Happy New Year

 

Happy New Year from KB Fitness!!!

Don't spend another year limited in what you can do because of pain!

Take the initiative to help yourself or a family member get rid of lower back, neck or knee pain!

 

 

 

  Order a Strength On Demand Physical Therapy Home Exercise DVD Today at

www.strengthondemand.com

 

 

Make sure you stick to your New Year's Resolution of being pain free!!!

 

 

Is My Patient Exagerating Their Pain Level?

Is My Patient Exagerating Their Pain Level?

 

 

Many times, when working with clients who have been experiencing lower back pain for a long time (months or even years), the slightest touch or smallest movement will send their pain level through the roof.  Initially, as therapists we may think this to be an exaggerated response, a patient with a low pain threshold, or a patient with other motives.  But can the patient's experienced pain level really be this intense upon light touch or gentle movement?  It is believed that when tissue damage in a body region exists, the nociceptors (nerve cell that responds to painful stimuli) are increasingly stimulated, which amplifies the sensitivity to that stimulus.  You do not get used to pain caused by tissue damage, but become more sensitive to it.  This may cause a doctor to prescribe higher intensity pain medications or refer their patient to the pain clinic.  However, if we take a step back and treat the source of the tissue damage, which many times may be poor body mechanics or posture, we may be able to spare the tissue damage.  Once the pain level decreases we can begin to incorporate more aggressive rehabilitation exercises.  For information on posture and body mechanics, go to Posture & Body Mechanics DVD           

Avoid Tunnel Vision

Many times, I will see a client who complains of knee pain.  During my initial assessment, I will check the knee strength and range of motion.  I will perform special tests to detect deficits with the ACL, PCL, Collateral Ligaments, Menisci, etc.  I will compare the "good" knee to the "bad" one with the prior tests and measures.  That would be considered a "FAIR" assessment.  But to provide a "GOOD" assessment, I must perform a 'peripheral joint scan' checking at least one joint above and one joint below the "problem" area to truly pinpoint the problem.  The knee pain could be caused by some biomechanical problem at the ankle such as over pronation due to tight gastrocnemius, tight soleus or restricted subtalar joint.  It could also be caused by weak hip musculature, particularly the posterior gluteus medius.  You may not pick up on these other areas as being potential causes until 2 or 3 sessions have gone by.  But the point is, do not have tunnel vision.  If your client attends 2 weeks of sessions, and there has been no change in the symptoms, that is your cue to look elsewhere as a possible cause.  Check one joint above and one joint below the knee.  You can usually detect signs of deficiency in these other joints while simply observing your client's posture, gait and stepping activities.  So always pay close attention to your client's movements, especially as they transition from one exercise or position to the next.  You will be surprised at what you see, as it may be the cause of their main complaint.

Client Assessment Part 4

C.H.A.R.T.S.

"R" Stands for Range Of Motion (ROM)

During your client assessment, you will want to evaluate the range of motion, particularly of the area related to the chief complaint.  You are looking for the 3 R's (Range or quantity, Resistance or quality/willingness to move, and Reactivity to the movement).  Be  especially attentive to the "Comparable Sign." The comparable sign is the client's chief complaint or symptom.  If you have your client perform an action that causes pain, however it is not the same pain that he is usually complaining about, then it is not the comparable sign.  Reproducing the symptoms/comparable sign will help you figure out the source of the problem. 

First have your client perform the movement actively.  If he feels symptoms, then you take him through the movement passively.  Lastly, test that movement resistively to assess strength.  With each of these, you are always looking for the 3 R's.  If there is pain prior to applying resistant, your client is highly reactive. Pain with resistance means he is moderately reactive.  While pain after resistance means low reactivity. 

A normal result of active range of motion is as follows:

-smooth motion at all speeds

-full ROM

-Pain free

-Normal strength

Abnormal result of active range of motion is:

-client resists movement

-painful area in the movement

-pain at end range

-compensations are observed

-you hear joint noises/crackling

Limited active range of motion may be a sign of the following:

-weakness

-tightness

-nerve issues

-internal derangement (you can use special tests to figure this out)

-pain

-tight joint capsule

What does Passive Testing tell you (you take your client through the movement)?

-Normal and pain free means no lesion

-Normal and painful may mean a minor sprain

-Hypomobile and painfree may mean a muscle contracture or joint adhesion

-Hypomobile and painful means acute sprain with guarding

-Hypermobile and painfree means a complete rupture of the tendon

-Hypermobile and painful may mean a partial tear

What does Resistive Testing tell you?

-Strong and no pain: no lesion

-Strong and painful: minor lesion

-Weak and painless: nerve damage or complete rupture

-Weak and painful: partial rupture

When performing Resistive Testing, remember the following:

-Isolate one motion for the test

-Test one joint at a time

-Test the motion at its mid range

-Increase your applied resistance slowly (do not crank on it)

-Hold the resistance 5 seconds

The above information should help a great deal in figuring out the cause of your client's condition. 

Client Assessment Part 3

C.H.A.R.T.S.

"A" is for Asymmetries

After taking an extensive history and finding out what your client's chief complaint is, you will want to begin gathering objective measures as a baseline status.  The first observation should be your client's posture. 

From the back, look for the following:

1. Foot position: are the toes pointing in or out, or is the foot flat?

2. Check out muscle mass: Is one calf bulkier than the other?

3. Position on the knees: Are they pointed in towards eachother or is it bowlegged?

4. Check for scoliosis: Does the spine have an 'S' curve?

5.  What about shoulder position: Is one shoulder elevated?

From a lateral view:

1.  Is the knee flexed or hyperextended?

2.  Is there an arch in the lower back?

3.  Is there a rounded upper back, rounded shoulders or a forward head posture?

With this section, you rely heavily on your observation skills and vision to determine asymmetries.  Noting these asymmetries will help a great deal in customizing an exercise plan with goals for your client. Setting up a plumb line to assist in your facility may help. 

Next we will discuss Range of Motion ('R' in C.H.A.R.T.S.)

Another Acronym To Help Organize a Detailed Assessment

C.H.A.R.T.S.

When first meeting a client/patient or upon re-assessing that client to assess progress, a good guidance system to help accurately collect information is to base the assessment on the acronym C.H.A.R.T.S.  In the next few blog entries, I will break down each section.  Today, I will discuss "C".

"C" stands for Chief Complaint.  This is the subjective section of the client/patient interview/assessment.  Here you are finding out why that person is seeking your assistance.  It is also during this interview that you will decide whether there are other possible causes of the client's issues, especially any life-threatening pathologies that may contraindicate your services.  If the client has a complaint of pain, you will use the O-P-Q-R-S-T question format (previous blog entry) to analyze that.  Again, it is during the interview process that you want to rule out any other serious pathology that the client may have.  Some things the client may tell you that would lead you to believe there is a more serious issue are the following:

1.  Unexplained weight loss - Was he/she trying to lose weight?

2. Malaise/decrease in energy level

3. Fever/chills

4. Weakness/numbness

5. Fainting (loss of consciousness) or syncope (no loss of consciousness)

6. Pain at night

7. Pain at rest that is not affected by position change

8. Bowel or bladder problems

Also check out the previous blog entry on "Red Flags"

Lastly, you will want to assess that client's response to working with you. 
1. Did he/she have an unusual response?
2. Was there any symptom magnification?
3. Did the symptoms improve but then return for no reason?
4. Was their pain unaffected by your session/treatment?
5. Was the pain worsened by the session/treatment (considering you were not being too aggressive)?

 

All of the above information should help guide you in obtaining an in-depth description of your client's or patient's problem and will later help you in developing goals and customizing a program.  Next entry will focus on "H" for History of the condition.

How Hard Should I Push My Client???

If you are working with a client who has one or more pre-existing medical or orthopedic conditions, you may be nervous when progressing him or her.  How aggressive should you be? 

Here are a few things to keep in mind when advancing your client.

1)Is their diagnosis recent or long standing?

You must find out whether the condition is acute (days old), subacute (weeks old) or chronic (months old).  If it is acute, you should be cautious, and advance intensity slowly.  If chronic, you may be more aggressive.

2) What is your client's reactivity?

Ask yourself: "Does a little activity causes a great deal of pain?"  If so, you need to modify.

3)Is the problem an inflammatory or mechanical issue?

Acute inflammation may present as red, swollen, hot.  It is usually better with activity due to the "moving around" of inflammatory chemicals.  Chronic inflammation presents with no resting pain, but may be worse with activity.  Is the activity you are performing creating more inflammation, rather than "flushing out" the inflammatory agents? With Mechanical issues, pain increases with activity and is better with rest.  However, there is no redness, swelling, or warmth.  If you adjust the mechanics, does the pain diminish?

4) What is the seriousness or severity of the condition? 

Is it a serious pathology that may worsen upon increased activity (Multiple Sclerosis, torn tendon/ligament, etc...)

So these are a few things to keep in mind when initiating a progression in your client's program.   They will help with your client's health and comfort level, his/her confidence level in you, the longevity of your relationship with your client, the speed of your client's recovery, and his/her return to a healthy fitness lifestyle.

"Red Flags" for Special Population Clients

When initiating sessions with special populations, many of them will come to you with an extensive past medical history.  They may be on medication for heart problems, diabetes, high blood pressure, cancer, etc... Although you should give each of your clients your undivided attention, you must pay particular attention to what these more "medically compromised" clients report to you.  Here are some "Red Flags" you must be aware of in order to maintain the safety of your clients.  If a client complains of any of the following, do not tell them to "brush it off!"  Refer him/her back to their physician before continuing your sessions.

RED FLAGS:
1)Complains of intense, unremitting pain
2)Pain is unaffected by medication or change in position
3)Complains of intense night pain
4)Complains of intense pain with no history of prior injury
5)Complains of intense spasms

Detailed Pain Assessment

When a new client begins working with you, he or she may come to you experiencing pain in one or more areas.  During your initial assessment, an easy way to formulate a detailed pain assessment is as simple as remembering O-P-Q-R-S-T.  If you know your alphabet, you can do this assessment.

"O" stands for onset of symptoms - when did the symptoms start? Is it an acute, subacute or chronic condition? Was it a slow or sudden onset?
"P" stands for properties of symptoms - What makes your symptoms better or worse?
"Q" stands for quality of symptoms - Type of pain...dull ache, sharp stabbing, shooting, etc...
"R" stands for radiating - Is it local or diffuse?
"S" stands for score - How does the pain rate on a scale from 0-10 where 0 is nothing and 10 is "get me to the emergency room!"
"T" stands for timing of symptoms - Is it constant or intermittent?

Answering these questions during an initial assessment and on subsequent sessions will provide you with a guidance system on whether your client is improving or not.  It will also help you to advise your client on what activities may be beneficial and which are detrimental.

Does Your Client Have Shoulder Issues?

If your client complains of shoulder discomfort, tightness or displays a limited range of motion with such exercises as the Shoulder Press or Kettlebell Snatch, it may be beneficial to teach him/her to perform a gentle Lateral Distraction Joint Mobilization for the Gleno-humeral Joint (shoulder).

In this video clip, learn a quick an easy "self" joint mobilization technique that will provide the following benefits:
-Improve overal shoulder range of motion/flexibility by gently stretching the joint capsule
-Assists in Synovial Fluid lubricating the shoulder joint
-Pain relief

Following the technique, be sure reassess the shoulder range of motion.  Then attempt the exercise again to see if you have made progress.

*Helpful with Frozen Shoulder (adhesive capsulitis) and impingement syndrome

http://www.youtube.com/watch?v=8pNziq4Ckbg

Knee Pain: What Can You Do For It?

Many people, especially athletes have complained of knee pain one time or another, especially during activities such as squats and stairclimbing.  Instead of focusing in strictly on the knee joint, neighboring joints/muscles should be assessed as possible causes.  For example, tight calf muscles and IT-band, weak gluteal muscles and poor motor control are contributing factors.  Check out these videos for further information on possible corrective strategies.  Also, make sure you attempt the painful motion following these corrective strategies to check for proper carry over.  Pain should diminish noticeably.
PFPS part 1
http://www.youtube.com/watch?v=kauwemDv0wo
PFPS part 2
http://www.youtube.com/watch?v=0l623GQDoKo

Hope this helps

Morning Stretches

Many of my patients and clients have previously been diagnosed with lower back bulging or herniated discs.  They have become frustrated because they can not function the way they used to due to the back and sometimes radiating leg pain.  When I ask them what their normal daily routine is, they tell me they wake up in the morning and begin a short stretch routine that usually consists of getting out of bed and bending forward to touch their toes.  They say this makes them feel less lower back stiffness.  Unfortunately, I explain to them that bulging or herniated discs may actually worsen with this morning routine.  Most often, a bulging disc is triggered by a flexion or bending maneuver.  If it is a forceful flexion movement, the intervertebral disc may actually bulge posteriorly and laterally.  This may "pinch" a nerve root in your spine.  That is why you feel symptoms in your leg.  During the night, gravity is no longer compressing your spine so the discs reabsorb their fluid.  If you already have a problem with that disc level, flexion of the spine with a disc that has become "swollen" with its own fluid can cause the disc to protrude, exacerbating your back problem.  My advice is to minimize your lower back flexion activities and begin a core strengthening program.  Although flexion type stretches may feel good, it is only temporary and may actually be slowing your progress.