Effectiveness and Safety of Arnica montana in Post-Surgical Setting, Pain and Inflammation

by Kayla Coad, PT, DPT

Arnica montana is a plant native to the Siberian mountains and Central Europe. This plant has homeopathic uses to treat symptoms caused by many inflammatory conditions. Evidence suggest that Arnica montana could be an alternative to non-steroidal anti-inflammatory drugs. Arnica montana has been sold as tincture, ointment, cream, and gel. Arnica montana may be more easily recognized under the different names that it has been sold under; leopard’s bane, wolf’s bane, mountain tobacco, and mountain snuff. This plant has been used for pathological conditions, including pain, stiffness, and swelling.

Arnica montana is able to treat some inflammatory conditions as it contains a high concentration of sesquiterpenes which is responsible for anti-inflammatory activity. In vitro studies have shown that the most active components in Arnica is helenalin, which is a type of sesquiterpene lactone that has anti-inflammatory properties. This article reviews several uses of Arnica which include acute ankle sprains, post-surgical pain, muscle soreness after exercise, and osteoarthritis. Arnica’s affect on muscle soreness post-exercise was measured in a study involving 82 marathon runners. The study showed that 5 pills of Arnica 30D, given 2 times a day from the evening before until 3 days after the marathon improved muscle soreness in marathon runners immediately after the competition, however it did not protect from cell damage. Another study involving 204 patients with osteoarthritis of the interphalangeal joints of the hands showed that topical application of a 4-cm gel strip of Arnica (50 g tincture/100 g) 3 times a day showed similar effectiveness as ibuprofen in reducing pain, functional hand capacity, number of painful joints in both hands and intensity of morning stiffness in the worst affected hand.

As mentioned before, Arnica can be administered in a variety of forms such as orally or topically. When applied topically, studies show that Arnica may be an alternative to ibuprofen due to the high levels of sesquiterpenes. The amount of sesquiterpene is dependent on which portion of the plant used. Due to various parts of the Arnica plant that can be extracted, the clinical effectiveness will vary. The safe use of Arnica is guaranteed by the European Pharmacopoeia and by specific Arnica monographs which provide guidelines for pharmaceutical companies to abide by. The article concluded that Arnica is a potential therapeutic alternative to non-steroidal anti-inflammatory drugs, especially for patients undergoing pharmacological polytherapy. Further research with larger cohorts of patients are needed to support the effect of Arnica on various inflammatory conditions.

Physical Therapy First Recommendation:

For patients seeking a homeopathic treatment for symptoms from inflammatory conditions, discuss with your physician the appropriateness of Arnica montana.


Iannitti, T., Morales-Medina, J., Bellavite, P., Rottigni, V., Palmieri, B. 2016. Effectiveness and Safety of Arnica montana in Post-Surgical Setting, Pain and Inflammation, The American Journal of Therapeutics, 23, e184-e197.

Ankle Injuries and Ankle fractures: Evidence-based treatment

by Jeslin Thomas

Did you know that two of the most common ankle injuries, specifically for sports, include ankle sprains and ankle fractures? Ankle sprains occur in 600-700 per 100,000 persons, and ankle fractures happen in 107-187 per 100,000 persons per year. After a sprain, persistent symptoms may linger for up to 30% of individuals, and a history of an ankle sprain remains a predisposing factor for recurrent future ankle sprains. Similarly, after an ankle fracture, symptoms may limit lower limb activities and persist long term.

This study aimed to identify the current treatments for ankle sprains and ankle fractures using the most recent systematic reviews and randomized controlled trials.

Treating Ankle Sprains:

Ankle sprains are usually managed conservatively; the acute phase involves symptom management followed by a period of rehabilitation. Current evidence supports the use of non-steroidal anti-inflammatory drugs (NSAIDs) and functional support during the immobilization or acute stage of an ankle sprain. When compared with a placebo, the participants who used NSAIDs during the first two weeks following the sprain reported a significant improvement in function in the long term. Functional support implies the use of braces, elastic bandage, tape, semi-rigid support, and lace-up ankle support over the injured ankle. Studies have found all supports equally effective in decreasing pain, swelling, preventing recurrent sprains, and providing support for ankle instability. When compared to adults who didn’t use functional support, the group of adults who used this form of support demonstrated greater range of motion (ROM), less persistent swelling, and reported a higher percentage of return to sports or work-related activities. Additionally, performing balance and ankle strengthening exercises during and after the subacute phase is beneficial for those with chronic ankle instability and those predisposed to recurrent ankle sprains.

According to the review, electro-physical agents (Ex: TENS Unit) were not recommended during the acute stage of an ankle sprain. There is weak evidence for the use of manual therapy for positive short-term or acute effect and this could be partially attributed to small randomized controlled trials and cross-over studies. Nonetheless, in one study, manual therapy has shown to increase ankle function up to one month following the treatment. In addition, current evidence proves that Mulligan’s mobilization with movement technique (anterior to posterior glide of the talus) during the subacute phase, is effective in increasing dorsiflexion range for participants with Grade 2 ankle sprains.

Treating Ankle Fractures:

As opposed to ankle sprains, ankle fractures usually involve surgical or a conservative fracture reduction and are followed by immobilization and rehabilitation. Usually, rehabilitation for ankle fractures is followed after the period of immobilization. This study suggests that early rehabilitation including weight-bearing exercises with an orthosis or brace during the immobilization phase may be beneficial for people after surgical fixation. In one randomized controlled trial, using an orthosis with ankle exercises led to better outcomes in function and ankle range of motion when compared to the group that only received cast immobilization. However, it is important to note that the use of a brace or orthosis to allow for exercise during the immobilization period of a fracture may also lead to a higher rate of adverse effects. Caution must be taken as early mobility during the acute stage may only be tolerable for some individuals. Current evidence on treatments for ankle fracture suggests the use of manual therapy, a gradual increase in activities, and a structured exercise program to enhance outcomes for individuals following immobilization.


Evidence-based treatment of acute ankle sprains should include functional support and NSAIDs during the acute phase after the injury. Manual therapy may also provide additional benefits during the subacute phase. Additionally, performing ankle strengthening and stabilization exercises have been shown to reduce recurrent sprains and chronic ankle instability. After an ankle fracture, current evidence supports early weight-bearing during the immobilization period for patients who are able to do so safely. After the immobilization period, treatment should be structured with a comprehensive and progressive exercise program.

The physical therapists at Physical Therapy First are trained and equipped to provide you with this specific care while meeting your individual needs. Questions? Feel free to contact any of our skilled therapists by phone or by appointment.


Lin CW, Hiller CE, de Bie RA. Evidence-based treatment for ankle injuries: a clinical perspective. J Man Manip Ther. 2010;18(1):22-28. doi:10.1179/106698110X12595770849524

Exercise guidelines for the prevention of osteoporosis in postmenopausal women

by Jeslin Thomas

30% of postmenopausal women in the US were reported to have Osteoporosis, and at least 40% of these women will sustain one or more fractures during their lifetime. That’s a significant number to think about.  Fractures can lead to pain, disability, loss of activity tolerance, and functional independence. Also, after an initial fracture, individuals are 2x at risk for secondary fractures within that year.

While the disease is more common in women, men are also at risk for osteoporosis. Nonetheless, if you are diagnosed with this or are at risk of being diagnosed, it’s essential to know that our bodies are still incredibly adaptable. Countless research has shown that exercise is an EXCELLENT evidence-based tool to decrease modifiable risk factors for falls and fractures! Your bone is a dynamic tissue that responds to your body and external loads by changing its structure/strength and alters its mass. It does so to withstand any excessive loads that are likely to result in a fracture.

This systematic review highlights the following key points:

  1. Principle of Specificity: target specific areas of the body that are most susceptible to fractures: wrist, hip, and spine
    • Incorporating back extension strengthening exercises was associated with increasing spinal bone density.
    • High impact jumping exercise interventions 2-3x/week in post menopausal women were found to have a significant positive impact on the femur 12 months after it was performed. (We recommend discussing with a Physical therapist to find a strengthening program that’s right for you- our bodies respond differently based on our needs)
  2. Principle of Progressive Overloading: as your bone adapts to an exercise, it must be increased progressively (Ex: increase time spent, add more reps, add weights or resistance bands)
    • We recommend progressing your exercise once it starts becoming easier/every 2 weeks as a guideline.
  3. Principle of Reversibility: Any skeletal changes from exercise training will be lost once you stop it. Minimum dose to have a positive effect on your bones for the long term is 2 sessions per week.
    • For true physiological skeletal changes to occur, the exercise intervention must last over 12-18 months. Patients may see the greatest changes in their bone mineral density during the first 5-6 months of starting the program.

Research-based parameters:

      • Weight-bearing exercises 4-7x/week
        • Ex: sets of jumping 20-40 times, bounding, skipping, hopping, playing tennis, dancing, recreational gymnastics, or playing football
      • Challenging balance training for ~3hrs/week reduces falls by 39% and doing reactive or volitional stepping training reduces falls by 50%
        • Ex: leaning/reaching over your toes, being able to stand still despite any perturbations, stepping over surfaces, and walking on unstable surfaces.
      • Type of exercise: water-based exercise has been proven to reduce age-related bone loss at the hip and lumbar spine. Land-based exercises are better for improving your bone health overall.
      • Resistance training: maintains and helps to improve bone mineral density when performed at high-intensity loads.
        • Minimal requirements: 2 sets, 12 repetitions, at 70% of your maximal muscle strength. Performed 2-3 times per week.
        • The exercise has to be progressively increased over time, and it must target your large muscle groups. Ex: squats, lunges, hip abduction/adduction, and abdominal strengthening/Transverse Abdominis focus.

At Physical Therapy First, our clinicians are highly knowledgeable and trained to create a program that is tailored to your needs. If you are someone who is at risk or have been diagnosed with osteoporosis or low bone mineral density, you could benefit from an evaluation by one of our therapists to decrease any modifiable risk factors and maintain your physical health.


Daly RM, Dalla Via J, Duckham RL, Fraser SF, Helge EW. Exercise for the prevention of osteoporosis in postmenopausal women: an evidence-based guide to the optimal prescription. Braz J Phys Ther. 2019;23(2):170-180. doi:10.1016/j.bjpt.2018.11.011


Spondylosis, Spondylolysis, and Spondylolisthesis: What’s the difference?

by Jeslin Thomas

It’s not as tricky as you may think. If you are curious or have been diagnosed with one of these, the therapists at PT First can help you out!

Spondylosis: refers to when you have degenerative osteoarthritis (OA) of the spine- this essentially means that the space between your vertebrae narrows as the protective cartilage that cushions the ends of the vertebrae wears down with age. With time, you may notice you have more of a flexed (forward bending) posture. Individuals suffering from this may experience lower back pain, leg pain, and/or numbness when standing or walking; symptoms may only seem to improve with sitting or lying down1.


Spondylolysis: refers to a stress fracture defect in the pars interarticularis of the vertebrae (commonly found in the L4/L5 region). This is usually caused by repetitive stress or trauma at the Lumbar spine from strenuous activities involving excessive twisting/rotating or back bending (ex: gymnastics, dancing, wrestling, and football.). Symptoms may or may not be present initially, but as the injury progresses, these individuals may complain of pain as they bend backward or pain with general activities2.

Spondylolisthesis: often refers to the progression of a spondylosis injury, but it may also be congenital or idiopathic in nature. Spondylolisthesis is defined as the displacement of one vertebra over the vertebral body below it (commonly known as a “step off” or “slip” at the L5/S1 level); individuals may even notice the presence of a bump by the area of the slippage. There are 5 different grades of this slippage, and it’s defined by the extent to which the vertebral body has slipped:
Grade I: O-25%        Grade III: 50-75%        Grade V: > 100%
Grade II: 25-50%      Grade IV: 75-100%
Individuals with this may complain of localized pain that may come and go with certain activities, and this may be the most notable when bending backward or forward at the affected segment. They may experience radicular pain down to one or both legs as the vertebrae slides and causes compression of the nerve root below, tense hamstrings, loss of bowel/bladder (rare), and difficulty with balance or walking.

Spondylolysis and Spondylolisthesis

What can we do?

First, you can consult with your Doctor to obtain an MRI, CT, Bone scan, or X-ray to confirm the diagnosis and determine the extent of the injury. Treatments can involve both operative (surgical) or nonoperative/conservative management (Physical Therapy, NSAIDs/analgesics, and bracing). Generally, surgical interventions are reserved for those with significant symptoms or failure of conservative treatments.

With spondylosis, conservative management involving aerobic exercises such as biking and general strengthening and stretching of your whole body has been correlated to greater quality of life among adults with lumbar osteoarthritis 3. In addition, maintaining good posture throughout and maintaining our postural muscle strength can help to decrease pain and promote proper muscle length-tension relationships.

With spondylolysis, as with any fracture, your body will need time to heal. This means 4-8 weeks (or longer) of rest from high impact activities such as sports and lifting heavy items. Your Doctor may also recommend pain medications such as NSAIDs or steroids to help reduce pain and inflammation. During this time, Physical Therapy may be recommended and can help with facilitating the healing process, reduce pain, strengthen and stabilize specific muscles, and help you navigate through your everyday activities.

In addition, with both spondylolysis and spondylolisthesis, studies have shown that specific strengthening of the deep multifidus and transversus abdominis can be beneficial for spinal instability that commonly occurs 3,4. Overall, exercises to promote the full spinal range of motion and lumbar strengthening exercises have been proven to be a successful treatment option for decreasing pain and functional limitations 2,4,5. At PT First, our therapists have treated multiple patients with success when using this evidence-based method. If you have any questions, don’t hesitate to ask any of our licensed therapists!


Middleton, Kimberley, and David E. Fish. “Lumbar Spondylosis: Clinical Presentation and Treatment Approaches.” Current Reviews in Musculoskeletal Medicine 2, no. 2 (March 25, 2009): 94–104.

Garet M, Reiman MP, Mathers J, Sylvain J. Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: a systematic review. Sports Health. 2013;5(3):225-232. doi:10.1177/1941738113480936

VIEIRA, S., et al, Abdominal muscle strength is related to quality of life among older adults with lumbar osteoarthritis. Journal of bodywork and movement therapies, 2015. (level of evidence 2A)

Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008;17(3):327-335. doi:10.1007/s00586-007-0543-3

Back Pain: Spondylosis, Spondylolysis, and Spondylolisthesis. SPARCC Sports Medicine – Tucson AZ. https://sparcctucson.com/2019/03/21/back-pain-spondylosis-spondylolysis-and-spondylolisthesis/. Published October 23, 2019. Accessed August 2, 2020.



The Acute Effect of Cryotherapy on Muscle Strength and Shoulder Proprioception

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT


Cryotherapy is a common intervention used in clinical and athletic environments, especially for acute injuries. Common forms of cryotherapy include an ice pack, ice massage, and cold-water immersion. Cryotherapy is used to decrease injury-related pain, muscle spasms and swelling. However, the cooling effect of cryotherapy can harm neuromuscular function, including muscle strength and proprioception. Proprioception is an individual’s ability to sense joint position, movement, and force as a means to discriminate body movement. The authors in the study, The Acute Effect of Cryotherapy on Muscle Strength and Shoulder Proprioception, analyze how cryotherapy affects the maximal force production of the shoulder external and internal rotator muscles and shoulder proprioception.


A randomized double-blind controlled trial was performed on 48 healthy women. The participants were randomly assigned to either the experimental or control group. The experimental group had 15 minutes of cryotherapy in the form of a crushed ice pack applied to shoulder and the control group had a body-temperature sand bag applied to the shoulder. Maximal voluntary isometric contraction (MVIC), force sense, threshold to detect passive movement (TDPM) and joint position sense (JPS) of the shoulder rotator muscles were assessed immediately before and after the intervention.

Muscle Strength Assessment

The MVIC of the shoulder’s internal and external rotators was recorded both before and after cryotherapy treatment. A dynamometer was used to record three MVICs and the average was recorded.

Force Sense Assessment

The force-matching procedures for the internal and external shoulder rotators were conducted at 20% and 50% of the participant’s MVIC. For force sense testing, participants were positioned like the MVIC assessment and instructed to achieve the target force using visual feedback. They were then asked to perform the same contractions without visual feedback. The mean from three trials was used for analysis.

Joint Position Sense Assessment

The authors passively positioned the participants’ shoulder into position and maintained for five seconds so the participant could memorize the position. The participant then actively moved her shoulder into the same position. The participants were blindfolded and wearing headphones during this test. Each participant performed this test three times and the average score was recorded.

Threshold to Detect Passive Movement Assessment

The participants were placed in the same seated conditions used to test JPS. Each participant was asked to press the remote button upon sensing any movement or change relative to the initial shoulder position, which was engaged at random by the tester. Three trials from two starting positions were used, and the shoulder was moved into either the internal or external shoulder rotation.


The cryotherapy reduced the skin temperature of the experimental group to 12.5 degrees Celcius compared to 33.5 degrees Celcius in the control group as measured by a skin thermometer.

MVIC: There was significant impairment in the force production of both the shoulder internal and external rotator muscles by approximately 10% of muscle strength in the experimental group.

Force Sense: There were no significant changes in both muscle groups at 20% and 50% of MVIC in the experimental group when compared to the control.

JPS: The error of JPS in external and internal rotation increased significantly in the experimental group post-cryotherapy application.

TDPM: Cryotherapy significantly diminished the participant’s ability to detect motion in the rotator muscles.

Conclusions and Physical Therapy First Implications

The results of this study demonstrate impairments of shoulder strength and proprioception following cryotherapy application.  These results suggest that application of an ice pack is harmful when it precipitates activity or exercise. There is a growing consensus that reduced shoulder proprioception increases the risk for sustaining a musculoskeletal injury. Athletes and trainers shoulder be educated on the proper timing of cryotherapy application for overhead athletes in order to decrease the risk for injuries. Cryotherapy is a modality we administer during rehabilitation which can help to reduce pain, swelling, and muscle spasm. At Physical Therapy First, we are conscious about the timing of cryotherapy intervention.


Torres, R., Silva, F., Pedrosa, V., Ferreira, J., and Lopes, A. (2017). The Acute Effect of Cryotherapy on Muscle Strength and Shoulder Proprioception. Journal of Sport Rehabilitation. 26, 497 -506

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