More than 80% of us experience low back pain at some point in our lives. In most cases, the pain goes away on it’s own or with a little “help” from the internet, yet recurrence rates of low back pain range between 24% and 80% within the first year.
A literature review by Steffens and colleagues summarizes the benefits of exercise and education for low back pain. The types of interventions included in the studies were patient education, core stabilization exercises emphasizing exercises for the back and abdominal muscles, stretching and spinal range of motion exercises as well as general aerobic conditioning exercises.
The reduction in recurrence rates of low back pain was impressive at 25% to 40% in the short-term.
The effects in the long term were more uncertain. Several studies showed no decline in recurrence rates after one year.
So what does this mean?
More than likely, the participants felt better and they stopped doing their exercises. Sound familiar?
In order to prevent recurrence of pain or injury in the future, it is crucial to continue with an exercise program that includes core stabilization training, flexibility and spinal range of motion exercises and general aerobic conditioning.
Don’t delay. Get a refresher from us ASAP or refer a friend or family member who is in pain.
Check out the link below or send it to a friend.
Acute low back pain (LBP) is a very common condition. 80% of people at some point in their lives will experience acute low back pain.
Could your tight hip flexors be the source of your hip or back pain?
Have you ever been checked?
I want to share with you what my staff and I have learned to improve your experience at OrthoWell and to remind you how awesome you CAN feel. Read on and let’s get you back on track.
Are you looking for a way to help those in need this holiday season?
Here’s how we can do it if we work together.
As a way of serving our community, OrthoWell Physical Therapy will be donating $10 for each new patient that comes through our doors through the end of 2015 to either of two awesome organizations in Beverly called Beverly Bootstraps or in Amesbury called Our Neighbors Table.
Let’s do this together!
Over the past several months I have been noticing a trend of increased number of patients complaining of neck pain which has sparked my interest to participate in continuing education focused on neck pain in order to get the best results for my patients. I recently completed a 16 hour course focused on cervical (neck) pathology at the Institute of Manual Therapy where I was able to refine my skills and apply new knowledge to all of my patient with neck pain.
So if you or someone you know is suffering from neck pain because life can certainly be a “pain in the neck”, then come on in. You are always guaranteed the most up-to-date, comprehensive and holistic physical therapy at OrthoWell.
“OrthoWell PT has given me my life back, no doubt! After 3 months of knee pain with every step I took, I feared for my job as a nurse and my normally active lifestyle was severely curtailed. Surgery was an option, but without guarantee for improvement.
After just one session of PT and 1 laser treatment i was able to walk without limping. After 1 month of therapy and new orthotics, I am closing in on 100% return of function and I am thrilled with the progress.
The holistic approach used by Chris and his team is unique compared to other PT experiences I have had. I highly recommend OrthoWell PT as the best option out there!”
It may sound like a strange question but “do you breathe properly?” Breathing pattern disorders (BPD) are surprisingly common in the general population. They remain commonly under-recognized by health care professionals and can contribute to pain, fatigue, and dysfunctions in the lumbopelvic region i.e. your CORE!
Core activation remains a hot topic in physical therapy. The problem is that there is not a universally accepted strategy to achieve optimal stability. A decade ago, we started using the “abdominal hallowing” technique which I have talked about before. The abdominal hallowing was an attempt to isolate a key core muscle called the transversus abdominis in which you would “pull your navel in and hallow out your abdoman”. The original work done by Hodges and colleagues on the transversus abdominis also demonstrated simultaneous activation of the diaphragm muscle. The diaphragm, however, took a back seat and has often been ignored during core training. So how do we correct your BPD and “wake up” your diaphragm?
Your diaphragm is attached to your lower ribcage, thoracic wall, and lumbar vertebrae. When you breathe, the diaphragm contracts and pushes DOWN into the abdominal cavity. This movement causes a pressure change which draws air into the lungs. As a result of the contraction, intra-abdominal pressure increases and lumbar spine stiffness, hence stability, also increases. The diaphragm acts in coordination with the abdominal muscles, spinal muscles, and pelvic floor to create lumbar stability in all directions. This is what some refer to as “360 degree of stiffness.” The contraction of the diaphragm creates core stability from the inside-out. When you perform an abdominal hallowing or abdominal bracing you create stability from the outside-in. Professor Kolar and colleages performed two MRI studies of the diaphragm and showed that the diaphragm can perform dual functions of inspiration and stabilization simultaneously! The activation of the diaphragm was shown to vary greatly among individuals. This variability may be the reason why one person can resolve low back pain and another cannot.
Lets take a look at HOW you can activate your diaphragm while breathing and HOW you can enhance the benefit of your core stability exercises. Check out the video below.
The sacroiliac or SI joint is the articulation between the bone at the base of the spine called the sacrum and the bones on both sides of the pelvis called the ilium. Refer to the picture below.
Over 22 years of physical therapy, I have treated many patients with low back and buttock pain who were diagnosed with an SI joint dysfunction. The difficulty with diagnosing an SI joint dysfunction is that the SI joint has no specific distribution pattern of pain. Pain directly over the SI joint does not necessarily mean that the joint itself is involved. SI joint pain can very often be referred pain from other structures such as the disc, nerve root, or facet joints of the lumbar spine. Many physical therapists or physicians attempt to diagnose an SI joint dysfunction through palpation of bony landmarks as well as assessment of SI joint mobility. There is only a very small amount of motion in the SI joint i.e. 2-3 mm or 2-3° of gliding or rotation thereby making an accurate diagnosis very difficult. In addition, evidence based research refutes the reliability and validity of accurately assessing bony landmarks and SI joint mobility. McGrath et al has published an article, entitled “Palpation of the sacroiliac joint: an anatomical and sensory challenge” in which the concept of SI joint palpation is scrutinized. Freburger and Riddle performed a literature review looking at our ability to perform SI joint motion testing. They found poor inter-tester reliability, low sensitivity, and low specificity in several commonly performed tests. Inter-rater reliability is essentially the ability for multiple practitioners to come to the same diagnostic conclusion. If you have multiple individuals perform the same test, the results should be the same. Riddle and Freburger in another study noted that the ability to detect positional faults of the SI joint also has poor reliability. At present, the only acceptable method of confirming or excluding a diagnosis of a symptomatic SI joint is a fluoroscope guided intra-articular anesthetic block ie an injection directly into the SI joint. (Laslett et al) So how can I, as your physical therapist, assist in the diagnosis of an SI joint dysfunction? The answer: SI joint provocation tests!
Two recent studies by Laslett et al and Van der Wurff et al have demonstrated that there isn’t just one key or ideal SI joint provocation test. However, by performing several tests together, you can increase your sensitivity and specificity of detecting an SI joint dysfunction. Both studies reported that the accuracy of detecting SI joint dysfunction is increased if least 3 of the 5 tests are positive. Furthermore, if all 5 tests are negative, you can likely look at structures other that the SI joint. Van der Wurff et al reported that if at least 3/5 of these tests were positive, there was 85% sensitivity and 79% specificity for detecting the SI joint as the source of pain. Interestingly, another study by Kokmeyer et al agreed with the previous findings, but also noted that the thigh trust test alone was almost as good at detecting SI joint dysfunction as the entire series performed together.
Combining the two studies, there are 5 provocation tests to perform when attempting to diagnose SI joint pain:
- Thigh thrust/Femoral Shear test
- SI Distraction Test
- SI Compression Test
- Gaenslen’s Test
- FABER / Patrick’s test
The following video will demonstrate these tests. I would like to thank Mike Reinold, PT for his blog information that was used to complete this explanation of SI Joint dysfunction. Check out the video below!!
CORRECTION: I would like to clarify the SI distraction test as described in Laslett. I believe that he considers the direct posterior shear of the innominates as a distractive force of the ilium away from the sacrum. I initially interpreted this test as a compression of the SI joint via a distraction of the ASIS’s. I guess it depends on HOW you apply the force to the ASIS’s. Also, the sidelying “compression” test needs to be performed in a straight, linear fashion as well in order to compress the SI joint. It is important to place a towel roll under the lumbar spine in women in order to prevent sidebending stress t the lumbar spine. In OMT, we use the sidelying position to “distract” the SI joint using more of a rotational force on the lateral edge of the ilium in order to “open up” and distract the SI to get a feel for joint play. As you can see, these tests are not definitive for exactly HOW they stress the joint but they are specific for a stressing maneuver TO the SI joint.
I would like to highlight one of the unique treatment techniques that we offer at OrthoWell. As many of you know, we spend a lot of quality time during our biomechanical evaluation trying to “figure things out”. This is the reason that several of our referring physicians call us “THINKERS”. We pride ourselves in determining your functional diagnosis. This diagnosis is what we use to develop your plan of care and to educate you in how to alleviate your pain or dysfunction. Many of our patients have seen several physicians or therapists before hearing about us. For this reason, we offer specialized evaluation and treatment services that our patients may not have heard of and that may be appropriate to alleviate symptoms that have been unresponsive to prior interventions. One of these is Nerve Mobilization or NeuroMobilization. So what is it?
What is NeuroMobilization?
NeuroMobilization or Nerve Mobilization is a technique that we utilize to treat nerves that may be adhered, irritated, or compressed. Many patients that have been unresponsive to other physical therapy and present with a chronic history of referred symptoms like pain, numbness, or tingling into the arms or legs may respond to NeuroMobilization. Every patient that presents with referred symptoms or pain that has been unresponsive to localized treatment receives a complete neural tension evaluation. Neural tension testing is a way for your therapist to determine the extent of nerve involvement. By mobilizing a nerve, we can determine, in combination with manual traction and sensitizing maneuvers, whether your pain is originating from the spine or the periphery.
We can then perform NeuroMobilization techniques utilizing controlled neural tension maneuvers to mobilize the nerve up and down. David Butler,PT, has been at the forefront of these techniques for over 20 years. Although we still do not completely understand the exact mechanism, he proposes that NeuroMobilization (what David Butler calls Neurodynamics) can accelerate nerve healing and quiet down what he calls an “altered impulse generating system (AIGs)”. These AIGs may respond to the oscillations of NeuroMobilization by enhancing circulatory exchange or ion transfer in and around the nerve. You can read more about the techniques and science in David Butler’s book The Sensitive Nervous System.
Here is a video that highlights a sciatic nerve tension test and Neuromobilization.
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!
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”