Posts tagged treatment
Energetic, Outgoing Physical Therapists Achieve Better Treatment Results
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An important shift has taken place in medicine away from the old paternalistic model of care toward the development of the therapeutic alliance. Patients are now encouraged to engage and interact with their medical providers in order to find an optimal path forward. The alliance aims to incorporate patient values and expectations, the best available medical evidence, and available resources to augment the treatment effects. Prior research has shown expert Physical Therapists create a collaborative, patient-centered environment focused on problem solving and treatment. Within this alliance a patient’s specific symptoms and goals can be more quickly and effectively addressed. It is no surprise research shows more optimal outcomes among clinicians utilizing this approach vs. the former paternalistic model of care. New research is also highlighting how a Physical Therapist’s personality may enhance outcomes in the clinic.

Kooijman and colleagues reviewed data from 2800 patient seen in Physical Therapy clinics for shoulder pain over a 3 year period (Physiotherapy. 2019). Authors also collected data on the personality traits of the treating Physical Therapist based on the big five inventory assessment. They were interested in finding the effect of personality on outcomes among patients with shoulder pain. Authors found a significant impact of personality on treatment outcomes with extraverted traits responsible for up to 12% of treatment outcomes. In addition, enthusiasm was also found to significant impact outcomes during treatment of these patients. Unfortunately, the patient’s personality traits were not assessed but future studies may indicate an optimal match of personality traits may even further improve treatment outcomes. This study highlights the importance of assessing psychological factors within in the patient and clinician to augment the effects of known, effective treatments.

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What Are The Best Treatments For Femoroacetabular (Hip) Impingement?
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Hip impingement or femoroacetabular impingement is a diagnosis consistent with bony enlargement of the hip joint, abnormal contact between the joint surfaces, and associated hip pain and loss of function. As we have described in our previous blogs, FAI is the one of the fastest growing hip diagnoses due in part to greater utilization of imaging including MRI and more surgeons being trained in FAI procedures. Significant research questions remain in the diagnosis of FAI since many individuals without hip symptoms or loss of function demonstrate FAI and/or labral tears on imaging. In addition, the optimal treatment pathway is yet to be established to determine which patients require surgery and which will improve with conservative treatments including injections and Physical Therapy. To date, Physical Therapy remains the go to first line intervention for this condition and a recent review of the evidence documents which treatments are most effective for this condition.

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Mallets and colleagues in the International Journal of Sports Physical Therapy reviewed the available evidence on outcomes after short term treatments for patients with impingement (2019). Authors included 7 studies on Physical Therapy or injections for this condition. They found conservative interventions such as activity modification, education, joint mobilizations and strength training are effective in the short term for reducing pain and improving function in this patient population. Physical Therapy exercise interventions demonstrated moderate to large effect sizes on pain and function. In comparison, joint injections alone demonstrated small to moderate effects on pain and function. The authors concluded Physical Therapy treatments “may hold more promise for recovery than joint injections alone.”

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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.

Education Alone Does Not Improve Outcomes In Patients With Acute Low Back Pain
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In any profession, utilized interventions and methods change with incoming ideas and evidence. New concepts and treatments often advance ahead of clinical research trials aiming to support or refute their utilization. Within Physical Therapy, pain neuroscience education has become a popular topic of late. Education topics regarding the development and chronicity of persistent pain are being utilized to teach patients about their current symptoms. Although helpful, I often find some clinicians over utilize this intervention in place of other proven strategies in the management of patients with musculoskeletal pain. A recent study examined the impact of intensive pain education among patients with acute low back pain.

Traeger and colleagues published their findings on the impact of intensive low back pain education and self management strategies in the Journal of the American Medical Association Neurology (2018). Authors randomized 202 patients with acute low back pain to two, one hour sessions of either placebo education (active listening, without information or advice) or patient education (biopsychosocial aspects of pain, back pain self management). These education sessions were in addition to other first line treatments for low back pain including pain medication. Authors reported no improvement in pain outcomes between the education and active listening groups. Consistent with clinical management of acute low back pain, education should not be used in isolation but rather in conjunction with other proven treatments including spinal manipulation and exercise.

How Does Exercise Heal Injured Tissues?

Each day we meet with athletes, clients, and patients who present with an injury or condition involving an injury to a muscle, nerve, ligament, tendon, or bone.  One of the most powerful tools we have to accelerate the healing of this injury is exercise.  A previous post discussed the impact of Physical Therapy exercises on Achilles Tendinopathy.  This post described the impact on exercise on achilles tendinopathy and how exercise improves injured tissue a process called mechanotransduction.  Mechanotransduction refers to the process by which the body converts mechanical loading into cellular responses (Khan Br J Sp Med 2015).  

Khan et al. in a recent article used the term "mechanotherapy" to describe the benefits of Physical Therapy exercises on injured tissues in the body (Br J Sp Med. 2015).  These authors updated the definition of this term to include "the employment of mechanotransduction for the stimulation of tissue repair and remodeling".  Each day we utilize exercise parameters including direction of force, speed, intensity, frequency, duration, and others to optimally impact a patient's injured tissue in order to promote healing and restoration of function.  Each tissue in the body seems to have unique responses to loading from Physical Therapy exercise.

A common example of this phenomenon occurs in our bones.  Gradual loading of the bones through exercise improves bone density, but aging and a lack of weight bearing exercise can lead to osteoporosis.  Bone cells (osteocytes) are stimulated through loading in weight bearing and exercise to promote fracture healing in injured bones.  Research by Challis et al. examined the impact on loading in addition to standard fracture care in patients with forearm fractures (Aust J Phys 2007, J Bone Joint Surg Br 2006, Clin Orthop Relat Res. 2005).  The authors noted improved fracture healing, strength, and range of motion when fractures were exposed to low load, cyclical pressures from a pneumatic cuff wore under the cast.  This suggest gentle, controlled loading in addition to immobilization may accelerate fracture healing. 

Muscle and tendon offer us some of the best examples of exercise's impact on tissue.  The benefits of exercise on muscle are clearly known including increased size (hypertrophy) due to loading (weight training) and the loss of muscle size due to disuse or immobilization (cast).  After a brief period of controlled rest after a muscular injury (strain) exercise has been shown to positively effect the cellular healing and repair of these injured tissues (Jarvinen et al. Best Pract Res Clin Rheumatol. 2007).  Without proper loading these injured muscles may remain in a weakened state making them more prone to subsequent injury.  We often see this in recurrent injuries such as hamstring strains.

Ohberg et al. examined the impact of achilles tendon exercises on achilles tendinopathy.  These patients demonstrated quick improvements in pain and function, but they were also followed over the coming years to determine how their tendons healed from this exercise (Br J Sp Med 2004).  The authors noted improved tendon structure with 19/26 tendons returning to "normal" quality on ultrasound imaging.  As described in our previous blog post early pain relief and restoration of function is likely due to a different mechanism than tendon restructuring since these changes often take years to develop. 

In short, Physical Therapy exercise will always be a hallmark conservative treatment for the regeneration of injured tissues.  Utilize a Physical Therapist to learn how to best manage your injury and how to utilize specific exercise parameters in get back to life and sports. 

Short or Long Duration Isometrics Equally Effective For Patellar Tendinopathy
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Patellar Tendon pain, also known as jumper's knee, is a painful condition most commonly seen in athlete's engaged in jumping sports such as track and field, basketball, and volleyball.  Common causes of this condition include training errors (too much too soon) and underlying weakness in the quadricep and hip musculature.  The gold standard of treatment for this condition involves the application of sub maximal loading through Physical Therapy exercises to promote healing (remodeling) of the tendon.  In short, doing too little is as bad as doing too much.   Exercise begins to heal the injured tissue through a process called mechanotransduction and without it tissues remain in an immature, weakened condition.  In the knee, promising research is being conducted showing the immediate and short term benefits of isometric loading (45-60 seconds), but new research suggests patients may benefit from shorter loading times.  

In the Clinical Journal of Sports Medicine, Pearson and colleagues randomized patients with patellar tendinopathy to one of two groups (2018).  Patients were placed in either a short duration (24 sets of 10 seconds) or long duration (6 sets of 40 seconds) isometric loading program at 85% of their maximum voluntary contraction.  As you can see from the prescriptions time under load (240 seconds) was balanced between groups.  Authors reported the short duration isometric loads were as effective as the longer duration isometric loads as long as the time under tension was equalized.  This study provides more flexibility to both patients and Physical Therapists when treating patellar tendinopathy.  The take home message is one size does not fit all and tendons should be optimally and progressively loaded over time based on the individual.

Contact the experts at MEND to learn how exercise can heal your current injury