All posts in Clinical Case of the Week

https://www.facebook.com/mdtclinics/posts/10156206590002442

Last week, I had a patient come into the clinic with neck pain that had started the week before. He had been a patient in the past and knew that the sooner he got in for treatment, the better.

Terry had pain medial to his left shoulder blade. This pain was limiting him with sleeping and with driving, as left rotation caused pain. He was rating his pain a 4/10 at the time of the evaluation.

Evaluation and Assessment

Scapula connects Upper Arm with Collar Bone

During the evaluation, left and right rotation motions produced pain medial to the left scapula. Upon palpation, the musculature where the pain was produced was very tender, acting like trigger points. I chose not to treat the trigger points, as these things are likely secondary to the real problem: a derangement.

During the repeated movement assessment, I had Terry go through retraction, extension and flexion.  When we tested repeated left rotation, Terry’s pain decreased with repetition.  Terry was sent home performing repeated left rotation with over-pressure.  By his next visit, his pain was significantly decreased and the trigger points of the muscles had also decreased with pain when palpated.  I had Terry increase the frequency of which he was to perform the rotation exercise. By the next visit, Terry had abolition of all pain, no limitation with sleeping or driving and the trigger points were completely gone!

Getting to the Root of the Problem

The Mechanical Diagnosis and Therapy (MDT) Method is very effective at getting to the root of the problem. When the core issue is fixed, the secondary impairments almost always resolve on their own. If a clinician is always treating the symptoms and not the cause, this will lead to more visits, more time until recovery and more money from the patient. This is one of the fundamental reasons that we practice the MDT Method here at Nick Rinard Physical Therapy – to fix your core issues!

‘R.I.C.E.’ Coined in 1978

‘R.I.C.E.’ (rest, ice, compression, elevation) was coined in 1978 by Dr. Gabe Mirkin. Since then, ice has been the standard treatment for injuries and sore muscles. The RICE guidelines have been used for decades, but it now appears that ice and rest may delay healing.

Scientific Articles Don’t Support Ice for Healing

A study from The American Journal of Sports Medicine, June 2013 asked athletes to exercise intensely enough to develop muscle damage that caused extensive muscle soreness. It was found that icing delayed swelling, but did not quicken the healing process.  A summary of 22 scientific articles found little to no evidence supporting that ice and compression facilitate healing over compression alone.

Inflammation

Inflammation is required for healing. Inflammation is a part of our immune system and is essential in the healing process. Inflammatory cells migrate to the injured tissue to start the healing process. Macrophages (inflammatory cells) release a hormone into injured tissues, which helps muscles and other injured tissues heal.  Applying ice to reduce swelling can delay healing by preventing the body from releasing this hormone.

Icing can also prevent healing cells from entering the injured tissues by constricting blood-flow.  It can take hours for the blood vessels to return to their size. Icing can also decrease strength, speed, endurance and coordination.

General Tips for Using Ice

If you’re going to ice, only apply ice for 10-15 minutes at a time.  Utilize ice for the first day of injury.  Seek medical attention from a mechanical physical therapist if the pain is severe or you cannot actively move a body part.

A mistake that people often make is waiting too long to start physical therapy treatment for their aches and pains. This commonly occurs because you may be thinking, “this will go away on its own,” or, “it’s just normal for me to feel like this at my age.” I want to clear up some confusion on mechanical pain versus normal muscle soreness that does not require skilled therapy or treatment.

Muscular Pain:

• Experienced after a sudden increase in activity or exercise.
  • Running 6 miles when you typically only run 2 miles
  • You increased the intensity or length of time to your typical workout
• Will be experienced 1-2 days after the increased activity has been performed and will typically begin to dissipate or be gone in 3-5 days after onset.
• Is typically vague pain or experienced in a general area. The pain will not be sharp or pin-point to a specific area.
• If you’re educated on what muscles perform which actions, the sore muscles will correlate with what activity you were performing.
• Does not have increased or decreased pain associated with positions.

Mechanical Pain:

• May have a sudden onset without explanation of occurrence (you woke up with pain for no apparent reason).
• Will typically have a loss in range of motion. For example: it may be difficult to stand up straight in the morning or after prolonged sitting or driving.
• Will have positions that will increase or decrease symptoms. For example: pain increases with sitting, pain is better while lying down.

If you’re experiencing mechanical pain the sooner you seek physical therapy treatment, the better! A good Physical Therapist can determine which exercises will reduce your symptoms and get you back to doing the activities that you love!

A few months ago, I treated a young Portland area woman who was suffering from low back pain. “Beth” had been in a car accident 10 months prior to my evaluation.  She was rating her worst pain as a 9/10 and was moderately limited with walking, sitting, bending and lifting. Because of the pain associated with these activities, Beth was limited with her duties as a student nurse, and somewhat concerned with how her back condition will affect the rest of her life.  Beth had been to a chiropractor and to a different physical therapy clinic, neither of which proved to have any lasting benefits.

Beth’s objective findings included what mechanical therapists call a “Left Shift” in standing.  This means that her shoulders were not centered over her hips, but rather, off to the left side.  We know this as a relevant lateral component and is typically associated with a derangement (something out of alignment or out of place).   Beth also demonstrated limited, painful movements of the spine; primarily in the frontal plane.

The exercise to correct Beth’s shift and reduce her derangement was repeated right side glide in standing.  Beth was able to perform this exercise throughout her day to decrease her pain and by 3 weeks out, she was reporting little to no pain.  Beth was then able to begin core strengthening exercises, after her pain was gone, and get back to her duties as a nursing student.  At our last treatment visit, Beth told me that she was able to work multiple 12 hour shifts as a nurse without any pain!

If the physical therapy treatment you are receiving does not get feeling better within 1 or 2 weeks, find something that works!

Quick Answers Are Never a Guarantee

We live in a culture that seeks immediate results and quick answers to solutions. Most of the time, unfortunately, we also want what requires the least amount of effort on our part. In the medical community, this boils down to people deciding to have surgery to fix the problem. Unfortunately, surgery is never a guarantee. Time and time again I treat patients here at Nick Rinard Physical Therapy who were advised to have surgery and, after the procedure was performed, their pain remained. This happens because of both the general public and medical practitioners’ lack of understanding about how the body moves and heals. Recently, there was a man referred to our Portland airport (PDX) clinic by his friend for knee pain. He was scheduled to have knee surgery the next week, but wanted to have a second opinion. My colleague diagnosed him with a very simple problem: knee capsulosis, and he was reporting decreased pain and improved range of motion by his 2nd visit. He cancelled his surgery and is expected to have a great outcome with conservative care.

Regimented Exercise Can Decrease Knee Pain without Surgery

I recently came across a study that found simple regimented exercise routine focusing on quadriceps strengthening and cardiovascular endurance decreases knee pain associated with osteoarthritis. What a great concept: exercise can decrease pain and improve function and avoid surgery! The authors of the study concluded: “Optimal exercise programs for knee OA should have one aim and focus on improving aerobic capacity, quadriceps muscle strength, or lower extremity performance,” the authors concluded. “For best results, the program should be supervised and carried out three times a week. Such programs have a similar effect regardless of patient characteristics, including radiographic severity and baseline pain.”

Physical Inactivity is THE Major Public Health Problem of the 21st Century

I came across a quote that really resonates with these findings: “…most medical schools only allocate a perfunctory hour to the fact that physical activity is medicine. This is a major failing of medical education when physical inactivity is the major public health problem of the 21st century.”

Resources

Meta-analysis: Quadriceps exercise best reduces knee OA pain:
http://news.todayinpt.com/article/20140329/TODAYINPT04/140328005&SearchID=73533945353381?utm_content=sf25084815&utm_medium=spredfast&utm_source=facebook&utm_campaign=social2013&sf25084815=1
Accessed on May 1st, 2014
Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. K M Khan, A Scott. Br J Sports Med 2009;43:247-252