Interesting Facts about Physical Therapy and Health

1-Direct access to physical therapy for neck and back pain can save you money

- Individuals with neck or back pain who see a physical therapist first before going to see a physician have on average $1,543 lower cost through the course of their care compared to those with a physician referral. 1

2-Sham (placebo) surgery may be just as beneficial as actual surgery

- A review of 6 previous research studies on sham surgery compared to actual surgery for many orthopedic conditions has shown that indivifrduals who had sham surgery had similar outcomes compared to those that had the actual surgery. 2

3-Only 44% of total knee replacements in the United States meet criteria to be performed

-In a study done on a group of individuals who received knee replacements, 34% were deemed to be inappropriate for a total knee replacement, 22% were inconclusive, and only 44% met criteria to actually be performed. Considering that more than $20 billion are spent each year on hip and knee replacements in the US it is possible that a great deal of money is spent on surgeries that really shouldn’t be performed. 3, 4

4-One in five individuals who get a spinal fusion require a second spinal fusion within 4 years.

- In a study of 433 individuals that had a lumbar spinal fusion about 20% of those individuals had to have a reoperation to their spine within 4 years. The most common reason for reoperation was pathology to an area adjacent to the initial surgery site. 5 This is especially concerning when considering the outcomes of lumbar fusion. In fact 55.8% of individuals that have a lumbar fusion report that they are no better or worse. 6

5-Meniscus repair surgery does not improve functional outcome compared to physical therapy

-A physical therapy protocol that focuses on knee range of motion, knee strength, and aerobic conditioning that consists of about 9 visits of therapy was just as effective as arthroscopic surgery of the meniscus according to patient reports at 6 months and 12 months. 7

6-Heavy load deadlifts can reduce low back pain

-The once prevailing belief that lifting heavy things was bad for your back can be put to rest. In a study of individuals with persistent (chronic) low back pain it was found that 12 weeks of progressively heavier deadlifting significantly reduces low back pain. Progressive deadlifting with training for proper form was just as effective as other physical therapy training for reducing low back pain. 8

7-When picking a running shoe comfort should be the most important factor

-When it comes to reducing injuries in runners with running shoes or inserts, it appears that the variable that is most important is that the runner select a shoe or an insert that they feel is the most comfortable. The decision on what kind of shoe should be decided by the runner, and not be swayed by fancy jargon used by a salesperson. 9

8- It is a myth that CrossFit is more dangerous than other sports such as running

-In a study from 2018 out of 1032 runners, 198 (19%) of them reported an injury, while out of 144 CrossFit athletes 12 (8%) of them reported injuries. Though the key to avoid injuries in any sport is proper training and skilled coaching. 10

9- Lumbar disc herniations will most commonly resolve on their own with no surgical intervention.

-A recent meta-analysis showed that 66.66% of lumbar herniations will spontaneously resolve with conservative care and no surgery. 11 The most unique aspect of spontaneous disc resorption is that it appears that the most severe cases of disc herniations are also the most likely to spontaneously resolve. 12

10- 50% of all non-contact ACL injuries can be prevented with proper training

-As little as 3 sessions of 20 minutes that includes strength and motor control training over 9 weeks can significantly reduce the risk of having an ACL injury by 50%. 13

11- Back braces and education about lifting techniques are not actually helpful at reducing low back pain

-A review from 2018 done on all past research found that back braces and instruction on lifting technique, regardless of whether or not it was 30 minutes or 4 hours, do not actually reduce the likelihood of someone getting back pain at work. In fact what was actually beneficial was performing exercise interventions such as back and abdominal strengthening, stretching, and cardiovascular fitness training 14

12-Breaks during work help prevent and reduce low back pain

-The best part is that they also do not impede on work production. It is definitely clear that active breaks from work are superior to passive breaks. 15 In this same vein a sit to stand desk can be helpful at reducing low back pain experienced at work. 16

13- Running does not actually increase the likelihood of an individual developing arthritis

-Despite what was once thought that arthritis develops related to overuse of joint; it actually appears that running does not increase the prevalence of arthritis. 17 In fact what we actually see is that recreational running is better for your knee cartilage than a sedentary lifestyle. 18 We see increases in arthritis in the hands linked to obesity which is indicative of the role that inflammation from fat tissue has in the development of arthritis in our bodies. Thus, exercise and maintaining a healthy lifestyle are ideal for reducing the likelihood of developing arthritis. 19

14- In order to improve endurance capacity athletes should include heavy and explosive resistance training to their training program.

-Many endurance athletes are still cautious of adopting heavy resistance training out of fear that it will impair their performance. Heavy lifting with fewer repetitions and sets in major lifts, both powerlifting and olympic lifts are helpful for endurance athletes as it improves neural recruitment of the muscles and decreases the oxygen demand to generate the same amount of force, thus improving running economy. 20

1- Denninger, T. R., Cook, C. E., Chapman, C. G., McHenry, T., & Thigpen, C. A. (2018). The Influence of Patient Choice of First Provider on Costs and Outcomes: Analysis From a Physical Therapy Patient Registry. Journal of Orthopaedic & Sports Physical Therapy, 48(2), 63-71.

2- Louw, A., Diener, I., Fernández-de-las-Peñas, C., & Puentedura, E. J. (2017). Sham surgery in orthopedics: A systematic review of the literature. Pain Medicine, 18(4), 736-750.

3- Lam, V., Teutsch, S., & Fielding, J. (2018). Hip and Knee Replacements: A Neglected Potential Savings Opportunity. JAMA, 319(10), 977-978.

4- Riddle, D. L., Jiranek, W. A., & Hayes, C. W. (2014). Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis & Rheumatology, 66(8), 2134-2143.

5- Irmola, T. M., Häkkinen, A., Järvenpää, S., Marttinen, I., Vihtonen, K., & Neva, M. (2018). Reoperation rates following instrumented lumbar spine fusion. Spine, 43(4), 295-301.

6- Franklin, G. M., Haug, J., Heyer, N. J., McKeefrey, S. P., & Picciano, J. F. (1994). Outcome of lumbar fusion in Washington State workers' compensation. Spine, 19(17), 1897-903.

7- Katz, J. N., Brophy, R. H., Chaisson, C. E., De Chaves, L., Cole, B. J., Dahm, D. L., ... & Levy, B. A. (2013). Surgery versus physical therapy for a meniscal tear and osteoarthritis. New England Journal of Medicine, 368(18), 1675-1684.

8- Aasa, B., Berglund, L., Michaelson, P., & Aasa, U. (2015). Individualized low-load motor control exercises and education versus a high-load lifting exercise and education to improve activity, pain intensity, and physical performance in patients with low back pain: a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy, 45(2), 77-85.

9- Nigg, B. M., Baltich, J., Hoerzer, S., & Enders, H. (2015). Running shoes and running injuries: mythbusting and a proposal for two new paradigms:‘preferred movement path’and ‘comfort filter’. Br J Sports Med, bjsports-2015.

10- Bueno, A. M., Pilgaard, M., Hulme, A., Forsberg, P., Ramskov, D., Damsted, C., & Nielsen, R. O. (2018). Injury prevalence across sports: a descriptive analysis on a representative sample of the Danish population. Injury Epidemiology, 5(1), 6.

11- Ming Zhong, M. D., & Liu, J. T. (2017). Incidence of spontaneous resorption of lumbar disc herniation: a meta-analysis. Pain Physician, 20, E45-E52.

12- Chiu, C. C., Chuang, T. Y., Chang, K. H., Wu, C. H., Lin, P. W., & Hsu, W. Y. (2015). The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clinical Rehabilitation, 29(2), 184-195.

13- Arundale, A. J., Bizzini, M., Giordano, A., Hewett, T. E., Logerstedt, D. S., Mandelbaum, B., ... & Beattie, P. (2018). Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy and the American Academy of Sports Physical Therapy. Journal of Orthopaedic & Sports Physical Therapy, 48(9), A1-A42.

14- Sowah, D., Boyko, R., Antle, D., Miller, L., Zakhary, M., & Straube, S. (2018). Occupational interventions for the prevention of back pain: Overview of systematic reviews. Journal of Safety Research, 66, 39-59.

15- Waongenngarm, P., Areerak, K., & Janwantanakul, P. (2018). The effects of breaks on low back pain, discomfort, and work productivity in office workers: A systematic review of randomized and non-randomized controlled trials. Applied Ergonomics, 68, 230-239.

16- Ognibene, G. T., Torres, W., von Eyben, R., & Horst, K. C. (2016). Impact of a sit-stand workstation on chronic low back pain: results of a randomized trial. Journal of Occupational and Environmental Medicine, 58(3), 287-293.

17- Lo, G. H., Driban, J. B., Kriska, A. M., McAlindon, T. E., Souza, R. B., Petersen, N. J., ... & Kent Kwoh, C. (2017). Is There an Association Between a History of Running and Symptomatic Knee Osteoarthritis? A Cross‐Sectional Study From the Osteoarthritis Initiative. Arthritis Care & Research, 69(2), 183-191.

18- Alentorn-Geli, E., Samuelsson, K., Musahl, V., Green, C. L., Bhandari, M., & Karlsson, J. (2017). The association of recreational and competitive running with hip and knee osteoarthritis: a systematic review and meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 47(6), 373-390.

19- How Fat Affects Arthritis. Retrieved from https://www.arthritis.org/living-with-arthritis/comorbidities/obesity-arthritis/fat-and-arthritis.php

20- Denadai, B. S., de Aguiar, R. A., de Lima, L. C. R., Greco, C. C., & Caputo, F. (2017). Explosive training and heavy weight training are effective for improving running economy in endurance athletes: a systematic review and meta-analysis. Sports Medicine, 47(3), 545-554.

What Brings You to Physical Therapy Today?

When you kick off a new project at work, chances are you spend a fair amount of time setting and reviewing goals. These goals help you, and those you’ll be working with, to get a clear sense of what you’re looking to achieve and begin to map out a plan of attack. Along with specific goals, you also probably find it helpful to set some key milestones to ensure that you stay on task and to prevent your motivation from waning.

These same principles apply when going to physical therapy for an injury. Communicating what you hope to get out your therapy sessions can help your physical therapist individualize the treatment plan and design an exercise program that aligns with your goals. The idea is to move from “I’m here because my knee hurts” to “I’d like my knee to feel better so I can get back to doing X, Y and Z.”

Let’s talk about a concrete example to illustrate goal-setting in action: A father of three ruptures his Achilles tendon while playing a game of pickup basketball after work. When he lands in rehab, he explains to his PT that he’s scheduled to walk his oldest daughter down the aisle at her wedding in a few months. This gives the PT a specific event and a timeline to reach this goal. Of course, not every patient has a goal tied to such a momentous occasion. It can be as simple as carrying your groceries to your car unassisted or lifting your grandchild into a high chair. Either way, it’s important to have goals, and to communicate them clearly to your physical therapist.

Your PT wants you to get better but without the right guidance from you, he or she might default to following a checklist and design a program that unknowingly misses your goals. Only you know precisely what you want out of PT: If you have a wrist injury and getting back to your knitting hobby is important to you, that’s a great specific goal!  Another patient could come in with the same injury but have completely different goals, so guide your PT to help you achieve what’s most important to you.

If you find yourself making an appointment to see a physical therapist for a new injury or a nagging pain, make sure that you prepare in advance. Being prepared to answer this one simple question can help to ensure that rehab is a success: What brings you to physical therapy today? After all, you wouldn’t walk into a kickoff meeting at work without first giving some thought to the goals that you planned to share with your team, would you?

Some Americans Pay More for Back Pain Relief, But Are They Really Getting Less?

Payless recently conducted a very telling social experiment. You probably heard about the shoe chain’s stunt in the news but just to recap quickly, “The Payless Experiment” tricked consumers into buying their typically budget-friendly shoes at sky-high markups. To carry out the clever ruse, the discount retailer invited style influencers to a (fake) launch party for a new high-end label in one of Los Angeles’ glitziest shopping areas. The attendees believed that they were buying fashionable, high-quality footwear and therefore didn’t object to the three-figure price tags.

Aside from being a brilliant marketing ploy for Payless, what lessons does “The Payless Experiment” have for our current healthcare system, and specifically for patients suffering from low back pain? The experiment is a commentary on perceived vs. real value but also how easily people can be swayed into believing that something is reliable as presented. Think about someone who has had weeks of pain and dysfunction stemming from low back pain: she wants to find a solution that will relieve her symptoms. If a physician presents surgery as the best option—and she’s assured that her pain will go away—then it’s going to sound appealing, right?

Today’s consumer has so many choices when shopping for just about anything from apparel to healthcare. But while it’s customary to shop for the best price for a goose down jacket (without sacrificing quality), shopping around for the best solution (and value) for our ailments is less typical. Doing our due diligence in healthcare may ultimately bring us back to the first proposed solution, but it also may introduce us to solutions that we didn’t know existed.

In the case of low back pain, one such under-heralded solution is physical therapy. Physical therapy, yoga and acupuncture are gaining in popularity as equally (or more) effective and less costly than surgical procedures, injections, MRIs and pain relievers—and for good reason.

Physical therapists are trained to restore and improve patients’ mobility, reduce soft tissue pain, improve function and build muscle strength. They not only develop custom strategies to treat persistent or recurrent low back pain, but educate patients on the prevention of future issues. Some preventive techniques include adopting and following a regular exercise program and learning to lift correctly by keeping the object close to the body.

As the holidays kick into high gear, you likely have a long list of gifts to buy. I’m willing to guess that you have a strategy in place for selecting appropriate gifts for each recipient.

As you match the right price point, size and color to each person on your list this holiday season, think about approaching your healthcare needs with the same level of scrutiny. After all, finding the right solution at the right price for our health needs contributes to improved long-term outcomes and better piece of mind.

Treating Your Pain with Evidence

When it comes to musculoskeletal (think back, neck, shoulder, hip, knee etc.) pain there are just about as many treatment options as there are colors in the rainbow. That can be a good thing as it allows people to seek out potentially helpful options. However, in a country where hundreds of billions of dollars are spent each year on managing these conditions it is important to have some current facts to support how we manage musculoskeletal pain. That is why we look to the research.

In 2017 a research article was published that summarized 146 other research studies on the best treatments for musculoskeletal pain. The article gave us insight into what areas we can focus on to help people feel better when they are hurt. This was a valuable paper because it got to the heart of a complex problem and was supported by solid evidence, not the most recent fad treatment option that are shared by friends on Facebook or that you find on Buzzfeed.

Exercise, The Key To Pain Treatment

The pyramid below is a basic representation of what actually works based on current research.

The research article found that for musculoskeletal pain, exercise was the best treatment option available. The amazing thing about exercise as a treatment is that when someone is compliant with the exercise it has lasting effects. The trouble with more passive modalities such as acupuncture, TENS, ultrasound or manual therapy (hands on) techniques, is that when we follow individuals long-term the benefits decrease unless they are combined with exercise based interventions. It is amazing! A relatively low-cost treatment has a powerful effect to change pain for the long-term.

The Importance of Psychological Interventions

I do think that it is important to mention how important psychological treatments such as cognitive behavioral therapy and instruction on coping behaviors can be. It is important to always remember that none of us are just a bag of muscles and bones. We all have thoughts, emotions, feeling and perceptions, and all of those things can influence the pain that we feel. Because of that, it is important to dedicate time to making sure that our thoughts, emotions, feelings and perceptions are not interfering with our health and healing.

Pharmaceuticals and Surgery

Lastly, there are many cases where musculoskeletal conditions should be managed with surgery or pharmaceuticals such as NSAIDs or cortisone injections. However, those should be looked at as first line treatment options only in more rare circumstances. While also being costly, treatment of pain using pharmaceuticals and surgery comes at a greater risk of side-effects or complications. In most cases I highly recommend that an individual try more conservative options before moving towards injections or surgery to decrease the possibility of adverse effects as a result of these treatments.  As a former patient of mine once said, “No one ever dies of back pain, but some people have died from the treatment of back pain.”

So, next time your back pain flares up, or you try to throw someone out in your rec league softball and hurt your shoulder, consider trying conservative care before seeking out more involved treatment options. A physical therapist can be a great starting point that can help you determine whether or not you would benefit from conservative management with exercise or if you need to move further up the pyramid.

Babatunde, O. O., Jordan, J. L., Van der Windt, D. A., Hill, J. C., Foster, N. E., & Protheroe, J. (2017). Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PloS one, 12(6), e0178621.

Your Perception Matters

In a world of uncertainty it is always important to know what we don't know. In the world of health it is safe to say that we really don’t know enough. One thing that we are starting to get a grasp on is how very important our mindset and perceptions are in determining our health.

For many years now people have been aware of the “placebo effect.” In these studies, participants assume that the sugar pills they are taking are actually providing some type of therapeutic effect. The powerful influence of our mindset goes well beyond what we can comprehend. However, there are some poignant examples in fairly recent research that demonstrate how our brains can change the outcomes of our health.

Perception Alters Our Physiology

Consider this, in 2007, 84 hotel maids were divided into two groups. One group was instructed that their work alone was enough to achieve the recommended amounts of weekly physical activity. The other group was given no instruction at all. Four weeks later, the researchers checked in with both groups of hotel maids to re-measure some important health markers. The group that was told they were doing enough physical activity actually showed improvements in their blood pressure, hip-to-waist ratio, and a decrease in their body mass index (BMI). The group that was given no instruction showed none of those positive changes. These improvements were made without either group changing their physical activity!

It is phenomenal to think that by simply challenging our own perceptions we can see improvements in our health. The keyword in the previous sentence being perception.

Perception of Stress

Most individuals around the world are very familiar with stress. Not stress in the way an engineer might think about it, but stress from a mental and biophysical stand point. We can see that stress is having major impacts on our health. Interestingly enough, the degree that we perceive stress has a negative impact on our lives is related to having poor health and the risk of premature death. So, while most of us have stress, how we feel about that stress changes what it does to our bodies.

Perception Can Be Misleading

It is through these same perceptions that marketers make money. Someone who is skilled in psychology and knows how to adjust an audience’s perceptions, can play a big role in our behaviors.

For example, I often hear people use the following terms to describe their bodies: words such as tear, degeneration, bone-on-bone, the worst [insert body part] that a doctor has ever seen, disc bulge, nerve pinch, etc. All of these terms lead to perceptions of what someone feels about their body, and these perceptions influence their health. For this reason around 1 o’clock in the morning there will be numerous TV advertisements about the next best treatment option for all of the above problems. Most of those options have little to no research to support their use, and are most likely to only make a difference with the “placebo effect”.

There are a great deal of studies that show how individuals with numerous types of structurally pathologies will have no symptoms (references with the asterisks). Which indicates that in the realm of which pathologies count and which ones don’t probably comes down to what our perception of those pathologies mean. None of this indicates that the pain is all in your head. By no means. Only that what we think about what is going on in our bodies, actually changes our response to any given symptom.

The Brain Changes

The beauty in all of this is that our minds are extremely plastic. Our thoughts, beliefs and perceptions are constantly changing. As we continue to learn we change the way we perceive the world, as well as changing the way our bodies respond to the world we live in. Meaning, what we felt yesterday, (sadness, pain, fatigue, etc.) does not dictate what we will feel tomorrow (joy, strength, energized, etc.).

A lot of times all we need, to change the trajectory of our perceptions is some guidance. Someone to help us by setting a road map for our nervous system to change. That is where a skilled professional can be a huge help. From coach to psychologist, trainer to physical therapist, and chiropractor to physician you should be offered a plan to help you feel well and think well.

Keller, A., Litzelman, K., Wisk, L. E., Maddox, T., Cheng, E. R., Creswell, P. D., & Witt, W. P. (2012). Does the perception that stress affects health matter? The association with health and mortality. Health Psychology, 31(5), 677.

Crum, A. J., & Langer, E. J. (2007). Mind-set matters: Exercise and the placebo effect. Psychological Science, 18(2), 165-171.

*Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., ... & Wald, J. T. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816.

*Campbell, J., & Colvin, L. A. (2013). Management of low back pain. BMJ, 347, bmj-f3148.

*Guermazi, A., Niu, J., Hayashi, D., Roemer, F. W., Englund, M., Neogi, T., ... & Felson, D. T. (2012). Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ, 345, e5339.

*Girish, G., Lobo, L. G., Jacobson, J. A., Morag, Y., Miller, B., & Jamadar, D. A. (2011). Ultrasound of the shoulder: asymptomatic findings in men. American Journal of Roentgenology, 197(4), W713-W719.

*Nakashima, H., Yukawa, Y., Suda, K., Yamagata, M., Ueta, T., & Kato, F. (2015). Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine, 40(6), 392-398.

Annual Physical Therapy Check-Up!

In my early 20’s, I lived in Argentina for 2 years. During that time it never occurred to me that I should be seeing a dentist on a regular basis. Growing up my mom would set up my regular dental exams, and I would show up to the dentist office every 6 months. However, after living in Argentina and then on my own through the early part of college, I had definitely fallen out of the habit of attending regular dental exams. I had 8 cavities filled over a 4 week period. Needless to say, I never missed another dental check-up!

The practice of meeting with a trained expert is important in order to learn what we should be doing to keep our bodies in optimal condition! For the most part it has become common practice to see the dentist every 6 months, and to have a physical with a doctor every year. However, most people are not going to see their physical therapist for annual or semi-annual check-ups.

It is often understated how important a physical therapist can be in finding deficiencies in movement, strength, cardiovascular capacity or range of motion that can become detrimental in the future. Physical therapists are experts in movement! That is what they are trained to be. Whether it be identifying compensations or overcoming current limitations, a physical therapist can play a valuable role in keeping you healthy and well.

This is a really common story that I hear in my practice, “Well, my shoulder pain started about 4 years ago while I was doing some over head activities, and I felt a pop in the shoulder. It has been hurting on and off since then. I haven’t done anything besides take advil every now and then, but now I can’t sleep on that side. So, I figured I should finally do something about it.”

I love seeing people with any number of problems going on. It is really fun to diagnose their situation and get them on a path to meet their goals. However, I think about those times when the patient spent nights where they maybe only slept 1-2 hours or days when they missed work all because of their aches and pains in the shoulder.

I think about how that situation would have been different had that person seen their physical therapist every year for a check-up. Maybe it is not something that the patient would go out of their way to seek care for initially, because it is not interfering too much in their life at the start. However, it could be something mentioned and evaluated in an annual check-up. Then that person could be helped to get on an exercise regimen that could help their shoulder or other condition before it evolves into something more complex. That is the value in checking in regularly with your physical therapist.

As the saying goes “An ounce of prevention is worth a pound of cure.” When it comes to my teeth I know better than to skip out on my regular teeth cleaning and exam. When it comes to my physical health I know better than to miss out on a chance to be screened, and make sure that I am on the right track to a healthy life.

In the state of Minnesota anyone can see a physical therapist directly without a physician referral. If you would like to schedule an annual check-up with a physical therapist, please click here.

Who Is Your Physical Therapist?

The Best Treatments for Plantar Fasciitis

It’s 6:30 am, and the alarm goes off! You wake up a little groggy, but ready to start planning your busy day. You are lying in bed thinking about all of the things that need to be done and then, nature calls. You quickly throw off the sheets and step out of bed to an unwelcome shot of pain in the bottom of your foot. It’s that same unforgettable pain you experienced yesterday, and the day before that, and the day before that. Ugh!

Pain in the bottom of your foot (near your heel), regularly referred to as plantar fasciitis, is extremely common. Approximately 2 million Americans suffer from plantar fasciitis each year. For runners, plantar fasciitis is the most common condition that is diagnosed around the foot, making up 8% of all running related injuries. Unfortunately, many people experience the painful symptoms and experiment with endless proposed treatment options.

I have heard a fair amount of plantar fasciitis treatments. They range from rolling a frozen bottle of ice on the foot, running barefoot, and using odd-looking massage tools.

Additionally, everyone has their special favorite stretch that gets passed around like a secret recipe for the best chocolate chip cookies. Sure, it is probably a good stretch or a good treatment option, but even the best chocolate chip cookie recipe doesn’t work for everyone. We all have different taste preferences, likewise, we all experience different forms of plantar fasciitis and different feet!

There are so many different thoughts and recommendations available that it is important to follow the research. Fortunately, there are great research reviews that summarize the best treatment options for plantar fasciitis.

I will split up the treatment options into 3 sections: Things you should try because research supports them, things you can do because some research supports them, and things you should do in more rare circumstances because research doesn’t really support them.

Treatments You Should Try

Plantar Fascia Stretch: Seated with the painful foot and leg crossed over the other leg and then pulling up on the toes to feel a stretch along the bottom of the foot. This stretch should be done 3 times a day with ten holds of 10 second duration. Ideally the first round of stretching would be done before getting out of bed in the morning.

Calf Stretching: Can be done in any number of styles. A traditional runners’ calf stretch, standing with the painful foot and leg behind the other and keeping the knee straight as you lean forward (towards the wall), can be an effective stretch. With this particular stretch, try placing a rolled-up towel under the toes which allows for more stretch of the plantar fascia. However, listen to your body because the stretch should be gentle to moderate, not severe. Calf stretching should be held for 60 seconds, for up to 5 repetitions a day.

Taping: Certain taping styles have been found to be helpful for plantar fasciitis. For the most part the researched taping styles rely more on stability taping around the foot, and can include some antipronation strips. Low-dye taping is commonly used, though high-dye taping can also be effective. Taping is usually reserved for licensed professionals to perform, though anyone can be taught the techniques, and try to manage them on their own. In a general sense the taping is designed to help with the forces through the foot to relieve some pressure off the plantar fascia.

Orthotics: Custom made foot orthotics can be beneficial for those that suffer from plantar fasciitis. However, treatment options can become very expensive when you seek an orthotic.

Studies that have compared custom orthotics to over-the-counter orthotics found that both are helpful with no significant difference between the two besides the price point. When purchasing orthotics, I recommend you try them on before purchasing. It is important to get a good feel for what type of orthotic feels comfortable to you. Check out Super Feet insoles, which typically cost around $50 (available at most specialty shoe stores).

Night Splints: If the plantar fasciitis symptoms have been lasting for more than 3-6 months, and you are having pain with the first step in the morning, then I highly recommend consistently wearing a night splint for 1–3 months. While many people have a hard time wearing night splints, they are helpful. Night splints can be purchased at most major retailers for $20–$50. The most popular night splint is a Strassburg sock because of its high comfort reviews. Anything you find should work, though you do want the pull to be from the front of your foot.

Hands on Therapy: There is some research that shows that a professional helping with some ankle and foot joint mobility as well as some soft-tissue work in the calf and foot can reduce pain. Since the symptom reduction is usually temporary, this type of treatment option is usually an adjunct to other treatments.

Dry Needling: The research for dry needling for plantar fasciitis is growing. As a whole dry needling research is still in the early phases. However, it appears that dry needling can be an effective addition to treatment for plantar fasciitis. Consider dry needling if your symptoms have not improved with other treatments.

Treatments You Can Try

Shoe Wear: Despite the overwhelming amount of research and recommendations about shoe wear, it doesn’t seem to have much of an impact. First, the important thing to consider is comfort. The shoes you wear should feel good and not bother you. Beyond that, consider switching between at least 2 different pairs of shoes during the week, whether it be that you are running or standing. Having a shoe rotation can help reduce plantar fasciitis risk by upto 72%.

Strengthen Up the Chain: Our bodies are not strictly divided into different parts. There is connection from the bottom up and from the top down. There is some rationale for strengthening the muscles around your hips, thighs, as well as the muscles of the back and the abdominal region.

Treatments for Rare Circumstances

Ultrasound: Therapeutic ultrasound may have some value in other conditions, but is not effective as a primary treatment for plantar fasciitis.

Steroid Injections: Getting a steroid injection into the plantar fascia has not demonstrated clinical benefit in 2 systematic reviews done on the subject.

As you can see there are a lot of things that you should do, can do, and should only do in rare circumstances for the treatment of plantar fasciitis. It is not an all-inclusive list of treatment options. I have tried to include the list of things that have some evidence to back up claims being made. This does not mean that a frozen water bottle wouldn’t feel good on the bottom of your foot, only that there is no research to say that it is making a difference. So, keep doing your favorite treatments, and add some of the researched options into your rehabilitation and recovery.

It is also helpful to work with a licensed professional to help you modify your activity to avoid further irritation to the plantar fascia, and to help you work through the recovery process. Physical therapists can be very helpful in diagnosing and treating plantar fasciitis.

Martin, R. L., Davenport, T. E., Reischl, S. F., McPoil, T. G., Matheson, J. W., Wukich, D. K., ... & Davis, I. (2014). Heel pain—plantar fasciitis: revision 2014. Journal of Orthopaedic & Sports Physical Therapy, 44(11), A1-A33.

He, C., & Ma, H. (2017). Effectiveness of trigger point dry needling for plantar heel pain: a meta-analysis of seven randomized controlled trials. Journal of Pain Research, 10, 1933.

Dry Needling in Physical Therapy

Poking into a structure that has been hurting may not make intuitive sense for pain relief. However, there appears to be value in having small filament needles inserted into an irritated structure.

The History of Needling for Medicine

Needling has been going on for millennia as more of an Eastern medicinal practice. Acupuncture as a practice may date back almost 8,000 years, though more certainly there is evidence of the practice appearing around 2,300 years ago. It was in those ancient texts that we can find information about meridians and the flow of Qi (chi), as well as how ancient Chinese people used acupuncture to resolve a variety of medical concerns.

Dry needling originated from studies based upon the principle of injecting very irritable muscles in the body with a small needle and some form of pain relieving substance. Then, it evolved as practitioners realized that they were seeing positive outcomes from the needle pokes alone without any injected substance. Thus, here we are currently with a more Western Medicine practice of using a small filament needle to address a muscle or fascia tissue that has become tender and painful (sometimes referred to as a trigger point).

The most frequently asked question that remains is: what is the difference between dry needling and acupuncture? The answer to that question is tricky due to the fact that both involve using the same or at least similar needles and the needles are poked into the skin to treat a given pathology. However, acupuncture is a treatment designed to affect the “energy” and Qi while working through meridians, while dry needling is a treatment designed to affect a specific muscle and the surrounding fascia and nerve tissue.

Research to Support Dry Needling

In comparison to other forms of therapies, dry needling itself is a relatively new treatment option. With any new treatment option the research is new and growing. However, at this point we are starting to see more randomized controlled trials and other studies about the effects of dry needling in rehabilitation. We have at this point research for the following conditions and anecdotes for treating a host of others;

• Knee pain

• Hip pain

• Tendinopathy

• Headaches

• Neck pain

• Shoulder pain

• Low back pain and Sciatica

• Plantar Fasciitis

• Tennis Elbow

• Myofascial Pain Syndrome

• Fibromyalgia

Does it Hurt?

Between 60% and 70% of individuals will experience temporary pain during the actual treatment session. It is also not uncommon to experience soreness following the treatment. Not everyone does, but you may feel that for 24-48 hours you have soreness at the site of the needling. Icing and gentle massage to the area can help with the soreness. However, remember that this procedure is done to help reduce pain related to musculoskeletal problems, so any temporary soreness should not interfere with the benefits of having needling performed.

Making the Benefits Last

Dry needling itself should not be the only thing you do to help your painful condition. You should be performing exercises including stretching that have been prescribed by your physical therapist. The needling is intended to help you have less pain and move better.

Call now to schedule! 952-303-4550 Or book online at www.agadapt.com

White, A., & Ernst, E. (2004). A brief history of acupuncture. Rheumatology, 43(5), 662-663.

He, C., & Ma, H. (2017). Effectiveness of trigger point dry needling for plantar heel pain: a meta-analysis of seven randomized controlled trials. Journal of Pain Research, 10, 1933.

Dunning, J., Butts, R., Mourad, F., Young, I., Flannagan, S., & Perreault, T. (2014). Dry needling: a literature review with implications for clinical practice guidelines. Physical Therapy Reviews, 19(4), 252-265.

Gattie, E., Cleland, J. A., & Snodgrass, S. (2017). The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: a systematic review and meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 47(3), 133-149.

How to Reduce Stress with Diaphragmatic Breathing

“Slow down. Take a deep breath.” These are words we have all heard from our parents or mentors. The advice to focus on your breathing is more helpful than they probably even realized.

Many of us remember those dreadful days sitting in high school psychology class learning about the autonomic nervous system. The terms “sympathetic” and “parasympathetic” may ring familiar. While the terminology may sound confusing the basic phrase we commonly use to describe the sympathetic nervous system is “fight or flight,” and the common phrase for the parasympathetic nervous system is “rest and digest.”

Finding Balance in the Nervous System

As our bodies seek for balance, the sympathetic and parasympathetic nervous systems work as opposites of each other. For example, if you trip while you are crossing the street, you want your sympathetic nervous system to kick into high gear so that you pick yourself up and run across the road before getting hit by a car.

On the other hand, you do not want that same sensation of panic and protection when you are about to lay down to fall asleep. It is also not pleasant to feel that urge of “nature calling” from a parasympathetic drive while you are playing in a high level athletic event. The balance between those two systems helps us to stay healthy. More and more people in the United States are living in a constant state of “fight or flight.” In other words they are living in a constant state of stress and anxiety.

The Negative Impacts of Stress

Anxiety and stress weigh heavy as they negatively affect multiple bodily functions. Rapid heart rate, rapid breathing rate, high blood pressure, elevated pain states, digestion problems, lack of attention, and emotional reactivity are just some of the common effects of stress on our body.

All of these changes are managed by hormones (chemicals) in our blood. For the sake of simplicity, the hormone you want to think about is cortisol. An increase in cortisol is a sign of your sympathetic (fight or flight) nervous system getting turned up. Which is great when it is needed, but detrimental when it is not.

Most of us can think of individual moments when we know we are under a moment of increased stress such as moving, changes in jobs, or family emergencies. During those moments, our appetite changed, we noticed more tension in the shoulders or back, maybe a really fast heart rate, and potentially even some irritable bowel syndrome. Those are times where you may have started to notice some achy joints in your body. You become aware that you aren’t feeling quite as robust as you did 5 or 10 years prior. When stress is persistent, our bodies begin to sense the harmful effects of stress.

Conscious vs. Unconscious Breathing

This is where some of the research on breathing can improve our life! Now, I know that if you are reading this article, you have most certainly been breathing up to this point. No one taught you how, you just do it. In and out. Inhale and exhale. You just assume that when you fall asleep tonight that your lungs will continue to fill with air and provide your body with much needed oxygen.

That is because some of your breathing is managed by your brainstem (lower brain level) which does not require any cortex (higher brain level) functioning. However, at the same time, we have the ability to use our higher brain levels to override the basic brainstem breathing function. This is why you can hold your breath underwater, or when someone tells you to take a deep breath, you can do it on command.

The Anatomy of Breathing

Now we need to work through some of the basic anatomy of breathing. Most people recognize their lungs as two big balloons sitting inside their chest somewhere around their heart. That is a good starting point. Around your lungs there will be some ribs that run from the sternum and around to the thoracic spine (upper back), and then just below the lungs is an odd shaped muscle called the diaphragm.

The diaphragm is a dome-shaped muscle that runs from front to back and side to side and works to divide the space where our lungs are (thoracic cavity) from the space where our intestines are (the abdominal cavity). When the diaphragm contracts it effectively lowers the dome allowing an increased amount of space in the thoracic cavity for the lungs to expand and fill with air. However, as a back-up or secondary mechanism we can also generate space for the lungs by raising our rib cage using accessory breathing muscles.

These two different types of breathing have become popularized by the names horizontal (diaphragmatic) or vertical (accessory) breathing. Diaphragmatic breathing as a practice is effectively breathing in as large of a breath as you can with your lower ribs and abdominal space expanding out slowly without your shoulders elevating to compensate, and breathing out slowly while contracting your abdominal muscles to help exhale or expel the air in your lungs. On the other hand, vertical breathing looks more like you are shrugging and lowering your shoulders with each breath. The physiology of our bodies change based upon our breathing patterns.

The Benefits of Diaphragmatic Breathing

Sessions of focused diaphragmatic breathing can last anywhere from 5 to 30 minutes. The sessions usually involve a coach helping you become aware of your breathing pattern. Also, you will learn how to more effectively breathe with your diaphragm and maintain your focus on your breath as a mindfulness practice.

Research has shown that you can see positive effects on your blood pressure, pulmonary function, and increase your heart rate variability (HRV; one of the easiest ways to track your balance of sympathetic and parasympathetic drive) with diaphragmatic breathing. In a randomized controlled trial, researchers looked at the effects of a 30-minute session including 15 minutes of quiet normal breathing and 15 minutes of diaphragmatic breathing for 20 sessions over an 8 week period. They noted that after the study period participants in the diaphragmatic breathing group had significantly lowered their negative affect, improved their attention, while also lowering their cortisol levels in their blood. This study helps to highlight how diaphragmatic breathing can have a role in our physiology, emotion, and our attention, or in other words our mind, body, and spirit.

The Vagus Nerve

Returning to the ideas of the sympathetic and parasympathetic nervous system we can see that diaphragmatic breathing plays a role in helping with the balance between those two systems. The way it works is beautiful. In our bodies we have a very important nerve that often does not get enough discussion—the vagus nerve. The ever-so-important cranial nerve exits the brain and travels a convoluted path around many muscles and organs before reaching its destiny around the colon. The vagus nerve is the major player in the parasympathetic nervous system. Meaning that it is the connection of our “rest and digest” between our brain and our body.

Where things get really cool is that we can manipulate the drive of our vagus nerve called “vagal tone” by adjusting our breathing. That’s right, the slow controlled diaphragmatic inhale and slow exhale with some abdominal contraction can increase your vagal tone and thus rev up your parasympathetic nervous system to help you to relax. Remember “rest and digest!” As we increase our parasympathetic activity, we will naturally decrease our sympathetic nervous system activity, thus decreasing cortisol levels and decreasing stress.

A literature review on the topic of breathing highlights the vast ways that diaphragm breathing can help our health. The list includes

• Improved heart rate

• Improved blood pressure

• Improvement in quality of life

• Improvement in exercise tolerance

• Improved blood lipid levels

• Reduced anxiety and panic

• Alleviate pain

• Improve mood

• Reduced fatigue

• Reduced insomnia

• Improvements in GERD

That list is convincing enough to practice diaphragmatic breathing at least 2 times a week. It may be important to get a coach that can help you through the process.

Step-by-Step Instructions for Diaphragmatic Breathing

So, how do you do it? Don’t feel discouraged; I have written out clear instructions to help you get started.

First; positioning does matter. You should get into a relaxed and comfortable position. Lying on your back with your knees bent up, lying flat on your back, or sitting in a very comfortable chair are all good choices.

Second; take a deep breath in. Preferably through the nose, though if necessary you can breathe in through the mouth. The key is to focus the breath so that you notice your lower ribs and abdominal region expand without your chest and shoulders elevating. Sometimes placing both hands on your abdominal region or one hand on the abdominal region and the other on the chest can be helpful. You should feel your hand on your abdomen moving, meanwhile your hand on your chest does not move. This breath in should be slow and purposeful. Your focus should be entirely on how you are breathing.

Third; breathe out. Now, after taking a slow purposeful breath in there will be a temptation to quickly exhale somewhat like a sigh so that you can quickly get back to breathing in. Resist that temptation. When breathing out, breathe out through the mouth with the lips slightly pursed together.

Breathing out should not feel like you are trying to blow out birthday candles on your 10th birthday, but rather that you feel some resistance to the breath at the mouth. The next thing that you should feel is that during the process of breathing out you should be slightly crunching your abdominal muscles. Your positioning will change what you feel in the abdominals. Lying down flat with the knees straight will require the most focus on the abdominals. You should feel that you are pushing out most, if not all, of the air from your lungs.

Fourth; repeat steps one to three.

Setting Goals for Diaphragmatic Breathing

The amount of time you should spend doing diaphragmatic breathing depends on what your goal is and how much time you have. I recommend to start with 5–15 minute sessions for 2 days a week. Three to five days a week is likely superior, butI cannot guarantee that from a research standpoint.

Another suggestion if you are willing to set aside more time is to do 15 minutes of normal breathing with your eyes closed while focusing on your normal shallow breath followed by another 15 minutes of diaphragmatic breathing as instructed above. The benefit of this method is that it helps your body learn to distinctions between the two breathing patterns.

Seeking Out Help

I do not intend to establish an argument that diaphragmatic breathing can or should replace psychological or physical treatments by a skilled and licensed professional. It is a great option for those that are looking to add some focused mindfulness into their regimine. It is not a “cure-all,” but rather a great tool to have in your arsenal.

As more individuals seek out ways to improve their health, it will become increasingly important to have well-established and researched interventions for those in need. There are certainly other options to help those in need of some mindfulness. I also recommend that individuals trial a free week of the Headspace (available to download in the iTunes or Android app stores).

If you or a friend or family member would like more information about diaphragmatic breathing, or are in need of other health related treatment, please feel free to reach out to me via email, phone, or schedule an appointment.

Rickard, K. B., Dunn, D. J., & Brouch, V. M. (2015). Breathing Techniques Associated With Improved Health Outcomes.

Ma, X., Yue, Z. Q., Gong, Z. Q., Zhang, H., Duan, N. Y., Shi, Y. T., ... & Li, Y. F. (2017). The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults. Frontiers in psychology, 8, 874.

Mehling, W. E., Hamel, K. A., Acree, M., Byl, N., & Hecht, F. M. (2005). Randomized controlled trial of breath therapy for patients with chronic low-back pain. Alternative Therapies in Health and Medicine, 11(4), 44-53.

Hopper, S. I., Murray, S. L., Ferrara, L. R., & Singleton, J. K. (2018). Effectiveness of diaphragmatic breathing on physiological and psychological stress in adults: a quantitative systematic review protocol. JBI database of systematic reviews and implementation reports, 16(6), 1367-1372.