It’s All Connected!

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Have you ever been to see a Physical Therapist with complaints of low back pain and they are watching you walk or talking to you about your foot?  Have you ever questioned (to yourself or out loud!) why they are discussing your knee movement or hip strength when you came in because you can’t sleep because of back pain?  Have you ever wondered what is going through their minds?  I am here to tell you –

It’s all connected! There are two bones, the tibia and fibula, that run between the ankle and the knee.  As we age, all bones become stronger and less flexible.  By the time we are adults, the bones have very little “give” or movement in them.  So, any movement that occurs through the ankle is transferred through these bones up to the knee.

Helping to move the foot and knee through daily activity are several muscles.  Many of these muscles start just below the knee and cross the ankle joint to insert into the foot.  These are the muscles that help your foot move up, down, and side to side.  The big muscles in your calf even cross above the knee joint!

On top of all this you have fascia.

Have you ever tried to pull fat off a raw steak?  You know that silvery white stuff that firmly holds the fat onto the steak – THAT is fascia!

The fascia is what holds everything together under our skin. There is fascia throughout our body and there are thick sheets of fascia that help to keep the lower leg connected – to each other and to the rest of the body.

Moving on up the leg, we have the largest and strongest bone in our bodies – the femur!  The weird thing about the femur is that it has a ball at one end and a straight edge at the other end.  Also, it doesn’t run completely up and down.  Instead, it runs at an angle which makes the hips wider than the knees.  So, any force that is coming up through the ankles and into the knees has to take a turn before it heads into the hips.  This has the potential to be a turn for the worse!

Between the hip and the knee we find many big, strapping muscles – the quadriceps (in the front) and the hamstrings (in the back).  These big muscles help to get the hip and knee moving which allows the foot to be in the optimum position to walk, jump, run, or play.  If these muscles are having any problems then the foot has difficulty connecting to the ground.  The reverse is also true – if the foot has any restriction that limits motion then the knee/hip will not receive the required motion they need.  The problem that starts in one area can easily lead up (or down) the chain!

Remember that fascia?  Well, along the outside of our leg we have the largest single piece of fascia in our bodies – the iliotibial band (or ITB for short).  The ITB is a thick, fibrous band that starts from the gluteus medius on the side of the hip and inserts into the fibular head.  The ITB directly transfers force from the lateral hip into the knee joint – and vice versa!  This band can particularly be a problem for women as our hips are wider than our knees.  Pro tip – pain in the ITB may be due to weakness in the gluteus medius!

Moving up the chain and headed towards the low back, we cross the pelvis. The pelvis is made of 3 bones.  One ilium on each side and a sacrum in the middle.  The spinal column stacks up onto the sacrum.  So, the 5 lumbar vertebrae stack up onto the sacrum which is attached to an ilium on either side.

What holds all that together? There are muscles that help to connect the lumbar spine to the sacrum, the ilium, and the femur.  There are muscles to connect the ilium and the sacrum (this is often called your pelvic floor).  And, of course, the silvery/white fascia helps to hold all these bones, muscles, tendons, and ligaments together.

Now, I don’t mean to get controversial here but I am just going to say it – the ilium move on the sacrum!  If that makes sense to you – HOORAY!  This is a huge discussion among health care practitioners that has received endless debate.  You see, the ilium and sacrum are connected by very thick, fibrous ligaments that allow for very little movement in the pelvis.  This helps to provide stability for the pelvis while you are performing daily activities.  However, too much movement can be a big problem.

Back to our foot-low back connection.  If your foot doesn’t interact with the ground the way it should, this can cause an immediate pain (as in our example of stepping off the curb above) or cause a wearing of the joints over time in your low back.  If you challenge your muscles to work harder by walking in the sand, this can actually improve the muscle control through the foot that decreases the stress on the joints in your low back.

As you can see, the bio-mechanics through our legs are complicated. Each bone, muscle, and joint interacts with other bones, muscles, and joints to allow us to move through our environments.  This is why your body deserves a full, comprehensive evaluation of the pain or dysfunction you are experiencing.  And why Physical Therapists look at your foot, knee, hip, and pelvis while talking about your low back pain.

Hip pain – it’s not just for “old” people anymore!

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Let’s admit it – we expect pain as we age!

When we are young, our bodies seem to be able to get away with anything. We can run, jump, play, fall off our bikes, jump on a trampoline, and basically run ourselves ragged without any further complications. We go to bed and wake up feeling fine the next morning – and we run out to do it again! This is the joy of youth.

However, what happens when our young ones start complaining of a pain that will not go away? We take them to the doctor to start figuring out what is wrong and how we can help them.

In the case of hip pain, long term pain that does not go away with rest can often lead to a consultation with an orthopedic surgeon. The surgeon will often have X-rays or an MRI taken to assess how the bones inside the hip look. In the past 10 years, this has led to a new diagnoses or CAM or PINCER hip morphology. This means that there is a bony abnormality that is causing the hip to “pinch”, which is what brings about the pain in younger people as they tend to be more active. Of course, if the problem is a bone issue, surgery is what is recommended to fix it.

This increase in hip surgery in our younger population has become extremely concerning to myself and many other Physical Therapists. That is why there are now studies assessing hip strength, hip motion, and how the hip moves while also looking at the bony structure of both hip joints.

A recent study in the Journal of Orthopaedic and Sports Physical Therapy (JOSPT) was looking at that specific issue. The study assessed sub-elite football (soccer) players for pain, motion, strength, and motion analysis. They also took an X-ray to see what each hip actually looked like.

What they found was that the hip structure looked the same on X-ray between the painful hip and the pain free hip. Both of the hips had the same structure but only one hip had pain! Both the hips had the same bony changes that would be classified as needing surgery. However, sub-elite athletes were able to continue their sport and only have pain in one hip. Where they did see a difference between hips was in how the person was walking and the muscles they used while jumping.

This study shows that your hip pain may not be caused by how your bones look on X-ray. The pain may be caused by how your muscles are functioning while you walk, work, and play. Therefore, I strongly urge you to consider visiting a Physical Therapist to see if changing how you move through space can change your hip pain. It may help you to avoid surgery and the painful recovery that follows. Plus, you may be able to get back to your sport, your work, or your life more quickly!

Sub-elite Football Players with Hip-Related Groin Pain and Positive Flexion, Adduction, and Internal Rotation Test Exhibit Distinct Biomechanical Differences Compared with Asymptomatic Side. JOSPT: 48(7):584-593.

Hip Osteoarthritis – The Latest Clinical Practice Guideline

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Physical Therapy utilizes art and science to create a specific program for restoration of each patient’s physical function. Later blog articles will focus on the ART while this article is focusing on the SCIENCE. Physical Therapists are passionate about finding, confirming, and using optimal treatment strategies for their patients. We are greatly indebted to the researchers who dedicate their lives to helping us in that pursuit.

The Journal of Orthopaedic and Sports Physical Therapy (JOSPT) is one of my “go to” journals for good, sound research. In June 2017 they published a new Clinical Practice Guideline for Hip Osteoarthritis. What does that mean for you, the person living with hip osteoarthritis? That means that a bunch of really smart people combed through all the research and made recommendations for people like me to use when helping the most important people involved – our patients! And, here is what they said…

How do we diagnose Hip Osteoarthritis? Adults over the age of 50 with moderate anterior or lateral hip pain during weight-bearing activities, morning stiffness less than 1 hour duration after waking, hip internal rotation (IR) range of motion less than 24 degrees or IR and flexion 15 degrees less than non-painful side, and/or increased hip pain associated with passive hip internal rotation. What is hip internal rotation? Lie on your back with one knee and same hip bent to 90 degrees. While maintaining this hip and knee position, try to bring your foot out to the side. Compare the motion to the other side.

What tests and measures should be included in the evaluation? You should be assessed for physical function measures, balance performance/risk of falls assessment, active range of motion for the hip, and muscle strength.

How should we treat Hip Osteoarthritis? Manual therapy should be used to improve hip mobility. This should be followed up with flexibility, strengthening, and endurance exercises to address impairments in hip range of motion, specific muscle weakness, and limited muscle flexibility. Patients should receive education on activity modification, exercise, weight reduction when overweight, and methods of unloading the arthritic joints. Bracing should be used as a last resort if these forms of treatment are not effective.

If you have any questions regarding these recommendations, please feel free to contact us here at Physical Therapy for Everybody – amykonvalinpt@gmail.com or (360)367-0970.

If you would like to read the complete article:
http://www.jospt.org/doi/full/10.2519/jospt.2017.0301

Chronic Pain Review

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Thank you for walking with me through this blog series on chronic pain. I hope you have found it useful in discerning the optimum path for your health and wellness. This post is a general review of what we have covered.

Chronic pain includes pain that has not resolved in a normal, timely manner. In general, it is pain that lasts longer than 3-6 months although we have seen that it is actually a change in the pain state. Chronic pain is mediated through changes in the peripheral and central nervous systems. This means that the tissue injury model of acute pain no longer applies. Acute pain is directly related to a trauma to the tissue and has a normal progression of resolution. This can be greatly aided by Physical Therapy to prevent it from coming back or to address any related issues. For instance, I have had patients who successfully treated an acute injury with a steroid injection only to have the pain come back 6-12 months later. That is often due to the fact that the comorbidities surrounding the initial injury were never addressed. However, chronic pain that has been sustained for a long period of time is no longer related to a specific tissue injury. That injury was the trigger that set into motion a change in the nervous system that needs to be addressed in a new way.

Chronic pain must be addressed at multiple levels simultaneously. I have had patients who “try” one form of therapy at a time to see what works and what doesn’t. Although I agree with this scientific approach for acute pain, it does not stand up to the current understanding of chronic pain. A scientific approach for chronic pain is to add one treatment at a time. I have begun working with other health care professionals in the area to maximize outcomes for patients. When I work with a chiropractor, I focus on the exercise portion of treatment to improve the patient’s ability to “hold” manipulations and decrease their need for adjustments. When I work with a massage therapist, I focus on joint mobilization to ensure proper tissue length and exercise for patients to maintain the benefits of massage. Although I feel medications in general are over prescribed, I help assist medical doctors in ascertaining the benefits of prescribed medication to the treatment plan being carried out in Physical Therapy.

Chronic pain truly takes a village that is focused together on the goals of each patient. Every body responds differently to an intervention and this needs to be constantly reassessed. This is why I opened my company in the first place. To give each patient one-on-one access to one provider so they can be followed through a successful treatment regimen. The input I receive from each patient directly influences the treatment they receive that day. Education is always emphasized and I encourage my patients to ask as many questions as they can.

If I can be part of your team, please feel free to contact me at (360) 367-0970 or amykonvalinpt@gmail.com.

Maple Valley Physical Therapy

Complex Regional Pain Syndrome

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(formerly known as Reflex Sympathetic Dystrophy)

Complex Regional Pain Syndrome (CRPS) occurs after a trauma to the distal part of the extremity or after direct injury to the nerve. CRPS is associated with distal extremity pain and swelling, with the pain being disproportionate in time and degree to the injury. Patients may also have increased blood flow and swelling, abnormal hair/nail growth, loss of motion, and weakness. This is a classic example of what happens with chronic pain. The initiating event led to a sensitization of the nervous system that is now causing abnormal reactions throughout the limb.

Before we talk about Physical Therapy treatment, let me state that this is one particular case where pharmacological approaches have been well researched and proven extremely effective. Systemically administered antidepressants and anticonvulsants or topical use of capsaicin and lidocaine have been proven to significantly reduce symptoms of CRPS. I have had patients who are frustrated by being placed on an antidepressant because they feel the doctor is saying their pain isn’t “real”. However, the truth is that the antidepressants affect the processing of the pain through the nervous system and have been shown to significantly decrease symptoms. I would strongly recommend that patients discuss all pharmacological options with their doctors so they can find a path that works right for them.

Okay, back to the Physical Therapy stuff! CRPS is a challenging disease that makes slow progress no matter the treatment option. A graded exercise program to return each patient to their desired activity level has proven effective for long term management of CRPS. Along with this, instruction in home TENS use and performance of mirror therapy has proven to be effective in treating CRPS. The goal is to support each patient with pain reduction and making positive steps towards improving range of motion and strength so they can return to their lives.

If I can help you on your path, please feel free to contact Amy at (360)367-0970 or amykonvalinpt@gmail.com.

Physical Therapy in Maple Valley

Neck Pain

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Neck pain typically comes in two flavors – Whiplash Associated Disorder (WAD) and nontraumatic neck pain. There are many types of treatment for neck pain both within the physical therapy realm and outside of PT. Which makes the research confusing and difficult to interpret!

For instance, the book I am using for this blog series is titled “Mechanisms and Management of Pain for the Physical Therapist”. In the “Neck Pain” Chapter, the author states that “early results from trials of cervical disc arthroplasty for radicular symptoms seem to show similar early symptomatic improvement when compared with anterior discectomy and fusion surgery”. In my personal experience, I have had one patient who had a cervical disc arthroplasty who had extremely poor results. So, is the research not really far enough along to recommend this surgery as the new “gold standard”? Or did my patient just have poor surgical results? These questions are difficult to discern and I am trying to hold out on passing judgement on cervical disc replacement. From a biomechanical perspective, replacing the disc allows for maintenance of normal motion which is GOOD. This is opposed to fusion surgery which disturbs normal motion which is BAD. However, all my patients who have had fusion surgery report GOOD results after the surgery. Now, to be fair, they almost all require future surgeries later in life as the body compensates for the decreased motion from the fusion – which is BAD.

Patients who have been in a motor vehicle accident and suffer from WAD tend to do better if they receive early intervention that consists of manual therapy, exercise, and education. Patients who have higher levels of pain and dysfunction tend to require longer treatment times. Therefore, beginning treatment for the problem earlier most likely decreases long term dysfunction and improves outcomes.

Nontraumatic neck pain also responds well to intervention consisting of manual therapy, exercise, and education. However, since there is not an “event” that started the neck pain, these patients tend to wait longer to start treatment. This increases the likelihood of the pain transitioning into a chronic pain situation which then involves abnormal processing through the central and peripheral nervous systems.

What’s the take away here? If you have neck pain of unknown origin or from a car accident, take conservative measure for the first few days. Move your neck gently through pain free motion. Use ice to decrease pain. Limit activities that cause pain but keep exercising as usual if at all possible. If your symptoms do not resolve with the first 4-7 days, it is time to contact a medical professional to get to the root of the problem.

If you have any questions regarding your neck pain, please feel free to contact Amy at (360)367-0970 or amykonvalinpt@gmail.com.

Low Back Pain

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Dear Friends,

I cannot believe that I find myself writing a blog about low back pain. The interweb is FULL of blog articles about low back pain. Some are very informative/helpful and some are just personal stories or what worked for one person. See, that is the struggle with low back pain – everyone has a story about it and something that worked for them – but may not work for you!

Yes, I realize that low back pain affects 85% of people at some point during their lifetime. Yes, I realize that LBP is the leading cause of chronic pain and disability with a financial cost in the billions of dollars annually. Yes, I realize that some people have had great outcomes from Chiropractic, from pain medication, from inversion tables, from traction. But, can I just be honest for a couple of minutes here? First, let’s agree that we are only talking about nonspecific low back pain – pain that is not attributed directly to a structure in your low back. So, we aren’t going to discuss your grandma’s spinal stenosis. That is a specific cause of low back pain and is treated in a much different way! Okay, back on topic here. I have seen too many patients during my career who have had negative results from chiropractors, medication, inversion tables, and traction. In fact, a Cochrane review of 32 studies clearly shows that traction is not effective for acute, subacute, or chronic low back pain. We can talk about inversion tables if you want to – I have a great story of a patient who I fired from therapy for using an inversion table. I am not saying that inversion tables do not work for some people – it does! But, you have to know what you are dealing with before using an inversion table.

What has been substantially proven in the research and what have I learned is effective treatment for low back pain that significantly resolves the issue and decreases re-occurrence? Manual therapy (hands on treatment), trunk coordination and strengthening and endurance exercises, centralization and directional preference exercises, patient education and counseling, and progressive endurance exercise and fitness activities. Which basically boils down to hands on treatment to decrease pain and normalize movement followed by progression to an independent exercise program. That is what we offer at Physical Therapy for EveryBODY. The research proves that it works, my clinical experience tells me it works, and my patients show me it works.

So, can we please not discuss how your friend had amazing results after spending $5000 on a traction regimen at the Chiropractors office? Many thanks!

TMJ (Pain in your Jaw!) & Headaches

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Temporomandibular disorders (TMD) involve pain and dysfunction around the TMJ (your jaw) and jaw muscles. The National Instititue of Dental and Craniofacial Research performed a 3 year study to identify biopsychosocial and genetic risk factors in the development of TMD. Potential risk factors for first-onset TMD were identified with older age, African American, pain on jaw opening and palpation tenderness of head and neck muscles, increased incidence of other regional pain conditions including low back pain and irritable bowel syndrome, other nonspecific comorbid conditions including fibromyalgia and depression, and lower overall quality of life and health status. Systematic reviews have repeatedly supported instruction in a self-management strategy including education, resting during pain, relaxation techniques, massage, hot and/or cold packs, and stretching and/or exercise. Did you know there were exercises for your jaw? Yes, there are! Use of medication and splints has not been found in the literature to be effective in decreasing pain and dysfunction from TMD. Conservative treatment with a home program has the best results found in multiple systematic reviews.

Now, headaches are a bit more complicated tale to tell because there are different types of headaches with different findings in the research. Migraines are primarily managed with pharmacological agents. Physical therapy can be beneficial if included with relaxation and biofeedback treatments. Cluster type headaches are very rare and, therefore, there is little research on the effectiveness of physical therapy with this diagnosis. Tension-type headaches are effectively treated with physical therapy which involves education regarding posture and biomechanics, an exercise program aimed at improving posture of the cervical spine, and manual therapy to reduce muscle tension.

Seventeen years of clinical experience tells me that tension type headaches respond really well to physical therapy. Migraine intensity, duration, and frequency can be dramatically altered with physical therapy. The one cluster type headache patient I saw had a significant decrease in intensity and frequency of his headaches.

If you would like to discuss your TMD or headache symptoms, please feel free to contact Amy at (360)367-0970 or amykonvalinpt@gmail.com.

Myofascial Pain & Fibromyalgia Syndrome

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Myofascial pain has been estimated to be the source of pain in 85% of patients attending a pain center. Fibromyalgia affects 4-12% of the population. Both of these are rather “new” diagnoses in our medical system and there has been a great deal of research done recently. Let’s dive into understanding WHAT these diagnoses mean and HOW they should be treated.

Myofascial pain is a local or regional pain syndrome occurring in one or two body regions. Travell (guru type person in my world) has defined the following diagnostic criteria:

1. Palpable taut band in muscle

2. Exquisite spot tenderness of a nodule in the taut band

3. Pressure on the nodule should reproduce patient’s current pain complaint

4. Restricted motion due to pain


Myofascial pain syndrome responds very well to Physical Therapy including manual therapy, exercise, and transcutaneous electrical nerve stimulation (TENS). There is some evidence to demonstrate that outcomes may be improved with use of trigger point injections (performed by an MD) before Physical Therapy.

Fibromyalgia is diagnosed as at least 3 months of widespread pain occurring in each quarter of the body. People with fibromyalgia literally hurt everywhere! Further, people with fibromyalgia commonly present with sleep disorders, fatigue, depression, and irritable bowel syndrome. (Remember, if you aren’t sleeping, you aren’t healing!) Little is known about fibromyalgia, but it is generally accepted to be a disorder of central pain amplification. This causes normally pain free input to be perceived as painful. So, there is enhanced excitability in central pain transmission pathways and loss of pain inhibition. What can be done?

Fibromyalgia treatment requires a multidisciplinary approach involving pharmacological management, psychological treatments, and physical therapy combined for best outcomes. Physical therapy emphasizes an active protocol aimed primarily at an appropriate aerobic conditioning program. There is also moderate evidence for implementing a strengthening home exercise program to decrease pain as well as increasing global well-being.

If you would like more information on either of these diagnoses, please feel free to contact Amy at (360) 367-0970 or amykonvalinpt@gmail.com.

Manual Therapy

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Manual Therapy is the art of knowing what tissue needs to be moved in which direction combined with the science behind the biomechanics of the body. Manual therapy may include soft tissue mobilization, joint mobilizations, joint manipulations, and teaching self-mobilization exercises. But it also includes the knowledge of WHICH tissues to move to obtain optimum results. Manual therapy, or hands on treatment, is the backbone of Physical Therapy for EveryBODY because of the research supporting the long term effects on pain inhibition.

Soft tissue mobilization has been shown to decrease the expression of inflammatory genes and increase the expression of genes involved in healing. In animal models, soft tissue mobilization has been shown to increase oxytocin (happy, happy, joy, joy) in the plasma. Don’t you want to volunteer for those studies?!

Joint mobilization and manipulation has been shown to increase pain thresholds, improve muscle activation, decrease muscle tension, increase pain free motion, and affect the chemicals that float around your brain and make you feel good. Any way you slice it, getting those joints moving right is good, good stuff.

Teaching self-mobilization exercises is important so YOU can continue your treatment at home. 1) You get the benefits on your body as noted above and 2) YOU become empowered to help control your pain.

In all honesty, after 17 years as a Physical Therapist and obtaining my PhD in Orthopedic Manual Physical Therapy it all comes down to this – empowering YOU to manage your pain through education regarding self-treatment and appropriate exercise leads to the best long term results. If you are interested in finding out more, please feel free to contact Amy at (360)367-0970 or amykonvalinpt@gmail.com.