Human Performance and Rehabilitation Centers, Inc.

Pregnant with Back Pain? Physical Therapy Can Help!

I recently had the opportunity to work with a woman in her 34th week of pregnancy, with a diagnosis of low back pain (LBP).   She was experiencing right sided buttock pain (pelvic girdle pain or PGP), with mild intermittent mid posterior thigh pain.  Her pain was made worse with attempting to stand on one leg as in dressing or washing her feet.   Her treatment included manual therapy, postural education and awareness to decrease the strain on her joints, and appropriate exercise.  As you can see in the photo to the right, with therapy she was able to adjust her posture so that she was carrying her baby instead of her baby carrying her.

When I encounter pregnant women with low back pain I expand my normal evaluation to focus on the unique physiological and musculoskeletal changes that occur during that exciting nine month period.   Pregnancy is a common time for back pain to begin, with over 50% of pregnant women reporting back and or pelvic girdle pain.   20-25% continue to experience LBP and PGP postpartum.  Think about the changes that occur in a woman’s body throughout pregnancy and it is no wonder women are three times more likely to develop low back pain than men. Physiological changes, alterations in hormone levels and necessary weight gain during pregnancy contribute to the increased postural demands on the musculoskeletal system.  How often do we gain an average 25 pounds in nine months? The growing baby places significant demands on the mothers’ core!

The mother’s spine adapts to the baby’s growth.  The natural spinal curvatures increase from the lumbar (low back) to the cervical (neck) spine.  The typical pregnancy sway back posture increases the load on the spinal joints.  The pelvis takes on an anteriorly rotated position, which places excessive stress on the SI joints, not to mention making it harder for the muscles around the joint to function accordingly and affects the stability of the pelvic ring.  Hence low back and pelvic girdle pain, (pain between the top of the pelvis and the fold of the buttock including the sacro- iliac joints and the joint of the anterior pelvis the pubic symphysis).  Hormonal changes produce laxity in the joints of the body, which is most recognized in the pelvis.  The joint at the front of the pelvis begins to widen in the 10th to 12th week, and averages a 6 millimeter separation which is considered normal.   The increase in laxity places a greater demand on the muscle system and it is theorized that it is the asymmetrical laxity and increased demand on the joints and muscle that lead to pregnancy related back pain.

Looking at the diagram above it is obvious that the abdominal muscles stretch in all pregnant women.   The rectus muscle, the most superficial of the abdominal group is stretched at its midline attachment to the underlying tissue called the linea alba. (Stay tuned for another blog about caring for abdominals before and after pregnancy)   Some women will have spontaneous return of their abdominal muscles postpartum and some will not. Weak and stretched abdominals limit the function of the core to assist in support of the spine.  Bending forward becomes impossible through the later stages of pregnancy, and alternative strategies for bending become the norm.

The bottom or basement of the pelvis is supported by 3 layers of very important pelvic floor muscle.  This group of muscles attaches from the pubic bone in the front to the tail bone in the back and along the sides of the pelvis.  These are muscles that we generally do not think about, but they are muscles that are under voluntary control. They function to support the contents of the pelvis, which in the last few months of pregnancy can be a considerable number of pounds.  PFM assist the back and pelvic joints with stability for increased loads, such as carrying and lifting.  They also function to keep us dry or continent, which is a demanding job considering the extra weight they are already supporting.  So, it is not uncommon for women to experience bladder leakage in the latter part of pregnancy.   Women with PGP are more susceptible to bladder leakage.  More argument to get help for your back pain!  No bladder leakage is ever considered normal !  The good news is, UI can be prevented with the use of Kegel exercises.

Since physical exam is the primary means of diagnosing back pain in pregnancy, a physical therapist with pregnancy postpartum specialization is one of the best options to help reduce or even eliminate your back or pelvic girdle pain, help you protect your abdominals, teach proper Kegel ex through pregnancy, and advise on regular exercise.  The mechanical dysfunctions of pregnancy related back pain  are helped by restoring and supporting  joint function, participating in regular and  appropriate  exercise (www.acog.org) and adapting posture and regular everyday day tasks to accommodate the growing baby.

Most patients believe that pain will be eliminated once they give birth but, up to 1/3 of women continue to experience pain 1 year or more after their pregnancy. Back pain during pregnancy does not have to be “normal”.   If you are experiencing back and or pelvic girdle pain with your pregnancy that is limiting your regular activities talk to your doctor, and request a visit to either one of our 2 women’s health physical therapists that specialize in pregnancy postpartum back and pelvic girdle  pain.

Managing Workplace Injuries

Following up on our previous blog post, we also received some great tips from Birmingham clinician Morgan Jackson, PT, DPT on managing workplace injuries.

  1. Know Your Body: It’s important to monitor any aches and pains that begin to appear. The earlier you catch the injury the better – if injuries last more than 2-3 weeks, it’s time to see someone. Recovery can be much quicker, and you can avoid more serious issues that could require surgery and/or physical therapy.
  2. Know Your Symptoms: Dull aches that go away may be normal, but a persistent burning sensation or sharp pain may indicate that it’s time to see someone.
  3. Know Your Situation: If your activity level has changed, pains may be expected, but if your activity level hasn’t changed and you aren’t doing a new job with different movements – it may be time to see a therapist.

Most small strains or overuse injuries go away after two weeks, if the proper adjustments and rest are performed.  It’s important to see a doctor if the pain persists to avoid a more serious injury, for example, carpal tunnel syndrome, that could require surgery and/or physical therapy.

This is also an important time to talk to your employer’s HR team (or the person in charge of injury prevention, such as a safety manager) about your pain.  They can review the setup of your work area, chair and look at your posture to help you get into a more comfortable position.

Be sure to ask questions about the changes they suggest so you have a full understanding of the reasons for the changes.  And finally, if you don’t already have it, now would be a good time ask for any materials they have on injury prevention.

Preventing Workplace Injuries

We recently spoke with Birmingham clinician, Morgan Jackson, PT, DPT, about preventing workplace injuries. She shared great tips on how employees and employers can work together to prevent injuries and build a workplace where employees thrive.

Employees:

  1. Know your policies: Many workplaces have injury prevention plans in place. Reach out to the HR team or safety manager at your company to see if they have a program.  The tips they provide can be as simple as proper posture, setting up your chair properly and the correct placement of your monitor and keyboard.
  2. Take breaks: Take micro break every 20 minutes to stand up and stretch or move a bit. Then, most importantly, follow their guidelines and if you start to feel pain such as a sore back, wrist or shoulder ask them to come back for a tune-up.
  3. Escalate when appropriate: If pain persists more than 2-3 weeks, it may be time to see someone before it gets worse.

Employers:

  1. Have a policy and follow up: The most important thing the employer can do is have an injury prevention plan in place that can be tailored to each employee. But as important is the follow up and reinforcement.  Have a plan that starts on day one, but continues to educate and remind employees.
  2. Set up employee work stations: If in an office environment, help employees set up their work area in the proper way, including desk, chair, monitor, keyboard and mouse and explaining proper sitting posture to the employee.
  3. Don’t just tell the what, explain the why: Explain what things SHOULD feel like, but more importantly, explain why it’s important and what can happen if they don’t take direction properly.

A Testimonial that Warmed Our Hearts

We were so thrilled to receive this heartfelt letter from the mother of one of our valued patients.  There is something so very special about working with our peds patients and are honored to have served this family.  Thanks Kathy and little Emmet!

“I am a mother of a 3.5 year old son with Joubert Syndrome and we just left our first medical conference. As we began the drive home today, I was reminiscing on our long journey here and felt compelled to reach out to the team at Pediatric Rehabilitation in Columbus, GA. These women worked with my son from about 1 years old until we moved just before his third birthday, and they were the true reason we were able to find our son’s diagnosis.

They had worked with him for about 6-9 months before letting me know that our son was definitely improving with his gross and fine motor skills, but was also displaying unusual behaviors/not progressing in areas that normally should. They made a point of mentioning, gently and with absolute respect for our opinion, that seeking a second opinion for our son’s neurologist could possibly be very beneficial and offer answers to his medical questions. I definitely hesitated (until close to when he was about 2.5), but after consistently observing the same things they pointed out, we requested a referral to see a neurologist at Children’s Healthcare of Atlanta and within a week an MRI was conducted and we had an official diagnosis.

With Emmet’s condition, there is a high likelihood of retinal degeneration, liver, as well as kidney failure. Had we not followed up on their expert advice, we would have never known to be monitoring his eyes and internal organs. Your employees quite possibly saved our son’s life and our family is forever indebted to the fantastic staff you have at Peds Rehab.

Regards,

Kathy”

All About Parkinson’s

Parkinson’s disease (PD) is a chronic and progressive movement disorder, meaning that symptoms continue and worsen over time. Nearly one million people in the US are living with Parkinson’s disease. The cause is unknown, and although there is presently no cure, there are treatment options such as medication and surgery to manage its symptoms.

Parkinson’s involves the malfunction and death of vital nerve cells in the brain, called neurons. Parkinson’s primarily affects neurons in the area of the brain called the substantia nigra. Some of these dying neurons produce dopamine, a chemical that sends messages to the part of the brain that controls movement and coordination. As PD progresses, the amount of dopamine produced in the brain decreases, leaving a person unable to control movement normally.  The specific group of symptoms that an individual experiences varies from person to person.

Symptoms

Primary motor (movement) signs of Parkinson’s disease include the following:
Tremor of the hands, arms, legs, jaw and face
Bradykinesia or slowness of movement
Rigidity or stiffness of the limbs and trunk
Postural instability or impaired balance and coordination

Each person with Parkinson’s will experience symptoms differently. For example, many people experience tremor as their primary symptom, while others may not have tremors, but may have problems with balance. Also, for some people the disease progresses quickly, and in others it does not. By definition, Parkinson’s is a progressive disease. Although some people with Parkinson’s only have symptoms on one side of the body for many years, eventually the symptoms begin on the other side. Symptoms on the other side of the body often do not become as severe as symptoms on the initial side.

Progression

The progression of Parkinson’s disease varies among different individuals. Parkinson’s is chronic and slowly progressive, meaning that symptoms continue and worsen over a period of years, but is not considered a fatal disease. Movement symptoms vary from person to person, and so does the rate at which they progress. Some are more bothersome than others depending on what a person normally does during the day. Some people with Parkinson’s live with mild symptoms for many years, whereas others develop movement difficulties more quickly.

Non-motor symptoms also are very individualized, and they affect most people with Parkinson’s at all stages of disease. Some people with Parkinson’s find that symptoms such as depression or fatigue interfere more with daily life than do problems with movement.

Since Parkinson’s disease (PD) is a chronic condition, it is important to develop and maintain a solid PD management plan. Research has shown that those who take an active role in their care see an improvement in their Parkinson’s symptoms.

Management

Managing your care means not only finding the right doctor, but ensuring you are prepared for your visit and talking to your doctors about the right issues. It means, not just taking your medications, but keeping track of when you need to take them. People with Parkinson’s are best served by a multi-disciplinary approach that provides not only the expertise of a PD specialist, but also the help of a physical therapist, occupational therapist, speech therapist, nutritionist and social worker. Some people also require medical consultants in areas such as psychiatry and neurosurgery. It is important that these healthcare professionals are aware of each other and communicate regularly, and that they all know the full list of treatments and medications that each is prescribing.
Physical and Occupational therapy focus upon restoring the ability to move effectively and safely by instructing and facilitating normal movement patterns and providing safety education and adaptive equipment to facilitate a person’s ability to maximize independence with mobility, self-care and activities of daily living.

Speech therapy focuses upon restoring swallowing, speech and language production and understanding and cognitive (thinking/memory) functions.

National HelpLine:
Ask the experts at PDF your questions
Are you looking for a support group? Call us at (800) 457-6676 or email info@pdf.org to find a group in your area

The toll-free HelpLine/email service – staffed by a team of information specialists – can:
Answer your questions about Parkinson’s disease: symptoms, treatments, complementary and alternative therapies and the latest scientific studies reported by the media.

Identify financial, legal and other resources to help you live well with Parkinson’s.
Provide access to an interpreter for non-English speaking callers.

Good Posture Provides Tangible Benefits

We have probably all been told at some point in our lives, more often than not by mom or grandma, that we should fix our posture or stand up straight. Well grandma was on to something there! More often than not, while working with patients who are experiencing back, neck, or shoulder pain, I will identify one or more postural deviations which are likely contributing to their symptoms. Some of the most common postural deviations that I see on a regular basis include forward head, anterior pelvic tilt, and rounded shoulders.

Ideal posture gives our body a solid foundation from which to move. The spine is naturally made up of curves with the neck and the low back arching slightly and the mid back rounding slightly. Proper posture minimizes the strain on our muscles and joints and decreases the amount of work that our muscles need to do in order to fight gravity and keep us upright. In ideal standing posture from a side view our ears should line up with our shoulders, hips and knees and there should be a slight curve outward at the mid back and inward at the low back. In a sitting position, our bottoms should be near the back of the chair with our backs supported by the chair. The knees should be bent at approximately 90 degrees (meaning many of us need to adjust our chair height) and our shoulders and neck should be relaxed.

A postural deviation that is increasing in prevalence is forward head posture. This is what it’s called when our chins are sticking out and our ears line up in front of our shoulders. This commonly occurs with reading, computer work, television viewing, and texting. We have a tendency to bring the neck/chin forward in an attempt to get our eyes closer to whatever is holding our attention. Unfortunately, prolonged forward head posture can contribute to neck tension and soreness, headaches, and tingling in the arms. Cell phones tend to bring out the worst neck posture because we often bend our necks down at significant angles while also bringing the chin forward as we read, text or play games on the relatively small screen. The perceived weight of the head increases significantly the more we bend our heads forward. An exercise that you can do to correct forward head posture is cervical retraction with a chin tilt. To perform this exercise nod your chin down just a tiny bit then bring your neck straight back as you think about lifting the base of your skull as if it were being pulled by a string tied to the ceiling. Hold for a few seconds and then relax.

A second common postural deviation is excessive anterior pelvic tilt. This often occurs as a result of tight hip flexor muscles. As a culture, we spend more time sitting than what is ideal for our bodies. We often sit for extended periods for transportation, work, and recreation/relaxation. This can enable the muscles at the front of our hips to shorten and get tight, pulling our pelvis forward. When we stand with anterior tilt, we often increase the arch in our low back as a compensation to stay upright. This can put excessive strain on the low back over time. By pulling the hips forward and the pelvis into a neutral position the back can return to its natural position. An exercise to correct excessive anterior pelvic tilt is the posterior pelvic tilt. This can be performed in multiple positions. One way to do a posterior pelvic tilt is to start lying on your back with your knees bent and the bottoms of your feet flat on the floor. From this position gently press your low back down to the floor and use your abdominal muscles to gently rock your hips back or “tuck your tail”. Another exercise which may be necessary to correct excessive anterior pelvic tilt is to stretch the front of the hips or hip flexor muscles if they are tight.

The final postural deviation that I see very frequently is rounding of the shoulders. This often shows up as a combination of the shoulder blades being far apart and the arms being rotated in so that if a person is standing with their arms relaxed by their sides their palms would be facing behind them. It is also common for people with rounded shoulders to also have a greater than usual bend in the upper back. People with this posture commonly report neck or shoulder pain. This posture puts the body in a poor position for reaching or lifting overhead. Try rounding your shoulders and slumping your upper back, then try to raise your arms overhead from that position. Now try raising your arms while sitting up tall and gently pulling your shoulder blades back. Your arms should be much easier to raise from the second position. Not only is it harder to move your arms from the rounded position but this posture makes it easier for your rotator cuff tendons to be pinched. People with proper posture have the lowest incidence of rotator cuff tears. An exercise to correct this postural deviation is scapula or shoulder blade retractions. To do this exercise stand with your arms by your sides and gently pull your shoulder blades back and together with your thumbs facing out. Hold for a few seconds then relax. Be sure that your shoulders aren’t coming up toward your ears when you do this exercise.

In order to efficiently move our limbs, it is essential to have good posture. We can decrease the strain on our muscles and joints by making small adjustments in our static and dynamic positions. Proper alignment can be one step toward decreasing pain in the neck, back, or shoulder.

Hurt on the Job? You May Need a Functional Capacity Evaluation

Functional Capacity Evaluations (FCE) are full body assessments that are performed to determine an individual’s ability to safely return to work at pre-injury status or to determine if work modifications are necessary to allow the employee to safely resume their job. FCE’s are commonly used for:

  • Employees that have suffered musculoskeletal work related injuries and an evaluation is requested to determine their physical abilities in comparison to the demands of a target job
  • Establishing a disability claim
  • A generic test to assess an individual’s current physical ability when the job goal is unknown

The Process

Your therapist or trainer will request a job description for review to assure all job demands are evaluated. The results of the FCE are then compared to the job description. If the client does not meet all the job demands, the evaluator will determine if the employee is a candidate for a work reconditioning program and recommendations will be made to the physician ordering the exam.

The length of the test and the number of days required to complete testing will vary depending on the injured body part. Hand, elbow, and shoulder exams are performed on one day and take approximately 4 hours to complete. Spine, hip, knee, foot, and ankle exams are performed over two separate days, taking approximately a total of 6-8 hours to complete. Clients are asked to dress in clothing and shoes that permit them to safely perform the presented tasks, and that information is provided prior to the day of testing.

The test may be executed by a physical therapist, occupational therapist, athletic trainer, or a kinesiologist. The test items are designed to determine cardiovascular fitness, lifting capabilities, strength, balance, and hand coordination. In order to perform the test, the individual must be medically stable and have met maximum medical improvement as determined by their physician.

Feeling Faint? Everyday Activities Can Make You Dizzy.

Dizziness can be caused by many things: side effects of medication, low blood pressure, low blood sugar, and anxiety. Dizziness following bending over to tie shoes, lying down in bed, looking in the blind spot, and walking down a grocery aisle are all frequent causes of dizziness related to a vestibular disorder. Vestibular dizziness symptoms may include everything from the room spinning to a feeling of off balance or unsteadiness.

There are three major systems in the body that help you maintain your balance. Vision helps to locate the horizon and objects in a person’s path. Sensory mechanics in the feet and legs help identify the type of ground underneath a person’s feet. The last system is the vestibular system which is located in the inner ear behind the ear drum. The vestibular system is what causes motion sickness, makes the stomach turn on a roller coaster, and what jolts a person awake when dreaming of falling.

The vestibular system has three main functions: stabilization of visual images (keeping eyes on a target), maintaining postural stability (especially with head movement), and providing spatial orientation. These three functions are controlled by coordination of the central vestibular system (brain and brain stem) and the peripheral vestibular system (shown to the left). There are two main parts of the peripheral vestibular system. The three fluid filled semicircular canals that detect angular head movement such as shaking your head to say “yes” and “no”. The vestibule contains the otolith organs which detect vertical and horizontal acceleration, like riding in a car and an elevator. If either of these systems are disrupted in any way it can cause dizziness. Two of the most common vestibular issues are benign paroxysmal positional vertigo (BPPV) and unilateral vestibular hypofunction (UVH).

BPPV is caused when otoconia (calcium carbonate crystals) from the vestibule fall into the semicircular canals. This causes movement of the fluid in the canals, which in turn moves the hair or ampulla, which triggers the sensation of movement. When someone with BPPV lies flat, bends forward, or looks up, this movement causes the crystals in the canal to move, moving the fluid, and then the hair, which triggers the sensation of spinning in the brain. This can be fixed by moving the crystals out of the canal by performing specifically sequenced positions which can treated by a medical professional familiar with vestibular rehabilitation in as little as 1-2 visits.

Unilateral vestibular hypofunction usually occurs following a viral illness, head trauma, or a vascular incident, such as a stroke or blockage, that decreases or eliminates the receptor input of the vestibular system to the brain. This causes less intense sensation of dizziness, more commonly characterized as feeling off balance. Common complaints of UVH are off balance or slight dizziness when turning a corner, picking something up from the floor, walking in the grocery store, or driving. Rehabilitation for UVH can take between 6-8 weeks with therapy to improve gaze stabilization (maintaining vision on a target), postural stability (maintaining standing balance), and decrease motion sensitivity.

Balance Issues? Your Appointment Explained.

Many times, doctors will send a patient to physical therapy if he/she has experienced a fall, been ill, or just felt unsteady while walking. There are several different components to increasing and maintaining balance and mobility.

When you arrive for your appointment, there will be paperwork to complete, most importantly a past medical history form, including a list of your medications. This information is needed to see if you have any conditions or take any medication that could contribute to your symptoms.

During the evaluation, the therapist will test the muscle strength in your legs and assess your balance. These tests are done in an effort to determine which system of balance needs to be addressed. There are three primary systems of balance: vestibular, visual, and proprioceptive. The vestibular system is located in your inner ear and is sensitive to head movements and can create dizziness if there is a dysfunction. The visual system plays a role in your balance by interpreting what you see and making adjustments to obstacles that are ahead, such as a curb. Proprioception is the feedback that you receive from your feet being in contact with a surface. This is important if you are walking on an unstable surface, such as grass or gravel. These three systems help maintain your balance, and your legs have to be strong enough to help hold you up!

The PT will analyze how you walk and determine if you need an assistive device, such as a cane or walker, for safety. Your balance may be tested by performing tasks such as balancing on one leg and standing with your eyes closed and by performing tasks that involve putting your feet close together or in front of each other. Some of these tests may seem silly, but they give the therapist information about your ability to perform daily activities safely.

Often, your therapist will want to see you once or twice a week to work on increasing strength and balance. One thing to remember with balance is that repetition helps the body re-learn the correct way to perform daily activities. More than likely, the PT will send you home with exercises to perform on your own. Performing these exercises will help maintain your mobility and strength between PT visits. Working on balance is a time-consuming process; you will need to be patient with yourself as your symptoms improve. Most importantly, therapists want patients to remain safe with their mobility and prevent future falls. By improving strength and balance, you will be on the right track to stay injury free!

Knee Pain Explained

Knee pain is something nearly every person experiences at one point or another, usually related to a particular injury or provocative activity, such as lots of kneeling for spring planting in the yard or playing the occasional game of basketball. How do you know the difference between a serious injury versus simple overuse? The causes of knee pain typically fall into one of three categories: traumatic, overuse, and degenerative.

Traumatic is self-explanatory; a fall, collision, twist, or awkward landing can create enough force to damage the structures inside the joint. When this type of damage occurs, the person may experience severe and immediate swelling, severe pain, a loss of ability to move the joint, and an inability to bear weight through the limb; a safe bet is when two of the three exist, the person should seek medical attention from a physician and/or physical therapist immediately. Attempting to “walk it off” is not recommended.

An overuse injury can be a little tougher to recognize. Starting a fitness program or a dramatic change in a person’s activity level (more or less) can provoke this type of pain. So can rapid increases in body weight, such as pregnancy. Adolescents who are going through growth spurts will often have pain in the knees because of changes in the way the muscles and joint function together. The pain may show up immediately or gradually, appearing more and more frequently until it is constant. Swelling may appear but is typically not severe and disappears overnight. Depending on the structure inside the knee that is taking the abuse, surgery may be needed, but many times this is treated quickly and effectively with a short course of rest, stretching and strengthening.

“Degenerative” describes the normal changes our joints experience with aging, specifically thinning of the articular cartilage and the loss of quality in the soft tissue of the joint. Knee pain from degenerative changes generally does not produce swelling and is provoked by remaining in one position for a great deal of time.

Besides pain, a problem within the knee (or any joint) will also cause the muscles around the joint to stop working effectively. Over time this will produce a loss of muscle size as well as a loss of control of the joint. The longer the joint remains untreated, the more severe the muscle atrophy and loss in function will become. Other joints may become painful as a result, particularly the areas above and below the injured joint or the opposite side. Medical treatment should begin before the body learns bad movement patterns.

Unless severe structural damage is present, a course of physical therapy will often be successful in getting rid of pain and restoring a person’s usual activity level. Any physician can refer to physical therapy and in many states no referral is required; in most cases, the therapist can make an accurate assessment of the problem and begin treatment immediately. If the problem is severe enough that a specialist should be involved, the therapist can facilitate the referral and also make recommendations for any diagnostic testing.