Functional Dry Needling has been a great addition to my manual therapy ‘tool box’ especially for those with low back pain. Recently, Nelson Min PT from Kinetacore (the group that trained me) wrote a short article on using dry needling for patients with spinal stenosis.
Spinal stenosis is one of the most common causes of low back pain in folks 50+ years of age. The most common presentation is pain with standing and walking that is relieved with sitting down, forward bending, or lying down.
So here is Nelson’s article on Functional Dry Needling and the treatment of Spinal Stenosis:
“I listen for several things when evaluating a new patient with low back pain. I take particular interest when my patient informs me that their pain increases with prolonged standing or walking versus pain that increases with prolonged sitting. An older patient that tells me that their back pain increases with prolonged standing and walking, and is then relieved immediately with sitting, makes me suspect stenosis. For someone younger, I am suspicious of spondylosis or some other instability. I would confirm this with my biomechanical exam but this little detail in the patient’s history often steers me in the right direction.”
Listen to your patient — he is telling you the diagnosis. – William Osler MD
It’s that time of year when we’re all going to start seeing more golfers coming in with injuries. The standing thoracic rotation assessment is one I picked up from TPI a few years ago, and what I’ve found is that is often a difficult pattern for many golfers to manage. This main objective of this movement is to look at the golfer’s ability to separate the trunk and hips, but what is often overlooked is the ability of the golfer to maintain cervical stability with trunk rotation.
The golfer is to assume a 5 iron posture – pretend you have a five iron addressing the ball – cross the arms over the chest, and then rotate the trunk as far as possible in each direction while stabilizing the pelvis and hips. There is no set ROM requirement in the assessment as it meant to look at the ability to stabilize and separate the upper and lower body, but I’d still like to see at least 45 degrees of rotation in each direction.
The other big thing to look at here is the ability of the golfer to keep his head down on the ball. This requires a significant amount of cervical spine rotation as the trunk moves ‘under’ the neck. As you can probably see in the video, its quite a chore for me to maintain this posture.
Obviously the qualities will improve the mechanics of the golf swing and contribute to more consistent accuracy. An inability to maintain optimal posture and control throughout the swing will not only be detrimental to the swing but can also create undo stress on the cervical spine, shoulders, and lumber spine.
Assessing cervical ROM and stability is crucial but often overlooked in this population, and it seems like I end up treating a few of these folks every summer. Establishing full ROM is the first step and then working motor control back into rotational patterns at lower postures is a prerequisite.
Poor trunk rotation mobility and motor control can also take it’s toll on the shoulders. The shoulders can be forced into excessive ranges of motion during the back swing and follow through, and over time can lead to injury here as well.
I recently assessed a high school golfer with bilateral congenital shoulder instability who was having shoulder pain during his swing. He was mobile as could be through his spine but was lacking proper control in standing thereby over reaching through the shoulders. Improving control in this standing patten went a long way toward eliminating his pain during the golf swing.
Standing trunk rotation with pelvic stabilization can be a great assessment for your golfers, as well as other rotational athletes, and can also be used as a corrective or warm-up activity.
I recently did an interview on the GT forum along with Ashli Linkhorn (head chiropractor – NCCA Women’s College World Series) in which we discussed the benefits of Graston Technique and how it can be used as part of the rehabilitation process with baseball/softball players. Some nice info in the interview although I really can’t stand listening to myself on these things. They will be doing one podcast per month so if you’re interested in GT, or are a practitioner, hopefully there will be some valuable info.
Graston Technique in the Treatment of Injuries to Baseball Players
Functional Dry Needling is a very effective manual therapy technique that I’ve been wanting to learn for some time now, and was recently trained though Kinetacore. I’m very excited to be using this new technique and I’m already seeing some great results.
In this week’s blog post, I want to give some very basic background on what Dry Needling is, and is not. The article below doesn’t mention this but I want to make it quite clear that this is not acupuncture. The only similarity is the use of the same type of needle. Dry Needling performed by a physical therapist requires a thorough musculoskeletal evaluation, and placement of the needle into specific taut bands of muscle (a.k.a. trigger points) that are pain generators and creating dysfunction within the system.
My knowledge of acupuncture is somewhat limited but generally speaking the points that are treated in the body are mapped out along ‘meridians’. Needles are placed into these preset points and left for a certain amount of time.
There is a lot more to it than just this, and I think it is important to understand that there are differences. The description of Functional Dry Needling below comes from the Kinetacore website. It’s a quick primer on the technique. If you want to see it in action, check out the video at the bottom of the page featuring Terry Bradshaw.
“Dry Needling is a general term for a therapeutic treatment procedure that involves multiple advances of a filament needle into the muscle in the area of the body which produces pain and typically contains a ‘Trigger Point’. There is no injectable solution and typically the needle which is used is very thin.
Most patients will not even feel the needle penetrate the skin, but once it has and is advanced into the muscle, the feeling of discomfort can vary drastically from patient to patient. Usually a healthy muscle feels very little discomfort with insertion of the needle; however, if the muscle is sensitive and shortened or has active trigger points within it, the subject may feel a sensation much like a muscle cramp — which is often referred to as a ‘twitch response’.
The twitch response also has a biochemical characteristic to it which likely affects the reaction of the muscle, symptoms, and response of the tissue. Along with the health of the tissue, the expertise of the practitioner can also attribute to the variation of outcome and/or discomfort. The patient may only feel the cramping sensation locally or they may feel a referral of pain or similar symptoms for which they are seeking treatment. A reproduction of their pain can be a helpful diagnostic indicator of the cause of the patient’s symptoms. Patients soon learn to recognize and even welcome this sensation as it results in deactivating the trigger point, thereby reducing pain and restoring normal length and function of the involved muscle.
Typically positive results are apparent within 2-4 treatment sessions but can vary depending on the cause and duration of the symptoms, overall health of the patient, and experience level of the practitioner. Dry needling is an effective treatment for acute and chronic pain, rehabilitation from injury, and even pain and injury prevention, with very few side effects. This technique is unequaled in finding and eliminating neuromuscular dysfunction that leads to pain and functional deficits.”
If you have further questions about the technique, or feel that this technique may work for you then feel free to contact us: email@example.com or 231 421-5805231 421-5805.
Pain is something many of us deal with everyday, whether it our own or working with others to help them overcome that pain. At Elite Physical Therapy, we feel that it is very valuable for our patients to understand how pain works, and how we should deal with pain during the different stages of healing. Chronic low back pain and neck pain are two very common cases where this new science is having a valuable impact.
This is a great video by Lorimer Moseley explaining pain and how it is processed by our brains. Dr. Moseley and Dr. David Butler are definitely changing the way we think about pain in the medical professions.
The take home message is that with chronic pain, the tissues are often completely healed, but the brain still perceives pain. In this situation, movement and activity are often the best medicine. You can’t hurt anything so try to do as much as you’re capable of doing without going overboard. You may just gradually improve your functional abilities while decreasing pain using this approach.
This article was originally written for physical therapists and other clinicians dealing with shoulder pain and loss of motion so excuse some of the medical terminology. I know a number of them read this blog so I’m leaving the article as is.
The jist of this article is as follows: most of us have too much extension (arch) in our lower spines, and we go into even more extension any time we try to raise our arms overhead. Over time this can lead to shoulder pain and low back pain. The article below describes a great warm-up exercise to improve shoulder mobility while controlling spinal posture.
As always if you have any questions feel free to email me: firstname.lastname@example.org
Joe Heiler PT, CSCS
This is a great correction for the shoulder mobility movement patterns and also for the shoulder flexion component of the MS Extension pattern. The lumbar spine frequently contributes excessive extension to the shoulder patterns when the shoulder itself is limited. Mobility work is required to free up the shoulder, but this pattern will continue if motor control is not imparted to lock in the new range of motion.
I would not want to be her low back right about now!
The ‘wall posture’ as I describe it to the patient is an attempt to get the entire spine to touch the wall. By having the feet out in front and knees slightly flexed it makes it easier to get the lumbar spine flat onto the wall which is really just a less extended, and probably more neutral position, for most folks. If you’re concerned that it is too much flexion, or if it is not well tolerated due to back pain, and towel roll/lumbar support could be used but contact must be kept at all times.
The cervical spine is a little trickier when it comes to proper positioning. I will cue to get the spine to the wall, but to a point. That cue will usually bring the chin down and back (into cervical retraction) which again will bring most folks to a more neutral posture. Too ‘straight’ is not a normal position either and could affect the shoulder mobility component of this corrective so don’t force it. If their forward head posture is so severe that their head won’t touch the wall without going into extension, then place a towel roll behind the head and require them to hold the towel in place as the arms go overhead.
Maintaining the proper positioning throughout the movement is the most important factor here. The shoulder motions in the video are a challenge to that positioning. When posture is lost, the movement is done.
Breathing is critical here as well. My preferred way of cuing the breathing is to inhale at the bottom and slowly exhale during the overhead motion. The more the ribs stay down in the front the better. This can be incredibly hard for many people, and especially so for many overhead athletes, weight lifters, dancers, and gymnasts.
The order in which the motions are presented in the video go from easier to most challenging:
If following the SFMA’s 4×4 matrix, this would be considered a level 4 posture, unloaded but with assistance (the wall as the positional cue) so 4:1. Competency must be attained in each of the previous postural levels: 1) supine/prone, 2) quadruped, 3) tall or half kneeling.
Progressions per the matrix:
4:2 – shoulder mobility work without the postural cuing or any activation 4:3 – loaded with cuing or activation. Shoulder Flexion/Extension (reciprocal patterning) or pressing overhead with the spine against the wall or a corner (I prefer a corner to allow the shoulders to move more freely). 4:4 – loaded without cuing or activation – Shoulder Flexion/Extension in standing, any type of pressing.
You go to the dentist for check-ups and cleaning every six months.
I bet he’d rather be seeing his physical therapist!
The doctor sees you for an annual physical.
You see the eye doctor for an annual check up.
So why not see your physical therapist for an annual musculoskeletal health exam?
Here are a few startling statistics:
we lose .5%-1% of our muscle mass per year after the age of 30.
nerve conduction velocity decreases by 1m/s every 10 years
testosterone levels decline about one percent a year after age 30. Growth hormone levels begin to decrease after the age of 20.
These are just a few examples of normal age related physiological changes. The direct result is a decrease in strength and power with age. Over time this can manifest itself as poor balance, poor movement ability, difficulty getting out of a chair or bed, limited endurance, and the list could go on and on. These declines in performance can also lead to injuries and musculoskeletal problems over time which will lead to a further decline in performance. The vicious cycle is in full swing now!
There is no way to stop these changes from happening, but we can certainly work to slow them down through smart exercise, nutritional strategies, proper recovery, etc. The exercise component is where we come in.
Here is what this annual musculoskeletal exam would consist of:
The Functional Movement Screen (FMS) is a battery of 7 screens to determine movement competency – or how well you move. The FMS has been shown in the research to be highly predictive of injury in athletics and in the military. We can’t necessarily pin point what the injury will be, but we do know that the wheels are much more likely to come off at some point.
The FMS is being used in all the major sports, in the military, and even at the NFL combine to look at injury risk and prediction in these populations. The beauty of the screen is twofold: 1) ability to identify poor movement patterns, and then apply corrective exercises to improve competency within these patterns thereby reducing future injury risk; 2) ability to identify acceptable movement, and create exercise programs to further strengthen and add capacity to these patterns.
The Y Balance Test looks at single limb balance, strength, and motor control. Right to left symmetry and poor reach distance are both predictors in injury. The Y Balance test is a great way to evaluate both, and to compare scores to peers in the same sport or activity level. There is also an upper body Y Balance test for shoulder stability which is a great way to test overhead athletes. Depending on your sport, one or both of these tests would be appropriate.
Power Output is a measure of work over time. In other words, how much work can you get done in the shortest amount of time. Athletic measures of power include the vertical jump, standing broad jump, and medicine ball throws. There are other measures that could be used as well depending on your chosen sport(s) or activities, goals, age, etc. For older adults it may be as simple as how quickly one can get up off the floor and walk a certain distance.
There are certainly other things that could be assessed and measured including strength, balance, and endurance but those will be specific to each individual case.
When all the testing has been completed, a report is generated using the Move2Perform software providing a movement and injury risk baseline.
This report also helps to generate a program to specifically address the identified needs. The program would address movement deficiencies through corrective exercises, and also include options for strength training, power production, cardiovascular conditioning, and more.
Follow up appointments are an option to track progress throughout the year and increase the intensity of the program as needed. Or if you just need a few pointers to get started, we’ll see you again next year.
Give us a call at 231 421-5802312231 590-1364 or shoot me an email: email@example.com for more information including how to get started.
This is an article I originally posted on SportsRehabExpert.com, and thought it would be a great piece for the blog audience as well so I apologize ahead of time if some of the terminology is a bit too ‘medical’.
I’m constantly on the lookout for ways to challenge my patients and athletes, but without overloading their joints and tissues. Many of them want to really push themselves, but sometimes they are at that point in their lives or careers where it’s just not appropriate for longevity sake. In this article I’ll discuss some of the strategies I use to get the most out of strength training without overloading the weakest link.
There are 4 basic ‘solutions’ to this problem that I will use. I think the best way to cover these would be to describe a couple cases for the lower body and upper body:
Case 1: Active military gentleman with 2 episodes of disc hernation and radicular symptoms within a two year period. Both episodes were brought about with heavy lifting, but he also spends quite a bit of time sitting in the back of a helicopter in a seat that’s about 6″ off the ground (his knees are practically in his face).
I worked with him after the first incident, cleared his movement and had no symptoms. He resumed weightlifting and all other previous activities. After 6 months in the clear he went back to heavy squats and deadlifts, and after 2-3 months of that began noticing the radiating pain into his left leg again.
This guy is an absolute beast when it comes to his fitness level and his form has always been very good. But because of his past and his work demands, this is a guy that I want to limit the load he is using, as well as the positions he puts himself in.
Solution #1 – Move from bilateral stance to split or single leg stance
This one is pretty obvious in that there is no way he is going to load single leg activities the way he can load a traditional squat or deadlift. Single leg deadlifts and squats are great options here because of the extra stabilization needed just to balance and control the trunk. There is only so much weight you’re going to pull with these single leg movements.
Solution #2 – Asymmetrical loading
An example of this would be a single leg deadlift in which the weight is held in the opposite hand (of the stance leg) so the trunk must work in an anti-rotation manner as well as anti-flexion (see video above). Another great example would be a front squat with a kettlebell in one hand (see picture below) using either the traditional grip or bottoms up. The demands on the core can be quite high loading in this manner so the athlete gets a great workout with less overall load.
Single Arm Kettlebell Squat
Solution #3 – Postural Assist
Split squats or rear foot elevated split squats (REESS) are ideal for this type of athlete because the positioning makes it easy to maintain an upright spine and therefore decrease the shearing type loads you would see with a traditional squat where the trunk is angled forward. Mike Boyle (one of the top strength coaches in the world) has talked extensively about this and thus his programs have moved from back squats to front squats to RFESS over time. This type of squat can easily be asymmetrically loaded as well (different weighted dumbbells in each hand).
Rear Foot Elevated Split Squat
Solution #4 – Bottoms Up
There are many reasons I like kettlebells, and the ability to go bottoms up is another one of those reasons. I can instantly make any kettlebell exercise much more challenging to the athlete’s grip and stability. The video above showing the KB front squat is a great example, plus I will frequently use this with Turkish Get-Ups, various carries, and presses.
Case 2: This is more of a general example here as I work with a number of adult athletes post rotator cuff repair looking to return to their sport and the gym. Unless they are competing in powerlifting or weightlifting events, I really don’t need them putting a whole bunch of weight on the bar to bench or shoulder press any longer.
My #1 job is to protect the repair while they are seeing me in PT, but also when they are beyond my care. Job #2 is to give them tools to enhance performance and get them back to the sports they enjoy. Again I believe this can be done using the ‘Solutions’ mentioned above. Here are some examples for the upper body (although in the clinical or performance setting I would never really divide them up this way).
Solution #1 – Move from bilateral to single arm exercises.
The same idea applies to upper body as lower. The amount of stabilization and balance needed to perform single arm presses (horizontal and vertical) is going to make it quite difficult to really load up with weight.
The single arm bench press is one of my favorites. I have the athlete scoot their hip and shoulder off the bench so they really have to fight the weight pulling them off the bench. I usually have to start athletes at about 50% of what they could dumbbell bench using the traditional two arm method. Athletes are not always happy about going down in weight but they feel right away this is going to make them work.
Solution #2 – Asymmetrical loading
In the case of upper body pushing and pulling, the ‘solution’ of asymmetrical loading is usually just a version of ‘Solution #1′. Another way to inject greater asymmetrical loading into singe arm lifts would be to have the athlete lift from a single leg stance position. This isn’t something I use real often but there have been times I’ve had to be cautious with someone’s shoulder and wanted to increase intensity without increasing load. Single leg/single arm kettlebell presses fall into this category, as well as single leg rows (hamstring killer!).
Can’t believe I couldn’t find a better picture than this!
Solution #3 – Postural Assist
In this instance, requiring the athlete to stand to overhead press (or go tall or half kneeling) brings a lot of postural and stability requirements to the table. It makes it more difficult again to really load up the lift when they don’t have a bench to press into.
Solution #4 – Bottoms Up
Same thing again using the kettlebell bottoms up to work the grip harder and force great stability from the upper quarter.
Single Arm Press – Now that’s a picture! That KB is 55 KG by the way
Now don’t get me wrong, I still love to see big lifts. There are just times when the person in front of you needs less loading so be creative and use these techniques to help create an optimal environment to make gains without risking injury.
I’ve been meaning to write an article about this for awhile now, and since the New Year and the many changes in the insurance industry it’s prompted some action on my part.
The current trend in the health insurance industry is to increase the patient’s responsibility for their health care. This shows up in rising co-pays that are as much as $60 per visit or deductibles that can be as high as $10,000. This pretty much means you pay the first $10,000 of your medical expenses before the insurance company starts kicking in anything. On top of that you max have an ‘out-of-pocket’ max to reach so that you may still have a co-pay or a co-insurance until you reach that magic number.
I’ve had this type of insurance myself so I know full well how it works. To be able to afford the monthly premiums anymore, some folks are forced to go this route and then pray that nothing bad happens to them or their family.
I’ve always offered what I think is a rather fair private pay rate since many people didn’t have insurance prior to the Affordable (laugh) Care Act. Everyone is required to have insurance from this point forward or pay a fine. Many younger folks are choosing to pay the fine for now since it is much cheaper than paying for insurance they probably will not use. In this case private pay for physical therapy is a no-brainer.
Now what about for those of you that do have insurance? This is where is can be a little tricky.
The private pay rate here at Elite Physical Therapy is $75 per visit. This was the lower end of what insurance companies would typically pay for a physical therapy session, although with cost cutting more companies are hovering around this point. There are still companies that do pay significantly more than that depending on what is billed.
The typical session at Elite is 45 minutes (60 minutes day 1 with the evaluation), and is one on one with the physical therapist. You have 45 minutes of my undivided attention plus access to me by phone or email with questions. The typical frequency of visits is 2x per week, and in some cases 1x if cost, schedule, or distance are issues.
That being said, for a person who is private paying for physical therapy, that would come to $150 weekly.
Most clinics are going to see you at least 2-3x per week so if you have a $50 co-pay you’re already up to $100-150. Not only that but most other clinics in this area will allow you 15 minutes with your therapist and the rest of the session is spent exercising on your own or with a tech. You may save a little, but the quality of care may not be the same.
Here are a few other scenarios I have run into where someone chooses private pay over insurance:
They do not anticipate meeting their deductible and choose to pay the $75 private pay rate rather than what they would be charged if it were billed through the insurance. Going through insurance can cost as much as $225 for the first visit and $90-120 for subsequent visits.
Some people would just rather keep their health information between them and their doctors so they request to private pay versus going through their insurance. I’ve heard a number of valid reasons for this but the big one being concerns over the deductibles going up (much like claims against auto or home insurance).
Here are a couple other points to consider when choosing between private pay and insurance, or even which PT clinic is right for you:
My thought process with many injuries/conditions is that you should see substantial improvement within 4-6 sessions. I tell my patients this right up front. You may not be 100% that quickly but you should be well on your way. I don’t want to waste your time and money so if things are not improving in that time frame its time to go back to your physician. I hate to say this but I’ve had patients come to me with 20-30+ visits to PT under their belt already and no results.
Many clinics in this area do not give discounts for private pay physical therapy! PT services, just like physician or hospital services, are billed out at a much higher rate than what would actually be paid out. It’s a game we all have to play with the insurance companies unfortunately, but to bill a patient that same rate to me is ridiculous. At a minimum you’re probably talking $150 for a 30-45 minute session.
This goes along with the point above – I’ve done some checking and as far as I know I have the cheapest private pay rate around. I’ve even had a couple referrals from other PT’s because their ‘friend’ didn’t have insurance and I had the best rates.
The point of this article is to let you know that you have options! Great care for a fair price is what it’s all about here. If you have any questions at all feel free to contact me at 231 421-5805 or shoot me an email: firstname.lastname@example.org
Big thanks to Dave Chalmers who wrote this guest blog post. Dave is an athletic trainer who currently writes on behalf of DME Direct
It’s every athlete’s worst nightmare. Tearing your anterior cruciate ligament and sustaining a devastating ACL injury. The reason these injuries are so terrifying to athletes is that the road to recovery is long and arduous, and even then there is no guarantee you will ever be the same player and you always run the risk of re-injury. However, over the years there have been major advancements in ACL rehabilitation and it is now much more plausible to return to competition after an ACL injury and compete at a high level.
One aspect of ACL rehabilitation that often gets overlooked is the important time following the injury prior to surgery. As more people are realizing the significance of getting a recovery program off to a good start, the practice of prehabilitation is being implemented more frequently.
Typically the aim of prehab is to reduce swelling and stabilize the knee prior to surgery. This can be achieved through cold therapy and wearing a knee support to compress and stabilize the knee. Some mobility exercises can be performed at this stage if you experience no pain while doing them.
After successful reconstructive surgery, the rehabilitation process begins. This process can be broken down into a timeline with various phases. It is important that you stick to this timeline and do not rush things and risk re-injury.
The first two weeks immediately following surgery should be spent focusing on reducing swelling and controlling swelling. Similar to the processes of prehab, icing and compression should be applied here and the use of crutches combined with rest is commonly advised. At this time you can begin with static strengthening exercises such as lying down quadriceps and hamstring contractions.
After these two weeks, you should being a second phase of recovery. Mobility and strengthening exercises should continue and you can start to introduce exercises like shallow lunges and half squats. You can also start implementing adduction and abduction exercises for hip flexor strengthening as well as begin proprioception and balancing exercises.
At about the six week mark you can begin another phase of the rehabilitation. At this stage you can advance to full lunges and squats. You can now start to add weight for increased resistance and begin straight line jogging exercises.
Approximately twelve weeks after surgery you can begin to mix in training activities specific to your sport. The key here is to gradually increase speed and intensity of drills. Along with sport-specific drills, you should also focus on exercises that strengthen hip abductors and external rotators such as monster walks and single leg glute bridges.
Return to Competition
When and only when, your surgeon gives you permission to return to competition will you be able to start competing again. If you follow the processes outlined here you will give yourself the best chance to return to competition physically capable of competing at a high level. However, there is also a mental aspect that many athletes overlook.
Even if your body is ready physically, you may not be mentally prepared to trust your knee in live competition. Again, it is important to be patient and avoid returning until you are fully ready. Use the exercises mentioned above at the end of your recovery program to test yourself a bit and build confidence in your repaired knee. Once you return to competition, wearing a trusted ACL knee brace can give you extra support both physically and mentally.
The long road to recovery after an ACL injury can seem overwhelming at times. Dedication and discipline are required to rehabilitate yourself successfully. However, if you put in the work to reach a level where you are properly prepared physically and mentally to return, you can begin competing at a high level again.
Dave Chalmers is an athletic trainer who currently writes on behalf of DME Direct on topics related to sports medicine and physical therapy. When he’s not writing, you will most likely find Dave at the Staples Center cheering on his beloved Lakers.