Neck Pain

Should I receive manual therapy and/or exercise for my neck pain?

Background:

·         Neck pain affects approximately 1/3 adults each year¹

·         Many people with neck pain say it is disabling²

What is effective treatment for neck pain?

·         The best available evidence suggests a multimodal approach including manual therapy and exercise may be the optimal treatment for neck pain^3-6. 

What do most people do for their neck pain?

·         A survey in 2001 suggested that only 1/4 people with neck pain receive care from a health care practitioner⁷.

·         Many people with neck pain receive care with limited or no supporting evidence, including: heat, cold, electrotherapy, massage, bracing, ultrasound, and certain narcotics⁸.

·         The treatment with the most supporting evidence, exercise, is underused⁸.

Why are patient decision aids helpful?

·         It is important that people with neck pain are involved in their own care to make sure that their treatment matches their preferences⁹

·         In order to make a treatment decisions, patients need support and knowledge

·         Patient decision aids increase patients knowledge and get people more involved in their own treatment decisions¹⁰

Why is a patient decision aid for neck pain needed?

·         We recently conducted a study where we asked people with neck pain about their experience in seeking care for their condition¹¹

·         People said they needed more useful information and needed to be listened to

·         People with neck pain also voiced concerns over the potential benefits and side effects of treatments, in particular, chiropractic manipulation

·         The patient decision aid attached provides the useful information needed to make a decision on whether or not to receive manual therapy and exercise for neck pain.

·         The patient decision aid provides a tool to help people discuss the risks and benefits of treatment with their health care provider

Should I receive manual therapy and exercise for my neck pain?

·         The decision aid attached to this blog post is meant to help you decide whether or not to receive manual therapy and exercise for your neck pain¹².

·         You can use it on your own or take it with you to your doctor or physiotherapist to talk about the options

References:

1)      Croft PR, Lewis M, Papageorgiou AC et al. Risk factors for neck pain: a longitudinal study in the general population. Pain 2001 September;93(3):317-325.

2)      Webb R, Brammah T, Lunt M, Urwin M, Allison T, Symmons D. Prevalence and predictors of intense, chronic, and disabling neck and back pain in the UK general population. Spine (Phila Pa 1976 ) 2003 June 1;28(11):1195-1202.

3)       Graham N, Ho E, Khan M, Gross A, ICON. Physical Modalities for Neck Pain: A Systematic Overview. Unpublished

4)       Gross A, ICON. Manual therapy and exercise for neck pain: A systematic overview. Unpublished.

5)      Gross A, ICON. Psychological Care, Patient Education, Orthoses and Prevention for Neck Pain: A Systematic Overview. Unpublished.

6)       Khan M, Gross A, Sataguida L, Lowcock J, Peloso P, Shi Q, Langevin P, ICON. Medicinal and Medical Injections for Neck Pain: A Systematic Overview. Unpublished.

7)      Cote P, Cassidy JD, Carroll L. The treatment of neck and low back pain: who seeks care? who goes where? Med Care 2001; 39(9):956-967.

8)      Goode AP, Freburger J, Carey T. Prevalence, practice patterns, and evidence for chronic neck pain. Arthritis Care Res (Hoboken ) 2010; 62(11):1594-1601.

9)      Institute of Medicine (2001).Crossing the quality chasm: A new health system for the 21st century.National Academy Press. Washington, DC.

10)  Stacey D, Bennett CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Légaré F, Thomson R. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD001431. DOI: 10.1002/14651858.CD001431.pub3.

11)  MacDermid J, Walton D, Miller J, ICON. What is the experience of receiving care for neck pain. Open Orthopaedics 2012 (unpublished).

12)  Miller J, Gross AR. Should I receive manual therapy and exercise for my neck pain? A patient decision aid. Physio-pedia 2012. Available at: www.physio-pedia.com. 

Ankle Sprains

Eramosa Physiotherapy: Client Education for ...
“Ankle Sprains”

What is an ‘ankle sprain’?

-          a sprain refers to damage that occurs to ligaments after they have been put under a certain amount of stress

-          ligaments are meant to withstand forces placed on a particular joint in the body and provide mechanical stability during activity

-           ankle sprains most commonly occur to the ligament(s) on the outside or lateral aspect of the ankle, but can also occur to the ligaments on the inside or medial aspect of the ankle

-          sprains can be graded from 1 to 3 depending on the amount of damage to a ligament

What are other injuries that can occur at the ankle?

-          Avulsion Fractures

-          Stress fractures

-          muscle strains

-          Achilles tendonitis

-          Neuropathies

How do ankle sprains happen?

-          A lateral ankle sprain, the most common of all ankle sprains, occurs when

o       the foot is forcibly turned inwards

o       landing from a jump

o       stepping off a step onto the side of the foot

o       landing on uneven surfaces with a twist

-          a medial ankle sprain does not occur as often as a lateral sprain because the foot is stronger and more stable along the inside of the ankle joint but can be sprained by:

o       a high force exerted that forces the foot outwards

-          a high ankle sprain may occur in people who

o       participate in sports involving boots (hockey and skiing), as well as football, rugby, wrestling, and lacrosse

o       a high ankle sprain occurs to ligaments that hold the two leg bones together (tibia and fibula) at the bottom of the lower leg

What will aggravate a sprained ankle?

-          Depending on the grade of tear, walking may cause pain

o       Grade one: no/little limp

o       Grade two: limp and unable to put weight through the foot

o       Grade three: unable to put weight through the foot and the leg of the injured ankle

-          The injured ligament is tender and painful when touched

What will relieve a sprained ankle?

-          Depending on severity, not walking on it

-          No touching or pressing on the ligament

-          Wrapping the ankle as soon as the injury has happened with a tensor band to help prevent much swelling from pooling in the ankle complex/ foot

-          Recognition of injury and initial treatment (see below)

-          Physiotherapy

How will I know if I’ve sustained an ankle sprain?

-          *note: depending on the grade, severity of signs and symptoms will vary:

o       swelling within the first two hours

o       tenderness over ligament

o       a feeling of instability with standing and/or walking

o       bruising

o       loss of range of motion (movement)

What long-term issues may arise if this injury is not dealt with?

-          After you’ve sprained an ankle, the recurrence rate of sustaining another sprain is as high as 70% (1), so treatment is vital for maintaining function

-          Chronic ankle instability: a sequence of ankle sprain injuries that lead to residual symptoms and decreased physical activity abilities (i.e. running)

-          Altered gait (walking) mechanics

Treatment:

The natural history of this injury or prognosis for ankle sprains is proportional to the severity and grade of injury.  Thus, a grade 2 injury takes longer to heal than a grade 1. 

-          Typical treatment protocol:

o      

In the early stage of healing, the goal is protection of the damaged  ligament  to ensure no further damage can be done.  Ice is commonly used to help to decrease pain and help slow down any build up of inflammation and swelling soon after injury.  Elevation of the foot above the heart will help promote movement of any swelling in the ankle back toward the heart to flush out.  The most recent evidence suggests that early mobilization and functional treatment is more effective than immobilization with casts or special boots; in terms of returning to work/sport, less swelling, less instability and greater patient satisfaction (2).  During this early stage, stretching of muscles to prevent contractures and simple pain-free movements at the ankle are recommended to help move fluid out of the swollen foot as well as help maintain the amount of possible movement before progressing to more aggressive treatment

o       In the subacute healing stage, the goal of treatment is to eliminate residual swelling, obtain complete pain-free range of motion in the movements of the foot, and begin strengthening muscles surrounding the ankle to help with function

o       In the final stage of healing, walking with a normal gait pattern is promoted, further strengthening is encouraged, balance exercises are incorporated into a home exercise program to ensure safe and effective walking, stair-climbing, running etc...

o       It is recommended that after one sustains an ankle injury, braces should be worn to prevent further injury/ies when performing leisure activities; whether the activity is a recreational or competitive nature (2)

-          Advanced treatment:

o       development of balance over time and return-to-sport activities are incorporated toward the end of treatment to help you get as close to pre-injury level as possible

o       Return-to-sport activities may not be necessary for all patients

What can Physiotherapy do for this injury?

A registered physiotherapist will help arrange and follow through with a treatment plan that works best for you.  With their extensive knowledge regarding the use of manual therapy to help increase range of motion and decrease pain used in conjunction with modalities, such as a TENS machine, to further aid in decreasing pain, you will notice results after one visit.  Particular stretches and exercises will be prescribed as a part of a home exercise program to help you help yourself get the results you are looking for in no time. 

References:

1.      Hubbard TJ, Hertel.  Mechanical Contributions to Chronic Lateral Ankle Instability.  Sports Med. 2006;36(3):263-267.

2.      McKay G, Cook J.  Evidence-based Clinical Statement: Physiotherapy management of ankle injuries in sport [Internet].  Australia: Australian Physiotherapy Association, 2006 [cited 2012 March 25]. Available from: www.physiotherapy.asn.au

Novel movements for the low back

A day in the life of a physiotherapist –  Low Back

After talking about how I relieved my own neck pain with novel movements last week, I thought I would touch on some novel movements for the low back.

We can use the exact same strategy that I used for my neck in order to regain rotation through the back.  Remember that usually throughout the day, we move the top part on the bottom part.  When rotating our back, we move the upper trunk on the lower trunk (picture swinging a baseball bat or shooting in hockey).  Our nervous system recognizes this movement very quickly because it is a movement that we do all of the time.  If our brain thinks that moving into a rotated position is threatening, it might protect against that movement by producing pain or by turning on muscles that stop you from getting into that position. In order to get into the same rotated position without our brain protecting against this motion, we want to try a novel way of getting there.  Rotating from below is one option. 

Watch the video below and try it for yourself:

1)   In standing turn your body as far as you can and see how far you can see in that direction

2)   Lie on your back and keep your knees together. 

3)   Slowly and carefully rotate your knees from one side to the other while breathing in a controlled way

4)   After you have completed about 10 repetitions, retest the rotating in standing see if the movement is changed.

More commonly in low back pain, bending forward or bending back is the movement that hurts or is limited rather than rotating.  In this case, we want to find a novel way to flex (bend forward) or extend (bend backward) the low back without the brain producing pain or turning on muscles to stop you from getting into that position.

See the video below for a novel flexion and extension movement of the lower back. Once again, the results will be more dramatic if your nervous system is protecting against this movement, but most people will experience a significant gain in range of motion after performing this exercise.  Don’t take my word for it, try it yourself!

1)   Bend forward or bend back up to the point that you start to feel discomfort.  Remember how far you get.

2)   Get onto your hands and knees

3)   Slowly flex and extend your lower back while breathing in a slow and controlled way.  Do this by thinking about which direction your tailbone is pointing.  Point your tailbone up towards the ceiling as you extend and point your tailbone down towards the floor as you flex your back.

4)   After performing about 10 repetitions, stand back up and retest bending forward or bending back and see if the movement changes.

[Insert video: flexion or extension of the low back]

There are a couple of reasons that flexing and extending is easier in this position than it is in standing.

1)   Gravity is now perpendicular to our low back rather than parallel to our low back

·        Changing the direction of gravity relative to the back changes the movement enough that our brain does not recognize it as quickly

·        Our brain therefore doesn’t protect against the movement as quickly

2)   Our knees and hips are now flexed

·        When standing, we have more stretch or tension through the nervous tissue that crosses our back

·        Bending the knees and hips puts these tissues in relaxed position

·        When we bend forward or back, we can move further into the position before these sensitive tissues send signals of that may be protected against by the brain

There are lots of ways to perform novel movements to regain a painful or limited movement.  Moving from below or flexing and extending while on your hands and knees are just two examples.  Your physiotherapist can provide you with other strategies to get moving again.

*Note: this movement strategy is an effective option for your typical work to hard the day before or get up in the morning stiff low back pain. If your low back pain is associated with a traumatic event, prevents you from performing your daily activities, or persists for an extended period, I would recommend seeing a physiotherapy for a thorough assessment.

References:

1)   Blinkenstaff C (2011). Edgework for the neck. Available at: www.blog.forwardmotionpt.com

2)   Butler D, Moseley GL (2002). Explain Pain. Noi Group Puclications. Adelaide, Australia.

Eramosa Physiotherapy - EPA: A day in the life of a physiotherapist - Getting r...

Eramosa Physiotherapy - EPA: A day in the life of a physiotherapist - Getting r...: Last week, I used one patient experience as an example for how physiotherapists might use tape to reduce the threat value of a particular mo...

A day in the life of a physiotherapist - Getting rid of my own stiff neck:

Last week, I used one patient experience as an example for how physiotherapists might use tape to reduce the threat value of a particular movement and therefore reduce the pain associated with that movement.

This week, I would like to use myself as an example.  This morning, I woke up with a sore neck.  It’s not excruciating, but it is annoying and it prevents me from turning my head all the way to left.  For some reason, my brain does not want me to turn my head to the left because it interprets that movement as threatening.  Currently, it is protecting against that movement by causing pain and contracting muscles to prevent me from turning my head.

Similar to the way I wanted to change the nervous system input associated with bending forward for Henry last week by putting a stretch through the skin on his lower back, I would like to change the to the nervous system input associated with rotating my neck to the left.  Taping is something that is hard to do on your own, so I am going to use a movement strategy.

Essentially, I want to perform a novel movement pattern that gets me into the position of left rotation without the brain stopping me by producing pain or turning on the muscles that stop me from moving into that position. 

Usually, during day-to-day activities, the head turns on top of your body (picture checking your blind spot while driving).  My nervous system is really good at recognizing that movement and protecting against it, so the strategy I am going to use is to rotate my body underneath my head.  This novel movement pattern is one that my brain does not have an opinion of yet and therefore it will not protect against it as quickly.  It provides me with a way to get into the position of left rotation until my nervous system learns that it is safe for me to rotate left and calms down its protective mechanisms.

Watch the video below and try it for yourself.  The results are most dramatic if you have neck pain stopping you from achieving full motion, but nearly everyone will experience a significant improvement in range of motion with this exercise.  Don’t take my word for it, try it for yourself!

[Insert video: rotation of the neck from below]

There are lots of ways to perform novel movements to regain a painful or limited movement.  Moving from below is just one example.  Your physiotherapist can provide you with other strategies to get moving again.

*Note: this movement strategy is an effective option for your typical get up in the morning stiff neck pain. If your neck pain is associated with a traumatic event, prevents you from performing your daily activities, or persists for an extended period, I would recommend seeing a physiotherapy for a thorough assessment.

References:

1)   Blinkenstaff C (2011). Edgework for the neck. Available at: www.blog.forwardmotionpt.com

2)   Butler D, Moseley GL (2002). Explain Pain. Noi Group Puclications. Adelaide, Australia.

A day in the Life of A Physiotherapist

A day in the life of a physiotherapist – October 14, 2011 by Jordan Miller, Registered Physiotherapist

As a physiotherapist, I find the most exciting time with a patient to be the day that I get to discharge them.  It’s not that I do not enjoying seeing my patients, I do, but discharge means that patient has reached their goals and that is why I am a physiotherapist

Today, I discharged a patient that I have been seeing for about 8 weeks.  She had been diagnosed with fibromyalgia and osteoarthritis and has been in pain for most of her life. On her first visit, she reported that her feet and knees were the most painful parts and limiting her from her day to day activities.

When I first saw her, I asked her, “What would you like to accomplish with physiotherapy?” or stated in another way, “12 weeks from now, how will we know that physiotherapy was successful?”  The patient responded with one simple goal: to be able to take a bath.  She said that if she could get into and out of her bath, she could accomplish everything else that she was currently having difficulty with.

So, we had a goal. This goal was a longer-term goal for her as when I first saw her, she was unable to get up from a chair without pushing up from the chair with her hands. She was a long ways from being able to get up from the bottom of a tub. In this case, we had to set a number of shorter-term goals in order to progressively work towards the long-term goal. We started with exercises aimed at increasing her pain free range to achieve the range of motion needed to get into the tub and strengthening exercises to develop the strength needed to lower herself safely into the tub and to get back out again after a soak.  We gradually progressed to more functional exercises mimicking the process of getting into or out of the bath.

This week, she has taken two baths and I probably won’t see her in the clinic again.  While I thoroughly enjoyed having her in the clinic, I am happy that I do not need to see her again.

The take home message from this story is that physiotherapy should be about reaching your own goals.  You will be in charge of guiding your own treatment and determining whether or not treatment is successful.  Your physiotherapist can help you reach those goals by making sure your goals are realistic and by providing the tools and intermediate steps to get there. If you are going to attend physiotherapy, make sure that both you and your physiotherapist know what the goals are.

Low Back Pain and Exercise

Eramosa Physiotherapy - EPA: Low Back Pain and Exercise: Exercise for low back pain Exercise can be effective for the treatment of low back pain. This may seem obvious, but sometimes when researc...