Physical Therapy

After total knee replacement (TKR) surgery, many patients suffer from weakness in the quadriceps muscle group. This muscle, located on the top of the thigh, helps to straighten the knee. Weakness in the quadriceps can last for years after TKR and can limit normal functional mobility which may lead to increased disability.

A recent study published in the February issue of Physical Therapy Journal investigated the effects that using neuromuscular electrical stimulation (NMES) had on muscular function after total knee replacement surgery. This form of electrical stimulation is often used to help improve the contraction of muscle groups that may be inhibited after the surgery. As an adjunct to active rehabilitation, NMES may provide benefits of improved muscle contraction, and therefore, improved function.

The study involved a total of 66 patients aged 55 to 85 years who were planning to undergo a TKR surgery. The patients were randomized into one of two groups; the control group would receive standard post-operative rehabilitation, and the experimental would receive standard rehabilitation along with NEMS twice daily, starting 48 hours after surgery. Outcomes measures were muscle strength, function, and self-reported measures and were obtained before surgery and at regular intervals after surgery, up to 52 weeks.

The results of the study indicate that the group using the NMES twice a day showed significant improvements in muscle strength, function, and self-reported measures. At 52 weeks post-op, the gains were not as great, but still significant as compared to the group that received no NMES.

If you have knee osteoarthritis and are having a difficult time functioning, physical therapy may help improve the range of motion and strength around your knee. If you do need a TKR operation, ask your doctor or physical therapist if early use of NMES after surgery is a good choice for you to help improve muscle activation of the quadriceps.

Quick Links:

• Physical Therapy for Knee Pain
• Exercises for Knees

This past week, you may have noticed that your physical therapist was not in the clinic as usual. That's because he or she may have been attending the Combined Sections Meeting (CSM) of the American Physical Therapy Association (APTA). This year the meeting was held from February 8th through the 11th and took place in Chicago, Illinois.

The APTA special-interest sections give physical therapists the opportunity to stay current with specialty topics. Currently there are 18 sections in the APTA. You can find more about specific sections at the APTA's website.

The CSM is an opportunity for all members of all sections to gather and share ideas or network. An exhibit hall also features vendors with many new products that your physical therapist may find useful in his or her practice. Educational programming is offered at the CSM as well.

If your physical therapist has been out of the clinic over the past few days, be sure to ask if he or she was at this year's CSM!

One of the most rewarding aspects about being a physical therapist is the opportunity to meet a lot of people. I enjoy helping my patients move and feel better, and I love chewing the fat with them to learn about what makes them tick. Most people are pretty fine folks who often share funny stories or witty quips. Here is a recent encounter that I had:

Last night in the clinic, I was meeting with a new patient who had low back pain. While talking with him, he noted several times that he feels his poor posture is playing a role in his pain and he wishes he could learn to change his posture.

During the evaluation, I assessed his posture and, sure enough, it was pretty bad. I took a few minutes to teach him how to attain and maintain proper posture.

As I guided his low back into the proper posture, I gave him the instruction to sit up tall, like a soldier. I then asked him if he had ever been in the armed services.

"Yeah," he replied. "I was in the army."

"Oh. Thank you for your service," I said. "Didn't they teach you how to stand and sit with good posture in basic training?"

"Of course," he said.

I asked, "Well then what happened to make your posture so bad now?"

He looked at me with a slight smile. "When I got to Vietnam, they told me to crouch down."

So Punxsutawney Phil poked his head out of Gobbler's Knob early this morning and saw his shadow. The groundhog from central Pennsylvania has confirmed that there will officially be six more weeks of winter.

Of course, winter means snow and ice, so be careful while out walking on the sidewalks, as slippery walkways could lead to FOOSH injuries and upper extremity fractures. (FOOSH stands for fall on outstretched hand.)

A confirmed six weeks more of winter also means that skiing and snowboarding shall continue. If you haven't done so, try to perform your ski and snowboard prep exercises to be sure you maximize fitness and minimize injury on the slopes.

This past summer, my mother-in-law fell off the back of a moving truck while my wife and I were packing up our house to relocate. She suffered a FOOSH injury and ended up in the emergency room with a broken wrist and a pretty good sized laceration in her head. So what is a FOOSH injury?

FOOSH is an acronym occasionally used in physical therapy clinics. FOOSH stands for fall on out stretched hand. It is used to describe the mechanism of injury that may cause common upper extremity injuries like wrist and shoulder strains or arm fractures.

In my clinic we use the term FOOSH whenever someone has suffered a fall and their arm and requires physical therapy to help manage the injury. FOOSH is a lot quicker to use when speaking, its meaning is readily understood, and it surely is a lot more fun to say.

Learn More:

• Common Upper Extremity Fractures
• Physical Therapy after Elbow Fracture

If you have attended physical therapy, then you may have been poked, prodded, and measured. Your physical therapist usually starts a plan of care with an initial evaluation. During the evaluation, information about your condition is collected. Your physical therapist may measure your strength or measure your range of motion with a goniometer.

Collecting baseline data is important, as it can help your physical therapist determine the cause of the problem. Baseline measurements can also help your physical therapist decide if the treatment and intervention provided is effective.

Every Sunday morning, I see really big advertisements in the newspaper for a revolutionary new product to help treat low back pain. Non-surgical spinal decompression promises to help eliminate low back pain or sciatica and improve your function and quality of life. The trade name for many of these decompression units are the VAX-D, the DRX 9000, or the SpinalAid system. (Fancy, space age sounding names, right?) But does spinal decompression really work?

While researching the answer to the question, I came across many different websites for spinal decompression units. Some of the websites were run by doctors, physical therapists, or chiropractors. My favorite website was for the VAX-D system. I liked it because the site listed many different published studies that prove how effective the VAX-D is. It made my search for scholarly studies a lot easier.

One of the studies listed on the VAX-D site was "published" in the Journal of Orthopedic and Sports Physical Therapy (JOSPT). Great! I have access to that journal, and I can easily find the study to evaluate the power of the study and decide if the VAX-D system is really as great as the VAX-D folks say it is.

One problem: I couldn't find the study in the JOSPT. The study was not listed in the table of contents in the JOSPT edition that was cited in the study. As a member in good standing with the American Physical Therapy Association (APTA) and a member of the Orthopedic Section, I should be able to find this study.

I contacted the JOSPT via email about my inability to locate the study that the VAX-D website listed. I got a response quite quickly from Edith Holmes, Executive Director/Publisher of the JOSPT. She noted that the citation in question was listed as a poster presentation at the 2005 Combined Sections Meeting (CSM) of the APTA. These lists are usually tucked in the back of the JOSPT during the month of the CSM. She went on to write, "The abstracts are presented here as prepared by the authors. (her bolding) The accuracy and content of each abstract remain the responsibility of the authors."

I responded to her with gratitude, and asked if those abstracts presented at the CSM were peer reviewed. She responded, "JOSPT does not peer-review these abstracts." (Peer review is important. It pretty much says, "Hey, this is a well-designed study and the results should be considered highly when making clinical decisions.")

Oh. So the study listed on the VAX-D is not peer reviewed. But the abstract is published. In the very back of the journal. Gotcha.

So back to the original question: Does spinal decompression really work as it says it does? The data available is from poorly designed studies that are very weak. Some of the studies, although "published," are not even peer reviewed.

Spinal decompression is a form of lumbar traction, and lumbar traction received a grade of "C" (no benefit demonstrated) in a (peer reviewed) study published in the October 2001 issue of Physical Therapy Journal. Spinal decompression may work, but we really can't prove it works. Plus, many insurance companies don't provide coverage for spinal decompression, so the out of pocket expense may be great.

Proven treatments for low back pain include advice to remain active, exercise, and maintain good posture. Your physical therapist can help you decide which exercises to perform to help you recover quickly from your episode of low back pain.

Have you used spinal decompression to help treat your low back pain? If so, please share your story and let us know how things turned out.

Winter weather here in the northeast US brings snow and ice on the roads and sidewalks. One common injury often seen in physical therapy clinics is a Colles' fracture. This common wrist fracture occurs if you fall onto your outstretched arm. The force of the fall causes the distal end of the radius to break and become displaced, leading to severe pain and swelling.

Physical therapy after a Colles' fracture involves improving range of motion and strength of the wrist, elbow and hand. Pain and swelling management may also be a part of your physical therapy program for a Colles' fracture. If you required surgery to repair your wrist fracture, scar tissue massage and mobilization may also be indicated to help restore normal mobilty.

Quick Links:

• Colles' Fracture Evil Twin: Smith's Fracture

I am often asked in the clinic if inversion tables really work for people with low back pain (LBP). Many of my patients have seen advertisements on TV or on the internet that promise pain relief and functional improvement with the use of inversion tables. But do inversion tables really help low back pain?

While doing some research into the benefits and risks of inversion therapy, also known as gravitational traction, I came across a study by Tekeoglu, et al. The study measured the amount of traction that was achieved by using inversion tables. Thirty people with low back pain were put on an inversion table and x-rays were used to measure the amount of separation of the lumbar vertebrae that occurred. A group of 30 people with no LBP were also measured.

The results indicate that both the LBP group and the no-LBP group showed distraction of the spinal bones during gravitational traction. Therefore, gravitational traction may be effective in separating the lumbar vertebrae.

Sounds great, right? But wait...does inversion traction help low back pain? While researching, I came across a website that cited the study by Tekeoglu. This website concluded that gravitational traction is effective for low back pain. Hmm. Wait a minute. The real study said that the inversion provided traction, not relief from LBP. And many high quality studies have shown that traction is not very effective in the treatment of LBP.

When choosing the treatment or modality you use to treat low back pain (or any other medical condition) you must be careful about evaluating the research. Sometimes the conclusions drawn by one group may be different than the conclusions published by the actual researchers.

The risks of inversion tables (changes in heart rate, blood pressure and eye pressure) might possibly outweigh the benefits of (maybe) reduced low back pain. Plus, inversion tables can be quite expensive.

A proven low cost treatment for LBP is postural correction and low back exercises. Your physical therapist can teach you how to care for your own back and prevent future problems with your condition.

Special thanks to my friend Debbie Colgrove, the Guide to Sewing at About.com, for asking me to investigate this topic for her.

Photo: Pricegrabber.com.

_{Source: Tekeoglu I, Adak B, et al. Distraction of lumbar vertebrae in gravitational traction. Spine, May 1998;23(9), pp1061-64}

Quick Links:

• Read more: Does an Inversion Table Help Low Back Pain?

Once again, another study has been published examining hip strength in females with patellofemoral pain (PFP). The study by Khayambashi, et al is published in the January 2012 issue of the Journal of Orthopedic and Sports Physical Therapy.

The researchers recruited 28 females with PFP and randomly assigned them to an exercise group or control group. The exercise group performed hip abductor and hip external rotator strengthening exercises 3 times per week for 8 weeks. The control group was instructed to take 1000 mg of Omega-3 and 400 mg of calcium as a placebo. Both groups were allowed to take pain medication or anti-inflammatory medication as needed.

Outcomes measures included pain, health status and hip strength. Assessments were made at baseline, at 8 weeks post-intervention, and at 6 months post-intervention.

The results indicate significant changes in pain, strength, and health status in the exercise group as compared to the control group after 8 weeks. The exercise group maintained gains at the 6 month follow up period. No person dropped out of the study, and no detrimental effects were reported in either group.

This study supports the growing body of evidence that hip strength, particularly the hip abductors and external rotators, plays a major role in PFP. It is thought that these muscle groups help stabilize the thigh bone and don't allow the thigh bone to rotate internally. Internal rotation of the thigh is thought to change the forces around the knee cap and cause the pain associated with PFP.

If you are having knee pain, a visit to your physical therapist may be in order to help determine the cause of the problem. While some focus should be placed on the knee, be sure that your PT checks out the strength of your hips. The evidence indicates that hip weakness could be the culprit.

Quick Links:

• Physical Therapy for PFP
• Physical Therapy for Iliotibial Band Syndrome
• Advanced Hip Strengthening