Physical Therapy for Shoulder Pain

By Mai Vu, Physical Therapist
Shoulder pain is one of the most common complaints that we see in our office. Some common causes of shoulder pain are:
Tendonitis – This occurs when inflammation is present in tendons. Tendons are the structures that connect muscles to bones.
Bursitis – This occurs when inflammation is present in a bursa. A bursa is a fluid-filled sac that helps to decrease friction when the body moves.
Tears – Tears can occur as a result of trauma such as a fall, or they can occur slowly over time. Tears can range from a microscopic level to a complete tear where the muscle or ligament is no longer attached.
Radiculopathy – This occurs when there is a problem with the nerves from the spine. The nerves from the neck travel across the shoulder and down the arm. When there is a problem in the spine, pain can be felt along the path of the nerves.

When there is shoulder pain there are many structures that may be involved, including:

• Rotator Cuff which is comprised of 4 different muscles (supraspinatus, infraspinatus, teres minor, subscapularis)

• Long head of the Biceps Tendon Subacromial Bursa Acromioclavicular Joint – this is where the clavicle (collar bone) meets the scapula (shoulder blade) 

• Glenohumeral Joint – this is where the scapula (shoulder blade) meets the humerus (upper arm bone)

• Labrum – this is part of the glenohumeral joint

• The muscles, bones, and nerves from the neck (cervical spine)

• The muscles, bones, and nerves from the trunk (thoracic spine)

We will cover some of these topics in more detail in later posts.

Stretching Tips for Office Workers

Our bodies were designed to be up and moving around.  Unfortunately in today’s world, many of us are stuck at a desk sitting down for the majority of the day.  When you sit too much, certain muscles tend to get too tight.  One muscle that commonly gets tight is the iliopsoas, also known as the hip flexors.  This muscle often needs to be stretched when we sit too much.

The iliopsoas muscle is located in the front of the hip, which is where you should feel the stretch.  There are many ways to stretch this muscle:

Standing:

Stand in a lunge position with your right leg in front.  Tuck the buttocks under.  A stretch should be felt in the front of the left hip.  If you still do not feel the stretch, lift your left arm all the way over your head.  Switch legs to stretch the right side.

Kneeling:

Start by kneeling on your left knee.  Slowly bend the right knee until a stretch is felt in the front of the left hip.  Do not arch your back.  If you still do not feel the stretch, lift your left arm all the way over your head.  Switch legs to stretch the right side.

Laying Down:

Start standing.  Lean your buttocks onto the edge of a bed or bench.  Without readjusting your buttocks position, lay onto your back and hug your knees.  Then let the left leg hang down.  You should feel a stretch in the front of the left hip.  To stretch the right side, hug your left knee and let your right leg hand towards the floor.

Generally, we recommend holding the stretch for 30-60 seconds and repeating 2-3 times per leg.

The Benefits of Pool Exercise

By  Saralyn M. Switzer, PT, DPT, Doctor of Physical Therapy
Since the summer has ended and fall is here we remember how much we enjoyed the warm weather and being in the pool.  Many people are more active in the summer since everyone enjoys going outside walking on the boardwalk or in the park, running, biking, swimming, hiking, and other outdoor activities.  This active pace is hard to carry over into the colder, winter months once we are forced indoors more.  The time is rapidly approaching when we will not want to exercise outside and we must start thinking of fun indoor alternatives.  Swimming and pool exercise can be performed in an indoor pool to continue the benefits of this activity year-round.
Pool exercise:

• increases endurance by doing continuous cardiovascular exercise in the water
• builds strength due the constant resistance from the water
• is conducive to relaxation and promotes flexibility by using the buoyancy of the water that lessens the weight of gravity on the joints
• improves circulation by using the water pressure to help the fluid in our arms & legs return easier to our heart
• improves balance
• improves chronic pain conditions, joint pain, and back pain

With all these benefits, who wouldn’t want to get in the pool this winter?
Now that you want to exercise in the water, what type of exercise can you do? As with any exercise program, aquatic exercise should focus on increasing endurance, strength, and flexibility.
Endurance or cardiovascular exercise can include walking in the water, kicking across the pool with a kick board, and doing cycling while floating on a noodle, or good old-fashioned laps
Strengthening exercises include standing at side of pool doing leg kicks backward, sideways, and forward on each leg; squatting at the side of the pool; leaning your back against side of pool and squatting so your shoulders are under water then pushing and pulling the kick board like you are making waves without letting your body come off the wall.
Flexibility can include traditional stretches performed in the water such as a runners calf stretch standing at the side of the pool facing the wall with one leg back, or hamstring stretch with one foot up on the step or ladder in the pool. The best part of stretching in the water is using the buoyancy ability to float. This can be done by using noodles to help you float and move through more motion until a stretch is felt. To stretch your hip, put one noodle under your arms to float and then put another under one knee while the opposite leg hangs down. Other types of flexibility exercise can be tai chi or yoga poses adapted for the water.
These are just some examples of many different types of water exercises.  What you choose will depend on your fitness level and comfort with the water.  Many community pools offer water exercise classes to help get you started.  Local colleges or universities may offer pool membership to the community.  Also, physical therapists and personal trainers who specialize in aquatic exercise can help you develop an aquatic exercise program that is right for you.  So, keep that bathing suit out for the winter and start swimming!
*Before starting any exercise program including aquatic exercise, clearance by your medical doctor is important.  Remember, swimming or exercising in a pool with a life guard is the most important safety rule of water exercis

Taking Control of Neck Pain

By Dr. Jay Mazzella, DC, Clinical Director
Common causes of neck pain include watching TV, using a computer, reading a book, ortalking on the phone, especially with the receiver held on your shoulder or under your chin. Fortunately, this pain usually subsides within a short period of time, particularly if you discontinue the offending activity for a while. On the other hand, chronic neck pain, the kind that doesn’t go away or that keeps “coming back,” can be a far more serious and debilitating problem.
Current treatment of chronic neck pain runs the proverbial gamut, from anti-inflammatory and pain-relief medications to group gymnastics, neck massage and manipulation. Neck-specific strengthening exercises have also been suggested as a potential treatment option. In a recent study designed to evaluate this potential, 76 men and women with chronic neck pain received active care, home care, or simple recommendations on exercising.
Active care included postural control exercises, relaxation training to reduce muscle tension, and cervical muscle endurance/coordination training. Home care comprised a neck lecture and training on exercises to be performed at home. The third treatment protocol (the control group) received a lecture on neck care and general recommendations to exercise. Patients in the active group reported greater satisfaction, reduction in pain severity, and improvements in working ability at three and 12-months compared with the home group and the control group.
If neck pain’s putting a crimp in your day, it’s about time you did something about it. For more information on neck pain and the various treatment options available to you, schedule an appointment with us for a complete evaluation. For information on line


If you have questions as to how much of your care may be covered by your health insurance, contact our desk staff and ask about a COMPLIMENTARY INSURANCE VERIFICATION.

Steps to Preventing Falls in the Home

Falls in the elderly are the leading cause of fatal as well as non fatal injuries. Thirty percent of people over the age of 65 will fall each year. The U.S. spends approximately $20.2 billion annually for the treatment of injuries to older people after falls. The majority of the cost is for hip fracture care, which averages $35,000 per patient.
The most common types of injuries sustained after falls include: hip, spine, and wrist fractures as well as head trauma. These types of injuries can result in serious disabilities and prolonged rehabilitation stays as well as possible death.
It is important to be aware of this situation, because falls can be prevented. Sixty percent of elderly falls occur in the home. By safe proofing your or your loved ones house, you can help decrease this number. Read these easy steps to fall proof a house.

Kitchen:
Clean up spills as soon as they occur
Do not store any objects above a hands reach
Use a step stool with hand rails if needed
Avoid climbing on counters to obtain objects
Living Room:
Pick up any throw rugs…. Do not have them anywhere in the house
Have ample space to walk in between furniture
Keep all electrical cords out of the way

Bathroom:
Keep a night light on at all times
Install rails in the bathtub or shower
Place a non skid mat in the shower or bathtub

Stairs:
Keep all stairways free of clutter
Install hand rails on both sides of the steps

Get the Most Out of Physical Therapy

 

While not all physical therapy experiences are the same, some general rules apply to ensure that your experience will be a positive one. Whether you have your therapy treatment in a clinic, a hospital, or at home, following some general guidelines can help you get the most out of physical therapy.

1. Arrive on Time for All Appointments

Physical therapists usually run on a pretty tight schedule. We want to spend as much time as we can with our patients to ensure that they receive the best possible care. Arrive on time to your appointment to get the best care and attention possible. If you are going to be late, call ahead and ask if the therapist can still see you or if it would be better to reschedule.

2. Wear Comfortable Clothing

Rolling up the legs of your jeans is tough to do, and it makes the examination of a painful knee difficult. Long sleeved shirts get in the way of a shoulder examination. Skirts make exercising almost impossible. Before going to therapy, plan ahead and choose the best clothing to wear. If you are unsure, call ahead and ask what clothing would be best suited for your specific condition. Many clinics have changing rooms so you can get out of your work clothes and into your exercise clothes. Also, wear or bring comfortable shoes. Exercises for hips, knees and shoulders often require that you hold weights. Wearing sandals (or no shoes at all) could put your toes at risk for fracture if a weight were to fall on them.
If you are receiving physical therapy in a hospital and are wearing a hospital gown with the opening in the back, be sure to tie it up. You may also want to put on a second gown with the opening in the front to make sure you stay modestly covered up.

3. Ask Questions About Your Condition and Treatment

As a patient, you should not simply follow the orders of your therapist. Rather, have an open dialogue with your therapist about what is to be done and what to expect. Think of your relationship with your physical therapist as a therapeutic alliance. Both you and your therapist should be working together to help you move and feel better.

4. Perform Your Home Exercise Program as Directed

Usually in physical therapy you may be required to perform an exercise program at home (or on your own in your room if you are receiving physical therapy in the hospital). It is essential that you do your best to perform the exercises prescribed by your physical therapist. If, for some reason, you cannot do the exercises, tell your therapist. Taking responsibility for your condition and engaging in a self-care exercise program can help you return to optimal function quickly.

5. Work Hard

Occasionally after injury, illness, or surgery you need to work hard to regain normal mobility. Your physical therapist won’t expect every patient to get better and dance out of the clinic or hospital. Your physical therapist will expect that you work hard and try your best.
By following some simple rules in physical therapy, you can be sure that you have a positive experience. Plus, you can feel good about working hard to decrease and eliminate your pain and improve your functional mobility. If you are unsure of what is expected, be sure to ask your physical therapist.

Types of Physical Therapy

There are many specialty areas in the field of physical therapy. Although this is well known throughout the profession, it is often overlooked by the general public. Below is a brief description of the five most common specialty areas in physical therapy. Read on to find out what specialty area is most appropriate for you or your family member.
Orthopedic Physical Therapy
Orthopedic physical therapists diagnose, manage and treat disorders and injuries of the musculoskeletal system. They also help people recover from orthopedic surgery. This specialty of physical therapy is most often found in the out-patient clinical setting. Orthopedic therapists are trained in the treatment of post-operative joints, sports injuries, arthritis and amputations, among other injuries and conditions. Joint mobilizations, strength training, hot packs and cold packs, and electrical stimulation are often used to speed recovery in the orthopedic setting. Those who have suffered injury or disease affecting the muscles, bones, ligaments or tendons of the body may benefit from assessment by a physical therapist specialized in orthopedics.
Geriatric Physical Therapy
Geriatric physical therapy covers numerous issues concerning people as they go through normal adult aging. These include (but are not limited to) arthritis, osteoporosis, cancer, Alzheimer's disease, hip and joint replacement, balance disorders and incontinence. Geriatric physical therapists develop individualized programs to help restore mobility, reduce pain and increase fitness.
Neurological Physical Therapy
Neurological physical therapists work with individuals who have a neurological disorder or disease. These include Alzheimer's disease, ALS, brain injury, cerebral palsy, multiple sclerosis, Parkinson's disease, spinal cord injury and stroke. Common problems of patients with neurological disorders include paralysis, vision impairment, poor balance, difficulty walking and loss of independence. Therapists work with patients to improve these areas of dysfunction.
Cardiovascular and Pulmonary Rehabilitation
Cardiovascular and pulmonary rehabilitation physical therapists treat a wide variety of people with cardiopulmonary disorders as well as those who have had cardiac or pulmonary surgery. Primary goals of this specialty include increasing patient endurance and functional independence.
Pediatric Physical Therapy
Pediatric physical therapy assists in early detection of health problems as well as the diagnosis, treatment, and management of infants, children, and adolescents with a variety of injuries, disorders and diseases that affect the muscles, bones, and joints. Treatments focus on improving gross and fine motor skills, balance and coordination, strength and endurance as well as cognitive and sensory processing and integration. Children with developmental delays, cerebral palsy, spina bifida and torticollis are a few of the patients treated by pediatric physical therapists.

Physical Therapy for Parkinson's Disease

Parkinson's disease (PD) is a neurological disorder that affects normal movement and movement planning. It is a chronic, progressive disease with no known cure. People with PD may have difficulty with movement of the hands, arms and legs. These movement difficulties make basic functional tasks like reaching, walking and speaking difficult.









Parkinson's disease is caused by a decrease in the production of a chemical called dopamine in the brain. This chemical is a neurotransmitter that works in an area of the brain called the basal ganglia. The basal ganglia is responsible for movement planning and coordinating movement, thus a decrease in dopamine causes functional motion to become abnormal.

Who Gets Parkinson's Disease?

There is currently no known cause of PD. It typically affects people above the age of 50. About one in 20 people with Parkinson's are below the age of 40. People with a close relative with PD have a slightly increased risk of developing the disease, but there is no known genetic component in PD. Males are more often affected than females.

Signs and Symptoms of Parkinson's Disease

The diagnosis of Parkinson's disease is largely made by clinical observation. Since the area of the brain affected coordinates movement for many systems in the body, many different clinical signs may be present. These are typically motor control changes and can affect different parts of the body. If you have PD, you may have difficulty with speech, swallowing, hand motion, leg motion and walking. Some of the clinical signs of PD include:

    Rigidity. Rigidity refers to increase stiffness around a joint in the body. You may find it difficult to easily bend or straighten your arms, hands, or legs.
    Tremor. Tremor is a rhythmic, uncontrolled oscillation in a body part. Most often tremor is seen in the hand or hands of someone with PD. Tremor at rest is often the first sign of PD.
    Lack of movement or slowness of movement. Since the area of the brain that controls movement planning is affected in PD, there often is a lack of movement with the disease. Slowness of movement may also be present.
    Freezing phenomenon. This refers to the difficulty with starting or continuing movement. Some movements affected may be handwriting, speech or walking. You may be suffering from the freezing phenomenon if you are walking and suddenly stop for no apparent reason. You may then have difficulty starting to walk again.

Physical Therapy for Parkinson's Disease

If you have been diagnosed with PD, you doctor may refer you to a physical therapist to evaluate you and offer treatment to help you move and function better. The physical therapy evaluation and treatment for PD may include many items, such as:

    Postural assessment
    Endurance assessment
    Gait evaluation
    Strength measurements
    Measurements of flexibility and range of motion.
    Breathing function

Since so many different body functions can become altered with PD, your doctor may also refer you to other specialists such as a speech therapist or occupational therapist. It is important that all healthcare providers communicate with each other and your doctor to ensure that you receive the best care possible.

It is a good idea to also include family members in your care planning, as they can help provide assistance when necessary.

While physical therapy will not provide a cure for PD, you may be able to function better and maintain movement longer by following the guidance of your physical therapist and doctor.

Parkinson's disease can cause major neurological deficits and movement dysfunction. If you are experiencing signs of PD or suspect you may have PD, you should contact your doctor immediately. He or she can help you get the proper treatment, including physical therapy, to ensure that maximal function is maintained as long as possible.

Single Leg Hip Thrust with Band-Resisted Hip Drive

First of all I would like to say thanks to Mike Reinold for letting me write a guest post here. I’ve been reading and learning a lot through his blog so it’s kinda cool to write a post here.  I wanted to share a new exercise I have been performing.
At the time I was doing this exercises I only had sprint mechanics in my head, but some days ago I read the articles on Mike’s site onFunctional Assessment and Exercises to Enhance Hip Flexion and The Importance of Hip Flexion Strength.
I’m always looking for exercises that will give me the most bang for the buck, just like everyone else.  I figured that this exercise would be good for both sprint mechanics and also can be a good progression for some of the exercises Mike was recommending by incorporating hip flexion drive into other exercises.
My goal with training, when I started doing the exercise, was to improve my sprint mechanics. I was always finishing trainings with single leg hip thrusts, moved on to add motion, and then to simultaneously flex the other hip (basically a hip flexion drive).  It felt very natural, so I tried out with a band to resist the hip flexion.

3 Reasons to Not Use the Sleeper Stretch

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Ah, the sleeper stretch.  Pretty popular right now, huh?  Seems like a ton of people are preaching the value of the sleeper stretch and why everyone needs to use it.  It’s so popular now that physicians are asking for it specifically.
I don’t like the sleeper stretch and I rarely use.
There, I said it, I felt like I really had the get that off my chest!  Every meeting I go to I see more and more people talking like the sleeper stretch is the next great king of all exercises.  Then I get up there and say I don’t use it and everyone looks at me like I have two heads!  Call me crazy, but I think we probably shouldn’t be using as much as we do.

When the Sleeper Stretch is Appropriate

There are times when the sleeper stretch is probably more appropriate.  I could see recommending it in two cases, in young overhead athletes that don’t have anyone that can stretch them and in people with tight posterior capsules (I’m not talking about overhead athletes, you know my thoughts on this, but more so the adhesive capsulitis patient).  But of course, there are good ways to perform the sleeper stretch and there are bad ways, technique is important.
For more information on how to correctly perform the sleeper stretch and some alternatives to the sleeper stretch


Together, these three articles should really help you understand the pros and cons of the sleeper stretch.

 

3 Reasons to Not Use the Sleeper Stretch

So why don’t use the sleeper stretch?  There are actually a few reasons.  Let me describe each in detail.
1. It Stretches the Posterior Capsule
If you have heard me speak at any of my live or online courses, you know that I am not a believer in posterior capsule tightness in overhead athletes.  Maybe it happens, but I have to admit I rarely (if any) see it.  In fact, I see way more issues with posterior instability.  The last thing I want to do is make an already loose athlete looser by stretching a structure that is so thin and weak, yet so important in shoulder stability.
Urayama et al in JSES have shown that stretching the shoulder into internal rotation at 90 degrees of abduction in the scapular plane does not strain the posterior capsule.  However, by performing internal rotation at 90 degrees of abduction in the sagittal plane, like the sleeper stretch position, places significantly more strain on the posterior capsule.

2.  It is an Impingement Position
This one cracks me, check out the photos below, if you rotate a photo of the Hawkins-Kennedy impingement test 90 degrees it looks just like a sleeper stretch.  I personally try to avoid recreating provocative special tests as exercises.



3. People Get WAY too Aggressive
Despite the above two reasons, this may actually be the biggest reason that I don’t use the sleeper stretch – people just get way to aggressive with the stretch.  The whole “more is better” thought process.  Being too aggressive is only going to cause more strain on the posterior capsule and more impingement.  You may actually flare up the shoulder instead of make it better.

Femoroacetabular Impingement – Etiology, Diagnosis, and Treatment of FAI

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Femoroacetabular impingement is a pretty hot topic right now.  This week, we have a great guest post from frequent contributor Trevor Winnegge.
Recently, femoroacetabular impingement, or FAI, has been increasingly recognized as a cause of hip pain. While femoroacetabular impingement can be a source of hip pain at any age, this post will focus primarily on the adolescent and young adult.  Femoroacetabular impingement is considered a cause of labral and chondral injuries as well as secondary osteoarthritis of the hip. Emerging evidence suggests that early surgical intervention improves function and perhaps prevents or delays the onset of degenerative changes in the hip joint.[1] I hope to provide a thorough overview of FAI, the signs and symptoms of it, and how to treat FAI in an effort to allow us to play an important role in the management of these patients.

What is Femoroacetabular Impingement?

Femoroacetabular impingement occurs when the femoral head and acetabulum rub abnormally, resulting in damage to the articular cartilage and/or the labrum, as well as limited range of motion (ROM). FAI is commonly classified into 3 forms

1. Cam impingement deformity
2. Pincer impingement deformity
3. Mixed impingement deformity resulting in a combination of the two.

These are clearly seen in the following illustration taken from Lavigne et al.[2]:

In a Cam impingement, there is an abnormal contour of the femoral head-neck junction, resulting in impingement against the acetabulum, particularly with flexion, internal rotation, or a combination of flexion and internal rotation of the hip.[3] This is better illustrated here in this picture from the Childrens Healthcare of Atlanta[4].

Pincer impingement is caused by an acetabular abnormality, usually anterior, resulting in overcoverage of the femoral head. This could be an isolated bony protrusion or it could be a degree of acetabular retroversion. Here the ROM is limited as the femoral head impacts the extended acetabulum which can also lead to labral tears and chondral lesions.[5] This is well illustrated in the following picture, also from the Childrens Healthcare of Atlanta.[6]

A Mixed type of femoroacetabular impingement is a combination of both Cam and Pincer impingement deformities. It is important to note that both Cam and Pincer impingement have been associated with progressive joint degeneration.

Etiology of Femoroacetabular Impingement

Femoroacetabular impingement is linked to childhood hip disorders such as Legg-Calve-Perthes Disease, Slipped Capitol Femoral Epiphysis, hip dysplasia, septic hip, and prior fractures of the pelvis or femur. [7] Despite those correlations, the majority of FAI cases are of unclear etiology[8]. It is theorized that physeal stresses placed on the femoral head and/or acetabulum during development may play a key role in the onset of FAI. Activities such as gymnastics, dancing, and rigorous sports during the development process are potential sources of FAI.

Diagnosis of Femoroacetabular Impingement

Diagnosing femoracetabular impingement starts with a good subjective history. Patients will often complain of hip or groin pain- laterally, anterior or posterior. This pain is often acute during a sporting activity or will be insidious onset after prolonged exertion. Patients with FAI are often quite capable of completing their daily tasks, but have difficulty with high demand sports/activities. Typically there is no rest or night pain. When asked to pinpoint their pain, they will often demonstrate a “C” sign, described by Byrd[9], and seen below in this picture from hiparthroscopy-Ireland.com[10].
Patients will report a lack of ROM of the hip, which in an adolescent patient is often described as a functional deficit such as “I can’t do a split anymore” or “I can’t move my leg in this position”. When asked about their activity level, these patients will often be involved in a high level sport or activity such as dance, gymnastics, lacrosse, hockey, tennis, baseball, and football. Objectively, there will be a loss of ROM, particularly hip flexion, IR and adduction. Joint capsule hypomobility may or may not be present. A positive hip impingement sign will often be present, which is flexion, adduction and IR of the hip in a combined movement[11].

Diagnostic Imaging in Femoroacetabular Impingement

Plain film X-rays are most commonly used to view the bony changes of the femoral head and acetabulum. MRI or MR-arthrograms are useful in diagnosing secondary injuries such as chondral lesions and labral tears.

Differential Diagnosis for Femoroacetabular Impingement

Often times, patients with femoroacetabular impingement get misdiagnosed early on and are treated for a variety of diagnoses such as back pain, hip pain, groin pain, bursitis, piriformis syndrome, tendonitis of iliopsoas, groin strain, apophysitis, and “growing pains”[12].

Treatment of Femoroacetabular Impingement

While surgical management of the femoroacetabular impingement remains the an option for treatment, non-operative care can sometimes be successful. Unfortunately, we can not alter the bony changes, but we can normalize soft tissue length, joint capsule mobility, strength and educate on joint preservation techniques. Think of it as treating a patient with a large bone spur in the shoulder that has subacromial impingement. Treatment can be successful despite the bony changes, if the objective deficits are addressed. The success of conservative care for FAI is largely dependent on the patients willingness to modify their sport/activity and become less active in impact sports.
For most adolescents and young adults, this is not an option. While most patients will try conservative care first, often they are unable to fully participate in their sport/activity and seek further management of their FAI. Surgical management can be done open or via the arthroscope, which is becoming the more commonly used method due to its lower level of invasiveness. Surgical treatment is aimed at addressing the secondary injuries such as the chondral lesions and labral tears. The surgeon will address the primary cause of the femoracetabular impingement, typically performing a decompression/osteoplasty.[13] Post-operative rehabilitation is dependent on the procedure performed (labral debridement vs repair; open vs arthroscopy, etc). Typically, recovery from most FAI surgical procedures is 3-4 months, with the expectation that the patient is then able to return to full, unrestricted activity and sport.
In conclusion, I think it is important that we are aware of femoroacetabular impingement and the presentation of FAI. Given it is often misdiagnosed early on, we can play an integral role in the management of these patients. Early diagnosis and treatment is critical for long term health of the hip joint and to allow the patient a lifetime of active living.

Specific Manual Physical Therapy Techniques

Before beginning manual therapy or any type of physical therapy, the practitioner usually performs a full assessment of the blood and nerve supply in the area, as well as a bone and muscle assessment, in order to decide whether or not there is an increased risk of complications from the use of these back pain management techniques. Depending on the results of that assessment and each individual back pain patient’s particular situation, the healthcare provider may perform some or a combination of the following types of manual physical therapy:

Soft Tissue Mobilization

It is important to recognize the role of muscles and their attachments around the joints. Muscle tension can often decrease once joint motion is restored, but many times the spasm will continue to be present. In such cases, muscle tension should be addressed or the joint dysfunction may return. The goal of soft tissue mobilization (STM) is to break up inelastic or fibrous muscle tissue (called ‘myofascial adhesions’) such as scar tissue from a back injury, move tissue fluids, and relax muscle tension. This procedure is commonly applied to the musculature surrounding the spine, and consists of rhythmic stretching and deep pressure. The therapist will localize the area of greatest tissue restriction through layer-by-layer assessment. Once identified, these restrictions can be mobilized with a wide variety of techniques. These techniques often involve placing a traction force on the tight area with an attempt to restore normal texture to tissue and reduce associated pain.

Strain-Counterstrain

This technique focuses on correcting abnormal neuromuscular reflexes that cause structural and postural problems, resulting in painful ‘tenderpoints’. The therapist finds the patient’s position of comfort by asking the patient at what point the tenderness diminishes. The patient is held in this position of comfort for about 90 seconds, during which time asymptomatic strain is induced through mild stretching, and then slowly brought out of this position, allowing the body to reset its muscles to a normal level of tension. This normal tension in the muscles sets the stage for healing. This technique is gentle enough to be useful for back problems that are too acute or too delicate to treat with other procedures. Strain-counterstrain is tolerated quite well, especially in the acute stage, because it positions the patient opposite of the restricted barrier and towards the position of greatest comfort.

Patients often get diagnosed with a pulled muscle in their back and are instructed to treat it with rest, ice and massage. While these techniques feel good, the pain often returns because the muscle spasm is in response to a restricted joint. Joint mobilization involves loosening up the restricted joint and increasing its range of motion by providing slow velocity (i.e. speed) and increasing amplitude (i.e. distance of movement) movement directly into the barrier of a joint, moving the actual bone surfaces on each other in ways patients cannot move the joint themselves. These mobilizations should be painless (unless the operator approaches the barrier too aggressively).

Muscle Energy Techniques

Muscle energy techniques (MET’S) are designed to mobilize restricted joints and lengthen shortened muscles. This procedure is defined as utilizing a voluntary contraction of the patient’s muscles against a distinctly controlled counterforce applied from the practitioner from a precise position and in a specific direction. Following a 3-5 second contraction, the operator takes the joint to its new barrier where the patient again performs a muscle contraction. This may be repeated two or more times. This technique is considered an active procedure as opposed to a passive procedure where the operator does all the work (such as joint mobilizations). Muscle energy techniques are generally tolerated well by the patient and do not stress the joint.

Maintaining Back Pain Relief Long-Term

To continue the healing process and prevent recurring pain, back pain patients are encouraged to engage in other appropriate treatments (including an exercise program) during and after manual therapy treatment. Exercise programs for back pain usually include stretching and strengthening exercises and low-impact aerobic conditioning, and should include a reasonable maintenance exercise program for patients to do on their own. The goal is to maintain the right type and level of activity to prevent the pain from re-occurring and avoid the need for frequent return visits to the therapist.

Nature of the Work

Physical therapists, sometimes referred to as simply PTs, are healthcare professionals who diagnose and treat individuals of all ages, from newborns to the very oldest, who have medical problems or other health-related conditions, illnesses, or injuries that limits their abilities to move and perform functional activities as well as they would like in their daily lives. Physical therapists examine each individual and develop a plan using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability. In addition, PTs work with individuals to prevent the loss of mobility before it occurs by developing fitness and wellness-oriented programs for healthier and more active lifestyles.
Physical therapists provide care to people of all ages who have functional problems resulting from, for example, back and neck injuries, sprains/strains and fractures, arthritis, burns, amputations, stroke, multiple sclerosis, conditions such as cerebral palsy and spina bifida, and injuries related to work and sports. Physical therapy care and services are provided by physical therapists and physical therapist assistants who work under the direction and supervision of a physical therapist. Physical therapists evaluate and diagnose movement dysfunction and use interventions to treat patient/clients. Interventions may include therapeutic exercise, functional training, manual therapy techniques, assistive and adaptive devices and equipment, and physical agents and electrotherapeutic modalities.
Physical therapists often consult and practice with a variety of other professionals, such as physicians, dentists, nurses, educators, social workers, occupational therapists, speech-language pathologists, and audiologists.
Work environment. Physical therapists practice in hospitals, outpatient clinics, and private offices that have specially equipped facilities. These jobs can be physically demanding, because therapists may have to stoop, kneel, crouch, lift, and stand for long periods. In addition, physical therapists move heavy equipment and lift patients or help them turn, stand, or walk.
In 2008, most full-time physical therapists worked a 40-hour week; some worked evenings and weekends to fit their patients' schedules. About 27 percent of physical therapists worked part-time.