In the corner of my clinic there is a small whiteboard where we write the date and some timely messages to our patients. More recently my colleagues and I have been writing inspirational quotes on the board, and our patients have really enjoyed reading the quotes. Some of the recent quotes have been:
- "Don't quit. Suffer now and live the rest of your life as a champion." Muhammad Ali
- "To give anything less than your best is to sacrifice the gift." Steve Prefontaine
Each day we try to add a different quote, and our patients are starting to look forward to a new inspiration when they come to physical therapy. The problem is we are pretty busy each day, and we don't always have time to brainstorm or search the internet to come up with good motivational quotes.
We need your help. Do you have an inspirational quote that helps you through tough times? Are you a patient in physical therapy who finds motivation and inspiration in a special quote? Are you a PT who knows a few good quotes that can help your patients through the tough times?
Please comment below and share your favorite inspirational quote that I might use on the whiteboard in the clinic. Your motivational quote today me become someone's inspiration tomorrow in the PT clinic.
Related: Stay Motivated in Physical Therapy
Achilles' tendinopathy is a common problem among runners. It causes pain in the back of your lower leg just above the heel. Often the pain is accompanied by a small lump of tissue that can be felt in the tendon.
Notice that I called the problem tendinopathy and not tendinitis. You see, tendinitis translates into "inflammation of the tendon." Many histological studies find that no inflammatory cells are present in the Achilles' tendon with chronic tendinitis. So the name tendinopathy has been adopted to more accurately reflect the condition.
Regardless of what you call it, Achilles tendinopathy can be a big pain, and it can keep you from running or participating in normal recreational activities.
So what do you do to treat Achilles' tendinopathy? Try the Alfredson protocol.
The Alfredson protocol involves performing two exercises, the eccentric heel drop and the eccentric heel drop with knees slightly bent. Here's the kicker: the protocol calls for performing the exercises for 3 sets of 15 reps, twice daily. For each exercise.
So that means to treat your Achilles' tendinopathy you should perform about 180 eccentric heel drops each day. Recent reserach published in the Journal of Orthopaedic and Sports Physical Therapy indicates that performing the exercises with a "do as much as tolerated" modification to the protocol yielded the same results as performing the 180 rep Alfredson Protocol. So the choice is yours.
Do you have Achilles' tendinopathy? If so, check in with your doctor or PT, and then start some eccentric heel drops via the Alfredson protocol. Let us know how it works out for you!
- Read more and do it right: The Alfredson Protocol for Achilles Tendinopathy
Source: Stevens, M. and Tan, C. (2014) Effectiveness of the alfredson protocol compared with a lower repetition-volume protocol for midportion achilles tendinopathy: a randomized controlled trial. JOSPT 44(2) 59-67.
When I was a hockey player in college I suffered a shoulder injury when I got check into the boards. My shoulder hurt for a week or so, and then I was back to normal.
Or so I thought.
After I graduated college and started getting a bit older, my shoulder would often feel loose and unstable. It would sometimes pop out of place when I reached for something. When I was in physical therapy school, we learned about shoulder special tests, and I found that I had a positive apprehension and relocation sign. A visit to an orthopedist and an MRI later, it was confirmed: I had a torn labrum.
I elected to have surgery to fix the problem, so I had an arthroscopic repair of my labrum. I went through PT, and things have been going well with my shoulder. I have had 100% function with my shoulder for ten years now.
But one thing remains: my sulcus sign.
The sulcus sign is a sign of a loose shoulder joint. To find out if you may have shoulder instability, you can perform the sulcus test. Here's how:
- Sit or stand comfortably.
- Bend your elbow and have a friend gently but firmly grasp your arm just above your elbow and give a little pull down.
- If a small notch appears in the area where your arm meets your body, you have a positive sulcus sign.
Now don't worry if you have it and don't have shoulder pain or loss of function. But if you have a feeling like your shoulder is loose, have pain in your shoulder, and have a positive sulcus sign, perhaps it is a good idea to visit your local PT or doctor to get it checked out.
I recently posted a blog about my patient who was facing a painful lumbar fusion surgery because he had low back pain and sciatica for about two weeks that was limiting all of his motion. He was unable to sit or stand without terrible pain down his leg.
At his first physical therapy session, I found that he was able to centralize his symptoms to his low back with a simple exercise and postural correction, and 5 days after his first appointment his right leg pain had significantly improved.
More recently, I saw this patient in the clinic, and he reported that his right leg pain was virtually gone. He did have one episode of his leg pain, and it came on at a very inopportune time.
My patient was preparing to give a presentation at work, and he was making final preparations. Just before he was set to go into the presentation, his right leg started hurting. He learned that whenever he feels the pain in his leg, he could do his press up exercises to centralize his symptoms and he would be fine.
So when his leg started hurting before his presentation, he needed to find a place to lie down on his stomach and do some press ups. The only acceptable location: the restroom. Ugh.
My patient reports that he went to the men's room and set some paper towels on the floor about where his knees, hips, and hands would contact the floor. He started cranking out some press ups to centralize his pain, and he reports he was able to go into his presentation pain free soon after the bathroom press ups. We shared a laugh as we talked about the implications about exercising in the men's room. What if someone walked in? What about the hygiene aspects of what he had done?
We laughed as he said it didn't matter that he was exercising on the restroom floor. He needed to take care of his condition quickly so he could do his presentation, and the restroom was the only suitable location.
Perfect. My patient was armed with the right exercise to rapidly take care of his condition so he could do the things he needed to do. Fancy machines like inversion tables or traction wouldn't be effective in this situation. He needed rapid relief, and he got it with his PT exercise.
His story reminds me of a story told by Robin McKenzie in his book Treat Your Own Back. This story was also told to me at many of my classes that I took during my training in the McKenzie Method. It goes something like this:
McKenzie and his wife were traveling on vacation one day, and as they were driving they came upon a car on the side of the road. This happened long before Robin became known in the PT world as a spine guru. He pulled his car over to the side of the road to offer assistance, and when he came around to the front of the car, a man was on the ground performing press ups.
McKenzie knew it must have been a patient of his, and he inquired about the man's well-being. The man told McKenzie that he was just doing his exercises as instructed.
"Just checking." said McKenzie, and then he casually walked back to his car and drove off.
The point of the story is that the man doing exercises in the road found the right maneuver to manage his pain. He felt the need to do the exercise to manage his pain no matter where he was. Just like my patient performing press ups with the paper towels under his hands in the restroom.
One important component of a physical therapy program is to learn what you should do (and shouldn't do) whenever you have a painful condition like back pain or sciatica. Your PT should be able to teach you simple solutions that you can apply whenever you are hurting to help you rapidly improve your condition and help you return to your previous level of function quickly and safely.
Even if it involves performing press ups in the restroom.
I had a patient a few weeks ago who was suffering from low back pain and severe sciatica. His symptoms were so severe for two weeks that his doctor recommended he have a lumbar fusion surgery to correct his problem.
My patient was desperate to try something conservative first, so he asked the doctor if he could attend physical therapy. He landed on my schedule and we met one morning. His pain was so severe that he could not work his office job, he could not sit or stand for any length of time, and driving was out of the question-his wife had to drive him to his appointment.
When he arrived in my clinic, he was unable to sit long enough to fill out some papers about his condition and his medical history. He bypassed the waiting room and came directly into the clinic to lie down while his wife filled out his paperwork.
I started chatting with my patient about his medical history and how the past few weeks had been. Turns out he was shoveling snow and awoke the next morning with severe low back pain. Soon after, the pain started traveling down his right leg to his shin. He told me his doctor ordered an MRI and he was sent to the surgeon and lumbar surgery was recommended, but he wanted to give PT a try before going under the knife.
I asked my patient some specific questions about the nature of his condition, what makes his pain change, and I asked some questions to rule out sinister lesions like cauda equina syndrome or possible infection. All clear.
I did a quick neurological screen on my patient, and noted decreased reflexes in one patella. His strength was good in his legs. I quickly checked his lumbar range of motion-he couldn't stand too long-and noted severe loss of lumbar flexion and extension, with all motions increasing pain in his leg.
I then had my patient lie on his stomach and relax. He reported his leg pain was much better lying like this. I asked him to prop onto his elbows to progress his motion into lumbar extension. My patient reported central low back pain and no leg symptoms. After a few minutes of my patient lying slightly propped up, I asked him to perform some gentle press ups.
As he pressed up, his pain continued to centralize, and his right leg pain was gone quite rapidly. After about 10 or 15 reps of the press ups, I asked my patient to stand, and he did. His leg pain remained better for a few minutes, but then started coming back. My patient reported that the intensity was less, and it seemed to take longer for the leg pain to appear when standing.
So my patient was able to centralize his symptoms, which is a good sign that his sciatica is mechanical in nature and he may be able to rapidly reverse his painful condition. This guy was facing a pretty painful and risky surgery to fuse his back, and he showed me in a few minutes that he may be able to achieve rapid relief of his sciatica with a simple exercise and postural correction.
He was sent home with press ups and prone lying as an exercise program, and he returned to the clinic the next day with full control of his symptoms. He still felt leg pain with standing and sitting, but the symptoms were much less and would centralize whenever he did his exercise.
Three days later, my patient returned with virtually no leg pain. He reported occasionally his pain would arise, but he would do his press ups and the pain would quickly go away. No need for surgery. His range of motion improved as his symptoms improved, and it looked like he may be able to avoid surgery.
Now I know that physical therapists don't prevent everyone from needing surgery. Sometimes patients do not centralize their symptoms no matter what is done, and the pain remains. Sometimes the damage to the spine is too great and surgery is absolutely necessary to decompress the sciatic nerve. But a visit to a physical therapist (especially one trained in the McKenzie Method) is a good first step in your care before considering surgery, especially if there is no emergent reason to rush to the operating room.
I recently evaluated and treated a patient with chronic neck pain. And when I say chronic, I mean chronic. She had been dealing with neck pain for many years, and has managed it quite well with multiple episodes of physical therapy and chiropractic care.
More recently, her pain has worsened and she has started feeling arm pain. As we talked, she described the nature of her pain and how it has been changing. We talked about activities that make her pain better or worse and if she experienced disrupted sleep as a result of her pain.
Whenever I meet a patient, I ask about previous treatments and exercises that the patient has experienced. What worked? What exercises have been tried? Has posture been addressed? Is the patient currently performing exercises for neck pain, and what effect do the exercises have on my patient's pain?
As we talked, my patient told me about a PT clinic that she had been going to for quite some time. She states that this particular clinic specialized in many manual techniques, and often the physical therapist would perform manual techniques on her feet. The PT explained that poor foot mechanics and position would throw things out of alignment and may possibly be a cause of her neck pain and subsequent arm pain.
Now, I'm no genius. Really. But when a patient comes to me with neck pain, I typically focus on the patient's neck. Sure, other parts of the body and other nearby joints may be contributing to decreased mobility in the neck, but the feet are pretty far away from the neck to be considered a primary cause of my patient's pain. Can foot position change the way you stand and alter your posture? Sure. But foot position should not be the primary thing your PT addresses session after session to help improve your neck condition.
It gets better. As I was working with my patient and focusing on self-care strategies to help manage her arm and neck pain, I asked why my patient no longer seeks care at the previous PT clinic.
She told me that after spending weeks working on her feet, her PT started focusing on my patient's teeth. (Yes, I said teeth.)
Apparently my patient had some dental work done, and the PT was convinced that muscle imbalances in her mouth and jaw were a cause of her neck pain. Focus shifted from the feet to performing manual techniques in the patient's mouth.
There is evidence of a relationship between neck posture and jaw position. But a chronic neck condition with recent onset of arm pain is not likely to be related to dental work. My patient stated that after the intra-oral treatment was done for a couple sessions, she jumped ship and started seeking out a different PT, and she landed in my clinic.
(I didn't assess her jaw or feet. I focused on her neck range of motion and how her neck motion affected her left arm pain.)
If you visit a PT, chiropractor, or other healthcare professional, how do you know that the treatment you receive is appropriate? You don't, but if you get a sense that something is way off, perhaps you should question the treatment you are getting. In general, the mantra in PT is to focus on the main problem area, and check the joint above and the joint below for dysfunction that may be contributing factors.
If you have low back pain, you may benefit from PT to help you manage your pain and improve your mobility. But what if you attempt PT but continue with pain and require surgery? Should you visit a physical therapist after surgery for rehab?
A recent study indicates that physical therapy after a microdiscectomy (a common surgery for low back pain and sciatica due to a herniated disc) is linked to better outcomes. The study, published online in the journal Clinical Rehabilitation, examines the effect of 12 weeks of intensive exercise and education when compared to education alone for patients who have had a lumbar microdiscectomy.
Ninety-eight patients who had undergone a single level lumbar discectomy were randomized into one of two groups: the education only group or the education and intensive exercise group. The exercises focused on improving strength and endurance of the lumbar extensor muscles, mat exercises, and upright exercises.
The main outcome measure in the study was the Short Form 36 (SF-36), a questionnaire used to determine quality of life for patients with low back pain. The SF-36 was administered at 4-6 weeks after surgery and after 12 weeks of intervention.
The results indicate the SF-36 scores were significantly improved for patients in the exercise and education group as compared to the education only group. The researchers concluded that intensive exercise and education improves quality of life in patients who have had a lumbar microdiscectomy.
If you have had low back surgery, perhaps you should talk to your doctor about visiting a physical therapist. Your PT can provide you with education about your back and can prescribe you the correct exercises, and low back exercise progression, to help you get back to your normal activities quickly and safely.
I often have patients who come to me with low back pain or sciatica who have had an MRI, and sometimes these patients bring their MRI disc with them to PT. They want me to have a look, and I usually put the disc in the computer and check out the pictures. I then take a look with the patient and try to explain different things that I see in the MRI pictures.
Often, I see a host of problems on MRI pictures of the spine; bulging disc at L2 and L3, foraminal stenosis at L4 with a disc bulge, and perhaps some darkening of the disc at L5, indicating degeneration of that disc.
After looking at the MRI, I then proceed to perform my physical therapy evaluation and clinical examination as if I had not seen the MRI. You see, an MRI picture or report is great for showing where things are. An MRI never tells me how those structures behave under stress or loading. An MRI never tells me how your pain changes while moving.
When I evaluate a patient, I perform a mechanical assessment that includes specific loading strategies designed to evaluate how a person's symptoms change under those specific loads. What effect does flexing your spine have on your pain? What does extension of your spine do? What about bending sideways? Do any of these specific motions change your symptoms? Do any of these motions change your range of motion or strength.
It's true, MRI pictures have value. They certainly can help rule in or rule out sinister lesions like tumors or fractures. But often, MRI pictures just show multiple problems that may not be specific to your condition. That's where a focused, clinical examination utilizing specific mechanical loading strategies comes in.
Sure, I'll look at your MRI. And then, let's get moving so we can sort everything out.
If you read my blogs and articles, then you know how I feel about maintaining proper posture if you have low back or neck pain. It is so important to make sure the everything is in correct alignment as things are healing after an injury.
Maintaining proper posture while sitting is pretty simple. Slide your hips to the back of your chair, and then place a lumbar roll behind your back at about the level of your belt. Sit up nice and tall and allow the lumbar roll to support your low back. This should also help put your neck in the proper place over your shoulders.
But what about keeping good posture while sleeping? How can you support your neck as you are sleeping?
To keep proper support of your neck as you sleep, use a cervical roll. A cervical roll is a small pillow that fits inside your pillow case and helps to keep your neck in the correct position while you sleep. You can get one on the internet at OPTP for about $20 (US).
To use your cervical roll, simply slide your it into your pillow case and make sure it supports your neck when you lie down. If you roll onto your side, the roll helps to fill the space between your head and shoulder to support your neck.
Neck pain can be a real nuisance, and it can disturb your normal sleep routine. Using a cervical roll can help you keep your neck in the correct position while you sleep.
- Related: Make Your Own Cervical Roll
One of the more frequent questions I get from patients is about what to do first when pain strikes. An important part of any physical therapy program is to make sure you are equipped with the tools necessary to help you stay healthy and the knowledge of what to do when pain first strikes.