Many doctors prescribe opioids to people with low back pain. Prescription opioids are a main source of the increasing rate of drug addiction and overdose deaths in the USA. In 2014, the Centers for Disease Control and Prevention (CDC) reported that prescription opioids killed 29,000 people. Last week the American College of Physicians published a new guideline for noninvasive treatments of adults with back pain that urge medical professionals to avoid the use of opioid medications as a primary treatment. Instead, the guidelines recommend non-pharmacological treatments be used. The guideline recommends different treatment options for acute back pain/sub-acute back pain (0-12 weeks duration), and chronic back pain (>12 weeks duration).
For acute and sub-acute back pain non pharmacological treatments such as superficial heat, massage, acupuncture, or spinal manipulation should be tried. If pharmacological treatments are desired nonsteroidal anti-inflammatory drugs (i.e. Ibuprofen) or skeletal muscle relaxants should be used.
Those with chronic back pain should try non pharmacological treatments such as exercise, multidisciplinary rehabilitation, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation. Pharmacological treatments should be considered only if the previously mentioned treatments have failed. Non-steroidal anti-inflammatory drugs (i.e. Ibuprofen) should be used as a first line pharmacological treatment, and tramadol or duloxetine (Cymbalta) as a second line pharmacological therapy. Opioids should only be considered after the previously mentioned treatments have been attempted and proven inadequate, and only if the potential benefits outweigh the risk of opioid medication use.
As a physical therapist that treats people with painful spinal conditions on a daily basis, I have seen many patients gain control of their pain using their own movements and positions with a classification based treatment system known worldwide as the McKenzie Method (aka MDT). The system uses exercise, spinal manipulation, and patient education as the primary means of treating mechanical spinal pain. This system can be successful for those with acute, sub-acute, or chronic back pain. This method of evaluation and treatment can quickly identify (usually 1-5 visits) those who are capable of responding to this form of treatment. The small percentage of non-responders can be triaged to other forms of non-pharmacological or pharmacological treatments as described above.
If you have back pain try MDT and avoid the pitfalls of opioid medication use. If you live in the Oklahoma City metro area give me a call to see if MDT will work for your pain. If you live elsewhere you can find a clinician with expertise in this form of treatment at The McKenzie Institute USA
Low Back Pain (LBP) is a very common life experience that is estimated to affect 31 million Americans at any given time. 85% of all LBP cases are considered “nonspecific”. This means that despite all of the sophisticated imaging studies available the exact anatomical source of the pain cannot be accurately detected. What is known is that most LBP is mechanical in origin. So what is mechanical LBP? Mechanical LBP is caused by overloading or overstretching the various soft tissues (muscles, tendons, capsules, ligaments, discs, etc.) that are innervated by the vast network of free nerve endings located in and around the joints of the spine. There are a few different situations that can make this happen:
So what typically causes LBP to develop? Our life styles and habits play a major role in the development of these disorders. The most common predisposing factors in our lifestyles that most often cause LBP are the frequency of bending in our work and play habits, and poor habitual sitting posture.
Many treatment options are available for LBP and many different types of caregivers are available to deliver treatment (PT, chiropractic, massage therapy, acupuncture, personal trainers, pain management, surgeons,etc.). I believe the best person to treat your LBP is you and the best method in which to treat it is with your body’s own movements. You have firsthand knowledge of how your pain effects your movements and activities and with appropriate guidance you can be taught the right movements and positions to fix it!
In my clinical practice I have evaluated and treated hundreds of patients with LBP utilizing a system known as Mechanical Diagnosis and Therapy (MDT) to determine the cause and provide in many cases a rapid resolution to the patient’s LBP. MDT is a system that utilizes the patient’s own movements and positions to identify mechanical pain syndromes that readily respond to mechanical therapy exercises and techniques. The clinical phenomenon known as centralization that commonly occurs during the MDT assessment process is the key to identifying those likely to rapidly recovery with such treatment. Centralization of pain is the progressive retreat of the most distal extent of referred or radicular pain toward or to the lumbar midline.
Centralization occurs in over 50% of LBP cases. Physical therapists formerly trained in MDT have demonstrated the ability to more frequently identify centralization compared to those who are not trained in MDT. The patient who centralizes will have better outcomes if they are prescribed movements in accordance to their directional preference (DP). DP is a term used to describe the specific direction of end range spinal movement that causes the patients symptoms to rapidly decrease, centralize, and eventually abolish.
At Stover Physical Therapy, I have compiled the Oswestry Low Back Disability score of over 573 patients with LBP. 55% of these patients demonstrated DP at the initial evaluation. The average initial Oswestry score for these patients with DP was 31% (moderately disabled) and the average Oswestry score at discharge was 11% (minimally disabled).
If you are among the many unfortunate sufferers of LBP, undergoing a MDT examination by a therapist competent in MDT would be a wise first step in learning how to effectively reduce your discomfort. Furthermore the experience is a great way to learn the steps involved in the prevention of these frequently recurrent problems. Many times full recovery can be achieved within a few weeks and without the need for expensive imaging studies. Call me to schedule your MDT assessment if you live in the Oklahoma City metro area.
1. McKenzie RA, May S. Mechanical Diagnosis and Therapy. The Lumbar Spine. 2nd. Waikanae, New Zealand : Spinal Publications; 2003.
2. Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine. 1997; 22(10): 1115-1122.
3. Balague F, Nordin M, Sheikhzadeh A,Echegoyen AC, Brisby H, Hoogwoud HM,Fredman P, Skovron ML. Recovery of severe sciatica. Spine. 1999; 24(23): 2516-2524.
4. Brotz D, Kuker W, Maschke E, Wick W, Dichgans J, Weller M. A prospective trial of mechanical physiotherapy for lumbar disk prolapse. Journal of Neurology. 2003; 250: 746-749.
5. Kopp JR, Alexander AH,Turocy RH,Levrini MG, Lichtman DM. The use of lumbar extension in the evaluation and treatment of patients with acute herniated nucleus pulposus. Clinical orthopaedics and related research. 1986; 202: 211-218.
6. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine. 2004; 29(23): 2593-2602.
7. Skytte L, May S, Peterson P. Centralization: Its prognostic value in patients with referred symptoms and sciatica. Spine. 2005; 30(11): E293-E299.
I woke this morning to a beautiful white blanket of snow in the backyard with heavy snow still accumulating. It was pure pleasure drinking my coffee in my heated glass sun room and watching the snow fall. It reminded me of past trips to the Colorado Rockies, sitting on the balcony of ski lodges and enjoying the fresh mountain air. After a while the bliss ended and I started thinking about the exhaustion of clearing this slushy mess from my walkways and driveways at my home and at my office. I started to remember some statistics I once read about the risk of snow removal. According to the U.S. Consumer Product Safety Commission, in 2015:More than 158,000 people were treated in emergency rooms, doctors' offices, and clinics for injuries that happened while shoveling or removing ice and snow manually. The most significant health risk is heart attack and orthopedic injuries particularly to the lower back and shoulders. Those at greatest risk are individuals that are older or unfit for the task at hand.
The following are tips for safe snow removal.
Choose a snow shovel that is right for you.
Your shoveling technique is very important.
Remember to Stretch!
The pictures above are a few helpful stretches for the lowerback and shoulder to prevent injury when shoveling snow. You should perform 6-10 repetitions each. Take each stretch as far as possible. Perform these stretches before, during, and after your snow removal.
Finally, for those of us who are able bodied, it is always worth remembering neighbors on your block who might not be able to remove the snow from their sidewalks. A few minutes of help can make the world of difference to the wellbeing of a less able bodied person as well as make you a good neighbor! Heres to safe shoveling!
AAOS. (2016, November). Ortho Info. Retrieved January 6, 2017, from AAOS.org: http://orthoinfo.aaos.org/topic.cfm?topic=a00060
SIMA . (n.d.). Safe snow shoveling. Retrieved January 6, 2017, from SIMA.org: http://www.sima.org/discover-sima/public-safety/safety-tips/safe-snow-shoveling
Those who have suffered from adhesive capsulitis aka frozen shoulder know it is no pleasant task to recover from. The following link details the condition and its rehabilitation in detail.
Frozen Shoulder and Mechanical Therapy
The video below demonstrates the rehabilitation process and the results one can achieve with appropriate mechanical therapy.
If you suffer from this condition seek help from a PT experienced in dealing with this conditon. This condition requires motivatiion and guidance over a protracted period of time. You will need someone on your side to re assure and encourage you to succeed.
Low Back Pain (LBP) is common. It is cited to affect about 80% of all adults at some point in life. LBP is the most common musculo-skeletal cause of disability experienced by adults. LBP is frequently recurrent, with about 60% of LBP cases suffering recurrent episodes. LBP is not always curable, and for some is a lifelong problem. The cost of LBP is enormous. In the US, medical cost for LBP has been estimated between 8-18 billion dollars annually. The majority of cost is spent on the chronic back pain population.
Medicine should be taking measures to improve the overall management of those with LBP. Classifying patients with non-specific LBP into sub-groups based on specific clinical characteristics and matching these sub groups to specific therapeutic management strategies has been advocated to improve the management of those with LBP. One such clinical characteristic is called Directional Preference (DP).
DP is considered to be present when a patient’s spinal and/or referred spinal pain is decreased in intensity, abolishes, or centralizes, and their spinal range of motion increases in response to a repeated movement or positional loading strategy (i.e. flexion, extension, or lateral directions). DP is a common finding in patients who are evaluated by clinicians trained in the use of Mechanical Diagnosis and Therapy (MDT). MDT is a system that utilizes the patient’s own movements and positions to identify specific sub groups of patients with mechanical pain syndromes that readily respond to mechanical therapy exercises and/or manual therapy techniques.
Long, Donelson, and Fung (2004) studied 312 patients with LBP and/or sciatica for the presence of DP during a structured physical examination. 230 (74%) of these patients exhibited a clear directional preference when examined (See pictures for the statistical breakdown of the directions preferred).
The researchers divided these 230 patients into three treatment groups and recorded their outcomes.
Performed exercises matching their individual directional preference.
Performed exercises opposite their individual directional preference.
Performed "non-directional" exercises. Performed 8 commonly used mid-range exercises not biased in any particular direction.
The outcomes measured were pain intensity, disability, medication use, degree of recovery, depression, and work interference before and after the treatment period.
The results of the study were impressive. 95% of the people in Group 1 (matching exercise) rated their pain/disability better or resolved. Group 1 improved significantly more than both Group 2 and 3. Most dramatically, 35% of group 2 and 33% of group 3 withdrew from the study because of worsening of their symptoms. In contrast, not one individual in group 1 withdrew from the study due to worsening symptoms. The authors concluded that exercises matching a person's directional preference have the potential to significantly and rapidly decrease pain, disability, and medication use in people with LBP with or without sciatica.
At Stover Physical Therapy we use MDT to treat patients with LBP. Before administering any treatment we always complete a comprehensive history and evaluation based on MDT principles. Following the evaluation, we classify the patient’s disorder to aid in the development of an individualized treatment program that commonly includes directionally specific exercises and manual therapy procedures.
We use a validated health questionnaire called the Oswestry Low Back Disability Questionnaire to monitor our outcomes. The Oswestry is an instrument specifically developed to assess pain intensity, and assess how LBP affects activities of daily living. Oswestry scores vary from 0% -100%, with the lower number representing less pain and disability.
We have compiled the Oswestry results of 573 patients with LBP, with and without sciatica. 313 (55%) of these patients demonstrated DP at the initial evaluation. The average initial Oswestry score for this group of patients with DP was 31% (moderately disabled) and the average Oswestry score at discharge was 11% (minimally disabled) for this group of patients (see graph below).
If you are among the many unfortunate sufferers of low back pain,undergoing a MDT examination by a qualified therapists, would be a wise first step in learning how to effectively reduce your discomfort. Furthermore the experience is a great way to learn the steps involved in the long term management of these frequently recurrent problems. Many times full recovery can be achieved within a few visits and without the need for expensive imaging studies..
Low Back Pain (LBP) is a common life experience and is the most common musculo-skeletal cause of disability experienced by adults.1 LBP will affect about 80% of all adults at some point in life.1 Sciatica is a term used to describe pain caused from irritation, compression, or adherence of the sciatic nerve as it exits the lower segments of the lumbar spine. Sciatica is reported in 5-12% of the LBP population.1 Sciatica is commonly the end result of a disease progression that occurs with chronic and recurrent LBP episodes.1 Clinically it is detected by activity limitation such as difficulty sitting, bending, lifting, standing, walking, loss of normal range of spinal movements, and positive neurological tests such as straight leg raise, motor weakness, sensory loss, and reflex loss.3 Disc herniations are the most common cause of nerve root involvement in the LBP population, causing sciatica.1 Disc hernations commonly occur in adults between 30 and 50 years of age1. The natural course of sciatica caused by disc hernation left untreated is generally considered favorable yet protracted.1 The most significant improvement in sciatica occurs in the first 3 months.1,4,9 Balague et al. 4 and Weinstein et al. 9 reported the outcomes of large groups of separate populations of patients with sciatica over 1-2 years respectively and documented similar changes in pain and function despite the treatment chosen. See figure 1 for a summary of the outcomes of both studies.
In my clinical practice I have evaluated and treated hundreds of patients with sciatica utilizing a system known as Mechanical Diagnosis and Therapy (MDT) to determine the cause and provide in many cases a rapid resolution to the patient’s sciatica episode. The clinical phenomenon known as centralization that commonly occurs during the MDT assessment process is the key to identifying those likely to rapidly recovery with such treatment. Centralization of pain is the progressive retreat of the most distal extent of referred or radicular pain toward or to the lumbar midline.2 Peripheralization is the oppositely directed phenomenon that helps identify quickly those who are not appropriate for MDT treatment.2
Symptomatic intervertebral lumbar discs causing back pain and/or sciatica can be reliably identified by PTs credentialed in Mechanical Diagnosis and Therapy (MDT) using a standardized mechanical assessment that incorporates end range repeated movement testing to detect the presence or absence of centralization and or peripheralization.2
Centralization occurs about 43-50% of the time in the sciatica population, and even more frequently in the nonspecific Low Back Pain population.2,6,7,8 PTs formerly trained in MDT have demonstrated the ability to more frequently identify centralization compared to those who are not trained or only minimally trained in MDT.1,2 The patient who centralizes will have better outcomes if they are prescribed exercises in accordance to their directional preference.7 Directional preference is a term used to describe the specific direction that caused the patients symptoms to rapidly decrease, centralize, and eventually abolish.
Basic MDT exercise/techniques that commonly lead to centralization and identification of a preferred direction of movement. A. Flexion in Standing (FIS) B. Extension In Standing (EIS) C. Side Gliding In Standing (SGIS) D. Lateral Shift Correction E. Extension In Lying (EIL) F. Flexion In Lying (FIL) G. Rotation Mobilization In Flexion
Patients with discogenic pain and sciatica who are able to achieve centralization of symptoms with mechanical therapy techniques are 6 times less likely to require surgical intervention and more likely to recover rapidly with conservative treatment.5,6,8 Therefore, suffering for months while awaiting natural resolution of sciatica as described previously or undergoing surgical intervention for sciatica can be avoided by many individuals if they choose or are allowed to be evaluated by clinicians formerly trained in MDT.
Here is what a patient with severe sciatica treated in my office had to say about his MDT treatment.
"I came to my first therapy visit stooped over about a 45 degree angle and using a crutch. I left that visit standing erect and I have not needed the crutch again. I continued to improve my next 2 visits. I went back to work after my 3rd visit. After my 4th visit I had lost all the pain in my left leg and most of the numbness, I have just finished my 5th visit, and feel great! No pain or numbness in my left leg and just a slight pain in the middle of my back."
1. McKenzie RA, May S. Mechanical Diagnosis and Therapy. The Lumbar Spine. 2nd. Waikanae, New Zealand : Spinal Publications; 2003.
2. Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine. 1997; 22(10): 1115-1122.
3. Butler DS. Mobilization of the nervous system. Churchill Livingstone; 1991.
4. Balague F, Nordin M, Sheikhzadeh A,Echegoyen AC, Brisby H, Hoogwoud HM,Fredman P, Skovron ML. Recovery of severe sciatica. Spine. 1999; 24(23): 2516-2524.
5. Brotz D, Kuker W, Maschke E, Wick W, Dichgans J, Weller M. A prospective trial of mechanical physiotherapy for lumbar disk prolapse. Journal of Neurology. 2003; 250: 746-749.
6. Kopp JR, Alexander AH,Turocy RH,Levrini MG, Lichtman DM. The use of lumbar extension in the evaluation and treatment of patients with acute herniated nucleus pulposus. Clinical orthopaedics and related research. 1986; 202: 211-218.
7. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine. 2004; 29(23): 2593-2602.
8. Skytte L, May S, Peterson P. Centralization: Its prognostic value in patients with referred symptoms and sciatica. Spine. 2005; 30(11): E293-E299.
9. Weinstein JN, Lurie JD, Tosteson TD, Skinner JS, Hanscom B, Tosteson AN, Herkowitz H, Fischgrund J, Cammisa FP, Albert T, Deyo RA. Surgical vs nonoperative treatment for lumbar disk herniation. the spine patient outcomes research trial (SPORT): A randomized trial. JAMA. 2006; 296(20): 2441-2450.
So I was visiting a referral clerk at a busy orthopedic practice in my local area and discovered she was suffering from a knee problem that was scheduled for arthroscopic surgery. I offered my services to her either pre operatively to possibly avoid this pending procedure or post operatively to aid in a full recovery. The clerk stated she has already been in PT at the orthopedic practice’s own PT facility and it was not helping. She expressed interest in working with me after her surgery, so I urged her to start as soon as possible to assure the recovery was uncomplicated. I wished her luck, and we parted ways.
About 6 weeks later I get a phone call from this clerk stating she had her knee surgery about 3 weeks ago. She was still in a lot of pain, and she was ready to start post-operative PT. I was thinking to myself, did she not get the message about starting as soon as possible? I held my tongue and graciously agreed to see her right away. When she arrived I observed a very stiff knee with significant gait disturbance and quadriceps atrophy. Her ROM was lacking about 10 degrees of full extension and was about 70 degrees of flexion of course pain was produced with movement into these restricted movements. I began explaining to her about the healing process after trauma and the need to start moving the injured and healing tissues to promote a stronger and more flexible scar. I explained to her that the therapeutic movements typically will produce pain when the healing and abnormal tissue are stretched or contracted, but the pain should not get worse with repetition or last more than a few minutes after completing the movements. She understood and we began gently moving this stiff knee. We initially began with active knee extension in sitting and passive knee extension in standing which she reported seemed to actually become less painful with reps. I took that as a good sign and sent her home to work on these movements about 4-6 times daily. She came back a few days later with improved gait and significantly improved ROM no loss of extension and minimal loss flexion (0-110). We proceeded that session to added step standing knee flexion to restore the last bit of ROM. This also was tolerated well. She came back a few days later still improved and now had normal gait and full knee ROM. This session we began to explore her functional strength loss with bilateral stance squatting and step exercises. These movements were difficult and provoked quadriceps fatigue but no pain. So we added these activities 1 time daily to restore strength/function. We progressed these activities over 3 more sessions with good tolerance and further improved function. After the 6th session she mentioned she was to follow up with her surgeon’s PA the following week. I said ok and thought the amount of progress made in these few sessions might impress this PA.
The following week I get a message from the patient. She informs me that her PA wants her to stop PT. He tells her that her therapy should not provoke any knee pain, and convinces her to undergo a series of injections into her knee to attempt cartilage regrowth. I was reading this message and thinking WTF? So less than 6 weeks ago they tell this poor lady she needs surgery to remove torn cartilage in her knee, and now they convince her that she needs injections to regrow cartilage that they just removed? What kind of BS is that? Clearly this patient had improved from surgery to follow up. Does this PA not assess reported pain and function in his follow ups? What type of physiology courses are taught in PA school? Did they skip the section on soft tissue repair process? Has this PA ever personally recovered from a trauma or surgery to a body part that is vital to movement?
I have been working with orthopedic injuries for over 20 years and I cannot remember 1 patient who went through the entire rehab process and recovered fully without experiencing pain. Pain is not always a sign that tissue is being damaged. The idea that pain should be avoided at all costs often leads to maladaptive pain behavior such as kinesiophobia (fear of movement). This type of behavior should be discouraged as it frequently encourages the development of crippled mindsets often seen in the chronic pain population. This type of maladaptive behavior has been the culprit of many disabilities.
Pain and changes in the affected body parts ROM are used as a guide by rehab professionals to determine appropriate treatment strategies following musculoskeletal injuries such as post-operative trauma following knee surgery. Many rules and clinical reasoning guides have been devised and taught to rehab professionals over the last few decades regarding pain. The traffic light guide and the soreness rules are just a few that I employ as a guide during patient care.
So if your physician or physician’s PA tells you that exercising your injured body part should not be painful, ask them if they have experienced such injuries personally?. Ask them if they felt pain when they were recovering from these injuries? More importantly, ask them did they fully recover? If they did not fully recover,encourage them to see a PT. PT might just fix their problem, although pain may be experienced, harm will not occur.
Shoulder pain is one of the most common problems affecting the joints and muscles of the human body. According to the American Academy of Orthopedic Surgeons more than 4 million people in the USA seek medical attention each year due to shoulder pain. Many of these shoulder problems frequently recur or persist. It has been reported that 50% of people who seek medical attention for shoulder pain continue to have shoulder problems 1 year after the onset of their symptoms.
Shoulder problems are often given a medical diagnosis such as tendonitis, rotator cuff tear, impingement syndrome, frozen shoulder, capsulitis, or arthritis. Shoulder pain is often felt in the shoulder and upper arm region often only felt with specific activities such as dressing, reaching overhead, or reaching behind ones back. Sometimes shoulder pain can be felt constantly and significantly disturb sleep making life miserable.
Common treatments for shoulder pain are medication, injections, acupuncture, and electrical modalities (ultrasound, TENS, etc.). Some of these may give short term relief, but do not provide effective long term relief from pain or loss of function. Exercises to stretch and strengthen the shoulder, especially when combined with manual therapy techniques to restore shoulder mobility have been proven to be effective treatments for many shoulder problems. However, doing exercises for the shoulder is only part of the solution. Often overlooked or ignored are the positions we hold our arms in the rest of the time. It is important to realize that the way we move our arms and/or the way we hold our arms during many activities can significantly contribute to shoulder problems. In fact, these abnormal stresses will most certainly continue to cause recurrence of shoulder problems unless action is taken to modify these habits.
Although shoulder pain can be caused by forces that place sudden severe strain on the shoulder such as starting a lawn mower, and falling onto the shoulder, elbow, or hand, more often shoulder pain is caused by postural stresses that place less severe strain on the shoulder over a longer period of time.
4 common postural stresses that frequently cause and/or aggravate shoulder pain are:
1. Repetitive or prolonged tasks in raised arm postures
2. Sitting in slouched postures
3. Standing in slouched postures
4. Sleeping with the shoulder unsupported or lying in a raised arm posture
In order to successfully treat shoulder pain it is important to become aware of which shoulder positions and activities aggravate and perpetuate your problem, and learn correct positions and ways to hold the shoulder to avoid aggravation or recurrence of symptoms, yet still remain as active as possible. Below are some suggestions to correct shoulder posture and reduce stress to the shoulder
To avoid raised arm positions, you should always attempt to adjust your environment to allow the arms to be held in a correct position with the elbow close to the body. If this is not possible, interrupt sustained raised arm postures frequently.
Patellofemoral pain syndrome(PFPS) is defined as idiopathic pain arising from the anterior knee, that is of otherwise unknown origin.2 PFPS is characterized by diffuse pain at the front of the knee that is exacerbated by activities that load the knee in flexion, or sustain the knee in flexion (running, stairclimbing, squatting, or prolonged sitting.1,2 Some describe a feeling of giving way or crepitation in the knee.1 PFPS is highly prevalent among active individuals.3 The pain and disability resulting from this condition not only affects short term participation in daily and physical activities, but can have a significant long-term impact, with symptoms shown to persist in 1 of 4 sufferers for up to 20 years after initial presentation.3 As regular physical activity is highly recommended for the prevention of conditions such as cardiovascular disease and type II diabetes, PFPS may have important implications for the long term health of affected individuals.3 PFPS is thought to be caused from compressive and shearing forces to the undersurface of the patella (knee cap), excessive lateral pressure to the patella, lateral maltracking of the patella, instability of the patella causing recurrent subluxation.1 These factors are thought to cause softening, thinning, and degeneration of the cartilage underneath the patella.1
Risk factors for the development of PFPS are:
1. Female gender
2. maltracking patella
3. tight iliotibial bands/lateral retinaculum
4. various lower extremity malalignments
5. weak vastus medialis obliquus (VMO)
6. weak hip abductors
7. weak hip external rotators
8. training errors
9. history of trauma or degenerative changes in the cartilage
Medical intervention including NSAID drugs have not been shown to be effective in managing the symptoms of PFPS.2 Unless the underlying biomechanical problems are changed, the majority of people with PFPS do not experience relief.2 The only undisputed form of relatively effective treatment for PFPS is exercise.1,2,3 Within this realm however, there are many ideas as to what is best. Some advocate the use of taping techniques or a custom foot orthoses to decrease symptoms and improve patellar tracking, in conjunction with exercise.3 Others use specific equipment and exercises to isolate activation of the VMO. Some clinicians promote using unloaded exercises for treatment. Others use loaded exercises almost exclusively. In other words, the mechanism for why exercises are effective is unclear.
I believe a patient with anterior knee pain must be evaluated to determine if the
symptoms are arising from a mechanical or an inflammatory process. If inflammation is ruled out as a source of pain, as it is in most cases, further mechanical testing is indicated. Typically these patients have very few, if any, mechanical signs. However, their complaints can usually be reproduced with mechanical tests/activities that involve loaded flexion.
My management of PFPS involves stretching any tight tissues in the lower limb and strengthening the quadriceps and hip abductor muscle groups. Occasionally we utilize patellar mobilization and/or taping techniques. We believe strengthening exercises must primarily be done in weight bearing, and in a dynamic manner. Mini squats and lunges on the affected leg, step down exercises, and other simple closed chain exercises are prescribed. Generally we seek to produce some degree of symptoms with the exercises in order to remodel dysfunctional tissue; however, repetition should never worsen the symptoms or cause symptoms to last for more than a few minutes following the exercise. Lingering pain on any exercise is a contraindication to that particular exercise, and modification of the routine is indicated.
Each patient with knee pain referred to my office is asked to complete a Lower
Extremity Functional Scale (LEFS) during his/her initial evaluation and at any subsequent re-evaluation. The Lower Extremity Functional Scale is a 20-item self-report questionnaire that asks the patient to rate his/her level of difficulty on a 0-4 scale during various daily activities. The score ranges from 0(extremely low function) to 80 (extremely high function). The minimal detectable change for the LEFS is 9 points.4 We have documented outcomes on 64 patients with non-specific knee pain. The average score on the LEFS for patients with non-specific knee pain was 44/80 initially.After treatment, the average score rose to 66/80. This is a significant change of 22 points. The average number of visits for this group of patients was 10 over a 5-week period. From these results, it is apparent that physical therapy that primarily utilizes mechanical therapy and general exercise can be effective at reducing pain and increasing function associated with nonspecific anterior knee pain such as PFPS. I hope that as more literature becomes available, the management of PFPS will become more efficient.
1. Dressendorfer, R., & Granado, M. (2010).Clinical Review: Patellafemoral pain syndrome (PFPS). Cinahl.
2. Mckenzie, R., & May, S. (2000). The Human Extemities: Mechanical Diagnosis and Therapy. Wellington: Spinal Publications New Zealand Ltd.
3. Vicenzino, B., Collins, N., Crossley, K.,Beller, E., Darnell, R., & McPoil, T.(2008). foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: A randomised clinical trial. BMC Muskuloskeletal disorders , 1-12.
4. Binkley, J.M., Stratford, P.W., & Lott, S.A.(1999). The lower extremity functional scale(LEFS): Scale development, measurement properties,and clinical application. Physical Therapy,79, 371-383.
Back surgery should be a last resort for most people who suffer back pain and sciatica. For some patients who have failed adequate conservative treatment it is a good option. But the surgery itself is only part of the treatment; just as important is the type of post surgical advice, activity, and treatment that is undertaken to ensure a full recovery.
A recent survey indicates that there are large differences among healthcare providers in the type and intensity of rehabilitation, if any, provided after lumbar surgery as well as in the restrictions and advice given to patients in the post-operative period (McGregor, Doré, Morris, Morris, & Jamrozik, 2010).
According to a recent review on rehabilitation following lumbar decompression surgery, active post-operative programs that involve exercise lead to a faster decrease in pain and disability when compared to no treatment. There has been evidence that active treatment programs, even those involving high intensity exercise, do not result in increased re-operation rates. The review concluded that it is not harmful to return to activity after lumbar disc surgery and therefore it is not necessary for patients to stay passive after first time lumbar decompression surgery (Ostelo RWJG, 2011).
It is well known that early and appropriate activity enhances recovery from most surgical procedures. Especially when the surgery affects areas of the body that play a role in the way we move. The spine is no exception to this rule. The keyword is appropriate activity. The intent of a post operative rehab program is to prevent tissue dysfunction by applying early graded activity to prevent formation of dense, inelastic scar and restore overall functional tolerance to normal activity. Rehabilitation following lumbar decompression surgery should consist of advice and activity that is appropriate for the 3 phases of tissue healing (inflammatory, fibroplasia, and scar maturation). During the initial phase of healing, advice on avoidance of excessive stress to the healing tissues is appropriate and justified to prevent recurrent disc herniation and/ or prolong the inflammatory phase of tissue healing. Within a few days gentle controlled movements can be initiated to enhance normal collagen formation. The type and amount of controlled movement and activity is determined by the patient’s pain response and tolerance to movements and positions. Typically the movements begin with gentle mid-range movements performed in unloaded postures, and are gradually progressed to end range movements performed in loaded postures at a rate determined by the response of the patient and phase of healing. In addition an individualized functional restoration program to increase general strength and endurance is implemented.
Examples of movements/positions that are appropriate during the inflammatory phase
Examples of movements/positions that are appropriate during the fibroplasia phase
Examples of movements/positions that are appropriate during the scar maturation phase
I measure functional outcomes of the patients seen in my facility using validated health questionnaires. For post operative lumbar spine disorders, I use the Oswestry Low Back Disability Questionnaire. The Oswestry is scored as a percentage from 0-100 with the higher number representing a higher level of pain and disability, and the lower number representing less pain and disability. A score ranging from 1-20% is considered minimally disabled, 21-40% moderately disabled, 41-60 % severely disabled, 61-80% crippled, and 81-100% incapacitated. I have recorded the Oswestry sores of 99 patients treated in my facility following lumbar decompression surgeries (laminectomy, discectomy). The average initial Oswestry score for these patients was 43% (severely disabled) the average final Oswestry score for these patients was 20% (minimally disabled). The average number of visits to achieve these results was 14. The average duration of time these patients were seen was 7 weeks.
McGregor, A., Doré, C., Morris, T., Morris, S., & Jamrozik, K. (2010). Function after spinal treatment, exercise and rehabilitation (FASTER): improving the functional outcome of spinal surgery. BMC Musculoskeletal Disorders , 11 (17), 1-8.
Ostelo RWJG, C. L. (2011). Rehabilitation after lumbar disc surgery (Review). The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Don Stover PT
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Thanks for visiting my blog page. My name is Don Stover. I am a seasoned physical therapist in Oklahoma City OK. with over 20 years in the biz. I have a lot of knowledge and training in orthopedic PT and spine care. I will be sharing my thoughts on physical therapy for orthopedic problems such as spinal pain, extremity joint pain, sports injuries, health/fitness, and life in general. I hope you enjoy reading!
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