Improving Physical Therapy Practice: A Patient’s View

After 6 years, and 4 failed courses of physical therapy for chronic neck pain and 2 failed courses for rotator cuff tears in right and left shoulders, I discovered that both my neck and shoulder pain had one root cause — many years of poor upper body posture and resulting shoulder blade instability.  It also became apparent that strengthening shoulder blade stabilizers and improving my upper body posture was not enough; correction of my lower body posture was also needed.  After all it is the lordotic/inward curve of the lower back that positions the upper body over the hips and allows a stable erect well-aligned posture.  (Other primates like chimpanzees don’t have a lumbar lordotic curve, but have a long kephotic curve to the entire spine; and mostly they knuckle–walk with a hunched-over upper body.)

The degree of lumbar lordosis is determined by the tilt of the pelvis.  The tilt of the pelvis depends on the action and balance of  4 groups of muscles: hip extensors, hip flexors, anterior abdominals and low back extensors. Ultimately neck alignment depends on the state/balance of muscles in the lower torso and legs.  Physical therapy for musculo-skeletal neck and shoulder pain should include correction of both upper and lower body posture. Initially that may take more time but treating musculo-skeletal problems piecemeal and having to repeat physical therapy later for the same problem or what seems at first to be a different problem but that stems from the same root cause (such as poor posture and weak upper back from that poor posture) is absolutely a waste of time, money (the patient’s, the insurance company’s and/or the taxpayer’s) and the waste of one of the few opportunities a patient has to receive intensive, personalized, one-on-one help from a qualified professional.

[The following applies to chronic musculo-skeletal problems but acute injuries can lead to chronic problems if not resolved effectively or perhaps poor posture alignment might have predisposed to the injury in the first place. Addressing some of the same issues may help.]

Physical Therapy should be more than a spa experience and more than a patient robotically doing exercises from a long list without knowing the specific purpose for each and how to monitor his or her own progress.  Patients need to know what the problem is, how it developed and what exactly needs to be done to fix it.

Such a conversation/instruction might include:
— an explanation of the problem’s root causes, whether postural such as forward head, or muscle imbalance such as tight outer thigh muscles and weak inner thigh muscles, and how it is (or probably is) causing the symptoms and/or pain;
— which muscles are too long or too weak and need to be strengthened, and which ones are too short or too strong and need to be stretched;
— the best exercises to correct that imbalance.  And these should not be a long list of exercises because more than likely there won’t be enough time for the patient to perform them as slowly or with as much concentration as is required to really make a difference.

In order to assign fewer but more precisely targeted exercises, the testing and initial evaluation are of utmost importance. (A classic reference such as Muscles, Testing and Function with Posture and Pain,  5th edition, by Kendall et al is invaluable for determining muscle strength, weakness, and length, and any joint misalignments. )  After progress has been made and pain is less, perhaps more exercises may be assigned to provide a routine that takes into account the patient’s occupation and life style (e.g. an office-worker at a desk 8 hours a day needs a different plan than a gardener) so that the patient’s particular misalignment/muscle imbalance doesn’t return.

— And if relevant, a discussion with the patient about changes to the ergonomics of his or her work situation. Sometimes people don’t realize there’s a better way to sit, bend, lift, work at the computer or text message.  Practicing a better way helps to instill that change.

When introducing an exercise, the therapist should instruct the patient what to notice/look for when doing that exercise, and how it feels to activate or stretch those specific muscles and how slow and how far to go; To this end, the use of pictures or diagrams of the body and the specific joints and muscles involved, along with a mirror set-up for the patient to see their own body in action is very important.  In this way the patient can visualize the muscles, joints and bones as his body is doing the exercise.  Studies using functional MRIs of the brain have shown that when a person visualizes a body action, the same area of the brain is activated as when the movement is actually performed. Combining visualization and actual performance might speed improvement, and in my experience the two together make all the difference.

The exercise that helped me overcome my chronic neck pain, the “fix the shoulder blades” exercise, I’d  learned and done in physical therapy for rotator cuff tears along with a bunch of other exercises. At that time, over 6 months prior, it hadn’t helped my shoulders much or my neck pain  (though it was for the shoulders not the neck, but the root causes of both problems — weak upper back muscles and hunched posture — were the same). But later when I did the exercise using a mirror set-up so I could see my back and the muscles around the shoulder blades during the exercise, and could concentrate on the muscles to make them contract harder, that made all the difference. Nothing in my experience of 6 courses of physical therapy for neck and shoulder came close to the way I worked those shoulder blades.

But getting back to the “should’s” of patient exercises (sorry to sound so authoritarian but I want to be more direct.)

After introducing the exercise, the therapist must follow through by carefully monitoring the patient for correct form, effort and time taken during the assigned exercises. (Assistants are not always helpful on this.) Ways for the patient to monitor their own progress should be devised; an example is the mirror set-up for the Fix the Shoulder Blade exercise; another is self-observation of the alignment of a body part that can be seen easily, such as the knee cap. When I had physical therapy for knee pain (PT course # 7), the physical therapist showed me that my knee caps had drifted off center. He didn’t use technical terms but explained to me why I needed to strengthen my inner thigh muscles and stretch the outer thigh muscles to recenter my knee caps. I could visualize this fix, and knew best where to focus my effort. I also knew what my knee caps would look like when I’d succeeded.  Another example is for tight quadriceps. Patients can self-test how effective their quad stretches are, by lying supine,  and pressing their lower backs to the mat/floor by tightening  their abdominals. Then they observe how much their knees have to bend to accomplish that.  The less their knees need to bend, the looser their quads.

The therapist should make sure that the root causes of the problem are being addressed. If chronic musculo-skeletal pain is involved, in many cases it may be complicated by poor posture alignment  which can stem  from long standing habit,  a secondary consequence of an acute injury, or the weakening effects of a chronic illness.  Many acute injuries resolve in a timely manner; but if the patient has poor posture, acute injuries may take much longer to resolve, if ever, and become a chronic pain problem, unless poor posture is addressed and improved.  

Treat the whole patient, not just the symptoms, and teach patients what they need to know so the problem is less likely to return.  Patient empowerment through knowledge will improve their treatment and your practice.

And before I forget, a therapist should not assume that the information in a patient’s radiology report or an image in an MRI or CT scan dooms  therapy to failure; or use that information as an excuse when therapy does fail. And just because most of a therapist’s neck patients don’t get better doesn’t mean it’s because of arthritic changes or something else beyond the therapist’s control. (plenty of people with significant degenerative spine changes don’t have chronic pain. I’m one of those.) Maybe it’s what the therapist is NOT doing.

My first PT in particular, the spine specialist at a large PT practice, and the only one (of four) I brought my MRIs too, was dismissive when I told her that I still had neck pain doing the exercises. She said it was to be expected with my degree of spinal arthritis, and gave me the phone number of the “best” spine surgeon in the city. Sometimes I imagine running into her at the grocery store and saying “Look at me now, 8 (or so) years later and I can do whatever I want, with no neck pain and no surgery. What use are your fancy spine mobilization techniques and all the weekend continuing education classes, when in the end they weren’t effective at all?

 

Pillows

When my neck pain was bad, I went through—I can’t remember how many pillows…firm, soft, overstuffed, feathers, brand names, hotel, orthopedic etc.—trying to find one that didn’t leave my neck worse in the morning. Finally I took a medium polyester filled pillow, removed some filling from the center to cradle my head, then used the extra filling to form a “hump” at the lower edge to support my neck, and that was about all that “worked,” but even that wasn’t perfect because the fluff kept compacting. The fancy shaped orthopedic pillows didn’t help. The neck support area always seemed too thick and the new fangled “visco-elastic” material never shaped to my neck (which had lost it’s normal lordotic curve years ago). So I always ended up whittling away at the foam, reshaping it again and again until I had to throw the pillow out. (Some in my neck/back pain group put their memory foam pillows through the dryer several times to soften them. I think I tried it once but it didn’t help.) The one with the little styrofoam beads didn’t help either. I opened it to remove some of them; they got everywhere and stuck to everything, and still my neck didn’t like it. And then there was the water pillow that I ordered online. No matter how much or little I filled that thing, it still wasn’t comfortable. And besides it was heavy with all that water sloshing around and lifting it was tough on my neck.

From all this trying of pillows, it became clear to me, there was no “magic” pillow when one’s neck is inflamed and painful. Some can make it worse, especially the high, over stuffed ones that force your neck to curve into flexion/kephosis (“C” curve). But most won’t help reduce pain that’s already there because of long term poor posture.

Well my neck pain is gone thanks to my new posturally correct self. Currently, I have a nondescript, unmodified, no-name pillow that works fine. I have been thinking of getting a slightly firmer one because I always sleep on my side now. A far cry from when I slept rigidly on my back, towel rolls under the ends of my pillow to prevent my head from rolling to either side.

 

Dear D….

My reply to a support group post from a woman, who was prescribed muscle relaxers and physical therapy. This combination didn’t help after 2 weeks, so her doctor stopped both and prescribed Celebrex instead.  Celebrex seemed to help but she was concerned over the side effects her friends had experienced, including kidney damage from long term use.

 

Dear D…,

Celebrex helps but it is not a long term solution because of potential side
effects, which are different for each individual and of course there are the
lucky ones, who never have any side effects. I became allergic to all nsaids
after I was on high dose Celebrex for several months, which I hadn’t been
before. One Celebrex or an aspirin sends me into anaphylaxis.

If you don’t have out-right bony nerve compression in your neck and don’t need
surgery, then the right kind of physical therapy should help you.

It took me years of physical therapy to figure out that a lot of what is offered
by PTs is not the right kind of therapy for neck pain.

The right kind is to start off first with evaluating postural alignment, in
particular upper body alignment, and then begin a program of strengthening
certain muscles, mainly back muscles, and stretching others mainly chest
muscles, so that you can more easily maintain correct alignment of the
upper body. And the consequence of correct alignment of the upper body is
correct alignment of the head and neck.

After that, any other kind of treatment a PT wants to give: heat, ice, stim,
mobilization, traction, or other exercises may help but only short term unless the posture
issue is addressed first.

Posture of the lower body and also posture while sitting and doing daily work is
also important. How you hold your head, which is like a 10 pound bowling ball
perched on a stick of a spine, determines the stress on your neck muscles. Hold
the head out in front of your shoulders all day long and your back neck muscles are
over-worked and become very unhappy. And if you always let your upper back slouch,
the poor muscles that suspend your shoulder blades from your neck cry “uncle.”

If you have a lot of neck joint inflammation to begin with, allow at least 2
months of posture training to see reduced neck pain. My neck had gotten so bad,
that the pain flared with direct neck massage, cervical joint mobilization and
neck traction. A good posture correction program corrected that in 2 to 3
months.

I realize that Fixing Posture First sounds counter-intuitive, but try it, it
might just work for you like it did for me.

Rochelle

Slouched Posture: Efficient or Not?

Inspired by Todd Hargrove’s post at BetterMovement.org: “Is “Efficient” Movement Unsafe?

The Back Extensor Group of Muscles

I remember reading that good posture was the most energy efficient way to stand and sit. But why does it seem to take so much more energy to keep the spine straight than to slouch, especially with fatigue or illness. If energy efficient means using the least amount of energy to perform work then at first glance, slumping with rounded back does seem to take less energy because the back extensors, a large group of back muscles, slack off from straightening the back and let the weight of the upper body hang passively off spinal ligaments and joints. But is the spine well suited to supporting this much dead weight by itself? The short answer is “NO” because the spine has inherent flexibility that allows it to bend when needed for everyday activities. The fact is that by itself the normal spine cannot be both flexible to allow us to bend down to tie our shoelaces and inflexible enough to completely support our bodies. A fused spine can’t bend and therefore doesn’t need stabilization, but a normal, flexible spine does need the stabilization that is provided by the balanced action of two antagonistic groups of muscles—the back extensors, which bend the spine backwards (and keep us erect), and the front abdominals which bend the spine forward. For ideal posture the extensors and flexors act in concert to stiffen the spine in as close to a vertical position as the natural curves allow. This is the spine’s most stable and least stressful/damaging upright position and results in even distribution of compressive forces on intervertebral discs.

When the back is excessively rounded forward, discs are unevenly stressed, and over time their outer layer or annulus prematurely develops tiny cracks that cause loss of moisture and disc height, which causes spinal instability, increased pressure on facet joints, bone spur formation and stenosis. A rounded back also causes an imbalance of head and upper body weight. Optimal distribution of body weight is important for our ability to stand upright. Moving around on two legs is precarious to begin with. And if the ten to fourteen pound head juts out in front of the body because the top of the thoracic spine curves forward, and the upper chest and back, shoulder and arms also curve forward, it’s more difficult.

There is already a natural imbalance of weight due to the rib cage chest area extending out front of the thoracic spine,

Balanced(which has a natural kephotic (posterior) curve to counterbalance the rib cage (see balanced posture at left) and this weight imbalance causes a constant forward bending pressure on the spine that must  be resisted for the body to stay upright.

 

 

 

 

With excessive rounding of the upper back, the body must realign itself to keep from falling forward. One of three strategies is used:
Flat_Back

 

1. The pelvis rotates backwards, trying to pull the upper body upright, and pulls both the lumbar and mid thoracic spine flat. But since the upper back and head are still held forward of the torso, and there’s no counter-balancing curving of weight to the back, the entire body leans a little forward, not so much that one would fall over (unless trying balance exercises), but enough to have difficulty flattening the entire back and head against a wall without extending (bending slightly backwards) the back. see Flat Back Posture

Sway_Back1

 

 

 

 

 

 

 

2. The upper torso shifts backwards in a long, rounded curve that is also counterbalanced by the pelvis shifting forwards. See Sway Back Posture.

 

 

 

 

 

Kephotic_Lordotic1

3. The excessively hunched upper back is counterbalanced by the abdomen, which pooches out in front because of an excessive inward lordotic curve of the lower back. Against a wall, the upper back and butt may touch, but there’d be lots of space between wall and lower back. See Kephotic-Lordotic Posture.

 

 

All three strategies/postures produce their share of sore backs and necks.

 

 

 

 

Balanced Posture

Now, getting back to the subject of “Efficient Movement.”  A better definition for “efficiency” would be “The least energy used to achieve the best possible result.”  The back extensors must be engaged to stabilize the spine, so that body weight and other forces are borne with vertebra stacked vertically, one on top of the other and the forces are spread evenly on discs and ligaments. When the back is as straight as possible, given the natural curves,  body weight is close to being balanced around the spine. The vertical black line (the center of gravity) in the posture illustrations, represents equivalence of weight in front of and behind the line. When weight is balanced, posterior muscles like back neck muscles and lower back muscles, as well as hip extensors (hamstrings) (depending on the type of faulty posture) are not over-worked. But also front postural muscles like neck flexors, abdominals and hip flexors are not under-worked and weak.

In Todd Hargrove’s words: “any local gains in energy efficiency from “floppy joints” are more than offset by a general loss of energy efficiency that comes from poor alignment of the bones and inadequate stabilization of the joints….In other words, valgus knees (knees collapse inward), rounded backs, and overpronated feet (foot rolls inward and arch collapses) are not actually energy efficient at all, because they sacrifice the stabilization and proper bony alignment which is the key to efficient movement and posture.” Yes, it feels easier to slouch especially when one is tired or not feeling well. Add a chronic illness, and it seems like there’s little energy left to stand tall with good posture. But it is so worth the effort because the strength and balance of postural muscles is preserved and the chances of postural neck and back pain are greatly reduced.

Examples of Poor Posture

Posted on June 22, 2012 by Rochelle

The Thinker by Auguste Rodin, one of the most recognizable sculptures in Western Culture, is an example of really bad posture. I’ve added the skeleton to show that his rib cage sags and constricts his breathing. His lower back is rounded, which puts excessive, one sided, pressure on the intervertebral discs of the lumbar spine. His posture though, is not the worst  I’ve seen. He doesn’t sit on his lower back like so many  young people. He sits squarely on his sitting-bones or  ischial turberosities.

 

Gwyneth Paltrow is a beautiful woman but tends to have swayback posture. In Duets, a marvelous  movie combining multiple story lines with love and karaoke,  Paltrow exaggerates her poor posture even more to portray a gawky, young innocent, who melts the heart of her long absent karaoke-hustler father, played by Huey Louis.

 

 

 

 

 

 

 

 

 

 

 

 

 Lily Cole, an English model and actress, tends toward a rounded back.

 

 

 

 

 

 

 

 

Myley Cyrus, like many teenage girls, tends to have curved forward shoulders, rounded back, and depressed chest.

 

 

This is approximately what my posture looked like before I realized that slouching had caused my chronic neck pain. Unfortunately, none of the many doctors or the four physical therapists  I went to for help ever mentioned my poor posture as a possible cause of neck pain. One PT commented that my shoulder blades weren’t working right, but he didn’t say why and didn’t give me exercises to fix it. (Or maybe he did but I was clueless at the time. In my defense, I had a debilitating stomach illness, was in a lot of pain and my neck felt so weak I could barely make it to PT sessions. ) Regardless, I’m still amazed and very disappointed that all these professionals could not help me. I had to find my own way.    See fixtheneck.com

Rear and Side View Car Mirrors

A panoramic rear view mirror* became a necessity when my neck muscles were so spasmed I could barely turn my head.  To this day, I still use a panoramic rear view mirror, because it feels wrong not to.  Why don’t all cars come so equipped?  They have loads of new technology and safety equipment,  front and side airbags, hands-free blue tooth, GPS, T.V. and wired for mobile everything.  A simple panoramic rear view mirror seems a no-brainer. (However, when I couldn’t turn my head at all, I didn’t dare drive even with the panoramic mirror; it was just too dangerous.)

*Auto parts stores have inexpensive, light-weight panoramic rear view mirrors that fit over the existing rear view mirror.

To help with seeing cars  in the blind spot, I use a little stick-on convex mirror in the corner of the driver’s side-view mirror.  This was another necessity when my neck was so stiff and now I still use it.

Fitness Classes

I don’t know how common this is, but many of the stretching/strengthening exercises in my fitness class at a local senior center (yes, I am that old.) involve some kind of bending-forward . This is particularly true of the mat exercises, which include crunches (modified sit-ups) for strengthening abdominals, several types of jack-knife type positions (sitting while leaning backwards with legs extended and raised) while holding weights in various positions,other variations of sit-ups and also the bending-forward, reaching-for-the-toes exercises for stretching hip extensors (hamstrings), and even though the instructor says to keep the back straight many of the students hunch their upper backs to reach their toes, which elongates/weakens the thoracic back extensors which worsens the hunch  And too many crunches can worsen sway back posture. Meanwhile strengthening back extensors, the muscles that pull our backs erect, is ignored.  If exercises only target front abdominals for strengthening and end up stretching opposing back extensors, that is a prescription for worsening hunched posture. More bending forward exercises to strengthen abs increases the tendency for the body to bend forward all the time. After all, isn’t that what these exercises are training the body to do?  For healthy balanced posture, at least equal attention must be given to back extensor strengthening.  And for those who already have hunched posture, more attention must be given to back extensors, and depending on the type of faulty posture, only particular abdominals may need to be strengthened and perhaps abdominal strengthening is not needed at all, in fact may be counter-productive as in flat back posture.  For a senior population already tending toward hunched posture because of increases in chronic illness and age-related decline in bone density (a risk for wedging of vertebral bodies and compression fractures with bending forward exercises), a balanced muscle strengthening program is even more important.

The rest of the class, which includes 30 minutes of aerobics is enjoyable. Doing the steps to “up beat” music keeps participants coming back and that is  important. I intend to stay with the class especially for the step aerobics, which gets the heart pumping but not excessively. There is no pressure to do all the exercises and I can opt out of the exercises that are counter to my posture type (flat back).

 

Tai Chi classes: Tai Chi is done slowly, mindfully, with arms and legs coordinated and both moving throughout the movements. Learning it well takes balance, understanding the logic and flow of the movements, and sensitivity to the proprioceptive senses — all of which is very challenging,

From the aspect of improving posture, you’d think that good posture would come automatically with Tai Chi practice, however, from what I saw in this Senior Center Class, Tai Chi by itself does not improve posture. Over half the participants have a more kephotic upper back than is healthy.  Perhaps if there were mirrors on all the walls or practices were video-recorded, and people actually saw themselves  maybe they’d straighten up. But how likely is that?

Two articles of interest for those considering back surgery

A New England Journal of Medicine article–Surgery versus Prolonged Conservative Treatment for Sciatica, Conclusions: “The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery.”
The Journal of Bone and Joint Surgery–Surgical Compared with Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis, Conclusions: “Compared with patients who are treated nonoperatively, patients in whom degenerative spondylolisthesis and associated spinal stenosis are treated surgically maintain substantially greater pain relief and improvement in function for four years.”

Yoga

As a teenager I dabbled in it, but either injured myself as when I tried a yoga headstand and strained my neck, or began wondering what all that extreme twisting and bending was doing to my joints and ligaments. I watched my dad, a student and teacher of Hatha yoga, who did the positions much better than I could. He also had a lot more determination than I, maybe too much. He would remain in a headstand propped against a wall for quite some time—his face turning bright red. Later I wondered if that had something to do with the Alzheimer’s that overtook him in his late 60s. (Or was it head trauma from boxing as a heavyweight on his college team? No one else in his family ever had Alzheimer’s.) Anyway, he finally did stop doing the extreme lotus because he figured it caused the painful phlebitis (a blood clot in a deep vein of a lower leg) that swelled his lower leg. The lesson here being: don’t do yoga to extremes.
But mostly I’ve heard good things about Yoga from friends. However, a recent article in the New York Times, How Yoga Can Wreck Your Body, discusses the small but growing numbers of serious injuries to the lower back, shoulder, knee and neck. Glenn Black, a well known New York instructor states that injuries occur because students have underlying weaknesses that need to be addressed first. Also mentioned is Yoga Instructor, Carol Krucoff, who tore a hamstring muscle while being filmed doing Kitchen Yoga for a national TV show. See Insight from injury: If the practice of hatha yoga was meant to heal, why are so many yogis getting hurt? Instructor Glenn Black in another interview, Yogi Glenn Black Responds to New York Times Article on Yoga, lists pinched nerves in the neck, low back tightness, injuries to hips, knees and shoulder problems and also which yoga poses to avoid. And most disturbing of all:

EF: You now have a spinal fusion and screws in your lower lumbar spine to stabilize herniated discs and spondylolisthesis. How did your own yoga injuries come about?

Glen Black: Extreme back bends, and twisting coming up from my hands on my ankles. I overstretched my ligaments and destabilized my spine. 

But any sport or activity done to extremes can cause injury. See: Practicing Safe Yoga — 5 Tips to Avoid Injuries by Eva Norlyk Smith, Ph.D.

Do Glucosamine and Chrondroitin help arthritis?

Well designed studies say no (see “Glucosamine and Chondroitin for Arthritis: Benefit is Unlikely” by Stephen Barrett, M.D. at Quackwatch. In brief: the largest and best study, the Gait or Glucosamine/Chondroitin Arthritis Intervention Trial, showed virtually no pain relief and an extension of the study showed no significant structural benefit, defined as slowing of the narrowing of the joint space in the knee). Another study specifically studied 250 adults with chronic low-back pain and degenerative arthritis for a year. Half received glucosamine and half placebo with no difference between the two. A more recent study involving 662 GAIT patients looked at glucosamine and chrondroitin sulfate, either separately or combined, and celecoxib (Celebrex) as well as a placebo. No statistically significant differences were found among the groups.
I myself took Glucosamine and Chondroitin for several months without positive effect, but then Celebrex at that time didn’t help either. There are people I know who claim they have been helped, especially by formulations with MSM, but it’s no miracle cure. So far there don’t seem to be any serious side effects of these supplements, but since supplements in general are not regulated, I’d be careful and also ask a doctor for advice. For a possible mechanism of action for glucosamine see “Food Intolerances: The Controversy Over Gluten Grains and Nightshade Plants: Do They worsen Arthritic and/or Intestinal Inflammation?