How to Have Happy, Healthy Intervertebral Discs

By: Gema Sanchez, PT

As many as 85% of people are affected by low back pain at some point during their lives. Of the  many causes of low back pain, intervertebral disc degeneration and disc herniation are among the most common. So, if you want to have a healthy spine and minimize low back pain, you need to have healthy discs.

What is an intervertebral disc?

The discs are partially movable joints that connect the bones of the spine (the vertebrae).  The function of the disc is mechanical: it transfers loads, dissipates energy and helps joint mobility.  It is composed of two parts: the nucleus pulposis in the center and the annulus fibrosis which encircles the nucleus. The nucleus is gelatinous, it has a high water content in a matrix which resists forces of compression. The annulus is composed of rings of fibrous cartilage surrounding the nucleus which resist the forces of rotation.. Most of the disc has a very poor blood supply so it relies on the squeezing and releasing of the spine through everyday motion to provide it with  nutrition, much like squeezing soap though a sponge. To maintain health, the disc maintains a delicate balance of breaking down and rebuilding. This balance is easily disrupted by factors such as aging, mechanical loading, and environmental and genetic factors.

How is the disc damaged?

Disc degeneration is part of the natural process of aging but can also be caused by excessive and/or repetitive loading.  Disc herniation, also known as a disc bulge, occurs when the annulus tears and the disc begins to change shape, sometimes leaving it’s normal confines and pressing on the spinal cord or nerves. Disc herniation can occur as a result of degeneration or from a sudden injury such as very heavy lifting or a car accident.

What can I do to keep my discs healthy?

  • Don’t smoke. Smoking has been demonstrated to have a profound impact on disc degeneration and herniation. Smoking causes changes to the chemistry of the disc resulting in decreased cell production, disruption in cell architecture and disintegration of cells and matrix.
  • Keep a healthy weight. Increased body mass increases the load on the disc, accelerating disc degeneration. There is also evidence to suggest that there may be a link between disc degeneration and the secretion of the peptide hormone leptin from adipose tissues. This hormone is a biomarker of obesity and is believed to promote the production of abnormal nucleus cells.
  • Stay active, but don’t overdo it. Mechanical loading effects on the disc depend on how much of a load there is and how long it lasts. The normal pattern of unloading at night and loading during the day maintains the balance of breakdown and rebuilding in a healthy disc. If the disc does not get enough of a load, it begins to swell and lose structure. But continuous or excessive loading causes cell death and disc degeneration. So moderate loading is best: laboratory and clinical evidence suggests that moderate mechanical loading promotes effects which protect and repair the spine and may delay the development or progression of disc disease.

Can the disc heal?

Well, that depends on location. The nucleus and inner annulus does not have a blood supply, so it does not heal well. In fact, it is still uncertain if regeneration and repair of the nucleus or the inner annulus is even possible. But there is some research that suggests that releasing compression on   a degenerated disc results in rehydration and chemical changes which indicate tissue recovery. In terms of the outer annulus, the news is better; it appears to demonstrate good healing potential. In animal models, the outer annulus has been shown to be able to resist  pressure within the nucleus in as little as six weeks of healing. The outer annulus is different from the nucleus and inner annulus in several ways; it is anchored directly to bone, has some blood supply and shares similar cells and composition to tendons and ligaments. It has been shown that application of appropriate levels of tension along the lines of fiber orientation assists healing in tendons and may assist in reducing excessive scar formation following an injury. Since the outer annulus shares several important characteristics with tendon, we can apply these healing principles to the outer annulus to promote healing.

So exercise can help heal the disc?

We think so, but the exercise has to target each part of the disc separately and be progressed individually, depending on where you are in your healing process. We use rotation exercises to encourage healing of the annulus and modified compression-decompression exercises for the nucleus, starting with the right amount of force for where you are in your healing process and progressing as you improve.

 

Want more information? Come to our upcoming lecture on How to Prevent Low Back Pain (Thursday, May 18th @ 6PM)

Getting Back to Gardening

By: Gema Sanchez, PT

If you are a gardener in Portland, February is the longest month of the year. You wait for those rare sunny days and bundle up to finish the fall clean up, admire the hellebores and hunt around for the first signs of Spring. And while all that fresh air and sunshine is good for the soul, your body may be a little stiffer than it was in the Fall, putting you at risk for injury. Here are some recommendations to prevent injury as you transition back to the gardening season:

 

  1. Alternate light and heavy tasks: Analyze what you have to do and determine if it is a light task such as stacking tomato cages or a heavy task such as clearing awkward branches. Give your body a break from the heavier tasks by alternating them with the lighter tasks. For example, take a break from taking out dead shrubs by spending some time tidying up plastic pots from last year’s garden. After moving heavy pots, rest your back and arms by doing a light task such as starting seeds. When you alternate heavy and light tasks, you use your body in different ways, thus reducing overuse.
  1. Take frequent breaks from repetitive tasks. Early spring cleaning often involves repetitive tasks such as clearing debris and weeding. Staying in these forward bent positions for long periods or repeatedly reaching down and coming back up can be very hard on your back. Remember to take frequent breaks to stretch your back and legs and walk around a bit. A good place to start is to take a 10 minute break for every 30 minutes of work.
  1. Sharpen your pruners and saws: Dull blades are not only dangerous but very hard on your hands and arms. Pruning is much easier, more precise and better for you and your plants with sharp tools in good working order. Pruning can also be a repetitive task, so take frequent breaks to rest your hands and arms, especially if you are pruning thicker branches.
  1. Remember your biomechanics: All the basics of proper lifting and carrying very much apply in the garden. Bend your knees, carry objects close to you, alternate sides when you are carrying buckets or watering cans and get help for awkward or very heavy lifting.
  1. Bring your work to you: Whenever possible, bring your work to your level. Use a waist level surface for potting, transplanting, seed saving, tool maintenance and any other task you can easily lift onto the surface.
  1. Cool down with some stretching: After a day in the garden, take a few minutes to stretch out, especially your back, shoulders and hips. Your therapist can help design a program that is right for you. Hold stretches for at least 20-30 seconds and remember stretching should never be painful.
  1. Start out slow: As tempting as it is to spent the entire day working in the garden, consider limiting your time to a few hours the first day. Or at very least, take a good long lunch break, put your feet up and admire you work.

Treating Painful Tendons – Tendinopathy and Its Real Cause

By: Gema Sanchez, PT

tendinopathy, tendinitis, physical therapy
Pain relief and increased strength are a few of the benefits of treating tendinopathy with Physical Therapy.

Pain and tenderness in a tendon, sometimes lasting for many months, is a fairly common occurrence. Many people would still call this tendon pain tendinitis, which means inflammation of the tendon. But when researchers began looking more closely at the structure of chronically painful tendons 20 years ago, they found that many of the painful tendons did not have inflammation. Instead, the tendons showed signs of degeneration without inflammation. These findings indicate that there is much more going on than just inflammation, so the diagnosis of tendonitis was no longer accurate. In an effort to more accurately describe the state of the tendon, a chronic painful tendon is currently diagnosed as tendinopathy, meaning a disorder of the tendon.

Tendinopathy is diagnosed using clinical findings. These include:

  • tenderness/pain with palpation of the involved area
  • pain with activity, stretching and contracting the muscle
  • decreased function
  • gradual onset of stiffness in the tendon
  • sometimes localized swelling and palpable crepitations (a crackling sound or feeling)

An ultrasound or MRI could be used to confirm clinical findings, but these tests are not accurate for diagnosing tendinopathy.

Tendinopathy affects both athletes and non-athletes. The most commonly affected tendons are the Achilles, kneecap, shoulder rotator cuff and elbow extensor tendons. Pain can be debilitating, leading to the inability to perform work and sport activities.

Causes of tendinopathy are not yet fully understood.  It is believed that it occurs due to a combination of intrinsic factors (such as muscle tightness/imbalance/weakness, age, joint hypermobility and systemic disease) and extrinsic factors (such as occupation, physical load and overuse, inadequate equipment and environmental conditions).

Treatment of tendinopathy has influenced and been influenced by the evolving understanding of tendon pathology and healing. Various forms of intervention aimed at decreasing pain and promoting tendon healing have been used. These include: extracorporeal shock wave therapy, low level laser, glyceryl trinitrate patches and injections. Surgical intervention has been shown to be successful in non-responsive cases, but is in general considered a last option.

The most widely used and favored treatment for tendinopathy is eccentric exercise, which has been shown to reduce pain, improve function and normalize tendon structure. Eccentric exercise refers to a specific type of muscle contraction. There are two types of muscle contraction, concentric and eccentric. A concentric muscle contraction is when a muscle contracts while getting shorter. This is what you normally think of as contracting a muscle to move a joint, for example, flexing your biceps to bend your elbow. An eccentric muscle contraction is when a muscles contracts while getting longer. When you are relaxing your elbow back down to straight, the biceps works eccentrically to slow and control the motion.

 In order for an eccentric exercise program to be effective for treating tendinopathy:

  • loading must be customized to the particular tendon involved, taking into account length of tendon, load, and speed
  • exercise program should be as similar as possible to the usual mechanical stressors that the person experiences
  • exercise must be gradually progressed
  • exercise progression must last for at least 12 weeks

Physical therapists have the correct training and knowledge to design, monitor, instruct and progress a customized eccentric exercise program.. They will provide you with a program that stresses the tendon in the right way to promote healing and help you return to your normal work and sport/recreation activities safely and without pain.

Physical Therapy Shown to be Effective Treatment for Headaches

Physical Therapy for Treating Headaches. New Heights Physical Therapy in Vancouver WA and Portland OR.

By: Gema Sanchez, PT

Headaches are one of the most common disorders of the nervous system, affecting approximately 47% of the global population. For three of the most common headaches; tension type headaches, cervicogenic headaches, and migraine headaches; several studies indicate that physical therapy can be a good treatment option.

Tension type headaches are the most common type of headaches and affect 38% of adults every year.  Several studies indicated that these types of headaches respond well to specific exercise. In a study by Van Ettekoven and Lucas, patients performed exercises against an elastic resistance band in conjunction with manual techniques. They found that the patients had a significant decrease in frequency, duration, and intensity of headaches for up to six months after the program. In another study, Anderson and colleagues had office workers with frequent neck and shoulder pain perform 10 weeks of resistance training using an elastic resistance band. Their findings showed decreased frequency of headaches in these patients in response to as little as 2 minutes of daily resistance training.

Cervicogenic headaches affect 22-25% of the adult population. This accounts for 15-20% of all chronic and recurring headaches.  These headaches are thought to arise from joint and muscle impairments of the neck. Two recent reviews looked at studies assessing the effectiveness of conservative physical therapy management on cervicogenic headaches. Both reviews concluded that neck spinal manipulation is effective in the management of cervicogenic headaches. In addition, one review also concluded that the most effective intervention for patients with cervicogenic headaches may be a combination of mobilization, manipulation, and neck and shoulder strengthening exercises.

Migraine headaches are reported by approximately 15% of the population. These headaches are believed to come from the blood vessels and the nervous system. Migraine headaches are usually managed using medication such as Propranolol and Topiramate. There are some patients, however, who do not tolerate medication due to side effects or who prefer to avoid medication for other reasons. For these individuals, manual therapy may be an alternative treatment option. In 2011 Chiabi and colleagues performed a systematic review of seven studies on manual therapies for migraine treatment. These included two massage studies, one physical therapy study, and four chiropractic spinal manipulative therapy studies. Treatments included massage, trigger point therapy, myofascial release, soft tissue work and stretching, postural correction, exercise, relaxation, mobilization, and manipulation. They concluded that the current studies suggest that massage therapy, physical therapy, relaxation, and chiropractic spinal manipulative therapy might be as efficient as medication (Propranolol and Topiramate) for prevention of migraines.

Physical therapy treatment for patients with headaches will vary depending on the type and origin of the headaches. At New Heights, we treat headaches using many different techniques including specific neck and shoulder strengthening exercises, stretching, postural correction, and manual techniques such as graded mobilization, myofascial release, augmented soft tissue mobilization (ASTYM), muscle energy techniques, and tender point therapy.

 

Abdominal Separation In Post-Partum Women

By: Gema Sanchez, PT (Edited by Bradley Brown)

Diastasis rectus abdominis (DRA) is a structural impairment of the muscular and connective tissue of the abdominal wall which presents as a separation of the abdominal muscles along their midline. It is measured as the distance between the right and left sides of the abdominal muscle grid (the “six-pack”), and is referred to as the inter-recti distance (IRD). Measurement of IRD in the clinic is generally made by hand or with calipers. Criteria for the diagnosis of DRA vary, but IRD is generally considered abnormal if it exceeds 2 fingers width at rest, measured at or just above the navel. DRA has been linked to support-related pelvic floor dysfunction and lumbopelvic pain.  One study in 2009 found that 74% of women seeking physical therapy for abdominal or lumbopelvic symptoms exhibited increased IRD and had significantly greater pain than those without DRA.

Risk of pregnancy-related DRA is about 27% during the second trimester and peaks in the third trimester at 66-100% due to the baby’s increase in size. Luckily, there is some research which suggests that exercise during pregnancy may mitigate the occurrence of DRA. In 2005, one such study looked at the effect of abdominal strengthening on the presence and size of DRA in pregnant women. Eight women who participated in a prenatal exercise program of abdominal muscle strengthening, pelvic floor exercises and education were compared to 10 non-exercising women. They found that only 12.5% of the exercising women exhibited a DRA as compared to 90% of the non-exercising women.

Incidence of DRA decreases postpartum but is still present in as many as 39% of women six months postpartum, and some women still have not fully recovered one year postpartum. DRA-related abdominal instability can be especially limiting during this time, as women return to previous normal activity in addition to the load of caring for their child.

Integrity of the anterior abdominal wall is essential to stability, posture, breathing, trunk movement and support of internal organs.  Specific abdominal exercises are used to narrow the IRD and help prevent future separation. In two recent studies, ultrasound measurements were used to assess the effect of active abdominal contraction on DRA in post-partum women. Both studies concluded that IRD was reduced with regular, static abdominal contraction. In another study, researchers used ultrasound to measure IRD at rest and during abdominal exercises in 84 women during and after their pregnancy. Their results support the notion that conservative abdominal exercises consistently produced a significant narrowing of the IRD.

It is important that women with DRA receive individual supervision and assessment so that adjustments can be made based on each patient’s reaction to exercise as well as rate of improvement.

New Heights Physical Therapy Plus has physical therapists with the training, skill, and knowledge to assist your clients with DRA during and after their pregnancy.

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Pregnancy Related Low Back and Pelvic Pain

By: Gema Sanchez, PT

Prevalence of low back and pelvic pain during pregnancy has been estimated to be as high as 90%. It is so common that many obstetricians consider it a normal finding in pregnancy. Many women also consider pain to be an inevitable and normal part of pregnancy and do not seek treatment, despite significant limitations in day to day activities. As many as 80% of pregnant women report that back pain affects daily activities such as walking, rolling over in bed, getting out of a chair and getting out of bed.

Low back and pelvic pain during pregnancy also has significant repercussions post-partum. Risk of return of pain in a subsequent pregnancy has been estimated at 85%. One study found 20% of women with back pain during pregnancy reported residual pain three years later and 10% of women with chronic low back pain link the onset of their pain to pregnancy. This is unfortunate, since several studies have shown that simple interventions for pain during pregnancy such as exercise, education and manual therapy techniques can significantly improve pain and function during pregnancy and prevent persisting and chronic pain post-partum.

Exercise combined with education (in anatomy and physiology, posture, pain, normal pelvic changes, self help management, ADL modifications) has been found to be an effective treatment for pregnancy related lumbar, pelvic, and symphysis pubis pain. In 2014, Van Benten et al reviewed 22 randomized controlled trials on the effectiveness of physical therapy interventions in treating lumbopelvic pain during pregnancy.  They concluded that exercise combined with education had a positive effect on pain, disability and/or sick leave. In one of the reviewed studies, Shim et al provided education and an exercise program to a group of 56 women with pregnancy related lumbar and pelvic pain. After 12 weeks, the women in the intervention group reported an almost three point decrease in pain. Education and exercise were also provided to late pregnancy subjects with symphysis pubis pain and dysfunction in the study by Depledge, et al. They found that after only one week of education and exercise, average pain decreased by 31.8% and disability decreased by 38.6%.

Osteopathic manual techniques, practiced by osteopathic physicians and physical therapists, have also been shown to be effective for pregnancy related back pain. Licciardone et al compared the effect of the addition of 5-7 sessions of osteopathic manual techniques (soft tissue, myofascial release, muscle energy and range of motion mobilization) to usual obstetric care in 146 women with late pregnancy back pain. They found that back pain decreased and back specific functioning deteriorated less in those women who received the manual techniques.

Low back pain, pelvic pain and functional limitations because of pain should not be considered an inevitable or normal part of pregnancy. Intervention during pregnancy can decrease pain, improve function and reduce the risk of persisting and chronic pain. Physical therapy at New Heights Physical Therapy Plus provides safe and effective customized assessments and interventions in all stages of pregnancy and post-partum.

In June, we will be welcoming a new physical therapist, Julie Burtis. Julie specializes in women’s health and will be splitting her time between the West and East clinics. She will be giving a lecture on Postpartum Rehab at New Heights (East Clinic) on June 29th from 6-7PM.

Five Tips for Making the Most of Your Physical Therapy Experience

Making the Most of Your Physical Therapy Experience. New Heights Physical Therapy in Vancouver WA and Portland OR.

We’re at about mile 18 on the new clinic marathon, and while our efforts are yielding some beautiful results, there’s still some distance to go. At this point in the project, New Heights owners Kevin Poe and Donna Gramont have to dig deep and call upon the lessons they’ve learned in physical therapy to see them through the daily grind. Turns out rehabbing a building isn’t much different than rehabbing a body, it requires the same grit and determination. They offer up these five tips for turning pain into gain to help you reach your recovery goals.

 

Tip #1: Begin with the end in mind.

Donna and Kevin envisioned a bigger space for patients and staff to work their recovery, which led them to purchase the former Montavilla Sheet Metal building, a treasure trove of raw materials. In their mind’s eye, they pictured the rubble of lumber not laid to waste, but instead transformed into desks, tables, cabinets, and other furnishings for the beautiful new clinic. 

Having A Good Physical Therapy Experience - New Heights Physical Therapy - Portland OR Vancouver WA

What do you imagine for your recovery? If you’re rehabilitating a broken ankle, picture yourself on campus walking to class or taking a hike with a friend. A powerful first step is placing yourself at the finish line having achieved your goal.

Tip #2: Learn some new skills.

Kevin didn’t know how to weld and Donna had never built furniture before, but both knew that they were capable of learning. Yes, they were operating outside their comfort zone, but they also knew the furniture wouldn’t build itself. They asked friends and family for help, and with some trial and error, they gained the necessary skills to make the furniture.

What new skills do you need to learn to reach your goal? Pilates? Strength training? Our therapists excel at educating patients about their injury or condition. Lean on them and bank some knowledge that will help you achieve your goal.

Tip #3: Show up and do the work.

Every.darn.day. Donna and Kevin realize they can’t carry this heavy load forever, but until the new clinic opens in December they have committed to working hard every day in order to realize their dream of a new clinic.

Recognize that physical therapy can be hard, challenging work. But it’s a matter of fact: you’ll realize your recovery goals sooner if you commit to your therapy plan and do your home exercises. Sometimes life just doesn’t offer shortcuts!

Tip #4: Find the Zen in the work.

Planing, sanding, joining, and staining a thousand board feet of lumber would be enough to drive anyone mad, but Donna resists the urge to resist, and settles into the work itself. By finding a peaceful zone in which to work she ensures that she isn’t expending unnecessary energy that would be better spent accomplishing her goal.

 

Pay attention to when you feel overwhelmed and frustrated during your recovery. Try to accept your current reality and work with what is, not what isn’t. You may find that things will soften and shift, ultimately moving you closer to your goal.

Tip #5: Prepare to Celebrate!

You better believe there is a big party planned in early 2015 to celebrate the opening of our new clinic, we can hear the champagne corks popping now! We want to share this with you, our valued patients, whose health and well-being is the reason all of this is hard work is happening.

We recommend that you celebrate every small achievement you gain during your recovery! It’s easy to lose sight of how far you’ve travelled and the ground you’ve regained. Take a moment to pat yourself on the back for all the hard work you’ve put in and the results you’ve achieved. Let the sparks fly!

Guest Blog: Treatment Options for Knee Osteoarthritis

 Reflex Tag

Guest blog: by Reflex Clinic

According to the CDC one out of every two people in the United States will develop symptomatic knee osteoarthritis (OA) by age 85. Factors such as age, weight, gender, activity level and genetics can increase or decrease the likelihood of developing OA in your lifetime. Although there is no cure for osteoarthritis of the knee, there are more treatment options available than ever before, especially if detected in its early stages.Continue reading