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My Shoulder is Frozen-What?

by | May 10, 2021 | Health Tips

By Joseph Holmes, PT, DPT, CDN, FNCP

Adhesive capsulitis, more commonly known as frozen shoulder, is a debilitating and rapidly developing impairment of the shoulder. Adhesive capsulitis is defined as having a painful shoulder with pain present vaguely throughout the whole shoulder, with subsequent and rapidly progressing stiffness limiting range of motion in all directions (1). The typical loss of motion presents in the following manner, external rotation is most limited then abduction, and followed by shoulder internal rotation (2). The following images defines external rotation, abduction, and internal rotation:

basic shoulder movements

Image courtesy of sequenewiz.com

Primary adhesive capsulitis affects 2%-5.3% of the general population (3,4). Secondary adhesive capsulitis affects 4.3%-38% of the population (3,4,5). Secondary adhesive capsulitis is that which derives from a known injury or an underlying systemic disease such as diabetes mellitus (type I or type II) or thyroid disease). A study by Milgrom et al discovered that of people with adhesive capsulitis, approximately 30% have diabetes, and around 21% of women had hypothyroidism (6). This is a disease and subsequent impairment which has a debilitating effect on a large portion of the population, and as seen above affects those with diabetes and thyroid disease at a higher rate than those without diabetes or thyroid disease. Adhesive capsulitis has also been found to be most common in people 40-65 years old, women>men, and those who have had adhesive capsulitis previously in the opposite shoulder, as well as those with Dupuytren’s disease (6,3,7).

Categories of Adhesive Capsulitis (1)

  1. Primary: Of unknown cause or origin
  2. Secondary: Of known cause or origin, especially injury or systemic disease
    1. Systemic: Diabetes or other metabolic conditions
    2. Extrinsic: Stroke, Heart Attack, Parkinson’s Disease, etc.
    3. Intrinsic: Rotator cuff tear, labral tear, biceps tendinopathy, etc.

Stages of Adhesive Capsulitis:

Adhesive capsulitis occurs in 4 progressive stages, which typically runs through a time period of approximately 18-24 months total. Adhesive capsulitis, unlike most other musculoskeletal conditions, dissolves of its own accord after this time frame and people typically return to pre-disease levels of pain and function, however residual stiffness and muscle tightness can be present.  The stages of frozen shoulder are as follows (8,9,11):

  1. Onset (0-3 months from onset):
    1. Sharp pain at end ranges of motion
    2. Achy pain at rest
    3. Sleep disturbance
    4. Minimal to no ROM restrictions
  2. Freezing/Painful (3 months-9 months since onset)
    1. Gradual loss of overall shoulder motion due to pain
  3. Frozen (9 months-15 months since onset)
    1. Severe pain
    2. Extreme loss of shoulder motion all directions
  4. Thawing (15-24 months since onset)
    1. Pain begins to resolve
    2. Significant stiffness still persists

What Do I Do if My Shoulder Freezes?

The best recommendations based off the 2013 Clinical Practice Guideline for Adhesive Capsulitis recommends a combination of the following treatment interventions in order from strongest to weakest support from the evidence:

  • (Strong Evidence): Corticosteroid injections from a qualified practitioner in combination with the shoulder stretching and strengthening.
  • (Moderate Evidence): Patient Education on the course of adhesive capsulitis as well as activity modification to allow a minimal pain lifestyle, and physical therapy activities which match and do not aggravate the person’s current level of irritation and pain.
  • (Moderate Evidence): Stretching exercises which match the intensity of your pain and irritability.
  • (Weak Evidence): Modalities and passive interventions such as shortwave diathermy, ultrasound, and electrical stimulation.
  • (Weak Evidence): Joint mobilizations or deep joint stretching to the affected shoulder with the goal of decreasing pain and improving range of motion.
  • (Weak Evidence): Manipulation under anesthesia. This is a common practice but has in recent years been performed less frequently as most often the stiffness returns after the manipulation under anesthesia.

Physical Therapy First

Your physical therapists at Physical Therapy First will provide you with the highest quality of care for your full 60-minute session. Physical Therapy First is the only outpatient physical therapy clinic in the Greater Baltimore area providing 1-on-1 care with your physical therapists for your full treatment session. Call in any of our four locations in the greater Baltimore region today to be seen immediately for your shoulder pain!

References:

  • Webpage: https://www.physio-pedia.com/Adhesive_Capsulitis
  • Cyriax J. Textbook of Orthopedic Medicine. Diagnosis of Soft Tissue Lesions. Baltimore, MD: Williams & Wilkins; 1970.
  • Aydeniz A, Gursoy S, Guney E. Which musculoskeletal complications are most frequently seen in type 2 diabetes mellitus? J Int Med Res. 2008;36:505-511. http://dx.doi.org/10.1177/147323000803600315
  • Bridgman JF. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis. 1972;31:69-71.
  • Lundberg BJ. The frozen shoulder. Clinical and radiographical observa­tions. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabo­lism. Acta Orthop Scand Suppl. 1969;119:1-59.
  • Milgrom C, Novack V, Weil Y, Jaber S, Radeva-Petrova DR, Finestone A. Risk factors for idiopathic frozen shoulder. Isr Med Assoc J. 2008;10:361-364.
  • Balci N, Balci MK, Tüzüner S. Shoulder adhesive capsulitis and shoulder range of motion in type II diabetes mellitus: association with diabetic complications. J Diabetes Complications. 1999;13:135-140. http://dx.doi. org/10.1016/S1056-8727(99)00037-9
  • Hannafin JA, Chiaia TA. Adhesive capsulitis. A treatment approach. Clin Orthop Relat Res. 2000:95-109.
  • Neviaser AS, Hannafin JA. Adhesive capsulitis: a review of current treatment. Am J Sports Med. 2010;38:2346-2356. http://dx.doi. org/10.1177/0363546509348048
  • Neviaser RJ, Neviaser TJ. The frozen shoulder. Diagnosis and manage­ment. Clin Orthop Relat Res. 1987:59-64.

 

The Effects of Vitamin D Deficiency and Benefits of Supplementation

by | May 4, 2021 | Health Tips

by Logan Swisher, PT, DP

Introduction

Vitamin D (VITD) is important in bone health, skeletal muscle growth, inflammatory modulation, immune and cardiopulmonary function. VITD can also interact with extraskeletal tissues to modulate injury recovery and influence of the risk of infections. It is estimated that 1 billion people in the world currently have VITD deficiency and that number is on the rise. The major cause for the VITD deficiency is the lack of awareness in the population that sun exposure is the main source of vitamin D. In relation to food sources of VITD, it is difficult to obtain vitamin D through the diet because very few foods naturally contain the vitamin, exceptions being eggs, cheese and fatty fish such as salmon, sardines, herring.

How is Vitamin D Metabolized?

Vitamin D is an organic compound in food needed in small amounts for growth and good health but the human requirement can actually be met entirely through synthesis in the skin upon exposure to sunlight. The ultraviolet-B (UVB) radiation in sunlight converts to D3 and the newly synthesized vitamin D (as well as vitamin D obtained from the diet) is escorted to the liver. In the liver, vitamin D is rapidly converted to 25(OH)D, the main storage form. Further activation in the kidney is driven by parathyroid hormone (PTH) when blood calcium and/or phosphate concentrations fall below the normal range.

Benefits of Vitamin D

Sufficient levels of Vitamin D provide multiple musculoskeletal benefits such as: increased muscle protein synthesis, ATP concentration, strength, jump height and velocity, exercise capacity, physical performance, decrease muscle protein degeneration and reverse myalgias. It is also well known that vitamin D plays an important role in bone health, fracture prevention and reducing the risk and impact of diabetes, multiple sclerosis, certain cancers, cardiovascular diseases and hypertension, cerebrovascular diseases, infectious diseases, asthma, depression, and other autoimmune and chronic inflammatory disorders.

How much Vitamin D do you need?

In order to properly assess levels of Vitamin D, blood levels of total 25-hydroxy vitamin D (25(OH)D) must be taken. There are studies which suggest that a value of 25(OH)D >30 ng/mL should be considered as acceptable for maintaining bone health and reducing the risk of fracture in healthy young people and adults, while others suggest that necessary levels should be set at >40 ng/mL. 25(OH)D levels above 40 ng/mL are required for fracture prevention, including stress fractures. Optimal musculoskeletal benefits occur at 25(OH)D levels above the current definition of sufficiency (> 30 ng/mL) with no reported sports health benefits above 50 ng/mL. The Institute of Medicine recommended dietary allowance (RDA) of vitamin D for the US and Canada is 600 IU for children and adults under 70 years of age and 800 IU for those over 70 years old. It is important that you discuss this with your primary care provider prior to taking any Vitamin D supplements.

 References

De la Puente Yagüe M, Collado Yurrita L, Ciudad Cabañas MJ, Cuadrado Cenzual MA. Role of Vitamin D in Athletes and Their Performance: Current Concepts and New Trends. Nutrients. 2020 Feb 23;12(2):579. doi: 10.3390/nu12020579. PMID: 32102188; PMCID: PMC7071499.

Shuler FD, Wingate MK, Moore GH, Giangarra C. Sports health benefits of vitamin d. Sports Health. 2012 Nov; 4(6):496-501. doi: 10.1177/1941738112461621. PMID: 24179588; PMCID: PMC3497950.

Treating Your Low Back Pain: But my MRI says….

by | Apr 26, 2021 | Health Tips

By Joseph Holmes, PT, DPT, CDN, FNCP

The likelihood that any adult in the United States will experience some form of low back pain each year is 1.5%-36%. Moreover, about 25% of adults report having at least 1 day of low back pain in the past 3 months (1). There are many factors that affect the likelihood of this happening (2). Most people assume that when back pain occurs, whether it is aggravating or debilitating, an x-ray or MRI is needed and that they should be prescribed muscle relaxers and/or painkillers. However, updated guidelines from the American College of Physicians recently announced that, “doctors should avoid prescribing opioid painkillers for relief of back pain and suggest that before patients try anti-inflammatories or muscle relaxants, they should try alternative therapies like exercise, acupuncture, massage therapy or yoga” (3). Furthermore, previous guidelines stated that imaging, such as an MRI, demonstrated no value to the patient and can also lead to worse and more costly outcomes. Thus, imaging should only be prescribed if severe neurological symptoms are present (4).

To address the growing demand for treatment of the increasing number of people who have low back pain, physical therapists have created the Low Back Pain clinical practice guidelines. These are rigorous guidelines which synthesize all the available evidence on low back pain assessment, diagnosis, and intervention/treatment. The most recent version of the guidelines, published in 2012 by the American College of Physicians, stated that people need an active intervention in order to show the quickest improvement in healing their pain and returning to normal function. Often low back pain will heal on its own eventually, that is, if the proper actions are taken.

Physical therapists, guided by the clinical practice guidelines, use the most up to date information to help the approximately 30-50 million Americans who experience low back pain every year. Because most back pain cannot be directly associated with a specific cause of injury, this leads to many inaccurate findings on MRIs, CT scans, and X-rays, including people with no back pain symptoms whatsoever being diagnosed with “abnormal” findings of the lumbar spine 32% of the time (5). Thus, the best available evidence supports a classification approach that de-emphasizes the importance of identifying specific anatomical lesions after red flag screening is completed. There is still so much that experts do not understand about low back pain. What we do know is that the best physical therapists will diagnose and treat your back pain based on your individualized symptoms and reported limitations.  We will work with you to create goals and interventions that will help to alleviate your pain and allow you to return back to your regular function.

The 2012 Low Back Pain Clinical Practice Guidelines utilized the four treatment-based classifications to categorize low back pain that were created in 2007 (6). They are as follows:

  • Manipulation (based on strong evidence from the Flynn et al Clinical Prediction Rule):
    • A person is a great candidate for manipulation if they meet most of these criteria:
      • No symptoms below your knee
      • Recent onset of symptoms less than 16 days
      • Low fear avoidance based off a validated questionnaire (FABQ-work <19)
      • At least 1 stiff/hypomobile segment of the lumbar spine
      • At least 35 degrees of internal rotation, a measurement of hip rotation, in 1 hip
    • Stabilization:
      • A person is a great candidate for the stabilization if they meet most of these criteria:
        • <40 years old
        • Post-partum or straight leg raise >90 degrees
        • Positive prone instability test
        • Poor rhythm of bending over and flexing the spine
      • Specific Exercise, Centralization, or Directional Preference:
        • A person is a great candidate for specific exercise if they meet most of these criteria:
          • Symptoms below the buttock
          • Older age
          • Preference to bend over in to flexion or back into extension to get relief
        • Traction:
          • A person is appropriate for intermittent traction if they meet most of these criteria:
            • Signs and symptoms of nerve root compression, weakness, or crossed SLR
            • Peripheralization of symptoms or worsening of symptoms in the legs with both bending forwards and backwards

            After your physical therapist categorizes your clinical presentation into one of these four categories, your individualized program will be created using the support of the best evidence available combined with years of clinical expertise. Additionally, the low back pain clinical practice guideline recommends the following interventions which best match your treatment-based classification (7). A is considered the best evidence and E is the worst evidence.

            • (A): Manual therapy such as soft tissue mobilization, core stabilization, directional preference, and progressive endurance training and exercise.
            • (B): Patient Education: Do NOT increase patient’s fear or perceived threat
            • (C): Flexion or bending forward for lumbar stenosis: people with lumbar stenosis should be performing strengthening, stretching, and increased endurance activities
            • (D): Lumbar traction: If a person is classified in to the above traction classification, then traction can be slightly helpful, otherwise it is of no benefit
            • Not listed: no grade or recommendation was made towards heat, ice, electrical stimulation, or dry needling

            Physical Therapy First

            At Physical Therapy First, you are provided with more individualized time in your initial evaluation and treatment sessions than with any other provider in the region. Our physical therapists perform 60 minute 1-on-1 initial evaluations and all follow up sessions are 1-on-1 for 60 minutes with your physical therapist. We provide the best care in the region with the highest qualified clinicians. Call or email any of our four locations in the Greater Baltimore area to set up your appointment today.

            References:

            1. Deyo RA , Mirza SK , and  Martin BI . Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976). 2006;31:2724-7. [PMID: 17077742]
            2. Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010;24:769-781. http://dx.doi.org/10.1016/j.berh.2010.10.002
            3. Amir Qaseem, Timothy J. Wilt, Robert M. McLean, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med.2017;166:514-530. [Epub ahead of print 14 February 2017]. doi:10.7326/M16-2367
            4. Chou R, Qaseem A, Snow V, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med.2007;147:478-491. [Epub ahead of print 2 October 2007]. doi:10.7326/0003-4819-147-7-200710020-00006
            5. Savage RA, Whitehouse GH, Roberts N. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J. 1997;6:106-114.
            6. Fritz, JM, Cleland, JA, Childs, JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007;37:290–302.
            7. Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ. Low Back Pain: Clinical Practice Guidelines. J Orthop Sports Phys Ther 2012;42(4):A1-A57. doi:10.2519/jospt.2012.42.4.A1

Blood flow restricted exercise for athletes: A review of available evidence

by | Apr 19, 2021 | Health Tips

by Stephanie Beatty, SPT

Introduction: What is blood flow restriction and how does it work?

– Blood flow restriction (BFR) involves the placement of a cuff around an arm or leg in an effort to prevent venous return, or the flow of blood through the veins of the limb back to the heart, while still allowing blood to flow from the heart to the limb through the arteries. By occluding blood flow, lighter weights and lower exercise intensities can be used to achieve similar benefits to those that would be achieved with higher intensity exercise without blood flow restriction. While the exact mechanisms are unclear, when used during exercise, blood flow restriction is thought to induce both short- and long-term changes in muscle characteristics, muscular development, and overall performance. Blood flow restriction is commonly used in older patients, patients recovering from an injury, and other patients who are unable to tolerate exercising with higher loads, but it has been shown to be beneficial to athletic populations as well. The objective of this literature review was to assess the evidence of acute and longer-term adaptive responses to exercise with BFR in trained athletes.

Methods

– The authors in this literature review identified twelve papers that fit their established inclusion criteria and assessed acute and adaptive responses to different types of exercise with BFR in various athletic populations, including track and field athletes, football players, netball players, rugby players, basketball players, and ice hockey players.

Summary of Evidence

– Training responses to BFR combined with low-load resistance exercise included:

o Decrease in metabolic stress imposed on muscles during exercise
o Increase in growth hormone concentration with a decrease in the concentration of chemical indicators of muscle damage
o Increase in squat, bench press, and leg press 1-RM (depending on activity during which BFR was applied)
o Decrease in sprint and acceleration times
o Increase in muscle strength
o Increase in muscle endurance
o Increase in muscle torque production
o Increase in muscle cross-sectional area and girth
o Improved performance on sport specific physical assessments

– Training responses to BFR combined with moderate-load resistance exercise included:

o Increase in squat and bench press 1-RM
o Improved jump and sprint performance
o Increase in levels of testosterone and cortisol
– Training responses to BFR combined with low-intensity cardio included:
o Improved aerobic capacity and anaerobic power
– It should be noted that many of these studies reported that training adaptations were sport specific and varied by athletic population (i.e. endurance-dominant athletes experienced different adaptations than strength-dominant athletes). Additionally, low intensity exercise with BFR has not been shown to produce significant changes in connective tissues. For this reason, authors stressed the importance of combining low-intensity BFR exercise training with high-intensity strength training without BFR to allow proportional changes to occur in the tendons and reduce the risk of tendon injury.

Conclusion and Clinical Applications:

– BFR can be used with low-intensity resistance training to produce changes in muscle and improvements in performance in higher-level athletes.
– Exercise training with BFR should be sport specific.
– It is important to combine low-intensity BFR training with high-intensity training without BFR to continue to stress the connective tissues and reduce the risk of tendon injury.
– BFR with low-intensity exercise can be used as an adjunct during de-loading weeks or during recovery from injury.
– Exercises done with BFR should still be progressed for continued improvements.

At Physical Therapy First, we treat a variety of patient populations including well-trained athletes, recreationally active patients, post-operative patients, and deconditioned patients, all of whom blood flow restriction has been shown to help. We offer individualized therapeutic exercise and home exercise routines. During your evaluation, your therapist can further discuss blood flow restriction and how it may help you recover from an injury and improve your function.

Reference:

Scott BR, Loenneke JP, Slattery KM, Dascombe BJ. Blood flow restricted exercise for athletes: A review of available evidence. Journal of Science and Medicine in Sport. 2016; 19(5):360-367. doi:10.1016/j.jsams.2015.04.014

Sleep Hygiene Tips and Tricks

by | Apr 13, 2021 | Health Tips

Gabrielle Herman, PT, DPT, CMPT

 The three pillars of health include diet, exercise, and sleep. Optimizing all three is critical to exercise recovery as well as overall health and well-being. Ignoring one pillar often causes the other two pillars to suffer. For example, someone that is sleep deprived may perform poorly in exercise or begin to crave unhealthy foods. These negative effects of sleep deprivation must be addressed regularly by sports medicine providers as well as general practitioners as there are clear negative effects of sleep deprivation on performance in athletes such as accuracy, reaction time, endurance, submaximal strength as well as cognitive functions including judgement and decision-making.

 Sleep Deprivation in Elite Athletes

High level athletes are known to get less total sleep than non-athletes due to demanding training and competition schedule and travel and time zone changes. Stress and anxiety before an upcoming game or match may also hinder an athlete from getting a healthy sleep. In addition to this, the significant increase in smartphone and electronic devices further interrupt sleep schedules with possible negative impacts on melatonin production from blue-light emissions.

Negative Effects of Sleep Deprivation

  • Neurocognitive, metabolic, immunologic, and cardiovascular dysfunctions are shown in general population
  • Physical effects in athletes:
  • Decreased running performance
  • Decreased muscle glycogen concentration
  • Reduced submaximal strength
  • Decreased soccer kicking skills
  • Decreased tennis serve accuracy
  • Decreased time to exhaustion

Positive Effects of Sleep Extension

  • Restoration of sleep and sleep extension can improve the following
  • Sprint times
  • Tennis serve accuracy
  • Swim and kick stroke efficiency and swim spring
  • Basketballs shooting accuracy
  • Time to exhaustion
  • Psychomotor vigilance tasks, alertness, vigor, and mood
  • Decreased sleepiness and fatigue
  • Newer studies demonstrate a nap the day following a night of sleep deprivation may be beneficial
  • A new concept of “banking sleep” which is a sleep extension prior to a night of sleep deprivation in a pilot study improved motor performance
  • Most studies agree upon increasing sleep by 2 hours with the goal of 9 hours for elite athletes
  • Future research is needed to further detail the benefits of banking sleep

Top Ten Recommendations for Healthy Sleep Hygiene

  1. Don’t go to bed until you are sleepy
  2. Regular bedtime routine/rituals help you relax and prepare body for sleep
    • Warm bath
    • Reading a book
  3. Try to get up at the same time every morning (including weekends and holidays)
  4. Try to get a full night’s sleep every night and avoid daytime naps (if you must nap, limit to 1 hour and avoid nap after 3 pm)
  5. Use the bed for sleep and intimacy only; not for any other activities including TV, phone use, or laptop
  6. Avoid caffeine if possible, if must use, avoid after lunch
  7. Avoid alcohol is possible, if must use, avoid right before bed
  8. Don’t smoke or use nicotine, ever
  9. Consider avoiding high-intensity exercise right before bed
  10. Make sure bedroom is quiet, as dark as possible, and a little on the cool side rather than warm

Additional Sleep Hygiene Recommendations

  1. Avoid blue light emitted from screens at least 2 hours before bed
  2. Get bright, natural sunlight upon awakening – some suggest at least a 10,000 lux lamp if you cannot get natural sunlight
  3. Don’t hit the snooze button, it does not improve sleep quality
  4. If you have difficulty waking up, some suggest a dawn-simulator alarm clock
  5. If you must use a computer at night, consider installing blue-light reducing software or wear blue-light blocking glasses
  6. Higher Carbohydrate foods at night may actually improve sleep, as well as high protein including tryptophan. High fat intake may disrupt sleep. Inadequate total caloric intake during the day may impair sleep at night.
  7. Topical magnesium (salt bath, topical mineral oil, or oral magnesium may help if you are deficient
  8. Melatonin naturally occurring in foods (Tart cherry juice, raspberries, goji berries, walnuts, almonds, tomatoes) may potentially improve sleep, but avoid artificial melatonin supplements
  9. Don’t fall asleep to the T.V. Sleep studies show you frequently wake up during the night and have poor quality sleep.
  10. Herbal supplements are largely unknown with potential serious side effects, and may be on the USADA-prohibited list or result in positive banned substance test for athletes
  11. Consider reducing fluid intake before bed so you don’t get up to go to the bathroom (Only if you maintain enough hydration during the day)
  12. Cooling body temperature may improve sleep. Some suggest keeping the room between 60-70 degrees; however, keep hands and feet warm
  13. Check your mattress – it may be too old and have allergens (most last 9-10 years)
  14. Recovery from exercise should not only focus on muscle recovery. Reducing mental fatigue is just as important for health sleep. Reduce external stressors in your life.

References:

Vitale, K. C., Owens, R., Hopkins, S., Malhotra, A., Sleep Hygiene for Optimizing Recovery in Athletes: Review and Recommendations. Int J Sports Med. August 2019: 40(8): 535–543. doi:10.1055/a-0905-3103