After graduating from my physical therapy program I took it for granted that the general public truly knows what physical therapy is. I assumed (first mistake!) most people knew the basics since it is a common and relatively mainstream intervention for injuries...or so I thought. It also seems like most people have sought care from a physical therapist or know someone that has and yet there still seems to be a lot of misinformation out there. Now that I've worked with hundreds of clients and have been talking to many people within my community as I build my practice I have found that there is a huge spectrum of knowledge about what physical therapy is and who it can help as it relates to an outpatient style clinic.
Here are some of my favorite thoughts I've heard over the past several years about physical therapy:
You only work with people after they've had surgery.
It's just a bunch of exercises.
Chiropractors take care of the spine, you do everything else.
You use cool gadgets like ultrasound and electrical stimulation.
I thought physical therapy is hot/cold packs, massage and a couple of exercises.
It's kind of like personal training, right?
This is PT? This is a lot different than I expected!
While there is some truth to a few of these statements, they are pretty amusing if you ask me because there is so much more to physical therapy than these ideas. I especially like the last one.
The most common definition(s) you will see for physical therapists is something along the lines of someone who is licensed to evaluate, treat and/or prevent pain, disability, injury, movement dysfunction, disease and functional limitations using physical, mechanical or chemical means including but not limited to therapeutic exercises, mobilizations and/or manipulations, and modalities (cold/hot packs, ultrasound, electrical stimulation, etc.). The definition I prefer to use is physical therapists are neuromusculoskeletal experts (not to be mistaken with gurus), movement educators and performance enhancers (the legal kind). This means we are specialists in the human body, how it moves and how to address issues like pain, injury, strength deficits, dysfunction, disease progression and performance optimization among many others. No matter what exact definition you use for physical therapy they are very open ended which is great because it means we can work with virtually anyone.
Through our training we have the knowledge to analyze and understand each component of the neuromusculoskeletal system including the brain, spinal cord, nerves, muscles, bones, joints, tendons, ligaments and connective tissues. More importantly, we understand how each of these components interacts with each other to influence and allow the human body to function. In order to address any and all of these components and their impact on the whole system, we have an extremely diverse skill set at our disposal.
To begin with, we perform a thorough physical examination and assessment as it relates to a client's specific situation and complaints. We have a wide variety of tests and measures that reveal valuable information which is interpreted to develop a diagnosis, a treatment plan and a prognosis. As far as treatment is concerned there are several interventions we can choose from in our skill set. The specific mix of interventions will vary from clinician to clinician and from client to client depending on each individual case. They include:
Education: This is quite possibly the most important part of treatment. First and foremost, it is our job to listen so that we know what to teach and explain. It is our job to teach anatomy and physiology, pain science, biomechanics, relaxation techniques...whatever is necessary to help our clients understand their bodies better. It is our job to dispel myths and fears so that the brain and body isn't in a constant state of stress and exacerbating any issues. It is our job to develop a plan and strategies for our clients so that they are able to help themselves and reach their goals.
Manual Therapy: More often than not, physical therapists will be using their hands at some point. It is here that you will see many different philosophies and schools of thought. It is impossible to list all of the manual therapy variations but some of the general categories they would fall under are soft tissue mobilization like trigger point therapy, various styles of massage, active release technique and instrument assisted soft tissue mobilization to name a few, nerve mobilizations, joint mobilizations including chiropractic/thrust manipulations (depending on the state; legal in NY), stretching, and facilitation of movement to retrain motor control and movement quality. How each of these is performed and accomplished will differ from clinician to clinician.
Exercise: This can be broken up into two subgroups even though they overlap quite a bit. The first being neuromuscular re-education which is a fancy way of saying movement retraining. Think balance, control, reaction and technique. Single leg balance is a perfect example of an exercise that would be considered neuromuscular re-education. The second group is therapeutic exercises and functional activities. Traditionally you can think of strength training, flexibility and range of motion exercises fitting into this category as well as activities of daily living like walking, stair climbing and carrying objects. You would obviously need good technique and control in order to accomplish these more traditional types of tasks. With any of these exercises, what sets physical therapy apart is they are prescribed and progressed very specifically to achieve certain goals that can be tested and measured. It is much different than a general fitness plan.
Modalities: This is where the gadgets can be listed like electrical stimulation (my favorite), ultrasound and mechanical traction. It would also include things like heat and cold therapy. In many cases, these passive modalities are used for pain control which is very helpful and a good adjunct to treatment but they will rarely ever resolve the underlying issues. That is what the education, manual therapy and exercise is for. There are other times when modalities are used therapeutically like electrical stimulation to improve activation (and strength) of the quadriceps after knee surgery or cold therapy to reduce swelling and inflammation.
Long story short, physical therapy is an extremely versatile and comprehensive solution to issues related to the neuromusculoskeletal system. You might even consider physical therapists to be jacks of all trades as we have a wide array of skills to choose from in order to help our clients reach their goals.
So if you have neck or back pain, we can take care of you. If you just had surgery, come on in. If you feel like you have balance issues, we've got that covered. If you can't play your favorite sport, we would love to fix that. If you have pain/chronic pain and you can't figure out why, we'll figure out why. I could keep going. As you can see, physical therapy is an excellent first option if you have pain, suffered an injury, have functional limitations, etc. and you want to resolve these issues so that you can move better, feel better and live better.
Knowledge = Power; Share the Power:
This is a follow up to my previous post Patellofemoral Pain Syndrome: What Is It? For the purposes of keeping this discussion on the shorter side I am going to skip the smaller subgroup of people who fall into the category of actual structural factors like a shallow patellar groove or bony abnormalities and focus on the majority of people who have functional deficits that can change with treatment.
In most cases, the knee joint itself is usually healthy and absent any major issues but is sensitive and irritated as a result of deficits elsewhere. Upon examination, these deficits most commonly show up in the hip and/or the ankle. There are occasions where the lumbopelvic complex can play a significant role as well but not as frequently. For these reasons alone it is highly recommended to consult with a physical therapist who will perform a thorough physical exam to decipher which factors are the probable culprits causing the patellofemoral pain.
Going back to 1976, Nicholas et al shed some light on this issue and found that proximal thigh muscle weakness was strongly associated with a variety of lower extremity conditions, particularly with patellofemoral pain. (1) More recently, Peters and Tyson performed a systematic review of the literature addressing proximal (read: hip) interventions and their effectiveness in resolving patellofemoral pain. Based on their review, there is very good evidence suggesting that proximal exercises is an appropriate and effective treatment, especially early on. (2) If you are wondering why this is the case, think of the hip as the foundation of your leg. Weak foundations of any structure leads to all kinds of problems and the same can be said of the hip. By strengthening the muscles of the hip and thigh you provide a solid foundation for the joints below, particularly the knee, to function as they were designed to. Another way to say that is strong hip and thigh muscles are able to control the mechanics of the knee more appropriately which can eliminate whatever was irritating the patellofemoral joint.
Another driving factor can be below the knee at the ankle joint. The foot can as well but that's another topic for another day. To illustrate my point I've attached a video courtesy of Chris Johnson:
As you can see, mobility and range of motion issues at the ankle can have a dramatic effect on knee positioning and mechanics. Imagine if that is what your knee is doing every time you squat, negotiate stairs or get out of your car. My knee(s) (patellofemoral joint) would be pretty cranky too! Last time I checked, the knee is supposed to flex forward and back more than rotate in. It doesn't take a rocket scientist to realize that this situation would completely change the forces and stresses applied through the patellofemoral joint potentially resulting in knee pain. Since I did not work with this individual it is unclear whether the ankle range of motion limitation is due to a loss of joint mobility, calf tightness or both. Again, this is why it is highly recommended to consult with a physical therapist who can figure out the main factors. Either way, by addressing the ankle through mobilizations and/or flexibility work, there is a high probability of resolving issues further up the chain like patellofemoral pain.
At this point you might be saying "well that's great information but what can I actually do about it, Greg?" The following is by no means an exhaustive program but a good starting point for patellofemoral pain:
Hip (Proximal) Strength
There are many good techniques to improve ankle dorsiflexion but this is my go to for two reasons: 1) It works, and 2) You don't necessarily need the compression wrap for it to be effective. For some other ideas and if you have access to wraps or bands, Mike Reinold put together a bunch of them in his aptly titled article Ankle Mobility Exercises To Improve Dorsiflexion.
Steps and stairs make for great calf stretching. In either case, your forefoot is placed on the edge with a slight toe in of about 5 degrees. If your heel is touching the floor, keep your leg straight and lean forward until you feel a strong stretch. If you are using a stair, allow your heel to drop until the same strong stretch is felt. Hold for 60-90 seconds and repeat 3-5 times.
If you've been experiencing anterior knee pain or have even been diagnosed with Patellofemoral Pain Syndrome, these exercises may provide with some relief but consider consulting with a physical therapist who can fine tune your treatment.
1. James A. Nicholas, M.D., Alan Marc Strizak, M.D., George Veras, M.B.A., M.P.A. A study of thigh muscle weakness in different pathological states of the lower extremity. American Journal of Sports Medicine. December 1976, vol. 4, no. 6, 241-248.
2. JS Peters, NL Tyson. Proximal exercises are effective in treating patellofemoral pain syndrome: a systematic review. International Journal of Sports Physical Therapy. 2013 Oct; 8(5): 689-700.
Knowledge = Power; Share the Power:
Dr. Greg Cecere
Your personal physical therapist, movement educator and knowledge dispenser.
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The contents of this blog is meant for educational purposes only. Momentum Physical Therapy of New Paltz and Dr. Greg Cecere are not responsible for any harm or injury that may occur due to any information on this blog as it is by no means a substitute for a thorough evaluation by a medical professional.