Why Does My Shoulder Hurt?

Shoulder pain is one of the most common ailments treated by physical therapists.  There are many potential causes of shoulder pain, but the two primary issues to consider include poor mobility and muscle imbalance.  The key to treating most common shoulder related pain is to improve your posture while focusing on thoracic mobility, shoulder position, and proper shoulder strengthening.

Poor Mobility

The most common reason for mobility issues is poor posture.  Poor thoracic mobility and tightness in the posterior capsule of the shoulder are the most common contributors to the lack of mobility which can ultimately lead to shoulder pain.

Mobility issues can occur if you adopt a chronic forward head with rounded shoulders posture.  As this position becomes more chronic, the thoracic vertebrae lose backward mobility (extension).  This happens in conjunction with shortening of the pec minor (which is located underneath the pec major) and causes the shoulders to roll forward.  The forward shoulder posture causes the humeral head (arm bone) to be positioned more forward.

This causes tightness in the posterior (back) portion of the shoulder joint which affects the natural roll and spin motion of the joint.  The alterations of the roll and spin motion combined with alterations in shoulder blade motion negatively affects the mechanics of the shoulder joint.  The alteration in mechanics is what ultimately leads to pain as the rotator cuff or biceps tendons become impinged, irritated, and painful.

This is commonly referred to as Shoulder Impingement Syndrome.  Shoulder impingement pain is often associated with pain reaching overhead, behind your back and/or out to the side.  Those who experience it may feel weaker in the affected shoulder and experience pain when sleeping on the affected side.

Perform the following stretch to address shoulder posterior capsule tightness.  Lie on the side of the affected shoulder.  Be sure to support your head with a pillow.  Your arm should be straight out from your body with your shoulder tucked under your body.  The goal is to pin your shoulder blade down with the floor.  Gently push your arm down (as shown).  You should feel a gentle stretch.  Hold for 30-60 seconds for two to three times.  Perform once or twice per day.

In case you haven’t already subscribed to my e-mail list, please take a moment to do so in order to access my FREE resources, including My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain.  It’s a downloadable .pdf file with my recommended stretches and exercises to address poor thoracic mobility and pec minor tightness.  These simple exercises (with complete instructions and photos) will help you to improve thoracic mobility and can be performed at home.

GET MY FREE RESOURCE

Muscle Imbalance

Muscle imbalance is often an associated causative factor for shoulder pain.  In addition to mobility issues, altered strength and muscle activation patterns are also related to shoulder pain and shoulder impingement syndrome.  The reasons for muscle imbalance can vary, but are often associated with poor posture and/or cervical/neck related issues.

Two common muscles that must be strengthened in order to insure proper shoulder mechanics are the lower trapezius muscle and the supraspinatus muscle (which is one of four rotator cuff muscles).

The rotator cuff muscles are responsible for the stability of the shoulder and proper roll, glide, and spin of the ball and socket shoulder joint.

The lower trapezius muscle is responsible for proper shoulder blade timing and rotation during arm movements.  It helps in maintaining a proper upright posture.

For three easy and effective exercises to perform to improve your lower trapezius and rotator cuff muscle strength, please refer to Exercises for Lower Trapezius and Rotator Cuff Muscle Strength.

Most shoulder symptoms typically resolve when thoracic mobility and strength in the shoulder is improved.  Shoulder impingement is painful, but worse yet if left untreated.  It can lead to fraying of the rotator cuff tendons (and ultimately, a rotator cuff tear).  It’s always best to be proactive and address the causative factors early.

If you’re not improving or your symptoms worsen, consult with your medical provider to determine if other causes are contributing to the problem.  The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area.  In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to hear your physician’s opinion as well).

If you’re experiencing shoulder pain, do you think either poor mobility or a muscle imbalance is causing it?  How can you improve your thoracic mobility and strength in your shoulder?  Please share below.

If you have a question that you would like featured in an upcoming blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

My Top 5 Most Popular Posts of 2016!

As 2016 comes to a close, more and more people are realizing the value of taking control of their health care and personal well-being.  In today’s health care environment, we all need to learn how to treat common aches and pains proactively instead of reactively.  We must get to the root of the issue instead of placing a Band-Aid over it.  Our present health care system in America is not designed to help you optimize your health–that is your job!

2016 marks the first time that the media started to wake up to America’s prescription opioid addiction.  The news and many research articles discussed America’s opioid addiction including their disastrous consequences on one’s health and the nation’s health care system in general.  Not to mention, how poorly opioids actually are in managing long term pain.

The purpose of The Physical Therapy Advisor is to help people like you to take control of your health and to save money by learning how to safely self-treat and manage common musculoskeletal, neurological, and mobility related conditions safely and effectively without opioid use.

My Top 5 Most Popular Posts of 2016:

  1. How to Use Shoulder Pulleys to Regain Shoulder Motion – Maintaining adequate shoulder mobility is critical after surgery and/or avoiding osteoarthritis of the shoulders.  The shoulder pulley is often one of the first exercises initiated after surgery or injury. However, it’s often performed incorrectly.  In this video, I demonstrate the proper way to utilize a shoulder pulley.
  2. Exercise as Medicine – Too often, people look towards pharmaceuticals in order to help manage medical conditions.  Exercise is a highly effective and often underutilized method to treat many common, yet serious, medical conditions such as diabetes, heart disease, and osteoporosis.  Exercise is medicine when prescribed and performed correctly.
  3. 3 Simple Exercises to Help You Age Well – Maintaining functional mobility as we age is critical.  First, you need to maintain the ability to stand up.  This insures that you can get up from a chair or a commode/toilet.  Second, you need to maintain your ability to ambulate to insure that you can perform the other needed activities of daily living more easily.  Lastly, you need the balance to safely perform these tasks.  Walking, squatting, and improving your balance will help you to age well.
  4. 5 Strategies to Train Smarter for your next Obstacle Course Race – Obstacle course racing (OCR) is one of the hottest new sports around for all fitness levels (including the novice to expert thrill seekers).  This post highlights the five lessons I learned from my training seminar on OCR races with Ben Greenfield from www.Bengreenfieldfitness.com and Michael Caron from www.Getburly.com.
  5. Got Text Neck? – Have you noticed that wherever you go nowadays that you constantly see people walking and looking down at their cell phones?  No wonder that the term “text neck” is now being used to describe chronically poor posture!  This post explores the role of poor posture related to neck and headache pain along with tips for prevention and treatment.

2016 has been a wonderful year!  I successfully launched my first eBook and video package, Treating Low Back Pain (LBP) during Exercise and Athletics.  I share very specific strategies for LBP prevention among athletes such as sport enthusiasts, CrossFitters, weightlifters, and runners.  These principles are helpful for anyone participating in athletics as well as those implementing a healthy lifestyle.  This eBook addresses the specific causes of LBP as well as the best practices on how to prevent and self-treat when you experience an episode of LBP.  A 7-part series of instructional videos is also available and includes nearly 60 minutes of actionable advice to prevent and treat LBP.

CLICK TO LEARN MORE!

In addition to my new eBook, I have continued to feature reader submitted Q & A’s as well as many exercise and training posts including posts written for the Marathon Training Academy.

This past fall, I featured a six part series on headache pain which includes prevention and treatment tips.  An important focus continues to be on longevity and healthy aging.  This includes ongoing guest posts on healthy senior living for the Seniors Blue Book.  (Check out my top 3 recommended daily fall prevention exercises as featured in the latest Seniors Blue Book!)

Looking toward 2017, I will continue to offer free self-treatment advice to help YOU manage common musculoskeletal, neurological, and mobility related conditions in a timely manner.  Together, we can all learn to age well and reach our optimal health!

Don’t forget subscribe to my e-mail newsletter!  I will send you my blog posts on how to maximize your health, self-treat those annoying orthopaedic injuries, and gracefully age.  To thank you for subscribing, you will automatically gain access to my FREE resources, including a FREE CHAPTER from my eBook, Treating Low Back Pain During Exercise and Athletics.

Thank you for supporting The Physical Therapy Advisor! I look forward to serving you in 2017!  If you have a question that you would like featured in an upcoming blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Q & A: How did I get a Stress Fracture in my Foot?

Q.  I have been diagnosed with a stress fracture in my foot.  What causes a stress fracture?  Now what should I do?  The doctor wants me to avoid any weight bearing for the next four weeks.  How do I heal?  Denise

A.  Thanks for your question, Denise.  I’m sorry to hear that this has happened to you.  Stress fractures are a unique type of bone fractures as they rarely occur due to a specific trauma.  Stress fractures typically occur due to a silique of events that leads to the bone not being able to handle the stress of your activity which results in a crack in the bone.  Stress fractures are common in the foot, but they can occur almost anywhere.

Initially, you might barely even notice the pain associated with a stress fracture, but the pain tends to worsen with time.  The tenderness usually originates from a specific spot and decreases during rest.  As the injury worsens, the pain tends to spread out and become more diffused with a focal area of tenderness.  You might have swelling around the painful area.  In some cases, the entire foot may begin to swell.

footpain

Stress fractures typically occur as the bone is subjected to a new unaccustomed force without enough time for recovery.  Bone adapts gradually to increased loads through remodeling, a normal process that speeds up when the load on the bone increases.  During remodeling, bone tissue is destroyed, and then rebuilt.  This is a similar process in muscle tissue.  When the load and/or volume of activity are too much for the bone, a fracture will occur.

Risk Factors for a Stress Fracture:

  • Certain sports.  Stress fractures are more common in people who participate in sports such as track and field, basketball, tennis, dance or gymnastics.  High repetitive impact sports tend to have the most stress fractures.
  • Increased activity.  Stress fractures often result from increasing the amount or intensity of an activity too quickly.  For example, people who suddenly shift from a sedentary lifestyle to being more active (increasing training volume significantly) or those who rapidly increase the intensity, duration or frequency of training sessions.
  • Gender.  Women are more likely to develop a stress fracture, especially those who have abnormal or absent menstrual periods (known as amenorrhea).
  • Foot problems.  People who have flat feet or high, rigid arches are more likely to develop stress fractures.  Worn or poorly fitting footwear or high heels can also contribute to this issue.  For runners, transitioning too quickly from a more built up running shoe into a minimalistic style can be a factor.
  • Osteoporosis.  Osteoporosis or osteopenia causes weakening in the bones that makes it easier for stress fractures to occur.
  • Prior stress fractures.  If you have experienced one or more stress fractures, you’re at a higher risk.
  • Poor nutrition.  Lack of Vitamin D, calcium, Vitamin K, and magnesium can make bones more likely to develop stress fractures.  Generally poor eating habits are also a factor.
  • Hard surfaces.  Spending long periods of time or training on hard surfaces, such as concrete, can increase your risk.
  • Smoking.  Smoking leads to poor blood flow and affects the body’s ability to heal and recover.
  • Obesity.  The heavier you are, the more forces that ultimately go through your foot.  Depending on how you are exercising, your particular footwear and the surface which you walk on can contribute to increasing your risk factors.
  • Gait abnormalities.  Alterations to your normal mobility (from either another injury or a change in your body) that affect how you typically move.  The change in mobility, along with your activity level, can be enough to overload the bone.  Particularly, when other risk factors are present.

In most cases, it’s not one specific risk factor that leads to the stress fracture, but a combination of risks and events that lead to the injury.  Diagnosis is usually through X-ray.  However, an acute injury may not initially show, so a second X-ray may be needed after a week or so to confirm the diagnosis.  A bone scan can also be useful to determine if there is an injury to the bone.

In the case of a poorly healing bone, the use of a bone stimulating electrical device may be recommended by your physician.

Initial Treatment

Non-weight bearing or limited weight bearing for four to six weeks is a very common course of treatment.  It provides enough time to initiate the healing response while reducing the stress on the injury site.  If you continue to stress the site of injury, the fracture can worsen and require more invasive treatments (possibly even surgery).  Crutches, a walker or a Roll-A-Bout knee walker can be used while you have weight bearing restrictions.  A walking protective boot is also typically used to protect the injury site.

As with many injuries, the initial treatment for a stress fracture in the foot is PRICE (Protection, Rest, Ice, Compression, and Elevation).

  • Protection.  Wear a walking boot, and limit weight bearing on the foot.
  • Rest.  Limit any activities that cause pain.  Depending on the severity and your personal health status, this can last from two to eight weeks.  Those with diabetes usually take a significantly longer period of time to heal.
  • Ice.  Use ice as needed for pain and edema control.  The rule for icing is to apply ice no more than twenty minutes per hour.  Do not place the ice directly against the skin, especially if you are using a gel pack style.  A bag of frozen peas can be ideal.  Individuals with poor circulation or impaired sensation should take particular care when icing.
  • Compression.  If swelling is present, utilize a simple ACE wrap around the foot and ankle to help with the swelling and pain.  Start at the toes, and work up the leg.  Take care to not apply the ACE wrap too tightly as over squeezing the foot can be irritating.
  • Elevation.  Use pillows to position the foot above the level of your heart to help reduce swelling.  This would be an excellent time to apply ice, too.

In general, the application of heat, cold, or over the counter (OTC) topical agents, such as Arnica Montana (an herbal rub) or Biofreeze, may help you to manage pain and stiffness.

Addressing Your Risk Factors

After you have initiated PRICE and the pain and swelling has decreased, address any risk factors (if and when possible).

Stop Smoking

If you smoke, please stop.  It not only affects your bone density, but it has negative effects on every other body system.  It also increases your risk of cancer and heart disease.

Nutritional Management

Address any nutritional deficits.  This includes having adequate levels of Vitamin D3, Vitamin K1 and K2, magnesium, and healthy fats.

Vitamin D3 is critical to the absorption of calcium, through the intestinal wall, which is important for bone health.  Although calcium is a critical component of bone health, I cannot recommend extra supplementation because of the potential cardiac risks to over supplementation.  A healthy varied diet will typically supply adequate calcium levels (assuming that adequate Vitamin D3 levels are present for absorption and that you are avoiding drinking soda).  Vitamin D3 is also a critical nutrient in maintaining a healthy immune system.

Research indicates that Vitamin K can help to reduce bone loss by helping the body regulate osteoclast function with in the bone.  An osteoclast is a type of bone cell that breaks down bone tissue.  These very important cells are integral in maintaining proper bone density and insuring an appropriate amount of calcium in the blood stream.  Without adequate calcium, many critical cell functions can be affected (including heart function).  Both Vitamin K1 and K2 have been proven to reduce the risk of fractures, including hip and vertebral.

Vitamin K, found in green leafy vegetables, has anti-coagulation benefits.  If you take blood thinning medications, your physician will need to know how much you consume on a regular basis.

Magnesium is a critical component of bone health and health in general.  Magnesium helps the body to regulate calcium levels.  This has a positive effect on bone health and also has been proven to reduce the risk of kidney stones.

I also use magnesium as a sleep and recovery aid.  I consume it at night to help me sleep.  Magnesium can also reduce muscle soreness, cramps, and/or spasms.  You can take Mag Glycinate in pill form or by eating foods higher in magnesium such as spinach, artichokes, and dates.

Most people are deficient in the amount of magnesium they consume on a regular basis.  I recommend beginning with a dose of 200 mg (before bedtime) and increasing the dose in 100 mg intervals as needed.  I would caution you that taking too much magnesium can lead to diarrhea.  Mag Glycinate in its oral form is the most highly absorbable.  Although not quite as absorbable, Thorne Research Magnesium Citrate is also a fantastic product.

If you’re female (and especially if you suffer from amenorrhea, abnormal or absent menstrual periods), then consuming adequate levels of fats is pertinent.  Adequate levels of Omega-3 fatty acids and other healthy fats (primarily from plant sources such as avocados and coconut or olive oil) are critical in order to insure that your body has what it needs for proper hormonal support.  Amenorrhea can be a sign that your diet is lacking in adequate high quality fats as well as a sign of overtraining.

Avoid Soda and Distilled Water

Excessive soda intake (particularly diet soda) has been linked to poor bone density.  The exact cause isn’t entirely clear.  Many theorize that the acidic nature of the soda along with the chemicals and additives cause increased osteoclast activity in the bones.  This releases more calcium into the blood stream in order to help fight the negative effects of soda consumption.  It’s clear that too much soda is bad for your health and bones.  Similarly, distilled water is water that has been leached of all other nutrients and minerals.  Drinking too much distilled water can leach needed nutrients out of the bones. 

Weight Management

It’s important to manage your weight effectively.  Excessive body weight can cause additional stress on the body.  Whenever possible, work toward optimizing your health.  This includes maintaining a healthy body weight.  The heavier you are the more stress forces present throughout the lower extremity.

Rehabilitation

Once you’re cleared by your physician to initiate exercise and activity, it’s time to progress your rehabilitation.  For detailed descriptions and photos of potential helpful exercises, please refer to Foot Stress Fracture Rehabilitation Exercises(If you’re already working with a rehabilitation professional, such as a physical therapist, consult with him or her prior to starting my recommended rehabilitation exercises.)

  • Strengthen your foot and ankle complex. Weakness in the foot and ankle muscles (as well as the smaller foot intrinsic muscles) can lead to excessive strain on the tissues on the bottom of the foot including the plantar fascia.  I recommend initiating a complete ankle/foot strengthening protocol.  Please refer to Ankle Resistance Exercises Using the Elastic Exercise Band.
  • Improve your balance.  Poor balance is often associated with muscle weakness in the foot and ankle as well as weakness in the knee and hip musculature.  Weakness and balance deficits can lead to poor foot mechanics, which ultimately can lead to a stress fracture or even metatarsalgia.  Improving your balance can help to reduce the risk of metatarsalgia and is an important part of the rehabilitation process.  For more ideas on how to improve your balance, please refer to Improving Balance by Using a Water Noodle.  As your pain level improves, I recommend that you perform these balance exercises without shoes on.
  • Add an orthotic.  Often times, the stress fracture occurred due to alterations in foot mechanics or an old or poorly fitting shoe or orthotic.  If you are recovering from a stress fracture, consult with a podiatrist or a physical therapist that specializes in orthotics to determine the proper orthotic or shoe for you.
  • Did you progress too quickly into a minimalistic shoe?  The standard built up shoe offers more foot support and padding than most minimalistic style shoes.  If you attempted a quick progression, this may have contributed to the injury.  Unless you are a child or teenager, expect a safe transition to take at least three months.  A slow transition will allow your body to adequately adapt to the new stresses.
  • Weight training.  Once you’re cleared by your physician, initiating or returning to a weight training program is critical to the development and maintenance of strong bones.  Weight training (particularly barbell training) loads the skeleton progressively over time, which can decrease bone loss and increase bone mineral density.  It also positively affects the hormones, such as human growth hormone (HGH) and testosterone, needed to improve bone density and muscle strength.  Barbell training is the most effective method due to the progressive load on the skeletal system, and the muscle pull being exerted on the bone, which also stimulates bone formation.  The key to maintaining and improving bone density is always progressive axial skeletal loading and the associated pull of muscles against the bone during activity (particularly, strenuous activity).  Examples of such exercises include squats, lunges, and dead lifts.

It’s critical that you to slowly progress back into high impact activities.  It’s equally important that you address any of these risk factors in order to help reduce the risk of re-occurrence.  If you have experienced one or more stress fractures, you’re already at a higher risk.  As you taper up activity, monitor for signs of swelling and pain.  If symptoms occur, taper down the intensity.  Continue to work in a pain free range in order to strengthen around the injury site.

If you don’t experience a significant relief as you progress into your rehabilitation, please consult your medical professional.  I recommend a physical therapist that specializes in feet or who works with athletes for the treatment of stress fractures.  The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area.  You may also consider consulting with a podiatrist.

Thanks, Denise, for the question.  I hope you find this information to be helpful as you manage your condition.

Have you experienced a stress fracture in your foot before?  Which treatments worked the best for you?  Which treatments didn’t seem to help as much?  Please leave your comments below.

If you have a question that you would like featured in an upcoming blog post, please e-mail contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice.  No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.

How to Recover Quickly from a Quadriceps Strain

mta_quadstrain

http://marathontrainingacademy.com/quadriceps-strain

Marathon Training Academy

November 15, 2016

After straining your quadriceps, you remain at a higher risk of injury. In this guest post for Marathon Training Academy, you will learn which strategies to implement as you work through your rehabilitation and your return to activity.

Muscle injury. Man with sprain thigh muscles

A quadriceps strain, also known as a quad pull or thigh strain, is a relatively common running injury.

Strains can range from a mild discomfort to a full blown tear of most of the muscle which can result in severe pain and the inability to run or walk. The injury typically happens when one or more of the quadriceps muscles become overloaded.

In this pose you will discover the factors that increase your risk of straining your quadriceps, and learn specific strategies to implement during your rehabilitation and return to activity. Continue Reading

How to Self-Treat IT Band Pain with a Mini Plunger

Pain in the lateral (outside) leg or knee is commonly associated with a condition known as Iliotibial Band Syndrome (ITBS).  (Iliotibial Band Syndrome is also known as IT Band Syndrome, ITB Syndrome, or IT Band Friction Syndrome.)  Pain can range from the lateral side of the leg up toward the hip area to just below the lateral side of the knee joint (where the head of the fibula bone begins).  The pain can be very debilitating to the point that running or hiking activities have to be stopped.  Even walking can be difficult.

Although ITBS can be very painful, it can be easily self-treated if you handle your pain and symptoms quickly.  For many years, I have taught people how to use a mini plunger as a method to provide a suction force for self-treatment.  In this video, I demonstrate how to utilize a mini plunger as a “cupping” technique to self-treat IT Band Syndrome.

Cupping is a method or technique to massage and mobilize tissues such as muscles, skin, fascia, and tendons.  The exact treatment effect is unclear, but presently the research indicates that it helps to reset neural pain receptors and stretch receptors.  Thus, reducing pain and allowing for improved movement.

Cupping has been around as a treatment technique for thousands of years.  The research on cupping is interesting and for the most part, concludes that cupping is helpful in pain management.  There are some indications that the “suction” may lead to improved blood flow to an injured area which could speed up healing times.  Other health claims of the benefits of cupping haven’t been adequately proven in current research.

Traditionally, cupping has been performed with glass cups by using a flammable paper to quickly “burn” the oxygen in the cup which causes a suction force.  There are now many types of plastic or silicon cups that can easily be purchased online.  CupEDGE Massage Tools are what I use and recommend.  Fancy cups are not necessary.  The cups can be more convenient, but even a small sink plunger will do.

Have you tried cupping to treat ITBS?  If so, what was your experience like?  Additional discussion can help others to manage this condition more effectively.  Please leave your comments below.

For more information on how to self-treat ITBS, please refer to the following:

Looking for that exercise or book I mentioned in a post?  Forgot the name of a product or supplement that you’re interested in?  It’s all listed in the Resource Guide.  Check it out today!

If you have a question that you would like featured in an upcoming blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Cupping, Should Runners Try it Too?

mta_cupping

http://marathontrainingacademy.com/cupping

Marathon Training Academy

October 17, 2016

In this guest post for Marathon Training Academy, you will discover what cupping actually is and how to use it to massage and mobilize tissues in order to reduce pain and improve movement.

calfactivemobilizationusingacup

The 2016 Rio Olympics brought new light to an old treatment–cupping.  The world stared as athletes like Michael Phelps proudly displayed his petechia for the world to see.

Petechia is the medical term for the purplish bruise that can form with certain types of cupping techniques.

After seeing so many Olympic athletes with bruises this year, the rest of us were left wondering about this trend of using cupping as a medical treatment or sports enhancement treatment.  Does cupping really work?  Can I utilize cupping as a self-treatment method for common running related pains?  Continue Reading

Q & A: A Holistic Approach to Managing Autoimmune Disorders (Myasthenia Gravis)

Q.  I have been diagnosed with Myasthenia Gravis.  It’s affecting my speech, swallowing, and general head, neck, and arm strength.  Are there certain activities that I should modify or avoid?  Which type of exercise can I perform in order to improve my function?  Owen

A.  Thanks for your question, Owen, as it presents an opportunity to discuss a very devastating autoimmune disease, Myasthenia Gravis (MG).  Your willingness and desire to maintain your strength and physical function despite the disease is an encouragement to others who may be suffering as well.

Approximately 50 million Americans (20 percent of the population or one in five people) suffer from autoimmune diseases.  Women are more likely than men to be affected.  Some estimates state that 75 percent of those affected are women.

Myasthenia Gravis (MG) is one of many different types of autoimmune diseases such as Rheumatoid Arthritis (RA), Multiple Sclerosis (MS), and Amyotrophic Lateral Sclerosis (ALS, which is also known as Lou Gehrig’s Disease).

An autoimmune disorder occurs when the body’s immune system attacks and destroys different parts of the body because it has confused itself with a foreign body or invader.  The body’s own immunogenic response against itself is a challenging and difficult problem to fix.  Although there are many different and evolving treatment methods, most (if not, all) autoimmune disorders are not curable.

manwithhishandonthroat

In the case of MG, it’s considered a neurologic autoimmune disease because the immune system attacks the nerves that control certain muscles of the body.  Symptoms of MG vary wildly and sometimes can be quite severe.  Symptoms may include:

  • Muscle weakness
  • Drooping of one or both eyelids
  • Double vision
  • Altered speech
  • Difficulty swallowing
  • Problems chewing
  • Limited facial expressions
  • Weakness in your neck, arms, and legs.  (If the neck is weak, it may be hard to hold up your head.)

Proper medical management is critical in all cases of autoimmune diseases.  Those diagnosed with MG (or any other autoimmune disease) should always be medically managed by a specialist in the disease.  In most cases, management of MG will be overseen by a neurologist (preferably, with experience in treating MG and other neurologic autoimmune diseases).  

In order to best address any autoimmune disorder, a multifactorial approach to managing the disease should be implemented.  Although the condition may affect one specific aspect of your body, a healthy and balanced body will always function better and be more resilient to fight and thrive in spite of the condition.  In addition, it’s important that you and your loved ones learn as much about the disease as possible.

A Holistic Approach to Managing Autoimmune Disorders (Myasthenia Gravis):

  • Medical/Physician Management.  Depending on the condition and triggering events, this may include pharmacological management or surgical intervention.  In the case of MG, the trigger may be a tumor in the thymus gland.  Your physician may order a CT Scan of your chest to screen for a tumor.
  • Speech TherapyOften with MG or other autoimmune disorders, you may develop difficulties with swallowing.  I highly recommend that you work with a Speech Therapist (ST).  Speech therapists are highly trained medical professionals that specialize in treating disorders that affect swallowing, speech, and cognition.  They can use very specific treatment modalities from exercise to diet modification.  Neuromuscular electrical stimulation (NMES) can be utilized to help the muscles responsible for swallowing improve in strength and coordination.
  • Nutritional Management.  Consume foods that promote a low inflammatory diet, including a diet high in Omega-3 fatty acids and other natural herbs (like garlic and turmeric) which can naturally lower inflammation.  Consuming food that helps to support the immune system is important because the nervous system is affected by MG and other autoimmune diseases.  This includes a diet high in Omega-3 fatty acids and having adequate Vitamin D3 levels.  Include foods that support the nerves and are typically high in good fats such as avocados, coconut oil, and healthier fish (such as sardines and wild caught salmon).  If you’re experiencing difficulty with swallowing, be sure that your food is prepared in such a way that you can safely eat and that it’s in accordance to advice from your speech therapist.
  • Weight Management.  It’s important to manage your weight effectively.  Excessive body weight can cause additional stress on the body.  Whenever possible, work toward optimizing your health.  This includes maintaining a healthy body weight.  Depending on the autoimmune disease and your body in particular, this may also mean maintaining enough body weight.
  • Activity Modification.  As the disease progresses, it’s important to understand how your body is functioning, and then learn how to adapt to manage the disease.  Unfortunately, certain activities and how you perform them will need to be modified or avoided.  Learn to pace yourself and take more frequent rest breaks.  Adequate night time sleep is also critical.  If any of your joints are affected, learning to limit the use and strain on them will be important.  Utilize adaptive devices (such as a cane) in order to limit the strain placed on your body during activities.  An assistive device will allow you to be mobile and will reduce your risk of falling.
  • ModalitiesThis is a broad category, but there are many ancillary treatments that can be utilized to help you feel more comfortable.  The good news is that they rarely have associated side effects.  In general, the application of heat, cold, or over the counter (OTC) topical agents, such as Arnica Montana (an herbal rub) or Biofreeze, may help you to manage pain and stiffness.  Gentle massage and TENS (Transcutaneous Electrical Nerve Stimulation, a form of electrical stimulation performed by a physical therapist) may also be beneficial for pain relief.  TENS is different than the neuromuscular electrical stimulation (NMES) used by speech therapy.  TENS is used for pain control only.
  • Limit StressOften in cases of autoimmune disorders and in particular, MG, poor stress management will lead to worsening symptoms.  The ability to effectively manage stress will be critical in managing your symptoms.  There are many different methods to help you manage stress more effectively.  Common methods include:  meditation; journaling; deep breathing; Tai Chi; and yoga.  You may also need to reconsider certain friendships and relationships in your life.  The key to effectively managing stress is to find an enjoyable activity, and then stick with it.  This is a process–a journey (not a destination).
  • Exercise.  Implementing exercise in order to promote general health will not only help you to feel better, but it will optimize your well-being during this very difficult time.
    • Strength TrainingStrength training is encouraged, and the exercise program should be established by a professional who is familiar with managing MG.  All exercises should be performed in a slow and controlled environment within the available range of motion (ROM).  Maintaining muscle mass through strength training is critical and should be performed only one to two times per week to minimize any risk of over fatigue.
    • Endurance Training.  Endurance training is critical for general health and should be included as part of a comprehensive exercise program for individuals with MG.  Focus on less impact activities such as bicycling, rowing, and water aerobics.  Avoid excessive fatigue.
    • Flexibility TrainingFlexibility training is important for everyone as part of a healthy lifestyle.  Take every joint through a full ROM at least once a day.  I highly encourage a regular two to three times a week flexibility program in addition to a daily ROM program.  Tai Chi and yoga both also address aspects of strength and balance and are wonderful for managing stress.  Other options include:  Pilates; water aerobics; and a stretching routine.
    • Aquatic Therapy.  Water can also be very useful in pain control and help with relaxation.  Many find that performing a regular exercise program in an aquatic environment can satisfy most exercise needs, including flexibility and strength.

Managing an autoimmune disorder, such as MG, is difficult and everyone’s journey will be different.  Your specific treatment protocol should be individualized based on your specific condition, how the symptoms are affecting you (which will vary over time), and your current health status.

Thanks, Owen, for the question.  I hope you find this information to be helpful as you manage your condition.

What has your experience with managing autoimmune disorders been like?  Are there any treatments that have or have not worked well for you?  Additional discussion can help others to manage these difficult diseases as well.  Please leave your comments below.

If you have a question that you would like featured in an upcoming blog post, please e-mail contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice.  No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.

When to Return to Running after Experiencing Low Back Pain

mta_returntorunning

http://marathontrainingacademy.com/return-running-experiencing-low-back-pain

Marathon Training Academy

September 13, 2016

In this guest post for Marathon Training Academy, you will learn why initial activity and exercise are critical when treating low back pain (LBP) and how to determine if you are ready to return to running after experiencing an episode of LBP.

WomanWithLowBackPain

Low back pain (LBP) can be so severe and debilitating that it can completely derailing your training. It’s hard to run if your back, buttocks or leg hurts. You either won’t try to do it or you try to suffer through it only to be rewarded with worsening symptoms later on. However, initial activity and exercise are critical when treating LBP. Continue Reading

Got Text Neck?

With the ever increasing obsession over portable technology devices, it isn’t surprising that cases of “text neck” are also increasing exponentially.  Text neck is a term used to describe pain that is felt in the head, cervical spine (neck), and/or thoracic spine (upper back region) from chronically poor posture associated with using mobile technology such as smart phones and E-readers.  This tends to go hand in hand with “text thumb” (or what was once called “BlackBerry thumb”) pain.

poorposturewhiletexting

With over 90% of Americans currently using mobile phones, it’s not surprising that cases of text neck are skyrocketing.  People are spending hours hunched over their hand held devices.  This is causing chronically poor posture.  This forward head and rounded shoulders posture is responsible for causing headache pain, neck pain, upper back pain, and even shoulder pain.

The average sized head weighs approximately 10-12 pounds.  Imagine bending over or looking down.  At even 30 degrees, the relative weight of the head as felt by the neck and upper back is up to 40 pounds.  Increase the flexion to 60 degrees, and the weight goes up to 60 pounds.  Over time, the extra strain fatigues the muscles of the neck and thoracic spine.  It causes excessive strain on the muscles as well as the ligaments and the discs and joints of the cervical and thoracic spine (ultimately, leading to pain).

When left untreated, you could experience ever increasing levels of pain.  Pain in combination with poor posture can place ongoing stress that can lead to pre-mature degeneration of the cervical spine and development of osteoarthritis and other degenerative conditions.

How to Prevent and Treat Text Neck:

  • Stop Looking Down.  The most obvious treatment for cases of text neck is to address the underlying postural dysfunction.  This means that you should stop looking down at your phone or mobile device.  Try to keep your devices at eye level.  Limit the amount of time spent looking down.  If you tend to spend 30-40 minutes at a time looking down at your device, work toward reducing that time in half.
  • Use Voice Text Options.  To avoid looking down so much, try to use voice text options or hands free options.  This can help limit your time spent looking down at the screen.
  • Reverse the Position.  In today’s society not using a mobile device is a difficult option.  Instead of not using a device or never looking down, be proactive by spending time moving in the opposite direction.  The neck and upper back are meant to move in many directions.  Be sure to extend your neck and thoracic spine frequently throughout the day.  Imagine how good it feels to stretch backward while yawning.  Perform that motion more frequently and after every prolonged period of looking at your device.
  • Perform Cervical Retractions.  After looking down for more than a minute, perform cervical retractions (as shown below).  Sit up straight, and retract your chin straight back.  Repeat 5-10 times.

cervicalextensionexercise_collage_960pxwide

  • Exercise.  Keeping the areas of your body which support your arms, neck, and thoracic spine strong is a critical step in preventing text neck pain.  Focus on the muscles that extend the neck and thoracic spine as well as stabilize the shoulder girdle (including the muscles of the rotator cuff).  Please refer to Rotator Cuff Exercises for two simple exercises that will work your shoulder girdle and rotator cuff muscles while using an exercise band.
  • Focus on Your Posture.  The chronic forward head with rounded shoulders posture associated with text neck causes excessive muscular tension throughout the cervical spine, upper trapezius region, and mid-thoracic area.  Over time, this also leads to muscle weakness and/or dysfunction in the cervical spine and upper thoracic area.  Maintaining proper posture allows for the optimal alignment of your spine.  Neurologically speaking, this allows for your muscles to down regulate by reducing tension.  Poor posture is almost always associated with muscle knots and trigger points.  Be sure to vary your positions frequently throughout the day.  My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain is a downloadable .pdf file with my recommended stretches and exercises to address posture.  These simple exercises (with complete instructions and photos) will help you to improve poor posture and can be performed at home.

DOWNLOAD NOW: My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain

  • Massage.  If you are already suffering from trigger points and muscle spasms, massage can be an excellent modality to reduce these symptoms.  It’s important to actively and physically address the muscle tension.  This is the time to contact a masseuse, physical therapist, athletic trainer or friend who is skillful in body work and massage to relieve the area in spasm.  The specific massage technique to use will vary according to your preference.  Massage techniques range from a light relaxing massage to a deep tissue massage or utilization of acupressure points.  This can also be an effective prevention strategy.
  • Foam roller.  The foam roller allows you to perform self-massage and tissue mobilization.  Utilize a foam roller on a daily basis in order to avoid neck and upper back pain.  Please refer to the following posts for more information:  Foam Rolling For Rehabilitation and 5 Ways to Improve Range-Of-Motion.  I highly recommend a foam roller to help aid in your recovery.
  • Acupuncture.  I am personally a big fan of acupuncture.  It is very useful in treating all kinds of medical conditions.  It can be particularly effective in treating headaches, muscle trigger points, muscle cramps, spasms, and pain as it addresses the issues on multiple layers.  Acupuncture directly stimulates the muscle by affecting the nervous system response to the muscle while producing a general sense of well-being and relaxation.
  • Manual Therapy.  A physical therapist or chiropractor can use manual therapy techniques which can be beneficial in reducing pain and addressing some of the mechanical causes.  However, manual therapy is a passive treatment.  For long term treatment and prevention, an active approach needs to be taken.  I would encourage you to perform proper exercises to insure that you have adequate cervical and upper thoracic strength and mobility.  Also, address any precipitating factors (such as poor posture).
  • Medications.  Medications can be an effective short term solution for pain, but I strongly encourage you to transition off of medications over time.  In some cases, prescription medications may be used initially to help you tolerate the pain as you work toward prevention.  Please speak to your physician regarding prescription options.
  • Speak with your Physical Therapist (PT) or Physician (MD).  If you are suffering with headache and muscle tension/pain, there are options.  Please speak to your medical provider to determine if other causes are contributing to the problem.  The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area.  In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to hear your physician’s opinion as well).

Whether you suffer from text neck or you’re experiencing pain from chronic poor postures, these prevention and treatment strategies will help you overcome the discomfort.  Begin by implementing one or two of these treatment tips, and then assess how well they worked for you.   If the technique helped, continue with it and then implement another strategy.

Which strategies can you implement in order to avoid and/or alleviate the discomfort of text neck?  Please share below. 

If you have a question that you would like featured in an upcoming blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Cervicogenic Headaches: A Real Pain in the Neck (and Head)

Cervicogenic headaches are a certain type of headache in which the head pain is specifically caused by an issue in the cervical spine.  Cervicogenic pain is often a trigger for other types of headaches, such as migraines or tension headaches.  As a physical therapist, I find it more effective to classify cervicogenic headaches separate from tension headaches.  Tension and cervicogenic headaches may be treated similarly, but in many cases, it depends on the actual dysfunction present.

Young man experiencing neck pain against a white background

Cervicogenic headaches are almost always mechanical in nature.  This means that there is a structural or mechanical cause in the neck which is leading to the headache pain.  Since the trigger is mechanical, these headaches can come on very suddenly with certain movements and can also be reduced or eliminated quickly if the correct movements can be initiated.  When the cervical spine is the cause of the pain, you may experience cervical pain, headache pain, and other correlated or referred pain in your upper back or down your arms (even to your fingers).

Cervicogenic Headache Symptoms include:

  • Pain in the front of your head, behind your eyes or side of your head.
  • Pain which begins from your neck and extends to between your shoulder blades or upper shoulders.
  • Pain which is exacerbated or changed by certain neck movements or neck positions.
  • Pain which is triggered by pressure applied to the upper part of the neck near the base of the skull (known as the suboccipital area) or in the upper trapezius area.
  • Pain down one or both arms and can be felt as far as your fingers.
  • Stiff neck.
  • Blurred vision.
  • Nausea, vomiting, and/or dizziness.

Potential Causes for Cervicogenic Headaches

There are plenty of reasons why one might develop cervical derangements or dysfunction.  Examples include:  motor vehicle accidents; sports; falls; sleeping on a poorly fitting pillow; poor posture (especially when texting); and/or carrying items that are too heavy (such as a backpack).  Chronically sustained non-symmetrical postures, stress, and/or a sedentary lifestyle are also potential causes.

The actual pain generating structures of the neck (listed below) also vary wildly and can be difficult to pinpoint.

  • Nerve related injury or pain
  • Muscle spasms
  • Trigger points
  • Facet joint dysfunction
  • Cervical mal-alignments
  • Cervical disc issues
  • Postural dysfunction

Cervicogenic pain and headaches tend to be more common in women than men.  In general, women experience this due to an anatomical difference.  Men tend to have more muscular necks while women tend to have more long and slender necks with less muscle to provide support to the head (meaning that there is less muscle strength for support).

Treatment for Cervicogenic Headaches

In cases of mechanical pain, you should be able to alter and change your neck or headache pain within a short period of time.  The first step is to establish a directional preference by identifying a pattern to the pain.

Which head motions change or alter your neck or headache pain?  Does the pain get worse or does it improve when you turn your head?  What happens when you look up, look down, slouch or sit up straight?  What happens when you repeat this movement?

Determine how your pain responds.  If it spreads away from the spine and down into the upper back or arm, beware that you are moving in the wrong direction.  Stop that particular movement, and instead try the opposite direction.

In my experience, most episodes of cervical and headache pain tend to respond better to cervical extension biased movements and improvements in posture.  Often, gaining extension in the thoracic spine is also critical to treatment.

In order to determine if extension biased (cervical retraction or extension) movements help you, I recommend starting with this exercise (as shown below).  Sit up straight, and retract your chin straight back.  Repeat 10-20 times.

cervicalextensionexercise_collage_960pxwide

Carefully monitor symptoms for peripheralization or centralization.  The rule of thumb for movement:  If the pain worsens by spreading peripherally down the arm into the hand, fingers, down into the shoulder blade/upper back or the headache is worsening, then the condition is worsening.  Stop that activity.  If the pain centralizes and returns back toward the cervical spine, and the headache pain improves (even if the pain in the neck worsens slightly), then keep moving as the condition is actually improving.

If you are unable to help or change the pain in any way, then you may need assistance from a medical provider.  For a thorough discussion and an excellent treatment resource, please refer to Treat Your Own Neck by Robin A. McKenzie.

Other Treatments for Cervicogenic Headaches:

  • Exercise.  A primary treatment modality and prevention technique is exercise.  Exercise in general has been shown to be beneficial in treating and preventing cervical pain and headaches.  However, a specific exercise program designed to maintain cervical and thoracic mobility and strength should be the main portion of your treatment.  Focus on your thoracic mobility (particularly, into extension).  Work on cervical stabilization exercises that involve the muscles that support your head and neck.
  • Focus on your posture.  Poor posture is a bane of modern society.  The most common example of poor posture is a forward head with rounded shoulders.  This causes excessive muscular tension throughout the cervical spine, upper trapezius region, and mid-thoracic area.  Over time, this also leads to muscle weakness and/or dysfunction in the cervical spine and upper thoracic area.  Proper posture allows for the optimal alignment of your spine.  Neurologically speaking, this allows for your muscles to down regulate by reducing tension.  Poor posture is almost always associated with muscle knots and trigger points.  My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain is a downloadable .pdf file with my recommended stretches and exercises to address posture.  These simple exercises (with complete instructions and photos) will help you to improve poor posture and can be performed at home.

DOWNLOAD NOW: My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain

  • Massage.  Many trigger points and muscle spasms will refer pain into the head (which causes the headache).  It’s important to actively and physically address the muscle tension.  This is the time to contact a masseuse, physical therapist, athletic trainer or friend who is skillful in body work and massage to relieve the area in spasm.  The specific massage technique to use will vary according to your preference.  Massage techniques range from a light relaxing massage to a deep tissue massage or utilization of acupressure points.  This can also be an effective prevention strategy.
  • Foam roller.  The foam roller allows you to perform self-massage and tissue mobilization.  The foam roller is a wonderful tool to prevent muscle cramping and spasms.  Please refer to the following posts for more information:  Foam Rolling For Rehabilitation and 5 Ways to Improve Range-Of-Motion.  I highly recommend a foam roller to help aid in your recovery.
  • Other self-mobilization tools.  Many times, a friend or masseuse isn’t available to assist when you need the help the most.  A foam roller cannot effective reach places in the upper back or arms, so other self-mobilization tools may be necessary.  You can get creative and use a tennis ball or golf ball, but I like a specific tool called a Thera Cane Massager.  This tool allows you to apply direct pressure to a spasming muscle.  When held for a long enough period of time, the Thera Cane Massager will usually cause the muscle spasms to release and provide much needed pain relief!
  • Magnesium.  A deficiency in magnesium is often associated with headache symptoms and can also heighten the pain response.  Take magnesium orally (such as Mag Glycinate in pill form) or apply it topically in order to help mediate the pain response.
  • Topical agents.  Many topical agents can help to decrease and eliminate muscle spasms or mediate the pain response which can help to reduce headache pain.  You can apply a small amount of the topical agent directly over the headache pain area if it’s accessible and not near your eyes.  (Please use common sense.)  You may find that one product works better than another.  Some of my favorite products in my medicine cabinet include:  Biofreeze Pain Relieving Gel; Arnica Rub (Arnica Montana, an herbal rub); and topical magnesium.
  • Magnesium bath.  The combination of warm water with magnesium is very soothing and relaxing.  Magnesium is known to help decrease muscle pain and soreness.  Options include: Epsoak Epson Salt or Ancient Minerals Magnesium Bath Flakes.  I find that the magnesium flakes work better, but they are significantly more expensive than Epson salt.
  • Acupuncture.  I am personally a big fan of acupuncture.  It is very useful in treating all kinds of medical conditions.  It can be particularly effective in treating headaches, muscle trigger points, muscle cramps, spasms, and pain as it addresses the issues on multiple layers.  Acupuncture directly stimulates the muscle by affecting the nervous system response to the muscle while producing a general sense of well-being and relaxation.
  • Manual Therapy.  A physical therapist or chiropractor can use manual therapy techniques which can be beneficial in reducing pain and addressing some of the mechanical causes.  However, manual therapy is a passive treatment.  For long term treatment and prevention, an active approach needs to be taken.  I would encourage you to perform proper exercises to insure that you have adequate cervical and upper thoracic strength and mobility.  Also, address any precipitating factors (such as poor posture).
  • Medications.  Medications can be an effective short term solution to headache pain, but I strongly encourage you to transition off of medications over time.  In some cases, prescription medications may be used initially to help you tolerate the pain as you work toward prevention.  Please speak to your physician regarding prescription options.
  • Speak with your Physical Therapist (PT) or Physician (MD).  If you are suffering with headache and muscle tension/pain, there are options.  Please speak to your medical provider to determine if other causes are contributing to the problem.  Physical therapy is very good at assisting those suffering with these types of headaches.  The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area.  In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to hear your physician’s opinion as well).

Don’t give up hope!  Headache pain is difficult to manage, but with proper care most headache pain can be cured or effectively managed.  Begin by implementing one or two of these treatment tips, and then assess how well they worked for you.  If the technique helped, continue with it and then implement another strategy.

If you suffer from cervicogenic headaches, which treatments have worked the best for you? Please share below. 

If you have a question that you would like featured in an upcoming blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com. Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice.  No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.