Many patients arrive at their first physical therapy appointment expecting to receive hot packs, ultrasound and instructions on how to complete a series of exercises. These modalities are warranted in many instances and most therapists would agree that exercise is needed to help restore muscle imbalances. However, many therapists now approach the restoration of function from a different perspective. These therapists are interested in why a muscle isn't functioning properly and view back exercise not as the driving mode of recovery but as a complement to manual therapy. They may, for instance, look to restore proper sacroiliac or lumbar joint function to treat piriformis syndrome rather then directly manipulate the piriformis muscle through exercise.
Manual physical therapy is a specialized form of physical therapy delivered with the hands as opposed to a device or machine. In manual therapy, practitioners use their hands to put pressure on muscle tissue and manipulate joints in an attempt to decrease back pain caused by muscle spasm, muscle tension, and joint dysfunction.
Manual Physical Therapy is Less Established for Back Pain Management
While all physical therapists have the option to use manual therapy in their practices, many don't spend the time or the resources to become efficient in this area of practice. Patients should be aware that it is a lesser known physical therapy technique among physicians and may not be as commonly prescribed. Also, many of the conditions that practitioners treat with manual therapy are not demonstrated with imaging or lab tests but rather during motion testing and treatment, and therefore insurance company reimbursement may be limited.
While patients may be referred for physical therapy treatment by their primary care doctor, an orthopedic surgeon, or other doctor involved in their back care, most states have direct access laws permitting patients to seek help for low back pain from a licensed physical therapist without having to seek a written referral.
Manual therapy can be helpful for the treatment of joints that lack adequate
mobility and range of motion in certain musculo-skeletal conditions. This
limitation can cause discomfort, pain, and an alteration in function, posture,
and movement. Manual physical therapy involves restoring mobility to stiff joints and reducing muscle tension in order to return the patient to more natural movement without pain. Thus, manual physical therapy may provide back pain relief both for patients with chronic back pain involving joint problems, such as sacroiliac joint dysfunction, and acute back pain from soft tissue injuries such as a back muscle strain or a pulled back ligament. Although extensive clinical studies have yet to be performed on all areas of manual therapy, limited clinical data and patient reports support the assertion that manual physical therapy can be effective in relieving back pain for certain patients.
As a group, manual physical therapy techniques are aimed at relaxing tense back muscles and restricted joints in order to decrease back pain and increase flexibility. In general, manual physical therapy techniques employ the following types of movement:
So-called arthroscopic knee surgery is becoming a less common treatment for adults with torn cartilage or painful arthritis as a growing body of evidence shows little benefit from these operations, a U.S. study suggests.
Researchers examined data on all surgeries done on patients 18 and older in Florida from 2002 to 2015, including a total of 868,482 arthroscopic knee procedures. Overall, rates of these operations declined 23 percent during the study period, with sharper decreases after 2008.
Many experts believe doctors don’t change the way they treat patients when studies show those treatments don’t work, and knee arthroscopy is often cited as an example, said study author David Howard of Emory University in Atlanta.
“There was some evidence that use of arthroscopy was declining, but this study shows that the decline was large and has been sustained,” Howard said by email. “I think patients can be reassured that doctors reacted to the evidence.”
During this operation, a surgeon makes a small incision in the knee and inserts a tiny camera called an arthroscope to view the inside of the joint, locate and diagnose the problem, and guide repairs.
While this is minimally invasive, it’s not risk-free. Patients receive anesthesia, which in any surgery may lead to complications such as allergic reactions or breathing difficulties. In addition, this specific knee procedure has the potential to damage the knee or trigger blood clots in the leg.
Multiple studies have shown that knee arthroscopy isn’t any better than non-operative treatments for conditions like arthritis, torn cartilage and knee pain, Howard notes in JAMA Internal Medicine. But evidence to date hasn’t offered a clear picture of how much doctors and patients are avoiding the operations as a result.
Between 2002 and 2015, knee arthroscopy rates in Florida declined from 449 procedures for every 100,000 adults in the population to 345 procedures for every 100,000 adults, the current study found.
Declines were steeper after 2008, when a second major trial was published that failed to detect a difference between surgery and “medical management,” which might include things like medications to ease pain or inflammation or use of heat or ice, or physical therapy.
These declines in surgery happened even as the prevalence of knee osteoarthritis among U.S. adults more than doubled from 6.6 percent in 1999 to 14.3 percent by 2014, Howard writes.
The study wasn’t a controlled experiment designed to prove what factors might have influenced any declines in these surgeries or whether or how patients might have different health outcomes as a result. And it only included data from Florida.
Still, the results suggest that doctors and patients are getting the message that these operations aren’t the best approach for wear and tear that contributes to knee pain as people age, said Andrew Carr, a researcher at the University of Oxford in the UK who wasn’t involved in the study.
“Rest and time are often very helpful,” Carr said by email. “If symptoms persist then other treatments including physiotherapy and the use of anti-inflammatory medication may be of benefit.”
There are still, however, far too many operations being done on patients who may not benefit and may be harmed instead, said Jonas Bloch Thorlund, a researcher at the University of Southern Denmark who wasn’t involved in the study.
“There is still room for improvement,” Thorlund said by email. - (Reuters Health)
Be sure you understand your diagnosis.
This sets the tone one and is the key to your Physical Therapy success because it gives you a big picture and what to expect in the weeks and months to come. Physical therapists identify movement impairments and dysfunction, so a PT diagnosis may be more detailed than your surgical or injury diagnosis or the diagnosis written on your doctor’s referral. After the initial full evaluation, the physical therapist will give you their diagnosis. That diagnosis then dictates treatment intervention and plan of care, outlining goals for therapy as well as frequency and duration of treatment. By understanding your diagnosis, it will provide insight as to why particular treatment methods are necessary and why they will be effective. That way, whether you're doing exercises at home or having manual therapy performed by your PT, you'll understand why and how your treatment works.
Ask the right questions.
Asking the right questions can help in the prevention and avoid getting that injury ever again, and much of your ability to do that depends on your therapist and how willing they are to put in that preventative work with you.
You can ask something like: "What will you teach me that will keep this from being a problem again in the future?" Your PT should not only be interested in helping get you back to full function, but also in teaching you about 'why' behind treatments, your movement, recovery, and how your overall lifestyle plays into it all.
Keep a journal.
Motivation can aid you during a long recovery process, so it's helpful to look back on how far you've come. Keep your own notes on pain levels and how you are feeling from day to day (happy, sad, motivated, discouraged, etc.). Recovery can be slow, so by having notes of how your feeling over time lets you see the progress. Seeing results also helps keep patients motivated to continue with their recovery process."
Frequency of Physical Therapy Sessions .
Most people think that the more often they see their PT for a session, the better. But this isn't always the case. Oftentimes, physical therapy referrals read two to three times per week; However, when you seek hands-on, one-on-one treatment with a physical therapist for 45 to 60 minute sessions, weekly or biweekly sessions may be more appropriate, depending on your condition. Not only will these types of sessions help you get better faster, but they'll be more cost-effective, she says. Given that you are invested in your health and healing and therefore compliant with your program, fewer sessions could actually be better than more! For those who aren't dedicated to following their program, greater frequency or duration of sessions may be necessary."
Think of your PT sessions as education, not exercise.
It’s important to remember that you're not here to work out; you're there to learn how to heal your injury and prevent it from happening again. To get the most out of your PT session, think of your session not as an exercise session, but as an educational session. “An effective physical therapist must be an effective educator. That's why learning as much as you can from your PT is critical. Take advantage of the opportunity to ask questions, because Physical Therapists often have much more time to answer basic questions than most health-care providers. A therapist may not be able to answer all your health-care questions, but can often help you seek out the appropriate answer by contacting the appropriate channels.
Ask your therapist for feedback.
Physical therapists keep track of metrics like range of motion that tell the story of progress, but many times patients don't know to ask about it. Check in with your physical therapist every few weeks or once per month to understand how you are improving quantitatively.
Be honest with your PT.
Didn't have time to do your exercises? Feeling worse than when you started PT? Tell your therapist! Physical Therapist’s appreciate their honesty. Sometimes this will alert me to other stressors in a patient's life or allow me to suggest changes. Physical therapists are trained to make recovery possible, but if they don't have all the information, it can be tough for them to make appropriate recommendations. " The more your physical Therapist knows the more they can be a resource for you.
Distracted driving can cause crashes, injuries, and even death; it's a prevalent public issue that the American Academy of Orthopaedic Surgeons (AAOS) continues to champion. But what about distracted walking? What are the consequences of pedestrians talking on the phone, texting, listening to music, or selfies.
Today, more and more people are falling down stairs, tripping over curbs and other streetscapes and, in many instances, stepping into traffic, causing cuts, bruises, sprains, fractures, even death. Alan Hilibrand, MD, chair of the AAOS Communications Cabinet reports, "The number of injuries to pedestrians using their phones has more than doubled since 2004, and surveys have shown that 60% of pedestrians are distracted by other activities while walking.
In Physical Therapy this position is known as a half lunge. There are many variations of this pose. This modified Yoga pose (Asana) is an excellent example of specific muscles lengthening and contracting around the hips.
The blue color represents muscles which are contracting and the muscles in red are lengthening. This image is shared graciously with permission from BandhaYoga from their book The Key Muscles of Hatha Yoga by Ray Long, MD. To see their amazing YogaAnatomy books, visit their website.
The muscles in blue which are contracting:
1. Left sided Triceps
2. Left sided Hamstrings
3. Left sided Iliopsoas
4. Right sided gluteus maximus
5. Right sided hamstrings
The muscles in red which are lengthening:
1. Right sided Iliopsoas
2. Right sided Quadriceps
This is a great asana posture to stretch the iliopsoas.
•Origin (1st attachment site):
Transverse process of L1-L5 and anterior ilieum
•Insertion (2nd attachment site):
Flexes the hip and trunk. Laterally flexes trunk ipsilaterally.
Involved in sit-ups.
This muscle tends to get very tight and shortened in individuals who sit a lot of the day. Most of us would benefit from regularly stretching this muscle.
Musclces that are very tight or weak can cause misalignment of joints and posture. These muscle "impairments" (such as tightness and weakness) can lead to painful movement or discomfort in certain postures. Physical Therapists (P.T.) are experts in movement and posture. By assessing the body in different positions and planes of movement, a skilled P.T. can determine which muscle imbalances exists and then take the proper steps to correct for the musculo-skeletal impairments. For instance, certain muscles are commonly shorter on one side and longer on the other, while others are stronger on one side and weaker on the other. This can set up a muscular "tug of war" between muscle groups. In the hips, there is often a complex tug of war that goes on between the iliopsoas and it's antagonist, the gluteus maximus.
There are a number of other muscle interactions as well, which will be addressed. Applying out knowledge of functional Anatomy, we gain a deep insight in how to overcome pain conditions of posture and movement.
Physical Therapists who are also trained in Yoga, such as those at Zenergy
PT, utilize their knowledge of Anatomy and Yoga to correct muscle imbalances and
postural dysfunctions using Yoga postures and techniques. There are many other ways to address muscle imbalances as well.
Future blogs will go into more detail about common muscle imbalances and how to treat them using out knowledge of Anatomy, Yoga, and Therapy.
Comments are always welcome!!
MOVE RECEIVE RELEASE STRETCH
General exercise helps relieve pain,
improve heart strength, endurance, muscular activity, coordination, mental
health, and is good for every system of the body.
Perform activities that are comfortable, listen to your body for when to
slow down. Swimming and walking and biking tend to have less impact on the
joints of the back than other activities such as jogging.
Welcome into your life what is
nourishing and life affirming. Receiving massage and bodywork has been shown to
help reduce pain and muscle tension, as well as a sense of wellbeing and joy.
Some body types find more benefit from deeper body work, whereas other’s gain
more benefit from lighter, more subtle bodywork or energy work, such as
acupuncture, therapeutic touch, or reiki. Choose a therapist/healer that you
feel very comfortable and safe. Receiving bodywork from someone who is
compassionate and sets a healing tone can make a world of difference when
receiving healing therapies.
Releasing toxicity and stress from
your life is essential to optimal health and spinal function. Fear, stress, and
anger have been associated with longer recovery. Pay attention to making
nourishing and conscious choices. Participate in activities that reduce stress,
such as meditation, mindful movement (such as t’ai chi), or relaxation
breathing. Release toxic and heavy food from your diet, as well as let go of
toxic/negative thinking. Release stressful, toxic relationship from your life is
also a good practice.
STRETCH: Daily stretching is a simple, safe and very effective
way of releasing strained and tense muscles. Yoga has been shown to be
beneficial for people suffering from back pain. The muscles and fascia store
tension from traumas, mental, emotional, and postural stress- where regular
stretching and bodywork can help relieve this built up tension. It is important
to move into postures and stretches slowly, so not to overstrain. You may need
professional guidance on safe, effective, therapeutic stretches for
Physical Therapy/ Neuro-musculo-skeletal Perspective:
This is a very common problem seen by Healers and Health Care Providers. Tension headaches commonly relate to the sub-occipital region where the vertebrae of the neck, the cranium, and the surrounding tissues come together. In anatomical terms this is known as the craniovertebral junction, which is a collective term referring to the atlas, axis, occiput, and surrounding ligaments and soft tissue.
The headaches arising from this region are also known as “Occipital Headaches” which according to many clinician’s, originate in the cervical region, especially if cervical traction decreases the headache pain. This type of headache typically has it’s origin from a structural source. In other words the structures of the neck and craviovertebral junction are strained from poor posture, overuse activities, or movements. The strain of the cervical structures can be associated with headaches.
According to the Mayo Clinic “tension headaches are the most common type of headache and yet the causes are not well understood.” With tension headaches, the muscles that supported the head, including the posterior and anterior sub-occipital muscles, deep neck flexor and extensor muscles are frequently found to be involved. Tense or constricted muscles of the neck often relate to headaches, which can be very intense and unrelenting, and often difficult to resolve. It is often throbbing, pulsating, and radiating in nature.
The sensation of pain can also relate to areas of the neck, jaw, shoulders, upper back, back of head, and refer to the frontal region of the head.
A brief overview of the anatomy involved in this area involves the following:
· Joints – Occipito-atlanto joint (O-A), Atlanto-axial joint (A-A), Mid Cervical Joints
· Ligaments – OA and AA ligaments, including Alar and Cruciform ligaments
· Muscles – Anterior Suboccipital Muscles (Rectus Capitus Anterio, Rectus Capitus Lateralis), Posteiror Suboccipitals (Rectus Capitus Posterior Major and Minor, Inferior and Superior Oblique), Splenius Capitus, Trapezius, Pectorals, and masseter.
· Nerves – Dorsal Ramus of spinal nerve C1 and C2 (Greater occipital nerve). C2 has a large cutaneous distribution and has a large dorsal root ganglion in a vulnerable location between C1 and C2. Cervical extension motions compress this region and thus Forward head posture can relate to Occipital headaches through this relationship. (ref below)
Abnormal posture has often been related to numerous musculo-skeletal and neuro-vascular impairments. In the area of postural mechanics there is a term that describes a very common position of the head and neck that relates to sub-occipital tension – known as Forward Head Posture. This position puts an abnormal load on the cervical, thoracic, and jaw regions places high amounts of stress on the muscular system. The further forward the head position, the higher the muscular force of the neck muscles must be to counteract gravity.
This posture causes excess mechanical strain on the neck region and results in a cascade of muscular and skeletal problems. As indicated above, it can relate to occipital and tension headaches due to the compression pressure that can aggravate the sensitive C2 nerves.
When working long hours at a desk or computer forward head posture often results- because the body posture will follow the eyes, usually forward, and the posture gets more and more flexed with time due to the force of gravity.
Common history and/or complaints of individual with tension headaches:
· Job that requires prolonged sitting, especially if using computer
· Recent life changes – change of job, living situation, relationship, ANY major change
· Under High amount or long duration of stress
The main clinical objective findings for tension headaches:
· Postural: FHP (Forward Head Posture) with associated increased thoracic flexion and scapular protraction. Occipito-Atlanto Backward Bending.
· Hyper tonicity and shortening of posterior sub-occipital and scapula-cervical muscles
· Tenderness to palpation of external occipital protuberance
· Taut bands and trigger points in mid belly of upper trapezius, sub-occipitals, and often upper cervical joints- especially the transverse processes.
· Restricted Active Range of motion with Chin Tuck, Cervical Forward Bending, and often Cervical Side Bending to contralateral side
· Restricted Passive Range of motion with OA forward bending and often mid cervical upglide restrictions
· Functional Limitations: Varied, often related to increased pain with looking upward, computer work, prolonged sitting, sleep disturbance
Ayurveda relates this type of headache to a Vata disturbance, related to the following qualities:
· You cannot have pain without Vata.
· The rough quality of Vata relates to muscle stiffness.
· The dry quality of vata relates to constipation, which sometimes accompanies this pain.
· You may notice these symptoms are worse during Vata times of day 2-6am and pm, and/or Vata seasons (Autumn).
· The mobile qualities of Vata relate to over-activity aggravating the skeletal, muscular, and nervous systems and cause headaches. Pain gets worse with certain movements and less if the body is at rest.
· Fear, anxiety, nervousness, stress can all aggravate Vata and relate to tension headaches.
· Typically Vata headaches are related more to the occipital region, whereas Pitta headaches will be more in the temporal region, and kapha headaches tend to be located more in the nasal/sinus regions of the head.
The treatment for these headaches varies depending on the type of health care practitioner you see. A Physical Therapist or movement specialist would certainly address ergonomics, posture, and physical restrictions with therapeutic exercises and body awareness. A stress management routine and breathing techniques would be indicated. This type of condition responds very well to manual and touch therapies – and in my estimation any treatment plan is incomplete without including it.
I will often use a combination of manual and touch therapies with great results in a short amount of time, including:
· Marma Therapy – healing points that can decrease muscles tension, stress, and pain.
The points right underneath the external occipital protuberance are considered the most influential points, called Krikitaka in Ayurveda, and well known in modern medicine for pressure relief because of the location and insertion of the posterior suboccipital muscles into the cranium.
· Manual Therapy – sub-occipital release and myofascial release techniques. These techniques can decompress to posterior joints of the neck and create more extensibility in the soft tissue.
· Yoga Therapy – there are a number of Yoga Asanas and Breathing Techniques that can offer great relief from sub-occipital tension. Alternate nostril breathing can calm the mind and Postures involving gentle neck flexion can relieve the muscular shortening and tension.
· Massage with Sesame or Vata Oil to the back of the head, scalp, and neck muscles, can help relieve the pain.
Future Blogs will give more detailed treatment approaches according to Marma and Manual Therapy principles.
_Welcome to the Blog on Integrative Medicine
Written by Brent Cesare, DPT
Integrative Physical Therapist, Scientist, and Philosopher
The intention of this blog is for me to share information in the field of Integrative Medicine and to connect people from around the world to the exploration of the science and art of treating individuals with health conditions holistically.
Topics will vary and cover a broad spectrum – as with anything holistic in nature – if you talk about any one topic and are good at connecting the various pieces, you can in fact relate anything to everything. This is because life is interconnected, which is a basic principle of systems and quantum mechanics, and to any mindful human being is in fact, self-evident.
We may discuss practical advice for orthopedic conditions such as arthritis, back pain, and sciatica and in the same breath explore the realm of mind and consciousness in the healing process. The purpose of this blog is to promote a discussion on this explosive topic that is core to all of us as the healthcare system (or more aptly called “disease care system”) is starting to change to a more integrative, systems approach because of those of us who are seeing the value in a more holistic way to manage our well-being.
There are many, many questions that we will explore together. Some are a matter of semantics and coming to an agreement with defining certain terms, such as:
Other questions are more philosophical in nature.
The above questions and topics are just a sample of a small tip of the iceberg of this vast topic. As a clinician who evaluates and treats individuals with multiple physical ailments/conditions every day of my life – I am interested in the practical application of integrative approaches that are rational, safe, effective, and based on sound science, whenever possible.
I hope you enjoy the topics and discussions. This is meant to be interactive – meaning I hope you take the opportunity to write and share your knowledge and thoughts! Taking part in the discussing is a great way to share your own insights and help enrich the experience and the journey for all of us.
You are encouraged to participate and post whenever you desire, and especially if there is a topic that you have a lot of knowledge or interest!
Until Sunday –
Peace and Blessings,
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