Posts tagged manual therapy
Physical Therapy Headache Solutions
boulder-headache-treatment-pain-relief

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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Physical Therapy Exercises Are Cost and Clinically Effective Compared To Primary Care Alone For Knee Arthritis
knee-arthritis-treatment-exercise-cost

Physical Therapy interventions including manual therapy and exercise remain the primary intervention for patients with knee arthritis. These treatments have been shown to delay or prevent the need for costly, more invasive treatments including total knee replacement. Prescribed Physical Therapy exercises are designed to reduce pain, improve mobility, and increase a patient’s leg strength. Stronger muscles attenuate forces across the painful knee joint allowing a patient to achieve a higher level of physical function and participation their prior levels of activity. Additional treatment options available to patients include primary care or orthopedic management involving diagnostic imaging, medication, injections, and education. A recent study compared the cost and clinical effectiveness of usual care versus Physical Therapy management for patients with knee arthritis.

A randomized controlled trial in the journal Osteoarthritis and Cartilage was conducted to compare the effectiveness of different conservative interventions among patients with hip or knee arthritis (Abbott et al. 2019). Authors randomized 206 patients with either hip or knee arthritis to one of four groups: usual medical care, supervised Physical Therapy Exercises, manual Physical Therapy, or combined manual and exercise Physical Therapy. Physical Therapy participants were provided with 10, 50 minute sessions including follow up “booster” sessions at 4 and 13 months. Authors found the greatest cost and clinical effectiveness in the patients who received supervised Physical Therapy exercises in addition to usual care.

Physical Therapy Offers Equivalent Outcomes To Surgery For Carpal Tunnel
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Carpal tunnel syndrome or the entrapment of the medial nerve at the wrist is a condition leading to pain, numbness, and pins and needles sensations along the palm side of thumb, index, and middle fingers. If the entrapment continues weakness can be experienced in the wrist and hand. Contributing factors include loss of nerve and wrist mobility, muscle imbalance, and work ergonomics. Although surgery remains a common intervention, previous research has shown no difference in long term outcomes between surgery and Physical Therapy for patients with carpal tunnel surgery (Fenandez de las Penas et al. J Pain. 2015.). A recent research study compared the cost of these Physical Therapy interventions for patients with carpal tunnel syndrome.

Journal of Orthopedic and Sports Physical Therapy published a recent article on the cost effectiveness of either Physical Therapy or surgery for the treatment of carpal tunnel (Fernandez de las Penas et al. 2018). Authors randomized 118 patients with carpal tunnel to either a surgical intervention or Physical Therapy consisting of 3 sessions of manual therapy, nerve mobilizations, and home exercises. As expected, patients in the surgical group required greater numbers of additional treatments, days lost from work, and greater costs compared to patients in the Physical Therapy group. In addition, this study supported previous research findings on equivalent outcomes found between surgery and conservative care treatments for patients with carpal tunnel.

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Upper Cervical Spine Treatment Improves Outcomes In Patients with Jaw Pain and Headache
boulder-jaw-pain-TMJ-TMD-treatments

Temporomandibular joint (TMJ) pain or Temporomandibular Disorder (TMD) is a painful condition limiting a patient’s ability to utilize the joint moving the lower jaw on the skull. When painful this joint limits an individual’s ability to eat, speak, and yawn. Pain is often felt in front of the ear over the joint surfaces. In addition to joint pain, patients often experience significant soft tissue and pain in the muscles involved in the aforementioned functions. Frequently patients with TMD experience concurrent headache symptoms driven from the cervical spine.

The upper cervical spine composed of the upper two vertebrae and the skull has an important contribution to TMJ function. These two regions of the upper quarter work closely together during normal head, neck, and jaw movements. Researchers and clinicians often find restrictions in the mobility and motor function of the upper cervical spine in patients with jaw pain. In our Boulder Physical Therapy practice, we find optimal outcomes after treating both regions in patients with jaw pain. A recent research article supports this treatment approach.

Calixtre and colleagues examined the impact of upper cervical manual therapy and deep cervical flexor strengthening in patients with TMD and headache (J Oral Rehabil. 2018). Authors randomized 61 patients to either upper cervical mobilizations and strengthening exercises or a control group. Patients in the intervention group received manual therapy and exercise interventions over 5 weeks. Authors reported significant reductions in both headache symptoms and oral, facial pain in the intervention group. This study highlights the importance of examining and treating adjacent body regions to the area of a patient’s pain.

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No Additional Benefit Of Injection Over Physical Therapy Interventions For Shoulder Pain
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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 muscles 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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Dry Needling Improves Effectiveness of Physical Therapy Treatments for Heel Pain
heel-pain-treatments-plantar-fasciitis

Plantar fasciitis is the most common cause of plantar heel pain estimated to affect 10% of the general population through their lifetime. Proper nomenclature of the pathology is dependent on the tissue involved and how long the symptoms have been in existence. “Fasciitis” suggests an acute inflammatory response, where “fasciosis” illustrates a chronic degenerative response without inflammation. Both terms describe impairments to the insertion of the plantar fascia and/or toe flexors as they attach to the medial heel. Both pathologies are also categorized by increased pain on the inside/plantar aspect of the heel, namely during the “first steps” in the morning or increased weight bearing activities throughout the day.

Manual therapy with exercise has proven to be the best course of action to manage pain and dysfunction of plantar fasciitis, however a recent study investigated the benefit of Electrical Dry Needling (EDN) as an adjunct treatment (Dunning et al. PLOSone, 2018). The study divided 111 participants into 2 groups (standard treatment without EDN vs. standard treatment with EDN). Both groups received up to 8 treatments in a 4-week period. The authors concluded the EDN group’s pain and disability improved significantly at 3 months after treatment compared to treatment without EDN.

To learn more about how Electrical Dry Needling can decrease pain and improve function, contact your local, trusted Physical Therapist.