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Cervicogenic Headaches and Conservative PT

by | Feb 28, 2019 | Health Tips

by Sean Phillips, PT, DPT

A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial
Stephanie Racicki, Sarah Gerwin, Stacy DiClaudio, Samuel Reinmann, Megan Donaldson

Introduction:

Headaches are a very common complaint, affecting nearly 47% of the population. Of these headaches, cervicogenic headaches (CGHs) account for ~20% and typically affect women more often than men. This condition can be debilitating and limit your ability to work, sleep, perform household chores, or even ruin the time you want to be relaxing. These types of headaches are very common following a trauma such as whiplash, but just because you may have never been in an auto-accident doesn’t mean you can’t have CGHs. Unfortunately, these can also be caused by the prolonged and poor postures many people assume in their everyday lives.

The International Headache Society (IHS) has classified CGHs as “pain referred from a source in the neck and perceived in one or more regions of the head and/or face”. This means that neck pain usually accompanies the headache, but it is also possible to complain of arm/shoulder pain, dizziness, nausea, lightheadedness, “eye” pain, and visual disturbance.

The next time that you are suffering from a headache, try feeling the back of your neck, specifically right below your skull, to see if there is any muscular tenderness. If so, you may be suffering from a CGH, especially if pressing into these muscles make your headache worse. But the big question is: “What do I do to make my headache go away?”

Review of existing research and literature:

In a systematic review by Racicki et al, researchers attempted to determine the effectiveness of conservative PT approaches to manage patients suffering from cervicogenic headaches. There have been many techniques utilized, including invasive and non-invasive treatments. Invasive approaches can include injections, dry needling, or surgery. Non-invasive treatments can include TENS, massage, mobilization, manipulation, and exercise.

The researchers were able to find a total of 6 articles that fit their criteria which required randomized control trials and an assessment on at least one type of conservative treatment. In these studies, the interventions which were utilized included: cervical manipulation and mobilization, self-mobilization (by the patient), exercise (cerico-scapular strengthening), and thoracic manipulation.

Although the studies reviewed different techniques, many involved similar outcome measures. These included headache frequency, intensity, and duration, as well as disability, neck pain, and amount of analgesic use (pain killers).

Results:

Although the studies assessed different techniques, the overall results demonstrated that the most effective conservative treatments for CGH pain included cervical mobilization and manipulation, as well as exercise to strengthen the cervicoscapular muscles. These were especially helpful in improving headache frequency, intensity, and neck pain.

In addition to the 6 articles that were utilized for this review, the authors reported that some articles that were not included indicated that conservative management could reduce analgesic use as well.

Although this article displayed good success with cervical manipulation and mobilization, the studies included did not report on many of the other conservative treatments that physical therapists offer. These can include deep tissue massage, modalities such as cold packs and TENS, or cervical traction, which could also provide benefits to this patient population.

Conclusion:

Headaches are a common disorder facing many Americans everyday. Conservative physical therapy management, including mobilization, manipulation, and exercise have been shown to have a positive effect on reducing headache intensity, frequency, and neck pain.

If you are suffering from persistent headaches that are affecting your quality of life, physical therapy may be an effective way to reduce your pain and get you back to where you want to be, while teaching self-management techniques to potentially reduce their recurrence.

A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial
Stephanie Racicki, Sarah Gerwin, Stacy DiClaudio, Samuel Reinmann, Megan Donaldson
Journal of Manual and Manipulative Therapy
2013; Vol. 21 ; No. 2
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3649358/pdf/jmt-21-02-113.pdf

Physical Therapy Could be the Answer for Pain Reduction for People Suffering with Osteoarthritis

by | Feb 27, 2019 | Health Tips

by Genevieve Bland, PT, DPT

Background

Osteoarthritis (OA) is when the cartilage that lines the bone of joints breaks down, causing pain, swelling and problems moving the joint, according to the Arthritis Foundation. OA is the most common chronic condition of the joints, affecting approximately 27 million Americans. OA occurs mostly in the knees, hips, and low back but can occur in any joint. The primary symptom of OA is debilitating pain that leads to impaired function and decreased quality of life. According to Benson et al., knee pain and radiographic evidence of osteoarthritis joint degeneration are not always correlated. Heightened pain from osteoarthritis has two mechanisms.  One mechanism is hyperexcitability of central nociceptive pathways (path that sends information to the brain) which has been shown to produce enhanced pain response, spread pain and lead to chronic pain. The second mechanism for heightened pain in individuals diagnosed with osteoarthritis is ineffective pain inhibition. The purpose of this study by Carol et al., was to determine the effect of joint mobilization on impaired conditioned pain modulation (CPM), which is a method of an application of a noxious stimulus at a distant site causes inhibition of pain at the initial site.

 Literature search and data analysis to minimize pain in knees with osteoarthritis

In a recent search Carol et al. investigated knee joint mobilizations for pain reduction in individuals that have been diagnosed with osteoarthritis. CPM has been examined through use of protocols that typically include cold or ischemic pain. The effects of surgical and transcutaneous electrical nerve stimulation (TENS) interventions on impaired CPM have been studied, but not manual therapy consisting of joint mobilizations performed by physical therapists to minimize pain from OA in the knees. Carol et al. hypothesized that CPM would be more effective following the application of joint mobilization and the vibratory deficits would normalize following joint mobilization.

Methods

Two experimental groups

  1. Cutaneous input: hands on cutaneous input only to the knee. This technique was executed by lightly placing both hands on the subject’s knee
  2. Cutaneous input plus joint mobilization: oscillatory joint mobilizations into slight tissue resistance. Physical therapist placed both hands on knee and glided the tibia forward and back on the femur within a pain-free range, moving slightly into tissue resistance.

Almost all subjects had knee pain in both knees with one knee pain being worse than the other and 85% reported occasions of the knee giving way. All interventions were applied by the same physical therapist, who was fellowship trained in orthopedic manual physical therapy. Experimental condition was applied 2 times for 3 minutes, with a 30 second interval between applications. Pressure pain threshold was established at the experimental knee. The tip of an algometer was applied perpendicular to the most painful site at the medial knee on the affected limb, at a rate of 50 kPa/s, until the subject reported a change from pressure to a painful sensation. The procedure was performed 3 times at 20-second intervals, and the average was calculated to determine PPT. Pressure pain threshold at all 3 sites and resting knee pain were measured preintervention, postintervention, and post-CPM reassessment. Screening protocol for impaired CPM is as follows:

  • Subject in supine position with hip and knee flexed 20 degrees
  • Most painful site was identified on medial aspect of affected knee and confirmed through gentle palpation by tester
  • Pressure pain threshold

 Results

No effect was noted from cutaneous input only. The main finding of the current investigation was the impaired CPM was enhanced following application of the joint mobilization intervention. This study suggest joint mobilization enhances CPM in patient with painful OA, demonstrated by decrease in deep tissue sensitivity to pressure. The investigators of this study also found enhanced somatosensory (sensation regarding pressure, pain and warmth) acuity in the knee following joint mobilization.
osteoarthritis pain reduction

Physical Therapy First:

Here at Physical Therapy First we provide one on one hands on care for our patients with various diagnoses. Our manually trained physical therapists offer an individualized care plans to assist our patient to achieve their optimal health.

 

  1. Courtney, C.A. et al. Joint mobilization enhances mechanisms of conditioned pain modulation in individuals with osteoarthritis of the knee. Journal of Orthopaedic & Sports Physical Therapy. 2016: 46, 168-176
  2. https://www.arthritis.org/about-arthritis/types/osteoarthritis/what-is-osteoarthritis.php
  3. https://www.google.com/search?q=visual+analog+scale+mm&safe=active&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjmoMevisvgAhULMd8KHQW8Aq0Q_AUIDigB&biw=1093&bih=514#imgrc=fjN0oJAZyYtSAM:&spf=1550692137843
  4. https://www.google.com/search?q=algometer&safe=active&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiWjL-PjMvgAhVJGt8KHQU0DRgQ_AUIDygC&biw=1093&bih=514

Running with Knee Osteoarthritis-Part 2

by | Feb 13, 2019 | Health Tips

By Lillian Wynn PT, DPT
Physical Therapist

Background

40% of American adults (110 million people) report walking or running as part of a regular exercise routine. Reports and ‘common knowledge’ about running and its impact on our joints are often conflicting. This is the second of three blog posts designed to look at current medical research regarding running on aging joints.

Article summary:

PARTICIPANTS:

Men and women 45-79 years old, were grouped into 3 groups.
1: No symptoms of knee osteoarthritis, and deemed low risk for developing knee osteoarthritis
2: No symptoms of knee osteoarthritis, and deemed high risk
3: Symptoms of knee osteoarthritis

METHODS

Patients were labeled as high volume runners, low volume runners, or non-runners. X-rays and pain questionnaires were provided at the start of the study, again at a 2 year follow up. Pain questionnaires were provided at the final 8 year follow up

RESULTS

Any history of running-low or high volume was associated with lower knee pain. There was slightly lower evidence of knee osteoarthritis on the x-rays of runners, but it was not statistically significant. Statistically the highest predictor of knee pain was BMI.

CONCLUSIONS

Other factors besides running seem to have more of an impact on symptomatic knee osteoarthritis. It is possible that wince runners tend to be more active and have lower BMI, that any potential damage is offset by the benefits of regular exercise.

PTF approach

Here at PTF, we want to keep you active in the activities that matter to you. If walking and running are important to you, and you feel limited by your knees, an evaluation could be useful. There are many factors besides osteoarthritis that could be contributing to your knee pain while running. PTF does a complete evaluation and then designs a treatment plan individual to you and your body to keep you moving.

Original Article

Lo, G., Driban, J., Kriska, A. McAlindon, T., Souza, R., Petersen, N., Storti, K., Eaton, C., Hochberg, M., Jackson, R., Kwoh, K., Nevitt, M., Suarez-Almazaor, M. (2017). History of Running is Not Associated with Higher Risk of Symptomatic Knee Osteoarthritis: A Cross-Sectional Study form the Osteoarthritis Initiative. Arthritis care res, 69(2), 183-191. doi:10.1002/acr.22939.

Running with Knee Osteoarthritis-Part 1

by | Jan 29, 2019 | Health Tips

By Lillian Wynn PT, DPT
Physical Therapist

Background

40% of American adults (110 million people) report walking or running as part of a regular exercise routine.  Reports and ‘common knowledge’ about running and its impact on our joints are often conflicting. This is the first of three blog posts designed to look at current medical research regarding running on aging joints.

Article summary

Often of most concern with running is whether the impact is harmful to the knee joint, as the thought is impact could cause and/or worsen osteoarthritis. Osteoarthritis is the term given to changes that occur along a joints surface as we age. The most common way to diagnose osteoarthritis is with an x-ray. A prospective study published in The American Journal for Preventative Medicine investigated whether running as we age increases the severity or frequency of knee arthritis.

PARTICIPANTS

45 long distance runners who were 50 years old or older, and had been running for at least 10 years; and 53 controls who were 50 years or older and did not run for exercise.

METHODS

Initial x-rays were taken of both knees of all participants. Over the next 18 years, 5 follow up x-rays were taken of each patient. These x-rays were graded on a standard scale to quantify the severity of knee arthritis.

RESULTS

Runners did not show higher rates or more severe cases of knee osteoarthritis than non-runners

CONCLUSIONS

Models found that higher BMI, higher initial damage on x-ray, and age to be most strongly correlated with arthritis on x-ray. There was no data to suggest that running, gender, previous knee injury, or total exercise time contributed to osteoarthritis of the knee. In short-go out and go for your run!

 PTF approach

Here at PTF, we want to keep you active in the activities that matter to you. If walking and running are important to you, and you feel limited by your knees, an evaluation could be useful. Often tight and/or weak muscles, stiff joints, and poor movement patterns can contribute to pain while running. PTF does a complete evaluation and then designs a treatment plan individual to you and your body to keep you moving.

Original Article

Chakravarty, E., Hubert, H., Lingala, V., Zatarain, E., Fries, J. (2008). Long Distance Running and Knee Osteoarthritis A Prospective Study. American Journal of Preventative Medicine, 35(2), 133-138. doi:10.1016/j.amepre.2008.03.032.

Pilates Training May Be Your Answer to Improve Your 5K Run Performance

by | Jan 18, 2019 | Health Tips

by Genevieve Bland, PT, DPT

Background

Running performance depends on several variables, which include: high maximum oxygen consumption, the ability to sustain maximum oxygen consumption for long periods of time, and the ability to move efficiently. The ability to move efficiently depends on metabolic cost, which is the amount of oxygen spent to move a runner a certain distance at a submaximal intensity. The lower the metabolic cost results in less energy expenditure and lower oxygen consumption, which makes a more efficient runner. There are numerous ways to lower metabolic cost such as: endurance training, strength and aerobic training, and plyometric training. Another way to improve metabolic cost is by engaging the muscles of the trunk and lower limbs to establish better control during a run. Pilates training has been utilized to strengthen trunk muscles in correlation with breathing. Research suggests, Pilates training strengthen core musculature, which decreases the amount of activation during running and increases the runner’s efficiency thereby improving running performance.

Literature search and data analysis to improve a recreational runners speed

In a recent search Finatto et al. investigated the effects of strength training of the postural and trunk muscles. There is research indicating that strength training improves running efficiency and performance that incorporate maximal and explosive programs to the lower extremities.
Finatto et al. hypothesized that metabolic cost and trunk muscle activation will be reduced and consequently, running performance may be improved. They studied the effects of strengthening the muscles of the center of force by Pilates training on metabolic cost and the muscle activation pattern and biomechanical parameters that could improve metabolic cost, which would lead to improve running performance.

Methods

Two groups
1. Pilates group: underwent running training combined with Pilates training
2. Control group: running training only

Both groups trained for 12 weeks and were evaluated before and after the training period. Post-training evaluations were performed 72 hours after the last training session

Running training: both groups participated in a 12-week racetrack training program 2x/week.

Pilate’s training: classic mat Pilates training two one-hour weekly sessions performed on days alternate to the days of the running training for the Pilates group only.

Table 1. 12-week periodization of Pilates training

12 week periodization of Pilates training

During the second session, the participants were evaluated for the maximum isometric amplitude of the electromyographic (EMG) signal of trunk muscles which include: obliquus externus, obliquus internus, longissimus, bicep femoris, vastus lateralis, latissimus dorsi, and gluteus medius. Each participant exerted max force with isometric testing after walking for 5 minutes. Three measurements were taken pre and post training. EMG were performed during running as well. Metabolic cost was measured after treadmill testing and participants rested for 15 minutes in the sitting position and at rest for five minutes in the orthostatic position to determine resting heart rate and maximal oxygen consumption.

Results

Running performance and respiratory variables were not significantly different between the groups in the pre-training period. In the post-training period, the Pilates group had significantly higher maximal oxygen consumption and significantly shorter 5-km running time with a significant lower metabolic cost. This suggests that distance runners are able to transfer effective gains from a slow-type core strength training method to the running movement.

Table 2

Effect of running training and running training combined with Pilates on performance and respiratory variables.

Data Represent the Mean Values (Standard Error) for 5-km Running Time, Maximum Oxygen Consumption (VO2max), Metabolic Cost at 10 km.h-1 (Cmet10), Metabolic Cost at 12 km.h-1 (Cmet12), Speed at the Second Ventilatory Threshold (VT2), and Oxygen Consumption at the Second Ventilatory Threshold (VO2 VT2).

Effect of running training and running training combined with Pilates on performance and respiratory variables

Physical Therapy First:

Here at Physical Therapy First we provide one on one hands on care for our patients to treat injuries, rehab after surgery and to help athletes optimize fitness performance. Our therapists can analyze your running technique and develop an individual treatment plan to assist you in achieving your goals for running.

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194057