Kelowna Manual Therapy Centre Blog

It is reported that one in six Canadians over the age of 15 is affected by arthritis. Osteoarthritis is one form of arthritis. This degenerative condition is characterized by wear and tear on the cartilage between joints.

Coinciding with the wear and tear is swelling and stiffness. The joints most commonly affected are the hip and the knee. Another common finding is the muscles and soft tissue around the affected joint will tighten and spasm.

Signs of hip osteoarthritis include hip pain (the pain can be deep inside the hip, on the outside of the thigh or in the groin and leg) a decrease in mobility (in rotation, moving the knee towards the chest and extending the hip), morning stiffness that lasts longer than 60 minutes and a limp.

Signs of knee osteoarthritis include knee pain, clicking or grinding with motion, more than 60 minutes of morning pain, joint swelling and bony enlargement around the knee. As well a limp develops while stairs, squatting and rising from chairs become increasingly difficult.

Physiotherapy will work best if the signs and symptoms of arthritis are recognized early and receive treatment in a timely fashion.

A recent study in Arthritis and Rheumatism showed a substantial improvement of symptoms in patients with hip osteoarthritis after 9 visits of manual physical therapy intervention. There was improvement of pain, stiffness, hip function and range of motion. Another recent study published in Physical Therapy demonstrated a decreased reliance on medications and improved function in patients who had knee OA after 8 treatment sessions of manual physical therapy combined with supervised exercise and a home exercise program.

Mulligan mobilization with movement (MWM) for hip stiffness

Manual Therapy is beneficial as it works to improve the mobility of sore and stiff joints as well as the tight muscles around the joint. The manual therapy can take the form of joint mobilization and manipulation, soft tissue work on the muscles and stretching.

Exercise is very beneficial in the treatment of arthritis and can be in the form of home exercise and/or aquatic exercise. In Kelowna there are a number of pool programs geared towards individuals with osteoarthritis. Typically exercise programs include both mobility and strengthening exercises.

The best current best research supports manual physical therapy combined with exercise for hip and knee arthritis.

Sleeping Advice

Poor sleep is a common complaint in a Physiotherapy practice.

Typical complaints include having to change positions frequently due to discomfort, having morning ‘stiffness’ that last for around 30 minutes, having to get out of bed throughout the night because of discomfort and waking with headaches.

Improving sleep while dealing with an acute or ongoing painful condition is important, as the body cannot heal as well without a good sleep pattern.  If you are tossing and turning due to discomfort it is best to get up and out of bed, try to move around, try some gentle exercise or movement before getting back into bed.

To help fall asleep a new technqiue called 'congnitive shuffling' developed by Luc Beaudoin, a Simon Fraser University professor, can be very helpful.  The technqiue involves either focusing on words or random objects to change your brains focus.  You can read more here or listen here for more information.  Professor Beaudoin also developed an app called 'MySleepButton' that helps coach you along the way.  The website for the app also has some great tips here.  While this technique was developed for stress and insomnia the technique can be helpful to improve sleep loss due to discomfort and pain.

It is useful to ask a client to show the position that they sleep in. This position can then be adjusted, incorporating a variety of pillows to find a position that is more comfortable. Generally speaking a side sleeper should consider a pillow between the knees whereas a back sleeper should consider a pillow underneath the knees.

The type of pillow used with patients that complain of neck pain or headaches is considered.

The type of pillow recommended depends on the body type and the position that they sleep in. As a general rule a thinner pillow is better for those that sleep on their back while a thicker pillow is better for those that sleep on their side. The goal is to try to support the neck in a comfortable ‘neutral position’.   Most people do not do well with the older cervical pillows made of foam, though the newer memory foam pillows seem better. Most people do well with regular polyester fill pillows. If that doesn’t work then a feather, water-filled or latex/memory foam pillow can be purchased. There is a huge amount of personal preference in pillows. Many cannot part with their favorite pillow, even if it is 20 years old!

Mattresses are supposed to have a life of around 10 years.

Some signs that you need to replace your mattress are an increased sag in the mattress, springs that pop or if the mattress has become lumpy.  As well, consider a new mattress if you are increasingly waking up more stiff and sore than normal. There are a lot of new materials being used in construction including wool, silk, bamboo, latex foam, memory foam, etc. The bottom line is that you need to test a lot of mattresses, keeping in mind your budget. Initially when testing mattresses you should try a range of firm to plush mattresses to find which balance of plushness vs. support you prefer. You can then try to narrow down your decision. When testing a mattress you should lay on the mattress in different positions with your partner to check for comfort. The mattress should not sag towards the middle. As well there should be very little movement felt when your partner rolls over. There are countless types of mattress construction and brands so you definitely have to get out and try the mattresses before you buy. Plan on spending a lot of time trying out a variety of mattresses.

Signs you should consider changing your mattress

• The mattress has an increase in sag or a ‘valley’
• The mattress has lumps in the top or springs that are popping
• Waking with stiffness or soreness
• Waking when your partner rolls over or get out of bed
• Having to frequently change positions

Many times patients wonder how long does it take to recover from hip replacement.

A recent study in the Journal of Sports and Orthopedic Physical Therapy looked at recovery time and disability after a total hip replacement.
http://www.jospt.org/issues/articleID.2569/article_detail.asp

The authors found that the most rapid recovery takes place during the first 12-15 weeks. Progress was found to plateau between 30 and 40 weeks.

Another study found continued hip weakness and muscle atrophy up to 2 years post surgery. Other researchers found that an exercise program 4-12 months post hip replacement which targeted weight bearing and balance exercises resulted in improved strength, balance and reports of function.

These studies demonstrate how important it is to continue with an exercise program consisting of range of motion, stretching, strengthening, balance and cardiovascular exercises. This study and the other studies mentioned illustrate how important it is to continue with the home exercise program for up to 40 weeks post surgery.

With the recent good weather and opening of golf courses many eager golfers are taking to the courses.  The number one complaint of both recreational and professional golfers is low back pain, especially as the season starts.

Part of the pain can be due to the unaccustomed activity, this pain should settle within a few days and works itself out during the first few rounds.  More concerning is low back pain that is a result of a golf game or practice session that lingers more than 2 days.  It is important to consider all factors when assessing low back pain in golf.

The factors that should be assessed are the biomechanics of the spine, golf swing mechanics, poor flexibility and conditioning as well as the training techniques utilized.

The golf swing requires high levels of bending and twisting forces.  Low back pain is more common on the ‘trail’ side of the low back. The ‘trail ‘side would be on the right for a right handed golfer. The ‘trail’ side is under considerable stress during the clubs impact with the ball due to the combination of compression and side bending.

The low back is under more stress especially with a ‘hip slide’, a steep swing plane and too upright a finish position.   Most improper swing mechanics that cause low back pain can be traced back to improper set up position and improper hip rotation.   Correct posture at ball set up is the first place to start.   Proper position would be; back straight with normal spinal curves, knees and hips bent to 25-30° and both feet turned out slightly. (See Picture Below)

A manual therapist can also assess and treat any mechanical problems such as stiff lumbar, sacroiliac or hip joints.  Tight muscles can be treated with soft tissue techniques and stretching.  An exercise program would also be taught to strengthen weak muscles, stretch overly tight muscles.  Basic golf drill exercises will be taught to correct the swing mechanics.  More complicated swing mechanics are best analyzed by golf teaching professionals.

Other things to consider while golfing are the importance of proper warm-up prior to golfing which would involve hitting balls at the practice range and gentle stretching.   If you use a cart it should be pushed around the golf course, except on downhills where it is safer to have the cart behind you.  If you chose to carry clubs you should use a lightweight bag with backpack type straps.

Wry neck presents itself as an acutely painful neck either caused by a sudden unexpected motion or discovered upon waking.  In either case the pain is so debilitating that medical help is usually sought.

The acutely painful neck presents itself in one of two ways either a lack of mobility turning towards the painful side.  The other typical presentation is that the person suffering wry neck has to hold the head bend and turned away from the side of injury.

The most effective treatment is manual therapy consisting of a quick manipulation if pain allows (or joint mobilization).

After the manual therapy treatment is followed up by heat and electrical stimulation for 15 minutes. After the 15 minutes a series of exercised to regain range of motion is undertaken. This wry neck treatment program was first written about by New Zealand physiotherapist Brian Mulligan. http://www.bmulligan.com/about/concept.html

In the vast majority of cases after this physiotherapy session the mobility is considerably improved.  The patient is then instructed to continue this program again that evening and again next morning.  If sleep is disturbed a towel rolled up around the neck can be used at night.

The good news is that around 90% of patients will feel better with early treatment in 1-2 days.

Physiotherapists commonly see patients attending physiotherapy for ankle sprains.  While there is commonly swelling and pain there is also a lack of mobility in the ankle joints.

Manual physiotherapists have known for a long time that early manual therapy (including joint manipulation and mobilization) in conjunction with exercise and modalities allows people to resume activities or sports earlier and with less difficulty.

This 2009 research study confirms the benefit of manual therapy. See the Research here in the Journal of Orthopaedic Sports Physical Therapy:http://www.jospt.org/issues/articleID.2257,type.2/article_detail.asp

The authors found that those that benefited most from manual therapy reported they felt worse with standing and squatting, had signs of increased foot flattening and had a lack of ankle joint mobility.  The authors found that manual therapy combined with exercise allowed for quicker recovery, compared to exercise alone.

So if you sprain your ankle seek out treatment early on.  The treatment should include manual therapy.

Knee pain is a common complaint of clients attending physiotherapy. One of the more common conditions is pain around the kneecap termed ‘patellofemoral pain syndrome’ or PFPS.

This condition is more common in young women and is typically worsened with physical activity, walking down stairs or hills, squatting and sitting with the knees bent.

Abnormal tracking of the kneecap creates irritation of the soft tissue around the knee resulting in pain.  There are numerous factors that contribute to the abnormal tracking.

These factors can be divided into:

Bony / Structural

• Rotated hip bones
• Increase leg angulation (i.e. wider pelvis)
• Kneecap position
• Excessive probation of the foot (i.e. flattening)

Soft Tissue

• Muscle tightness around the hip and knee
• Muscle weakness, especially of the hip and quadriceps muscle

Training Changes

• Increase in training load or unaccustomed activities
• Change in training surface
• Change in footwear

The patient typically attends physiotherapy complaining of a generalized ache in the knee, sometimes more outside than inside.  The pain can be worsened with stairs, squatting, kneeling, and sitting.  There also may be complaints of crunching or grinding in the knee, which is termed ‘crepitus’. There may also be complaints of knee swelling or puffiness.

The physiotherapy exam will consist of a thorough history and physical examination to determine the causes of the PFPS and come up with a treatment plan to reduce and eliminate the symptoms.

Typical manual physiotherapy treatment will consist of correcting any lack of mobility in the spine, pelvis, hip, knee and ankle/foot. A common finding is tightness in the soft tissue around the kneecap pulling the kneecap to the outside.

A taping technique called McConnell taping (named after the Australian physiotherapist who discovered the taping) is very useful in realigning the kneecap. This realignment improves the tracking of the kneecap in the groove. With correct taping, symptoms are typically reduced immediately.

While the kneecap is taped and the pain is reduced, a strengthening program can be initiated. The strengthening will focus on the Vastus Medialis Obliqus (VMO) and hip muscles. The VMO is the only quadriceps muscle that helps pull the kneecap to the inside. With re-training, the VMO can resume controlling the kneecap. The hip muscle’s strength is important in controlling and stabilizing the knee.

In summary, manual physiotherapy can effectively reduce PFPS through a combination of manual therapy, taping and exercise.