Treatment Tuesday: Focus on Low Back Pain

🩺It's Treatment Tuesday here at HAE🩺

With my goal of promotion of healthy aging for the patients I treat, I also think it's important to share information on a larger scale. Each Tuesday, I will review either new literature or established best-practice standards that address the best treatment for a particular disease, disorder or dysfunction. To kick things off, I choose a problem I'd be willing to bet we've all experienced a time or two....Low Back Pain.

While Low Back Pain is common, it is often mistreated. Here is a review of the recommended, most effective treatments, treatments options that are sometimes appropriate, and lastly, the few that are least appropriate and often less helpful. Primary source of this information collected from ChoosePT.com, a patient education resource guide from the APTA. See links below for more information.

RECOMMENDED: 

🟢 Movement: While it may be tempting to stay in whatever posture doesn't bother your back, the more effective treatment  is movement. Try to move more in ways you can tolerate - walking, swimming, cycling or simply gentle stretching can help alleviate and prevent low back pain. Consult a Physical Therapist to help you establish a physical activity plan that is safe and effective at reducing low back pain.

🟢 Education: Low Back Pain can commonly be attributed to muscle imbalances within the trunk, legs and along the spine. When you combine that with prolonged sitting, standing or repetitive motions, you get pain and dysfunction. Learning about your imbalances and about proper posture can help you take control of your low back pain.

🟢 Cognitive-Behavioral Therapy: This type of therapy (using your behavior to retraining your brain to respond in an alternative way to a stimulus) has been proven effective for any type of chronic pain. Next time you have a painful experience, notice what your response is. Do you get immediately anxious? If it happens, take that opportunity to focus on your breathing, instead of your anxiety. While you take time to be aware of your symptoms, take 5-10 slow deep breaths instead of turning to panic or googling what to do. This 'changing the conversation' can help your brain begin to dampen the response to the pain stimulus instead of turning to panic.

SOMETIMES APPROPRIATE:

🟡 Yoga: With a focus on controlled breath with movement and on core activation, yoga can be a helpful adjunct to your low back pain treatment plan.

🟡 Massage: While massage may give you some short term relief, evidence has shown movement-based therapy is more beneficial in the long term.

🟡 Acupuncture: Results of acupuncture for low back pain relief is similar to those associated with massage; while it may be helpful on the short term, it should be combined with recommended treatments for long term relief.

🟡 Spinal Manipulation: As with massage and acupuncture, spinal manipulation may help initially with function, but should also be combined with exercise and movement-based treatments.

RARELY APPROPRIATE:

🟠 Opioids: The CDC recommends use of opioid medications only for chronic pain that has been resistant to other recommended treatments. They are less effective and have considerable side effects.

🟠 Heat: Everyone loves to throw on a heat pack, but there is limited evidence of any long term benefit. Ice may be a better choice, but regardless, any use of modalities should be used in combination with recommended treatments.

🟠 Imaging Scans: Evidenced has shown that imaging like x-rays and MRI's is not necessary to diagnose and treat low back pain. It can also lead to unnecessary treatment.

🟠 Spinal Injections: Evidence has not found any long term benefit from spinal injections and it does not reduce the likelihood of surgery.

🟠 Surgery: Surgical intervention is not necessary or recommended for most types of low back pain.

NOT RECOMMENDED: 

🟠 Bed Rest: Not only is bed rest ineffective, it will likely make back pain worse. Try to move, in ways that are comfortable instead. 

To learn more about the best practice guidelines for the treatment of low back pain, check out these links:

Choose PT Guide to Low Back Pain:

https://www.choosept.com/symptomsconditionsdetail/physical-therapy-guide-to-low-back-pain

Choose PT Recommended Treatments for Low Back Pain:

https://www.choosept.com/resources/detail/recommended-treatments-low-back-pain-2

Choose PT Five Common Myths About Low Back Pain:

https://www.choosept.com/resources/detail/5-common-myths-about-low-back-pain

Michael J. Fox Foundation Research Update

I had the opportunity to sit in on a Michael J Fox Foundation research update this week, presented by Rachel Bulmer and Melanie Demakis, and wanted to share some updates with you that they shared with us. For those of you unfamiliar with the Michael J. Fox Foundation, they provide financial support to researchers working not only to advance the treatment of Parkinson’s Disease, but to find a cure. 

While I’ve always tried to stay up to date on management of the patient with Parkinson’s to provide the best standard of care for my own patients, I also have personal interest in the topic as my mother is living with Parkinson’s disease. This webinar was a great opportunity to hear about current state of genetic research and also to learn about some recently approved pharmacological interventions.

Genetic Trials

The presenters discussed the importance of finding a concrete biomarker for Parkinson’s disease. A biomarker is a quantitative measurement tool that enables researchers to more definitively determine efficacy of a treatment in testing, and also better identify the current stage of a person’s disease.  As there is no current validated biomarker for Parkinson’s disease, researchers have to rely primarily on clinical observation and functional outcome measures to determine whether a new medication or genetic treatment has made a significant and clinically relevant difference. They are able to perform brain scans that show some degree of dopamine loss, but this value is difficult to standardize and has not been used in a validated way as of yet. 

They discussed three areas of genetic research that are potentially relevant to finding a better treatment, or possibly a cure, for Parkinson’s disease. Alpha-synuclein protein is one of these areas of interest. Located in the brain, mutation or overexpression of this protein is believed to play a role in the development and progression of Parkinson’s disease. This protein essentially folds into clumps, leaving Lewy Body deposits, which slow the transmission of dopamine within the brain, leading to the motor effects we see in patients with Parkinson’s disease. There are presently 13 Phase 1 to 2 trials investigating how to slow or prevent the expression of alpha-synuclein, in turn, slowing or stopping the progression of the disease.

The other two genetic avenues they presented were related to the genetic markers GBA and LRRK 2. With 6 GBA trials, and 3 LRRK 2 trials already in progress, two large companies, Biogen and Denali, just announced they will be combining efforts to support a Phase 2 LRRK 2 trial. This is significant, as with promised financing of $1,000,000,000, their support to the project speaks to their belief that this research may be particularly promising. 

Pharmacological Treatments

The presenters also reported on three new medications that have recently hit the market. Interestingly, all three share a common goal - to reduce the experience of off-times, while each one approaches the problem in different ways. Kynmobi, a thin-film apomorphine strip can be taken sublingually as a rescue drug during off times. Ongentys, a COMT inhibitor, is also taken by mouth in pill form once daily, and though slightly older news, they also mentioned Inbrija, an orally-inhaled form of levodopa, which can be through an inhaler on as as-needed basis to reduce off-times as well.

Lastly, they touched upon the importance of volunteering for clinical trials, whether as a healthy control, or a person with Parkinson’s. You can access their trial database here and learn more about these opportunities. 

I thought this was a great over-coffee opportunity to hear about the latest progress in Parkinson’s Disease research. You can see more webinars from Michael J. Fox Foundation here. If you would like to support this wonderful foundation, you can make a donation here.

the HAE Senior Fitness Assessment

Curious how you stack up against the competition or just want to find out if there are areas you could improve on. Sign up for a HAE Senior Fitness Assessment. On the day of your assessment, I will meet with you in your home to discuss your goals, your health history and will perform a thorough physical fitness assessment that day.  Here are some of the areas I will be assessing:

Past Medical History and Current Conditions: I will review your pertinent health history, discuss with you any concerns you have about your current medical conditions, within the scope of my practice, and provide education on conditions that you may benefit from understanding better. If I feel like you could benefit from any specialist referrals, I will provide this feedback to you and your medical team.

Assessment of Goals: For your Wellness plan to be effective, it must start with you. We will discuss what your goals are at present and for the future. These goals can be anything from being able to get up from the ground with more ease, to participating in your favorite hobbies and leisure activities with less limitation. I will use this information to help with development of your Wellness plan and our success together is measured by your progress in these areas.

Clinical Assessment: I will then perform a thorough physical assessment of your areas of strength and any areas of potential weakness. I will perform tests and measures to assess the following areas:

o   Cardiovascular and Pulmonary Health

o   Functional Strength, Power and Muscle Endurance

o   Flexibility and Range of Motion

o   Aerobic Capacity and Activity Tolerance

o   Balance and Coordination

Functional Outcome Measures: By utilizing outcome measures with predetermined age-matched norms and cut-off scores that indicate associated fall risk and other functional outcomes, I can better gauge where you are at present, and where I hope you will be when by the time we finish. I use tests like the 6 Minute Walk, 2 Minute Step, Berg Balance Scale, Functional Gait Assessment, 30 Second Sit to Stand, Arm Curl Test, and the Activities Specific Balance Scale among others to help me set more specific goals for you, and to help illustrate for you where you land currently on the spectrum of health and fitness. I will provide you with your scores, and we will reassess these as you progress with your Wellness program.

Development of Your Wellness Plan

After careful review of your medical history, and after we address any pertinent current medical issues, I will review specific guidelines for physical activity and provide you with education on any relevant precautions or contraindications for exercise. I will then review your individualized Wellness plan and we will determine together how you would like me to help you along your journey. Visits can be made in person or virtually, and at a frequency that you and I decide together would be most beneficial.

While our routine may vary, and all Wellness programs are individualized, there are certain types of workouts I find most beneficial to my clients. All of your workouts can be done in your home with whatever equipment you have on hand, or no equipment at all. Here is an overview of some of the different types of workouts you can expect to try:

Functional Strengthening: I believe in performing exercises and activities that are designed to directly improve your ability to function. This means choosing activities that strengthen your body in ways it must move to perform functional mobility and everyday activities. Typically, these movements fall into seven categories: Pushing, Pulling, Hinging, Squatting, Lunging and Core Work and Twists. While these are the same types of patterns you may expect to see heavy weightlifters performing, I modify these to reflect the types of activities you perform during your everyday life. You perform a squat every time you get up and down from a chair or the toilet. Stairs require a form of lunging and you hinge every time you must retrieve an item from the ground.  Pushing happens when you rise from bed, and you pull often when get in and out of the car. Your core is active during every one of these activities and twisting is a part of everything you do – rarely do these actions happen in isolation or as straight plane. By getting away from the traditional single limb strength protocols (bicep curls, knee extensions) and focusing on the multi-body part, big muscle group motions that translate to increased function, your workouts will not only be more effective, but more efficient. To read more about the benefits of functional strengthening, check out this blog post I wrote about it here.

High Intensity Training and EMOM-Style Workouts: To get maximum benefit from your workouts, you must be working intensely. And while this doesn’t necessarily mean you have to be dripping sweat or exhausted, it does mean I will find ways to get you moving and keep you moving so your heart rate stays up and you get a cardiovascular benefit even during your strengthening. I do this frequently by incorporating low impact aerobic intervals into your strength sessions, or using Every Minute on the Minute (EMOM) style workouts that use strength activities performed at more intense speeds and efforts to achieve the same effect. 

Low Intensity (LISS) and Moderate Intensity (MISS) Steady State Cardio: While it may sound simple, there are so many benefits from participating in regular low to moderate intensity aerobic exercise, that it has a role in a every Wellness program I create. This is the place where you get to choose how you move; if you like to walk, I will help you create a walking program. If you like to dance, we will find a way for you to find your groove. If you want to get on a bike, we can do that too. The only guideline I have your LISS or MISS workouts is you pick something you like to do, that feels good for your body.

Balance, Coordination and Agility:  I rarely meet someone who couldn’t benefit from work on their balance. I will create a balance program specifically for you that starts with the areas I find deficit during your assessment. It will start easy, and progress to keep you challenged, with activities modified to present challenges to your static, dynamic and walking balance all designed to encourage more instinctive and effective use of your balance strategies when needed.  

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What is ‘Functional Strengthening?’ And Why You Should Care About It.

Think for a minute, then tell me what the most difficult thing you do in your house is each day? Is it taking out the trash? Or getting in and out of the shower? Of lifting that heavy jug of water? Now think about that task, and try to tell me what makes it so hard. Does it challenge your strength? Your endurance? Your balance? Maybe all of the above?

Fitness is a combination of all of these things - strength, power, speed, endurance, agility, flexibility, coordination and balance. And your ability to continue to perform everyday functions as you get older relies on competency in all of these areas. Getting out of bed in the morning? That is a feat of strength. Completing your daily shower? It’s a true test of endurance. Leaning forward to tie up your shoes? You’ll have to keep your balance. Taking out the trash? It’s a combination of all three. You need the strength to lift the bag, the coordination to maintain your balance while carrying it and the endurance to make it outside to the barrel. 

This is why working on your functional strength is so important. While strength alone is a simple measure of how much load a single muscle group can bear, functional strength is how well all of your muscles work together to perform a complex movement. These multi-muscle group, multi-joint movements enable you to move through a functional pattern - a pattern that translates to your ability to perform a real-life functional task. 

In exercise terms, functional movement patterns are broken up into six categories; the squat, the lunge, the hinge, the push, the pull and the carry. The twist is also included, but is used in combination. If you take a closer look at the tasks you perform on a day to day basis with your home and in your community, you’ll find these movements are part of everything you do. Reaching down to pick up the paper? There’s your squat. Walking up a hill, or taking the stairs are lunge patterns. Every time you pick up up an object up off the ground, you’re moving through a hinge. Push, pull and carry? You’ll find yourself doing these getting out of bed, pulling yourself into the car and simply walking around!

One of the most important foundations of exercise training science is the principle of specificity. Specificity dictates that in order to make progress in a sport or activity, you must practice and strengthen the skills required to perform that specific activity. You could do bicep curls every day, and while you may end up with stronger biceps, you aren’t going to get any better at tennis. If you’ve ever found yourself wondering what good these ridiculous ankle pumps are doing for you - then good! Because they probably aren’t doing much. If you want the things you struggle with every day to get easier (lifting those groceries, climbing those stairs, getting out of bed in the morning) - then you have to practice those skills. And you have to practice those skills repetitively, intensely and with purpose. 

A good functional strengthening program will help you get stronger in the whole-body movement patterns that you need to use to perform everyday activities with increased ease. When I design a functional strength program for you, it starts with an analysis of what activities you struggle with. We then work on exercises that mimic those movements - scaled first to your present ability then with progressive challenge. This may look like a sit to stand exercise from progressively lower surfaces, or hinge lifts with a weighted ball or bag first from a counter, then a chair and eventually from the floor. What will feel difficult initially, will soon start to get easier - and you’ll see the results carryover at home home. Whether you’re a seasoned athlete or an eighty five year old woman just trying to get through the day, functional strengthening is a more effective and enjoyable way to exercise - and will help you make specific improvement on the things that matter to you.

Wondering how you stack up? Sign up for a Senior Fitness Assessment and learn how a functional strength program can help you.

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So, you got Covid-19…now what?

Fortunately, about 80% of people who get Covid-19 will experience only mild symptoms. However, the other 20% can experience more severe symptoms and 5% may experience critical illness as a result. Recovery from moderate to severe Covid-19 can take weeks, months or longer. Generally, the longer you were in the hospital, ICU or on a mechanical ventilator, the longer you may experience residual effects, and the more protracted your recovery may be. The APTA has provided physical therapists with a wonderful resource, the PACER series (Post-Acute Covid-19 Exercise and Rehabilitation project) to help us best prepare to care for patients as they recover from Covid-10 and I have pulled together some of the most relevant information I learned from this course here for you. If you contracted Covid-19, and still don’t feel yourself despite the ‘all-clear’ of a negative test, here are some things you may be experiencing, and some information on how Physical Therapy can help you continue along the recovery process.

WHAT TO EXPECT DURING COVID-19 RECOVERY:

• Fatigue and Decreased Endurance: You will likely find you are more tired than normal from moving around, walking, and performing activities of daily living. This can be due to deconditioning from the bed rest and hospital stay, due to dehydration, because of decreased blood volume, or related to impaired use gas exchange and ventilation (your ability to pull oxygen out of the air and into your lungs). Anemia is also possible after Covid-19 and should be assessed for by your doctor if you are experiencing these types of symptoms.

• Muscle Weakness: You may feel like your body is weaker than it was before or it is harder to carry heavy items. Muscle weakness can develop from prolonged bedrest or decreased activity, but it can also be more significant if you have been diagnosed with Critical Illness Myopathy (CIM) or Critical Illness Polyneuropathy (CIP) related to your Covid-19 illness.

• Shortness of Breath or Difficulty Breathing: As Covid-19 causes damage to the lungs, you may find you continue to be short of breath at rest or with activity while you recover. You may notice you have to lean forward to support yourself to breathe deep or find yourself taking shallow breaths or breathing more rapidly when you feel out of breath. This may be due to damage to the alveoli, in the lungs, where the oxygen is extracted from the air and drawn into the blood stream, or it may be due to scarring and fibrosis that has occurred within the lungs during their healing process.

• Signs of Cardiovascular Impairment: If you already had Cardiovascular disease prior to developing Covid-19, you may find your symptoms are now worse. If you suffered any cardiovascular damage during your illness, you may experience periods of angina (chest pain), a higher than normal resting heart rate, feelings of irregular heart rate or arrythmia or swelling in your legs or your feet. If you are experiencing any of these symptoms, it is important to report these to your doctor, so they can assess your need for further care. You also may experience lightheadedness when you stand up. Orthostatic hypotension is common after spending time in the hospital, and can be improved by drinking plenty of fluids, and taking extra time to come to standing, especially first thing in the morning or when you get out of bed.

• Difficulty with your Balance: Whether due to impact on your neurological system or simply due to weakness and deconditioning, it is possible you may feel more off balance or unsteady when you walk. If are having falls, or even feeling like you may fall, it is worth seeking physical therapy to improve your balance and keep you from sustaining any falls-related injuries that could further set you back.

• Increased Confusion, Memory Loss, Anxiety or Depression: Lastly, it is common to feel anxious or depressed after a hospital stay and especially after a hospital stay for Covid-19. If these feelings become overwhelming or are distressing, it is important to bring these to the attention of your doctor. It is also possible to have some degree of delirium or new onset memory loss after an ICU stay. This can take some time to improve, and you may benefit also from seeing a Speech Language Pathologist to help you learn recovery or compensatory strategies to address issues you may be having.

HOW PHYSICAL THERAPY CAN HELP YOU RECOVER AFTER COVID-19:

As a skilled Physical Therapist, I can help you work to get stronger after Covid-19. These are some things I would likely work with you on as part of your rehabilitation.

• Functional Mobility: I will help you improve the things you may be struggling to do at home. This may include the ability to get in and out of bed, transfer on and off various surfaces around your home and in and out of your car. We will also practice walking in your home, outdoors and in more complex environments to get you safer at home and more comfortable walking within your community.

• Strength and Flexibility: I will teach you exercises to improve the muscles that have become weaker. Most of these exercises will incorporate whole body functional movements that will also help make your mobility and activities of daily living feel easier. I will also teach you safe stretching exercises to address any impairments in flexibility you may have developed during your hospital stay or as a result of prolonged bedrest.

• Breathing, Pacing and Energy Conservation: To improve your ability to breathe comfortably, I will teach you specific exercises that will strengthen the muscles involved with the breath cycle like the diaphragm and the intercostals. I will also teach you ways you can pace yourself when performing self-care and household activities and coach you in ways you can save your energy for things you really need it for. If you have come home using oxygen, I will work with you to wean off, if approved by your doctor, and if not, can teach you how to manage your oxygen equipment and oxygen needs ongoing.

• Fall Prevention and Safety Awareness: By working on your balance and ability to use your balance reactions, I will help you prevent losses of balance, and teach you how to respond quickly if you do experience any. We will talk also about safety awareness; I will make recommendations to improve your safety at home and when you go out and about in the community.

• Aerobic Capacity and Activity Tolerance: While keeping a careful eye on your vital signs and response to activity, I will help you improve your endurance in safe and comfortable ways. It may start as small as laps around the house, but I will help you progress over time, with a goal of getting you back to doing everything you were doing before.

• Home Exercise Program and Discharge Planning: While we will work together on these areas during your Physical Therapy sessions, I will also be giving you work to do on your own. This will likely be a mix of walking, strengthening, stretching and balance activities and will be scaled to what you can do right now, then progressed as you can do more. When we finish with our course of therapy, I will make sure you have a program you can continue with on your own, or we can continue to work together on a Wellness basis ongoing.

Click here to learn more about our HAE/PT Covid-19 Action plan for infection control and patient safety.

If you have experienced Covid-19, but still don’t feel back to normal, please call or email to set up a phone consult or in-person evaluation so I can help you get better.

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