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Exercise and Non-Pharmacological Treatment of POTS

by | Nov 7, 2024 | Health Tips

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Article: 

Exercise and Non-Pharmacological Treatment of Positional orthostatic tachycardia syndrome (POTS)

Introduction: 

Positional orthostatic tachycardia syndrome (POTS) is a condition where the heart rate increases to a tachycardic rate following positional changes.  Previous studies have demonstrated that patients suffering from POTS tend to have smaller hearts as well as lower blood volume.  These factors contribute to a large decrease in stroke volume during orthostasis which in turn leads to an increase in heart rate via the baroreflex.  Patients with POTS often have low exercise tolerance and poor cardiovascular conditioning.  Patients with POTS are commonly treated with exercise training along with volume repletion therapy.  This article proposes a structured, non-pharmacological treatment approach designed to treat patients with POTS.

Methods: 

The article divides its treatment approach into exercise, volume expansion, reduction in venous pooling and physical countermeasures.  The article draws on many other studies to pull its advice from but it is not an organized meta-analysis or systematic review. 

Results: 

The article gives the following advice regarding the treatment of POTS:

              A combination of endurance training and lower body strength training are the primary components in the treatment of POTS.  A structured exercise program is known to correlate with increased cardiac size, peak oxygen uptake, blood volume and improvement in functional capacity and patient mood. 

              In the early stages of treatment for POTS, patients should begin endurance training at about 75% of their predicted max heart rate or at an RPE of 13-15 which may be described as somewhat hard.  Sessions should take place for 25-30 minutes 3 times per week using a recumbent bike.  The use of the recumbent bike is critical in the early stages of treatment because it allows the patient to exercise without experiencing POTS symptoms.  Patients with POTS and Ehlers-Danlos Syndrome (EDS) are recommended to exercise either by swimming or by using a rowing machine at moderate intensity to avoid putting excess stress on ligaments that are inherently less stable than average.  These patients may also benefit from wearing knee or elbow sleeves depending on the severity of their condition. 

              As treatment continues, the goal is to gradually progress the patient over a 3-month period to doing more upright exercise such as an upright bike or elliptical.  Once the patient is confident with upright endurance training, they may progress to jogging or stair climbing if they want to and are encouraged to continue exercising for endurance 3 times per week. 

              Resistance training is also recommended for this patient population with an emphasis on lower body muscles since these muscles act as pumps to encourage more efficient venous return.  The author suggests that seated, machine-based lifts are preferable to free weight lifts at least in the early stages of treatment.  This is to lower the risk of injury and to allow the patient to exercise in a seated or recumbent position to avoid increasing POTS symptoms.  The routine suggested includes leg press, knee extension, hamstring curls, seated calf raises, chest press, seated rows and some form of floor-based core exercises such as planks and abdominal crunches.  The author suggests that weight training begin once a week for 15 to 20 minutes and gradually progress to twice a week for 30-40 minutes as the patient’s tolerance improves. 

              Since many patients with POTS are known to have low blood volume which may contribute to their symptoms, the author recommends a diet that includes high levels of salt as well as increased water intake.  Patients may also try to sleep in a head-up position to encourage an increase in blood plasma volume.  The author cautions that although effective anecdotally, there have not been large clinical controlled trials to assess the efficacy of this treatment approach. 

              Patients with POTS have been shown to have increased venous pooling while in upright positions.  To counteract this, the author recommends compression garments.  Compression of all lower body compartments is ideal so the author suggests using compression garments that cover the entire lower extremity even into the lower abdomen.  The author cautions that compliance with this treatment is often low because the garments are difficult to don and doff, even with assistance.  Custom compression garments have been developed by NASA that may be easier for patients to use. 

              The author also provides several physical countermeasures that patients can utilize while experiencing POTS symptoms acutely.  Rhythmically squeezing a rubber ball with the hands while engaging the core and lower body muscles has been shown to increase mean arterial pressure.  Crossing the legs and squeezing the glute and quadricep muscles has been shown to quickly return blood from the venous system to the heart, this is mainly mechanical effect but there is some evidence that it may also reflexively cause an increase in cardiac output.  Engaging the leg muscles in rhythmic contractions has been shown to effectively pump blood centrally from the lower legs. 

              Squatting, sitting and lying down have all been shown to reduce the symptoms of POTS acutely. Forceful coughing can increase intrabdominal pressure which increases cardiac output and mean arterial pressure, assisting the heart.  Using a device to increase inspiratory resistance is effective in increasing cardiac output.  Cooling the surface of the skin can also be effective in increasing orthostatic tolerance by encouraging blood flow toward the center of the body. 

Discussion and clinical utility: 

This paper does an excellent job not only of putting forth a structured, evidence-based approach for non-pharmacological treatment of POTS, it also explains the rationale behind each recommendation.  The suggested treatment approach may not be practical to use on all patients with POTS, but it gives a useful framework from which to draw, so clinicians can modify treatment to better suit their patient’s specific needs. 

References:

Fu Q, Levine BD. Exercise and non-pharmacological treatment of POTS. Auton Neurosci. 2018 Dec;215:20-27. doi: 10.1016/j.autneu.2018.07.001. Epub 2018 Jul 4. PMID: 30001836; PMCID: PMC6289756.

Patellofemoral Pain Clinical Practice Guidelines

by | Oct 30, 2024 | Health Tips

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Article:

Patellofemoral Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association

Introduction:

The orthopaedic section of the American Physical Therapy Association (APTA) published these clinical practice guidelines in 2019 to give recommendations to clinicians in the differential diagnosis, assessment and treatment of patellofemoral pain.

These recommendations are designed to fit into the International Classification of Functioning, Disability, and Health (ICF model) that was introduced by the World Health Organization (WHO) to improve clinician’s ability to appropriately treat and communicate with patients by including pathoanatomical, psychosocial and societal factors when assessing a patient’s wants and needs.

Methods: 

Content experts were appointed by the orthopedic section of the APTA to search the current literature for articles relating to the treatment, assessment and diagnosis of patellofemoral pain.  Articles included were taken from MEDLINE, Scopus, CINHAL, SPORTDiscus, and the Cochrane Library with dates ranging from 1960 to 2018.

The chosen articles were then categorized based on level of evidence where I represented the highest quality evidence and V represented expert opinion.  After the evidence was reviewed and ranked, the experts developed and ranked recommendations utilizing the information.  A ranked recommendations were based on strong evidence while F ranked recommendations were based on expert opinion.  These recommendations were further categorized into the following content areas; diagnosis, classification, examination, and interventions.

Results: 

After reviewing the available literature, the authors made the following recommendations:

Clinicians should use the reproduction of pain behind or around the patella during squatting or other motions that load the patellofemoral joint in a flexed position to help diagnose patellofemoral pain.

The following factors can be used to diagnose patellofemoral pain:  pain behind or around the patella, reproduction of pain when the patellofemoral joint is loaded in a flexed position, exclusion of all other conditions that can cause anterior knee pain including tibiofemoral pathologies.

Clinicians can use the patellar tilt test with the presence of hypomobility to support the diagnosis of patellofemoral pain.

Since there are no previously established classifications of patellofemoral pain, the authors propose the following 4 classifications:  overuse/overload without other impairments, muscle performance deficits, movement coordination deficits, and mobility impairments.

Clinicians should use the following patient reported outcome measures when assessing patients with suspected patellofemoral pain:  the Anterior Knee Pain Scale, the patellofemoral pain and osteoarthritis sub-scale of the Knee Injury and Osteoarthritis Outcome Score, the Visual Analog Scale, the Eng and Pierrynowski Questionnaire, the Numeric Pain Rating Scale.

Clinicians should use functional tests such as squats, or step downs that reproduce patellofemoral pain to assess a patient’s progress throughout an episode of care.

Clinicians may use body structure and function impairments such as joint hypomobility, muscle weakness and lack of muscle extensibility to assess progress throughout an episode of care.

Clinicians should employ an exercise approach that targets both hip and knee musculature.  During the early stages of therapy, exercises targeting the posterolateral hip musculature is preferred but as the plan of care continues, targeting knee musculature as well is essential.

Clinicians may use patellar taping in the early stages of rehabilitation with the goal of reducing pain to enhance exercise performance.  Evidence shows that this can be helpful early on but generally has no lasting impact on prognosis or symptoms.  Clinicians should not prescribe knee orthoses such as knee sleeves or braces for the treatment of patellofemoral pain.

Clinicians may prescribe prefabricated foot orthoses for patients with greater than normal foot pronation during the early stages of rehabilitation in concert with an exercise program.  There is limited evidence suggesting that custom foot orthoses are more effective than prefabricated foot orthoses.

Clinicians should not use electromyography-based biofeedback on medial vastii activity to augment quadriceps exercise therapy for the treatment of patellofemoral pain.  Clinicians should also not use visual biofeedback on lower extremity alignment during hip and knee targeted exercise during the treatment of patients with patellofemoral pain.

Clinicians may use gait retraining during running for multiple sessions to adopt gait changes during running for patients with patellofemoral pain.

Clinicians may use blood flow restriction plus high-repetition knee exercises for those with limited or painful resisted knee extension.

Clinicians should not use dry needling for the treatment of patellofemoral pain, however acupuncture may be used to reduce pain.  There is limited evidence that acupuncture is more effective than placebo so caution should be exercised with this recommendation.

Clinicians should not use joint mobilizations or manipulations as a stand-alone treatment for patellofemoral pain.  Clinicians should not use biophysical agents including ultrasound, cryotherapy, phonophoresis, iontophoresis, electrical stimulation, or therapeutic laser therapy to treat patellofemoral pain.

Evidence suggests that patient education regarding plan of care, patellofemoral joint loading and Kinesio phobia helps to improve exercise program compliance to a rehabilitation exercise program.  The evidence suggests that a multimodal approach is ideal in the treatment of patellofemoral pain but that exercise is the primary factor in successful treatment.

Discussion and clinical utility:

This CPG is helpful because it provides new classifications of patellofemoral pain to help clinicians guide their plans of care.  It is also useful to see that exercise is the biggest factor in the effective treatment of patellofemoral pain.  This helps clinicians empower patients to be active and help treat their own symptoms.

References:

Willy RW, Hoglund LT, Barton CJ, Bolgla LA, Scalzitti DA, Logerstedt DS, Lynch AD, Snyder-Mackler L, McDonough CM. Patellofemoral Pain. J Orthop Sports Phys Ther. 2019 Sep;49(9):CPG1-CPG95. doi: 10.2519/jospt.2019.0302. PMID: 31475628.

The Effects of Thera Band Exercises on Rounded Shoulder Posture and Breathing Capacity

by | Oct 9, 2024 | Health Tips

Reviewed by Maggie McPherson, SPT

Article:

Effect of TheraBand Exercises on Rounded Shoulders Associated with Pulmonary Capacity in Young Adults: A Pre-Post Intervention Study published in Indian Journal of Physiotherapy & Occupational Therapy DOI: 10.37506/cbecx947

Introduction

Rounded shoulder posture is increasingly common in today’s sedentary world. Rounded shoulder posture can lead to upper extremity pain and dysfunction. What some people may not know is that the posture can also lead to changes in breathing capacity by changing certain postural and respiratory muscles’ ability to fully expand the rib cage.

Methods

This study is a pre-post intervention design that looked at the effects of Thera Band exercises on improving rounded shoulder posture and breathing capacity. Twenty-three young adults between the ages of 18-23 years, both male and female, were recruited for the study. The intervention program consisted of a TheraBand training program and pectoralis minor and pectoralis major stretching. The Thera Band resistance increased one level each week. The program frequency was 4 days a week for 3 weeks. Rounded shoulder posture was measured in supine with a measuring tape (distance from highest point of shoulder to table in cm). Pulmonary capacity was measured by spirometry, including Forced Expiratory Volume (FEV-1) and Functional Vital Capacity (FVC).

Results

After 3 weeks of the Thera Band exercise program, there were statistically significant improvements in rounded shoulder posture (p<0.001) and non-statistically significant improvements in both FEV-1 and FVC (p>0.001).

Discussion

These results demonstrate that a simple Theraband exercise and stretching program could demonstrate improvements in rounded shoulder posture in just 3 weeks. This could be useful to improve and prevent upper extremity pain and dysfunction. It is unclear from these results whether these exercises can improve breathing capacity. A larger, broader sample size and a randomized control group would be needed. As there was no control group or randomization in this study, no causation can be determined from these results. However, these results lay a promising foundation for future studies.

Reference

Anitha M, Tamatta S, bhosle S. Effect of TheraBand Exercises on Rounded Shoulders Associated with Pulmonary Capacity in Young Adults: A Pre-Post Intervention Study. Indian Journal of Physiotherapy & Occupational Therapy. 2024;18(3):46-50. doi:10.37506/cbecx947

Metronome Augmentation Increases Cadence in Novice and Recreational Runners

by | Sep 26, 2024 | Health Tips

Reviewed by Maggie McPherson, SPT

Article:

A One Session Gait Retraining Protocol with Metronome Augmentation Increases Cadence in Novice and Recreational Runners published in International Journal of Sports Physical Therapy DOI: 10.26603/001c.90909

Introduction:

Inexperienced runners are more likely to sustain running injuries, potentially due to poor form and training strategies. Research shows that some of the highest performing running athletes have a higher cadence than the average runner. This study explores the effects of a training protocol that includes a one-time training session followed by metronome augmentation practice. The aim of the study was to see if the protocol resulted in increased running cadence, as increased cadence is widely believed to improve running biomechanics and decrease sub-optimal force distribution through the lower extremities.

Methods:

This is a randomized controlled trial that looked at the effects of a training protocol on 33 novice or recreational runners over the age of 18. Each participant completed a 12 Minute Cooper Run at baseline and again after 2 weeks of training. Outcome measures included rate of perceived exertion (RPE), heart rate, cadence and distance covered. They additionally measure biomechanics via inertial measurement units, tracking stance duration, vertical excursion, knee flexion, and lumbar flexion.

The protocol included a training session for how to use the metronome while running. Each runner’s cadence was set at a 5-10% increase from their baseline cadence. Each participant then ran 2-3 times per week for up to 30 minutes for two weeks, with their set cadence playing via metronome. The researchers used a Mann-Whitney U test to analyze significant differences between the control and intervention groups.

Results:

Cadence at one minute (p=0.037) and overall cadence (p=0.002) both demonstrated significant, meaningful improvement versus the control group at the follow-up 12 Minute Cooper Run. There was no significant difference for any other outcome measures, including biomechanics.

Discussion:

Improving cadence has been largely supported in the research to improve running form, as over-striding is the number one biomechanical running error for recreational runners. Over-striding may cause increased stress on the lower extremity during gait, as the knee cannot properly respond to the high ground reaction forces as the foot hits the ground. These results offer a standardized, practical tool for clinicians to implement in their practice. External augmentation via metronome is a feasible way to improve novice runners’ cadence.

Reference:

Huber A, Verhoff D. A One Session Gait Retraining Protocol with Metronome Augmentation Increases Cadence in Novice and Recreational Runners. International Journal of Sports Physical Therapy. 2024;19(1):1494-1502. Accessed August 15, 2024. https://research.ebsco.com/linkprocessor/plink?id=5898c2c8-8a54-3f8b-b4e7-bdb5239c4026

Physical Therapy Management of Neurogenic Thoracic Outlet Syndrome.

by | Sep 20, 2024 | Health Tips

 

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Article: 

Physical Therapy Management of Neurogenic Thoracic Outlet Syndrome.

Introduction: 

Neurogenic thoracic outlet syndrome is a difficult condition to treat for many reasons.  The region is complex, including multiple joints, the brachial plexus and the subclavian artery.  The diagnosis of neurogenic thoracic outlet syndrome is still considered a diagnosis of exclusion, and there are often other regions involved such as cervical or thoracic spine dysfunctions that can make it difficult to identify the cause or causes of the problem.

There have been many treatment theories presented that can include postural training to improve diaphragm function, scalene and pectoralis minor releases to open space for the neurovascular bundle, shoulder girdle strengthening to decrease fatigue of the muscles in the region and scapulohumeral rhythm training to improve overall mechanics of motion in the region.  Despite the challenges of physical therapy to treat this condition, it is still recommended before attempting surgical intervention.  In one observational study, as many as 27% of patients receiving physical therapy met their goals without needing to progress to surgical intervention.

Methods:

This article discusses different aspects of treating neurogenic thoracic outlet syndrome such as interviewing, different treatment approaches, assessment techniques, support for patients and psychologically informed care.

Results:

  When interviewing a patient with suspected thoracic outlet syndrome, it is important to pay close attention to provoking and relieving activities as well as specific symptoms as these can be clues to whether the symptoms are caused by aggravated vascular tissue or aggravated nervous tissue.  For example, vascular thoracic outlet syndrome can sometimes present with claudication-like symptoms while neurogenic usually does not.  Some patients may be more sensitive to activities that stretch the neurovascular bundle while others may be more sensitive to activities that compress it.  Understanding this information is essential to recommending exercises and activity modification that can help relieve a patient’s symptoms.  Patient reported outcome measures can be useful for gathering this information.

A detailed physical assessment is necessary to rule out other more common pathologies such as cervical radiculopathy which can present with similar findings.  Since the proposed pathoanatomical cause of thoracic outlet syndrome is compromise of the neurovascular bundle, postural and biomechanical screening is key in understanding what patterns or postures may be contributing to this possible compromise.  To get a clear picture of a patient’s presentation, a biomechanical and postural screen should include but is not limited to cervical motion, thoracic motion and scapulohumeral rhythm.

Functional assessment and reassessment can be a useful tool for creating a plan of care as well as helping patients understand what might be triggering their symptoms.  The author uses upper extremity elevation as an example.  While a patient is raising their arm, the therapist can provide a variety of manual cues or resistance to alter the movement pattern and reassess for symptoms.  This could involve shifting the entire shoulder girdle, retracting the cervical spine or facilitating scapular upward rotation.

For treatment, it is important to keep in mind that the goal is often to change the forces moving through the thoracic outlet region.  Bearing in mind that some patients are irritated by traction and others can be irritated by compression, the therapist must be mindful of what positions they want to train in while continually monitoring the patient’s response.  Manual therapy to the scalenes, pectoralis minor, lower cervical and upper thoracic spine can be beneficial to decrease forces across the region and to modulate pain levels.

Although the goal of therapy is active management of the thoracic outlet region via muscular control, passive modalities such as taping can be used during the initial stages of treatment to help patients manage their pain and decrease their tissues irritability levels so they can respond more favorably to other interventions such as scapular stability training.

Stretching of specific muscles found during physical examination such as the scalenes and pectoralis minor should be done with caution.  Although the shortened length of these muscles may be a contributing factor in thoracic outlet syndrome, performing stretches can increase pressure on the neurovascular bundle, exacerbating symptoms.  Instead, the author recommends lengthening these muscles with manual interventions while the core and neck are relaxed and supported in the supine position.  In this way, there is little to no increased pressure on the neurovascular bundle, but a similar effect can be obtained.

Once a more optimal posture is identified for a patient and they are comfortable in this new position, the course of treatment should shift focus toward building endurance in this new position to help maintain the positive changes discovered during therapy.  Additionally, to get carryover into a patient’s everyday life it is necessary to assess and modify the ergonomics of their work and home environments to prevent future exacerbations.

Although positive neural tension testing is often observed with thoracic outlet syndrome, the author cautions against the use of neural gliding or flossing techniques, as these can increase a patient’s tissue irritability rather than decreasing it.  The author instead suggests exercise that focuses on thoracic flexion and rotation to get a more favorable outcome.

During an episode of care, it is important to bear a patient’s emotional state in mind.  It has been shown that motivational interviewing can be an effective adjunct therapy to help manage a patient’s pain.  The physical therapist is in a unique position to help encourage a more active lifestyle for patients as well as to reinforce helpful though patterns that can help patients reframe their pain to help them manage more effectively.

Discussion/Clinical Utility:

  This article provides a basic framework for both assessing and treating neurogenic thoracic outlet syndrome.  Given that thoracic outlet syndrome is considered a diagnosis of exclusion, it is helpful to have some sort of guideline for assessment and treatment planning.  This article does a good job of demonstrating the nuance of the condition by explaining not just what treatments might be appropriate but also the rationale of when you may choose one treatment over another.

Reference:

Collins E, Orpin M. Physical Therapy Management of Neurogenic Thoracic Outlet Syndrome. Thorac Surg Clin. 2021 Feb;31(1):61-69. doi: 10.1016/j.thorsurg.2020.09.003. PMID: 33220772.

Yellow Flags and Chronic Neck Pain: Which Post-Traumatic Stress Disorder Symptoms are Associated with Chronic Neck Pain in Individuals Involved in Motor Vehicle Crashes?

by | Sep 12, 2024 | Health Tips

Reviewed by Maggie McPherson, SPT

Article:

Post-traumatic stress symptom clusters in acute whiplash associated disorder and their prediction of chronic pain-related disability published in Pain Reports.
DOI: 10.1097/PR9.0000000000000631

Current research shows that Post-traumatic Stress Disorder (PTSD) is related to Whiplash Associated Disorder (WAD) and chronic neck pain. These authors set out to determine which specific PTSD symptoms are more predictive of chronic neck pain in individuals suffering from WAD due to a MVC. The authors examined a sample of 146 individuals with an acute, painful whiplash injury from a MVC. They monitored neck pain symptoms using the Neck Pain Disability Index (NDI), and any potential PTSD symptoms with the Post-traumatic Stress Diagnostic Scale (PDS). These items were assessed at baseline (within 1 month of injury) and again 6 months later. Thirty percent of the participants met the threshold for a PTSD diagnosis, and the remaining 70% had symptoms of PTSD but did not qualify for the full diagnosis.

A confirmatory factor analysisa was performed to determine separate clusters of symptoms on the PDS that could potentially affect neck pain. The results showed two clusters, one deemed the “re-experience/avoidance” cluster and the other the “hyperarousal/numbing” cluster. The avoidance cluster of symptoms included recurrent recollections, recurrent dreams, reliving trauma, psychological distress, physiological reactivity, avoiding thoughts, behavioral avoidance, hypervigilance, and exaggerated startle response. The hyperarousal cluster symptoms included diminished interest in activities, sense of foreshortened future, difficulty sleeping, difficulty concentrating, detachment from others, restricted affect, irritability and anger.

The results of the study showed that the hyperarousal/numbing cluster was the only cluster of symptoms associated with long-term neck pain1. The authors theorized as to why this might be the case. They discussed how inactivity and sleep deprivation could potentially stem from the hyperarousal symptoms. For example, diminished interest in activity, difficulty concentrating, and irritability could all impact the individual’s ability to work, leading to more inactivity. Additionally, difficulty sleeping is a symptom that could understandably lead to increased pain and decreased levels of activity.

However, the authors noted the apparent “non-specificity” of the hyperarousal cluster’s symptoms– meaning they are a group of symptoms that appear in various mental health disorders and are not necessarily specific to PTSD. In contrast, they labeled the avoidance cluster symptoms as typically “specific” to PTSD and not appearing in many other mental health disorders. Therefore, if the hyperarousal cluster of symptoms are present in a patient, one must be careful not to assume PTSD is present. The symptoms could simply be a result of the physical whiplash injury itself, and not stemming from any psychological trauma. More research is needed to be certain.

In conclusion, symptoms such as diminished interest in activities, difficulty sleeping, difficulty concentrating, detachment, irritability and anger may be present in individuals suffering from neck pain after an injury. These symptoms may stem from psychological trauma accompanying the injury, or could perhaps be normal, expected coping mechanisms for neck pain. Regardless, these particular symptoms are indicative of a longer prognosis of recovery and may warrant consideration for referral to a psychologist.

Footnote:

a. Confirmatory factor analysis: “a technique used to analyze the efficacy of measurement models where the number of factors and their direct relationship is specified” In this case, it was done to determine which particular symptoms have similar elements and are likely to have similar effects on neck pain and dysfunction.

References:

Maujean A, Gullo MJ, Andersen TE, Ravn SL, Sterling M. Post-traumatic stress symptom clusters in acute whiplash associated disorder and their prediction of chronic pain-related disability. Pain Rep. 2017;2(6):e631. Published 2017 Nov 27. doi:10.1097/PR9.0000000000000631

Price LA, Confirmatory factor analysis: foundations and extensions. International Encyclopedia of Education (Fourth Edition), Elsevier. Published 2023. 607-618. doi:10.1016/B978-0-12-818630-5.10016-8.