Posts in treatment
Reducing Knee Pain In Cyclists
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Cycling is one of the most popular outdoor activities in Boulder.  Cyclists we encounter in our Boulder Physical Therapy practice most commonly complain of pain on the front of their knee or anterior knee pain.  Research shows 1 in 2 competitive cyclists have experienced this knee pain resulting in lost training and competitions in over half of those affected (Clarsen et al. 2010).  A cyclists exposure to the impact of poor pedaling biomechanics is amplified by the volume of their training.  It is not uncommon for a competitive cyclist to flex and extend their knee over 5 million times per year during their training sessions and competitions (Callaghan et al. 2005).  In addition to training errors, bike biomechanics remain one of the key sources of an athlete's knee pain.

Athletes who have excessive movement in their lower bodies both reduce their cycling economy and performance, as well as, increase their injury risk.  In particular, the movement of the knee toward or away from the frame increases stress across the knee especially during the power portion of the pedal cycle.  The suboptimal mechanics change the alignment of the knee and the ability of the leg muscles to import forces on the foot and pedal.  Commonly, bike fitters use shoe orthotics or wedges to modify the relationship between the foot, shoe, and pedal.

Research has shown a rigid cycling shoe is the most economical and efficient interface with the pedal allowing cyclists to pedal at a lower % of their VO2 max for a given work load compared to a softer shoe.   Research regarding orthoses or wedges on cycling alignment and mechanics are fewer in number.  The limited research shows these orthoses or wedges 5-10 degrees can temporarily impact mechanics but their long term efficacy as a tool remains to be limited (Fitzgibbon et al. 2016).  They are most likely to benefit those athletes with true structural alignment impairments in the leg.  

Conversely, many of our patients's symptoms improve quickly with Physical Therapy interventions to correct impairments such as limited range of motion and muscle imbalances in the leg.  Once these are addressed an athlete is better able to use cuing and movement retraining to improve static and dynamic alignment of the knee while cycling.  In summary, athletes need the capacity to control the knee position through strengthening then the appropriate retraining to use that strength in an optimal cycling pedal cadence.  

 

Individualized Physical Therapy Saves Money Compared to Usual Care for Low Back Pain
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As healthcare costs continue to rise, all stakeholders (patients, providers, and payers) are looking for ways to reduce costs associated with common conditions.  In our field, we see patients given generic, one size fits all exercise programs for common conditions including low back pain.  Our previous post highlights the limitations of this approach including providing incorrect, inadequate, and sometimes harmful exercises to patients without a proper Physical Therapy examination first.  In addition, patients provided these incomplete, generic exercise programs will often spend additional healthcare resources in the coming months looking for relief of their symptoms.  

A recent research article in the journal Spine compared the effectiveness of individualized Physical Therapy services to guideline based advice for patients with low back pain. (Hahne et al. 2016).  300 patients were randomized to one of the two groups then were followed for 1 year to determine the effectiveness and cost of each treatment group.  Patients treated with Physical Therapy reported higher levels of health benefits at a lower cost than the guidelines group.  Specifically, patients missed fewer work days at a savings of close to $2,000 per worker.  This study adds to the existing data on the importance of individualized Physical Therapy for patients with low back pain.  

Cost Effectiveness of Physical Therapy for Low Back Pain

Low back pain continues to affect many Americans leading to pain, loss of function, missed work days, and higher health care expenditures.  Much of this cost is attributed to the often unnecessary utilization of advanced imaging and procedures such as injections and surgery.  Previous research has shown early access to Physical Therapy without a prior MD referral saves patients on average $1000 per episode of care.  Further cost savings are noted if patients are treated early with Physical Therapy compared to national guidelines advocating a "wait and see" approach for care prior to deciding on Physical Therapy.  

A recent study was conducted to determine the cost effectiveness of primary care management with or without the use of early Physical Therapy for patients with acute low back pain (Fritz et al. Physical Therapy. 2016).  Economic data was collected on 220 patients with acute low back pain who were all treated with primary care management (education, medication) and then randomized to either 4 sessions of early Physical Therapy or primary care management alone.  The authors collected costs (health care treatments, loss time at work) associated with this episode of back pain.  The authors concluded that Physical Therapy was associated with higher quality of life scores at 1 year and was sufficiently cost effective to support its' early use for patients with acute low back pain.

Patients with low back pain are encouraged to seek out the services of a local Physical Therapist to reduce health care costs and improve symptoms and function compared to primary care management alone.  

Imaging's Role in Youth Baseball

In our previous blog posts we have written on the limitations of MRI for many injuries and conditions.  In general, these expensive tests have high rates of false positives where patients without pain often have positive results including ligament/labrum tears or tendon changes.  The incidence of false of positives increases in athletes with the majority of major league baseball players, regardless of symptoms, demonstrating rotator cuff tears or labrum injury.   It appears these changes are no different in our little leaguers.  

An article in the Journal of Bone and Joint Surgery examined 10-13 year old little league baseball players.  Each player underwent an MRI on both elbows at the start of the season.   The authors found many of the players with or without pain had imaging findings in their elbow.  Adding to our existing data that many athletes have positive MRI findings without pain or injury.  Two factors were associated with a positive MRI and elbow pain including year round baseball play and working with a private pitching coach.  

Athletes are encouraged to work with a local Physical Therapist to treat their elbow pain and reduce their risk of throwing injuries. 

Predicting Lasting Symptoms After An Initial Ankle Sprain

Ankle sprains are one of the most common orthopedic injuries we see in our Boulder Physical Therapy practice.  These injuries create local pain, swelling, loss of motion, weakness, and balance difficulties.  In past years these injuries were treated with R.I.C.E. (rest, ice, compression, and elevation), but more recent research has demonstrated improved outcomes and faster recovery with a more active approach.  Athletes treated with manual therapy and exercise by a Physical Therapist demonstrate superior outcomes than those treated with R.I.C.E.  The greatest limitation of the R.I.C.E. and wait and see approach involves prolonging treatment which may lead to lasting chronic symptoms throughout the lower extremity.  

A recent article in the American Journal of Sports Medicine attempted to identify predictors of chronic symptoms and balance difficulties among athletes after an ankle sprain (Doherty et al. 2016).  The authors followed 82 patients who sustained a first time ankle sprain.  The athletes were examined at 3 times points: 2 weeks, 6 months, and 12 months post injury.  At 12 months patients with lasting, chronic symptoms were identified and their data was analyzed to determine if prior clinical data could predict their lack of recovery.  The authors noted patients who were unable to complete landing and jumping tasks at 2 weeks post injury and/or were unable to demonstrate balance in multiple planes of movement demonstrated the greatest risk of lasting pain and symptoms.  

Individuals who sustain an ankle sprain are advised to contact their local Physical Therapist as soon as possible to accelerate recovery and prevent chronic symptoms. 

 

Injections for Knee Osteoarthritis

Knee osteoarthritis is a common condition in aging adults leading to pain and reduced performance of daily and recreational activities.  Manual therapy and exercise remain a hallmark of conservative care for this condition and have been shown to delay or prevent the need for a total knee replacement.  In addition to exercise, corticosteroid injections are often proposed to patients in order to reduce pain and improve patient participation.  A recent study in the Journal of the American Medical Association examined the impact of these injections in patients with knee arthritis.

Henriksen and colleagues studied 100 patients and randomized them to either a corticosteroid injection or a placebo injection prior to undergoing Physical Therapy 3 days a week for 12 weeks.  These patients all had evidence of knee arthritis on x ray and reported pain with daily activities including walking.  All patients improved through the course of the study, but no significant differences were noted at 2, 14, or 26 weeks between the group receiving a corticosteroid injection or a placebo.   The authors concluded there was no additional clinical benefit of a steroid injection and Physical Therapy compared to Physical Therapy alone.  Thus, Physical Therapy was the main reason for the patient's improvement.   

Patients with knee osteoarthritis are encouraged to seek out a local Physical Therapist to implement an effective rehabilitation program.