Pain Management Archives - Page 4 of 6 - Orthowell Physical Therapy

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Life is Sometimes “A Pain in the Neck!”

I think that most of you would agree that life is sometimes a “pain in the neck”! The source of the pain is usually multi-factorial and may include such things as emotional stress, muscle weakness, history of trauma, arthritis, herniated discs, and/or poor posture, let alone the screaming child (or boss!) thrown on top of that. Yikes!! Of course, as many of you have experienced, there are many different physical therapy and medical approaches to treating neck pain. So what does the research tell us about the most effective physical therapy treatments? In 2002, a systematic analysis of studies (performed up to that date) showed that passive physical therapy modalities such as ultrasound, heat, electrical stimulation were ineffective in the treatment of chronic neck pain in the long term. Basically, only temporary relief.

Can 2 minutes a day of exercise decrease your neck pain? How many of you experience neck or shoulder pain after using your computers? A study in Denmark evaluated 198 office workers with chronic neck and shoulder pain. The subjects were randomly assigned to either a non-exercising control group, a 2-minute exercise group, or a 12-minute exercise group. The exercise groups performed a lateral raise in the scapular plane to 90 degrees with elastic tubing. The exercises were performed 5 days per week for 10 weeks. After 10 weeks, both exercise groups significantly reduced their neck/shoulder pain and tenderness, and significantly increased their strength compared to the control group. The interesting thing about this study is that there were no differences between the 2 min and 12 min groups. The conclusion is that only 2 minutes (to failure) of the prescribed exercise could control your neck pain.

A Finish researcher by the name of Jari Ylinen has performed many controlled studies on neck pain. He is definitely the GO-TO guy for this research! He notes that several studies have been performed that show an improvement in neck pain within 5-11 weeks of rehabilitation, but that the results usually disappear 2-3 months later. So what he did was demonstrate how YOU, the neck pain sufferer, could maintain the desired results over a 12 month period. One of his studies in 2003 compared 180 female office workers with chronic, non-specific neck pain. They were randomized into two different strengthening groups, one consisting of 4-way isometric neck exercises with Tband at 80% effort, and a control group. Both training groups performed dynamic exercises for the shoulders and upper extremities with dumbbells. All groups were advised to do aerobic and stretching exercises 3 times a week and were educated in proper posture principles. At a 12 month follow-up, neck pain and disability decreased in both groups, yet maximal isometric neck strength had improved 69-110% in the isometric group, only 16-29% in the other strengthening group, and just 7-10% in the control group. Previous studies have shown either no or only temporary gains with active neck training and this study emphasizes the importance of performing your program at least 2x/wk for a solid year to achieve the described results.

For those of you who have a tendency for finding short cuts, read on! Ylinen in 2008 performed another study comparing the same active neck strength training exercises in the 2003 study to a control group that only performed neck stretches. At a 12 month follow-up, he found NO statistical differences in neck pain or disability between the groups and only minor changes in strength and mobility. Why? The big difference in this study? Patient compliance with the strength training decreased to only 1x per week!! Sound famliar from my Pump You Up post?

So how do you put this all together into a neat package for the BEST approach to neck pain? Education is the key. Number 1, evidence-based exercise will fail if you continue to assume poor posture. Number 2, you need to make time with the time you have. That means choosing the BEST exercises that can be done in a timely fashion and to continue your program 2 times per week. An interdisciplinary group of researchers and clinicians in 2009 reviewed the research to develop a ‘toolkit’ for clinicians to apply the best evidence for treating neck pain. The “Cervical Overview Group” created a clinical practice guideline that includes a therapeutic home exercise program for neck pain. You can view it HERE after signing up for free. In the next four videos, I would like to present 4 evidence-based exercises that incorporate isometric cervical strength training, scapular stabilization exercise, and functional retraining. Do these and you will take control of your neck pain once and for all!

CERVICAL ISOMETRICS

SCAPTION

ROWS

“W” SQUATS

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PUMP YOU UP!!

So how important is resistance training? I have had the privilege of working with one of my peers, a fellow PT, and strength and conditioning specialist, Mike Stare from Spectrum Fitness in Beverly, both professionally as well as personally. Mike helped to redirect MY fitness program while I was recovering from my knee injuries 1.5 years ago. Mike is on top of his game from a fitness training standpoint. He has devoted a lot of time and resources in developing an evidence-based approach to fitness and weight loss in ALL age groups. You can see this for yourself at his website. It is important for clients in a fitness program as well as our patients in physical therapy at OrthoWell to understand HOW to strengthen muscles.

The physiological principle of “overload” is what makes the difference between strength gains and stagnation. Resistance training is hard work! I tell my patients “If it’s easy, then you’re doing something wrong!” Is it true that people will lose 5-10% of muscle strength in every decade of life after the age of 40? Studies have shown that people can retain 100% of their muscle mass and strength from age 40 through their 80s with exercise! (Wrobelski, A. et al. The Phys and Sports Med, Sept 2011) You can read more on the Anti-Aging movement at Mike’s BLOG as well.

However, during exercise, you need to challenge your muscles physiologically. You need to provide a “load” that goes “over” your muscles comfort zone. In order for a muscle (including the heart) to increase strength, it must be gradually stressed by working against a load greater than it is used to. So how do you do this? There are many books and magazines such as Muscle Fitness that advocate all kinds of strategies for maximizing strength and muscle mass. Strength gains can be accomplished by performing a one-repetition maximum as well as via the typical 10 rep set approach. My approach, with the fine-tuning of Mike, is to instruct my patients in 2-3 sets of 8-12 repetitions per exercise. The most important factors to consider are the utilization of proper technique in order to isolate the specific muscle as well as to use the idea of the “loss of technical form” as your maximum output point. By the time you reach the 8-12th rep you should be tiring and on the verge of a loss of technical form. You should not work to fatigue as this will compromise your technique and become a safety concern. Regarding the frequency of strengthening exercise, studies show that strength gains are maximized at a frequency of 2-3x per week. The American College of Sport Medicine (ACSM) recommends working out a MINIMUM of 2x per week at an intensity that is equal to 70-85 percent of your one rep maximum (maximum weight you can use for one rep) for 8-10 reps and 1-3 sets. A program that comprises repetitions over 12 is considered endurance training. For cardiovascular benefits, the ASCM recommends exercising for a frequency of 3-5 times per week, at an intensity equal to 60-85 percent of your maximum heart rate for a time of 20-60 minutes. Research has shown that you’ll get the same beneficial results by exercising at 50-60% of your maximum heart rate that you would get exercising at an intensity 80% of your maximum heart rate.

At OrthoWell, as part of your physical therapy, we get you started on a strengthening program that targets your problem area. Finding the right practitioner to design a complete, individualized fitness program can be a very rewarding thing and Spectrum Fitness is definitely one of our choices. As Mike points out, “If there is one thing to do to improve the quality of life as we age, strength training would be it.”

For our athletes and runners, don’t forget that strength training has been PROVEN to enhance athletic performance. Read the following to get the facts!

-A University of Alabama meta-analysis of the endurance training scientific literature revealed that 10 weeks of resistance training in trained distance runners improves running economy by 8-10%. For the mathematicians in the crowd, that’s about 20-24 minutes off a four-hour marathon – and likely more if you’re not a well-trained endurance athlete in the first place.

-French researchers found that the addition of two weight-training sessions per week for 14 weeks significantly increased maximal strength and running economy while maintaining peak power in triathletes. Meanwhile, the control group – which only did endurance training – gained no maximal strength or running economy, and their peak power actually decreased (who do you think would win that all-out sprint at the finish line?). And, interestingly, the combined endurance with resistance training group saw greater increases in VO2max over the course of the intervention.

-Scientists at the Research Institute for Olympic Sports at the University of Jyvaskyla in Finland found that replacing 32% of regular endurance training volume with explosive resistance training for nine weeks improved 5km times, running economy, VO2max, maximal 20m speed, and performance on a 5-jump test. With the exception of VO2max, none of these measures improved in the control group that just did endurance training. How do you think they felt knowing that a good 1/3 of their entire training volume was largely unnecessary, and would have been better spent on other initiatives?

-University of Illinois researchers found that addition of three resistance training sessions for ten weeks improved short-term endurance performance by 11% and 13% during cycling and running, respectively. Additionally, the researchers noted that “long-term cycling to exhaustion at 80% VO2max increased from 71 to 85 min after the addition of strength training”

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Headaches!! Aspirin or Exercise?

One of the most common types of stress-related headaches is called a cervicogenic headache. This type of headache is the result of referred pain from boney or soft tissue structures in the neck. When your upper trapezius goes tense from stress and one of the attachment sites of the trapezius is the base of your skull, what do you think the end result could be? That’s right. A cervicogenic headache. When it comes to special testing such as XRays or MRI, there is no clear relationship between degenerative changes of the discs or cervical vertebrae and headaches (Ylinen et al 2010). As a result, most of our assessment comes from functional and palpation testing of the cervical joints and soft tissue. Conservative management of neck and headache pain often includes passive therapies such as the many specialized soft tissue techniques that we offer at OrthoWell Physical Therapy. But what does the research say about exercise-based interventions? Do neck exercises help cases of cervicogenic headache? According to Ylinen et al 2010, they certainly do. The strength group performed one set of 15 reps (in four directions) of cervical resistance training using rubber bands, upper extremity dumbbell exercises, and neck stretches 5x/week in combination with 4 hands-on physical therapy treatments. The control group performed only daily neck stretches, cardio 3x/week, and no physical therapy. What they found, at a 12 month follow-up, was that headache pain decreased by 69% in the strength group and only 37% in the control group. A more detailed analysis of the study can be found at the Theraband Academy website. In conclusion, the evidence-based combination of hands-on physical therapy, exercise, and patient education would be the best approach to resolving cervicogenic headaches.

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Why does your knee keep on hurtin’?

As the adage goes “ The more treatments we have for something, the more we don’t understand the cause”, it seems that anterior (front) knee pain or patellofemoral (kneecap) dysfunction would fall into that category. We understand that a torn meniscus or torn anterior cruciate ligament requires surgery. So how about that nagging, chronic pain in the front of your knee. The kind of pain that returns on a whim and makes you think twice about returning to your break-dancing hey day at your nephew’s wedding. The kind of “twinge” that shrinks your confidence on the 18th hole of your company’s summer, for-boasting-rights golf outing. The reason—not as obvious. So here’s one for you, for boasting rights, of course. In Dye et al (AJSM 1998), the lead researcher decides that he would be the guinea pig in a “mapping” of pain responses during arthroscopic probing, WITHOUT anesthesia, of his anterior knee and patellofemoral joint. Ouch!! The authors rated the level of conscious awareness from no sensation to severe pain. They also subdivided the results based on the ability to accurately localize the sensation. So what did they find? They found that palpation to the anterior synovial linings and capsule (front aspect of the inside of the knee joint), retinaculum (ligament on either side of the knee cap), and fat pad (underneath the patellar tendon) produced moderate to severe pain. The most interesting thing about this study, besides the masochistic aspect, is that NO sensation was detected on the patellar articular cartilage (the underside of the kneecap) even in high level “chondromalacia” or arthritis of the undersurface of the kneecap. The implication of this study is that anterior knee pain is NOT caused by the patellofemoral or kneecap joint.

To take it a step further, Faulkerson et al (Clin Orthop 1985) reported a direct relationship between the severity of pain in the anterior knee and the severity of neural damage within the lateral retinaculum (ligament on the outside of the kneecap). They found that patients presenting with moderate to severe pain were found to have the highest degree of change in the neural tissues of the lateral retinaculum. Very interesting! I’m sure you would agree.

What this means for your therapy is that we can utilize manual therapy and taping strategies to address the neural and soft tissue changes in the lateral retinaculum. KinesioTaping techniques can produce a “proprioceptive override” effect in which the stimulation of the tape on the skin can override and cancel out the pain receptors. This, of course, is an adaptive process that occurs through consistent intervention and compliance with a home exercise program. Let us show YOU how to get back control of your knee pain.

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Foam Rolling Technique

As most of you know, a very important part of our practice is the treatment of soft tissue dysfunction. This may be in the form of a muscle “knot”, chronic scar tissue, or post-surgical stiffness. We have many names ie “the doctors of knotology” and “the Marquis de Sade” to name a few. In spite of the many terms of endearment, at OrthoWell, we get our patients better- Faster! because of our approach. A very important part of your recovery has to do with your home program. Every conditioning program should include stretching, strengthening, cardio, and a close fourth should be self-massage and/or self-mobilization. Many of you have experienced “the twins” (my double tennis ball massager) as well as the foam roller. It is important to address your chronic “knots”, scar tissue, and muscle sensitivities in order to promote optimal tissue dynamics and to prevent future pain syndromes related to poor tissue dynamics.

The following video highlights our foam rolling strategy for your lower extremities. Each muscle group should receive 5-10 passes along the foam roll. The amount of weight you impart upon the roll will be dictated by your tolerance. Yes, this should hurt! Only mild to moderate pain, nothing severe. Use your arms and opposite leg to control the pressure being applied. Try to identify key areas along the way that may need additional passes. Yes, over time, the pain will subside and your pressure will increase. Consistency is the key. Ideally, stretching and self-massage should happen daily. Here is a run down of what is happening in the video.

1. In the first part of the video, I am treating the quadriceps. Longer muscles need more attention. Perform 5-10 passes each at the upper end, middle, and lower end of the muscle.

2. Turn 45 degrees and perform the same treatment at the junction between the quadriceps and iliotibial band(ITB). Pay close attention to the lower end near your patella.

3. Turn another 45 degrees and, in the same manner, treat directly along all three aspects of the ITB.

4. Next, turn over and treat your upper glute area. Cross one leg over the other as shown. The leg that is crossed is the side you are treating. Perform 5-10 passes.

5. Move down to the hamstrings and treat the upper, mid, and lower ends. Place your opposite leg on top of the treatment leg in order to impart more pressure.

6. Next, treat the calf muscle. Place the opposite leg on top for more pressure. Treat the entire length of the calf. You can also perform an up/down ankle movement in order to help glide the stiff tissue while imparting pressure onto the roll.

7. Finally, treat the inner thigh or adductor muscle group. It may be easier to use the 6” roll to treat this area effectively. You can purchase a white 6” roll which is the same material as the 4” or you may purchase the black roll which is firmer than the white.

Keep on rollin’

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Low Back Pain – Part 3 – BEST Evidence-Based Core Exercises!

So what are the BEST evidence-based Core exercises?

Evidence from random controlled trials of people suffering from low back pain show that core stabilization exercises result in significant improvements in pain and function(5,7) . However, the most effective combination of which muscles to target and which stabilization methods to utilize are still debated(1-11). One technique that has been suggested is abdominal hallowing or “drawing-in” your navel to activate the transversus abdominis (TrA) muscle. This technique has been shown to increase the cross-sectional area of the TrA(10), however, many exercise scientists are now advocating a method called “abdominal bracing”(demonstrated in my last post) in which ALL the abdominal muscles are recruited instead of just one(11). It should be the goal of core exercises to activate as many torso muscles as possible in order to ensure spinal stability and to prepare our bodies for the dynamic and often complex movements that occur during our daily activities. So what does the research say about which exercises activate which muscles the best?

Numerous studies have used EMG to determine the greatest electrical activity of torso muscles during various core stabilization exercises. In Escamilla et al(3), they used surface or skin electrodes to compare exercises such as traditional crunches, sit-ups, reverse crunches, and hanging knee-ups using straps to exercises using an Ab Roller/ Power Wheel and a device called the Ab Revolutionizer. What they found was that the activation of the upper and lower rectus abdominis(the “washboard” muscle) as well as both the internal and external obliques was the greatest with Power Wheel roll-outs and hanging knee-ups with straps. Because research indicates that the internal obliques are activated in the same manner(within 15%) as the tranversus abdominis(3), we can assume that these results apply to the TrA as well. The activation was least with a traditional sit-up! In Okubo et al(8), they used both surface electrodes and intramuscular fine-wire to compare curl-ups, side planks, front planks, bridges, and bird dogs. What they found was that the TrA was activated the greatest during front planks with opposite arm and leg raise and that multifidus activation was greatest with bridging. Although core stabilization exercises should be performed in multiple planes of motion, these two studies highlight the enhanced activation that occurs during “face down” exercises such as front planks and roll outs.

The functional progression of exercises as well as training in all planes of motion are important aspects of OrthoWell’s core stabilization program. Our program will uncover your weaknesses and maximize your strength by progressing through successive levels of difficulty in all directions of movement ie anterior, posterior, lateral, and rotatory. Optimal development of the “local” system ie your functional neutral position and bracing technique(my last post) should occur before attempting to train the “global” or big muscle system. Unfortunately, most people over-train the global system and need to be re-educated. So be patient as we take you by the “core” and steer you in the BEST, evidence-based direction.

The following videos are examples of some of our functional progressions for each plane of motion(sorry for the occasional “sideways” view). I demonstrate a particular exercise and then follow with an exercise of progressive difficulty. Functional progression is very individualized and requires skilled observation to determine competency. Many thanks to two of my peers, Mike Reinold,PT and Eric Cressey for being very helpful in this regard.

Anterior Core Stabilization Exercises

Anterior/Posterior Core Stabilization Exercises

Posterior Core Stabilization Exercises

Lateral Core Stabilization Exercises

Rotatory Core Stabilization Exercises

1. Allison GT, Mo4444rris SL, Lay B. Feedforward responses of transversus abdominis are directionally specific and act asymmetrically: Implications for core stability theories. JOSPT. 2008; 38: 228-237.

2. Ekstrom RA, Donatelli RA, Carp KC. Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. JOSPT. 2007; 37: 754-762.

3. Escamilla RF, Babb E, Dewitt R. Electromyographic analysis of traditional and nontraditional abdominal exercises: Implications for rehabilitation and training. Physical Therapy. 2006; 86: 656-671.

4. Faries MD, Greenwood M. Core Training: Stabilizing the Confusion. Strength and Conditioning Journal. 2007; 29: 10-25.

5. Hall L, Tsao H, MacDonald D. Immediate effects of co-contraction training on motor control of the trunk muscles in people with recurrent low back pain. Journal of Electromyography and Kinesiology. 2007; 19:763-773.

6. Hides J, Stanton W, McMahon S. Effect of stabilization training of multifidus muscle cross-sectional area among young elite cricketers with low back pain. JOSPT. 2008; 38: 101-108.

7. Hodges P, Kaigle A, Holm S. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: In Vivo porcine studies. SPINE. 2003; 28: 2594-2601.

8. Okubo Y, Kaneoka K, Imai A. Electromyographic analysis of transversus abdominis and lumbar multifidus using wire electrodes during lumbar stabilization exercises. JOSPT. 2010; 40: 743-750.

9. Stanford M. Effectiveness of specific lumbar stabilization exercises: A single case study. Journal of Manual and Manipulation Therapy. 2002; 10: 40-46.

10. Critchley, D. Instructing pelvic floor contraction facilitates transversus abdominis thickness increase during low-abdominal hollowing. Physiother. Res.Int. 7:65–75. 2002.

11. Kavic, N., S. Grenier, S.M. McGill. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine. 29:1254–1265. 2004a.

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Low Back Pain -Part 2- Getting Down To The “CORE”

Getting down to the CORE!!

What is your Core?

It is defined as the center or “core” of your body. It is the “powerhouse” around which all limb movement is performed. It consists of 29 pairs of muscles as well as boney, ligamentous, and discs structures that support the lumbo-pelvic-hip complex in order to stabilize the spine, pelvis, and kinetic chain during functional movements. In short, it’s pretty important!

What is the function of the Core?

The core functions to provide both stability and mobility. It can generate forces in order to complete a sit-up as well as provide spinal stability as you reach your arms overhead. The muscles that are most important in providing core stability can be divided into two groups: the primary stabilizers and the secondary stabilizers. The primary stabilizers are the transversus abdominis in the deep abdominal region and the multifidus muscles which are deep in your back and attach directly to each vertebrae in the spine. The secondary stabilizers are the obliques in the front, the quadratus lumborum & lumbar paraspinals in the back, the pelvic floor muscles at the bottom, and the diaphragm at the top.

So what does the research say about the Core muscles?

Current research has promoted the transversus abdominis (TrA) and the multifidus as the primary stabilizers of the spine.(1,4,6,8,9) The TrA is the deepest of the abdominal muscles and, when contracted, it increases tension of the thoraco-lumbar fascia, it increases intra-abdominal pressure, and increases spinal stiffness in order to resist the forces that act upon the spine(4,7) The multifidi span from 1 to 3 vertebral levels and attach one vertebrae directly to another. As a result, they provide the largest contribution to inter-segmental stability.(4,9) The TrA and multifidus have been found to activate prior to limb movement in order to prepare and stabilize the spine(1,4,9) and it has been shown that the EMG activity of the TrA may be delayed in patients suffering with chronic low back pain (LBP).(7) The TrA is activated regardless of the direction of trunk or limb movement(4) and this is the reason why performing spinal stabilization exercises in multiple planes of motion can be so effective. A significant reduction in the cross-sectional area ie atrophy of the multifidi as well as poor motor control of the TrA has been associated with patients with acute or chronic LBP.(6.9) Patients with LBP who did not receive exercises specific for the multifidi continued to have atrophy of the multifidi even after 6 weeks of being painfree as compared to the increases in multifidi cross-sectional area in those that performed the exercises.(6,9) In other words, just because your pain is gone does not mean that your muscles are functionally recovered. One of our primary objectives in physical therapy is to prevent FUTURE episodes of LBP! So how do we do it?

How do we test the Core?

Unfortunately, there is not a research-proven, valid testing regimen for core stability. However, Shirley Sahrmann has proposed a test called the Sahrmann Core Stability Test which is the most common test of function. It involves the use of a pressure cuff placed under the lumbar spine to measure one’s ability to maintain pelvic neutral while performing five exercises of progressive difficulty. The chart is included below.

How do we perform spinal stabilization exercises?

In physical therapy, we utilize the concept of a neutral spine while performing spinal stabilization exercises. Every joint has what we call a “resting” or “open-packed position”. It is the position of a joint when the joint spacing is maximized and the resistance from boney or ligamentous structures is the least. These are the fundamentals of Orthopedic Manual Therapy. In the following video, we will review the concept of the Functional Neutral Position as well describe how to activate the transverses abdominus and multifidi muscles in mutiple positions.

NEXT POST:

So what are the BEST evidence-based, core stabilization exercises?

1. Allison GT, Morris SL, Lay B. Feedforward responses of transversus abdominis are directionally specific and act asymmetrically: Implications for core stability theories. JOSPT. 2008; 38: 228-237.

2. Ekstrom RA, Donatelli RA, Carp KC. Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. JOSPT. 2007; 37: 754-762.

4. Faries MD, Greenwood M. Core Training: Stabilizing the Confusion. Strength and Conditioning Journal. 2007; 29: 10-25.

6. Hides J, Stanton W, McMahon S. Effect of stabilization training of multifidus muscle cross-sectional area among young elite cricketers with low back pain. JOSPT. 2008; 38: 101-108.

8. Okubo Y, Kaneoka K, Imai A. Electromyographic analysis of transversus abdominis and lumbar multifidus using wire electrodes during lumbar stabilization exercises. JOSPT. 2010; 40: 743-750.

9. Stanford M. Effectiveness of specific lumbar stabilization exercises: A single case study. Journal of Manual and Manipulation Therapy. 2002; 10: 40-46.

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Low Back Pain -Part 1- Common Sense or Evolution?

So why is it that 80% of people at some point will experience low back pain? Is it that we were never meant to evolve from knuckle dragging or is there a better reason? The answer to this question has more to do with common sense than with evolution. What do you think would happen to your car if you didn’t put oil in the engine? Common sense. Right? So why is it difficult for some people to understand the importance that proper posture, body mechanics and exercise play in spinal disorders such as neck and low back pain, herniated discs, and sciatica? Let me explain.
First, let’s think of the discs in between your vertebrae as water balloons. When you squeeze one side of the balloon, the fluid will move in exactly the opposite direction. Right? However, physics tells us that when a pressure is exerted on a closed system, the pressure is equal in all directions . This would be true for a “healthy” system. So, yes, when the disc is healthy and strong, the pressure exerted on the disc is the same in every direction. However, what if one of the “walls” of the system is weaker due to chronic overuse and microtrauma? Think about the daily sloucher at the computer.

The more we are slumped, or flexed forward, the more stress that occurs to the back part of the disc. Remember, if we pinch the front, the fluid moves toward the back. In this regard, evolution is cruel, because the back part of the disc is the thinnest and the most susceptible to trauma. Bingo! The origins of a bulging disc. Why is it that some people with low back pain have an MRI and it doesn’t show a bulging disc? Oh, and by the way, radiologists use the terms “bulging”, “herniated”, and “protruded” interchangeably. Some even go as far as saying “there is bulging, but no herniation”. Huh? The proper medical terms would be protrusion, extrusion, and sequestration. I hope you’re not totally confused now! So what if the radiologist report says “only mild bulging” of the disc? Does this mean that the disc is definitely not the origin of the pain? Absolutely not! Although there is no clear relationship between the extent of disc protrusion and the degree of clinical symptoms, the periphery or annulus fibrosis of the disc is highly innervated. In fact, Bogduk in 1981 reported that “nerve fibres were found up to a depth equivalent to one third of the total thickness of the anulus fibrosus”. Edgar in 2008 confirmed this deep penetration of sensory nerves into the disc. Therefore, any trauma or even “mild bulging” to the peripheral layers of the disc could elicit pain. Kuslich confirmed that probing and electrical stimulation to the annular fibers could produce local LBP, but not leg pain. However, Ohnmeiss discovered that partial or full thickness anular tears, with or without disc bulging/herniation, can reproduce sciatica symptoms in about 60% of properly screened patients with chronic lower back pain . So then, what is sciatica? It is referred pain down your leg from a pinched or irritated nerve or from a traumatized disc or facet joint. The facet joints are the “winglike” structures in the picture below and, as you can see, the spinal nerves exit the spinal canal right next to the disc. Hersch showed that injection of an “irritant” such as saline into the facet joints of the spine can cause LBP. In addition, McCallwas able to reproduce sciatic symptoms with facet joint injections. It has also been well documented that a protruded disc can cause a “pinched nerve” and associated sciatic symptoms. Ouch!

So what does all this evidence mean for you? It means that the source of your low back pain is not always definitive. It can be multifaceted. In most cases, a thorough physical therapy evaluation will determine your neural sensitivities and functional impairments. Common sense tells us that avoiding postural stresses will place the body in an optimal position to heal. Appropriate manual therapy such as joint & soft tissue mobilization and manual traction as well as evidence-based spinal stabilization exercises should alleviate and prevent reoccurrence of symptoms. These will be the topics of the next two blog posts. So stay tuned!

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KinesioTape-The Evidence

I have received several comments from bloggers that “there is no evidence” regarding the effectiveness of Kinesiology Taping or KinesioTaping Techniques. I would like to share with you some very detailed clinical study outcomes that are present, and copied here, from the SpiderTech website. This post is definitely more clinical in nature, but it can certainly help any interested patient or practitioner in understanding the evidence behind the WHY and HOW of KinesioTaping.

The Clinically Proven Effectiveness of Kinesiology Taping

Taping is widely used in the field of rehabilitation as both a means of treatment and prevention of sports-related injuries. The essential function of most tape is to provide support during movement. Some believe that tape serves to enhance proprioception and, therefore, to reduce the occurrence of injuries. The most commonly used tape applications are done with non-stretch tape. The rationale is to provide protection and support to a joint or a muscle. Utilizing existing stretch tape, investigators have shown clinical improvement in patients with grade III acromioclavicular separations, anterior shoulder impingement, and hemiplegic shoulders. In recent years, kinesiology tape has become increasingly popular as a therapeutic treatment option in North America and Europe. Kinesiology tape was developed in the 1970’s and was engineered to mimic the qualities of human skin. It has roughly the same thickness as the epidermis and can be stretched between 130% and 140% of its resting length longitudinally. The application techniques were developed through the use of applied kinesiology taping, which
logically gave the therapy and material its name. The tape reportedly has several benefits, depending on the amount of stretch applied to the tape during application: (1) to provide a positional stimulus through the skin, (2) to align fascial tissues, (3) to create more space by lifting fascia and soft tissue above the area of pain/inflammation, (4) to provide sensory stimulation to assist or limit motion, and (5) to assist in the removal of edema by directing exudates toward a lymph duct. The clinical information on kinesiology tape suggests improved function, pain, stability, and proprioception in pediatrics and patients with acute patellar dislocation, stroke, ankle and shoulder pain, and trunk dysfunction. The respective information comes from case series and pilot studies, the most important of which are summarized in the following:

In a prospective, randomized, double-blinded, clinical trial using a repeated-measures design Thelen et al. investigated the clinical efficacy of kinesiology tape for shoulder pain. Forty-two subjects clinically diagnosed with rotator cuff tendonitis/impingement were randomly assigned to 1 of 2 groups: A therapeutic kinesiology tape group or a sham kinesiology tape group. The therapeutic kinesiology tape group showed immediate improvement in pain-free should abduction after tape application. It was concluded that kinesiology tape may be of some assistance to clinicians in improving pain-free active range of motion immediately after tape application for patients with shoulder pain.

In 2009, Fraizer et al. examined in a case series the clinical outcomes for patients with shoulder disorders who were treated with a comprehensive physical therapy program that included kinesiology taping techniques. Five patients
were treated with this taping method among other interventions. All patients demonstrated clinically important improvements in function. The authors concluded that kinesiology taping should be considered as an optional clinical
adjunct in the treatment of shoulder pain as part of a comprehensive physical therapy regimen.

Also in 2007, Yoshida et al. studied the effect of kinesiology tape on lower trunk range of motions. Thirty healthy subjects with no history of lower trunk or back issues participated in the study. Based on their findings, the authors determined that the application of kinesiology tape applied over the lower trunk may increase active lower trunk flexion range of motion.

In 2007, Lie et al. studied the application of kinesiology tape in patients with lateral epicondylitis. The experimental results indicated that wearing kinesiology tape causes the motions of muscle on the ultrasonic images to be enhanced which the authors believe to indicate that the performance of muscle motion was improved.

The effect of taping using kinesiology tape in an acute pediatric rehabilitation setting was investigated in a 2006 pilot study by Yasukawa et al. The purpose of this pilot study was to describe the use of the kinesiology tape for the upper extremity in enhancing functional motor skills in children admitted into an acute rehabilitation program. Fifteen children (4 to 16 years of age), who were receiving rehabilitation services participated in this study. The improvement from pre- to post-taping was statistically significant. These results suggest that kinesiology tape may be associated with improvements in upper-extremity motor control and function in the acute pediatric rehabilitation setting. The authors concluded that the use of kinesiology tape as an adjunct to treatment may assist with the goal-focused occupational therapy treatment during the child’s inpatient stay.

In 2009, Tsai et al. evaluated the effects of a bandage replacement by kinesiology tape in decongestive lymphatic therapy (DLT) for breast-cancer-related lymphoedema. Forty-one patients with unilateral breast-cancer-related lymphoedema for at least 3 months were included in this study. The study results suggested that kinesiology tape could replace the bandage in DLT, and it could be an alternative choice for the breast-cancer-related lymphoedema patient with poor short-stretch bandage compliance after 1-month intervention.

As published in the journal Top Stroke Rehab., Jaraczewska et al. indicated that kinesiology tape could improve the upper extremity function in the adult with hemiplegia. The article discusses various therapeutic methods used in the treatment of stroke patients to achieve a functional upper extremity. The only taping technique for various upper extremity conditions that had previously been described in the literature is the athletic taping technique. The authors concluded that kinesiology taping in conjunction with other therapeutic interventions could facilitate or inhibit muscle function, support joint structure, reduce pain, and provide proprioceptive feedback to achieve and maintain preferred body alignment. Restoring trunk and scapula alignment after the stroke is critical in developing an effective treatment program for the upper extremity in hemiplegia.

The clinical efficacy of kinesiology taping in reducing edema of the lower limbs in patients treated with the Ilizarov method was investigated by Bialoszewski et al. The study involved 24 patients of both sexes subjected to lower limb lengthening using the Ilizarov method who had developed edema of the thigh or leg of the lengthened extremity. The mean age of the patients was 21 years. The patients were randomized into two groups of twelve, which were then subjected to 10 days of standard physiotherapy. The study group was additionally treated with kinesiology taping (lymphatic application), while the control group received standard lymphatic drainage. The application of kinesiology taping in the study group produced a decrease in the circumference of the thigh and leg statistically more significant than that following lymphatic drainage. It was concluded that kinesiology taping significantly reduced lower limb edema in patients treated by the Ilizarov method and that the application of kinesiology taping produced a significantly faster re-education of the edema compared to standard lymphatic massage.

Hsu et al investigated the effect of elastic taping on kinematics, muscle activity and strength of the scapular region in baseball players with shoulder impingement. Seventeen baseball players with shoulder impingement were recruited from three amateur baseball teams. All subjects were taped with both the kinesiology tape and a placebo tape over the lower trapezius muscle. The kinesiology tape resulted in positive changes in scapular motion and muscle performance. The results supported its use as a treatment aid in managing shoulder impingement problems.

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Reebok pays 25M – Kick in the Butt!

As an addendum to the my last post “Whats Up with the Shape-Ups?”, guess what happened to Reebok? They have to pay 25 million due to false “toning” claims. Talk about a kick in the butt!! Read on.

PORTLAND, Ore. — Reebok will need to tone down advertising for its shoes that claim to reshape your backside.

The athletic shoe and clothing company will pay $25 million in customer refunds to settle charges by the Federal Trade Commission that it falsely advertised that its “toning” shoes could measurably strengthen the muscles in the legs, thighs and buttocks. As part of the settlement, Reebok also is barred from making some of these claims without scientific evidence.

“Settling does not mean we agree with the FTC’s allegations,” Dan Sarro, a Reebok spokesman, said in a statement Wednesday. “We do not. We have received overwhelmingly enthusiastic feedback from thousands of EasyTone customers.”

It’s the latest controversy surrounding so-called toning shoes, which are designed with a rounded or otherwise unstable sole. Shoemakers say the shoes force wearers to use more muscle to maintain balance and consumers clamored for them, turning toning shoes into a $1.1 billion market in just a few years. Companies such as Reebok, New Balance and Skechers have faced lawsuits over their advertising claims. But the FTC settlement, announced Wednesday, is the first time the government has stepped in.

Reebok International Ltd. makes a range of toning products, including its RunTone running shoes, EasyTone walking shoes and flip flops and some clothing. The company, which is owned by Adidas AG, said that its toning shoes were one of its most popular product launches ever when they debuted in 2009. The company marketed them heavily with ads featuring women in short shorts and with shapely bottoms; one ad even said the shoes would “make your boobs jealous”.

The FTC took issue with Reebok’s ads that claimed its EasyTone footwear had been proven to lead to 28 percent more strength and tone in the buttock muscles and 11 percent more strength and tone in hamstring and calf muscles than regular walking shoes. The FTC said it could not disclose if it was pursuing similar actions against other shoe makers.

“We think this is a real victory for consumers,” said Dana Barragate, an FTC attorney involved in the case. “We hope it sends a message to businesses that if they are going to make claims they must be justified.”

Shoe makers, including Reebok, have funded studies and say they have anecdotal evidence that proves they are effective. Several experts have questioned their validity and the American Council on Exercise, a nonprofit fitness organization, conducted a study that found toning shoes failed to live up to the claims of shoe makers. However, the council said the shoes could be beneficial to one’s health if they motivate people to get moving.

Christopher Svezia, with the Susquehanna Financial Group, said many shoemakers have changed their advertising approach as criticism has mounted. “The emphasis has moved to fitness instead of making these kinds of claims and promises,” he said. “The question is who is next and how much is it going to cost them.”

The industry has faced other issues. There have been some injuries reported by wearers who have found themselves with shin splints, twisted ankles and sore muscles from the new gear and motions. Shoe makers suggest new wearers ease into wearing them.

Toning shoes were once the fastest-growing segment in the footwear industry, but recently lost some ground. SportsOne Source Group said that the $1.1 billion market of 2010 is expected to fall about 40 percent to $650 million in 2011 after Skechers flooded the market with products, forcing prices down. However, SportsOne Source said the number of shoes sold is only expected to fall 5 percent, suggesting there is still fairly strong demand.

Rebecca Sayre of Seattle, who bought a pair of Skechers more than a year ago, said they made her legs stronger and posture better. But, she says: “They’ve lost their luster.”

Story posted 2011.09.28 at 08:41 PM EDT

Category: Pain Management