ARTICLE REVIEW by Tyler Tice PT, DPT, ATC
It is common for individuals with low back pain to also have associated hip pain and is often times challenging to determine the primary source of the pain. This article, which was recently published in the Journal of Orthopaedic and Sports Physical Therapy in December 2021, suggests the focus of rehab for concomitant hip and low back pain should be to the low back. Below is a review of the article.
Introduction: The cause of low back pain is not always clear and for individuals with hip AND low back pain makes the cause even harder to find. Clinicians will often perform interventions to both hip and back without knowing which treatment interventions are truly helping. This has potential to prolong symptoms and increase health care costs. The goal of this study was to determine the short term and long term effects of low back only treatments compared to low back and hip specific treatments.
- Participants randomized to 1 of 2 groups: low back treatment only; low back and hip treatments
- Participants and therapists not blinded due to nature of the study
- Inclusion criteria: >/= 18 years old; low back pain 2/10 or more, self reported disability >20% on ODI, and concurrent hip impairment (groin pain, reproducible hip pain, limited hip ROM and/or strength, or positive special test for hip pathology)
- Exclusion criteria: contraindications to manual therapy, recent trauma to low back, positive neurological findings, recent spine surgery, hip replacement
- 76 total participants – 39 low back only, 37 low back and hip treatment
- 11 physical therapists provided treatments with each given a video training for this study
- Primary outcome measures: ODI (Oswestry Disability Index – a patient questionnaire that measures function), NPRS pain rating scale from 0-10.
- Secondary outcome measures: Fear Avoidance Beliefs Questionnaire, Global Rating of Change, Patient Acceptable Symptoms State
- Outcomes were assessed at baseline, 2 weeks, discharge, 6 months, and 12 months (please refer to article for more information on each measure)
- Treatments: all in person sessions, frequency/duration varied with recommendation of 2-3x/week for 45-60 minute sessions
- Low back only group received treatment based on therapist discretion
- Low back and hip treatment group received additional hip treatments including 2 manual therapy interventions and 2 exercise interventions based on a predetermined set of treatments
- 8 participants lost at discharge; additional 15 participants lost at 6 months; additional 5 lost at 12 months (Coronavirus played a role on this)
- Baseline characteristics and number of visits between the two groups were similar
- Disability and Pain: no significant difference on ODI and pain scores between groups at ANY time point. Both groups pain and disability improved at time of discharge and maintained at 6 and 12 month follow up
- Fear Avoidance Beliefs Questionnaire: For WORK subscale: better scores for low back group at discharge and long term follow up; For PHYSICAL ACTIVITY: no significant difference between groups
- Global Rating of Change: Slightly better for low back only group at 2 weeks and discharge; similar between groups at 6 months and 12 months; both groups improved
- Patient Acceptable Symptom Scale: no statistically significant differences between groups at ANY time; majority of patients reported an acceptable symptom state at discharge and 6 months, which reduced in both groups at 12 months
Based on these results, adding hip interventions for people with low back and hip pain did not improve functional disability or pain outcomes. There were some significant differences in the secondary outcome measures that favored low back only treatments. These findings suggest that adding hip treatments may not be necessary and to focus the interventions to the low back.
Limitations for this study include small sample size, missing data at long term follow ups, wide confidence intervals, and therapists and participants were not blinded. Therapists were also allowed to choose treatments per their discretion which is reflective of real world clinical practice, however can cause certain biases and non-compliance in eh research setting.
“Adding treatment directed at the hips to usual low back pain care for individuals with low back pain and concurrent hip impairment did not improve disability and pain in the short or long term”
This is a well designed randomization control trial with its obvious limitations, however these limitations were hard to control for given the timing and nature of study. Based on these results, it is not necessarily a BAD thing or WRONG to perform hip interventions for these individuals with both low back and hip pain. If one of my patients have a clinical finding of a hip impairment, I think I will still address it using specific hip interventions. With saying that, we can not exclude interventions for the low back and by focusing on the low back in a rehab program may help the patient progress along more quickly. I also think this can have clinical significance when giving patients home exercise programs (HEP). Using these findings, it will be better to provide patients with 1-2 low back exercises to manage their back and hip pain instead of additional hip exercises. Patients typically have poor adherence to a HEP so it is better to consolidate their HEP to the most effective interventions using the best evidence.
If you’re one of these individuals having both low back pain with a hip impairment, give Physical Therapy First a call and we can help you out!
Burns SA, Cleland JA, Rivett DA, et al. When treating coexisting low back pain and hip impairments, focus on the back: Adding specific hip treatment does not yield additional benefits—a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy. 2021;51(12):581-601. doi:10.2519/jospt.2021.10593
by Tyler Tice, PT, DPT, MS, ATC
I have seen multiple patients recently reporting they have developed shoulder pain and limited range of motion after receiving the flu or COVID vaccines. The cases that I have seen have varied in time of symptom onset from 2 days to 4+ weeks after receiving the vaccine and some reported developing pain and shoulder deficits in the opposite shoulder from the one they received the vaccine. This is questionable whether receiving a vaccine to shoulder musculature actually caused the pain and functional deficits, however it was worth looking into.
We are thankful to have vaccines readily available to help protect us from multiple different illnesses. During this time, a large amount of the population are receiving the COVID and flu vaccines and I wanted to highlight one possible specific orthopedic side effect from vaccine administration.
SIRVA, an acronym standing for Shoulder Injury Related to Vaccine Administration, is a potential reason for shoulder pain after injection. This occurs when a vaccine is injected into the shoulder capsule instead of the deltoid musculature, causing an inflammatory response to the shoulder. If this occurs, people may experience pain, decreased shoulder range of motion, and a temporary decrease in functional abilities. Patient diagnoses related to SIRVA may include shoulder bursitis, rotator cuff injury, and adhesive capsulitis. The only difference between SIRVA and other shoulder injuries not related to vaccines is the time of onset of pain and limited motion are usually within 48 hours after receiving a vaccine and do not improve with over the counter analgesic medications. There are no other known differences in the physical exam or with ultrasound imaging. Treatment for SIRVA is typically the same as treatment for routine inflammatory shoulder injuries.
Vaccines are intended to be administered in the deltoid muscle. When administering vaccines into the deltoid, the individual should outline the borders of the safe zone. The upper border is about 2-3 finger breadths below the acromion and the lower border is marked by the armpit. The thumb and index finger can make a “V” to outline the deltoid muscle in order to know the proper zone when injecting the needle at a 90 degree angle.
Prevalence of SIRVA is still being analyzed and there have been reports in the literature that SIRVA occurred due to multiple different types of intra-muscular vaccines. In a systematic review in 2020, 27 papers reported the accounts of SIRVA in the literature with the most common vaccine being the Influenza vaccine, most common symptoms were shoulder pain and loss of motion within 48 hours, and most common treatments were physical therapy or corticosteroid injection. Most cases reported had great outcomes. It is generally believed that SIRVA is under-reported, therefore there is likely more cases that have occurred, but it is still very uncommon.
Since this systematic review was published in 2020, there have been multiple more recent case studies reporting SIRVA in relation to the COVID vaccine. The COVID vaccine has been administered to a very large degree throughout the past year which makes sense that there will be some reported cases of SIRVA in relation to the COVID vaccine. Although this is a novel vaccine, SIRVA appears to occur due to inaccurate vaccine administration regardless of vaccine type.
SIRVA is preventable if using proper vaccine administration guidelines, however accidents do happen and there is always potential for this to occur.
In summary, incorrectly administered vaccines into shoulder musculature can cause shoulder pain and decreased shoulder functional abilities. These deficits typically present like other inflammatory shoulder conditions and people have great outcomes when seeking intervention and using physical therapy. It is encouraged that all people receive the necessary vaccines that are available to help protect against getting and spreading different illnesses.
Bancsi A, Houle SKD, Grindrod KA. Shoulder injury related to vaccine administration and other injection site events. Can Fam Physician. 2019;65(1):40-42.
Cagle PJ Jr. Shoulder Injury after Vaccination: A Systematic Review. Rev Bras Ortop (Sao Paulo). 2021;56(3):299-306. doi:10.1055/s-0040-1719086
by Nick Mattis, SPT, Ray Moore, PT
There are several aspects that go into game days when playing sports: traveling, getting suited up, pre-game warm-up, the game itself, and last but not least, the post-game recovery. This article looks into the different types of recovery strategies used in male soccer players to help them recover the fastest and most efficiently. Once competition ends, the body’s neuromuscular performance declines while in the recovery phase. The performance level often does not recover to baseline for 3-4 days after the end of the game through passive rest (1). This can be an issue as most athletes play 2-3 games per week, requiring them to be at peak levels much faster than the typical 3-4 day recovery period. Approximately how many intense intermittent actions are performed by soccer players during a match? Soccer players perform around 200 intense actions throughout a match on average. Due to this high number, it is vital for the body recovery properly.
Active vs Passive Recovery
Recovery methods fall under two different categories, active and passive. Passive strategy is quite simple and is the process of resting and relaxing without any other form of recovery. This allows the body to rest, recharge, and replenish energy storages in the muscles. In regards to active recovery, there are many different strategies used. Some of the following that were addressed in the article include: aerobic exercise, water-aerobic exercise, massage, compression garments, electrostimulation, and cold-water immersion. Which is true of the active recovery strategies that were reviewed? Active recovery techniques such as electrostimulation and aerobic exercise has been found to be more effective in the recovery process than passive rest. Which compounding factor of the players must be considered when implementing active recovery techniques? When performing the active recovery techniques there is one factor that must be considered, aerobic fitness level. This will often corelates directly to the removal of lactate as well as their adaptation to modalities.
There are a few different treatments that fall under this category. The two mainly focused on are an actual hands-on massage to sore/tired muscles and the use of a foam roller. The massage was analyzed in terms of a normoxic (muscles re-saturated with O2) as well as hypoxic (muscles deprived of O2) as would be found in high intensity activity. What effect was found for massage under hypoxic conditions compared to massage alone? Studies have shown that the massage is equally effective when comparing hypoxic and normoxic conditions. This means that the muscles are not time sensitive when receiving a massage during the recovery phase. On the other hand, foam rolling is a great way to lower blood lactate levels and speed up the recovery process. Foam rollers are inexpensive and easy to obtain and are practically a must for high intensity athletes looking to recovery faster. After strenuous activity, the muscles primarily used should be rolled to help recovery. What should be considered when implementing foam rolling to decrease perceptive muscle soreness? Rolling over sore muscles can be painful, which is why correct posture is the most important key to controlling perceived muscle soreness. Having the correct posture can reduce the amount of pain felt, while also targeting the muscle better. Overall massage is a very beneficial technique in the recovery process. What effect does massage have on blood lactate levels compared to passive recovery? Massage decreases blood lactate levels at a much faster rate than passive recovery (rest) making you feel less sore and ready to return to the field.
Compression garments are often leg or arm sleeves that are tight around the extremity and used to reduce swelling. Studies have shown using placebo and Far Infra-Red clothing that it took the participants a longer time to feel the muscle soreness, also know as delayed-onset muscle soreness (DOMS). However, this was just a perceived feeling of the clothing and not actually a decrease in any of the biomarker levels in the body. How significant have compression garments been found to attenuate exercised-induced biomarker response? The compression garments have been found to reduce the biomarker response but at a level that is deemed nonsignificant. In other words, they may help but there are better techniques for recovery.
ESTIM is a process of using electronic signals transmitted through nodes placed on the skin to the muscle to achieve a desired result. There are several uses of ESTIM, but for recovery, the purpose is to increase blood flow through the heavily exercised muscles. This allows O2 to be returned to the muscles as well has waste produced by the muscle to be removed. Which best describes the observed effect of electronic blood flow stimulation? Studies have shown that after stimulation, anaerobic exercise improved one hour after the intervention. This was deemed beneficial for athletes who compete in competitions that have several events or rounds in one day with short recovery periods in-between.
One of the most popular forms of recovery is the cold-water immersion. This has been seen primarily in terms of the “ice-bath” that many athletes hop into after an exhausting practice or game. The science supports the movement too. What effect did cooled phase change material have on recovery in elite soccer players? Cold-water immersion has found to accelerate the recovery process in the studies performed on male soccer players. However, unlike massage, there is not a broad window of time where it is found to be effective in the recovery process. What conclusion was made for the use of cold-water immersion as a recovery technique? It has found to be beneficial in the recovery of soccer players immediately after the match. Therefore, if you are unable to submerge your lower extremities for 10-15 minutes immediately after the strenuous exercise, then it often will not be beneficial in the recovery process.
Physical Therapy First
Here at Physical Therapy First, we have a team of skilled therapists who are able to assess, educate, and treat athletes in recovery from injury or regular sport activity to return them to their functional needs. Through manual techniques and other interventions discussed in this article, we can restore ROM, increase strength, and return you back to activity. We are able to educate you on the proper recovery process including how to optimize your return to sport as quickly as possible. Call today to schedule an appointment.
1) Ribeiro, João PhD1,2,3; Sarmento, Hugo PhD4; Silva, Ana F. PhD2,5,6; Clemente, Filipe M. PhD5 Practical Postexercise Recovery Strategies in Male Adult Professional Soccer Players: A Systematic Review, Strength and Conditioning Journal: April 2021 – Volume 43 – Issue 2 – p 7-22. doi: 10.1519/SSC.0000000000000582
by Nick Mattis, SPT
The development of strength and coordination in children is a rapidly evolving topic that many parents are concerned with. Questions surrounding what the best movements to perform are for child growth and the progression into sports are discussed in this article. Early and applicable activity in children can lead to long-term athletic development (LTAD). Strength, coordination, and motor skill competency are all vital components in the growth of children in activities. There are eight Athletic Motor Skill Competencies (AMSC) to which form a foundation of targeted areas of growth in children. Which is one of the athletic motor skill competencies? The competencies include: Lower-body unilateral, Lower-body bilateral, Upper-body pushing, Upper-body pulling, Antirotation and Core bracing, Jumping/Landing/Rebound mechanics, Throwing/Catching/Grasping, and Acceleration/Deceleration/Reacceleration. Through the progression of each competency, children will become more well-rounded in movement that is applicable to many scenarios as well as decrease the risk of injury through properly strengthened muscles and instruction of form.
The early stages of development begin in childhood. Which age is considered childhood for girls? Childhood is considered in girls <11 years of age and boys <13 years of age. At this age, the brain is more neural plastic than adolescent years, meaning the brain is able to adapt, change, and form new learning pathways. This allows the children to learn, process, and repeat movements at a greater success rate than later in life. Approximately how much training-induced gains can be achieved by pre-pubertal youth compared to adolescents? Children are able to achieve almost 50% greater gains in motor skills in comparison to adolescents with resistance training. Therefore, the movements should be introduced at the pre-pubescent age to maximize the growth of the child. At this age, it is important to get the child to adhere to the long-term program. This often involves making the program in to fun games with play like movements. An example of this is performing movements like animals. There are several benefits to these movements such as child enjoyment, easy to perform, and effective. What is the main purpose of animal shape exercises? The most important benefit of the animal exercises is the enhanced locomotion skills the child receives from the exercise. Asking the child to “walk like a gorilla” will effectively improve lower extremity strength and range of motion as the child walks in a squatted position with it seeming like a game to them. Which is recommended for teaching children key body positions and movements? Similarly, cues can be given to the children when performing the motion to help instruct them in a way they will remember. When they are “walking like a gorilla”, you can tell them to “duck under the branch” so they will squat lower in the exercise. Using cues like this will be easier for the child to remember and perform compared to verbalizing squatting lower. In Table 1 of the article is a list of several animals and how to perform the movements like them. What physical attributes does the vulture exercise help to improve? A great exercise for single-leg balance is the vulture exercise where one stands and balances on one leg.
It is important to introduce smaller, simple movements before larger more complex movements. The complex movements are often combinations of several simple movements. Therefore, mastering the simple movements will make a more fluid and easier complex movement when it is time to progress. For example, simple movements such as the tuck, arch, and pike should be performed and mastered first. Then the individual can progress to more difficult movements such as a squat, handstand, or bridge. Which represents an appropriate progression? An appropriate progression would be as follows: tuck, straddle, and lastly bridge. It is important to recognize and understand the difficulty of each exercise to make proper progressions. Figure 5 in the article shows levels of intensity of exercises for proper progressions. Which of the following horizontal pushing exercises is classified as the highest intensity? The barbell bench press is the highest intensity for the horizontal pushing exercises, while the press up hold (plank) is of the lowest intensity. What is the most likely result of constant movement variation during game-based activities? When progressing the exercise, studies have found that rather than continually performing the same motion over and over, there is greater retention results in the child with constant variation in the movement. The constantly changing movement is found to have greater retention in the child’s brain rather than repeated continuous movements. Similarly, it is not as important to train children for sport specific movements as it is to make them well rounded in many movements. What is recommended for practitioners using more structured training with young athletes? Practitioners and parents should be training the young athlete to develop gross athleticism relevant to sports performance. This will develop the child’s movement skills to be applicable to many different sports and other scenarios. Not only will they accel at multiple sports, but they will also not be stuck with one sport as a kid lacking skilled movements to participate in other sports.
Physical Therapy First:
Here at Physical Therapy First, we have a team of skilled therapists that are able to assess, educate, and treat your child in recovery from injury to return them to their optimal functional level. Through manual techniques, therapeutic activities and other interventions, we can restore ROM, increase strength, and return you back to activity. Call today to schedule an appointment.
1) Radnor, John M. PhD1; Moeskops, Sylvia MSc, CSCS1; Morris, Stephanie J. MSc, CSCS1; Mathews, Thomas A. MSc, CSCS1; Kumar, Nakul T. A. CSCS1; Pullen, Ben J. BSc1; Meyers, Robert W. PhD1; Pedley, Jason S. PhD1; Gould, Zach I. PhD, CSCS1; Oliver, Jon L. PhD1,2; Lloyd, Rhodri S. PhD, CSCS*D1,2,3 Developing Athletic Motor Skill Competencies in Youth, Strength and Conditioning Journal: December 2020 – Volume 42 – Issue 6 – p 54-70. doi: 10.1519/SSC.0000000000000602
by Logan Swisher, PT, DPT, OCS
Fibromyalgia syndrome is characterized by chronic and diffuse musculoskeletal pain. The exact cause of fibromyalgia is unknown but abnormalities of the pain processing in the nervous system, such as hyper-responsiveness and hyper-excitability, may explain the chronic pain. Myofascial trigger point pain is defined as pain from one or more hyperirritable or hypersensitive palpable nodules in skeletal muscle which can refer pain locally and globally over the body. Myofascial release is a therapeutic intervention aimed at providing pain relief by restoring impaired soft tissue function. Dry needling, on the other hand, is a minimally invasive technique where an acupuncture needle is inserted directly into myofascial trigger points with the end goal of decreasing local and referred pain. This article aimed to compare the effectiveness of dry needling vs. myofascial release for patient with fibromyalgia.
64 total participants (58 women and 6 men)
-32 participants assigned to the dry needling group
-32 participants in the myofascial release group
In this single-blind randomized controlled trial patients were assigned to a dry needling or myofascial release group. Pain pressure thresholds of trigger points in the cervical muscles were assessed as well as quality of life, impact of fibromyalgia symptoms, quality of sleep, intensity of pain, anxiety and depression symptoms, and impact of fatigue at baseline and 4 weeks post treatment.
Significant improvement was found in most pain pressure thresholds of the myofascial trigger points in cervical muscles in the dry needling group as compared to the myofascial release group. Dry needling also demonstrated higher improvements in quality of life, quality of sleep, anxiety, depression, fatigue and intensity of pain, whereas, myofascial release demonstrated significant improvement in intensity of pain and impact of fibromyalgia symptoms.
When appropriate, dry needling therapy should be strongly considered with myofascial release techniques for patients with fibromyalgia. Here at Physical Therapy First, we have therapists trained in dry needling and myofascial release techniques. We will complete a thorough evaluation and comprise a multimodal treatment plan to address your current functional limitations and pain levels to help you restore your previous level of activity.
Castro Sánchez AM, García López H, Fernández Sánchez M, Pérez Mármol JM, Aguilar-Ferrándiz ME, Luque Suárez A, Matarán Peñarrocha GA. Improvement in clinical outcomes after dry needling versus myofascial release on pain pressure thresholds, quality of life, fatigue, pain intensity, quality of sleep, anxiety, and depression in patients with fibromyalgia syndrome. Disabil Rehabil. 2019 Sep;41(19):2235-2246. doi: 10.1080/09638288.2018.1461259. Epub 2018 Apr 23. PMID: 29681188.
by Logan Swisher, PT, DPT, OCS
Osteoarthritis (OA) is the most common cause of disability in adults and it is estimated that 14 million individuals in the US have symptomatic knee OA. Total knee arthroplasty (TKA) has been proven as an effective and cost-efficient intervention for end- stage knee osteoarthritis. Most people who undergo a TKA have marked improvements in function and reduction of pain compared to their preoperative condition, however, others have varied recovery of their functional abilities and not all patients experience significant improvements after surgery. The aim of this study was to examine if preoperative measures could predict functional ability at 1 year and 2 years after surgery.
-155 participants at initial evaluation
-155 participants at 1 year follow up
-125 participants at 2 years follow up
Measurements of participants age, height, weight, bilateral quadriceps muscle strength, knee flexion and extension range of motion, the Timed “Up and Go” test (TUG), stair-climbing task (SCT), and two subsets of the Knee Outcome Survey (KOS) which were the activities of daily living and pain subsets.
The TUG, SCT and KOS scores at 1 and 2 years showed significant improvement over the scores at the initial evaluation. A weak quadriceps muscle in the limb that did not undergo the surgery was related to poorer 1-and 2-year outcomes. It was also found that older participants with higher body masses also had poorer outcomes at 1 and 2 years.
The study revealed the importance of rehabilitation regimens after TKA incorporating exercises to improve strength of the non-operated limb as well as treat the deficits imposed by surgery. If left untreated, weakness in the non-operated limb may continue to impede functional ability and result in poorer postsurgical outcomes. There should also be an emphasis on treating age-related impairment, such as poor balance and strength, and reducing body mass to help improve long-term outcomes. At Physical Therapy First, our physical therapists will perform a thorough 1-on-1, hour long appointment and work with you to create a plan of care that helps you reach your goals.
Zeni JA Jr, Snyder-Mackler L. Early postoperative measures predict 1- and 2-year outcomes after unilateral total knee arthroplasty: importance of contralateral limb strength. Phys Ther. 2010 Jan;90(1):43-54. doi: 10.2522/ptj.20090089. Epub 2009 Dec 3. PMID: 19959653; PMCID: PMC2802824