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I had an ankle sprain, why are you strengthening my hip?

by | May 26, 2019 | Health Tips

By Logan Swisher SPT

Ankle Sprain – Background:

Lateral ankle sprains are a significant burden on U.S healthcare with estimated costs of $6.2 billion annually. They can be associated with long-term consequences such as decreased health-related quality of life, decreased physical activity and post-traumatic ankle osteoarthritis. Some patients with a history of lateral ankle sprain develop chronic ankle instability; which is commonly marked by repetitive ankle injury, balance and mobility deficits, and perceived instability of the ankle.  Other patients with a history of lateral ankle sprain do not develop the subsequent characteristics of chronic ankle instability. Studies have shown that lateral ankle sprain copers have more favorable ankle range of motion, ankle strength, joint stability and postural control as compared to those who develop chronic ankle instability.

Dynamic postural control is the ability to maintain your balance while moving any part of your body (ie catching a ball, jumping, carrying, etc). Patients with chronic ankle instability tend to have limited dynamic postural control. In clinical practice, a star-excursion balance test (SEBT) is a simple measure of dynamic postural control. This study aimed to examine the differences in SEBT performance and hip strength in those with chronic ankle instability, lateral ankle sprain copers and control groups.

Participants:

84 participants total:

-30 chronic ankle instability

-29 lateral ankle sprain copers

-25 control

Methods:

Single-blinded, cross-sectional, case-control study design was utilized. One physical therapy clinic assigned patients to their appropriate group, and then after treatment, results were collected and analyzed. All participants were tested for leg length, SEBT, and isometric hip strength.  Averages of SEBT and isometric strength were taken from three trials respectively.

Results:

This research revealed that individuals with chronic ankle instability had lower SEBT score decreased hip strength compared to lateral ankle sprain copers and control groups. This indicates that dynamic postural control and isometric hip strength is compromised in individuals with chronic ankle instability.

Ankle Sprain – Clinical Application:

Physical therapists treating patients with chronic ankle instability should include exercises to target hip muscular strength deficiencies which may in turn have a positive effect on dynamic postural control performance.  Here at PT First we approach a patient globally and work to incorporate any insufficiencies found during examination into a well-rounded, dynamic rehabilitation program.

Original article – ankle sprain:

McCann, R. S., Crossett, I. D., Terada, M., Kosik, K. B., Bolding, B. A., & Gribble, P. A. (2017). Hip strength and star excursion balance test deficits of patients with chronic ankle instability. Journal of Science and Medicine in Sport, 20(11), 992-996. doi:10.1016/j.jsams.2017.05.005

 

Running with Knee Osteoarthritis-Part 3

by | Apr 28, 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 third of three blog posts designed to look at current medical research regarding running on aging joints.

Article summary

PARTICIPANTS:

This paper is a systematic review and meta-analysis, so the authors compiled research on knee osteoarthritis (OA) and running, and summarized the findings in order to provide a concise recommendation based on the general consensus of research. Articles were included if they: were level I-III evidence, written in English, used physician diagnosed OA with clinical and/or radiographic findings, and running was compared to non-running. Articles that compared running to other forms of exercises were not included in this study.

METHODS:

Literature searches were performed, and 1,907 articles were reviewed. Of those, 25 met their inclusion criteria. Statistical analysis was performed on those 25 studies to come to a meta-analysis, which summarizes and confirms the general recommendations based on significant research.

CONCLUSIONS:

The authors concluded that recreational running was in fact associated with lower levels of OA when compared to sedentary individuals. Competitive running was associated with higher levels of OA than recreational runners. Overall, sedentary subject demonstrated the most symptomatic OA. The study also argues that this simply compares runners to non-runners. So the only conclusion that can be drawn is that running is better than being sedentary. More research should be done into seeing if running vs other forms of exercise is the best for of 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

Alentorn-Geli, E., Samuelsson, K., Musahl, V., Green, C., Bhandari, M., Karlsson, J. (2017). The Association of Recreational and Competitive Running with Hip and Knee Osteoarthritis: Systematic Review and Meta-analysis. J Orthop Sports Phys Ther, 47(6), 373-390. doi:10.2519/jospt.2017.7137

Cost-Effectiveness of Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome

by | Mar 17, 2019 | Health Tips

by Leah Flamm, PT,

César Fernández-de-las-Peñas, PT, PhD, DMSc, Ricardo Ortega-Santiago, PT, PhD, Homid Fahandezh-Saddi Díaz, MD, PhD, Jaime Salom-Moreno, PT, PhD, Joshua A. Cleland, PT, PhD, Juan A. Pareja, MD, PhD, José L. Arias-Buría, PT, MSc, PhD.

Background

Carpal tunnel syndrome (CTS) costs more than $2 billion annually in the United States. Considered the most common nerve entrapment in the arm, CTS results in less work productivity and other healthcare costs. Surgery is most often recommended to treat CTS, perhaps because of limited evidence supporting nonsurgical treatments such as exercise and mobilization. A recent study found that compared to surgery, manual therapy (such as desensitization of the central nervous system) resulted in better short-term outcomes and similar long-term effects on pain intensity and function. This study compares healthcare costs between manual therapy and surgery in women with CTS.

Participants

Women younger than 65

Diagnosed with CTS based on clinical and electrophysiological findings

Must have had symptoms for at least 12 months

Methods

Alongside a randomized clinical trial in a hospital in Madrid, Spain, the researchers performed an economic evaluation to determine the cost-effectiveness of surgery versus manual physical therapy. Patients were randomly assigned to receive either manual physical therapy or a surgical procedure. Those in the manual physical therapy group received three 30-minute sessions once a week, with soft tissue mobilization at areas where the median nerve may be entrapped, lateral glides to the neck, and tendon- and nerve-glide exercises (which patients were also taught to do at home). Those in the surgery group had open or endoscopic release of the carpal tunnel and the same home exercises on tendon- and nerve-glides the manual physical therapy group received.

Economic Evaluation

For the economic evaluation, the researchers looked at direct healthcare costs, direct non-healthcare costs, and indirect costs due to CTS. For direct healthcare costs, they looked at the costs of each treatment (such as the number of sessions, number of visits to manual physical therapists), additional visits to healthcare providers, additional treatments received, prescribed medications, and professional home care. For direct non-healthcare costs, they looked at costs of over-the-counter medications, time spent visiting a healthcare provider, and travel expenses. They also looked at indirect costs of lost productivity due to CTS-related absence from work.

Outcomes

The researchers also measured health-related quality of life at baseline and at each follow-up period.

Results

The researchers found the surgery group was significantly more expensive than the manual physical therapy group. Additionally, patients in the surgery group also received a greater number of other treatments, mostly complementary manual physical therapy, and also made more visits to their orthopaedic surgeon and/or neurologist than those in the manual physical therapy group.

Missing paid work was significantly higher within the surgery group than in the manual physical therapy group, both in terms of the number of people missing work (86.7% vs. 6.9%) and the number of days off from work (mean, 65 versus 28 days; total, 3360 vs. 112 days).

Mean cost (including work absence) was €12,147 for manual physical therapy and €167,143 for surgery. Similarly, mean cost per participant (including work absence) was statistically higher in the surgery group than in the manual physical therapy group (€2785 versus €209, P<.001).

Cost-Effectiveness

The researchers found that manual physical therapy group was less costly (€−154,996) and more effective (5.844 Quality-Adjusted Life Years) than the surgery group.

Discussion

The results showed that manual physical therapy was more cost-effective than surgery, and healthcare costs and missed work within the surgery group were significantly greater than in the manual physical therapy group.

The generalizability of the results may be limited, as only women from a single hospital in Spain were included and the study was conducted in a particular health system. However, the study suggests that manual physical therapy, including desensitization of the central nervous system, may be an intervention option for patients with carpal tunnel syndrome as a first line of management prior to, or instead of, surgery.

Here at Physical Therapy First, we perform a complete evaluation to try to figure out what is the underlying cause of every patient’s symptoms. We may examine any or all of the following: range of motion, strength, muscle imbalances, joint mobility, functional movement, posture, and more. Based on those findings, we create custom treatment plans to reduce symptoms and help our patients return to living a full and healthy life. Just as the study suggests, some of our treatments may include soft tissue mobilization and neural desensitization, as well as other interventions such as muscle strengthening and stretching, improving posture, and creating a home exercise program.

Original article:

Fernández-De-Las-Peñas, C., Ortega-Santiago, R., Díaz, H. F., Salom-Moreno, J., Cleland, J. A., Pareja, J. A., & Arias-Buría, J. L. (2019). Cost-Effectiveness Evaluation of Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: Evidence From a Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy,49(2), 55-63. doi:10.2519/jospt.2019.8483

Peñas, C. F., Ortega-Santiago, R., Llave-Rincón, A. I., Martínez-Perez, A., Díaz, H. F., Martínez-Martín, J., . . . Cuadrado-Pérez, M. L. (2015). Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. The Journal of Pain,16(11), 1087-1094. doi:10.1016/j.jpain.2015.07.012

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.