Posted on 6/18/2018 by Erica Zettlemoyer, P.T., DPT
Multiple Sclerosis (MS) is a progressive disease in which the body’s immune system attacks the central nervous system (CNS). The CNS is composed of the brain, spinal cord and optic nerves. Our nerves are surrounded by a fatty substance called myelin, which allows electrical messages to be delivered quickly from the brain to the correct muscle. In MS, the myelin is damaged, scars are formed and the electrical message from our brain is disrupted. This creates a less efficient movement pattern, as well as pain, weakness, heat sensitivity, fatigue, numbness, vision changes and other impairments.
Multiple Sclerosis and Exercise – Though researchers are making significant advances in treating MS, there is still not a cure. However, there are various treatments which focus on slowing the progression of the disease and managing symptoms. Exercise is considered one of these treatments. In a published study, people with MS who participated in 15 weeks of three 40-minute training sessions per week were shown to demonstrate improved cardiovascular fitness, strength and overall health.¹
Multiple Sclerosis and Physical Therapy – Due to the complexity of MS, it is important to work with a physical therapist who will create a specialized exercise program based on one’s progression and severity of symptoms. Treatments will focus on general conditioning, strengthening, flexibility and balance as well as postural education, positioning and respiratory function. In more severe cases, a therapist will assist in the utilization of equipment, such as bracing, wheelchairs, standing frames. Several of the challenges that must be considered include:
Heat Sensitivity: Many patients with MS report a sensitivity to heat. A rise in core body temperature of as little as 0.5ᵒ C can intensify symptoms. A physical therapist can guide patients through several ideas that will assist in controlling body temperature while exercising. Using a fan, drinking cold water prior, during and after activity as well as utilizing cooling vests and wrist bands are helpful in controlling body temperature. Other ideas include placing a cooler in the car with cold drinks and starting the air conditioning in the car 10 minutes prior to leaving.
Lassitude: Fatigue affects 74 to 89 percent of those diagnosed with MS.² It is the initial symptom for almost half of those diagnosed, even predating diagnosis by as much as 10 years.³ A physical therapist can help patients address modifiable factors that increase fatigue, such as activity, respiratory weakness, thermosensitivity, pain, deconditioning and movement compensation.
Bone Density Loss: When exercising, it is important to focus on strengthening with resistance. Those diagnosed with MS may suffer from bone density loss due to Vitamin D deficiency and increased use of steroids. Participating in a weekly strengthening program while utilizing weights may improve bone health. A physical therapist can guide patients in safely incorporating resistance into an exercise program.
Examples of Appropriate Exercises – It is helpful to know that when exercising with MS, we should look at the total amount of exercise minutes for the day. For example, if someone can participate in riding a stationary bike for five minutes in the morning, five minutes in the afternoon and five minutes in the evening, that will give them 15 minutes of total cardio exercise for the day. Walking on a treadmill, walking inside or standing activities are other examples of exercises that can be modified to one’s functional and physical capabilities.
Strengthening exercises can include bridges, clams, heel raises, sit-to-stand transitions squats, step-ups and rows. Wall push-ups and triceps dips are especially important for fall recovery training. I recommend working on eight to 15 repetitions while using an appropriate resistance level.
Stretching is important and should focus on calf muscles, hamstrings, hip flexors and pectorals. When incorporating balance activities, vary the surface you are practicing on, whether seated or standing. For example, sitting on a wobble board or standing on foam will maximize training.
Beginning an exercise program does not have to be overwhelming or intimidating. Each patient with MS will tolerate exercise differently and a physical therapist can individualize each program to meet the needs of that individual. The MS Society and Multiple Sclerosis Association of America are also valuable resources for those who are seeking information on exercise.
For more information regarding physical therapy for MS, please contact a center near you today!
Petajan J, Gappmaier E, White A, Spencer M, Mino L, Hicks R. Impact of aerobic training on fitness and quality of life in multiple sclerosis. Annals of Neurology. April 1996 39(4):432-41
Murray TJ. Amantadine therapy for multiple sclerosis. Can J Neurol Sci 1985; 12:251-254
Krupp L, Alvarez L, LaRocca N, et al. Arch Neurol. 1988 45(4):435-437
White L, Dressendorfer R. Fitness testing in multiple sclerosis: a case report. Med Sci Sports Exerc 2003;35 (5): S314
By: Erica Zettlemoyer, P.T., DPT, is a licensed physical therapist at Baylor Scott and White Institute for Rehabilitation. She received a doctorate of physical therapy in 2010 from Texas Woman’s University and is a Certified Multiple Sclerosis Specialist.
Posted on 11/28/2017 by Rachel Linden, M.A., CCC-SLP
People tend to choose a career path based on what they enjoy doing or a special skill they possess. I have always enjoyed working with children, so a career like speech language pathology suited me. Once I started my major courses in college, I found that speech language pathology didn’t just suit me, it helped turn my greatest personal weakness into my passion.
Food preferences are a personal choice, but our tastes typically adapt and change as we grow. Eating should be an easy and natural thing, seeing as we eat at least three times a day, but it doesn’t always pan out that way. There’s picky eating and then there’s problem feeding.
As a young child, describing me as a picky eater would be an understatement. At times, I could be a problem feeder. Living on “kid food” such as macaroni and cheese or peanut butter and jelly was just fine with me. It always had to be the same brand, and my sandwiches had to be cut into triangles. No big deal; I was just a kid and would grow out of it, right?
As I got older, these habits stayed with me and food experiences became more difficult. I was anxious about birthday parties, sleepovers, meals with friends and dates, on edge about the available food options. There were some strategies I used to get by, like eating beforehand or stuffing snacks in my bag, but planning my life around food was difficult.
With marriage and family, life is about compromise and working together. My husband and I have had multiple conversations about my eating habits to ensure we can both eat and be happy. I’ve found success personally using some of the same treatment approaches that help my young clients and my son to become better eaters and enjoy less stressful mealtimes.
It took most of my life to realize that feeding contributed to the way I thought of myself, as well as my relationships with others. Through feeding training, I’ve been able to provide children and their families with interventions starting at a young age. Intervention provides a means to increasing skills and looking at foods in a new and more positive way, thus making mealtimes easier.
Feeding therapy using the Sequential Oral Sensory (SOS) approach focuses on developing the necessary skills for self-feeding as well as safe chewing and swallowing. The SOS approach uses a hierarchy to help the feeder gradually move toward their highest level of tolerance. Together, these approaches can expose the feeder to new foods and help him or her to increase their positive experiences with new and non-preferred foods.
Picky eaters are not the only children who can benefit from feeding therapy. Children who have weight gain issues, oral motor deficits, limited oral intake and are transitioning off a feeding tube are candidates for feeding therapy. Children who are highly specific about brands, refuse food and experience difficulty transitioning to new textures are also candidates. Moreover, families who have “power struggles” at mealtimes or children who display bad mealtime behavior may benefit from feeding therapy.
Therapy meals address behaviors, sensory responses to food, oral motor improvements and diet expansion. A meal is set up to remove distractions to allow for a “family style” meal. Each food is presented one at a time to increase tolerance to the offered food. Therapeutic assistance is provided to move a child up the feeding hierarchy to their highest point of tolerance and then the next food is presented. Mealtime rules and positive language about mealtimes and food is an essential part of feeding therapy to build trust and learn expectations.
If you suspect your child might be a picky or problem feeder, ask your NovaCare or Select Kids speech therapist about opportunities to expose them to exciting new food experiences.
Rachel LindenBy: Rachel Linden, M.A., CCC-SLP. Rachel is a speech language pathologist with NovaCare Kids Pediatric Therapy in Crystal Lake, IL. She has been practicing since 2013 and is committed to helping children live their best lives!
Posted on 11/10/2017 by NovaCare and NovaCare Rehabilitation
For the management of some types of pain, prescription opioids can certainly help. However, there is not enough evidence to support prolonged opioid use for chronic pain. We sat down with Katie McBee, P.T., DPT, OCS, M.S., CEAS, regional director of our WorkStrategies Program, to ask her a few questions regarding opioid use, chronic pain and the benefits of physical therapy as a safe alternative to prescription medication.
In your opinion, what are the main reasons for the opioid epidemic in the United States?
There is no simple explanation as to what caused the opioid epidemic in the United States. Opiates are not a new drug and have been abused at other time periods in American history, but not nearly to the extent that is happening now. Initial research on opiate medications said they were effective and safe and addiction was rare when used for short-term pain1. The development of FDA approved OxyContin in 1995 had labeling that stated iatrogenic addiction was “very rare,” and a widespread marketing campaign to physicians started to build medical providers’ confidence in prescribing these medications to decrease pain-related suffering2. Add to that the 2001 standards implemented by the Joint Commission on Accreditation of Healthcare Organizations for organizations to improve their care of patients with pain medication and this is probably what catalyzed the beginning of our current opioid epidemic.
With medical providers focused on pain as a vital sign, pain quickly became the enemy and had to be eradicated to show successful management for many conditions with an increased focus on post-operative pain management. As drugs became more widely available, aggressively advertised and culturally acceptable, a three-fold increase in prescription rates for these medications ensued. With the increase in opioid prescription rates, death rates from side effects also increased by three-fold to more 16,000 by 2011.
What is the difference between chronic pain versus pain suffered as a result of an injury?
Pain is a mechanism designed to protect us from harm. Pain is not the enemy. A common misconception about pain is that it is not a simple cause/effect relationship. The amount of injury does not equal the amount of pain we experience. Pain is a complex process based on many areas of the nervous system and the brain communicating together to let us know what we need to prioritize and protect. The more threatening the brain perceives something, the more we potentially feel pain.
Acute pain or pain suffered immediately after an injury or surgery to the body’s tissues is a protection mechanism from the brain to remind you to protect the area so that no further harm is done. As the tissue heals and time passes, there is less threat of injury so the brain stops signaling, the pain eases and you slowly get back to normal activities.
In chronic pain, the tissues are not signaling danger to the brain as much as they are in acute pain. When the brain perceives threat for extended periods, it starts to change the nervous system to become a pain-producing machine. It creates new nerve junctions to make things hurt that wouldn’t normally hurt, like light touch on the skin. It can decrease the amount of pressure needed to create a pain signal. It creates more chemicals along the nervous system so it can create greater pain experiences with fewer stimuli. Research is still trying to figure out why some individuals have pain that goes away as the tissues heal and others have pain that persists despite the fact that the tissue has healed.
Individuals can be at risk of developing chronic or persistent pain for a number of reasons, including unhelpful coping strategies, stress, chronic illness and poor sleep habits. It appears the more emotional or physical stress going on at the time of the injury and/or during the healing process, the more at risk you can be of developing a persistent pain issue. A holistic approach to address some of these drivers of persistent pain is showing promise in being able to reduce the pain and get people with chronic pain back into their normal lives again.
Why is physical therapy important and what are some of the benefits to patients?
Physical therapy is an ideal treatment for many types of acute and chronic pain and should be a part of any single or multidisciplinary treatment plan for pain. The goal of physical therapy is to increase function and keep people in their meaningful life activities while they are healing. Physical therapists are trained to address many of the drivers of chronic pain and can perform testing and screening to see if your pain system is sensitized and adjust treatment to desensitize the pain system as well as address the functional limitations many people often experience when they are in pain.
Physical therapists have many tools they can use to decrease pain and desensitize the pain system. These tools include education on pain to discover what could be driving pain issues. Once the pain drivers are discovered, a physical therapist will develop a holistic plan to address these drivers, including increased activity, sleep hygiene, stress management skills and pacing techniques.
The best thing about physical therapy for pain is that the outcomes for some of the techniques are better than many medications and procedures available; plus, there are no negative side effects. If you or someone you know has an issue with pain, consult with a physical therapist as a component of care.
For more information on physical therapy and its benefits, or to request an appointment today, please contact a Select Medical outpatient physical therapy center near you.
Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980;302:123.
Van Zee A. The promotion and marketing of OxyContin: commercial triumph, public health tragedy. Am J Public Health. 20:99 (2):221-227.
Posted on 10/19/2017 by NovaCare Rehabilitation and NovaCare
Play It SafeOne of the most devastating injuries in sports today is the anterior cruciate ligament (ACL) injury. We sat down with Trent Nessler, P.T., MPT, DPT, national director of sports medicine innovation, to ask him a few questions regarding ACL injuries and his exclusive evidenced-based ACL Play it Safe Program.
What are three measures that can be taken to prevent ACL injury?
If you were going to break it down into three measures, these would be:
Education – Almost 80 percent of ACL injuries are non-contact in orientation. This means there is no contact with another player or structure, but typically result from a rapid change in direction or jumping motion. There are certain movement patterns that put an athlete at greater risk for these non-contact injuries. Using a baseline movement screening process is critical to identifying those at risk. The results should further guide training that can be implemented throughout the season to reduce the athlete’s risk of injury.
It is also imperative for athletes, coaches and parents to understand that when you address movements that are associated with non-contact ACL injuries, they see a significant impact on their on-field athletic performance. The knee abduction that occurs not only puts excessive stress on the ACL and structures of the knee, but also results in a significant loss of kinetic energy transfer from the lower limb, hips to the core. This loss of energy has a direct impact on vertical jump, sprint speed, explosive power and pitching velocities.
Movement Assessments – There are many movement assessments on the market today. Although some have become the standard of practice in our industry, the fact that we are still depending on the eyeball to score the majority of these assessments introduces a tremendous amount of subjectivity into the equation. Three-dimensional technology, complete with cameras and wearable sensors, however, are removing the subjectivity from the equation and allowing for improved reliability.
Training – Many good injury prevention programs out there have been shown to reduce injury rates in athletes. However, the challenge is the adoption of these programs as a standard part of an athletic program or season has been very low. Why is that? If the program takes too long, then teams, coaches and athlete are less likely to do it. Knowing that these programs improve movement and movement efficiency, we should be promoting the impact on sports performance versus injury prevention. Approaching a coach or athlete with an effective and proven 20-minute program that helps to improve their sprint speed and vertical jump will cause the adoption rate to become much higher.
Technology is an ever-changing industry, and ACL injuries are a prevalent occurrence. How do the two go together and benefit patients?
One of the most exciting trends we are seeing today is the adoption of 3D wearable sensor technologies. These can and are having a huge impact on ACL injuries. The technology inside a 3D wearable sensor is what’s called an inertial measurement unit (IMU). An IMU detects and records motion, rotation and acceleration data. We now use these for movement assessments in our athletes to detect degree of knee abduction and the speed at which it occurs within a very high degree of accuracy. In addition, this becomes a much more efficient and reliable way to measure movement that puts athletes at risk for injury and performance issues. This is a huge step in ACL prevention! For the first time ever, we are collecting movement data with technology and combining it with demographic data for every athlete assessed.
Aside from use of IMUs in assessment, it can be used in training. We are in the process of leveraging this same technology to track movement during single limb training. This will not only give the athlete immediate feedback on how they are moving, but will identify those athletes at risk during their training. This information could be used to refer them to a provider for a more extensive movement assessment and treatment. This would expand the scope of ability to identify athletes at risk beyond just those who have a physical or who see a health care provider.
You developed a nationally recognized non-operative ACL program – the ACL Play it Safe Program – to decrease the likelihood of injury and enhance athletic performance. What sets this program apart from others and how can folks learn more about it?
Trent ACL 2As a result of numerous researchers’ hard work and the influence of great mentors, the development of the ACL Play it Safe Program was made possible. The things that set this program apart are:
The ACL Play It Safe program is specifically designed to improve performance on the movements that are assessed with the ViPerform Athletic Movement Index (AMI). So, athletes can be assigned to the level of the program based on an assessment.
The program has four distinct levels of progression; level one for athletes who don’t move very well, all the way up to level IV for athletes who move efficiently.
This program has a pre-practice routine that takes five minutes and a post-practice routine that takes 15 minutes. The post-practice routine is a fatigue-based training routine. This is where fatigue from practice is carried over in the post-practice routine. From a training specificity standpoint, we find that training in a fatigued state has better carry over to later in the game when performance issues are likely to arise and injuries rates increase.
Each athlete is given a kit that has standardized equipment in it. This prevents them from using different types of equipment or variations in resistance from training session to training session, allowing for more consistency in the progression.
The program offers a video instruction of each exercise that can be accessed on the complimentary ACL Play It Safe app. This ensures there is no error or change in interpretation of the exercise from athletic trainer to coach to athlete.
So far, this program has been implemented with more than 3,000 athletes across the country. We are using this as a part of their rehabilitation and return-to-play. When implemented correctly and with the ViPerform AMI, we are seeing an average of 58.2 percent reduction in lower extremity injuries from the spine to the foot and ankle.
For more information on this program, folks can email me directly at [email protected] I look forward to hearing from you!