Which Patients with Low Back Pain will Respond to a Stabilization Exercise Program?

When treating patients with low back pain, it is sometimes difficult to predict who may benefit from a lumbar stabilization exercise program. Researchers have come up with a list of prediction rules that can help with a physical therapist's decision. Over time, the overall reliability and validity of these rules will be proven to a greater degree.

These clinical prediction rules include:

- age less than 40
- history of frequent prior episodes, with increasing frequency
- frequent manipulation resulting in short-term dramatic results
- history of trauma or spinal surgery
- pregnancy related lumbo-pelvic pain
- radiographic diagnosis of spondylolysis or spondylolisthesis
- reports of "catching" pain and/or painful arc on forward bending or when lifting
- "thigh climbing" upon returning from forward bending
- general hyper-mobility during passive intervertebral motion testing
- reports of feeling "unstable" in the spine during functional activities or when lifting
- straight leg raise test bilaterally greater than 90 degrees
- positive prone instability test

Hicks, Fritz, Delitto, McGill. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005 Sep;86(9):1753-62.

Pregnancy and Back Pain

Approximately one half of all pregnant women have experienced low back pain. As a woman progresses through her pregnancy there are many changes that occur affecting her muscular and skeletal systems. An increase in the hormone Relaxin will increase ligament laxity, making the joints of the spine and limbs more prone to strains. As the uterus grows and weight gains progress, there is a shift in a woman's centre of gravity. Simply, she will feel drawn forward by the weight, which will alter her posture. All of these changes can cause pain for some women.

Pregnancy Related Body Changes

The weight of the abdomen will draw the pelvis into an anterior tilt thus increasing the curve of the low back and drawing the head forward. This can cause muscle tension, nerve irritation and strained joints, throughout the spine.

Irritation of the sciatic nerve (sciatica) can occur for several reasons causing pain to radiate from the buttocks down the legs as far as the feet. This can cause protective tone or cramping in the hamstring and calf muscles.

Due to ligament laxity, the pelvis becomes loose in the front at the junction of the pubic bones and in the back at the sacroiliac joints. If the muscles in the area are not strong enough to support the increasing weight and anterior tilt of the pelvis, these joints will be strained. Hypermobile and locked joints are also possible. Pubic pain is localized. Sacroiliac pain is one sided but can cause pain to radiate to the buttock or the leg.

As the abdominal wall and uterus stretch, the inguinal and round ligaments may be strained causing low abdominal discomfort. Their attachment to the pelvic cavity can cause strain and arching of the low back.

A partial or complete separation of the rectus abdominus muscle can occur down the centre of the abdomen (linea alba) as a result of changes in hormones, increase in mechanical stress and weakness of the abdominal muscles pre-pregnancy.

The pelvic floor muscles and fascia are like a sling which support the pelvic organs. These tissues connect to the sacroiliac ligaments and muscles in the hips. As the pressure and weight of the growing uterus increases, stress from the pelvic floor can be referred to the sacroiliac ligaments and hip joints. Organ prolapse and incontinence can also occur if the pelvic floor muscles are too weak to support the pelvic organs.

Pregnancy and the role of Physiotherapy

Physiotherapists are primary health care practitioners and are able to assess and treat your musculoskeletal needs when you are pregnant. They may teach a combination of stretch and strengthening exercises, use postural re-education and manual therapy techniques and assist with pain control. A physiotherapist is an important part of pre and post natal health.

About Shoulder Tendonitis

What Anatomical Structures are affected?

The rotator cuff is made up of four muscles and their attaching tendons. A tendon is a band of fibrous tissue which connects muscle to bone. The shoulder tendons of the rotator cuff, along with the biceps tendon help to keep the shoulder joint in place.

What is it?

Shoulder tendonitis is an inflammation of the tendons in the shoulder region and may lead to weakening and tearing of these tendons. This can result in pain, tenderness, and weakness in the shoulder.

What causes it?

-repetitive movements
-sports injury
-trauma
-repetitive overhead activity (i.e. from work activities or sports such as tennis, baseball, swimming)

What are the Risk Factors?

-Age (40+)
-Involvement in repetitive overhead work or sports
-Trauma to the shoulder (i.e. fall on an outstretched hand)
-Diseases which may weaken shoulder muscles – gout, psoriasis, or rheumatoid arthritis

What treatment is recommended?

Treatment may include the following
-Rest
-Ice
-Physiotherapy which may include the use of modalities, range of motion exercises, theraband strengthening exercises, stretching exercises, postural education, manual therapy, activity modification
-Medications – anti-inflammatory medications

PHYSICAL THERAPISTS CAN HELP RELIEVE PAIN

The following is provided by apta.org and is a great reminder for everyone to seriously consider physical therapy to help them relieve their pain:

ALEXANDRIA, VA, December 27, 2006 — In light of proposed sterner warning labels for acetaminophen, aspirin, and ibuprofen by federal health officials, patients may wish to consider the benefits of physical therapist intervention for pain relief from certain conditions, according to the American Physical Therapy Association (APTA).

"Many people are looking for alternatives to the sole use of medication to deal with painful conditions," said APTA President R Scott Ward, PT, PhD. "Pain medication may help you get through periods of severe pain, but it won't always help you eliminate the underlying cause of some kinds of pain. For many individuals, it is the underlying causes such as poor posture and alignment, weak and/or inflexible muscles, or tight joint structures that actually exacerbate the painful condition," Ward explained. "A physical therapist will perform a complete musculoskeletal examination and design an individualized treatment program to reduce pain and improve function."

There are many types of pain and inflammation that can be reduced by physical therapist intervention. For example, chronic pain in the back, shoulder, or knee, or pain associated with certain degenerative diseases such as osteoarthritis, can be reduced with the appropriate combination of medication and exercise. "The physical therapist, in collaboration with the patient and the patient's physician, can help the patient manage his or her health over the long term," explained Ward.

For pain of a "mechanical" origin such as back, shoulder, or knee pain, physical therapist intervention may include therapeutic exercise, manual therapy, and functional training. "The goal of the physical therapist is to reduce pain, improve the ability to perform daily activities, and help the patient return to doing the things he or she likes to do," said Ward. "It is also true that patients may unknowingly contribute to their own pain, such as by exercising improperly or with poor posture, and physical therapists can identify and help to correct those behaviors." Ward added, "Through the use of home programs designed to fit the patient's needs, the physical therapist can efficiently progress the patient's rehabilitation and teach the patient how to prevent a recurrence of the original condition."

For osteoarthritis, a degenerative disease of the cartilage and bone, physical therapist intervention may include exercises for strength, flexibility, range of motion, and the use of devices designed to rest or support the joint, such as orthotics or splints.

Physical therapists, who treat nearly 1 million people every day, work with individuals to prevent the loss of mobility before it occurs by developing fitness- and wellness-oriented programs for healthier and more active lifestyles. Many insurance policies also cover post-rehabilitation gym programs. "Most people who desire a fitness plan are not athletes," Ward explained. "They are ‘ordinary people' who exercise lightly to moderately. Many have a prior health condition, such as chronic low back pain, that can benefit greatly from physical therapist management focused on increasing muscle strength and endurance, restoring and improving range of motion in joints, increasing cardiovascular endurance, and decreasing muscle and joint pain." The physical therapist individualizes exercise programs based on functional limitations as a result of injury or illness.

For more information on physical therapy or to find a physical therapist near you, please visit www.apta.org/consumer.

The American Physical Therapy Association (www.apta.org) is a national professional organization representing more than 70,000 physical therapists, physical therapist assistants, and students. Its goal is to foster advancements in physical therapy practice, research, and education.

Shoulder Pain Poll

Myofascial Release

The Fascial System

The fascial system of the body is composed of connective tissue which travels through the body three dimentionally from the top of the head to the tip of the toes. The tissue binds, separates, connects and defends all other tissues in the body, including nerves, muscle, vessels, organs and bone. Since fascia permeates all regions of the body and is all interconnected, when it is injured and scars, the effects will be transferred throughout the system. Imagine the fascia in your body to be the equivalent of a full body panty hose. The tension in the body (or the pull on the panty hose) could cause pain to be felt by pain sensitive structures elsewhere in the body. For this reason, pain can often be experienced away from the site of the fascial trauma. This trauma could have been initiated by soft tissue or bony injury, repetitive strain, infection, surgical incision or any number of causes that would cause a disruption of the glide of the connective tissue. The fascial system is divided into superficial and deep layers. The deepest of these layers are horizontal thickenings of connective tissue which lie in the pelvis, above and below the lungs and at the base of the skull. Often all four of these diaphragms will become restricted when fascial adhesions occur in any other part of the body.

Unlike muscle, which responds to a relatively firm stretch, the fascia in your body gives way to a very small amount of pressure applied by a therapist's hands. Although it is estimated that fascia has a tensile strength of as much as 2000 pounds per square inch, it will soften and begin to release when a very gentle pressure is sustained over time.

Muscle provides the greatest bulk of our body's soft tissue. Because all muscle ("myo" means "muscle")is enveloped by fascia, myofascial release is a term that has been given to the techniques used to relieve soft tissue from the abnormal grip of tight fascia.

What to expect during a Myofascial Release treatment

Your therapist has been instructed in either indirect or direct fascial release techniques and has a thorough understanding of the fascial system in the body. The type of fascial release technique chosen will depend on where they find the restriction of the fascia in your body. With skilled and sensitive hands, your therapist will apply a three dimentional fulcrum and hold a gentle stretch to allow the tissue to release. You may notice subtle movements or full limb unwinding. There may be a perceived warmth, pulsing, tingling or tissue change in the area the therapist is working or in areas that seem unrelated. You may not perceive anything at all during a treatment but your therapists skilled hands will be able to detect areas of fascial restriction and the associated changes that occur with a release.

Myofascial release is a gentle technique but can have profound effects on the body's tissues. You may not perceive any change after your first session but later that day or even a day later you may begin to feel the effects of the treatment.

Occasionally after a treatment, there is an increase in discomfort for several hours, followed by remarkable improvement. This improvement can be noted during or immediately following a treatment. Sometimes, new pain may be noticed in an area that previously did not seem affected. Sometimes there is a short lived feeling of nausea or light headedness. A temporary emotional change may also be noticed. All of these reactions are normal. The fascial system is changing and adjusting to it's new range of mobility.

It is recommended that after a session you drink a lot of fluids to "flush your system". It is felt that after the release of tight tissue there is also a release of trapped metabolic waste products into the surrounding tissue and blood stream. Drinking fluids will limit the feelings of nausea, achiness and light-headedness after receiving myofascial release treatments.

Osteoarthritis

Osteoarthritis is the most common form of arthritis and is also known as degenerative joint disease or spondylosis. This condition, which occurs later in life, is a progressive disorder of the joints of the body, specifically the cartilage, which is located at the ends of bones. Over time, the cartilage may wear down and consequently lead to pain and inflammation. The most common areas affected are the hands, hips, knees and spine. Other symptoms may include stiffness, swelling, loss of range of motion, muscle weakness, joint instability, deformities and inflexibility.

Physiotherapy has been shown to help manage these symptoms. Specific stretching and strengthening exercises can help to increase flexibility, decrease pain, improve mobility, increase quality of life and reduce the risk of injuries. Stretching muscles that have shortened and strengthening muscles that have weakened will decrease the load on the joints affected, and therefore making osteoarthritis more manageable. Contact a physiotherapist for more information and to begin a specific treatment program catered towards your symptoms and goals.