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 Physical therapy and exercise proven a better alternative for neck And arm pain sufferers.

      By Dr. Chad M. Pens

Neck pain is one of the top 10 reasons for an individual to visit their physician. Cervical spine dysfunction can produce radiating arm pain often resulting from a pinched nerve.  The lead article in the most recent issue of 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 neck pain and arm symptoms compared to the current guideline group.   The subjects in the study experienced both short and long term improvements in their neck and arm 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 mobilization, spinal manipulation, and soft-tissue techniques designed to restore motion and reduce pain.  These manual techniques are applied to the neck or cervical spine and the thoracic spine considering the role and interdependence of the cervical and thoracic spine.  The decision of when and where to apply these skilled manual therapy techniques is based upon physical examination findings that are specific to each individual patient.  Hurwitz et al (2008) concluded in a systematic review on neck pain, also in the journal of Spine, “Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain.”
The combination of manual therapy and exercise results in more meaningful reduction in pain in both the neck and arm in less time as well as improved patient satisfaction when compared to spinal manipulation or neck exercises alone. Three recent studies have demonstrated improved satisfaction scores and that it is more cost effective to seek therapies consisting of manual therapy and exercise as compared to general practitioner care and other forms of physical therapy. The current best evidence supports the use of manual therapy and exercise for patients with cervicogenic headaches, or headaches that originate from mechanical neck dysfunction.
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 a physical therapist today.


      Physical Therapy an Alternative to the High Risks of Methadone 

A recent investigative report1 published in the New York Times highlights the alarming increase in methadone prescriptions for the treatment of chronic spinal pain.  The result has been a shocking increase in methadone related deaths.  Physical therapists can play a role in providing patients and physicians with an alternative to dangerous pain medications like oxycodone and methadone. 
Methadone was once limited to use in addiction treatment centers to replace heroin, but today it is frequently given out by physicians to manage spine and joint pain.  The Drug Enforcement Administration noted that from 1998 to 2006, the number of methadone prescriptions increased by 700 percent.  “Many legitimate patients, following the direction of their doctor, have run into trouble with methadone, including death,” noted pain specialist Dr. Howard A. Heit from Georgetown University.  Florida alone, which keeps detailed data, listed methadone as a cause in 785 deaths in 2007, up from 367 in 2003.
“These are senseless deaths,” 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 these medications are not the best option to reduce the symptoms of spinal pain. Research has shown that early movement and treatments like exercise and spinal manipulation offer strong benefits to spine pain and disability.”  Most spinal pain in the acute stage has components that are mechanical as well as chemical.  What this means is that some of the pain comes from the way the spine is moving, or not moving, and the presence of inflammation.  By addressing the pain via medications such as methadone or oxycodone, the problem itself is not being addressed, only the pain.  The sooner the mechanical component can be addressed, the sooner the individual can experience a reduction in their symptoms.
“The medical management of spinal pain in this country is a failure,” continued Flynn, “we too often initiate prescription drug therapy before choosing safe and effective alternatives.”  Flynn suggests that patients seek out physical therapists as a first-line treatment for these conditions.  Evidence supports the use of skilled manual therapy interventions, including spinal manipulation early in the course of low back pain.  By delaying these interventions may pose a significant risk, which is often the management approach.  Patients are often seen with acute low back pain, prescribed medications and instructed to follow up in a period of several days to several weeks.  Patients should be immediately directed to a skilled physical therapist to direct physical management of their spinal pain.
Many times in my practice I encounter patients who remark how narcotic pain medications have been prescribed to them, although they would prefer to avoid “taking pills.”  There also have been times that the individual has tried the medications, but they experienced adverse or undesirable side effects.
A February 2008 report published in the Journal of the American Medical Association reports that from 1997 to 2005, pharmaceutical expenditures for the management of low back pain increased by 171% while the rate of good outcomes fell.  "All the imaging we do, all the drug treatments, all the injections, all the operations have some benefit for some patients,” said Richard A. Deyo, a physician at Oregon Health & Science University in Portland and a coauthor of the report.  “But I think in each of those situations we've begun using those tests or treatments more widely than science would really support."
Instead of taking prescription pain killers for spinal pain, seek out a skilled manual physical therapist who attempts to determine the source of the pain.  Pain often times has a source, and if you treat the pain at its source, the management of that pain will be successful.
For more on the benefits physical therapists can provide in the management of spinal pain, contact the specialists at COAST Physical Therapy, P.C. or visit the American Academy of Orthopaedic Manual Physical Therapists website at www.aaompt.org.  AAOMPT represents physical therapists by promoting excellence in orthopaedic manual physical therapy practice, education and research.


By Dr. Chad M. Pens 




Pain In the Neck

By Dr. Chad M. Pens


Neck pain can develop in people from all walks of life, ranging from sports enthusiasts to people with a job that requires a significant amount of time at a desk, phone or computer.  The source of that neck pain can be from numerous different anatomical structures such as muscle, joint, or nerve.  This column is going to focus on a type of neck pain that originates from repetitive strain placed on the soft tissue structures around the neck and shoulders. 


The trapezius is a large muscle that spans from the hairline to the shoulders and collar bone and down between the shoulder blades, extending nearly to the low back region.  This muscle is broken down into three parts, an upper, middle and lower trapezius.   Neck pain sufferers can often present with pain coming from overuse of the upper trapezius.  These patients often complain of a pain in the neck midway between the ear and the shoulder.  This pain often times manifests on the side of one’s hand dominance and occasionally on both sides.  Individuals often complain of “knots” or “tightness” in their shoulders and neck.  This pain is often described as worsening as the day goes on and relieved by “massaging the area” and resting at the end of the day.  


The underlying cause of this type of pain is multifactorial.  It is often the result of long standing poor postural habits.  These poor postural habits lead to overall length and strength changes in the muscles that attach to the neck and shoulder blades.  The end result is a muscle imbalance whereby a majority of the physical stress of the workday and physical exercise is absorbed by one muscle, the upper trapezius. This overuse or repetitive strain leads to pain developing in the muscle.


This condition has been described in many ways in the literature.  It has been called upper trapezius overuse syndrome, or as Vladimir Janda termed it, “upper crossed syndrome.”  The causes are often poor posture, which lead to the pectoralis minor becoming adaptively short.  This muscle attaches to the shoulder blade, so when this muscle becomes shortened the shoulder blades are held forward from their proper anatomical position on the rib cage.  This results in the middle and lower trapezius muscles, as well as the rhomboid muscles, to be positioned in an elongated position or over stretched.  Because of this altered position, these muscles are placed in a mechanically disadvantaged position and subsequently weakened.  When these muscles become weak, the end result is that the upper trapezius is forced to absorb more of the workload.  This increased workload results in strain, and ultimately pain.  


If you are suffering from neck pain similar to what is described in this column, be sure to consult your physician about a referral to physical therapy.  A physical therapist can establish an individualized plan of care to address your specific areas of muscle inflexibility and strength deficits.  Below are some basic stretches and exercises to help you improve your posture and decrease the incidence of neck pain associated with upper trapezius overuse syndrome.  Please consult with your physical therapist for a more in depth and more individualized stretching and strengthening program.






Posture: Pay attention to sitting up straight, keeping your head over your shoulders, and avoid rounding your shoulders forward.


Scapular Retraction: Attempt to squeeze your shoulder blades together and down moving them toward the middle of you back.  Hold 10 seconds and repeat 10 times.


Shoulder Shrugs/Rolls:  Sitting in a good postural position, raise your shoulders up towards your ears, then roll them back and together as you lower them down.  Repeat 

10 – 15 times.


Your physical therapist will be able to provide you with very specific exercises to address flexibility of the muscles that need to be stretched as well as those that require specific strengthening and motor control training.  The details of which require very specific instruction in order to achieve maximum benefit..






Understanding Arthritis


By Dr. Chad M. Pens, PT, DPT, OCS, ATC, CSCS
Osteoarthritis (OA) is the most common joint disease that causes pain and limits activity in older adults.  At least 20 million adults in the United States suffer from the effects of OA, and 90% of all people over the age of 40 will have signs of OA on X-ray.  OA is a disease process associated with a degeneration of the joint surfaces whereby the cartilage, which serves as a shock-absorber, is first roughened and eventually worn away.  The spaces between the bones become narrow, eventually leading to bone on bone.  This leads to thickened rough bone and spur formation which can be painful.  However, it is important to note that the severity of OA on X-ray does not always correlate with symptoms.  OA is a disease process of the whole fluid-filled joint and not just the cartilage, whereas it has traditionally been associated with excessive “wear and tear.”  OA most commonly affects the knees and hips but can affect any joint in the body.  Presently, there is no cure for OA.  However, an individualized physical therapy program can help decrease pain, increase function and improve quality of life. 
Risk Factors
There are many risk factors for OA including obesity, muscle weakness, and joint laxity.
Being overweight is more a risk factor for OA in the hips and knees.  Weight reduction has been shown to decrease the signs and symptoms of OA.  Post-menopausal women are at an increased risk of developing joint laxity and thus OA due to hormonal changes in the body.  Participation in contact or collision sports and working with heavy machinery or squatting increases the risk of developing OA.  The OA process can be accelerated by trauma or biomechanical influences including boney deformities such as bow-leggedness or knock-knees.  This can lead to uneven wearing away of the joint’s cartilage.  Recreational running does not increase the incidence of OA when the bones in the legs are aligned properly.
The onset of joint pain is often subtle, and sufferers will describe the symptoms as joint stiffness, typically worst in the morning or after prolonged periods of rest.  Eventually sufferers experience joint pain that is aggravated by activities such as walking and standing and relieved by rest.  Involved joints will lose range of motion in a pattern characteristic to the joint.  Joint inflammation and swelling are typically mild and somewhat relieved by anti-inflammatories.  OA can lead to loss of mobility, chronic pain, deformity and loss of function.  The incidence of OA increases with age and is the most common indication for a total joint replacement. 
The Role of Physical Therapy
Physical therapy has been shown to be effective in the management of OA to improve function, muscle strength, walking speed, overall quality of life, and to decrease pain.  The physical interventions used to treat someone with OA is decided after a detailed evaluation by a physical therapist.  Patient education is essential in protecting the diseased joints from excessive stresses.  Therefore, the individual must understand how activity modification may be necessary. 
The physical therapist must educate, motivate and individually select specific exercises to fit one’s specific needs.  After careful evaluation, it may be necessary to treat other regions of the body such as the foot and ankle, given their influence on both the hip and knee.  The use of orthotics, shoe inserts or wedges may be appropriate to decrease physical stresses on the painful joint.  Improving flexibility about the affected joints is typically the first step to treating OA through the use of stretching and skilled manual therapy techniques.  Muscles are an essential shock-absorbing mechanism for the joint.  Therefore, by increasing the strength of the muscles around the joint this helps alleviate the stresses every day activities place on the joint.   The use of ice to manage pain and swelling is effective with OA, however other physical therapy modalities such as electric stimulation may be necessary to control swelling during flare-ups.  The physical therapist and physician may discuss aquatic therapy as a treatment option.  Aquatic exercise reduces stress on the affected joints which has been shown to have a positive therapeutic effect.  It is important to understand that the specific physical therapy treatments depend on the findings in the individual evaluation and each patient’s response to the selected interventions. 
If you are experiencing painful knees and or hips associated with OA, talk with your physician about your options and whether physical therapy is right for you.

Cayuga Orthopedic and Sports Physical Therapy, P.C. 
COAST Physical Therapy
Located in the Health Central Building
(Behind the Holiday Inn)
37 West Garden Street, Auburn
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