Posts tagged Physical Therapy
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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Early Physical Therapy Associated With Reduced Long Term Opioid Use
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Each day over one hundred Americans die from an opioid overdose. Over prescription and use of prescription pain relievers has largely contributed to these unnecessary deaths and the $78 billion dollar economic burden of the opioid epidemic. Authors estimate over 2 million Americans are currently suffering from a substance abuse disorder related to these prescriptions. Experts are now recommending non pharmaceutical pain relieving alternatives including meditation and Physical Therapy. Research strongly points to the early utilization of Physical Therapy as a safe, clinically and cost effective intervention for patients suffering from musculoskeletal pain. A new research study Physical Therapists may play in the opioid epidemic.

The Journal of the American Medical Association published a review article on the impact of early Physical Therapy on the utilization of opioid medication (Sun et al. 2018). Authors reviewed the cases of over 88,000 patients with neck, back, knee, or shoulder pain. Patient cases were then reviewed retrospectively to determine the type and amount of interventions utilized to treat these patient’s symptoms. Authors reported early Physical Therapy was associated with a significant reduction in the amount of opioids prescribed and the duration of these prescriptions. Authors recommended Physical Therapy as a first line intervention for a treatment of these musculoskeletal conditions.

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Altered Functional Performance Found Among Patients With Hip Impingement
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Hip impingement or Femoroacetabular Impingement is a common condition among athletes caused by abnormal contact within the hip joint.  Contributing factors include structural changes in the ball (Cam lesion) and/or socket (Pincer lesion), as well as, weakness in the hip musculature.  The powerful glut muscles act as both movers and stabilizers of the hip joint.  Many athletes with hip impingement remain asymptomatic if they maintain adequate glut strength and hip stability.  Conversely, hip impingement symptoms often worsen in the presence of glut weakness due decreased joint control and increased joint contact forces.  

A recent study in the Journal of Orthopedic and Sports Physical Therapy examined the biomechanical differences between patients with hip impingement (N=20) and their healthy peers (Lewis, C. et al. 2018).  Authors assessed biomechanical differences during a commonly used step down test.  Consistent with our Boulder Physical Therapy clinic's findings, patients with hip impingement demonstrated greater hip flexion and anterior pelvic tilt compared to their asymptomatic peers.  In addition, authors found decreased performance among females compared to male participants.  This study highlights the importance of regaining both glut strength and functional stability to restore function in patients with hip impingement.  

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What happens to unrepaired full thickness rotator cuff tears?
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In our previous blog post we described how few (16%) partial rotator cuff tears progress over time.  Understanding the non progressive nature of the injury allows patients an opportunity to explore non surgical options including Physical Therapy.  In this study they followed partial rotator cuff tears over time, but a more recent study followed patients with full thickness rotator cuff tears over a 5 year period.

Boorman and colleagues followed patients with chronic (> 3 months), full thickness rotator cuff tears (J Shoulder Elbow Surg. 2018).  All patients participated in a comprehensive, Physical Therapy home exercise program.  At 3 months, patients were categorized at successful (asymptomatic with Physical Therapy home exercises) or failure (continued pain and dysfunction).  These patients were then referred for surgical consultation.

At 5 years, 84% of all patients were contacted to determine their current symptoms and functional level.  75% of patients treated non operatively remained asymptomatic with their strengthening program.  Only 3 patients who were initially asymptomatic at 3 months required surgery over the 5 year follow up period.  Importantly, the authors noted no difference in functional outcomes at 5 years between those patients treated surgically or with a home Physical Therapy exercise program.  The authors concluded "non operative treatment is an effective and lasting option for many patients with a chronic, full thickness rotator cuff tear."  This study and our previous blog post challenge the belief that non operative interventions only delay eventual surgical interventions because very few tears regress and very few patients eventually undergo surgical repair.

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High vs. Low Intensity Physical Therapy after Total Knee Replacement
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Knee replacements are a common and effective solution for end state knee osteoarthritis.  Post operative Physical Therapy helps accelerate the recovery from this surgery by reducing pain, improving range of motion and leg strength after this surgical procedure.  Research questions remain regarding the optimal frequency and intensity of post operative Physical Therapy visits.  A recent randomized controlled trial completed by authors in Colorado examined the impact of these variables on a patient's recovery from a total knee replacement.

Over 160 patients were randomized to either receive a high or low intensity post operative Physical Therapy plan of care (Bade et al. Arthritis Care and Research. 2016).  Both groups attended Physical Therapy 2-3 times per week for 11 weeks but varied based on the intensity of the prescribed exercises.  The authors found no significant differences in post operative groups with either high or low intensity programs at either 3 or 12 month follow up.   It appears the early post operative recovery's high pain, swelling, and impairments may prevent individuals from getting the full benefits of exercise in the first few months.  

Surgery vs. Conservative Care for ACL Injuries
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In our prior posts on ACL injuries we have discussed the support in the medical literature for the conservative management of these tears using Physical Therapy alone.  The evidence supports the conservative management of segment of the injured population who are able to "cope" with their ACL tear and still function at a high level of activity.   These individuals demonstrate high levels of strength, balance, and agility after completing their Physical Therapy program.  

Recently a Cochrane Review was completed on the available evidence comparing the surgical versus conservative management of ACL injuries.  The authors concluded there was limited evidence showing no difference between surgery and Physical Therapy for acute ACL tears at either 2 or 5 year follow up.  Importantly, the research shows many individuals opting for early Physical Therapy remained symptomatic and opted for a later ACL reconstruction.  This study adds to the available evidence showing some individuals can return to high level activity after an ACL tear using Physical Therapy alone.  Others after completing a program of Physical Therapy may opt for the surgery due to remaining symptoms.