Archives for category: Physical Therapy

We looked up shoulder arthritis on the web, as our upcoming lecture series for PTs and other medical professionals will be focusing on common shoulder problems and arthritis. Here are a few of the things we found, and hopefully some elucidation and clarification of some of the common information found on the web.

One definition we found of “shoulder arthritis” is, in our opinion, a bit oversimplified and overblown. We’ll leave out the link, out of respect to the author. “In shoulder arthritis, the smooth cartilage that normally covers the surfaces of the ball (humeral head) and socket (glenoid) is lost. The result is that there is bone on bone rubbing between these two joint surfaces.” This is an accurate definition of very advanced arthritis. But arthritis, if broken down into it’s component parts “arthro-; of a joint, relating to joints” and “-itis; denotes inflammation” more literally means inflammation of a joint. It (arthritis) usually is not diagnosed as such until the inflammation has existed long enough for concomitant changes to have taken place. Even once changes have occurred, it is only at an advanced stage that there is complete cartilage destruction and bone is actually in contact with bone.

So, that may be interesting reading, but you may be thinking, ‘what can I do earlier to prevent this change?’ and ‘if my shoulder is irritated and inflamed, can I reverse that before the cartilage is gone and bone is contacting bone?’ Or, maybe you’re wondering more about what cartilage does and want to understand the anatomy and function, and why joints get irritated and cartilage breaks down in the first place.

Articular (joint) cartilage is the hyaline cartilage that lies on the surface of bones. This cartilage may be described in terms of four zones between the articular surface and the subchondral bone. It’s function is to provide a smooth contact surface to bear load and allow a joint to move, so we can in turn function.

Inflammatory by-products have been shown to have a negative impact on articular cartilage, accelerating the rate of destruction. If your activities cause prolonged inflammation, then the metabolic by products of the inflammatory process can accelerate cartilage degeneration and lead to earlier arthritic symptoms. Over loading of joints can stimulate a low grade inflammatory process, as can instability of a joint resulting from past ligament injury, or dislocation of a joint.

A couple articles that might be of further interest around this topic:
http://www.pnas.org/content/83/22/8749.short
http://rheumatology.oxfordjournals.org/content/41/9/972.short
http://www.ncbi.nlm.nih.gov/pubmed/22550965

According to the American Academy of Orthopedic Surgery, “Physical therapy exercises may improve the range of motion in your shoulder [relative to arthritis]”. Physical therapy ought to be able to do more than just that. In conjunction with increasing joint range of motion, a physical therapist should be able to teach someone with arthritis strength exercises to improve joint stability, muscle stretches to enable maintenance  of the range of motion gained, and techniques to manage and improve function without aggravating symptoms of arthritis.

One major risk of arthritis is that people become less active in response to pain. This may result in decreased conditioning, strength, balance (if the legs or back are involved) and a further decrease in range of motion as use of the joints declines. Use it or lose it, really does apply here. We like to say move it or lose it. So what we work on is how to manage the use and movement of joints and your body without provoking further pain, symptoms and without increasing unnecessary wear and tear on your joints.

WebMD lists “Performing physical therapy as assigned by the doctor,” as a treatment option for arthritis. The problem with this quote, is that a physical therapist is the person, the professional, that evaluates and decides on the course of physical treatment in concert with you. The doctor is not there. And when all the information the medical doctor provides is “shoulder pain”, or “OA R shoulder”, this may provide a false impression that the “doctor” is in control, directing and assigning treatment, when in actuality the physical therapist, who is more often now a doctor than not, is gathering information, assessing your goals with you, and making decisions around your plan of care to achieve your goals. The great thing about physical therapy and exercise, in our opinion, is that once you’ve learned what works for you and how to integrate it into your routine, you can keep doing it for as long as you own your body. Unlike medications, or treatment that temporarily relieve pain, you don’t have to keep paying for your exercise routine over time.

More resources and studies that might be of interest:

http://physther.net/content/85/12/1301.short
http://annals.org/article.aspx?articleid=713255
http://www.jrheum.org/content/28/1/156.short
http://annals.org/article.aspx?articleid=713967
http://171.66.123.206/content/18/6/375.short
http://www.sciencedirect.com/science/article/pii/S002192900700382X
http://orthoinfo.aaos.org/topic.cfm?topic=A00222
http://www.webmd.com/osteoarthritis/guide/shoulder-osteoarthritis-degenerative-arthritis-shoulder

“Each year, one in every three adults age 65 and older falls. Falls can cause moderate to severe injuries, such as hip fractures and head traumas, and can increase the risk of early death. Fortunately, falls are a public health problem that is largely preventable.” – CDC
http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

This is a frightening statistic, but one that we can impact positively. Even if your balance is good, maintaining your strength and balance is something everyone should work on.

Many people become less active as they age and challenge themselves less physically. But a few simple exercises can help with balance, strength and falls prevention. Here is a suggestion of 2 simple exercises you may try.

  1. Sit down in a dining room chair and stand up (without plopping into the chair) 5-10 times. Use good form by keeping your back straight (not vertical) and getting your weight over your feet. Your goal should be to do this without using your hands, but feel free to use them for balance if you need.
  2. March in place. The slower you go, the more emphasis you will be putting on balance. Make sure to place a hand on a wall or counter until you are steady enough to do this slowly without holding on. If you are really good, you can pause for 5-10 seconds on each leg and remain balanced.

Remember that these suggestions are only that, suggestions, and not a replacement for skilled physical therapy and exercise instruction. If you are apprehensive about doing these, or find yourself too unsteady to do them safely, please contact a physical therapist familiar with balance issues in older adults to be evaluated and have an exercise program designed specifically for your needs.

Squat over chair:
squat over chair

Marching in place:Marching

We were reading through “Diagnostic Testing and Treatment of Low Back Pain in United States Emergency Departments: A National Perspective” on MedScape and were struck by a couple items.

“Diagnostic testing was performed in nearly 1 of every 2 patients with low back pain and opioids were administered to nearly two-thirds of the sample.” http://www.medscape.com/viewarticle/732744_4

Most low back pain can be evaluated clinically and manually without imaging studies. A clinician familiar with back problems is usually able to determine the etiology (root cause) of the back pain, and then decide on an appropriate course of action. For example, in physical therapy graduate programs, neurological testing — sensation, reflexes, strength, etc. — is recommended (required really) when there are symptoms past the gluteal fold into the thigh or leg. If no loss of strength and function is present, then treatment and education may proceed.

Then the question of opioids comes in. While a physical therapist cannot prescribe medication, all treatment interventions are considered in the context of desired results. Pain control is a laudable goal, but healing, resolution, self management education, and return to function might be considered more desirable in the long, and even near, term.

“Savings may be realized if visits can be shifted to primary care settings, where typical charges and propensity for diagnostic testing may be less.”

We’d like to see people offered a solution to their problem, not simply more tests and treatment to mask the symptoms. What do you think?

There remains some confusion around Medicare’s coverage of maintenance physical therapy. The general idea is that if a skilled service is required to prevent decline in a person’s condition, then the service is now covered under Medicare.
The following is from the Center for Medicare Advocacy website:

SERVICES FOR BENEFICIARIES WITH CHRONIC CONDITIONS

A chronic condition requiring skilled care services can take many forms and is not limited to a particular set of disease, diagnosis, or disabling conditions.

COVERAGE REQUIREMENTS

The Medicare program recognizes the need for skilled care and related services for chronic, long-term conditions.  For care to be covered, the patient must require skilled services which may be designed to:

  • Maintain the status of a medical condition or the functioning of a body part; or
  • Slow or prevent the deterioration of a medical condition or body part.

WHERE ARE SERVICES PROVIDED?

Services can be provided in a variety of settings – at home, through Medicare certified home health agencies, in Medicare certified outpatient facilities, rehabilitation hospitals and centers, and in Medicare certified skilled nursing facilities.

WHO PROVIDES SKILLED SERVICES?

Skilled services are those services provided by (or under the supervision of) technical or professional personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists, and audiologists. Services must be a type that are not ordinarily performed by non-skilled personnel.

More information may be found at

http://www.medicareadvocacy.org/medicare-info/chronic-conditions/#Coverage%20Requirements

LindsayKnitting“Just one more row.”  I’ve thought it myself countless times- only to realize another 20 minutes has gone by without making any move to stop.  Regardless of your level of skill, anyone who knits has probably dealt with the aches and pains associated with working on a project for too long.  How can you avoid it?  One of the best things you can do is work on developing good habits so you can stop issues before they start.  As a knitter and a physical therapist, I see many patients with overuse injuries.  Here are some basic tips on how to stay comfortable while working:

Good Posture – I know we’ve all heard it time and time again but that doesn’t make it any easier to sit properly.  First, it is important to have good light when you are knitting so you do not need to ‘squint’ down at your project.  A good chair is key- not too hard, not too soft, but just right.  When sitting, your knees should be slightly lower than your hips, and your feet should be flat on the floor.  You should try to have your bottom at the back of the chair and have your weight shifted slightly forward.  Sometimes a towel or roll behind your low back can help provide proper lumbar support.  Your shoulders should be down away from your ears and your shoulder blades slightly squeezed together on your back.  Your elbows should be in at your sides and your chin slightly tucked.

Take Breaks – No one said it would be easy to maintain good posture, especially when you are just getting used to it.  Set a timer for 30-45 minutes and when it goes off, put your knitting down and get up to move around.  You should plan to take a 5-10 minute break.  Walk around, which helps with circulation, or do a few of the exercises below.  Changing your activity will keep you from developing repetitive strain injuries, and gives your body time to recover.

Stretch – Now that you are taking breaks- use the time to move around.  Gently stretch your neck side to side, and slowly look over each shoulder.  Roll your shoulders forwards and backwards.  Try to touch your elbows behind your back.  Make circles with your wrists clockwise and counter clockwise.  Use one hand to gently stretch the other wrist down and up.  Repeat on the other side.   If it feels okay gently twist your torso to the right and the left.  Reach both arms up as if you were to touch the ceiling.  None of these movements should cause you any pain or discomfort, just gentle stretch.  If one bothers you, try to modify it or lessen the intensity, or just don’t do it.

Breathe – When your posture isn’t optimal you aren’t breathing as efficiently.  Many people become ‘chest breathers’ using the neck muscles and shoulders to elevate the ribs.  Ideally you should use the diaphragm (the muscle at the bottom of your ribs, right above the belly button) to fill your lungs.  To do so focus on pushing your belly button out as you breathe in.  No one should see your shoulders moving up and down.

Listen to your body – If you do find yourself getting symptoms, it is important to rest and give your body time to recover.  Otherwise you can be at risk to develop repetitive or chronic injury.  Icing the area may help calm any irritation and decrease soreness (but make sure to put something between the ice and your skin!)  If your symptoms to not resolve with a week of rest, or if they get worse, you should go see a health professional.  You should DEFINITELY go if you are experiencing any numbness or tingling, loss of strength, or radiating pain.

Making small modifications and developing good habits will help you avoid knitting related injuries and ensure healthy knitting.  And remember to stop knitting and rest if you begin to notice any symptoms.

Lindsay Haas is an amateur knitter and a professional physical therapist at san francisco sport and spine physical therapy.  She enjoys helping knitters and other crafters ensure they can continue their projects pain free, as well as comparing notes on projects and learning new techniques from her patients.

An east coast transplant to California, I’ve fallen in love with the mountains.  In the winter, for me that means strapping on a snowboard to play in the snow in Tahoe.  As those of you who ski and snowboard know, this requires a certain level of fitness.  Aside from the endurance and general strength it takes to have fun out there, there comes risk.  Having the perspective of being on orthopedic physical therapist, I see first hand the injuries that can happen out there, to all different degrees.  I’ve also been injured myself, and was reminded how important it is to take care of my body properly so I can keep snowboarding…until I’m 80 or older!

Having started snowboarding later in life, having more awareness of the risks associated because of what I do, and just some of my personality, I definitely ride more conservatively out there; my main goal being having fun.  I know the consequences of taking more risks with my riding, especially when the conditions are firm or icy.  Now that being said, I still like to get out there, make smart decisions, like calling it a day when I feel that fatigue set in.  Most importantly, I train my body for the hill.  Sure it’s important to work on endurance and cardio, and cross train, but more importantly is balance and core stabilization training.  I make it happen, every day during the week…I pick 4 or 5 quick exercises to keep challenging my stability to increase my response out there, so my body knows how to respond to the variable conditions that present themselves.

Everyone out there should have a program to prepare themselves for the season, and upkeep during the season.  That should include a flexibility program (my foam roller lives up at my ski house during the season), a strength and core stability program (including things that challenge your balance on uneven surfaces), and a dynamic warm up program to start off before the first turns of the day.  With doing those things, you will significantly decrease your risk of injury, your body will be more stable on the hill absorbing those bumps, and you will even perform better.   And when you do have an injury, even a minor one, it’s important to consult with a PT (the movement experts) to minimize your time off the slope and get your body back to functioning quicker.  I didn’t do this when I should have last year, and ended up limited in my summer activities because of it…lesson learned!

Jessica Monaloy, PT CIMT
San Francisco Sport and Spine Physical Therapy
Jessica@sfsspt.com

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