Headaches are one of the most common reasons that people see their primary care physician and they account for 20% of outpatient visits to neurologists.  Persons with chronic headaches report disabling symptoms that interfere with daily activities.  Many have sought numerous different treatment approaches, have accepted that their headaches are a fact of life and have become dependent on medications to relieve their symptoms.

The International Headache Society has classified hundreds of different types of headaches into two categories: primary headaches and secondary headaches.  Primary headaches are the most common headache type and have a single cause.  They include migraine, tension-type, cluster and others. Secondary headaches are classified according to their causes.  Examples of secondary headaches are headaches attributed to temporomandibular joint (TMJ) disorders and cervicogenic headaches, which are attributed to mechanical disorders of the neck.  Both are treated by various clinicians including osteopaths, dentists, chiropractors, massage therapists, and physical therapists.

Sources of headaches are often a combination of factors, including musculoskeletal, psychological, neurovascular, nutritional and chemical imbalances in the brain.  Some headaches relate to or are indicative of a disease process; some are life threatening and others benign.  Thus, a thorough medical evaluation is necessary with any onset of a new or ongoing headache.  Most researchers agree that there is a musculoskeletal component in tension-type, cervicogenic, and TMJ disorder related headaches.

A thorough physical therapy examination attempts to determine the type of headache and to define the neuromusculoskeletal factors contributing to it.  Muscle tension, joint dysfunction of the neck and jaw, poor posture and stress are factors that can be addressed and treated by a skilled physical therapist trained in manual therapy.

The muscles of the face, head, neck and may contain tight bands and contraction knots called myofascial trigger points.  Trigger points found in these muscles typically refer pain to the head, causing headaches.  Manual physical therapy addressing muscle tension involves the release of those trigger points, stretching the involved muscle and soft tissue, and restoring normal muscle function.  Trigger point release can be accomplished by manual techniques and dry-needling.  Dry-needling is a technique in which a thin acupuncture needle is used to deactivate the trigger points and proves to be highly effective.

Dysfunction in the spinal joints of the upper neck and of the TMJ can directly cause headaches or can trigger migraine or tension-type headaches.  Treatment of spine dysfunction may include mobilization/manipulation of the spine or jaw and the performance of stabilization exercises of the neck and shoulder girdle.  In the case of TMJ dysfunction, referral to a dentist may be indicated for splint therapy and other dental interventions.

Prolonged poor posture of the head, neck and shoulders leads to the overloading of muscles, which in turn results in the development of trigger points and altered mechanics of the spine and TMJ.  Physical therapy treatment may include education for postural correction and prescription of a postural strengthening program.  In cases where stress is a contributing factor — which it almost always is — treatment would include education with relaxation and breathing techniques.

If you are a headache sufferer and you are looking for a way to manage your headaches beyond using medication, talk to a manually trained physical therapist about possible conservative treatment options.

Kerri Walsh- 2008 Olympic Beach Volleyball

The exciting thing about the practice of manual therapy, is the ability to incorporate other treatment techniques to restore pain free movement.   If you watched the 2008 Olympics in Beijing China, chances are that you noticed the intricate patterns of taping that adorned some of the athletes, especially the volleyball players.  The taping technique used is unique, in that it allows one to remain active with a muscle injury.

The taping technique used is known as Kinesiotaping, and is used as an adjunct to treat injured muscles and joints by enhancing the body’s own natural healing process through the activation of its neurological and circulatory systems.  Unlike athletic taping where a joint is immobilized and activity limited, Kinesiotaping allows for freedom of movement during the healing phase, making it a very favorable intervention.

This taping method was developed in Japan 25years ago by Dr. Kenzo Kase.  The goal of Kinesiotaping is to support injured muscles, correct joint problems, improve circulation and activate the analgesic system of the body.  Next time you have a muscle injury that results in pain with activity, ask your therapist whether you can benefit from Kinesiotaping to reduce your pain and promote healing and restore function.  Remember, Kinesiotaping works.

Hasheem Thabeet- 2009 Junior UCONN Basketball

ALEXANDRIA, VA — A new review article published in the Journal of the American Academy of Orthopaedic Surgeons should help convince many patients with low back pain to consider physical therapy as a first line of treatment for their condition, according to the American Physical Therapy Association (APTA). The review, published in February 2009, recommends that in most cases of symptomatic lumbar degenerative disc disease, a common cause of low back pain (LBP), the most effective treatment is physical therapy combined with anti-inflammatory medications. Approximately 75 to 85 percent of adults will be affected by low back pain during their lifetimes.1

Symptomatic lumbar degenerative disc disease develops when a disc weakens (often due to repetitive strain), is injured, or deteriorates from aging. As a result, the disc is unable to hold the vertebrae as it should and the lack of stability can cause back pain.

The review details the different treatment methods for symptomatic lumbar degenerative disc disease, including physical therapy with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), and concludes that, in most patients with low back pain, symptoms resolve without surgical intervention. The review also concludes that physical therapy and nonsteroidal anti-inflammatory drugs are the “cornerstones” of non-surgical treatment.

Physical therapist intervention includes strengthening of core muscle groups, including the abdominal wall and lumbar musculature, which can have positive effects in patients with this condition. According to APTA spokesperson Julie Fritz, PT, PhD, ATC, clinical outcomes research scientist at Salt Lake City’s Intermountain Healthcare and associate professor at the University of Utah, physical therapists have several treatment options that can help patients with LBP whether due to degenerative disc disease or a variety of other causes.

Exercise and manual therapy including spinal manipulation, have been shown to benefit many patients.2, 3. In addition, patient education to remain active and use appropriate body mechanics is beneficial. Physical therapists are trained to identify which of these treatment strategies will be most effective for an individual patient, which further improves the effectiveness of care.

In previous systematic reviews of the literature, it was found that exercise has been shown to improve function and decrease pain in adult patients with chronic LBP and that physical therapy was beneficial for the treatment of acute LBP.2, 3 In another systematic review, NSAIDs were found to provide LBP patients with short-term symptomatic relief.4

“Receiving care from a licensed physical therapist can further improve the odds that a patient can maintain their quality of life and avoid surgery,” said Fritz. In addition to building the core muscle groups, hands-on therapy to mobilize the spine has been shown to be particularly effective. 5, 6  “Spinal manipulation can be an important component of physical therapist treatment for low back pain. Supplementing exercise with spinal manipulation is also beneficial for many patients.”

Physical therapists can help patients develop a safe and effective exercise program that is tailored to an individual’s specific needs and goals. “Surgery should be the last option, but too often patients think of surgery as a cure all and are eager to embark on it,” said Luke Madigan, MD, an attending physician at Knoxville Orthopaedic Clinic, Knoxville, TN, and the lead author of the literature review.

Physical therapists are highly-educated, licensed health care professionals who can help patients reduce pain and improve or restore mobility – in many cases without expensive surgery or the side effects of prescription medications. APTA represents more than 70,000 physical therapists, physical therapist assistants, and students of physical therapy nationwide. Its purpose is to improve the health and quality of life of individuals through the advancement of physical therapist practice. In most states, patients can make an appointment directly with a physical therapist, without a physician referral. Learn more about conditions physical therapists can treat and find a physical therapist in your area at www.moveforwardpt.com.

1Andersson GB: Epidemiological features of chronic low back pain. Lancet 1999; 354:581-585.

2Hayden JA, van Tulder MW, Malmivaara A, Koes BW: Exercise therapy for the treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3):CD000335.

3Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG: Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev. 2004;(1):CD000447.

4vanTulder MW, Scholten RJ, Koes BW, Deyo RA: Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane collaboration back review group Cochrane review. Spine 2000:25:2501-2513.

5Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Maikowski GR, Delitto A: A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004; 141(12):920-928.

6Chou R, Huffman LH: Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.; American Pain Society; American College of Physicians; Ann Intern Med. 2007; 147(7):492-504.

[Last updated: 02/23/09 | Contact: public-relations@apta.org]

As a matter of fact, a lot of patients who have had an injury still experience pain and stiffness with certain movements and activities even after completion of conventional physical therapy.   This limitation makes it difficult for patients to fully return to activities they were able to perform and enjoy before their injury.  The issue is that proper postural and movement patterns are not properly evaluated and addressed during the rehab phase, and this could be the final piece of the puzzle.  An important approach I would like to focus as an adjunct to other treatment interventions is PNF.

PNF stands for Proprioceptive Neuromuscular Facilitation. It originated in the late 40’s by Dr. Kabat and Maggie Knott to provide tools to help patients gain efficient motor function (Adler 1993).  A simpler translation of PNF is the use of sensory receptors in the skin to stimulate nerves and muscles, to allow for easier and more efficient movement patterns.  PNF is a specific treatment approach used to improve movement, coordination, stability, strength, endurance and overall function.  It can be used to treat any body part from the cervical spine to the foot.

Pain is an inhibitor of effective and coordinated muscle performance and it can be a sign of potential harm (Hislop 1960, Fisher 1967).  This is always addressed during every treatment session.  During a session, a patient assumes a position that allows for the most effective movement of a specific body part.  The therapist uses manual contact to initiate and facilitate a specific movement pattern. This treatment approach requires active patient participation and involvement making it functional.  It also allows for integrative manual therapy skills to be incorporated into the treatment session.  This approach requires one on one therapist attention since it is tapered to each individual patient.

After a couple of sessions, patients see a significant improvement with postural and movement patterns needed in everyday activities.  They also develop easier and less painful movement patterns, thus allowing them to return to activities they were doing before their injury pain free.  This makes PNF a highly cost effective and efficient tool in today’s medicine, where patients are looking for ways to decrease pain and improve function in fewer treatment sessions and with the best outcomes.

Reston, VA, January 26, 2009– Richard Deyo MD, the keynote speaker at the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) National Conference in October 2008, has again published data indicting the US approach to chronic back pain dramatically increases costs without improved outcomes. Deyo and colleagues reported in the January 2009 issue of the Journal of American Board of Family Practice the following staggering statistics:
·    A 629% increase in Medicare expenditures for epidural steroid injections;
·    A 423% increase in expenditures for opioids for back pain;
·    A 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries;
·    A 220% increase in spinal fusion surgery rates.
The incidence of chronic and acute Low Back Pain, as documented by office visits, has not changed during the last 12 years. The application of these technologies is not without consequences Deyo et al noted, ‘Innovation has often outpaced clinical science, leaving uncertainty about the efficacy and safety of many common treatments. Complications and even deaths related to pain management are increasing.’ Indeed, the reoperation rates for low back pain have increased, not improved. The authors conclude that the ‘Prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain.’  They note that these approaches often are applying an acute care model to chronic pain and not acknowledging the current evidence that chronic pain requires a different approach and that there are ‘no magic bullets.’  In a “chronic care model” chronic back pain, like diabetes or asthma, ‘is a condition we can treat but rarely cure.’ Deyo et al suggest the solution that  ‘chronic back pain may benefit from sustained commitment from health care providers; involvement of patients as partners in their care; education in self-care strategies; coordination of care; and involvement of community resources to promote exercise, provide social support, and facilitate a return to work.’
Tim Flynn, PT, PhD, president of the AAOMPT states, ‘The manual physical therapist is the health care provider uniquely trained to manage individuals with chronic low back pain.  We utilize low risk, state-of-the-art care incorporating exercise, manual physical therapy, patient education and the application of the biopsychosocial model in managing this chronic condition. The Academy is dedicated to the application of current models for chronic pain management.’ The recent AAOMPT conference in Seattle focused on current theories and practice of chronic pain management with international experts on pain management.

Tallahassee, Florida, October 20, 2008 – Neck pain is one of the top 10 reasons for a patient to visit a doctor. The lead article in the most recent issue Spine reports on the results of a randomized clinical trial which demonstrated that patients who received manual physical therapy and exercise had twice the improvement in symptoms compared to the current guideline group. The subjects in the study experienced both short and long term improvements in their neck pain. The study compared the use of manual therapy and exercise compared to the current guidelines of advice, rest, and range of motion. The results of this study are comparable to those reported by Hoving et al in 2002, which also demonstrated that manual physical therapy and exercise resulted in excellent clinical results in the treatment of neck pain while also providing a significant cost savings compared to usual physician care (Kothals-de Bos et al 2003). Manual physical therapy includes the use of hands-on techniques including joint and soft-tissue mobilization, designed to restore motion and reduce pain. Hurwitz et al (2008) concluded in a systematic review on neck pain also in the journal Spine, “Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain.”

Tim Flynn, PT, PhD, president of the American Academy of Orthopaedic Manual Physical Therapy, expressed confidence that, “This study broadens the base and depth of evidence that manual physical therapy is the first line treatment for patients suffering from neck and arm pain.” He continued, “Year after year the physical therapy profession continues to produce high quality randomized, controlled trials that demonstrate conclusively that our profession provides better outcomes for less money, while also being substantially safer than other medical interventions. Wake up America, to a new day without pain.” If you have neck or back pain or the aches and pains of musculoskeletal problems contact your local physical therapist today.

BENEFITS OF SPINAL SURGERY DISAPPEAR AFTER 6 MONTHS
Physical Therapy offers same outcomes for patients with sciatica 6 months after surgery!

Tallahassee, Florida, June 23, 2008 – A recent study published in the British Medical Journal1 reports that spinal surgery for patients with sciatica offers a short term benefit, but by 6 months that benefit disappears and no difference is seen between patients who had surgery and those receiving physical therapy.  The study suggests that the benefits of surgery are only short-term and conservative treatments such as physical therapy may offer the same outcome.
Sciatica often resolves quickly, but in some patients it persists.  Previous to this study, only limited evidence existed that could guide patients about when or if that resolution was going to occur.  In this study, patients had the option of opting for early surgery, or prolonged conservative management under the guidance of a physical therapist.  The surgical group showed improvement in symptoms for only a brief period following surgery.  But, by 6 months, and up to 2 years following surgery, the difference between the groups having surgery and those that didn’t disappeared.
“The significance of this study is that patients may be able to avoid surgery if they realized they can expect a similar improvement in symptoms if they use other ways to manage the pain for 6 months,” said Dr. Timothy Flynn of Regis University in Denver, CO, and President of the American Academy of Orthopedic Manual Physical Therapists (AAOMPT).  “Patients should be aware that surgery is not the only option to reduce the symptoms of sciatica.”
The study’s authors conclude that since the early benefits of surgery are gone by 6 months, when deciding to have surgery for sciatica, well informed patients, and not physicians, should decide if and when they opt for surgery.
The results of this study, coupled with the findings of another study published earlier this year suggest expensive treatments for low back pain may not be the best approach.   Less expensive conservative options like physical therapy may be the preferred choice for patients with low back pain.
“The best course of treatment for low back pain is to make sure it is addressed early and does not progress to leg pain, or become a chronic condition,” continued Flynn.  “Research has shown that early movement and treatments like exercise and spinal manipulation offer strong benefits to this group of patients.”
These treatments include hands-on physical therapy to mobilize the spine and exercises designed to alleviate low back pain.  Flynn suggests that patients seek out physical therapists as a first-line treatment for these conditions.