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.