all kinds of pain and injuries, including shoulder tendonitis, hamstring strains, low back pain and running injuries.

Upon application, it lifts the skin, allowing for increased circulation and reducing inflammation. The recoil effect helps support muscles, ligaments, fascia and even bones. Furthermore, the sensory effect of the tape on the skin can reduce pain signals to the brain, bring the brain’s attention to muscles that are atrophied or underutilized, and calm a muscle that is overactive or in spasm. Seemingly like magic, patients often see an improvement in range of motion and decreased pain immediately!

In summary, kinesiology tape can be used on sports and non-sports injuries alike and it often helps reduce pain and increase range of motion on the spot. While it isn’t magic, it certainly can seem like it and it can be a very valuable and effective adjunct to your physical therapy program. If you are unsure about whether kinesiology taping is a good option for treating the injury you have, Lakeshore Physical Therapy has therapists with expertise in the taping technique and can provide recommendations to help you to heal properly.

Running Safely as We Age

by Meredith Franczyk, PT

Running is one of the most popular types of exercise around the world. Since it requires very little equipment and can be done just about anywhere, people of all ages have found themselves lacing up their shoes and going for a jog. Running's many physical benefits - increases in aerobic capacity and skeletal mass, improvements in balance and cognitive function, and decreased chance of heart problems, to name a few - also make it an attractive option.

As our bodies age, however, we experience changes that can affect our ability to run. From the age of 40 onward, adults experience sarcopenia, or degenerative loss of muscle, losing between 5-8% of their muscle per decade. In addition, increased body fat percentage, decline in muscle thickness, decreased vertebral height, and joint stiffness can make maintaining any kind of workout a challenge. A more specific challenge that runners face is a decrease in type II muscle fibers with age. Also known as fast-twitch fibers, these fibers help us to move quickly in short bursts, and the decrease in these fibers diminishes our ability to sprint.

Biomechanics and stride pattern also tend to change as a result of our aging bodies. Achilles tendinopathy and calf strains have the highest incidence rates in older adults due to decrease in big toe mobility and altered biomechanics, so it is important to adapt a running program to one's body to avoid injury. To decrease these risks, older adults should do the following:

• Cross-train more (bike, swim, etc.)
• Run slower (to control altered biomechanics)
• Change shoes more often (to help control stability)
• Improve flexibility
• Maintain range of motion
• Improve quadriceps, calf and hamstring strength

When performed properly, running can absolutely be part of a healthy lifestyle for an older adult. As long as we make the correct adaptations to maintain healthy running form, we can hit the track with confidence even into our later years.

References:

Conoboy, P. and R. Dyson. Effect of aging on the stride pattern of veteran marathon runners. British Journal of Sports Medicine. 40:601, 2006.

Cavagna, G.A., M.A. Legramandi, and L.A. Peyre-Tartaruga. Old men running: mechanical work and elastic bounce. Proc BiolSci. 275:411-418, 2008.

Chakravarty, E., H. Hubert, V. Lingala, E. Zatarain, and J. Fries. Long Distance Running and Knee Osteoarthrits: A Prospective Study. Am J Prev Med. 35(2):133-138, 2008.

TLC for the ACL

by Amy Goldstein, PT

No matter what sport you follow, there's a good chance you've heard of athletes suffering from an ACL tear. The anterior cruciate ligament (ACL) is a knee ligament that attaches the front top portion of the shin bone (tibia) to the back bottom portion of the thigh bone (femur). One of four ligaments in the knee, the ACL prevents the tibia from sliding forward and medially from the femur. ACL tears are one of the most common knee injuries, with over 100,000 occurring annually in the US.

While it may not be surprising that contact sports such as football and soccer are a common source of ACL injuries, it is possible to tear the ACL without any direct contact at all. Changing direction rapidly, stopping suddenly, landing from a jump incorrectly or landing with a hyperextended knee can also cause injury to the ACL. Females are 3.5 times more likely to tear their ACL than males, and ACL injuries are most prevalent among 15-19 year-olds.

So what can be done to prevent injury? Evidence has suggested that strengthening the muscles of the leg and core, as well as working on neuromuscular control and balance of the leg, can help prevent a tear of the ACL. Strengthening the hamstrings, gluteal muscles and external hip rotators can help to prevent the inward collapse that occurs during an ACL injury, while working on neuromuscular control and balance helps to improve the timing of the muscles in the leg. Athletes can also work on jumping mechanics to improve landing form and to prevent excess strain on the ACL. Typically, a strengthening program of 3 times a week for at least 6 weeks is required to notice a change.

Amy can be reached at amy@lakeshore-pt.com.