Don’t Forget the Warm Up!

by Tyler Tice, PT, DPT, MS, ATC

We all have busy schedules and it can be challenging to find time to get a good workout in. Between going to work, picking up the kids from practice, preparing dinner, and maintaining a clean household, some of us may feel that we only have 30 minutes to exercise. Due to this limited time, a lot of people may forego a warm up and jump right in to their workout routine.

BUT! A warm up can have a lot more benefits than we think. A warm up is meant to be more than “just to get loose” or “to help minimize soreness”. Warm ups have a positive impact on our exercise performance which in return may also help reduce our chances for injury.

Benefits of a Warm Up

  • Improves elasticity and contractibility of muscles
  • Improves efficiency of the respiratory and cardiovascular systems
  • Improves perception
  • Improves concentration
  • Improves coordination
  • Decreases reaction time
  • Regulates emotional stress

These benefits can help one enhance their workout and can help lower the risk of injury in the process too. It is especially important for athletes and those competing at a high level to utilize a warm up in their training routine since these benefits are all related to better performance.

Warm Up Ideas

  • Brisk walk
  • Light jog that progresses
  • Sport specific movements that begin slow and progress to higher intensity
  • Dynamic stretches
  • Self joint mobilizations
  • Muscle “activation” exercises (great for core and gluteal muscles)
  • An active or dynamic warm up is typically recommended over a static stretch warm up.

The best warm up routine varies for everyone based on the type of exercise being performed, the type of sport one may play, injury history and/or any current injuries, training and exercise goals, and many other factors.

Bottom Line

Find a warm up that works well for you, your schedule, your body, and for your goals. Find a warm up that you will be successful at and can stay consistent with! I know this is tough with our busy lives, but the warm up is just as important as the workout. Try to modify your exercise routine or change up your schedule in a different way in order to complete a warm up and keep you living a healthy lifestyle!


Kurz T. Science of Sports Training: How To Plan and Control Training for Peak Performance. 2nd Edition. Stadion Publisher Company. Y2001

Words Matter: Patient Language In Musculoskeletal Rehabilitation

by Tyler Tice, PT, DPT, MS, ATC

Viewpoint Article backed by Research

As physical therapists, we encounter many different types of people with various personalities and diverse backgrounds. These people come see us to move better and to feel better with the mindset that physical interventions can help them achieve their goals. However, we cannot disregard the psychological impact we can have on our patient care and the language we use is a HUGE component of this.

In a viewpoint article published in the Journal of Orthopaedic and Sports Physical Therapy, the authors give us insight on how the language we use with our patients can impact their understanding of their condition, their ability to improve, and the overall rehab process. Some common words that are mentioned to patients in day to day orthopedic care may actually be harmful and set them up mentally for a more challenging rehab process.

Below is a great chart that displays some of these common words that may have a negative connotation and can affect the rehab process. On the right side are suggestions for alternative words that patients can think of instead and what more clinicians should start using:

Chronic Degenerative Changes Normal age related changes
Negative test results Everything appears normal
Instability Needs more strength and control
Wear and tear Normal age changes
Neurological Nervous system
Don’t worry Everything will be okay
Bone on bone Narrowing/ tightness
Tear Pull
Damage Reparable harm
Paresthesia Altered sensation
Trapped nerve Tight, but can be stretched
Lordosis The normal curve in your back
Kyphosis The normal curve in your back
Bulge/herniation Bump/swelling
Disease Condition
Effusion Swelling
Chronic It may persist, but you can overcome it
Diagnostics X-ray or scan
You are going to have to live with this You may need to make some adjustments


Each word or phrase on the two sides have similar meanings, however the words on the right take some of the medical jargon out allowing patients to have a better grasp on their condition and be helpful for their rehab process.

The human body is complex and musculoskeletal rehab can be complex! But THAT’S OKAY, the physical therapists at Physical Therapy First are here to help make your rehab process go smoothly with less confusion. We have 1 on 1, hour long sessions with all of our patients which gives us the ability to provide you great care, get you feeling better, AND answer all the questions you have along the way!

Check out the article below for more information on this topic


Stewart M, Loftus S. Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation. J Orthop Sports Phys Ther. 2018; 48(7):519-522

Hip Osteoarthritis (OA): 2017 Clinical Practice Guidelines for Hip Pain and Mobility Deficits

Joseph Holmes, PT, DPT, FNCP, CDN

Every few years a group of expert physical therapists gather together to review the latest evidence-based research on a given area. The expert group reviews the quality of published research and discusses the best and worst strategies for clinical examination and treatment approaches. These summaries of evidence are referred to as the ‘Clinical Practice Guidelines’ and they are considered a guidebook for clinical physical therapists to follow in practice. In 2017, experts met with the purpose of updating the clinical practice guidelines for people with hip pain, stiffness, and potential hip osteoarthritis (OA) and improving treatment strategies when treating patients with hip pain and mobility deficits in relation to hip OA. Hip OA is extremely common with men showing higher rates of OA than women. Risk factors for developing hip OA include age, history of hip developmental disorders, previous hip injuries, reduced hip motion (especially internal rotation), presence of hip osteophytes, lower socioeconomic status, higher bone mass, and higher body mass index (BMI).

The evidence is compiled and rated by the panel of experts on a scale of A to F as recommendations to patients and clinicians with ‘A’ indicating strong evidence and ‘F’ indicating weak evidence. After reviewing all of the most cutting-edge, highest quality research on the topic of hip OA, the group released the following recommendations for treating hip pain, stiffness, and OA. I will highlight a few of the key takeaways and how this will affect you, the patient, when seeing your physical therapist for a full 1-on-1, one-hour session at Physical Therapy First.

 Assessing Baseline Pain and Function:

The evidence demonstrates level ‘A’ support in recommending the completion of the following three measures: (1) the visual analog pain scale (VAS) to provide a numeric rating for your pain; (2) the Lower Extremity Functional Scale (LEFS) to evaluate your difficulty in completing daily and recreational activities; OR (3) the Hip Disability and Osteoarthritis Outcome Score (HOOS).

The physical therapist will also utilize standardized validated functional tests to establish your baseline functional level. This provides a benchmark for comparison with future reassessments to determine the level of progress that has been made during your bout of physical therapy. These functional tests include:

  • 6-minute walk test: Walk consecutively for 6 minutes and measure the distance traveled.
  • 30-second chair stand: Stand up and down as many times as you can in 30 seconds.
  • Timed Up and Go Test: Stand up from a chair, and walk out 10 feet and back 10 feet.
  • Single leg stance: Stand on one leg for up to 30 seconds without losing your balance.
  • The step test: Step up and down off from an 8-inch step to assess balance and strength.

All of these functional tests are combined to evaluate your overall functional status and identify any potential limitations. They are all recommended in the clinical practice guidelines with support of level ‘A’ evidence.

Physical Exam:

The physical therapist will complete a hands-on assessment of your mobility, flexibility, and strength of your affected hip in order to identify specific restrictions or impairments. This assessment will include assessing your lumbar spine, hip, and knee to rule out the possibility of the back or knee referring pain into your hip. In addition, the physical therapist will look deeper into your hip restrictions to assess your overall hip flexibility in all directions. The hip primarily moves in six directions, as shown in the figure below:
Note: Image provided by

After assessing your hip mobility and flexibility, the physical therapist will then assess both your left and right hip strength with hands on strength testing of the hip abductors, adductors, internal rotators, external rotators, flexors, and extensors.  After completing the appropriate physical evaluations, and reviewing your history of what causes your discomfort, reported pain levels, and any functional impairments, the PT will then move to implement interventions that will specifically help you to heal the fastest.


The diagnosis of probable hip OA comes from a compilation of the key findings from the physical therapist’s evaluation. Factors that would indicate hip OA as opposed to non-hip OA are as follows:

  • Moderate anterior or lateral hip pain during weight-bearing activities
  • Morning stiffness less than 1 hour in duration after wakening
  • Hip Internal Rotation less than 24 degrees
  • Internal Rotation and Hip Flexion 15 degrees less than the nonpainful side
  • Increased hip pain associated with passive hip internal rotation
  • Absence of history, activity limitations, and/or impairments inconsistent with hip OA

Having more factors that are present on the above list suggests that it is more likely that a person has hip OA. Typically, after showing a few of the above factors, your physical therapist will be in contact with your primary care physician or orthopedist (when applicable) to discuss medical imaging to confirm this diagnosis.


The interventions prescribed will be those which are best matched by level of evidence available. These include:

  • Manual Therapy [Level A]: Soft tissue mobilization, hip stretching, and joint mobilizations
  • Patient Education [Level B]: Support for exercise adherence, and understanding of the condition are very beneficial for patients.
  • Exercise [Level A]: Specific stretching and strengthening specific to the patient’s limitations.
  • Modalities [Level B]: Ultrasound and heat can be beneficial in the short term for hip pain from OA.
  • Bracing [Level F]: Not recommended.
  • Weight Loss [Level C]: In collaboration with the patient’s entire medical team, weight loss for people who are overweight or obese could be beneficial in improving pain and function.

Follow Up Treatment and care both in Physical Therapy and at Home:

After reviewing all of the findings with your physical therapist, we will then determine your best individualized care plan. This includes how often to attend physical therapy sessions, how often to complete self-care activities and exercises at home, and what activities to do. Level ‘A’ evidence supports doing a combination of your home exercises and physical therapy 1-5 times per week, over 6-12 weeks in order to see beneficial results. The exercises prescribed to you for home are individualized for each person, but will most likely include activities such as hip stretching, hip strengthening, balance exercises, education on self-care including potentially using an assistive device, potential weight loss, and goal setting towards the goals that are identified by YOU, the patient.

Physical Therapy First provides 1-on-1 sessions with a licensed doctor of physical therapy, most of which are board certified in orthopedics, for full 60-minute sessions. We accept most major health insurances and have flexible scheduling to best accommodate your needs.

All of the above refers to the following citation: Michael T. Cibulka, Nancy J. Bloom, Keelan Enseki, Cameron McDonald, Judith Woehrle, Christine M. MacDonald. J Orthop Sports Phys Ther 2017;47(6):A1-A37. doi:10.2519/jospt.2017.0301

Physical Therapy Interventions for Subacromial Impingement Syndrome

by Logan Swisher, PT, DPT

What is subacromial impingement syndrome?

Subacromial shoulder pain (SSP) is the clinical presentation of pain and/or impairment of shoulder movement and function, usually experienced during shoulder elevation and external rotation. There are multiple structures involved, including the subacromial bursa, the rotator cuff muscles and tendons, the acromion, the coracoacromial ligament, and the capsular and intra-articular tissues. The hypothesized factors include: altered shoulder kinematics, rotator cuff and scapular muscle dysfunction, overuse from sustained intensive work and poor posture that can contribute to the pathogenesis of SSP.

What interventions are suggested for SSP?

The systemic review by Pieters et. Al in March 2020, aimed to evaluate the effectiveness of the following nonsurgical, nonpharmacological treatments: exercise, exercise combined with manual therapy, multimodal physical therapy, corticosteroid injection, laser, ultrasound, extracorporeal shockwave therapy, or pulsed electromagnetic energy. A total of 16 articles were reviewed with 9 out 16 having high quality evidence and 7 out of 16 having moderate quality evidence.


  • Exercise: Exercise therapy was effective for improving pain scores, active range of motion and overall shoulder function at short and long term follows ups. Some of the suggested forms of exercise included: scapular stability exercises, rotator cuff strengthening, and shoulder flexibility exercises. The article reported there was a Strong recommendation in favor of exercise therapy for patients with SSP.
  • Exercise combined with manual therapy: The article found moderate to high level evidence regarding the reduction of pain in the short term with the combination of exercise and manual therapy. The article concluded a Strong recommendation may be made in favor of exercises combined with manual therapy.
  • Multimodal physical therapy: This was defined as the combination of nonsurgical treatment including passive physical modalities, exercises, manual therapy, taping, corticosteroids or electrotherapy. Low level evidence was shown for taping, pulsed electromagnetic field therapy and multimodal care over isolated interventions. The article cited this may be due to the large variety of interventions and therefore multimodal therapy was given only a weak
  • Corticosteroid injection: Corticosteroid injection was found to be useful in the short and long term. One study recommended it as a second line of treatment in addition to exercise-based therapies. Overall, the study found a moderate recommendation for corticosteroid injection.
  • Laser Therapy: The study found a strong recommendation NOT to use laser therapy in the treatment of SSP.
  • Ultrasound: There was only a weak recommendation of ultrasound due to the reviews consistently concluding no evidence for the effectiveness of therapeutic ultrasound.
  • Extracorporeal shockwave therapy: Although a moderate recommendation was found, it was consistently concluded that the evidence did NOT support the effectiveness of extracorporeal shockwave therapy.
  • Pulsed electromagnetic energy: There is a strong recommendation there is NO evidence to support the effectiveness for the treatment of SSP.


There is strong evidence to support the use of exercise and manual therapy combined with exercise in the treatment of SSP. There is conflicting evidence that surrounds the use of multimodal therapy and corticosteroid injection. Finally, other commonly prescribed non-surgical interventions, such as ultrasound, low level laser, and extracorporeal shockwave therapy all lack evidence of effectiveness. Here at Physical Therapy First, we will work with you to create a program tailored to your individual needs with specific exercises and manual based therapies to treat your subacromial impingement syndrome.


Pieters L, Lewis J, Kuppens K, Jochems J, Bruijstens T, Joossens L, Struyf F. (2020). An Update of Systematic Reviews Examining the Effectiveness of Conservative Physical Therapy Interventions for Subacromial Shoulder Pain. Retrieved from

Sleep Disturbance and Its Association with Pain Severity and Multisite Pain: A Prospective 10.7 Year Study

by Joseph Holmes, PT, DPT, CDN, FNCP


For most of time it has been thought that increased pain levels lead to poor sleep, but the total body of research over the past decade is beginning to indicate increased pain and poor sleep is a bidirectional relationship. In the past two years, the paradigm is shifting further to indicate that poor sleep is becoming more of the casual factor in the relationship, and it is less reciprocal than what was originally thought. What this means is that a lack of sleep or poor sleep quality leads to increased pain sensitivity, not just the other way around. Up to 56% of adults in the United States report difficulty in falling asleep, difficulty staying asleep, or overall inadequate levels of sleep. 88% of people with chronic pain in the US report some form of sleep disturbances. The goal of this study was to examine the effect of sleep on persistent knee pain and multisite pain.


This longitudinal study consisted of adults ages 50-80 in Australia, with follow ups and tracking performed at 2.6 years, 5.1 years, and 10.7 years. 1,100 participants were recruited and 533 were traced and tracked through the completion of the entire study. Pain measurements were assessed subjectively through specific questionnaires for knee pain severity (WOMAC) and questioning if a person had any form of pain in 2 or more locations, and objectively through x-rays of the bilateral knees.


Over the 10.7 year period of the study, 533 participants completed all follow up reporting. Overall, these participants reported consistent knee pain and MSP, and the number of individuals reporting sleep difficulties was comparable at year 10 compared to onset of the study. In looking back at the data, WOMAC knee pain scores and multisite musculoskeletal pain worsened in correlation to the extent of sleep disturbances. An interesting breakdown of the participants who completed the full study, indicated that the participants who fell off after 2 and 5 years had comorbidities consisting of greater body mass index, less physical activity, greater overall pain scores, and higher levels of smoking, being unemployed, and taking pain medication.

Discussion & Conclusion

This is the first study of its kind to follow participants long term, and utilize objective measurements to get results. Simply stated, sleep disturbance was independently associated with an increase in pain severity, without a placebo effect. Unfortunately, what this study also shows is that once a person falls into poor sleep quality and increased pain levels, rarely does either improve over a 10-year period. According to the authors, what this tells us is that treating poor sleep quality or pain has a reciprocal effect and could help the other. Also, co-morbidities such as higher body weight, smoking, unemployment, and educational levels are variables associated with poor sleep and higher pain levels. Also, those with consistently poor sleep quality have higher levels of CRP (c-reactive protein) and IL-6, which are both objective measures of systemic inflammation, a common pathway for pain in the body.

Physical Therapy First Implications

As the primary provider for Musculo-skeletal related pain and injuries, the physical therapists at Physical Therapy First can help you create healthy sleep habits and patterns which will in turn improve your overall sense of pain. An improvement in pain sensitivity leads to an improvement in function, and will help you get back to the lifestyle you enjoy, pain free. At Physical Therapy First, our Doctors of Physical Therapy provide one on one treatments for one hour to assist you in making the improvements from where you are now to where you want to be regarding your pain.


Pan, F., Tian, J., Cicuttini, F., Jones, G. (2020). Sleep Disturbance and Its Association with Pain Severity and Multisite Pain: A Prospective 10.7-Year Study. Pain Therapy. 9:751–763