\Have you ever wondered what your physical therapist does when they aren’t working with you to help you feel and move better? Well, besides the necessary outdoor playtime that all of us thrive on, we work hard to stay fresh and up to date with the latest research and techniques to assist you to the fullest potential! The licensing regulatory board in the state of Colorado recently updated their requirements for continuing competency of physical therapists in order to make sure we are all on our “A-game” when it comes to treating patients.

Beginning in the renewal cycle from 2014-2016, PTs will be responsible for establishing learning goals, creating a learning plan, and then participating in professional development activities that will earn us points toward our requirement of 30 per renewal cycle. Professional development activities include such things as attending continuing education meetings, taking coursework towards a transitional Doctor of Physical Therapy degree (like Ellen just completed!), receiving a specialist certification such as the Board-Certified Orthopaedic Clinical Specialist designation that Ellen, Dave and soon I will have, attending a journal club or workplace in-service, and participating in a formal mentoring relationship (which Dave and I currently set aside one hour weekly to do). These are just a few examples of things that we are already doing here at Tomsic Physical Therapy to further our education and training. It just so happens that participation in these activities keeps us in good standing with the Colorado Department of Regulatory Agencies, as well.

The most important part of continuing competency requirements is being able to take the information and skills that we are learning and implement them into our current practice. That means that the most crucial part of our life-long learning is seeing you, the patient, so that we can make sure we are applying the most up-to-date evidence effectively.

Call us today to schedule an appointment with one of our physical therapists. We are committed to assisting you with your musculoskeletal pain and injuries, using the latest tools and techniques that we’ve gained through our continuing competency.

This time of year, the weather is just about right for running–not so hot that you feel you might faint on a steep uphill, and not so chilly that you need to don multiple layers that will inevitably be peeled off as you warm up. But, don’t take the ideal weather for granted. You still need to maintain proper conditioning and training techniques to ensure safety.

Whether you’re hitting the trails, the pavement or are already on a consistent training program, be sure to consider the amount of miles that you’re running and take care to ensure that your mileage increases are safe. You may have heard of the “10% rule”, which suggests that you do not want to exceed more than a 10 percent mileage increase per week in order to prevent injuries.1 At Tomsic Physical Therapy, we see knee and hip complaints often. Continue reading for some helpful information on why it is important to maintain a proper increase in running mileage.

A recent study in the Journal of Orthopaedics & Sports Physical Therapy sought to discern if there is a relationship between an elevation in injury risk and a sudden increase in weekly running mileage. The researchers also focused on specific activities, and how they influenced the rate of injury.2 Long-distance running and the injuries associated with it including patellofemoral pain, iliotibial (IT) band syndrome, medial tibial stress syndrome (shin splints), gluteus medius injury, greater trochanteric bursitis, tensor fascia latae injury, and patellar tendinopathy were also focus areas.

The study looked at 873 novice runners who tracked their self-guided runs over the course of year using a GPS system.2 Over that year, 202 of the runners had an injury involving their legs or back that was caused by running, leading to a restriction in the distance they were able to run for at least a week.2 After the types of injuries were divided into groups and the numbers were analyzed, the statistics showed that runners who progressed their weekly running distance by over 30 percent had increased vulnerability of a distance-related injury versus those who only increased their weekly running distance by less than 10 percent.2 Of note, this relationship did not exist for pace-related injuries, traumatic injuries, and other overuse injuries.

In summary, if you are embarking on a running schedule to train for a race or just to get a good workout while enjoying this season’s amazing weather, you will want to increase your weekly mileage by no more than 30 percent per week in order to decrease your risk of a distance-related injury.2 Just to be safe, it is prudent to refrain from increasing your weekly running distance by more than 10 percent.2 There are other effects of overtraining that you may experience by increasing too much and too fast, such as increased fatigue and pace associated with physiological changes.

For more information on this study, please visit the website here. If you have any other questions, or would like to speak to a physical therapist about what you can do to minimize your risks or to treat a running-related injury, please give us a call to schedule an appointment today.

1. Johnston CA, Taunton JE, Lloyd-Smith DR, McKenzie DC. Preventing running injuries. Practical approach for family doctors. Can Fam Physician. 2003;49:1101-1109.
2. Nielsen RO, Parner ET, Nohr EA, Sorensen H, Lind M, Rasmussen S. Excessive progression in weekly running distance and risk of running-related injuries: An association which varies according to type of injury. J Orthop Sports Phys Ther 2014;44(10):739-747.

It’s football season, which means that as the leaves begin to fall, Saturdays and Sundays are becoming filled with more time in front of the television to cheer on your favorite teams. Whether you or a family member are playing football recreationally, competitively, or simply just tossing the ball in the yard, the importance of injury prevention in this American pastime is undeniable. One tool that the NFL has implemented in their pre-season training to identify players who are more at risk for injury is called the Functional Movement ScreenTM, or FMSTM, which was created by physical therapist Gray Cook, MS, PT, OCS, CSCS.1, 2

So, how does the FMSTM work? The participant is put through a series of seven different activities and movements, including squatting, lunging, and flexibility and stability tests. As the participant performs the specified activities, they are graded on the overall quality of their motion as the rater looks for any asymmetries, poor mechanics, or compensatory movements. The purpose of the screening is to help identify any imbalances that the person may have that would indicate increased risk for injury.1 Research studies have determined score threshholds for this reliable screening that indicate increased injury risk, for which norms have been established based on the age and gender of the participant.2,3,4

For any recreational or team athlete, a qualified physical therapist has the tools needed for this assessment to take a good look at your movement during certain activities. Similar to what the NFL has employed, the FMS™ test can tell you if there are any obvious asymmetries or poor mechanics in your movement that could indicate areas where you are more prone to hurt yourself during your favorite activities. Even if you do not already have an injury, the information from this screen can be used for prevention purposes and help you figure out what steps you can take to avoid injury with the guidance of a physical therapist.

Call us today to set up an appointment and have the quality of your movements assessed by one of our well-qualified physical therapists. Through the FMS™ and other tools, we can detect your injury risk and identify ways for you to avoid hurting yourself, both on or off the field!

References:

1. Functional Movement Systems. https://www.functionalmovement.com. Updated 2014. Accessed on October 4, 2014.
2. Kiesel K, Plisky PJ, Voight ML. Can serious injury in professional football be predicted by a preseason functional movement screen? North Amer Journal of Sports Phys Ther. 2007; 2(3): 147-158.
3. Schneiders AG, Davidsson A, Horman E, Sullivan SJ. Functional Movement ScreenTM Normative Values in a Young, Active Population. The Intl Journ of Sports Phys Ther. 2011; 6(2): 75-82.
4. Teyhen DS, Shaffer SW, Lorenson CL, Halfpap JP, Donofry DF, Walker MJ, Dugan JL, Childs JD. The Functional Movement Screen: A Reliability Study. J Orthop Phys Ther. 2012; 42(6): 530-540.

Clinical Question: For patients with low back pain, is using the principle of Directional Preference through the McKenzie Method of Mechanical Diagnosis and Therapy Management efficacious?

Citation: Surkitt LD, Ford JJ, Hahne AJ, Pizzari T, McMeeken JM. Efficacy of directional preference management for low back pain: a systematic review. Phys Ther. 2012;92(5):652-665.

Clinical Bottom Line: Moderate evidence that directional preference management (DPM) was significantly more effective than a number of comparison treatments for pain, function, and work participation at short (12 months) follow-up. No trials found that DPM was significantly less effective than comparison treatment.

Summary of Key Evidence: The McKenzie Method is utilized in the treatment of LBP utilizing mechanical loading strategies (MLS). Directional Preference is the direction of MLS (exercise, etc.) that results in Centralization. Centralization is the proximal movement or abolition of distal symptoms in response to MLS. Directional Preference Management is individualized treatment based on the response to MLS.

• Procedure: 6 RCT’s were selected from an initial 5932 references from 1950 thru January 2010 randomizing 474 participants. Subjects were male and female, greater than 17 years of age, with lumbar pain with or without leg pain or neurological signs with varying duration. The PEDro scale was used to determine the methodological quality and treatment effect, 95% confidence intervals were calculated and homogenous study data was pooled.
• Outcome Measures: The Visual Analog Scale, numeric pain rating scale, Roland Morris Disability Questionnaire, Oswestry Disability Questionnaire and Functional Status Questionnaire were used with variability between the trials.
• Secondary Outcome: The trials compared DPM with lumbar mobilization, manipulation, stabilization, strengthening, general conditioning exercises and advice to remain active. Different outcomes were reported for different time periods of follow-up.
• Results: All trials except 1 were deemed high quality. Moderate evidence was found supporting the effectiveness of DPM when applied to participants with a Directional Preference in short and intermediate term follow ups. In high quality trials, DPM was shown significantly more effective than mid-range multidirectional exercises, advice and exercises in the opposite direction of DP.
• Appraisal of Applicability, Internal validity, and Statistical Validity:
  • Threats-Low number of subjects, different trials reported different outcome measures, trials were heterogeneous so meta-analysis was not possible.
  • Strengths-DPM was compared to common clinical treatments with heterogeneous patient population.

Applicability to Patient: If a patient has a Directional Preference, or their pain improves with certain movements, they will benefit from a management approach utilizing these principles.

For years the term “cross-training” has been tossed around in athletic and sports communities, in regards to off-season or winter fitness planning. “Cross-training” is touted as a way to decrease injury risk, build an aerobic base, improve strength and flexibility and to stave off boredom. That all sounds fantastic…but what do I actually DO when I “cross-train”?

According to Wikipedia, “Cross-training refers to an athlete training in sports other than the one that athlete competes in with a goal of improving overall performance. It takes advantage of the particular effectiveness of each training method, while at the same time attempting to negate the shortcomings of that method by combining it with other methods that address its weaknesses.”

OK, so that is also nice to know, but other than doing something besides my main sport, I’m still at a loss as to what I’m going to be doing while I’m “cross-training.”

Runners World magazine’s web site recommends a wide variety of activities. Cycling, swimming, strength training/fitness classes, Yoga, Pilates, etc.

Runners World is a magazine for runners, and none of those activities involve running, so that must mean I can do ANYTHING other than my main sport. Yes, and NO.

It is true, doing an activity other than your primary sport can be beneficial, and for many people it is enough to keep winter gym boredom at bay and even possibly improve your overall fitness.

However, I propose going a step further. Take this time to concentrate on areas of weakness or neglect that result after a full season of focused training on a particular sport. As Malcolm Gladwell and David Epstein have both described in their books Outliers, and The Sports Gene respectively, it is “purposeful practice” that takes athletes to the next level, not just simply trudging on with uninspired routines.

I have created a few guidelines to help with planning your own cross-training program. At first look they are very general, but only in title. In application they can be far more specific.

Change Direction

Many of us, myself included, participate in sports that involve one particular movement repeated over and over. Runners, cyclists and hikers do just that. They run, cycle, or hike. This leads to glaring muscular imbalances that not only can limit performance or enjoyability of your activity, but can even lead to over-use injuries in the long term. Each of these sports are uni-directional, meaning that you constantly are moving in one direction, forward (for the most part). Cross-training for these individuals should involve activities involving lateral movements.

Strengthening the hip muscles and core with side to side activities (hopping, grapevine runs, playing sports involving cutting, etc.) can go a long way in preventing over-use injuries. There are numerous research studies in both Physical Therapy and Exercise Science fields supporting the benefits of strengthening these areas. Not only will this help prevent injury, but a 2006 sports physiology study found that “horizontal whole body movement” is directly linked to improved speed and acceleration.

Changing direction is not only for unidirectional athletes. For athletes in overhead sports strengthening the hips and core in this manner is also essential. Biomechanical studies of tennis players found that 63-74% of the total power generated came from this region. Not from the shoulder girdle or elbow. In fact, when treating elbow or shoulder injuries in athletes in the clinic it is standard care to address hip and core weaknesses/imbalances as well. In doing so on your own during the off-season you can possibly prevent these injuries from ever occurring.

Strength, Strength, Strength

This is the best time to build a foundation of strength. Unless your sport involves a barbell, weight training can be intimidating at first, but do your best to stay off of the machines if you can help it. Research says that squats and lunges can improve balance, overall strength, and vertical jump nearly 3x greater than the knee extension or hamstring curl machines. In fact, these machines have zero effect on both squat strength and balance. There are concepts of intermuscular coordination and neuromuscular education at work when you have to lift free weights against gravity in unsupported positions. Though they are beyond the scope of this article, essentially you are educating your muscles to contract more efficiently to complete a given task. More efficiency translates into improved speed, endurance, and injury prevention come Spring.

Prevent Further Over-use

Winter can be a painful divorce from our favorite activity/sport. Just ask any runner. Runners are notorious for their dedicated addiction to their sport, often to a fault. But don’t let the love you have for your sport be the ultimate reason why injuries set you back come competition time. This is especially true for endurance junkies. It would be foolish for me to recommend avoiding running to a runner, or skipping spin class to a cyclist. However, a strong aerobic base can still be built without having to log long miles the same old way. This is where Runners World Magazine’s recommendation comes into play. Changing activity can provide a great mental break. plus, if you can keep your high heart rate up (approximately 70%x (220-your age), it can be a valuable way to build endurance. Personally, I am a big proponent of swimming in the off-season, despite the fact that I am quite terrible at it (according to my wife, the former collegiate swimmer). It is incredibly cardiovascularly taxing and zero impact on my joints, plus afterwards the hot tub is always welcome before hitting the cold winter air back to the car.

So don’t waste your time this winter wallowing in worthless workout misery. Take initiative and turn your sweat into time well spent. Finish this winter, and start next season, more explosive, balanced, and bomb proof.

Article also found at https://stockhausenpt.wordpress.com/

By Steve Stockhausen PT, DPT

This is a very common question I often get from my patients. They have come in for a Physical Therapy evaluation, and in the course fo the exam they ask about imaging.

Here are a few keys to keep in mind if you are a back pain sufferer and considering having imaging studies performed.

1. An MRI, CT Scan or X-Ray cannot see pain. If you take a photograph of a person smiling, all that you can rightly say about that person is that they are smiling. You cannot accurately predict the exact emotion they are feeling at that time, or the thought that is going through their head. They could be thinking about all of the great skiing they are going to do this weekend, or maybe they are uncomfortable and smiling to hide their uneasiness. Diagnostic imaging is very much the same. “Pathologic” findings on imaging can be helpful guides in predicting what the pain generator COULD be. But it is impossible to say that a specific result is definitely, 100%, the cause of a patient’s pain. Skillful clinical examinations by a PT or physician can assist in providing an accurate diagnosis, but imaging alone is of questionable value.
2. Imaging can often be misleading. As I described in my first point, an image is simply an image. There is no way to “see” pain. The problem this causes is a high incidence of what are called “false positives.” False positives are any findings on imaging that could potentially be a problem, but are not the actual pain generators.In the image above, you can see the results of a study done by Jensen and colleagues that took MRI’s of non-painful participants. That’s right, these are people who DO NOT have back pain! In looking at the graph it is easy to see how a clinician could misdiagnose low back pain as a facet arthropathy or disc injury, when so many of these findings are also in normal pain free people. Similar studies have since been completed with corresponding results.

   Just because it is in an image, does not mean it is the source of pain.

   The scarier version of this problem comes when surgery is performed on a patient based on the findings in an imaging study, and after the long recovery process the patient’s original complaints remain. Unfortunately this does occur, though thankfully not frequently.

3. Imaging can be costly. Low back pain has a yearly estimated health care cost of nearly $90 billion in the United States. This value does not include lost wages due to time off of work, or the personal expense back pain sufferers incur while trying over the counter remedies or tricks.The total cost is accumulated by prescriptions, imaging studies, surgeries, and rehabilitation. A 2003 study found that MRI’s performed early in a patent’s care, prior to PT evaluation, resulted in a 300% increase in surgical rates. And here is the kicker. Overall, there was no improvement in the patient’s condition even a year later. The patients in this study had to not only pay for an expensive MRI and then were subjected to costly, and more importantly, risky surgery. Only to be no better come a year later.

   It has been found that through judicious use of low back imaging, the total cost of an individuals care can be reduced by 53-60%, with quicker return to work and shorter recovery periods.

Now, keeping these things in mind, there are instances when imaging is necessary. The presence of progressive neurological symptoms such as changes in bowel or bladder function, or weakness is one major classification. Having a history of cancer with unexplained weight loss is another important one. Other collections of signs and symptoms exist that necessitate imaging studies to be performed, but a Physical Therapist is more than capable of screening for these, and is trained to do so during every initial examination.

So, when you begin to have an aching in your low back (as 80% of Americans will at one point in their life) be quick to get to your Physical Therapist. They will help you prevent unnecessary expense, rule imaging in or out based on your individual needs, and start you on a program to combat the problem right from the start.

Stephen Stockhausen recommended this article, written by a good friend of his. Please click on the link below (or copy and paste the url into your browser) to be directed to the original article:

https://chandlerpt.net/why-physical-therapy-is-worth-paying-your-deductible-for/

Exactly one year ago I underwent a surgical procedure to alleviate a long standing, and rather severe case, of Illiotibial Band Syndrome, or runners knee. This is a very common injury involving a pathologic tightening of the illiotibial band (ITB) causing sharp pain in the outside of the effected knee, likely due to a hip weakness. The uncommon part of my particular injury was its lack of progress with physical therapy. Ninety five to ninety seven percent of ITB related problems can be solved by conservative measures (skilled physical therapy and/or injections). Being a physical therapist myself, the lack of progress was particularly distressing, and was preventing me from doing the one thing I moved to Durango to do, which was run on the beautiful mountain trails. After nearly 4-1/2 yrs of hard work, I opted to have a procedure called a Z-plasty, performed by one of our local orthopedic surgeons.

Initially after surgery my knee was very stiff and painful, but I was able to walk the next day with only the support of one crutch. Within four days I returned to work at the clinic with only a slight limp, icing between patients and staying late to do my own rehabilitation.

Rehabilitation for this type of procedure is fairly straight forward. In the beginning days/weeks, a priority is placed on knee range of motion (ROM), especially for straightening. From there, making sure the muscles of the quadriceps are firing correctly and improving my walking form were emphasized. Shortly thereafter (2-4 weeks), gentle hip strengthening began, with the focus being placed on the gluteus medius.

The gluteus medius is responsible for abducting the leg, or swinging the leg out sideways. Also, when standing on one leg, it is the muscle responsible for keeping your pelvis level over the standing leg, preventing the hip from kicking out sideways. If this muscle does not work correctly, or is weak for some reason, an assortment of injuries can result. Some research has linked this muscle to injuries of the ankle, knee, hip, and even lumbar spine (low back). It was going to be essential for me to get my gluteus medius as strong as possible if I was going to be able to run again pain free.

By 6 weeks I was permitted to begin jogging again, which was incredibly encouraging for me. It was by no means pain free, but I never had the stabbing pain in the outside of my knee that I had become so accustomed to after 2-3 miles.

With the nearly constant help of Dave, Ellen and my wife (who is also a physical therapist), I made good progress. The greatest challenge, as it is with our patients, is in fact being patient. The body has specific healing times that must be respected in the rehabilitation process. Knowing the appropriate timing and progression during recovery can mean the difference between running for fun a few miles a week, and being able to compete at a high level again. It was with the guidance of other therapists who have the advantage of perspective (It is very difficult to be realistic in expectations when it is your own body in recovery. Even for a PT).

I spent much of the winter and spring of 2013 in the clinic and the Durango Recreation Center weight room strengthening my legs, and most specifically my glutes. By the time June came around I was running pain free and with improved form. I continued to work hard on my therapy, even though I was 7 months post op. All of my hard work began to pay off in big ways. Not only was I running pain free, but I was able to challenge my self again, running my first marathon, then a week later doing the Pikes Peak Ascent and setting a PR. However, these were only stepping stones to my ultimate goal that I have had for nearly 10 years.

On September 28, nearly 11 months after my surgery, I finished my first Ultra-Marathon. Not only did I finish the Devil Mountain 50K, but beat my goal time, and in the process finished 5th overall, which was a completely unexpected result.

It was only with a tremendous amount of hard work and good guided therapy that I was able to finally achieve a goal that I had nearly given up on a year prior. Through this experience I have grown an even greater appreciation for the efforts that our patients give towards their own rehabilitation and training. These are scary times after surgery, but with hard work and the advice of trusted clinicians, a 110% recovery truly is possible.

Nice to see some recognition for physical therapy in the national media. US News discusses the benefits of physical therapy before injections or surgery. The physical therapist is highly skilled in all musculoskeletal conditions, and is ready to get athletes (especially runners) back in action.

Read the article here: https://health.usnews.com/health-news/blogs/eat-run/2013/10/07/physical-therapy-for-running-injuries

Be proactive and get a movement screening before starting a new training regimen to prevent problems before they start!

Stephen Stockhausen PT DPT, @SStockPT

Ever have a stabbing feeling in your heel with your first step out of bed the morning after a long hike down the Colorado Trail? The stabbing pain is the call sign of a condition commonly called plantar fasciitis.

The plantar fascia is a strong fan-like band of stiff connective tissue that stretches from the base of the heel towards the toes. This band supports the bottom of the foot and is essential for transitioning the foot from a “shock absorbing state” (pronation), when the foot initially touches the ground, to a “force producing state” (supination) for final push off when walking or running. Intrinsic muscles within the foot also assist in providing muscular support. When these structures become over worked or stressed they cause a sharp pain usually felt in middle of the heel. Occasionally there may also be a component of heel pain stemming from a low back problem.

This condition has been referred to as an “itis,” meaning inflammation, but recent research has reported little evidence of true inflammation. Physical changes in the tissues of the plantar fascia are found instead.

Patients are often treated with orthotic devices, corticosteroid injections, night splints, stretching, and a referral to physical therapy.

Traditional physical therapy interventions have included stretching the Achilles tendon and plantar fascia, ultrasound, iontophoresis, and orthotic devices. However, these interventions are often only effective for short term.

A recent study by Cleland et al. in the Journal of Orthopaedic and Sports Physical Therapy showed manual, or ‘hands-on’, physical therapy, in which specific techniques were applied to mobilize the joints of the foot, ankle, knee and hip, as well as to the soft tissue of the plantar fascia to be more effective than a traditional physical therapy approach for the treatment of plantar fasciitis. Not only was manual physical therapy shown to have excellent short-term effects, but the benefits lasted at least 5 months after the final treatment was completed.

When you first feel the symptom of Plantar Fasciitis, you should begin self-treatment. A simple and effective technique to do at home is to massage along the bottom of the foot. Push deep and firmly into the soft tissues of the foot, gliding back towards the heel, feeling for any lumps or bumps along the way. These bumps may be painful, but working them out will be worth a few minutes of discomfort. Rolling your foot on a tennis ball or a frozen water bottle are also other ways to do this. Then begin stretching your calf and your hamstring.

So, next time you find yourself limping your way to work Monday morning after a long weekend out on the trails, be sure to give these techniques a try. If symptoms are not resolving, make your way to the nearest manual physical therapist for faster and more permanent results.