Snow Shoveling 101

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Snowpocalypse hit the Pacific Northwest and left behind snow, sleet, hail, slush, and ice.  Last I heard, the groundhog was awaiting extradition from the Bahamas for his poor forecast this year.  As we move forward to finally getting out of the house, here are some key tips to remember while you are shoveling all that snow.

#1 – Use the shovel to push the snow – Walk with the shovel in front of you to push the snow out of your way.  Kind of like your very own snow plow.  This puts the snow in a nice pile ready to be lifted.

#2 – Bend your knees – do a squat to pick up the snow with the shovel.  Bend your knees and keep your back straight.  This is critical when the snow is heavy as it is now.  Make sure you have two hands on the shovel to distribute the weight.

#3 – Pivot your feet – when you are getting ready to throw the snow make sure you pivot your feet.  This allows your back to stay in a neutral position.  Twisting of the spine with a weighted load (like snow!) is the most common cause of injury to the low back.

#4 – Make sure to breathe – keep your breathing regular.  Holding your breath while you are lifting increases the pressure on your back.  Breathing also helps to improve your endurance.

#5 – Take a break – we’ve gotten a lot of snow this year and clearing it away will take some time.  Make sure you take regular breaks to head inside, warm up, and drink some water.

Snow shoveling is a great workout when you can’t get to the gym, yoga studio, or Crossfit box.  If you need more of a workout, offer to clear your neighbor’s driveway too!  Be careful with your body if you are not used to performing heavy lifting or endurance type activities.  Give yourself lots of breaks and keep an even pace.

If you have any questions regarding proper snow shoveling technique or if you hurt yourself in the snow, please reach out to us at PT4EB.

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So, you have a herniated disc

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There are few things in life as painful as a herniated disc.  But it’s not just the pain that is difficult to deal with – it’s also the fear.  What is going on in my spine and am I going to live?  That may sound extreme but herniated discs are extreme.  They can cause extreme fear, extreme panic, extreme frustration, and extreme pain.

The first time I herniated my disc was in college.  I was in Air Force ROTC (don’t ask, long story) and we were doing physical training.  All of a sudden, I felt a ball of glass explode in my lower right spine.  Okay, I know that a ball of glass didn’t explode in my spine but that is absolutely what it felt like.

Of course, training must go on so I got up and went for a 3 mile run.  Each step caused a mini explosion of the glass shards in my right spine.  And I was one of the lucky ones.  My pain never touched my sciatic nerve and went down into my leg.

For many people, the disc herniates and then it irritates the nerves in the area.  The nerves are located close to the spine and right next to the disc.  When the disc herniates, the material inside the disc leaves the fibers of the disc and is hanging out right next to the disc.  This can cause increased pressure on the nerve which responds by sending pain down into your leg.

What are your initial steps when you have a herniated disc?

  1.  Breathe – Easy for me to say when the glass shards aren’t flying around my spine, right?  I know.  But it’s really important to breathe slow and steady.  Holding your breath increases the pressure on your spine which is not what you want right now.  I now it is incredibly painful right now but I promise it’s going to get better.
  2. Grab an ice pack and your favorite chair, floor, or bed.  You need to rest for the first 24-48 hours.  Find a comfortable position (as comfortable as possible) and an ice pack.  You might want to grab some magazines or the remote control.  You are going to be there for a day or two.
  3. Small movements matter. During the first 24-48 hours it is important to keep the area moving in small PAIN FREE ways.  This can mean trying to stand up straight while you walk to and from the bathroom.  Rolling your shoulders to get some movement in your upper spine.  Sitting and rotating your spine from side to side.  Don’t go crazy right now but keep those small movements.
  4. Get help. Once you can walk to and from the bathroom pain free you are ready to get some help.  A Physical Therapist will help you get back to moving pain free.  Yes, you will get back to all those activities you loved doing before.

Yes, the pain will go away.

Yes, we can help you figure out your path on this journey of healing.  Please fill out this simple form and we can get you started healing and back to living life on your terms.

Why more people are choosing to pay cash to eliminate their pain

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We are all familiar with the usual course of treatment when we are dealing with an injury or chronic
pain. First, we go see our Primary Care Physician (PCP) who recommends pain medication and muscle
relaxers. We take those for 4-6 weeks and go back to the PCP when the pain is not any better. The PCP
then orders an X-ray which doesn’t show anything and we are referred to a specialist. It takes a couple
of weeks to get in to see the specialist. Meanwhile, the pain medication is not eliminating the pain and
is upsetting our stomachs. The specialist recommends either surgery or avoiding the activities that
cause pain. This is the assembly line of the modern medical system that leaves many people feeling
frustrated or hopeless.

Did you know that you could bypass this system?

In Washington State, you can see a Physical Therapist directly to deal with your pain issues. You do not
need a prescription. You may even be able to go in for a free consultation to get all your questions
answered and see if PT is right for you.

Don’t I need an MRI?

What if you could avoid the cost, hassle, and exposure of having an MRI? Research has proven that
what shows up on MRI’s is often not correlated to what is causing your pain. Often the pain is caused by
a movement dysfunction that an MRI cannot see. Physical therapists are experts on movement
dysfunctions. They are able to “see” areas that are not moving correctly and help to get them moving
pain free.

How do I know if Physical Therapy will even work?

Often the art and science of Physical Therapy does work, it is the mode of delivery that doesn’t work.
Traditional PT’s in an insurance based model are forced to see more patients in less time. They are
compensated for using things like ultrasound, E-stim, and ice/heat. In this system, the insurance
companies decide how much treatment you get instead of you and your therapist deciding on the best
plan for you. Insurance companies often dictate the schedule you are seen on which may not be the
optimum for your body or for your lifestyle. Having 2-3 PT treatments per week can be a strain on your
already busy schedule.

All of this restraint has caused Physical Therapy to get a bad reputation.

What other options are available to you if you don’t want to take medication, you don’t want surgery, or
you have had a bad experience with Physical Therapy before? You can take matter into your own hands
and pay out of pocket for an experience that is custom tailored to your unique needs.

You want me to pay for Physical Therapy?

Yep.

Here’s why – people will see a chiropractor, massage therapist, and personal trainer in an effort to
manage their pain and move forward with their lives. Physical Therapists are specialist in movement
disorders and have training to move stuck joints, release tight muscles, and teach you specific exercises
to help your body heal. We will also offer you loads of education on how to keep yourself healthy and
pain free in the future.

Here’s how – at PT4EB we spend more time with you. Most sessions are one hour. You are given our
complete attention for that one hour. We usually only see people once per week for 6 sessions and
then we spread sessions out. Often people require a total of 10-12 sessions. During and after your
treatment, we can check in over E-mail if you have any questions. Traditional PT clinics blow through
your 12 visits in 4-6 weeks. This is long enough to get you feeling better but not long enough to make
real changes in your body. The real changes you need for long term results. This costs you more in the
long run as the problem comes back.

Since the insurance companies do not decide on your course of treatment, we are able to spread your
visits out. We are able to give you undivided attention. You have time to get all your questions
answered. You have complete access to us both during and after your treatment for any questions that
come up.

Many times sessions can be paid for by submitting your claims to your insurance company. Please let us
know and we will provide you with a superbill – the paperwork needed to submit your claims. We also
accept Flexible Spending Accounts (FSA) and Health Savings Accounts (HSA)

People often come to our clinic as a “last resort” after exhausting their other options. They refuse to
have surgery which is the only medical option provided to them. People are tired of taking medication
because they realize that it only masks the symptoms. They are frustrated, disheartened, and
sometimes depressed over their lack of activity. The biggest question I hear is – how come I didn’t find
you earlier?

Are you curious if this model is right for you?

If you are local to the Maple Valley area, please feel free to give us a call. We are happy to answer all
your questions or have you come in for a free Discovery Visit to see if we are a good fit for your needs.
Please click here to fill out a brief contact form (link to contact form).
If you are not local please feel free to give us a call. We have a network of other providers throughout
the US that we can connect you with who hold these same values.

Your health is at least worth a conversation, right?

Traveling to Kenya

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I recently returned from a two week teaching trip in Kenya. I volunteer with a program that teaches Physiotherapists in Kenya hands on skills and clinical problem solving.

So, what was I doing there? This trip I was able to go into the clinic with the Physiotherapists and treat patients. This is a great opportunity for the wheels to hit the pavement with everything the students have learned in class. And, it gives us a chance to really check out their skills in a clinical environment.

Many people have asked me why I travel so far away to help a group of people that I had no direct connection with before I started traveling there. I have boiled it down to two reasons.

Reason #1 I travel to Kenya to teach – I WAS ASKED!

About 5 years ago, this program had a teacher drop out at the last minute. They threw the net wide trying to find someone who could go to Kenya for two weeks at the last minute. I happened to be transitioning to a new job and could take the time off work. So I volunteered.

How many times in our lives are we stuck, frustrated, overwhelmed, in pain, unsure of how to move forward in a situation? And, how many times do we ask for help? Our society prides itself on being independent and not needing help from anyone else. But, a beautiful thing happens when we open ourselves up to help from others. Not only are we blessed with their assistance, they are blessed to assist us.

I encourage you to think about any situations where you feel stuck and may need to ask for help. It may be in preparing for the holidays, it may be in getting through the holidays, or it may be a need you have had for a while. Find the person that can unstick you!

Reason #2 – I AM UNIQUELY QUALIFIED TO SERVE

The program I teach with requires an OCS or FAAOMPT. I have both. I also have my PhD which is kind of like an advanced teaching certificate. There are very few people who have all three of these qualifications so I fit their unique profile of instructors.

I enjoy traveling – especially when I get to meet new people. I lived in Germany for 3 years with the US Air Force and I realized that I LOVE to travel. But, I prefer it when I get to meet the local people and spend time with them. The trip becomes way more meaningful when you are able to break bread and have true discussion.

I love being a Physical Therapist and want to see the quality of PT improved worldwide. I believe that Physical Therapists offer a unique perspective as movement specialists. We understand how things are supposed to move and what can happen to the body when things aren’t moving correctly. PT’s are qualified to work on joints, muscles, ligaments, fascia -the entire body.

I am uniquely suited with these aspects of my personality and education to serve the Physiotherapists of Kenya. You are uniquely suited with aspects of your personality and education to serve a certain group of people. It may be your neighbors, it may be at the school your child attends, it may be at the home where your parent is living because they are no longer safe alone. Your people are out there and they need you.

I encourage you to take some time to think about all the people you serve in your life. And, think if there is anyone else you might be uniquely gifted to serve.

 

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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.