FOOD FOR THOUGHT: Role of Nutrition Supplements on the Recovery from Total Hip Replacement and Total Knee Replacement Surgeries

by  Tyler Tice PT, DPT, ATC

Nutrition is a major part of health and nutritional habits can influence outcomes for people after surgery, especially in older adults. Two of the more popular orthopedic surgeries that older adults receive are hip replacements and knee replacements. These are major surgeries that create a stressful stimulus to our bodies which result in an increased inflammatory response and impairs our immune system due to metabolic changes. It is known that it is always good to optimize nutrition, especially prior to surgery. There are multiple supplements available as well that can stimulate our body’s metabolic response with the potential to speed up recovery.

In an article titled: What Is the Role of Nutritional Supplements in Support of Total Hip Replacement and Total Knee Replacement Surgeries? A Systematic Review; the authors analyzed nine research studies to determine the effectiveness of nutritional supplements specifically on the recovery after hip and knee replacement surgeries.

After review, there were three types of supplements studied including carbohydrate drink supplements prior to surgery, amino acid supplements prior to surgery, and Beta-Hydroxy Beta-Methylbutyrate, L-Arginine, and L-Glutamine (HMB/Arg/Gln) supplements, as well as other conclusions the authors have made from the available research.

  • Carbohydrate Drinks Before Hip and Knee Replacement Surgery :
    • evidence is limited
    • may increase insulin-like growth factor 1 (IGF-1) levels which can be beneficial in reversing the metabolism changes that occur after the stress induced from surgery.
    • may reduce hunger, nausea, and help regulate insulin growth sensitivity.
    • One pilot study found that patients who took multiple nutritional interventions, one being a carbohydrate drink prior to surgery, had shorter hospital stays and decreased inflammation after hip replacement surgery.
    • No conclusive evidence for benefits; HOWEVER low risk and high potential benefits which may be most beneficial for those who are frail or with multiple co-morbidities
  • Amino Acids
    • Some evidence to suggest decreased muscle atrophy (muscle loss) after surgery and better performance on functional tests at 2 weeks and 6 weeks post surgery
  • Beta-Hydroxy Beta-Methylbutyrate, L-Arginine, and L-Glutamine (HMB/Arg/Gln)
    • HMB is reported to promote muscle protein synthesis and suppress muscle protein breakdown
    • Some evidence to suggest decreased muscle loss in quad muscle from 0-14 days post surgery
    • Might lead to early improvements in physical function and fall prevention
  • Additional Findings
    • Consumption of protein is vital for stimulating muscle protein synthesis and can have greater impacts in frail or malnourished individuals.
    • Pre-operative period is the most effective intervention time
    • future work needs to be done in researching nutritional influence on muscle inflammation susceptibility using antioxidant ingredients or polyunsaturated fatty acids
  • Study Limitations:
    • Limited amount of data
    • Small sample size in most research articles
    • 2 pilot studies were used

Nutritional therapy is most beneficial to support individuals with a high risk of developing post-operative complications or are sarcopenic, frail, malnourished/undernourished and have a limited protein reserve. There are multiple factors that go into recovery from joint replacement surgery and nutritional supplements can be one of these important factors. It is supported that a combination of physical, nutritional, and psychological pre-operative preparation all have positive impacts on the recovery from surgery.

For more information on this topic and for more details regarding the research that was reviewed, please see the article referenced below. It is important for each person to understand the multiple factors that go into recovery from joint replacement surgery and to know that each person’s recovery is unique. At Physical Therapy First, we want to help make your recovery as smooth as possible. We understand that each person’s recovery is unique, that’s why we spend a full hour with each of our patients and provide each person with a rehabilitative routine that is specific for them. Check out our website and give us a call to schedule an appointment with us!


Burgess, L., Phillips, S. and Wainwright, T., 2018. What Is the Role of Nutritional Supplements in Support of Total Hip Replacement and Total Knee Replacement Surgeries? A Systematic Review. Nutrients, 10(7), p.820


Meniscus? What’s that?

by Joseph Holmes, PT, DPT, CDN, FNCP


Meniscus. It’s a strange word, right? Many people are not aware that the meniscus is the protective covering over the lower leg (tibia) which forms cushion and support for the knee (20 from CPG). There are many functions of the meniscus, including to facilitate joint gliding or movement, prevent the knee from over-extending, provide nutrition to the knee, serve as a support for the knee, and provide shock absorption (1). The meniscus is rarely strained like other structures of the body, but it can become injured through “wear and tear” over time or a specific acute injury in which a person feels a catch or a pop in the knee. The type of injury that occurs determines whether the person is more likely to benefit from physical therapy or surgery for treatment. Surgery is very common for this injury. In the United States, meniscal surgeries account for 10%-20% of all orthopedic surgeries which represents about 850,000 meniscus surgeries every year (2).

Should I have an MRI or X-Ray?

If you have had any type of injury to your knee, whether it is meniscal-related or not, the following guidelines are used to determine whether imaging such as an MRI or X-ray is appropriate. These guidelines, called the Ottawa Knee rules, recommend having an MRI if you meet any of the following criteria after a traumatic knee injury (3,4):

  • Age 55 or older
  • Isolated tenderness to your kneecap
  • Tenderness to the touch at the head of your fibula (just below your lateral or outside knee)
  • Inability to flex the knee to 90 degrees
  • Inability to bear weight immediately or unable to take 4 steps

Should I have surgery?

This is a very common question and the answer is complex. Evidence from a study in the New England Journal of Medicine demonstrated that among people with a meniscal tear and knee osteoarthritis at 6 months and 12 months, there were no clinical or significant differences found in functional outcomes between those who had surgery and those who did not (5). What does this mean? Surgery for a torn meniscus, especially one that is naturally worn over time as compared to a specific traumatic tear, often results in no benefit compared to performing non-surgical physical therapy. Physical therapists are clinical experts in diagnosing and treating meniscus injuries. Let’s take a look at what the latest research says about how physical therapists can help patients with meniscus injuries.

2018 Clinical Practice Guidelines for Meniscal Lesions

          First, your physical therapist will want to find out about the history of your mechanism of injury: What happened? Did you twist your knee? Did you feel a sharp pain? Is your injury tender to the touch? Are you able to put weight through it? How swollen is your knee? How bad does it hurt? Does it feel like it catches, locks, or buckles? What makes it feel better and what makes it feel worse? Does it have sharp infrequent pain or is it a subtle pain that is there almost always when you put weight through it? All of these questions will help to guide the physical therapist in performing objective tests to determine the diagnosis and severity of the injury. This examination will also include assessing the flexibility and strength of the hip, knee, and ankle and functional challenges such as climbing the stairs, walking for 2 to 6 minutes, and hopping on one leg. After these assessments are performed, the final step is performing specialized tests that are specific to the meniscus, including the “McMurray Manuever”. The McMurray Maneuver is the best test for assessing a meniscal injury according to the 2018 Meniscus Clinical Practice Guidelines and is defined as follows (6,7,8,9):

“With the patient supine the examiner holds the knee and palpates the joint line with one hand, thumb on one side and fingers on the other, whilst the other hand holds the sole of the foot and acts to support the limb and provide the required movement through range. From a position of maximal flexion, extend the knee with internal rotation (IR) of the tibia and a VARUS stress, then return to maximal flexion and extend the knee with external rotation (ER) of the tibia and a VALGUS stress.[1][2][3] The IR of the tibia followed by extension, the examiner can test the entire posterior horn to the middle segment of the meniscus. The anterior portion of the meniscus is not easily tested because the pressure to that part of the meniscus is not as great. Positive findings for the McMurray Maneuver include pain, snapping, audible clicking or locking can indicate a compromised meniscus.”

Image above courtesy of


The following exercises are recommended for persons with a meniscal injury who did not have surgery:

  • Progressive range of motion and flexibility of the knee all directions
  • Progressive strength training of the knee and hip musculature
  • Neuromuscular re-training such as balance activities

What is the goal of rehab for a meniscal injury?  As with most joint injuries, the primary goal is to return to your normal function as soon as possible. In order to do this, you will work with your physical therapist to improve knee flexibility, progress the strength of all the muscles of your hips and knees which also provide support to your meniscus, and improve your balance and control. This will allow you to return to your daily activities pain free and prevent other meniscus injuries in the future.

Physical Therapy First

The orthopedic specialist at Physical Therapy First will provide you with the highest quality care based on the latest research combined with decades of clinical experience to assist in decreasing the swelling of your knee, returning your knee to full range of motion, and helping you to create an individualized exercise program that will allow you to avoid surgery and experience a higher quality of life. Our therapists provide 1-on-1 treatment sessions with all patients for one hour and offer the best care you will receive in the greater Baltimore area. Call any of our four clinics to schedule an assessment today.


  • Brindle T, Nyland J, Johnson DL. The meniscus: review of basic principles with application to surgery and rehabilitation. J Athl Train. 2001;36:160-169.
  • Renström P, Johnson RJ. Anatomy and biomechanics of the menisci. Clin Sports Med. 1990;9:523-538.
  • Bachmann LM, Haberzeth S, Steurer J, ter Riet G. The accuracy of the Ottawa knee rule to rule out knee fractures: a systematic review. Ann Intern Med. 2004;140:121-124.
  • Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med. 1995;26:405-413.
  • Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, Donnell-Fink LA, Guermazi A, Haas AK, Jones MH, Levy BA, Mandl LA, Martin SD, Marx RG, Miniaci A, Matava MJ, Palmisano J, Reinke EK, Richardson BE, Rome BN, Safran-Norton CE, Skoniecki DJ, Solomon DH, Smith MV, Spindler KP, Stuart MJ, Wright J, Wright RW, Losina E. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84. doi: 10.1056/NEJMoa1301408. Epub 2013 Mar 18. Erratum in: N Engl J Med. 2013 Aug 15;369(7):683. PMID: 23506518; PMCID: PMC3690119.
  • Magee, D.J Chapter 12: Knee, in Orthopedic Physical Assessment. Pg 791. Saunders Elsevier. 2008.
  • Piantanida, A.N. Yedlinsky, N.T. Physical examination of the knee, in The Sports Medicine Resource Manual, Editors: Seidenberg, P.H & Beutler, A..I. 2008 Saunders. DOI
  • Waldman,S.D. Painful conditions of the knee, in Pain Management Vol 1., 2007. Saunders. DOI
  • Logerstedt DS, Scalzitti DA, Bennell KL, Hinman RS, Silvers-Granelli H, Ebert J, Hambly K, Cary JL, Snyder-Mackler L, Axe MJ, McDonough CM. J Orthop Sports Phys Ther 2018;48(2):A1-A50. Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions. doi:10.2519/jospt.2018.0301

Recovery after volleyball

by Elizabeth Kwon, SPT

There are a variety of recovery methods used to enhance the performance of athletes; however, the specific techniques and dosage are debated among various individual sports and athletes. Volleyball is an intermittent sport requiring bursts of high intensity movements during gameplay and with often little recovery time in between matches. While there is limited evidence on recovery techniques specific for volleyball players, several methods are discussed including the following:


  • Nutrition for athletes requires a higher caloric intake, proper carbohydrate and protein intake, and sufficient nutrients and hydration
  • Overall, female volleyball players tend to consume less than the recommended caloric intake per day as well as proper levels of protein, fiber, iron, carbohydrates, iron, and calcium
  • Current recommendations may lack sex-specificity.
    • Female volleyball players were able to improve their power, speed, and body composition despite maintaining a lower caloric intake than recommended
    • Female volleyball players require less carbohydrates compared to the recommended dosage suggesting that they may be less reliant on glycogen during exercise and less responsive to glycogen synthesis during recovery
    • Female volleyball players consumed more protein on average than the recommended amount
  • It is recommended that volleyball players maintain an increased carbohydrate to protein ratio to facilitate muscle recovery rather than a direct focus on the absolute amount of consumed protein
  • Antioxidant supplementation shows promise in enhanced antioxidant defense against free radicals during periods of intense training
  • Proper hydration prior to a match is important to improve performance and recovery
    • In a study of beach volleyball athletes, players lost an average of 1.4 L of sweat during a match.


  • It is recommended for athletes to obtain 7-9 hours of sleep with upwards of 10-12 hours for athletes who are adolescents or train 4-6 hours per day
  • Lack of sleep led to a depletion of energy and decreased time to exhaustion during exercise, and athletes with higher levels of insomnia were associated with decreased performance
  • Quality of sleep is also important in athletes, where those with greater sleep quality and won their games exhibited decreased stress levels and lower levels of confusion in comparison to those with lower sleep quality

Mental and psychological techniques:

  • Athletes who have a decreased amount of perceived recovery time are at a higher risk for injury
  • Spending time with friends, team building activities, and amusement are associated with promoting recovery and preventing injury
  • In a study of 11 female intercollegiate volleyball players, a program focusing on cognitive behavioral skills demonstrated that increased use of imagery and using a routine increased serving performance
  • High levels of anxiety and stress may lead to impaired performance, yet few athletes utilize mental or emotional recovery techniques

Cold water immersion (CWT) and Laser therapy (LLLT):

  • Limited evidence is available for CWT and LLLT for athletes, and there is no consensus on the effectiveness or dosage for either recovery technique.
  • CWT is suggested to improve submaximal muscle function in comparison to active recovery and suppress post-exercise levels of creatine kinase (CK) and lactate dehydrogenase (LDH)
  • LLLT is suggested to reduce post-exercise CK levels and other inflammatory markers of muscle damage; however, the research is limited by some of the studies using rat models as well as there being mixed results among studies.

Overall, current nutrition recommendations for female athletes lack sex specificity, and athletes may benefit more from maintaining a high carbohydrate to protein ratio rather than using absolute numbers. Supplementation using antioxidants may be beneficial in improved recovery among athletes. It is important to maintain an adequate amount of sleep as well as quality of sleep to improve performance levels. In terms of mental and psychological techniques, routines involving imagery for closed activities, like serving, and managing anxiety and stress levels may improve performance. It is essential to educate athletes on recovery time as perceived recovery time is a risk factor for injury, and likewise, it may be beneficial to encourage activities, such as team bonding and spending time with friends to decrease risk of injury and improve recovery. At Physical Therapy First, your physical therapist can provide you with protocols for proper warm-up and cool down activities as well as discuss the factors listed above with you to maximize your recovery, decrease your risk of injury, and improve your performance.


Closs, Brian. Burkett, Connor. Trojan, Jeffrey D. Brown, Symone M., Mulcahey, Mary K. “Recovery after volleyball: a narrative review.” The Physician and Sportsmedicine, Volume 48, Number 1: 8-16, (2020).

My Shoulder is Frozen-What?

By Joseph Holmes, PT, DPT, CDN, FNCP

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

basic shoulder movements

Image courtesy of

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

Categories of Adhesive Capsulitis (1)

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

Stages of Adhesive Capsulitis:

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

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

What Do I Do if My Shoulder Freezes?

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

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

Physical Therapy First

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


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


The Effects of Vitamin D Deficiency and Benefits of Supplementation

by Logan Swisher, PT, DP


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

How is Vitamin D Metabolized?

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

Benefits of Vitamin D

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

How much Vitamin D do you need?

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


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

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

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

By Joseph Holmes, PT, DPT, CDN, FNCP

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

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

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

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

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

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

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

            Physical Therapy First

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


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