Significant Cervical Weakness Found Among Patients With Migraine
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According to the Global Health Burden studies, Migraine is the 3rd most prevalent disorder (14.7% of global population: 1 in 7 people)  and 3rd most cause of disability in those under 50 years old. It is more prevalent than diabetes, epilepsy and asthma combined. Migraines occur with 17% of women and 6% of men.  Symptoms of migraine include: Headache on bilateral or unilateral sides around temporal region, with or without visual disturbances.

A recent study (JOSPT 2019) investigated the role of the musculature in the cervical spine in those with migraines. A lack in neck endurance strength of the neck musculature has been shown to be correlated with chronic migraines. The authors found a significant difference in neck extensor and flexor strength with those with and without migraines. The findings of the study suggest addressing the strength of the musculature of the neck to assist in management of headaches

Supervised Physical Therapy Superior To Home Exercise Program For Patients With Lumbar Stenosis
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Lumbar spinal stenosis is a narrowing of the bony canals in the spine which surround the nerves which supply our lower extremities. The condition is common among aging adults, > 60 years old, and can lead to symptoms such as single or bilateral leg pain, numbness, pins and needles, and/or weakness. Often leg symptoms are more frequent and severe than back symptoms. In our previous blogs we have discussed prior research papers indicating no long term (> 1 year) differences in outcomes between surgery and Physical Therapy for patients with lumbar spinal stenosis. Previous Physical Therapy approaches have focused on lumbar flexion exercises (ex. knees to chest) to create more space for the nerves, but more recent studies have shown benefits of manual therapy, strength training, and body weight supported treadmill walking. A recent research study highlights the importance of Physical Therapy compared to a home exercise program alone.

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Minetama and colleagues conducted a randomized controlled trial in the Spine Journal to compare the effectiveness of supervised Physical Therapy compared to a home exercise program for patients with spinal stenosis (2019). Authors randomized 86 patients with neurological claudication (symptoms in legs consistent with lumbar spine compression) to one of the two groups. The Physical Therapy group received treatment twice a week for 6 weeks while the home exercise group received a home program to be performed independently without supervision. Authors assessed function, gait, pain, and activity levels before and after the study. As expected superior outcomes on pain, gait, activity levels, and function were found among the supervised Physical Therapy group compared to those receiving a home exercise program.

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Physical Therapy Headache Solutions
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Headaches remain a significant source of pain and disability for patients in our country costing over $30 billion dollars each year. Symptoms can be driven by different types of headache including tension, migraine, and cervicogenic (driven from the neck). Cervicogenic headaches can be found in 4% of the general population, 20% of all patients with headaches, and up to 50% of patients with headaches after a whiplash mechanism of injury.

The upper neck vertebrae are most commonly associated with these symptoms with the 2nd and 3rd vertebral joint driving 70% of headaches. The clinical diagnosis can be made based on the following criteria

  1. Pain that originates in the neck and radiates to the frontal and temporal regions

  2. Unilateral symptoms (may be bilateral but never together)

  3. Radiates to ipsilateral shoulder and arm

  4. Provocation of symptoms with neck movement

  5. History of neck pain

Physical Therapy remains a first line treatment for cervicogenic headaches. Researchers advocate for a mulitimodal approach including spinal manipulation, neck and upper back strengthening (see videos). These interventions have received the highest grade (A) of evidence for treatment of this condition. Specifically, evidence supports the use of manual therapy and exercise over primary care management, manual therapy or exercise alone in patients with neck pain and headache. These benefits are sustained at 1 and 2 year follow up time periods. Finally, the number needed to treat (NNT) is 2 for patients with neck pain treated with manual physical therapy and exercise to achieve one additional successful outcome than would have occurred if patients received an alternative treatment.

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90% Of Patients With Back Pain Are Not Referred To Physical Therapy After Seeing Primary Care First
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Low back pain, along with death and taxes, remains one of the certainties of life. This condition affects over 90% of Americans and is often benign, but painful, in nature. Currently spending on low back pain is over 100 billion dollars a year and much of this spending can be attributed to unnecessary and unwarranted tests and interventions including early imaging (x ray, MRI, CT scans), advanced procedures (injections, surgery) abnd office visits. Consistent with many musculoskeletal conditions, early treatment of acute low back pain accelerates a patient’s recovery and may be our best strategy at reducing health care spending and excessive treatments. Our previous blog posts have highlighted the benefits of direct access to Physical Therapy services or patient self referral including cost savings of $1000-1500 per episode of care. Despite the clinical and cost effective benefits of Physical Therapy, a recent study highlights the limitations of seeing a primary care physician first for low back pain.

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Authors in the journal Spine analyzed over 170 million medical office visits for low back pain between 1997 and 2010 to determine health care utilization rates for this condition (Zheng et al. 2017). Authors found on average only 10% of patients with low back pain were referred to Physical Therapy after seeing a physician first and this rate remained stagnant over the study time period. Lower referral rates were found for patients covered by Medicare and Medicaid. Conversely, opiod prescriptions increased from 15% to 45% through the study’s 13 years of data collection. Authors found patients not referred to Physical Therapy were more likely to receive an opioid prescription.

Patients are encouraged to utilize direct access or advocate for a Physical Therapy referral for early treatment of their back pain symptoms.

No Differences Found Between Surgery Or Physical Therapy For Tendon Injury
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Overuse tendon injuries can present as an acute inflammatory response (Tendinitis) or a chronic degeneration condition (tendinopathy).   These injuries result when an individual’s volume of activity (type, duration, frequency, and intensity) exceeds the strength and integrity of the tendon.  At MEND, we commonly see these injuries in the tendons of the rotator cuff, knee, ankle or elbow.  Recent studies summarized in our previous blog posts have highlighted the importance of a Physical Therapy exercise program.  Optimal, progressive loading of these injuries is critical to the healing process (remodeling) resulting in decreased pain and improved function.  Despite overwhelming evidence supporting exercise interventions patients may still be provided with a surgical treatment.

A recent study from the British Medical Journal reviewed the available medical evidence to determine the effectiveness of Physical Therapy compared to surgery or no treatment in patients with tendinopathy (Challoumas et al. 2019).  Authors included 12 studies of over 1000 patients to determine the impact of these treatments on a patient’s pain, function, range of motion, strength and quality of life.  Authors reported Physical Therapy was as effective as surgery in both the mid and long term for improving pain, function, and quality of life.  Authors report surgery should be reserved for patients who do not improve with 12 months of a loading program. 

Research Shows Most Participants Select Inadequate Weights For Strength Training
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Money and time is some of the finite resources in life. As our lives become busier with work, family, and life commitments our exercise time must become more effective and efficient. One of the biggest and most common mistakes individuals make in the gym is an ineffective cardiovascular or strength training intensity selection. Although any movement of large body parts will contribute to a caloric deficit, selection of a low intensity of exercise will prevent participants from developing cardiovascular or strength gains. Research shows both novice and experienced weight trainers choose inadequate weights for strength development.

Glass and colleagues found novice lifters selected weights between 42-57% of their 1 repetition maximum (J Strength Cond Res. 2004). A second study found similar mistakes in sedentary individuals who initiated a strength training program (Elsangedy et al. J Phys Ther Sci. 2016). These self selected weights were all found to below the 60% value shown to create muscle growth and strength gains among novice lifters. Surprisingly, the influence of a personal trainer does not ensure participant reach intensities recommended by the strength and conditioning research. Ratamess and colleagues randomized females with weight training experience to either a self selected or a weight intensity selected by a personal trainer (J Strength Cond Res. 2008). Although selected weight intensities were improved (51% vs. 42%) in the personal training group authors found both groups selected weights below recommended intensities.

In our previous blog we discussed the value of using repetition in reserve to determine an appropriate intensity during weight training. This method of selection reduces the human error associated with weight training ensuring selected weights are appropriate for strength gains.

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