No Additional Benefit Of Injection Over Physical Therapy Interventions For Shoulder Pain

Subacromial impingement syndrome is the most common cause of shoulder pain. These symptoms are easily treated with Physical Therapy interventions including manual therapy and exercise. Specifically, strengthening exercises for the shoulder blade and shoulder improve both the quantity and quality of shoulder movements treating both the source of impingement pain and the underlying cause. Physical Therapy exercises remain the gold standard for treatment of impingement, but injections are still utilized by physicians to treat these symptoms. A recent research paper examined the benefits of an injection combined with Physical Therapy compared to Physical Therapy alone.

A randomized controlled trial in the British Medical Journal compared these two treatment approaches in 232 patients with shoulder impingement (Crawshaw et al. 2010). Patients were randomized to either a manual therapy, exercise, and an injection or manual therapy and exercise alone. Treating Physical Therapists were able to select the most appropriate manual therapy and exercise interventions based on the patient’s needs. Authors reported both groups improved over time, but no differences between groups on either pain or function were found at long term follow up. Thus, the improvements in shoulder pain and function can be attributed to the manual therapy and exercise interventions. No further benefit was found in the patients receiving injections.

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What Is The Best Exercise For Painful Muscles?

Muscles can be a significant source of pain in our bodies. Chronic muscular pain may be found locally over the muscle or can be felt in an area distant from the muscle known as referred pain. Multiple Physical Therapy interventions including dry needling, foam rolling, and soft tissue mobilizations can be utilized in the short term to reduce these symptoms. Conversely, long term relief of muscular pain requires examination of the muscle to determine why it remains painful.

Muscle imbalances are a common reason behind these chronic symptoms. Muscles worked above and beyond their normal function will become painful over time. A common example in the hip is the TFL muscle in the presence of glut weakness. Short term solutions can target the TFL but long term relief is found by strengthening the glut muscles allowing them to perform their appropriate function at the hip in turn relieving forces across the TFL. A second muscle imbalance is found when the painful muscle is not strong enough to withstand the forces applied during activity. The long term strategy with this type of imbalance is to strengthen the muscle of interest. A recent research study examined the impact of strengthening this type of chronic muscle pain.

Anderson and colleagues examined the neck muscle performance of patients with neck pain compared to their pain free peers (Bio Med Res Int. 2014). Patients with painful neck muscles were randomized to either 10 weeks of high intensity neck strength training, general fitness training, or a control group. As expected, significant weakness was found in the patient’s painful muscles at baseline compared to their asymptomatic peers. Authors reported improved strength capacity of these painful muscles following the focused strength training program. Improved functional tolerance of the painful muscles allows these muscles to be more resilient to the forces applied to them each day.

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One Strength Session Per Week Reduces Cardiovascular Disease Risk

Aerobic exercise has long been known to reduce an active individuals risk of chronic mental, emotional, and physical diseases. The majority of the publicity regarding the benefits of aerobic exercise has been related to the prevention of cardiovascular diseases and premature death due to these diagnoses. Government and professional medical organizations recommend 120-150 minutes of moderate exercise per week. These minutes should be at least 10 minutes in duration to receive the cardiovascular benefits of exercise. Interesting new research on strength training is being conducted on the benefits of this mode of exercise on the prevention of chronic disease and premature death.

Authors in the journal Medicine and Science in Sport and Exercise conducted an examination of the relationship of strength training, independent of aerobic exercise, and the development of cardiovascular disease (Liu et al. 2018). Authors included 12,591 participants who self reported their resistance training and disease status over a 16 year period. They reported a 40-70% disease risk reduction for all cardiovascular events with weekly resistance training frequencies of 1-3 sessions per week. No additional benefits were found with strength training frequencies of greater than 4 session per week. Interestingly, one session of up to 60 minutes of strength training was associated with decreased disease risk and early death independent of aerobic exercise participation. A patient’s body mass index (BMI) was found to significantly impact the impact of resistance training benefits.

This study supports the importance of strength training for cardiovascular health and wellness.

Is Aerobic Exercise Enough To Promote Muscle Growth?

Aerobic exercise should be a foundation of your weekly exercise program because of the mental, emotional, and physical health benefits associated with this type of exercise. Some individuals who complete daily aerobic exercise or training incorrectly believe this type of exercise is sufficient for muscle growth and strength development. Resistance training remains the gold standard for strength development, muscle growth, and injury prevention. A new review of the scientific evidence documents the importance of adding strength training into your weekly aerobic exercise schedule.

A review article was published in the journal Sports Medicine on the available evidence documenting the impact of aerobic or strength training on muscle growth (Grgic et al. 2018). Authors 21 studies of moderate to good methodological quality. The authors concluded aerobic training is not as effective as strength training for muscle type I (slow twitch) and II (fast twitch) muscle fiber growth (hypertrophy). Patient are encouraged to utilize both strength and aerobic training for optimal health and fitness benefits.

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Elastic Band Resistance Training Found Equivalent To Gym Based Machine Weight Training

The benefits of strength training are well established including improved bone density, metabolism, flexibility, body composition, and mental health. In addition, utilizing a strength training program 2-3 days a week on non consecutive days also slows the rate of sarcopenia or muscle loss due to aging. One of the main barriers individuals report for not exercising is time limitations and convenience of exercise. Driving to the gym to utilize an expensive membership may prevent individuals from strength training due to these barriers. A recent study demonstrates strength training does not need to be done in a gym to be effective.

Lima and colleagues randomized healthy middle and older aged adults to a resistance training program utilizing either conventional weight machines or resistance bands or a control group (J Sports Sci Med. 2018). Individuals in the exercise groups trained 3 days a week for 12 weeks with exercises designed to target the upper and lower body. The authors reported each of the exercise groups improved strength and functional capacity but no differences were noted between groups. It appears the most important training variable is not equipment but rather consistency to a resistance training program, as well as, choosing a challenging intensity during each exercise. Elastic resistance bands remain a low cost and portable option for individuals wishing to get stronger without going to a gym.

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Is There An Additive Effect of Ultrasound to Physical Therapy Care?

Few things remind me of how far we have come as a profession than ultrasound. Early in my career we utilized ultrasound and other modalities to help reduce a patients pain. Initially touted as a medium to deep tissue heating and healing, ultrasound has now fallen out of favor due to the lack of research benefits supporting its’ use. Little to no research supports its’ use for musculoskeletal conditions and any benefits have not been found superior to comparable placebo treatments. For these reasons we do not utilize or own an ultrasound machine in our Physical Therapy practice and instead utilize more evidence based interventions such as manual therapy and exercise for musculoskeletal conditions. A recent article examined if there was any additional benefit of ultrasound when combined with other Physical Therapy interventions.

A randomized controlled trial in the Journal of Orthopedic and Sports Physical Therapy examined the addition of either ultrasound or placebo ultrasound to a stretching program for patients with heel pain (Katzap et al. 2018). 54 patients were randomized to one of the ultrasound conditions combined with ankle and foot stretching exercises (note: stretching alone does not constitute an evidence based exercise program). Authors reported both groups improved but no significant differences were found between “therapeutic” ultrasound and placebo ultrasound. Authors recommended excluding ultrasound from treatment plans for patients with heel pain.

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