Manual Therapy vs Therapeutic Exercise in Non-Specific Chronic Neck Pain

by ptfadmin | Nov 14, 2022 | Health Tips

Reviewed by Mark Boyland PT, DPT, CSCS

This study sought to explore the effect times of manual therapy alone vs therapeutic exercise alone as well as to break down and compare the effects of these two interventions in the short and mid term.

The authors compared visual analog scale, pressure pain threshold, cervical disability through the Neck Disability Index Outcomes.  These values were assessed at evaluation, week 1, week 4, and week 12.

The participants were split into 1 of 3 intervention groups; Manual Therapy, Therapeutic Exercise, or Sham.  At the end of the trial the study was able to analyze date across 67 participants, 22 in the Manual Therapy Group, 23 in the Therapeutic Exercise Group, and 20 in the Sham treatment group. Demographic date was relatively similar between groups, however there were more female participants than males. 

The interventions were listed for each group.  The manual therapy group included frequency of interventions, grading of mobilizations/manipulations, speed of mobilization, duration of mobilization, and sets of mobilizations.  The therapeutic exercise group include progressions of exercises from week 1 and 2 and the exercises after week 2.  Exercise descriptions included patient position with equipment required, and duration/frequency of exercises.  The authors also provided a description for how the sham treatment was provided.  It is noted that the sham treatment group did receive either manual therapy or therapeutic exercise interventions only after completion of the study.  The study was conducted by researchers from the University of Seville, Seville, Spain and potential mistranslations may be present when reviewing the applied interventions.

The intervention groups had significant improvements in VAS at weeks 1,4, and 12.  Both intervention groups had significant changes for the NDI at weeks 1 and 4.  However, the manual therapy group was able to maintain these improvements into week 12 with no statistical difference and the therapeutic exercise group had a poorer score relative to the 4 week evaluation however the 12 week score was still lower than the patient’s initial score.  The pain pressure threshold was only reduced in the manual therapy group at 4 weeks, however at 12 weeks both intervention groups showed improvements.  The control group demonstrated no significant changes throughout the study.

In regards to selection of these interventions as stand alone treatments, therapeutic exercise may improve function more quickly whereas manual therapy may improve pain more quickly, both interventions can have similar results in the mid term.  The authors note that a larger sample size may refute their findings and that treatment of chronic non specific neck pain should include multiple interventions not limited to only manual therapy and therapeutic exercise but could also include patient education and pain science education.   The authors also note that there is no method that guarantees patients complete their home exercises.

For patients:  Physical therapy for non specific chronic neck pain can be treated with hands on and an exercise approach and there can be significant changes made within just 4 weeks that can last up to twelve weeks but there is some work on your part that has to be done as well in the short, mid, and long-term

Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy

by ptfadmin | Oct 27, 2022 | Health Tips

Article Review: by Kira Zarzuela, SPT, Tyler Tice, PT, DPT, OCS

Background:

Eccentric exercise is the most commonly prescribed exercise for the treatment of tendinopathy, however, is often too painful to complete. In the competitive season, athletes are less likely to adhere to an eccentric loading program due to increased pain and experiencing either no benefit or worse outcomes, however they may be more compliant with pain reduction strategies that enable ongoing sports participation. Few interventions reduce patellar tendinopathy (PT) pain in the short term. Isotonic exercise has been shown to be as effective as eccentric loading in PT, however there is little to no current research demonstrating this form of exercise’s effect on pain. Isometric exercise has been shown to reduce pressure pain thresholds in normal populations but has not been studied in PT. This study compared the effect of a short bout of isometric and isotonic quadriceps loading on PT pain, maximum contraction strength of the quadriceps, and the neurophysiology of the two exercises.   

Methods:

This study looked at six male volleyball players with PT pain. Three players had unilateral pain and the other three had bilateral pain. Immediate and 45-minute effects following a bout of isometric and isotonic muscle contractions were compared. Complete inclusion and exclusion criteria can be found in the original article. Below are the loading protocols utilized in the study.

Outcome measures:

PT pain during the single leg decline squat (SLDS), quadriceps strength on maximal voluntary isometric contraction (MVIC), and measures of corticospinal excitability and inhibition.

Results:

Isometric contractions reduced pain with SLDS from 7.0­­±2.04 to 0.17±0.41 and isotonic contractions reduced pain with SLDS from 6.33±2.80 to 3.75±3.28.
Isometric contractions released cortical inhibition from 27.53%±8.30 to 54.95%±5.47, but isotonic contractions had no significant effect on inhibition.
Condition by time analysis showed pain reduction was sustained by 45 minutes post-isometric but not isotonic condition.
The mean reduction in pain scores post-isometric was 6.8/10 compared to 2.6/10 post-isotonic
MVIC increased significantly following the isometric condition by 18.7%±7.8, and was significantly higher than baseline and isotonic condition, and at 45 minutes post-intervention.

Discussion:

Isometric exercise immediately reduced patellar tendon pain with the effect sustained for 45 minutes while isotonic exercise had a smaller magnitude immediate effect on patellar tendon pain that was not sustained. There were also no non-responders to isometric exercise regardless of pain severity or length of time of symptoms while there was variable pain reduction experienced following isotonic exercise that was no sustained. Individuals with PT have higher amounts of cortical muscle inhibition for their quadriceps and heavy isometric exercise reduced this inhibition, which may be a factor in the mechanism of pain reduction. The clinic implication of this is isometric exercise may be an important option for clinicians to offer in tendons that are difficult to load without aggravating symptoms. This study had multiple limitations, one of which was the small sample size that was comprised of men, which makes it difficult to determine if the results are generalizable to all patellar tendon pain. Another limitation of the study was participants were diagnosed with patellar tendinopathy so it is difficult to determine if the same effects would be observed in other cases of anterior knee pain. This study also lacked a control group, or group where no intervention was performed, which would further qualify observed results of the study.

Take Home Message:

One of the most well-known interventions for tendinopathy in the world of physical therapy is to eccentrically load the tendon to an individual’s pain tolerance, however what interventions are you left with when the patient is unable to participate because of high levels of pain? The findings from this study give clinicians an alternative intervention for their patients that have more painful tendons by reducing the patient’s pain in the short-term, which would then allow them to tolerate other interventions that may have previously been too painful. As stated in the article, the use of isometric exercise for pain reduction in patellar tendinopathy is a great option for in-season athletes who may not want to stop participating because of their pain but would still benefit from short-term pain reduction. This study had a handful of limitations, such as a small sample size, however this shouldn’t deter clinicians from utilizing isometric exercise as a tool for pain management for PT pain.

Article Reference:

Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British journal of sports medicine, 49(19), 1277–1283. https://doi.org/10.1136/bjsports-2014-094386

Mariano Rocabado’s Approach to Tempormandibular Joint Evaluation and Treatment

by ptfadmin | Oct 20, 2022 | Health Tips

Orthopaedic Treatment for Benign Calf Amyotrophy

by ptfadmin | Oct 13, 2022 | Health Tips

by Ray Moore, PT, DPT, OCS

The purpose of this capstone project was to describe the case of a patient who presented to the clinic with an uncommon motor neuron disease including the treatment plan and discussion of orthopaedic manual therapy principles.  Benign calf amyotrophy is a sub category of lower motor neuron diseases often called benign focal amyotrophy.  This condition was originally reported by Hirayama et al. (Cintas 2017) and focused on Asian male youth with distal upper extremity muscle atrophy and weakness.  Lower extremity involvement was later reported as Wasted Leg Syndrome by Prabhakar et al. in 1981.  Since, several forms and presentations of benign focal amyotrophy have been studied and reported on yet there remains a gap between empirical studies and clinical treatment.  Relative to other motor neuron disorders such as ALS and myopathies, little is known of the etiology, cause and treatment of benign focal amyotrophy.  Some reports indicate that fewer than one hundred cases involving the lower extremity have been diagnosed, with most in the eastern hemisphere, particularly India.  Consequently, this author was unable to locate significant research pertaining to physical therapy or other treatment of benign calf amyotrophy (Cintas 2017).

There are two proposed origins leading to benign focal amyotrophy: repetitive trauma and idiopathic cause.  The available literature notes that males are considerably more affected, up to 10:1 male to female ratio, and most patients are under the age of 30 at diagnosis (Cintas 2017).  There is some variability of age range in different parts of the world which has led some to believe that benign focal amyotrophy is a diverse condition with varying types of presentations.  The earlier upper extremity variant described by Hirayama was believed to be caused by repetitive cervical spine flexion trauma or microtrauma causing flattening of the cord. 

However, MRI of the lumbar spine of patients with lower extremity involvement are typically normal with no cord or nerve root abnormalities detected (Cintas 2017).  However, MRI showed “marked atrophy and increased signal intensity were found mainly in gastrocnemius and soleus muscles” in one study (Hamano 1999).  EMG is one of the most helpful diagnostic tools and findings include “fibrillations, positive sharp waves and fasciculations” (Cintas 2017).  Nerve conduction velocity can be normal or slowed. 

(Stain of normal gastrocnemius cells vs. muscle cells in BCA, Felice et al. 2003)

Other signs indicative of lower motor neuron involvement can be present including hyporeflexia, absent Babinski sign, visible atrophy, calf muscle fasciculations, and fatigable weakness.  Surrounding musculature is typically spared such as foot intrinsics however Hamano et al. reported involvement of some quadriceps and hamstring muscles in one patient (Hamano 1999).  To date, there is no clear explanation for the predominant involvement of the gastroc-soleus muscles.

A key difference between benign focal amyotrophy and other motor neuron diseases is the lack of progression and self-limiting nature.  Patients with benign calf amyotrophy experience lower leg weakness over a period of months to years which can last for a variable period.  Most reports suggest that lower leg weakness and atrophy slowly worsens then stabilizes.  Due to the lack of long term studies, it is unclear whether patient experience a full return of muscle strength, girth and function once the progression has ceased.  Treatment for severe upper extremity cases can include avoidance of cervical spine flexion, cervical collar use, and cervical spine surgery with duroplasty (Cintas 2017).  A search for treatment of lower extremity or benign calf amyotrophy revealed no empirical studies other than a brief mention of physical and occupational therapy.  Given the lack of findings on lumbar MRI versus cervical and upper extremity involvement, novel functional treatment approaches must be discovered.

Case Presentation

The patient, referred to as Robert, presented to our clinic and was referred by a neurologist with a special interest in neuromuscular disorders and EMG.  He is a 28 year old male of Greek origin who began experiencing gradual right calf weakness about one year prior to this evaluation.  Robert reported no trauma or known change in activity level prior to symptom onset.  He also experienced right lateral foot numbness which did not progress.  Prior to this evaluation, Robert reported some left lateral foot numbness but states that this fully resolved.  Robert’s right calf weakness progressed over several months and six months later he began seeing his neurologist.  At this point, Robert reported visible right calf atrophy compared to the left.  His neurologist ordered lumbar spine MRI with and without contrast which was unremarkable and EMG/NCV testing.  Robert’s NCV testing was normal bilateral but needle EMG showed fibrillation potentials and positive sharp waves in the right medial gastrocnemius muscle and to a lesser degree in the tibialis posterior.  There were no motor unit action potentials of the right gastrocnemius and reduced recruitment of the tibialis posterior.  Additionally, Robert’s serum creatine kinase was elevated at 596 U/L. 

On examination, Robert is a tall and physically fit individual who was previously an avid runner.  Robert is a school teacher and waited six months after seeing his neurologist to schedule a PT appointment due to his schedule.  Upon PT evaluation, the primary diagnosis was a suspected S1 nerve root lesion and benign calf amyotrophy was not mentioned on his PT prescription.  He reported no history of pain and Robert demonstrated abbreviated stance on right lower extremity during gait with limited toe push off in end stance phase. 

Robert’s right mid-calf muscle girth measured two cm less than the left and his right Achilles deep tendon reflex was absent while all other lower extremity reflexes were within normal limits.  Sensation to light touch was normal except diminished over right lateral 5^th metatarsal.  Lumbar and lower extremity range of motion was normal, straight leg raise and slump tests negative, and Babinski/clonus were absent.  Small, infrequent fasciculations were detected in the right gastrocnemius and ankle plantarflexion was measured at 3+/5 compared to 5/5 on the left.  All other lower extremity MMT was 4+/5 to 5-/5 and normal for his age. 
Of note, there was minimal palpable contraction of the right gastroc-soleus during resisted plantarflexion.  No significant lumbar or other orthopaedic abnormalities were found during the examination.  Robert was instructed in some lower extremity therapeutic exercises and we attempted to finish the session with Russian muscle stimulation to the right gastroc.  Interestingly, Russian stimulation was unable to evoke muscle activation or twitch response from Robert’s gastroc-soleus, though he did feel increasing tingling sensation, a finding I had not previously seen in eight years of experience. 

At a subsequent follow up visit, Robert reported that he had seen his neurologist to review findings and she suspected he had benign calf amyotrophy, which is often a diagnosis of exclusion once other neuromuscular pathologies are ruled out.  Since I was not previously aware of this rare condition, I researched the topic thoroughly to best provide a treatment plan for my patient and quickly found a lack of evidence or even non-empirical discussion.  While benign focal amyotrophy is a self-limiting lower motor neuron disease, it is still possible to positively affect a patient’s outcome and quality of life with orthopaedic manual therapy and other physical therapy interventions.

Treatment and Research

Erl Pettman discusses the facilitated segment and its impact on extremity strength (NAIOMT 2005).  In this article, Pettman details how acute or repetitive injuries leading to segmental stiffness can cause additional unexpected outcomes.  Facet hypomobility at a segment can cause an adjacent or nearby hypermobility.  For example, limited left hip spin can lead to lack of left hip extension and/or rotation.  For normal gait to occur, this individual will have to hyperextend a segment in the lumbar spine or sacroiliac joint to allow upright gait.  Similarly, an L3 hypomobility into extension may lead to an extension hypermobility at L4 or L5 to promote full normal lumbar extension during functional movement.  When this issue becomes sub-acute to chronic, abnormal segmental input to the segment occurs which can present with both changes locally and in the extremities (Pettman 2005).
Segmental facilitation can cause muscle tenderness, hypo or hyperreflexia, altered skin and muscle sensitivity, muscle hypertonicity, inhibition of antagonist muscle groups, and muscle weakness that it typically not fatigable.  Pettman discusses common segmental facilitation at C2/3, C5/6 and L4/5, though it can occur at any spinal segment.  “It is proposed that the constant afferent barrage ultimately leads to a state of ‘central segmental excitation’ that, in turn, lowers the synaptic resistance and facilitates neuronal transmission” (Pettman 2005).  Furthermore, as discussed throughout the lab courses in the Fellowship program, manual therapy treatment to the axial spine can be beneficial in improving peripheral signs and symptoms.

One of the hallmark examples discussed by Pettman is the treatment of C5/6 for tennis elbow caused in part by segmental facilitation (Pettman 2005).  Manipulations, mobilizations, proprioceptive mobilizations, muscle energy techniques, and proprioceptive neuromuscular facilitation can improve the afferent barrage that this segment is receiving and reduce the peripheral consequences of that segment.  One such benefit of these treatments is the increase of peripheral myotomal muscle strength.

In a randomized controlled trial, Chilibeck et al. tested the effects of spinal manipulation on imbalances in lower extremity strength (Chilibeck 2011).  These authors performed segment specific chiropractic manipulations on subjects found to have a 15% or higher strength discrepancy between lower extremities.  Chilibeck et al. performed manipulations and placebo treatment to the spinal level associated with the muscle that they found weakness.  For example, subjects with hip flexor weakness received treatment to the corresponding L2-3 level.  This study found that lumbar spine manipulation can lead to a statistically significant increase in strength in knee and hip flexion for individuals with 15% or greater difference in pre-treatment strength.  The authors discuss possible explanations for increased lower extremity strength following spinal manipulation including “reduced nerve impingement, altered discharge from muscle spindles, Golgi tendon organs, mechanoreceptors and nocioceptors, altered sensory processing in the spinal cord, and altered skeletal muscle reflexes….to cause an increase in motor neuron excitability” (Chilibeck 2011).  This can lead to improved motor unit firing and increased strength in the associated myotome.

Robert’s mechanical lumbar exam did not show any significant instabilities, hypomobility, or considerable tenderness.  Robert was limited in thoracic-lumbar junction right rotation and demonstrated hypermobility into right extension at L5-S1 as measured by PPIVM, PAIVM and H/I testing.  Robert’s end-range was excessive but pain free.  For this reason, a thoraco-lumbar junction manipulation was performed followed by neuro-muscular re-training to this level.  Robert’s right rotation immediately improved but hypermobility was still noted at L5-S1.  While it was understood that the cause of Robert’s right calf weakness was clearly not restricted to the musculoskeletal system (given his negative lumbar MRI and other findings), it was hypothesized that some deficits may be caused by segmental facilitation at L5-S1, or that the minor mechanical lesions in the lumbar spine were a result of altered gait pattern due to neuropathic gastroc-soleus weakness.

Following the thoracic-lumbar junction manipulation, proprioceptive wobble PA mobilizations were performed at L5/S1 to improve afferent inputs with the possibility of increasing some gastroc-soleus strength that was limited by potential segmental facilitation versus motor neuron pathology.  Given the self-limiting nature of the patient’s diagnosis, it was explained that any additional safe method to increase his lower extremity strength would be worth a trial.  After two treatment sessions, the patient reported about 10% improvement in his right lower extremity strength with weight bearing activities and he began to demonstrate a slight observable and palpable contraction of his gastroc-soleus muscle upon voluntary contraction.

An early indication that Robert’s condition was not limited to the musculoskeletal system was his response to Russian current muscle electric stimulation.  Following his initial evaluation, I and a colleague attempted to apply muscle stimulation to Robert’s gastroc-soleus.  Using multiple currents and variations of parameters, we were unable to elicit a single twitch response.  The patient was able to feel the current sensation but no muscle contraction.  After reviewing Michelle Cameron’s Physical Agents in Rehabilitation, I found that “denervated muscles do not contract in response to the pulses of electricity that produce contractions in innervated muscles” since the “current causes depolarization of their motor nerves” (Cameron 2003).  At this time, I hypothesized that this patient was experiencing a condition related to pathologic denervation.  Cameron mentions that denervated muscles can be stimulated by “long pulses of electricity, lasting for 10 ms or longer.”  The typical treatment for denervated muscle is direct current stimulation however research has shown that any effect may be related to placebo and DC stimulation could hinder nerve regeneration (Cameron 2003).  Therefore, I did not continue with muscle electric stimulation.  However, in retrospect, I may have considered Russian muscle stimulation to the lumbar multifidus for the same reasoning as mobilization/manipulation for segmental facilitation.

Much of this patient’s treatment consisted of therapeutic exercise as well as a home exercise program.  Initially, Robert performed de-weighted calf raises in the seated position, single leg stance to tolerance with one hand assist, and theraband exercise for tibialis posterior strengthening.  Robert performed 3-4 sets of 20 repetitions for endurance training or he performed exercises to fatigue.  Robert was instructed to allow additional rest between sets for 45-60 seconds due to the fatigability of his lower extremity muscles.

Since Robert was an avid runner and weightlifter prior to this condition, his exercise routine included functional activities with modifications made as necessary.  Robert was unable to perform standing de-weighted bilateral heel raises, but after two sessions, he was able to complete sets of heel raises on the leg press on the lowest resistance.  Robert also performed bilateral leg press until he was able to complete weight bearing squats without excessive left trunk lean.  Resistance for the leg press was set based on Robert’s subjective ability to perform repetitions without heavily relying on the left lower extremity.  Robert also performed stool scoots early with right leg for activation of neighboring musculature.

Emphasized throughout the Fellowship didactic and lab work is the role of the individual spinal segmental stabilizers, like the multifidus, and their role in global stabilization and mobility.  Much like a train, if each car is not properly connected and stabilized, the entire train will not move.  If the multifidus and other segmental stabilizers do not properly stabilize a segment, such as L5-S1, then the entire mechanics of the spine can be affected and locomotion and functional mobility is not optimal.  For this reason, specific activation of the L4-S1 multifidus, as well as transverse abdominis and kegel exercises were implemented.  Robert was instructed on multifidus step-down activation with tactile cues.  Transverse abdominis and kegel muscle activation was added and more advanced exercises were built from this foundation.  Robert was encouraged to include segmental stabilizer activation in all static and dynamic activities of his daily routine.

After two sessions, Robert was able to progress to balance and higher level strengthening activities such as single leg dead lift with one hand assist, balance activities on soft surface, and hopping on trampoline on right leg.  Advanced balance and strengthening exercises such as plantarflexion and dorsiflexion on foam board and double leg squats on bosu ball were added at subsequent visits.  On the fourth visit, I saw Robert in the evening and he complained of lower leg swelling.  He stated that it was improving but he still experienced swelling in the evening.  Due to lack of function of the muscle pump, I provided Robert with a lower leg sleeve to be worn on days that he would be in the dependent position.  Additionally, since Robert is a teacher, I suggested that Robert take seated or supine rest breaks whenever possible and perform ankle pumps.  These modifications helped to reduce Robert’s complaints of lower leg swelling in the evening.

By his sixth visit, Robert reported about 25% improvement in right lower leg strength and 50% or more improvement in overall functional improvement since initial evaluation.  He was demonstrating a palpable and observable contraction of his gastroc-soleus and had progressed to exercises like right SLS on trampoline with soccer ball kick and the slide board for agility.  While Robert was unable to return to running, he was much more confident in his gait and did not experience tripping over his right foot.  Robert then had a follow up visit with his neurologist and left the country for a two week vacation.

When he returned three weeks later, Robert reported that he was being referred to another hospital for work up and treatment for benign calf amyotrophy.  He reported that while on vacation, he did not get to perform his home exercise program or other exercise much and stated that his right lower leg strength improvements had diminished.  However, functionally, Robert felt that he had made considerable improvements in physical therapy and reported improved confidence following treatment.  Robert was resuming teaching the following week and stated that he would have to self-discharge due to time restrictions.  Robert had a follow up EMG study that showed “some firing” compared with little to no activity prior.  He was able to voluntarily contract his gastroc-soleus with visible contraction during exercises.  Robert still complained of mild sensory deficit over the lateral foot but stated that it had improved since beginning physical therapy.  Robert’s right calf girth increased by one centimeter in a six week period.  Robert reported that he had experienced the most progress in over a year while he participated in physical therapy.  Robert was discharged with the recommendation that he follow up as his schedule allowed to continue to improve any remaining functional deficits.

Discussion

          As expert clinicians, we are expected to be able to treat both simple and complex cases, perform detailed yet directed evaluations, demonstrate pattern recognitions, and have a wealth of knowledge of conditions to perform differential diagnosis.  However, the knowledge and preparation an expert clinician should possess cannot be limited or contained in a box.  Often, clinicians are forced to adapt to new information on unforeseen exposure.  In this case, a patient with a motor neuron disease that is so uncommon that very few in the physical therapy field are aware of it, came to my clinic with an atypical presentation.  Having performed the lumbar and lower extremity scan many times, I was quickly able to recognize that this patient did not show the normal signs and symptoms of radiculopathy or lumbar pathology. 

          Furthermore, I determined that this patient probably did not exhibit an atypical presentation of a common condition.  For example, while receiving mentoring during this Fellowship, my mentor and I evaluated a patient with lateral thigh pain.  While I hastily suspected the lumbar spine, I learned about a potential entrapment point for the lateral femoral cutaneous nerve just above the iliac crest.  Like much of the valuable knowledge and experience I had gained during mentorship, I was previously unaware of this entrapment site.  Still, I was able to recognize that this patient could have an atypical presentation of a common condition.  This Fellowship Program also furthered my ability to recognize patients that require attention outside of the scope of physical therapy practice.  Had Robert come to our clinic as a direct access patient, I would have immediately referred him to a physician. 

          Since Robert was under a physician’s care and he presented with functional impairments from an undiagnosed condition, I used my training to develop an individualized treatment plan for Robert both before and after his diagnosis was confirmed.  The expert clinician may be occasionally challenged by an unfamiliar diagnosis or presentation.  Fellowship and other training can assist in making that clinician adaptable to apply previously learned material and experiences to the creation of a treatment plan for a new diagnosis. 

          The particular difficulty that this case provided was a lack of clinical or empirical evidence for treatment of benign focal amyotrophy.  Several searches uncovered some literature that mentions the words physical and occupational therapy, but little other treatment was specified.  One might assume that since self-limiting, individuals with benign focal amyotrophy do not require physical therapy.  However, physical therapy is a critical component in the recovery of people diagnosed with Guillaine-Barre Syndrome and other self-limiting diseases.  Physical therapy is not limited to conditions that it is the primary treatment of choice such as whiplash or tennis elbow.

Conclusion

          This capstone project involves the application of skills and knowledge possessed by a Fellow in training to a topic not previously highlighted in physical therapy literature.  Limitations included the lack of considerable literature, especially pertaining to treatment, and a sample size of one patient.  While preparing for this capstone project, one intervention I would have implemented was muscle stimulation to the lumbar multifidus.  Still, it was a very valuable experience to treat a patient with such a rare condition and assist in his progress and regaining of functional mobility.  It is often difficulty for a young and active patient to understand their condition and why they can’t perform at the level they were accustomed.  As a physical therapist, part of our job is to help return that function to the best of our ability and provide understanding and education for the patient.  Both before and after confirmed diagnosis, Robert appreciated the education he was provided and he fully bought into his treatment plan.  He showed some progress which was uncertain given his diagnosis.  Fortunately for me, Robert presented to my clinic after I have performed much of the requirements for Fellowship training, including mentoring hours.  While my mentor did not specifically prepare me to treat someone with benign calf amyotrophy, I was prepared to adapt and care for a patient with a condition that I could not reasonably be trained for, which I believe is one of the chief purposes of Fellowship training.

References:

• Cintas, P. (2017). Motor neuron diseases: Benign focal amyotrophy. Revue Neurologique, 173(Motor neuron diseases), 338-344. doi:10.1016/j.neurol.2017.03.016
• Felice K, Whitaker C, Grunnet M. Benign calf amyotrophy: clinicopathologic study of 8 patients. Archives Of Neurology [serial online]. October 2003;60(10):1415-1420.
• Hamano T, Mutoh T, Kuriyama M, et al. MRI findings of benign monomelic amyotrophy of lower limb. Journal Of The Neurological Sciences [serial online]. June 1, 1999;165(2):184-187.
• Chilibeck P, Cornish S, Schulte A, et al. The effect of spinal manipulation on imbalances in leg strength. The Journal of the Canadian Chiropractic Association.  September, 2011; 55(3): 183-192.
• Pettman, E. The Facilitated segment.  The North American Institute of Orthopaedic Manual Therapy. October, 2005; Volume IX, Issue 5.
• Cameron, M. Physical Agents in Rehabilitation: From Research to Practice (Second Edition).  Saunders.

Plantar Fasciitis: Stretching vs Strengthening and Stretching only a 2-study comparison

by ptfadmin | Sep 22, 2022 | Health Tips

Reviewed by Mark Boyland PT, DPT, CSCS

Plantar fasciitis is a common diagnosis with symptoms including pain at the heel, difficulty walking, and increased foot pain usually for the first few steps in the morning or when walking after a period of immobility.  While there are many treatment options available we will review two studies which examined primarily exercise interventions on the treatment of plantar fasciitis pain. Effects of Strengthening and Stretching Exercises on the Temporaspatial Gait Patterns in Patients with Plantar Fascitis: A Randomized Control Trial and Effect of a home-based stretching exercises on multi-segmental foot motion and clinical outcomes in patients with plantar fasciitis. Both study participants were educated by a Physical Therapist on proper execution of these exercises and received a written home exercise program with instructions on how to perform and progress exercises.

The study which compared strengthening vs stretching group had 84 participants, a sizeable group, whereas the stretching only study had only 20 participants.  Participants were selected if they had only plantar fascial pain without other systemic conditions or other forms of lower extremity pain.  The strengthening vs stretching group was monitored for 12 weeks whereas the stretching only group was monitored for just over 3 weeks.

Interestingly enough the general pain, time of the worst pain, gait parameters, and muscle strength improved regardless of stretching only or strengthening only in either study.  However, there was limited changes on multisegmental mobility of the foot before and after interventions and there were no significant between group differences in any of the noted parameters.  However, both studies had significant decreases in pain from baseline to the first 2 weeks with progressively improving symptoms in following weeks, though not as significant.

Both studies provided the exercise protocols including sets, reps, progressions, and approximate time to complete assigned exercises.  The PMCID will be provided for free article access to review both protocols via Pubmed. The strengthening vs stretching study was a more traditional protocol including 3 sets of 10-15 repetitions of 4 strengthening exercises or 3 repetitions of 30 seconds with 10 seconds rest for the stretches. Patients were instructed to complete these exercises 3 times per day. The stretching vs strengthening study exercises took between 6-10 minutes to complete per session. The stretching only study had 3 stretching exercises which were performed for 20-30 seconds with 10 seconds rest for 10 sets 5 days a week over 3 weeks, the stretching only study took about 20 minutes to complete their exercises.

For Therapists:  Recent research has been guiding us to introduce a progressive loading program to help manage and improve our patient’s symptoms.  These two studies provide a framework on how to provide this progressive loading to your patients and that you have 3 options to provide your patients, pending their compliance/preference for exercise.  There seems to be no agreement between these two papers as to what a minimal/maximal dose of exercise intervention at this time, however 20-30 minutes of dedicated exercise seems to be a good start.

For Patients:  Plantar Fasciitis can be a difficult condition to recover from and that pain improvements can continue for up to 12 weeks after beginning an exercise program.  Your therapist can provide you with a stretching and/or a strengthening program to help manage/improve your symptoms depending on what you feel that you prefer.  This condition can be self-managed at home for the most part and your Therapist should be progressing you on a weekly to bi weekly basis pending your overall symptoms.  However, before you begin self-treating, a Physical Therapy Evaluation is critical to rule out other diagnoses or pathologies

References

Effects of Strengthening and Stretching Exercises on the Temporospatial Gait Parameters in Patients with Plantar Fasciitis:  A Randomized Control Trial.  PMCID PMC6960082

Effect of a home-based stretching exercise on multi-segmental foot motion and clinical outcomes in patients with plantar fasciitis.    PMCID: PMC7493445