Knee Pain Doesn’t Always Mean Surgery

As discussed in the video, chronic knee pain doesn’t always mean surgery. Our patient, Rosa Underwood’s* experience demonstrates how physical therapy helped resolve her chronic knee pain, even though she had been advised that surgery was her only option.

Patient Spotlight: Rosa Underwood*

The Issue: I had severe knee pain, constant arthritis pain in my right knee that was affecting my quality of life. The limited mobility affected my ability to shop, play with my grandchildren, garden, enjoy myself in general. I was fearful of being stigmatized professionally because of my limping and the possibility of not working due to needing knee surgery. I was miserable.

How was your physical therapy treatment? The physical therapy felt immediately empowering! I felt that I had an active role in getting better and the better I understood how muscles functioned the more I realized I was not helpless, that a lot of my pain was due to extra stress being put on my knee because of how I moved at many joints and that my knee was not going to crack in half.

The moment things changed: Chris found that I was compensating by clenching my jaw, he treated that and my knee pain decreased significantly. I thought, “What just happened?” My knee pain was decreased significantly, and I was able to garden that weekend kneeling with very little pain, I have not been able to do that in months.

The difference over the past few weeks is incredible… I am walking longer, my attitude is hopeful, I don’t describe my pain as severe…I play with my grandchildren and enjoy myself again. I have not worn a knee brace or wrapped my knee since. My doctor is pleased with my progress and so am I! The ATR team is truly outstanding!

The Therapist’s take: Rosa had significant movement restrictions in her knee, ankle, and hip which piled on top an existing arthritic condition. Her Gluteal muscles were not firing much, and her knee was not able to get straight. It is a common compensation pattern, inhibited gluts put more pressure on the muscles that surround the knee. We tested her glut, it was strong, but she was clenching her jaw. Retesting with a relaxed jaw decreased the glut strength drastically. Palpation revealed increased tenderness at her right masseter, and quick, patient-directed release resulted in the gluteal muscles firing again so they tested strong with a relaxed jaw. With the gluts back on line, it took pressure off of the knee and the patient’s squat test improved dramatically. This is a great example of how the pain is rarely problem, it is the symptom of dysfunction. This is why we examine and treat function, treating structure alone without addressing function rarely leads to long term success.

*Use of quotations and names are with permission of patient

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Generic “One Size Fits All” Home Exercise Programs Can Cause More Harm than Good

Often after a visit to a medical office for pain, patients are provided with a list of exercises, a pamphlet or brochure or worse, they find a “one size fits all” exercise “cure” on the internet. Many feel these are often sufficient replacements for a skilled physical therapy evaluation and subsequent treatment, with the notion that strengthening or exercising the painful area will improve the pain in function.

The leading experts in the therapy, movement and performance field will tell you that this assumption is incorrect.

Physical therapists, with a foundation of anatomical structure, neurological pathways, and motor control are the recognized functional experts the in healthcare industry. With the proper education and approach they can easily explain to you not only what is hurting, but why it is hurting. With the proper approach, they will look at the entire kinetic chain. Many times, the pain is not the problem; it is a symptom of movement dysfunction elsewhere, putting more stress on the area that is experiencing pain. Direct, “one size fits all” programs for a painful area rarely lead to a decrease in pain and often can make symptoms worse and lead to an unsatisfied patient.

The Problem in Theory:

All too often patients receive a home exercise program with the “one size fits all” approach with the painful area being the sole focus. These programs often disregard an injury with individual characteristics resulting in improper recovery, decreasing their ability to return to prior level of function and often result in reoccurrence. The number one cause of re-injury is a result of insufficient or improper rehabilitation. Generic home exercise programs are not sufficient nor are they proper for comprehensive rehabilitation for an individual with pain.

Here are 5 reasons why a stand-alone Home Exercise Program can be ineffective.

1. A home exercise program is not self-care program; it is a component of one. Many incorrectly assume the terms are one in the same. Often important components such as patient education workplace, and home modification to name a few, are not included, to the detriment of the patient. Just as a grade school homework assignment reinforces what is taught in class:

Home Exercise Programs are NOT synonymous with physical therapy, they are an adjunct.

2. The body is designed to compensate and often does without the knowledge of the person performing the exercise. With a “one size fits all” home exercise program these issues often go unaddressed and result in compensation, decreasing the effectiveness of the exercise. Additionally, improperly performing home programs reinforce incorrect motor patterns resulting in additional stress on structures that are not designed to handle the force. The  work of Richard A Schmidt, PhD. tell us that tells us that it takes 300 repetitions to create a bad habit, and 3000 correct repetitions to undo it. That is the human condition.  Exercises given without compensation safeguards can quickly have detrimental results to one’s movement patterns and pain.

3. Generic programs are limited to a specific painful area and ignore other affected areas of the body. The “one size fits all” exercise program usually only addresses the site of pain with the assumption that the pain is the problem. In most cases the pain is the symptom of movement dysfunction elsewhere. The entirety of the kinetic chain, which is the interaction of muscle, nerves and joint to create movement, is often ignored. When this occurs, people with foot pain, for example, develop knee, back or hip pain because their functional requirements of other areas have increased, but have gone unaddressed. In this same light, if a non-painful dysfunction at the thoracic spine creates issues at the shoulder blade and in turn shoulder pain, shoulder exercises are not going to address the problem.

4. There is often no progression, increasing the chances of re- injury. Without progression, the structures are improperly prepared for the functional demands of everyday life and the end result is some level of pain, be it reoccurring or new.

5. It is an incorrect assumption that if an individual has a program that addressed the structures involved in a specific movement that motor patterns will take care of themselves. Generic orthopedic programs that do not address movement patterns may improve isolated strength, but will not improve the dysfunction that caused the injury.

The Problem in Practice:

Just this week we had a patient who had been in chronic pain for a while. She performed exercises that was a “one size fits all” and her pain had gotten worse. The patient had shoulder pain, so she was provided the “shoulder exercise program”.  The patient’s shoulder was painful, but as a result of rounded shoulders and weak shoulder blade stabilizers, not because of decreased shoulder strength. Yet, repeated the very mechanical issue that caused the pain. This program did not address the tight chest muscles and weak scapular stabilizers which were the primary causes of the painful shoulder.

All too often this occurs, resulting in an unsatisfied patient who remains in pain. There are many limitations to performing a general program. To start, the proprioceptive mechanism, which is what tells am individual where their body is in space, is not well tuned, making it nearly impossible for an individual to self-correct. Good pure movement is often altered in the non-painful population, let alone a painful one. Many won’t correct a problem unless they know there is one in the first place, if they don’t know there is a problem, the correction won’t happen.

The “one size fits all” approach is counterintuitive to all other aspects of medicine, and yet it seems to be the “go to” approach for orthopedic pain. Two people with similar health problems are rarely going to be prescribed the same prescription medicine, with regard to frequency and dosage. People are different; so it stands to reason that many factors should be taken into account. Returning to the scenario above, shoulders are not created equally, and yet, the “one size fits all” approach was the “cure.”

If you have received or given an exercise program, you should ask yourself these questions:

Does it include self-treatment education on proper use of modalities, home and workplace modification?
Does it have safeguards against compensation to protect functional movement from becoming dysfunctional?
Does it focus on multiple areas vs .one?
Does it include motor pattern correction?
Is it being performed correctly? How do I know?
Is it too easy? Is it too difficult? How do I know?
If you do not know the answer to one or more of these questions, a physical therapist will be able to answer them for you or your patient.

Fall Prevention for Senior Citizens

Did you know that 1 in 3 senior citizens fall each year? Many of these falls result in hospitalization or assisted living. Did you know that physical therapists can help prevent falls and help choose and correctly size assistive devices like walkers and canes? Chris Stulginsky of Ayrsley Town Rehab discusses ways you can help the senior citizens in your life prevent falls.

Ayrsley Town Rehabilitation (ATR) provides performance-enhancing, preventative and rehabilitative programs and services that maximize functionality and promote well-being in patients of all ages and abilities. Watch the video below to learn more about fall prevention and what you can do to help protect those you love.

Fall Prevention: The long term impact of a little slip.

Fall Prevention Can be Easy but it is Up to You to Take the First Step.

It is not uncommon to hear anyone over the age of 50 to say, “I am not moving around as well as I used to”. Many accept that as just a part of life. The problem is that this complacency can have very real consequences to everyone. It can require increased care for a parent, it can result in a move from home, and it can cost a lot of money.

According to the Center For Disease Control, 1 in 3 adults over the age of 65 fall each year, 20 to 30% of which suffer what are classified as moderate to severe injuries. As a result of 2.4 non-fatal falls which leads a to an estimated 660,000 hospital admissions per year.

Benjamin Franklin noted long ago, that “an ounce of prevention is worth a pound of cure” so it is important to take note of the following:

FALLS ARE PREVENTABLE.

Many fail to remember or ignore this fact, but you can often do so with very little work and, in many cases, little to no out of pocket cost. Dr. Betty Perkins-Carpenter, who is on the President’s council of Physical Fitness and Sport acknowledges that, “It is not always possible to prevent the illnesses that change our live, but it is possible to prevent or minimize most of the falls that plague our senior citizens.”

Many know the basics, and things such as pulling up throw rugs modify lighting with auto timers for the evening are often done. However, both family members and some medical professionals often think they are helping when they are actually, and unknowingly INCREASING the risk of falls.

When someone is losing their balance, the first thought is to get a cane, a quad cane, walker or other assistive device.  In many places this is sole responsibility of the physical therapy team. In fact, at Johns Hopkins, the surgical patients are not allowed to leave the hospital until they were properly outfitted with a device and properly instructed in its safe and proper use.

Often devices are purchased at a pharmacy or given by a medical professional other than a physical therapist with the assumption that use is intuitive; it is not.

The incorrect device or a correct, but not properly sized device can actually increase your risk of falls.

As easy as it looks, there are nuances to choosing, sizing, and prescribing an assistive device, not to mention proper usage and, in some cases, the amount of practice that is required to use it correctly and safely. This education is included in the extensive post graduate course work in physical therapy school. In fact the billing code for gait training it unique to physical therapists and physical therapy.

The advantage, when you utilize a physical therapist the service is covered by medical insurance and does not require a doctor’s referral.

PREVENTION CAN BE EASY

Many know that physical therapists are experts in conservative, non-pharmaceutical pain relief; they are also experts in how the body moves and, more importantly, how the body compensates.

In addition to being able to examine and inform you of why you back may hurt as a result of the way your foot touches the ground when you walk, they can examine your balance centers, watch how you walk and move, identify what needs work and come up with a treatment plan to improve your balance and decrease your risk of falls.

THE ALTERNATIVE CAN BE LIFE CHANGING, DIFFICULT AND EXPENSIVE.

Falls account for 25% of all hospital admission, 40% of all nursing home admissions. 40% of those who are admitted to the hospital never return to independent living.

In the year 2000 falls accounted for a 19 billion dollar cost to Medicare and by 2020 that number is projected to exceed $54.9 billion. When you take into further consideration that these numbers are only for the treatment and do not include the cost of assisted living or long term care they skyrocket.

Balance is the interaction of your body with gravity. The body depends on three primary balance centers: what you see with your eyes, what you detect with your inner ear and what you feel with your body. If you lose one or one is diminished, balance is more difficult. This could, to a point explain, why more falls occur at night when it is tough to see. It is incorrect to assume that balance deteriorates because of age; in fact it occurs more do to disuse. As people get older, they move less, as a result their balance centers do not benefit from the daily interaction with gravity and the become less sensitive.

A simple 5 minute balance test that evaluates your standing (static) balance and walking (dynamic) balance can quickly set a benchmark. The plan will work on the areas of weakness and in a few weeks a re-test will be administered to monitor improvement.

With a very easy physical therapy program, these three balance centers can easily improve and tests bear that out.

No matter how complex one may think a medical issue is, it is generally agreed on that, “prevention is the best medicine”. Something that can change so much, can easily be prevented with little effort or cost. All you have to do is take the first step.

ATR Thoracic Spine Stretch for Golfers

Chris Stulginsky of Ayrsley Town Rehab in Charlotte, NC demonstrates a quick & effective stretch for the thoracic (middle) spine to improve mobility for golfers.

Chris is certified by Titleist Performance Institute and can help you take your golf game to the next level!

Ayrsley Town Rehabilitation (ATR) provides performance-enhancing, preventative and rehabilitative programs and services that maximize functionality and promote well-being in patients of all ages and abilities.

http://ayrsleyrehab.com/

Want to improve your golf swing? See a physical therapist!

With the days getting longer many take it as an opportunity to hit a bucket of golf balls after work, or to try to get out early one day to “squeeze in 9 or 18”.

As many golfers start playing more frequently, it is almost inevitable that they become frustrated with flaws in their game. Often one hears golfers saying, “I blocked the ball there” or “I was quick with my hands on that one”. Typically the frustrated reaction to a poor shot or round is, “I need some more time on the range”, “I need to get with my pro”, or “I need to look at a driver”. While practicing more, modifying your equipment and working with your pro can help, if your body won’t move enough to make  the adjustment or correction, other venues will probably continue to result in frustration. Additionally, this could result in injury or lead to a dysfunctional learned motor pattern that could have detrimental effects to one’s enjoyment of the game.

Your body is, after all, the only piece of equipment you never stop using on the golf course.

While the golfer may see a block, hook, early extension or reverse spine, a physical therapist certified by the Titleist Performance Institute (TPI) sees lead hip tightness, a lack of trail side shoulder stability or decreased thoracic spine mobility when they watch a swing.

Understanding how these dysfunctional motor patterns impact how golfer uses and performs with his or her golf club is imperative for improvement. Many people cannot perform basic functional movements, let alone produce a consistent golf swing on a foundation of a dysfunctional movement. Adding a physical therapist to your golf support team can help you assess and change the limitations of the body, making the lesson with your pro, or time on the range with your new wedge more efficient and beneficial.

With Adam Scott’s recent victory at The Masters, golf fitness has been on the national stage. Scott’s frequent appearances on the The Golf Channel’s, “Golf Fitness Academy presented by TPI” and his work with his Titleist Performance Institute team have helped him take his game to the next level.

Locally, Charlotte Country Club has started a “TPI Prep School”.  Director of Instruction, Rich Albright and Director of Custom Fitting, Allen Avakian have teamed up with TPI certified physical therapist, Chris Stulginsky in offering “Prep School” to the members.

“We wanted to connect body mechanics with the golf swing.  Each player’s body reacts differently to the body’s movement requirements for an effective golf swing.  When the body limits the movements within the golf swing, it is hard to hit the golf ball consistently”, said Rich Albright, Director of Instruction. “We saw each student gain efficiency in their ability to swing the golf club.

Both professionals also saw the personal benefits as it translates to their golf game as well,  Avakian pointed out, “personally, the program has helped to increase range of motion as well as ease of motion. My sense is that this increased mobility along with better stability will help in maintaining rhythm and tempo.” Albright added that, “[the program], had a direct impact on my back and my ability to rotate better during the swing.”

So many think that the program or physical therapy itself can be working with resistance band or stretching to improve flexibility. In fact they work a great deal on stability so one can build increase potential energy when they swing or on the motor control of functional opposites to make for a more consistent swing. With the properly trained eye, one can easily expand their program, and simultaneously make it more efficient and effective.

The program at Charlotte Country club has been a success leading the club to add another session says Avakian, “the feedback is leading us to start another session in the month of May.”