Monday Memo 4/15/19

The Monday Memo

April 15, 2019                                                                           PITT DPT STUDENTS

 

 

Resistance Training, Headache, and Cervical Spine Pain

 

Headache and/or neck pain associated with musculoskeletal disorders pose a significant problem not only to patients who report these symptoms but to society as well. The high prevalence of these disorders contributes to decreased productivity and increased time-off in workers (Schwartz et al., 1997). Many of these patients benefit from progressive resistance exercise to address cervical, periscapular, and glenohumeral musculature. However, there is much variation in the selection of resistance exercises, and innumerable factors to consider when seeking to drive adaptation in these patients. First, consider the FITTE principle:

  • Frequency
  • Intensity
  • Time
  • Type
  • Enjoyment

Above all else, clinicians must find a way to dose an appropriate volume – sets and reps – to drive positive adaptation that is enjoyable to the patient or client. There is research to support that exercise volume is a larger driver of hypertrophy than frequency of exercise or even intensity (Figueiredo et al.). However, pertinent contextual factors must be accounted for such as a patient’s current fitness level, lifestyle, occupation, previous level of activity, and training history. These factors play a large role in response to exercise, and the clinician must appropriately modify exercise dosage to account for them. Andersen et al. studied the effects of frequency of resistance training and found that, when weekly volume was consistent, patient outcomes did not differ between experimental groups for individuals with cervicogenic headache.

This means that the clinician and patient can tailor a program to fit the patient’s schedule and lifestyle. As clinicians we often hear, “I don’t have enough time to do my home exercises.” By carefully interviewing patients, it is possible to identify and agree upon the appropriate frequency for their program that will drive change and fit their schedule. For example, a patient may be willing to exercise 3 times per week for 20 minutes at a time, whereas another may only have two days per week to work out. The patient with only 2 days could then perform two 30-minute workouts.         Andersen et al. found that even 2 minutes a day of resistance exercise was enough to reduce neck/shoulder pain and tenderness! This short dose of exercise may be enough to get an otherwise sedentary patient to engage in physical activity. However, as discussed previously, volume is important to drive hypertrophy and develop strength in our patients. Once 2 minutes a day becomes manageable, the volume may be increased based upon patient tolerance. Let’s go over some exercises and progressions to address neck and/or shoulder pain. These are not all-inclusive.

  1. Seated cervical retraction + isometric sidebending:

Sample dose: 3 x 10; 10” 2 x 15 with isometric hold.

  1. Quadruped cervical retraction

Sample dose: 3 x 10; 10” 2 x 15 with isometric hold.

  1. Quadruped Y/T

Sample dose: 4 x 12; can add isometric holds or hand weights for progression.

 

  1. Blackburns Circuit

Sample dose: 6-10” holds in each position for 2 “laps.” Perform 3-4 sets.

 

 

-Joe Dietrich, SPT, ATC

 

References

Andersen, Lars L.a,*; Saervoll, Charlotte A.a; Mortensen, Ole S.a,b; Poulsen, Otto M.a; Hannerz, Haralda; Zebis, Mette K.a. Effectiveness of small daily amounts of progressive resistance training for frequent neck/shoulder pain: Randomised controlled trial. Pain. Volume 152(2), February 2011, p 440-446

C.H. Andersen, R.H. Jensen, T. Dalager, M.K. Zebis, G. Sjøgaard and L.L. Andersen; Effect of resistance training on headache symptoms in adults: Secondary analysis of a RCT. Musculoskeletal Science and Practice, 2017-12-01, Volume 32, Pages 38-43.

Figueiredo, V.C., de Salles, B.F. & Trajano, G.S. Volume for Muscle Hypertrophy and Health Outcomes: The Most Effective Variable in Resistance Training. Sports Med (2018) 48: 499. https://doi.org/10.1007/s40279-017-0793-0

https://www.bodyzone.com/neck-exercise-cervical-retraction/

https://myrehabconnection.com/cervical-extensor-exercise-progressions/

April 15, 2019 |

Monday Memo 4/8/19

The Monday Memo

April 9, 2019                                                                           PITT DPT STUDENTS

 

 

SBIRT

 

What is SBIRT, you may be asking? It’s a process consisting of screening, brief intervention, and referral to treatment. It is an evidence-based tool to assess and intervene with patients with suspected substance abuse or at risk behaviors.

As physical therapists, we should expect to encounter these patients often. Many of our patients may be prescribed pain killers that may modify their symptoms temporarily, but lead to dependence. It is within our scope of practice to screen for these at-risk behaviors and, if the patient consents, to have a brief conversation delving deeper. This may not always be the easiest conversation to have, but an important one nonetheless.

 

Screening

 

A therapist may be able to pick up on possible at-risk behaviors while taking a patient’s history. If found, there are useful tools for further screening, including the Alcohol Use Disorders Identification Test (AUDIT) and The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST).

 

Brief Intervention

 

Once at-risk behaviors are identified, the therapist should use their clinical judgment to determine how to discuss with the patient steps to change. Motivational interviewing allows the clinician to learn important details while letting the patient drive the conversation. Two acronyms to guide brief intervention are FLO and OARS. FLO stands for feedback, listening, and options. It is important to give the patient feedback, show them that you are engaged and listening, and allow them to explore their options. OARS stands for open-ended questions, affirmations, reflective listening, and summary. Asking open-ended questions allow the patient to share freely in a non-threatening environment. Affirmations are important to encourage positive ideas. Reflective listening and summary are used to demonstrate understanding.

 

Referral to Treatment  

 

If the patient expresses interest, there are several available resources to share with them:

SAMHSA’s Treatment Routing: 1-800-662-HELP

PA Single County Authorities: www.paedaa.org

Overdose Prevention Resources: overdosefreepa.org

Alcoholics Anonymous: 1-212-870-3400

Narcotics Anonymous: 1-818-773-9999

Tobacco Free Quitline: 1-800-QUIT-NOW

Rather than shy away from these conversations, it is our responsibility as physical therapists to explore options and actively listen to our patients without judgment. Patients are more likely to open up about their behaviors when they feel heard.

 

-Katie Schuetz, SPT

-Layne Gable, SPT

 

References:

https://www.integration.samhsa.gov/clinical-practice/sbirt/brief-interventions

https://www.apa.org/career-development/screening-intervention.pdf

April 8, 2019 |

Monday Memo 4/1/19

The Monday Memo

April 1, 2019                                                                           PITT DPT STUDENTS

 

Hands 

 

Have you ever looked at the hands of someone over the age of 75? They tell a story. You may notice spots left by days spent in the sun, callouses left by years of hard work, or scars from an old sports injury. Those hands have clapped for performances and held the hands of others. They have allowed their person to engage and interact with the world, but these hands tell another story. They tell the story of the future. You may also notice atrophy where plump muscles were once prominent, thinning skin prone to bruising, and swollen joints struck daily with the pain of arthritis. And we can see all that in the hands. What about the rest of the person? We have a whole body, and save tragedies, we are all destined to age. How do we approach these aging bodies and the souls inside them? How do we offer the respect deserved by years of life experience on earth? Atul Gawande offers a unique and moving take on the subject of aging in his novel, Being Mortal: Medicine and What Matters in the End.

 

Throughout the novel, Gawande, a physician, explores the obstacles many elderly people face as they begin to require more assistance with everyday life and, ultimately, the trials and tribulations of end of life planning and the emotions that go with it. Dr. Gawande acknowledges times he failed to have the ‘hard conversations’ and is open about the learning process he had to go through to better serve his patients, even in a well-established career. His take on assisted living homes and hospice care as avenues to facilitate life, rather than usher in death, is particularly powerful. The purpose of these institutions should be to allow people to decide how they want to LIVE their final days to the fullest, not how they want to die.

 

I believe physical therapists can gain a lot from this novel in dealing with the geriatric population. We are taught to push and encourage our patients to better themselves and improve, but what about the octogenarian who is simply, not into it or just done? I think we have a unique opportunity there to effect change, and this is where patient-centered treatment and goal setting comes into play. Of course, as Dr. Gawande learns in his book, it is important to be honest and realistic, but that does not mean you cannot improve the quality of life in terminally ill patients.  He notes, “Our ultimate goal, after all, is not a good death but a good life to the very end.” Every patient should have the opportunity to share their goals with their therapist. We cannot simply assume that all older adults are content living out their lives playing Bingo. We as a society need to respect and appreciate that every older adult has had a long life to decide what they do and do not like to do. As a physical therapist, take note of those activities and find ways to incorporate them into treatment in interventions that provide an appropriate challenge, while being enjoyable and specific to the patient.

 

The next time an older patient sits down in front of you, take a look at their hands, ask them their story, and listen to their goals for life.

 

“In the end, people don’t view their life as merely the average of all its moments—which, after all, is mostly nothing much plus some sleep. For human beings, life is meaningful because it is a story.” -Atul Gawande

 

-Katie Schuetz, SPT

 

Reference:

Gawande, A. (2014) Being Mortal: Medicine and What Matters in the End. New York, NY: Metropolitan Books.

April 1, 2019 |

Monday Memo 2/25/19

The Monday Memo

February 25th, 2019                                                                           PITT DPT STUDENTS

 

Challenging the Treatment of Lumbar Spinal Stenosis

Lumbar spinal stenosis (LSS) is defined as a narrowing of the spinal canal that results in compression of the nerves traveling down the lower back and into the legs. Lumbar spinal stenosis is often a degenerative condition that affects people later in life usually after the age of 65. Patients with LSS typically present with pain/symptoms below the buttocks, feel relief of pain/symptoms when seated, present with a wide base of support during gait, and have pain/difficulty walking.

Currently, the most common reason for surgery in older adults is LSS; however, there is very little evidence comparing surgery to non-surgical treatment, or of the efficacy of non-surgical interventions for LSS. Recently, a team comprised of members from the University of Pittsburgh looked to improve the evidence gap by publishing an article in the Journal of the American Medical Association that compared three non-surgical interventions for LSS.

The randomized control trial study specifically compared medical care, group-based exercise, and manual therapy with individual exercise. The non-surgical treatments were completed across 6 weeks. The main outcomes of the study were between-group differences at 2 months in self-reported symptoms and physical function and a measure of walking capacity.

Medical care involved 3 visits to a physician and typically the prescription of oral medications including any combination of nonnarcotic analgesics, anticonvulsants, and antidepressants. The medical care arm also gave physicians the option of prescribing epidural steroid injections if the patient was not responding to oral medications or presented with more severe neurological symptoms.

The group exercise arm participated in a supervised exercise class for older adults at 2 local Pittsburgh community centers. The study participants went to 2 exercise classes per week totaling to 12 classes.

The manual therapy and individual exercise group included treatment provided by a chiropractor or physical therapist. Treatment included light aerobic exercise on a stationary bicycle, lumbar distraction manual therapy, neurodynamics, hip, sacroiliac, and lumbar facet mobilizations, soft tissue mobilizations, and home exercise programs. The programs were individualized and stressed flexion-based exercises.

According to the study, the manual therapy and individualized exercise group showed greater improvement of symptoms and physical function compares to the medical care or the group exercise arm. At 6 months the study found that there were no differences between the groups. While this study did not directly compare non-surgical and surgical treatment for LSS it did demonstrate that patients experiencing lumbar spinal stenosis can make clinically and statistically meaningful improvements in walking capacity without the significant costs, risks, complications, and rehospitalizations associated with surgery.

 

-Janet Mitchell, SPT

 

References:

Schneider MJ, Ammendolia C, Murphy DR, et al. Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial. JAMA Netw Open.2019;2(1):e186828. doi:10.1001/jamanetworkopen.2018.6828

February 25, 2019 |

Monday Memo 2/18/2019

The Monday Memo

February 18th, 2019                                                                           PITT DPT STUDENTS

 

Battling the Gender Pay Gap in Physical Therapy

            The gender pay gap is alive and well in America. Despite women becoming the majority in the profession of physical therapy, women still get paid less than their male counterparts. According to data compiled in 2013 from the US Census Bureau, female PTs make 88% of what male PTs make. The APTA cited these statistics from the report:

Among the data related specifically to PTs:

  • Estimated full-time year-round number employed: 136,392
  • Male full-time year-round employed as PT: 49,118
  • Women full-time year-round employed as PT: 87,274
  • Median annual earnings: $72,260
  • Median annual earnings, men: $80,411
  • Median annual earnings, women: $70,509
  • Women’s earnings as a percentage of men’s earnings: 87.7%

There are a lot of misconceptions around the idea of why the gender pay gap exists. A few theories involve:

  • 1) The fact that women tend to choose lower paying jobs
  • 2) Women choose to work part-time
  • 3) Younger, more educated women do not experience a wage gap.

According to The Washington Post, these theories are not completely true:

 

Claim 1: Women choose lower paying jobs

Explanation: This is not always the case. In the 2017 analysis from The Washington Post, jobs with more women workers pay less than jobs with more men. The top 10 jobs with mostly men pay an hourly wage of about $17/hour, while the top 10 jobs with mostly women pay an average of about $16/hour. Also, women don’t hold as many supervisor, manager, or executive positions which would be higher paying jobs. It is not correct to say that this is a choice for women, as equal number of women and men have aspirations to hold higher positions. Men are chosen to hold these positions more often. This is often referred to as the “Leadership Gap”, and is seen in almost every profession, from politics to physical therapy.

 

Claim 2: Women choose to work part time

Explanation: This isn’t always a choice. With America being the only country in the developed world not legally mandating paid maternity leave and child care being extremely costly, a lot of women transition to part time or casual positions to be able to still work and take care of their young children. New mothers in Finland are entitled to three years of paid leave. Parents in Canada are entitled to 12-18 months of paid leave. America entitles new parents to absolutely no paid parental leave. Many employers offer up to three months of paid maternity leave, but there is no reason as to why fathers cannot receive parental leave as well.

 

Claim 3: The gender gap doesn’t apply to younger, more educated women

Explanation: While the gap is smaller for those younger than 35, it still exists. Women are now more likely than men to hold a bachelor’s degree, however, when compared to men in every age group with 3+ years of college, women are paid less across the entire continuum.

 

So, how do we battle this gender wage gap that still exists in America? We can do a few things, including being more educated about our rights. While the Equal Rights Amendment has not been ratified, there are laws that require people to be paid equally no matter what gender they are, such as the Equal Pay Act. Also, under Title VII of the Civil Rights Act, employers cannot pay women less than men for the same work and they cannot refuse to consider women for promotions based on the fact that they are women. Even though these are laws, employers are still getting away with paying men more.

To combat these inequalities, we can encourage people to be more transparent with their salaries and try to reverse the outdated stigma that discussion of salary with colleagues is taboo or inappropriate. The hiring process for men and women should be on a level playing field and women have the right to ask what men serving in the same role as them are earning to ensure they are being treated equally. We can also promote the utilization of workshops for women who would like to learn how to effectively negotiate salary. No matter what gender you may identify with, addressing the wage gap is an essential step in promoting equality for all workers. By increasing awareness of this disparity and encouraging action by men and women, we can work towards a professional environment that provides the most benefits for all.

 

-Kara Kaniecki, SPT

 

References:

G.V., X. (2017, October 26). Can We Talk About the Gender Pay Gap? Retrieved from The Washington Post.

Ingraham, C. (2018, February 5). The world’s richest countries guarantee mothers more than a year of paid maternity leave. The U.S. guarantees them nothing. . Retrieved from The Washington Post.

US Census: Median PT Earnings Nearly $10k Lower for Women than Men in 2013. (2015, March 17). Retrieved from APTA.

Washington Post: Female PTs Will Spend Last 4 Weeks of 2017 Working ‘For Free’. (2017, November 7). Retrieved from APTA.

February 18, 2019 |