Apple Therapy

March 20, 2018

Karin Biskovich, MPT

Opioids are certainly making the news.  One recent story from Health News on NPR highlighted a phenomenon called opioid-induced hyperalgesia.  Numerous studies looked at cases of this occurring in various populations.  One study in 2006 looked at the use of oral morphine with patients with chronic back pain.  They found an increase in pain sensitivity at the end of the four-month study.  Several studies have looked at pain levels after surgery.  Overall, they showed the groups that were given higher levels of opioids had increased levels of pain after surgery than the control groups given lower levels of opioids or a placebo.

Along the same lines, a study published in Health Sciences Research looked a large group (>5000) of people with non-cancer chronic pain and separated they into 3 groups: no-use of opioids, short term use of opioids and chronic use of opioids. Using a health-related quality of life survey they determined that the use of opioids did not improved the quality of life over the people who did not use opioids for their pain.  In fact, the opioids users showed a decrease in physical health over the 2-year study although this was not clinically significant.

Manual Lymphatic Drainage (MLD) and Complete Decongestive Therapy (CDT) are two forms of treatment that aim at reducing lymphedema, dynamic edema or a combination of both.  MLD is a very specific type of  massage that primarily addresses the superficial lymphatic system; CDT is the follow up treatment and is comprised of bandaging with specific foam and short stretch bandages that are to be worn during exercise and daytime movement.  This treatment can be provided by certified lymphatic therapists.  The certification is an intense class which is typically 160 hours of hands on training.  The types of patients who may benefit from MLD/CDT are:

           - post operative swelling from an orthopedic procedure

           - post operative swelling caused by radiation  or lymph node removal

           - post operative gynecological procedures

           - Swelling from trauma of any kind

           - venous insufficiency

           - sinus or congestion disorders

           - migraines

           - chronic constipation

           - neurological disorders such as MS

           - pain

Lynn Novier, OTR/L, CHT

October 16, 2017

Pilates is an exercise program and part of a lifestyle that focuses on strengthening the core muscles in our body.  It also improves flexibility and postural alignment.  Although it can be specific and focused on one body part, the carefully designed program takes your entire body into consideration.  It is an excellent stand alone strengthening program and also can be used to enhance performance for sports.  It particularly is combined well with people who perform sports that incorporate rotation as a part of the movement pattern.

Apple Nashua has a very successful Pilates program with  full balanced body studio equipment.  The program has successfully rehabilitated countless patients and has regular reformer classes open to the general public.  Personal training is also available for 1:1 training.

Our therapists have the highest level of training in the industry.  The training consists of a 450 hour certification program and mandatory continuing education by Pilates professionals who are also physical and occupational therapists.

June 30, 2017

Karin Biskovich, MPT

CAN WE STRENGTHEN OUR SPINAL DISCS?

A new article just published in Scientific Reports interestingly showed a positive change in intervertebral disc (IVD) height in a group of runners versus non-runners.  A group of 79 subjects ages 25-35 included a non-sporting group, joggers (20-40km/week), and long-distance runners (50+ km/week). The runners and joggers had to be performing this distance for a minimum of 5 years. The testing showed better hydration in the IVD in the runners versus non-runners.  Furthermore, the height of the IVD in the long -distance runners was higher than the joggers.  When they looked more closely at the speed of running that supported the most benefits for the IVD, they found that fast walking or slow running had the most positive change in the IVD height. 

RUNNING AND HIP/KNEE OSTEOARTHRITIS

Now that we have started talking about the benefits of running we may as well continue.  In the recent issue of The Journal of Sports and Orthopedic Physical Therapy, a group performed a systematic review looking at the prevalence of knee and hip osteoarthritis (OA) in recreational runners (amateur, non-professional), non-runners/sedentary individuals, and competitive runners (professional/elite athletes).  They included 25 studies with 125,810 individuals and found the prevalence of OA in competitive runners to be 13.3%, recreational runners 3.5%, and non-runners 10.2 %. 

May 31, 2017

Karin Biskovich, MPT

Every day we help our patients lower their current pain levels so they can work, play, and live without pain. This work is for the present but how about increasing fitness down the road?  High intensity interval training has been all the rage in fitness lately.  New research recently came out showing that 10 minutes of sprint interval training or SIT as part of a run workout is as effective as 50 minutes of moderate continuous exercise.  http://www.runnersworld.com/intervals/can-sprint-training-take-the-place-of-longer-more-moderate-exercise?utm_source=t.co&utm_medium=Social&utm_term=895512800&utm_campaign=Runner%E2%80%99s+World

10 minutes versus 50 minutes... seems like cheating, doesn’t it?  Well, you do have to work very hard for at least 3 repetitions of 20 second sprints during the 10 minutes of easy running.  If you do it right, research has shown it will improve your fitness.

The challenge with initiating this type of training (or similar types of high intensity training) is the risk of injury.  This is where the help of your local physical therapist comes into play.  If your muscles are not used to accelerating up to high speed quickly then this could cause injury, especially as we age and our muscles become less pliable.  The research study used subjects in their late 20s, an age group that is less prone to injury.  Have you ever wondered if you are doing the proper stretches and warmups before after a run?  This is something a sports PT can help with.  Come in for 1 to 2 visits as a preventive measure. In the state of NH you can see a PT without a doctor referral, so you could have to give the office a call. 

If you are interested in trying a SIT workout, we can make a few recommendations.  First of all, try slightly longer but less intense intervals to start, maybe 60 seconds as mentioned in the article.  You can work up to 20-30 second high intensity sprints.  Second, make sure you start your run with a quality dynamic warm up routine.  Here is one good example:

Nike Run Club Warm Up

Karin Biskovich, MPT

April 28, 2017

Water has a long history of use for medical ailments and to promote healing. In the early 1900s, the first pools were used to perform rehabilitation exercises for patients with cerebral palsy and spasticity.  Eventually the use of water therapy included many types of diagnoses and diseases to help restore range of movement and improve muscle function.  Water is a very safe environment to work with a patient and often a place one can maximize a therapy session. 

A patient who submerges their body to their belly button has reduced their body weight by 50%.  Decreasing the load on a joint can allow for increase ability to perform range of motion and strengthening exercises.  This can be very valuable in the rehab of a joint or injury that has a weight bearing restriction for an extended period of time.  Alternatively if one has increased pain with compression of a joint then getting in the pool could allow for increased tolerance to an exercise program. 

Another benefit to therapy in the pool is increased blood flow.  It is shown in research that there is a greater increase of muscle blood flow following exercise in water versus on land.  Increasing blood flow to a muscle aids with healing and allows a more effective exercise session.

In 2002, a research group looked at the neuromuscular performance and muscle mass of healthy women after a 10 week aquatic program.  They found a significant gain in the strength of the quads and hamstrings muscles in the women who performed the aquatic program.  

Guest blog by Stacie Hoegen, DPT of Apple Nashua

March 31, 2017

Many people suffer from vertigo, also known as BPPV (Benign Paroxysmal Positional Vertigo), which is most often described as dizziness caused by changes in head position. Other factors that commonly cause vertigo are activities like driving or riding in a car and shopping in a grocery store. Most people are unaware that physical therapy can not only help, but often times eliminate symptoms in just a few visits. PT’s will prioritize scheduling an evaluation for a patient with vertigo because it is most useful when symptoms are occurring and vertigo is actively affecting the patient. During the evaluation, the PT will assess eye and head movement, examine the patient’s ability to transfer out of bed, ambulate, & balance. The PT will then address these deficits by developing an individualized treatment plan. A PT will spend time one-on-one with patient to help them understand the disorder, recognize signs and symptoms, and most importantly teach the patient how to SELF-manage. Often, people visit 3-5 doctors when experiencing vertigo when all along their physical therapist could help treat their symptoms.

February 25, 2017

Have you noticed as you get older you are getting a little less flexible?  It happens. Our muscles become less elastic and our movements are mostly in the range we need for daily activity, for example just reaching up to the top kitchen shelf to put a dish away.  Before you know it, it is hard to get the arm all the way up overhead or behind the back to scratch that one itch.  But do you need that motion for other activities?  For example do you swim laps or lift weights overhead?  Then you need that motion!  Also as we age the space between the roof of our shoulder (the acromium) and the top of the shoulder (humerus) becomes more compressed; hence pinching the structures in between (the rotator cuff tendon and bursa sac). Have you heard of your friends getting shoulder bursitis?  That is basically the bursa getting pinched repeatedly over and over until it is very inflamed and painful.  It is usually not one event but many repetitions that causes this to happen (painting all weekend for example).  

I have made my case for why you need to keep up with this overhead motion so now here is how you can work on it on your own.

1.  Stretching - It is very important to stretch your chest and latissimus dorsi (lats for short).  Your chest muscles and lats get tight with increased sitting, computer use, and driving.  Hold these stretches for at least 30 seconds and do daily.  Of course if any stretch causes sharp or uncomfortable pain in an area other than your chest or lats then you should stop the stretch.

2. Trigger point massage ball and foam roller work - Lay on a long foam roller each day to open your chest up.  Hold for several minutes.  I can almost guarantee you will love this stretch.

You can lay on the foam roller to work on your lats and shoulder or use a massage ball on the wall.  Spend a few minutes working on these areas.

Pictures were found on HEPtogo.com. 

This is a good place to start when you have shoulder tightness but if there is any shoulder pain with overhead motion then it may be a good idea to check in with a physical therapist to individualize the program to you.  Don’t wait for the shoulder pain “to go away”.  Usually that means that you are just avoiding the painful movement and this can disrupt your shoulder mechanics even more (bigger problems down the line!)

Here’s to high reaching shoulders!

Karin Biskovich, MPT

January 31, 2017

Every year you are required to get an inspection for your car…similar to your yearly physical exam.   Now sometimes your car needs a little extra work in order to pass inspection.  This is because it has some wear and tear that has to be fixed.  You choose to spend that money because you trust the mechanic’s expertise (and to get that inspection sticker).  If you see your primary care physician and you bring up the shoulder pain or low back pain you are having, what is the next step?  They may give you a paper with some exercises, some medicine, or possibly a prescription to physical therapy.   What is your first thought?  How much is PT going to cost you?  Who do I go see?  What if you find out that you have a $50 copay or a high deductible to meet?  You may wonder if it is worth the cost.  You are not required to get an inspection sticker but this is the only body you get.  It is not as easy to replace a shoulder like a muffler.  If you let the wear and tear pain continue there is a good chance it will wear out faster.  This may not seem like a big deal until it is too late and the pain now limits you and affects your daily life.  

December 31, 2016

Karin Biskovich, MPT

I have long been an advocate of early intervention with physical therapy.  It is much easier to fix an early injury than a chronic injury.  That being said, many people still wait for the nagging shoulder strain to get better with time.  It is a great thought but works about as well as a faulty alignment in your car.  Your tires start to wear unevenly and now you have to replace your tires before they are actually worn out.  Same goes for your body.  You will start to use your shoulder differently causing new aches or muscle tightness. 

Often the initial muscle injury or joint strain will create an adhesion or scar tissue at the site of injury.  This adhesion will cause limitation in the movement of the muscles, fascia, ligament, nerve or tendons in the area.  Now imagine what the limitation in range of motion will create when you use that joint over and over.  Overuse injuries, muscle trigger points, tendonitis?  All of them are possible. 

Here is your chance to fix it before it becomes a problem.  Active Release Technique is a technique where the clinician uses their hands to test the tightness, texture, and movement of the fascia, muscles, ligaments, nerves, and tendons then treat the abnormal tissues with manual pressure and specific motion.  They can release the tension on the joint and restore it’s normal motion.

As a competitive triathlete, I have had to deal with nagging shoulder pain that started sometime during collegiate gymnastics.  I would feel it on every freestyle stroke during my swim training and it would tend to get worse as the workout went on.  I would treat it with strengthening exercises and keep the pain levels relatively low.  One day my co-therapist Carol Lewis CHT, OTR/L did 30 minutes of ART on my shoulder.  It was not immediate relief but most certainly an immediate change in how I used my shoulder.  Within a couple weeks I would get through a whole swim workout without thinking about my shoulder at all. With just the one session, the pain relief lasted my entire season.  I was amazed.  I quickly became an advocate and have recommended ART to many patients.  Interested?  Well, give us a call and try it out. 

 November 30, 2016

What to expect during your gait analysis

By Christine Shaw, PT, DPT

 Discussion

First, I need to know what brings you into the clinic. Is this a “healthy” or “unhealthy” gait analysis? It is important for me to know whether you have been running pain free, have a history of injury or are currently returning from an injury. Perhaps you are new to running. We will also discuss your goals and current training habits.

 Movement Assessment

This is an essential part of your running analysis. Abnormalities found during this screening are often reflected in your running form. You will be taken through a series of movements that test your flexibility, strength, mobility and balance. This will help me identify any abnormal movement patterns and their causes.

 Video Analysis

You will be filmed while running on the treadmill. Your gait will be captured from several angles. You may be asked to run at varying speeds based on your individual goals. For example, I may want to observe you while running at your training pace and race pace. You will be running between 5-15 minutes, depending on your goals and current ability. Walk breaks can be easily incorporated.

 Review and Recommendations

I will analyze and review your running mechanics using specialized software. You will be given recommendations on running technique, footwear, and/or correctional exercises and drills that will improve your form and prevent injury.

 Should I book a follow up session?

My goal is for you to leave your session with a good understanding of what you need to work on and how to begin doing that.

 If you are interested in reaching your full potential, you may find that you want to schedule follow up sessions. This would allow us to spend more time on areas that require further attention. Usually your follow up sessions will be a combination and progression of flexibility, strength and gait retraining exercises. If you require rehabilitation from an injury,  you may be referred to our physical therapy program.

 It is important to remember that improvements in flexibility, strength and running mechanics happen over time. You may need to master one set of exercises before moving on to the next. The physical act of running is a skill: it takes practice, repetition and reinforcement to improve your technique!

October 31, 2016

So you are wondering...what is telehealth?  According to the American Physical Therapy Association, it is defined as the use of electronic communications to provide and deliver a host of health-related information and health care services, including, but not limited to, physical therapy–related information and services, over large and small distances.  As of right now, telehealth is still limited by payment policy and licensure but it is likely to occur due to the cost-effective nature.  Telehealth is especially valuable for rural populations that have to travel far to access a clinic.  We have to be creative to promote physical therapy in the digital age.  We can make our practices visible via social media.  However, this is not enough.  We have to incorporate mobile devices in the clinic by using them to video running gait, walking gait, and exercise performance.  Instead of a written home exercise program, why not just take a picture or video with the patient’s phone?  Apple Therapy has put several videos and pictures of exercises on their website but it is not the same as the patient taking a video specifically describing the exercise with key points regarding form and technique. 

September 30, 2016

It is that time of year again...football, soccer, volleyball, field hockey are all in the midst of their seasons and the risk of concussion is very real.  Due to the NFL and other major league sports teams, concussion has been more in the media and a topic of discussion.  Recently we sent one of our PTs to be trained as an IMPACT certified PT for treatment of patients post-concussion.  But what about prevention?  I have been a proponent for quite some time of isolated neck strengthening with all my cervical pain patients.  I feel that the small stabilizing muscles in the neck gradually get weaker with time especially in our lifestyle of increased sitting and computer use.  I encourage my neck pain patients to perform small movement strengthening exercises on a daily basis.  They are often surprised on how hard these small motions are.  I recently had a high-school patient following neck injury and asked him to perform these neck exercises.  I was surprised on how challenging they were for him. 

Can these exercises help kids to prevent concussions?  Well, there is some interesting research out there to agree with that.  In 2014, a research group found that neck strength was a strong predictor of concussion, where the weakest in the test group suffered that most concussions and the strongest suffered the least.  Seems like a good reason to perform some simple exercises, right?  Try this one first:

Lying on your back nod your chin while keeping pressure on towel under your head.  Hold for 10 seconds and perform 10 repetitions.  To advance, try to maintain the chin nod while lifting your head ONLY 1 INCH off towel.  Your head should feel very heavy if you are doing it correctly.

Surprised on how difficult the exercise is?  Then you should make it part of your daily routine. 

by Karin Biskovich, MPT                                                        August 30, 2016

You have just thrown out your back, strained your neck, fell on your shoulder, pulled your calf...the list goes on..now what do you do?  Do you go first to the ER, your doctor, chiropractor, or how about your local PHYSICAL THERAPIST? Did you know that you can come directly to your PT before the doctor? We are the experts in all musculoskeletal and can therefore assess your injury and decide what the best course of action is.  Physical therapists are educated with a master’s or clinical doctorate degree and are clinically trained to evaluate, assess, and safely treat injury.  We are also trained to recognize signs and symptoms of conditions that need to be referred to other health care professionals.  

Are you wondering when to come in?  The answer is immediately.  The sooner you come in to PT, the quicker we can get you better.  After the first 2-3 days following an injury, you may start to change the way you move in order to avoid pain.  These movements can then become habit which is difficult to change and can cause pain in a different body part.  Come to physical therapy before you start these bad habits.  

Additionally, there is a new push for doctors to send their patients to physical therapy first, before medication.  The goal is restoration of function versus passive pain relief that causes reliance on pain medication.  Physical therapists can provide pain relief treatment and counseling on how to avoid re-injury or manage chronic symptoms that continue to reappear.  You can read the TIME magazine article about the reliance on opiods for more information.  There will be more discussion on this topic in next week’s blog.

June 28, 2016

Running is just one of those sports that you can pick up at any point in your life.  All it really requires is a new pair of sneakers and usually a goal to finish your first 5k.  There are races every weekend all over the country which inspires people to search for the next goal race. Typically this increases the running mileage and the chance for small injuries to start.  Running is a fantastic way to stay heart healthy and manage your weight so as a PT I want to help people continue with this endeavor and stay injury free.  

There has been a lot of talk about foot strike in recent years.  Do you know how your foot strikes the ground when you run?  The simplest way to find out is to have someone take a video of you running.  Do you land heel first with the front of your foot off the ground?  Or do you land with your whole foot on the ground (midfoot) ?  Or do you land on just the front of the foot with your heel of the ground?  

Most often, people land with their heel first.  I would like to make the case to change from heel strike to midfoot strike to help prevent injury.  Research has shown that heel striking causes an increase in ground reaction force.  What does this mean?  When you land on your heel, your body (ankles, knees, hips) has to absorb more force than if you were to land on your midfoot.  Repeat this with every stride = repetitive stress to your joints.  

Okay so how do you make the change?  Well it has to be VERY gradual and best done over 3-6 month time period (or even longer).  It probably took me over a year to switch.  If you go for a 30 minute run, try to perform 6 intervals of 30 seconds where you consciously try to land with the ball of your foot first.  You are using different muscles so they can get fatigued quickly.  Once this gets easy increase your midfoot strike time by 10% for the next run.  Continue to increase gradually as your muscles get better at performing the new form. 

June 2, 2016

Every day in my job, I am amazed how hard I have to work to teach patients how to engage their glutes properly during a exercise that is focused on hip strengthening (and how to not engage their glutes when doing an exercise that is focused on inner core strength...but that is another topic for another day).  In case you are wondering there are 3 different gluteus muscles, maximus, medius, and minimus.  Gluteus maximus is our power muscle,  It extends the hip and helps us get out of a chair and propels us forward with walking and running.  The gluteus medius is oriented on the side of our body so it is our key stabilizer with standing, walking, and running.  The glute med should be activating when the opposite leg leaves the ground to keep our hips level and reduce lateral strain to the leg that is in contact with the ground.  The gluteus minimus also stabilizes the pelvis and lies underneath the glute med.  These muscles are at the top of the chain of muscles that extend from hip to foot to keep us steady on our feet and also make us faster walkers, runners, hikers, and bikers.  

So what happens when your glutes don’t fire properly or lack strength?  The muscles or connective tissue above or below will have to bear the extra load and over time that can create some big problems.  Or even worse if there is asymmetry in activation or strength in the glutes, it can put some serious strain on that side.  This can lead to trigger points, tendonitis, or overuse injuries.

A few thoughts on how asymmetry can get started.  Do you tend to stand with more weight on one foot or sit with one leg crossed over the other?  Do you tend to have the same leg tucked underneath you when you sit in a chair?  It is in your best interest to break those habits quickly.  Over time that will pull and stretch one side more than the other potentially create weakness or asymmetrical activation.  Of course it won’t trigger pain immediately but slowly and gradually so that these habits don’t seem like the culprit.  

Now to see if your glutes are working properly.  Lie on your stomach and put your hand on one of your glutes.  Squeeze your glute and lift your leg off the floor trying to keep it contracted throughout the whole movement.  How much pressure are you using on the opposite leg to assist?  Or possibly your upper back muscles?  Perform 10-20 repetitions of this exercise a couple times a day to train your brain to fire your glutes properly.  

How about the glute med?  To test this muscle, lie down on your side a couple of inches from the wall with hips stacked and back straight.  Extend your leg so your heel is slightly pressed against wall and try to slide your heel up and down the wall.  Do you feel the outside of your hip working?  That is where you should feel it if you are properly activating your glute med.  Do this exercise 20-30 times a day to train the glute med.  

January 15. 2016

Did you get a Fit Bit for Christmas?  Make sure you mind that buzz it gives you to get up and move if you have been sitting too long.  There is a turn from encouraging everyone to get people more active in their leisure time to a focus on decreasing their time spent sitting.  The reason for this change?  Research has shown that adults, on average, spend more than half their waking hours (9.3 hours/day) in sedentary activities (prolonged sitting in transport, occupations, domestic tasks, and leisure activities). This has negative effects on daily energy expenditure. Total sitting time affects blood glucose control and contributes to overweight, obesity, and chronic diseases.  Interestingly, the research also showed that the light to vigorous physical activity performed in the context of a sedentary lifestyle was not enough to prevent the effects of time spent sitting. 

This research is eye-opening but there are no recommended clinical guidelines for how much of the time spent sitting needs to be eliminated.  That Fit Bit is just a suggestion but it is a place to start.  Try to take 5 minute breaks every hour at work.  Park further away from the grocery store entrance.  Take the stairs instead of the elevator.  Walk to the furthest restroom at work.   Incorporate movement in your day and do it for your health.