You have your shoulders to thank for many of the movements required to get through the day. Driving your car, turning doorknobs, shaking hands, and reaching up or across to grab an item are just a few examples of activities that would not be possible without the extreme mobility that the shoulder provides. The shoulder is the only joint that can rotate a full 360°, making it the most mobile and flexible joint in the body, and it’s this significant range of motion that allows you to perform most of the tasks that involve the arms. There is, however, one downside of all this mobility: it makes the shoulder extremely vulnerable to injury.

Often thought of as a single joint, the shoulder is actually an intricate system that consists of four joints, with the acromioclavicular and glenohumeral joints being most important for movement. The acromioclavicular joint is a gliding joint where a part of the shoulder blade (scapula) called the acromion and the collarbone (clavicle) meet, and it allows the transmission of forces from the upper extremity to the clavicle. The glenohumeral joint is what most people think of when discussing the shoulder, and it’s a ball-and-socket in which the ball is the head of the upper arm bone (humerus) and the socket is the glenoid, a shallow cuplike part of the scapula. It’s this joint that allows for the shoulder’s extremely wide range of motion.

Connecting the bones and muscles of the shoulder are a number of ligaments and tendons, plus several other important structures, including the following:

• Rotator cuff: a group of four muscles that run from the humerus to the scapula; the tendons of these muscles form a “cuff” around the head of the humerus, and all the muscles work together to allow movement and stabilize the shoulder
• Labrum: a ring of cartilage surrounding the glenoid that creates a deeper socket for the ball to stabilize the joint
• Deltoid: the largest and strongest muscle of the shoulder, which provides the strength to lift the arm
• Joint capsule: a fibrous sheath that encloses the structures of the shoulder joint
• Bursa: a fluid-filled sac that acts as a cushion between tendons and other structures of the shoulder

Why shoulder issues become more common later in life

As mentioned earlier, the cost of the shoulder’s wide range of motion is that it also means a higher risk for injury. Some of this risk is minimized by the many structures—like the rotator cuff—that provide it with protection and stability, but the shoulder can still be easily injured from a variety of causes.

Shoulder pain is essentially any pain that arises in or around the shoulder. It may originate in the joints themselves or from any of the surrounding muscles, ligaments or tendons that make up the shoulder. Shoulder pain can occur at any age from a variety of causes, with younger individuals usually experiencing issues due to sports participation. But the peak incidence of shoulder pain actually occurs between ages 30-50, at which point issues develop because of gradual age-related changes.

With age, the body undergoes a number of significant changes, many of which increase the chances for pain and injury. In the shoulder, the effects of aging can result from the accumulation of many earlier habits, such as previous injury, overuse or underuse or the shoulder, disorders of certain shoulder structures, or any combination of these factors. Changes in circulation, metabolism, nutrition, and physical fitness can also contribute to the development of shoulder pain and dysfunction.

As a result, everyone is at an increased risk for shoulder pain as they get older, whether they were active individuals or not. But this risk is even higher in those who regularly performed lots of overhead activities—like painters, carpenters, swimmers, and baseball players—at any point in their life. Understanding this risk and what shoulder conditions are most likely to occur in older age can help prepare you for what to expect and how to respond if you do notice any shoulder pain.

Physical therapy is an essential component of treatment for many neurological disorders

Getting diagnosed with a neurological disorder may be confusing since these issues involve the nerves rather than the muscles and ligaments. Some patients may be uncertain what the diagnosis means and how it will affect their life, which can make it difficult to know what to do next.

For some nervous system disorders, a specialist may be the best choice to lead the treatment process providing and explain various treatment options and a plan of care for a particular diagnosis. For some peripheral nerve problems like pinched nerves and entrapments, physical therapist directed care is a great place to start.

A physical therapist can help with pain relief, strength problems, and assists with mobility so that patients can recover/retain their function and maintain independence. Increasing mobility and physical activity levels will also improve overall health and reduce the risk for other conditions that can result from inactivity.

Helping patients retain and regain their abilities through physical therapy Physical therapists are usually part of a team of medical professionals that all approach different aspects of the disorder present, with treatment for some of the most common diagnoses consisting of the following:

Cervical radiculopathy

• Hands-on manual therapy to relieve pain and recover spine mobility
• A combination of stretching and strengthening exercises are typically used in conjunction with hands-on techniques
• The therapist will likely provide instruction on postural positions which can prevent the condition from getting worse
• As treatment progresses, functional training is usually added, which is aimed at helping patients return to their job, sport, or other activities

Lumbar radiculopathy

• Initial treatment usually includes manual therapy to take pressure off the affected nerves; as the pressure diminishes, the therapist will perform mobilizations of the soft tissue and stretches to help bring back normal movement to the spine
• Once the patient has regained normal spinal movement, treatment will progress to strengthening to help recover any muscle dysfunction

Piriformis syndrome

• Stretching and strengthening exercises that focus on the outer hip and piriformis muscle in the buttocks are often a core component of most treatment programs for this disorder
• The physical therapist may also use deep massage and soft-tissue mobilization to alleviate pain and increase flexibility, and may educate patients on lifestyle changes that will reduce their symptoms

Carpal tunnel syndrome

• Exercises to increase the strength and flexibility of the muscles of the arm, forearm, and hand are commonly recommended
• Patients are also educated on how to avoid further irritation of the median nerve, such as practicing good workplace ergonomics and making modifications or taking precautions when using vibrating tools
• Many therapists provide manual therapy interventions to improve nerve and joint mobility in the neck, shoulder, arm, wrist and hand; some examples of nerve gliding exercises for carpal tunnel syndrome can be found here

Other nerve entrapments

• Treatment usually consists of posture correction when poor posture is a contributing factor responsible for the entrapment
• The therapist may also prescribe bracing or splinting to encourage rest for the damaged nerve, and nerve gliding exercises if the nerve is at the appropriate phase of healing
• Range of motion and strengthening exercises are usually prescribed and performed at the clinic and/or at home as well.

Parkinson’s disease

• Physical therapists will focus on addressing range of motion, strength, and stamina to improve movement, safety, independence
• Traditional physical therapy includes general conditioning exercises, training to address balance and gait (walking) issues, and guidance on ways to reduce shuffling movements and function better in everyday life
• A relatively new treatment is called the Lee Silverman Voice Technique, which physical therapists must obtain a special certification to administer

Multiple sclerosis

• Aerobic training using a treadmill, stationary bike, or rowing machine is often recommended to help patients stay mobile and continue performing their daily activities normally
• In addition to aerobics, the physical therapist will often prescribe general strengthening exercises for the arms and legs, balance training, stretching exercises, and relaxation techniques
• If accessible, aquatic exercise has also been found to be particularly effective for patients with multiple sclerosis
• Avoiding excessive fatigue is important when working with MS patients

Stroke

• The goal is to help patients regain the functional skills that they have lost after a stroke in order to return to home, work, and social activities
• Physical therapists will help patients with walking and balance, how to use an assistive device (if used), and provide training to caregivers (when needed)
• As patients become more mobile, functional activities and strengthening exercises will become part of the treatment plan

Your nervous system is the line of communication between your brain and every bone, muscle, and organ in your body. It is responsible for all actions that take place within the body, from the nerve impulses that make your heartbeat, to the reflex that makes you immediately retract your hand from a hot stove, and everything else in between.

When the nervous system functions normally, you can easily take it for granted and not give much thought to the complex inner-workings that are taking place every second. But as with every other body part and system, problems can occur.

The nervous system is vulnerable to a wide variety of disorders, which can affect either the central nervous system (the brain and spinal cord) or the peripheral nervous system (everything else), or both. Nerves can be damaged by many possible causes, including trauma, infection, structural issues, degeneration, or autoimmune disorders. And the result of this damage depends entirely on the part or parts of the nervous system affected, which may lead to a range of potential symptoms. These can include problems with movement, speech, or breathing, as well as memory and mood.

A selection of the most common nervous system disorders

Below are some of the most common nervous system issues (also known as neurological disorders) and how each one affects the body.

Peripheral nerve problems are common and often treated in outpatient clinics.

• Cervical radiculopathy: occurs when one of the nerve roots in the neck is compressed or pinched where it branches away from the spinal cord, which is caused by any condition that injures or irritates these nerves. Symptoms may include a burning pain that starts in the neck and travels down the arm, upper back, and/or shoulders, along with weakness, numbness, and/or tingling in the fingers.
• Lumbar radiculopathy: occurs when a nerve root in the lower back is compressed or pinched when it branches away from the spinal cord, which is due to injury or irritation of these nerves; symptoms include pain, numbness, weakness, and/or tingling that radiates down the leg and sometimes into the foot
• Piriformis syndrome: a rare condition that occurs when a muscle in the buttocks (the piriformis) puts pressure on the sciatic nerve, which may be due to a spasm of this muscle; the most symptoms are tenderness in the buttocks and pain that travels down the back of the thigh, calf, and foot (sciatica).
• Carpal tunnel syndrome: a common condition caused by pressure on the median nerve, which runs the length of the arm and through a passage in the wrist called the carpal tunnel; symptoms usually start with a burning or tingling sensation, but eventually pain, weakness and/or numbness develop in the hand and wrist, and then radiate up the arm
• Other nerve entrapments: a number of other conditions also result when a single nerve is compressed or squeezed, such as cubital tunnel syndrome, Guyon’s canal syndrome, radial nerve compression syndrome, and thoracic outlet syndrome; symptoms vary depending on the diagnosis, but typically include aches and pains, tingling or numbness, weakness, and reduced flexibility

Conditions that Affect the Central Nervous System.

• Stroke: the fifth leading cause of death and one of the leading causes of disability in the U.S.; it occurs due to bleeding or the obstruction of blood flow in the brain; symptoms include trouble walking, speaking, and understanding, and possibly paralysis or numbness in the face, arm, or leg
• Ischemic: accounts for the majority of strokes; caused by blockage of an artery (or rarely a vein) in the brain, which affects blood flow to part of the brain
• Hemorrhagic: only accounts for about 13% of strokes; occurs when a blood vessel in the brain ruptures and bleeds, which deprives brain cells and tissues of oxygen and nutrients
• Parkinson’s disease: a progressive disorder (meaning it gets worse over time) caused by the loss of brain cells that make dopamine, a neurotransmitter that helps the body perform smooth and coordinated muscle movements; symptoms include tremors, trembling, stiffness or rigidness, and/or slowness of movements
• Multiple sclerosis: an autoimmune disorder, which means the body attacks its own healthy cells because it accidentally identifies them as foreign invaders; in multiple sclerosis, a substance called myelin (a fatty tissue that surrounds and protects nerves) is destroyed in many areas of the body, which leads to the formation of scar tissue called sclerosis; symptoms range widely but can include muscle weakness, numbness, stiffness, trouble with coordination, and fatigue
• Guillain-Barre syndrome: a rare autoimmune disorder in which myelin and other parts of the peripheral nervous system are mistakenly attacked, which prevents nerves from being able to properly send messages to and from the brain; the first symptom is usually weakness or a tingling sensation in the legs, which tends to come on rapidly and may spread to the upper body; symptoms may get worse, and may also include fatigue, pain, and loss of reflexes
• Myasthenia gravis: another autoimmune disorder that affects the communication between nerves and muscles throughout the body; symptoms include weakness in the arms, legs, and neck, difficulty swallowing, shortness of breath, blurred or double vision, and drooping of one or both eyelids
• Traumatic brain injury: sudden damage to the brain caused by a blow or jolt to the head, which can range from a mild concussion to severe brain damage; symptoms include headache, dizziness, nausea, lightheadedness, confusion, thinking, or memory issues, and behavior or mood changes
• Spinal cord injury: damage to any part of the spinal cord or nerves at the end of the spinal canal, which can result from car accidents, falls, violence, and sports-related trauma; symptoms include headache, numbness or tingling, an inability to move the arms or legs, difficulty walking, and pain or stiffness in the neck

Your nervous system is the line of communication between your brain and every bone, muscle, and organ in your body. It is responsible for all actions that take place within the body, from the nerve impulses that make your heartbeat, to the reflex that makes you immediately retract your hand from a hot stove, and everything else in between.

When the nervous system functions normally, you can easily take it for granted and not give much thought to the complex inner-workings that are taking place every second. But as with every other body part and system, problems can occur.

The nervous system is vulnerable to a wide variety of disorders, which can affect either the central nervous system (the brain and spinal cord) or the peripheral nervous system (everything else), or both. Nerves can be damaged by many possible causes, including trauma, infection, structural issues, degeneration, or autoimmune disorders. And the result of this damage depends entirely on the part or parts of the nervous system affected, which may lead to a range of potential symptoms. These can include problems with movement, speech, or breathing, as well as memory and mood.

A selection of the most common nervous system disorders

Below are some of the most common nervous system issues (also known as neurological disorders) and how each one affects the body.

Peripheral nerve problems are common and often treated in outpatient clinics.

• Cervical radiculopathy: occurs when one of the nerve roots in the neck is compressed or pinched where it branches away from the spinal cord, which is caused by any condition that injures or irritates these nerves. Symptoms may include a burning pain that starts in the neck and travels down the arm, upper back, and/or shoulders, along with weakness, numbness, and/or tingling in the fingers.
• Lumbar radiculopathy: occurs when a nerve root in the lower back is compressed or pinched when it branches away from the spinal cord, which is due to injury or irritation of these nerves; symptoms include pain, numbness, weakness, and/or tingling that radiates down the leg and sometimes into the foot
• Piriformis syndrome: a rare condition that occurs when a muscle in the buttocks (the piriformis) puts pressure on the sciatic nerve, which may be due to a spasm of this muscle; the most symptoms are tenderness in the buttocks and pain that travels down the back of the thigh, calf, and foot (sciatica).
• Carpal tunnel syndrome: a common condition caused by pressure on the median nerve, which runs the length of the arm and through a passage in the wrist called the carpal tunnel; symptoms usually start with a burning or tingling sensation, but eventually pain, weakness and/or numbness develop in the hand and wrist, and then radiate up the arm
• Other nerve entrapments: a number of other conditions also result when a single nerve is compressed or squeezed, such as cubital tunnel syndrome, Guyon’s canal syndrome, radial nerve compression syndrome, and thoracic outlet syndrome; symptoms vary depending on the diagnosis, but typically include aches and pains, tingling or numbness, weakness, and reduced flexibility

Conditions that Affect the Central Nervous System.

• Stroke: the fifth leading cause of death and one of the leading causes of disability in the U.S.; it occurs due to bleeding or the obstruction of blood flow in the brain; symptoms include trouble walking, speaking, and understanding, and possibly paralysis or numbness in the face, arm, or leg
• Ischemic: accounts for the majority of strokes; caused by blockage of an artery (or rarely a vein) in the brain, which affects blood flow to part of the brain
• Hemorrhagic: only accounts for about 13% of strokes; occurs when a blood vessel in the brain ruptures and bleeds, which deprives brain cells and tissues of oxygen and nutrients
• Parkinson’s disease: a progressive disorder (meaning it gets worse over time) caused by the loss of brain cells that make dopamine, a neurotransmitter that helps the body perform smooth and coordinated muscle movements; symptoms include tremors, trembling, stiffness or rigidness, and/or slowness of movements
• Multiple sclerosis: an autoimmune disorder, which means the body attacks its own healthy cells because it accidentally identifies them as foreign invaders; in multiple sclerosis, a substance called myelin (a fatty tissue that surrounds and protects nerves) is destroyed in many areas of the body, which leads to the formation of scar tissue called sclerosis; symptoms range widely but can include muscle weakness, numbness, stiffness, trouble with coordination, and fatigue
• Guillain-Barre syndrome: a rare autoimmune disorder in which myelin and other parts of the peripheral nervous system are mistakenly attacked, which prevents nerves from being able to properly send messages to and from the brain; the first symptom is usually weakness or a tingling sensation in the legs, which tends to come on rapidly and may spread to the upper body; symptoms may get worse, and may also include fatigue, pain, and loss of reflexes
• Myasthenia gravis: another autoimmune disorder that affects the communication between nerves and muscles throughout the body; symptoms include weakness in the arms, legs, and neck, difficulty swallowing, shortness of breath, blurred or double vision, and drooping of one or both eyelids
• Traumatic brain injury: sudden damage to the brain caused by a blow or jolt to the head, which can range from a mild concussion to severe brain damage; symptoms include headache, dizziness, nausea, lightheadedness, confusion, thinking, or memory issues, and behavior or mood changes
• Spinal cord injury: damage to any part of the spinal cord or nerves at the end of the spinal canal, which can result from car accidents, falls, violence, and sports-related trauma; symptoms include headache, numbness or tingling, an inability to move the arms or legs, difficulty walking, and pain or stiffness in the neck

Pick any function of the human body, and you can count on your nerves making it happen. Moving your eyes to read these words, the process of sending these images to the brain to be converted into useful information, and breathing while doing so are all made possible by the nerves.

The nervous system is a complex collection of nerves and specialized nerve cells called neurons that form a network reaching every part of the body. Collectively, this network rapidly transmits signals back and forth between the brain and the rest of the body to allow movement and every other bodily function. In essence, the nervous system is the body’s electrical wiring, through which all communication takes place. Neurons are the basic unit of this system, as they send and receive nerve impulses to other cells at an incredibly fast rate. More on this later.

When looking at the structure of the nervous system, it’s easiest to divide it into two main parts: the central nervous system and the peripheral nervous system.

Central nervous system

• The central command center of the body that integrates and organizes all the information coming in and going out
• Consists of the brain, spinal cord, and all the supporting nerves and neurons that serve them
• Brain: controls nearly all functions of the body, including awareness, movement, sensations, speech, and memory
• Spinal cord: a long tube—like structure that carries messages back and forth between the brain and the rest of the body; it extends from the brainstem down to the base of the spine and consists of 31 segments, each of which has a pair of spinal nerves that travel out to other regions of the body

Peripheral nervous system

• All the other nerves and neurons of the nervous system that are not part of the central nervous system; further divided into the somatic and autonomic nervous system
• Somatic (voluntary) nervous system: controls nearly all voluntary movements in the body; it does this by sending sensory information (from our five senses) to the central nervous system and receiving instructions to carry motor functions elsewhere in the body
• Autonomic (involuntary) nervous system: responsible for all the involuntary functions of the body, such as heart rate, digestion, respiration, urination, and sexual arousal; it is further divided into the sympathetic and parasympathetic nervous system
• Sympathetic nervous system: prepares the body for sudden stressful situations in what’s called the fight—or—flight response, which leads to increased blood pressure, heart rate, blood sugars, and fats to supply the body with extra energy
• Parasympathetic nervous system: responsible for actions that are complimentary to the fight or flight response, such as salivation, digestion, urination, and defecation, which are considered “rest and digest” activities

All of this communication takes place through neurons, which send signals to other cells through thin fibers called axons. These structures cause chemicals known as neurotransmitters to be released into synapses—the gaps between neurons—and are received by another neuron to convey the message. And lastly, the glia are specialized cells that support, protect, and nourish the neurons to help them perform their function properly and safely.

We distribute newsletters every week to educate you—our patients—on some of the most common injuries and conditions that we treat, and to explain why we always recommend seeing a physical therapist first when dealing with any type of pain. In working towards this goal, we also regularly summarize research studies that show how physical therapy typically leads to the best possible outcomes, and how it helps patients avoid surgery and other costly or unnecessary treatments in the process.

With the end of the year approaching, we’d like to look back at some of our favorite study summaries of 2019 in a four—part newsletter series with each one focusing on a different topic or region of the body. In part 4, we review research on physical therapy for arthritis and sports injuries, and how it compares to opioids for pain.

Arthritis

Arthritis is a term used to describe over 100 conditions involving inflammation of one or more joints, leading to pain and stiffness in those regions. It represents one of the most common causes of disability nationwide, as about 54 million Americans—or 23% of the population—currently have some type of arthritis. The majority of these individuals have osteoarthritis (OA), which occurs when protective cartilage in joints gradually wears away, but other forms of arthritis—like rheumatoid arthritis and juvenile arthritis—must also be recognized.

Level of participation in physical therapy or an internet—based exercise training program: associations with outcomes for patients with knee osteoarthritis (2018)

• Background: OA frequently affects the knees because they are weight—bearing joints that withstand significant loads from the rest of the body; exercise is generally regarded as one of the most effective treatments for these patients, but it’s not clear if delivering this through supervised physical therapy is necessarily better than self—instructed exercise
• How the study was conducted: researchers analyzed the results of an original study in which 159 patients with knee OA either completed physical therapy or followed an internet—based exercise training (IBET) program
• What the results showed: for the physical therapy group, a higher number of treatment sessions was associated with better overall outcomes for up to 12 months, and the greatest improvements were found in those who attended 6—8 sessions; for the IBET group, more frequent use of the website did not lead to any significant improvements for patients
• Take—home message: there appears to be a much better response to exercise treatments for knee OA when it’s guided by a physical therapist rather than led by online instructions, and more therapy visits leads to improved results; patients with this condition should therefore consult with a physical therapist to initiate an exercise therapy program

Sports injuries

Although the rate varies widely from one sport to the next, all sports carry a certain risk for injury due to their physical toll from contact, collisions, and pushing the body too far. About 8.6 million sports— and recreation—related injuries occur each year, meaning that about 34 injuries occur for every 1,000 individuals participating in sports. Sports injuries are most common between the ages of 5—24, but they can occur in athletes of any age.

Including the Nordic hamstring exercise in injury prevention programmes halves the rate of hamstring injuries: a systematic review and meta—analysis of 8459 athletes (2019)

• Background: injuries to the hamstrings—a group of three muscles located in the back of the thigh—are extremely common in many sports; the Nordic hamstring exercise strengthens these muscles and may reduce the risk for injury in various sports, but more research is needed to clearly show this
• How the study was conducted: a systematic review and meta—analysis was conducted, which analyze the results of all available research on a topic; 15 studies were included, which evaluated programs in which the Nordic hamstring exercise was performed to prevent hamstring injuries
• Results: exercise programs that included the Nordic hamstring exercise significantly reduced the incidence of hamstring injuries by up to 51%, and the reduction was found in athletes participating in multiple sports and at different levels of competition
• Take—home message: regularly performing a single exercise in addition to movement—based techniques can help individuals avoid a hamstring injury in many sports; therefore, it’s recommended that athletes visit a physical therapist for an injury—prevention program that will help reduce their risk

Opioids

Opioids are powerful pain—relieving medications that come with a high risk for overuse and abuse. Every day, about 130 Americans die from an opioid—related overdose, which is about 45,000 deaths related to opioids in 2017. Physical therapy is a much safer alternative to opioids for pain, and in many cases it can help patients avoid the need for a prescription altogether.

The Effect of Timing of Physical Therapy for Acute Low Back Pain on Health Services Utilization: A Systematic Review (2019)

• Background: although physical therapy is commonly recommended for low back pain (LBP), many patients either receive after a delay or not at all, and others may be prescribed opioids for their pain instead
• How the study was conducted: a systematic review was conducted, which is a comprehensive study that interprets the findings from similar research on the same topic; 11 studies were included, all of which assessed the use of healthcare services—like opioids—in LBP patients that either received early physical therapy, physical therapy after a delay, or usual care (which didn’t include any physical therapy)
• What the results showed: early physical therapy was associated with reduced use of healthcare services compared to delayed physical therapy, as patients spent less on care and had a lower risk for being prescribed opioids, having advanced imaging tests, or visiting the emergency department
• Take—home message: since starting physical therapy early can help patients with LBP avoid opioids and spend less on their treatments compared to waiting or getting non—physical therapy treatments, individuals with this condition are advised to make an appointment with a physical therapist

We distribute newsletters every week to educate you—our patients—on some of the most common injuries and conditions that we treat, and to explain why we always recommend seeing a physical therapist first when dealing with any type of pain. In working towards this goal, we also regularly summarize research studies that show how physical therapy typically leads to the best possible outcomes, and how it helps patients avoid surgery and other costly or unnecessary treatments in the process.

With the end of the year approaching, we’d like to look back at some of our favorite study summaries of 2019 in a four—part newsletter series with each one focusing on a different topic or region of the body. In part 3, we review research on physical therapy for knee pain, ankle pain, and foot pain.

Knee

The knee is one of the largest and most complex joints in the body. It’s also incredibly vulnerable to injury, with knee pain ranking behind just back pain as the second most common condition of the muscles and bones. Knee pain is the single greatest cause of disability in individuals who are 65 and older, and knee osteoarthritis is usually responsible in these cases. For more active individuals, injuries like runner’s knee, jumper’s knee, and tears of the ACL and other ligaments are most common.

How do the costs of physical therapy and arthroscopic partial meniscectomy compare? A trial—based economic evaluation of two treatments in patients with meniscal tears alongside the ESCAPE study (2019)

• Background: tears of the meniscus—a crescent—shaped piece of cartilage in the knee that absorbs shock—are common in athletic populations; many patients with meniscus tears are treated by a surgical procedure called arthroscopic partial meniscectomy, but it’s not clear if surgery is the best approach, and physical therapy represents an alternative
• How the study was conducted: 321 patients with meniscus tears were randomly assigned to undergo either an eight—week physical therapy treatment program—which featured stretching, strengthening, and balance exercises—or surgery; data on the effects and costs of these treatments was evaluated for up to two years to determine which led to better outcomes
• What the results showed: there was a relatively high probability that physical therapy was more cost—effective than surgery, and a relatively high probability that it was superior to surgery for both knee function and quality of life
• Take—home message: based on these findings, it appears that patients with a meniscus tear can experience better outcomes at a lower cost with physical therapy over surgery; these individuals are therefore urged to try a physical therapist program first before contemplating surgery

Foot and ankle pain

The feet and ankles have the tall task of withstanding the weight of the entire body, and as a result, injuries are quite common in this region. Foot and ankle issues are particularly common in active individuals, with ankle sprains being the single most prevalent injury sustained in sports. Other issues—like plantar fasciitis and Achilles tendinitis— typically occur in individuals who frequently do lots of running and/or jumping, but foot or ankle pain can strike anyone at any age.

Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta—analysis (2018)

• Background: Achilles tendinopathy is defined as either tendinitis (inflammation) or tendinosis (micro—tears without inflammation) of the Achilles tendon, and it causes pain, swelling and impaired performance; treatment options for this condition include physical therapy with exercise, splints, and orthoses (shoe inserts)
• How the study was conducted: a systematic review and meta—analysis was conducted, which collect and analyze research on the same topic; in this case, 22 studies were included, all of which evaluated either exercise, orthoses, or splints for Achilles tendinopathy to determine which is most effective
• What the results showed: moderate—quality evidence showed treatments that included exercise reduced pain and improved function in patients with Achilles tendinopathy; adding a splint or orthoses to an exercise program did not significantly change these outcomes
• Take—home message: exercise produced positive outcomes in Achilles tendinopathy, while splints and orthoses did not seem to have any notable impact; patients are therefore encouraged to see a physical therapist, where they can undergo an exercise—based treatment program and are likely to experience similar improvements

Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review (2018)

• Background: plantar fasciitis is a common injury involving inflammation of the plantar fascia, a strong piece of tissue that supports the arch of the foot; manual therapy is a hands—on technique commonly administered by physical therapists for these patients, but more research is needed to support this intervention
• How the study was conducted: a systematic review was conducted, which collects and analyzes data from research on the same topic; seven high—quality studies called randomized—controlled trials (RCTs) were included in this review, all of which evaluated manual therapy for plantar fasciitis
• What the results showed: manual therapy was found to improve patients’ function and threshold for pain more effectively than the other treatments analyzed
• Take—home message: since manual therapy appears to be a beneficial intervention for plantar fasciitis, patients with this condition should strongly consider seeing a physical therapist for a personalized treatment program that includes these techniques

In our next newsletter, we review our top summaries on studies of opioids for pain relief, sports injuries, and arthritis.

We distribute newsletters every week to educate you—our patients—on some of the most common injuries and conditions that we treat, and to explain why we always recommend seeing a physical therapist first when dealing with any type of pain. In working towards this goal, we also regularly summarize research studies that show how physical therapy typically leads to the best possible outcomes, and how it helps patients avoid surgery and other costly or unnecessary treatments in the process.

With the end of the year approaching, we’d like to look back at some of our favorite study summaries of 2019 in a four—part newsletter series with each one focusing on a different topic or region of the body. In part 2, we review research on physical therapy for wrist pain, hand pain, and shoulder pain.

Wrist and hand pain

Pain in the wrist or hands can result from a number of different causes. Some conditions (like carpal tunnel syndrome) develop from performing the same movements over and over, while others (like rheumatoid arthritis) are based on a more complex process that is largely uncontrollable. Injuries like wrist sprains and broken fingers are also fairly common, especially in athletes and active individuals.

Is manual therapy based on neurodynamic techniques effective in the treatment of carpal tunnel syndrome? A randomized controlled trial (2019)

• Background: carpal tunnel syndrome (CTS) is a common condition caused by a pinched nerve in the wrist, which usually leads to numbness, tingling and weakness in their affected hand; it can be treated either surgically or non—surgically with interventions like physical and manual (hands—on) therapy
• How the study was conducted: 103 patients with mild or moderate CTS underwent either a manual therapy program or no treatment (control group) for 10 weeks
• What the results showed: the manual therapy group experienced significantly greater improvements than the control group in several outcomes, with lower pain scores, reduced symptoms, and better functional status
• Take—home message: patients with CTS should seek out care from a physical therapist first to receive manual therapy, as it may lead to notable improvements and help them avoid surgery

Hand exercises for patients with rheumatoid arthritis: an extended follow—up of the SARAH randomised controlled trial (2017)

• Background: rheumatoid arthritis (RA) is a debilitating long—term disease that often leads to pain, fatigue, and less mobility, especially in the hands; physical therapy with stretching and strengthening exercises is often suggested as an effective intervention for these patients
• How the study was conducted: a follow—up analysis was performed on an original study of 490 RA patients that received either a personalized exercise program—consisting of strengthening and stretching exercises—or no treatment (control); the original study identified improvements from this program, and the follow—up was intended to see if these improvements lasted in the long term
• What the results showed: even though patients gradually performed fewer exercises (which they were instructed to complete regularly), they still showed better hand function scores compared to the control group for up to two years
• Take—home message: a strengthening and stretching exercise program can lead to long—term improvements in RA, so patients with this condition are advised to visit a physical therapist to begin treatment

Shoulder pain

The shoulder is a complex ball—and—socket made up of two joints. It is extremely mobile and allows the arm to rotate almost 360°, but this comes at a cost, as it’s also one of the most commonly injured areas of the body. Up to 26% of the general population is dealing with shoulder pain at any given point in time, with a higher concentration in those who regularly perform overhead movements (like painters, baseball players, and tennis players). Shoulder pain can come about immediately or develop gradually, with certain conditions being more likely to arise in older age.

EXERCISE THERAPY IN THE NON—OPERATIVE TREATMENT OF FULL—THICKNESS ROTATOR CUFF TEARS: A SYSTEMATIC REVIEW (2018)

• Background: the rotator cuff is a group of muscles and tendons in the shoulder that allows arm motion, and it’s often injured or torn in overhead sports like baseball; it’s not completely clear if surgery or non—surgical treatments like physical therapy and exercise are better for complete—or full—thickness—tears
• How the study was conducted: a systematic review was performed, which collects and analyzes all related research on a single topic; 35 studies—including nine high—quality studies called randomized—controlled trials (RCTs)—were included in this review, all of which evaluated the effectiveness of exercise for treating full—thickness rotator cuff tears
• Results: all of the RCTs showed that exercise was effective, as it led to an 86% reduction in pain, an 83% improvement in range of motion, an 89% improvement in strength, and an 85% improvement in function
• Take—home message: patients with rotator cuff tears should attempt a course of physical therapy first before considering the option of surgery, as an exercise—based intervention can lead to various improvements

In our next newsletter, we review our top summaries on studies that cover knee pain, ankle pain, and foot pain.

We distribute newsletters each week to help educate you—our patients—on some of the most common injuries and conditions that we treat, and to explain why we always recommend seeing a physical therapist early when dealing with any type of pain. In working towards this goal, we also regularly summarize research studies that show how physical therapy typically leads to the best possible outcomes, and how it helps patients avoid surgery and other costly or unnecessary treatments in the process.

With the end of the year approaching, we’d like to look back at some of our favorite study summaries of 2019 in a four—part newsletter series, with each one focusing on a different topic or region of the body. In part 1, we review research on physical therapy for neck pain, back pain, and issues with the jaw called temporomandibular disorders.

Neck pain

Of all conditions that cause disability, neck pain ranks fourth. It’s estimated that about 30% of adults experience neck pain each year, and up to 70% will deal with it at least once in their lifetime. A number of conditions can cause neck pain—including strains and sprains, osteoarthritis, spinal stenosis, a and herniated disc—but the end result is usually a limited ability to function normally.

Timing of physical therapy consultation on 1—year healthcare utilization and costs in patients seeking care for neck pain: a retrospective cohort (2018)

• Background: physical therapist—led interventions like hands—on (manual) therapy and stretching and strengthening exercises are commonly recommended for neck pain, and research suggests that the timing of when a patient starts treatment will affect their costs and use of other healthcare services
• How the study was conducted: 308 patients with neck pain who underwent physical therapy were placed into one of three groups based on when they first consulted with the therapist; these groups were early consultation (started treatment within 14 days), delayed consultation (within 15—90 days), or late consultation (within 91—364 days)
• What the results showed: patients who consulted with a physical therapist early saved about $2,172 compared to the late physical therapy group and $1,063 compared to the delayed physical therapy group; the early physical therapy group also showed a lower risk for being prescribed opioids and having injections or imaging tests compared to the late treatment group
• Take—home message: the timing of physical therapy makes a difference, and patients with neck pain are urged to start sooner rather than later in order to reap the greatest benefits at the lowest costs

Back pain

Back pain—especially low back pain (LBP)—is even more common than neck pain. LBP actually ranks as the most common painful condition and the number one cause of disability in the U.S. Recent statistics have shown that about 25% of the population has been affected by LBP for at least one full day within the past three months, about 80% of people will experience it at some point. While most cases of LBP will improve after some time, some patients are affected by persistent—or chronic—pain that lasts for several months or longer.

Immediate Physical Therapy Initiation in Patients With Acute Low Back Pain Is Associated With a Reduction in Downstream Health Care Utilization and Costs (2018)

• Background: although physical therapy is recommended for patients with LBP, not all patients start treatment right away, and this delay may affect what other healthcare services (like tests and other treatments) they end up using
• How the study was conducted: the medical records of 46,914 LBP patients were divided into five groups depending on whether they received physical therapy and when treatment started; these groups were 1) no physical therapy, 2) immediate physical therapy (treatment started within three days), 3) early physical therapy (4—14 days), 4) delayed physical therapy (15—28 days), 5) late physical therapy (29—90 days); the amount of healthcare these patients used and the associated costs were then compared between groups
• What the results showed: the longer patients waited to begin physical therapy, the more healthcare services they used and the higher the costs of their treatment; seeing a physical therapist immediately or early was associated with the lowest costs and healthcare usage
• Take—home message: patients with LBP are encouraged to see a physical therapist sooner rather than later, as doing so will likely lead to better outcomes and lower costs

Comprehensive Nonsurgical Treatment Versus Self—directed Care to Improve Walking Ability in Lumbar Spinal Stenosis: A Randomized Trial (2018)

• Background: lumbar spinal stenosis (LSS) is a common condition in which the space that surrounds the spinal cord narrows, which can cause pain and weakness in the lower back, buttocks and thighs; most patients with LSS are treated with conservative care like physical therapy, but more research is needed on its effectiveness
• How the study was conducted: 99 patients with LSS were randomly assigned to undergo either a conservative treatment that included exercise, education, and manual (hands—on) therapy, or self—care, which did not include any specific interventions; patients’ walking ability, pain, and function was assessed for up to 12 months
• What the results showed: patients who completed the conservative treatment program experienced significantly greater improvements than the self—care group in walking ability, pain, and function that lasted into the long term
• Take—home message: since conservative treatment that includes physical therapy was beneficial, patients who have LSS should strongly consider seeing a physical therapist to reduce their pain levels and improve their functional abilities

Temporomandibular disorders

The temporomandibular joint connects the part of the skull directly in front of the ears (temporal bone) to the lower jaw (mandible). It allows you to move your jaw up and down and from one side to the other, which is necessary for talking and chewing. Temporomandibular disorder—or TMD—is a general term used to describe a variety of conditions that cause pain and dysfunction of this joint, which can lead to problems moving the jaw.

The effectiveness of exercise therapy for temporomandibular dysfunction: a systematic review and meta—analysis (2017)

Background: physical therapy and exercise—based interventions (exercise therapy) are frequently used for TMDs, but the research is mixed as to how effective exercise therapy is for these disorders

How the study was conducted: a systematic review and meta—analysis was performed, which collects and analyzes research on the same topic; six high—quality studies called randomized—controlled trials were included, all of which compared exercise to other treatments or placebo for patients with TMDs

What the results showed: patients who underwent exercise therapy experienced moderate short—term benefits of reduced pain and improved flexibility compared to other treatments; a mixed approach to exercise therapy may be associated with the best outcomes

Take—home message: exercise therapy appears to be effective for TMDs, and patients with these conditions should therefore see a physical therapist to begin this type of treatment program

In our next newsletter, we review our top summaries on studies that cover shoulder pain, wrist pain, and hand pain.

Evidence on use of physical therapy during an initial episode of low back pain is mixed

Low back pain (LBP) is one of the most common health conditions, as about 65-80% of adults will experience it at some point in their lifetime. Many treatment options are available for LBP, and as a result, there is significant variation in how these patients are managed. Physical therapy has long been regarded as an effective treatment for patients with LBP, but some disagreement exists regarding its benefits, and not all international guidelines recommend it. In addition, evidence on the use of physical therapy for an acute episode of LBP—meaning it’s lasted for less than four weeks—is mixed. For these reasons, a study was conducted to evaluate the relationship between physical therapy and the use of other treatments for patients with back pain. The study particularly focused on the timing of therapy and if seeing a physical therapist sooner rather than later had an impact on their use of other healthcare services.

Patients are categorized into three groups based on when they accessed physical therapy

The researchers looked through a large database to identify the medical records of patients over the age of 66 who received treatment for LBP over a one-year period. This process led to a total of 431,195 patients being included in the analysis. Once these records were collected, patients were primarily grouped based on the amount of time between their first visit with a doctor for LBP and their first physical therapy visit. The acute treatment group consisted of patients who saw a physical therapist within four weeks, the subacute treatment group saw a physical therapist within four weeks to three months, and the chronic treatment group did so in 3-12 months. For each patient, the researchers counted the episodes of surgery, injections, and back-related doctor visits that occurred after the initial doctor visit to determine if there was an effect of the timing of physical therapy.

Low back pain patients should start physical therapy early to avoid other treatments

The results showed that in total, only 16.2% of patients received physical therapy within one year of seeing a doctor for LBP. Of these patients, 52% received physical therapy in the acute period, 18.1% received physical therapy in the subacute period, and 29.9% received physical therapy in the chronic period. Lastly, 11.9% of patients overall received an injection and 3.1% underwent surgery for their pain. Further analysis revealed that there was a significant reduction in the likelihood of having surgery in the acute and subacute groups compared to the chronic group. There was also a lower chance of having an injection, and a reduction in the number of doctor visits for LBP in the acute and subacute groups compared to the chronic group. Lastly, it was found that patients who started physical therapy in the acute period had the lowest risk of receiving these other interventions and frequent doctor visits, followed by those in the subacute group, and then the chronic group.

These findings suggest that patients who start physical therapy within four weeks of seeing a doctor for LBP are likely experiencing improvements, and therefore do not need to continue seeing a doctor or have other treatments like injections or surgery. Although it was not discussed in the study, this can also mean lower costs for patients, as surgery is an expensive intervention that may only lead to similar outcomes when compared to physical therapy. For these reasons, patients with LBP are strongly encouraged to see a physical therapist, preferably as soon as possible. Following this route will increase their chances of experiencing a successful outcome while avoiding other risky and expensive interventions. Patients should also consider seeing a physical therapist now in order to get the most out of their healthcare plan. As the year winds down, it’s recommended that everyone with a health insurance policy reviews it and checks on the current benefit status. For those who have already met their deductible or out-of-pocket maximum for 2019, co-pays will likely be lower or non-existent on physical therapy visits for the rest of the year, before deductibles renew on January 1, 2020.

-As reported in the April ’12 issue of Spine