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.

Organization: The Engine of our Practice

by Sally Fansler, PT

As we slowly approach warmer weather in Chicago, many of us are driven toward the traditional "spring cleaning." Here, however, we work to keep things tidy all year round. In my experience, being organized is every bit as important to our employees as being patient, knowledgeable, positive, compassionate, caring and accountable. It is frankly impossible to overstate the value of organization, especially if you are a busy clinician or a physical therapy practice office manager. 

Now, I am a pen-and-paper person at the core so my Office Manager, Lauren, has had to gently nudge me toward the simplicity of digital organization over the years. It has felt like such a success to streamline and digitize many of the day-to-day processes in our physical therapy clinics. Our online patient calendars are synced between both clinics for ease of scheduling and access. Each employee’s schedule is color-coded and clear. Our Google Drive folders are available at a finger’s tap to share research articles, doctor recommendations, or a running program with our patients. And since we already operate within the Google ecosystem, the Google Keep app is the best and appeals to my love of the traditional sticky notes! We create notes and lists, reminders, and check off completed tasks in vivid color. 

As with many medical offices, all physical patient care charts are gone and replaced by electronic medical records, creating efficient, secure, and compliant documentation that is accessible from anywhere. Innovation and technology changes can make anyone apprehensive, especially for those of us who have become accustomed to doing work in a particular way. However, the new technology benefits are making our daily processes smoother and helping maintain our office productivity as well. 

It is always a work in progress, but once you start to build a trusted organizational system that you use regularly, you can turn a hectic day to an efficient and calm one. It feels great to leave the clinic each day with a clean inbox and a clutter-free desk. With solid systems in place, we can relax and focus on what we do best – patient care.

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

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

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.

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

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