Is Your Pain Getting Better?

The primary reason individuals end up in physical therapy is because they are experiencing pain, with the most common cases being back pain, neck pain, knee pain, foot/ankle pain, and shoulder pain. Subsequently, the main goal in physical therapy is to reduce or eliminate pain in order to help the individual get back to normal activities (think walking, lifting, reaching, squatting, running, etc.). Evaluating whether or not pain is improving can be challenging for some individuals going through physical therapy, especially if they are new to the process. Physical therapists will often hear about the difficulty in the self-assessment of pain due to the inherent subjectivity of the experience. This is understandable, as pain is a subjective experience! With that said, there are several metrics within the study of pain that can be helpful to consider when attempting to assess how effectively your pain-relief strategies are working:

• Pain Severity

  • This is a measure of how much your pain hurts, typically taken on a 0 to 10 scale in most clinics. A rating of “0” is easy to understand, as this is the complete absence of pain, while a rating of “10” is much more subject to interpretation. In general, we describe 10 out of 10 pain as a medical emergency, wherein you are experiencing so much pain that your only course of action is to rush to the emergency room. A common example I offer up is, “Imagine you were just bitten by a shark. That is 10 out of 10 pain.” Whatever your pain level may be, tracking pain severity is a well-established way to measure your progress. I typically encourage people to pick three activities that are important to them and track the pain severity they experience while performing these activities over the course of 6-8 weeks. If the numbers go down, then you can confidently say your pain is getting better.

• Pain Frequency

  • This is a measure of how often you experience pain in a given time-frame (hourly, daily, weekly, etc.). This can be thought about very simply as intermittent versus constant. Or, if symptoms are intermittent from the start, you can either estimate how many times per day do you experience pain or what percentage of the day you experience pain. If the pain you are experiencing was initially constant and now is intermittent, that is a sign of progress. If the intermittent pain you are experiencing goes from occurring approximately 50% of the day to 25% of the day, that is a sign of progress.

• Pain Irritability

  • This is a measure of how easy it is to trigger the pain you have been experiencing. For example, if you experience pain with prolonged standing, how long you can stand for before you notice pain gives us a general sense of how irritable your symptoms are. Being able to stand for only 10 minutes before the onset of pain as opposed to being able to stand for 60 minutes before the onset of pain would indicate GREATER pain irritability. This could also be applied to more intense activities, such as running: being able to run for 30 minutes before the onset of pain as opposed to being able to run for 2 minutes before the onset of pain would indicate LESSER pain irritability. Therefore, if you are able to perform the painful activity for greater amount of time or at a higher intensity before you experience the onset of pain, you can safely assume that you are likely getting better.

• Pain Duration

  • This is a measure of how long the pain lasts when you experience it related to a particular activity. When triggered, does the pain last for seconds? Minutes? Hours? Days? A decrease in pain duration is indicative that your condition is improving, as it will have a lesser negative impact on your day-to-day life. For example, if I was experiencing pain for 2-3 days every time grocery shopping, but now I only experience pain for 2-3 hours after grocery shopping, I can definitely say my pain duration has decreased, which is a sign of progress.

These are just a few of the metrics you can use in order to track your progress in physical therapy, or when recovering independently from an injury. Keep in mind, most injuries will heal with time and do not require fancy tests or treatments. Patient, understanding, and persistence are the keys to getting back to full strength.

-Grant Hennington, DPT

GUEST BLOG: How To Cope With Dark Winter Days

Even as our days begin to lengthen it's important to continue with good self-care habits for the winter blues, seasonal affective disorder, and/or other mood changes related to longer nights. 

I'm in Seattle, and here in the northwest, we are blessed with a beautiful environment. But, in the winter months, it is one that gets less light than most places. Couple those short days with persistent clouds and drizzles and we have a recipe for some seasonal mood/stress challenges. (*Note: If you're not in the Pacific Northwest these tips are still just as relevant for you too.) You've probably heard of seasonal affective disorder. If not, a quick internet search will give you plenty of information. With or without that formal diagnosis, there are some helpful tips for all Pacific Northwesterners to help us survive and thrive in our darker season.

• Consider using a supplement with Vitamin D, and consult with a medical professional about any questions. Links have been shown between low Vitamin D (which can be caused by low sun exposure) and depression-like symptoms/feelings. 

• Get sunlight soon after waking - real or artificial. Your body and brain need sunlight. That's the problem in the PNW, as sunlight becomes a scarce commodity in the winter months. Consider getting a sunlamp and using that for 15-30 minutes each morning soon after waking up. If there is a sunny moment or day you can also try to maximize your exposure by taking a few short walks outside. It'll do the body good. 

• Exercise regularly - to help your energy level try and get at least 30 minutes of some cardiovascular exercise each day. Move the body when feeling sluggish even for 5 minutes. A regular body movement routine is crucial to good mind-body health in the winter. 

• Finally, after doing what you can to support your health with the darker season also practice acceptance of the pull to slow down. Embrace the cozy. The winter season is a time where it is OK to pull back from a busy schedule. Do things that are stimulating, fun, and/or give a sense of achievement. It can really be helpful to find ways to not fight the darker and rainier days. Do what you can (with the above recommendations), but also accept what is.

-Dr. Trevor Davis, PsyD, ABPP

Diagnostic Imaging: X-ray vs. CT scan vs. MRI

More than likely you’ve either had diagnostic imaging taken or have heard of X-rays, MRIs, and/or CT scans. These tests are great tools that provide medical professionals more insight and knowledge into the human body, allowing them to make more accurate diagnoses and choose the ideal treatment plan. Although all of these tools are used for diagnostic imaging, each one uses different techniques, providing varying levels of detail.

X-ray

X-rays are one of, if not the fastest and most accessible, forms of diagnostic imaging, commonly used as a first-line tool. It creates a 2D image by sending radiation through the body. How does this work? Dense areas of higher level of calcium (bones) block the radiation, leaving the image to appear white or transparent, while soft tissues (muscle, tendons, ligaments, etc.) allow the radiation to pass through and appear darkened, black, or grey. In some cases an X-ray may also look at internal structures with the use of barium sulfate, or dye, to make organs stand out more clearly. Although X-rays are great for seeing larger injuries to the bones, they don’t give a clear picture of more subtle injuries to bones or soft tissues.

Most commonly used for:

• Fractures

• Dislocations

• Bone disease or degeneration

• Pneumonia

• Cancers and tumors

Computed Tomography Scan

A Computed Tomography scan, or CT scan, is yet another fast option for receiving diagnostic imaging, utilizing radiation and occasionally dye just like an X-ray. However, instead of providing a simplistic image, a CT scan provides a 3D image, giving a detailed computerized 360 degree view of bones, blood vessels, soft tissues, and organs. This makes a CT scan ideal for injuries related to trauma or in emergency situations. 

Most commonly used for:

• Trauma

• Musculoskeletal disorders

• Heart disease

• Cancers

• Appendicitis

• Infectious diseases

Magnetic Resonance Imaging

Magnetic Resonance Imaging, also known as an MRI, utilizes a powerful magnet and radio waves instead of radiation like X-rays and CT scans, creating highly detailed 3D cross section images, providing views of soft tissue, nerves, and blood vessels. An MRI can also give better contrast resolution for bones and soft tissues when compared to other diagnostic imaging. Due to the use of a powerful magnet some patients will not be able to have an MRI completed if they have metal implants, pacemakers, or other implanted devices.

Most commonly used for:

• Injuries to ligaments, tendons, muscles (Meniscus, ACL, Achilles, Sprains/strains) 

• Cartilage damage

• Joint injuries

• Spinal injuries

• Brain injuries

Questions? Please contact the author, Brian Collins, DPT at brian@salmonbaypt.com.

Golf & Shoulder Pain

Shoulder injuries are common among golfers. The shoulder is an incredibly mobile joint that lacks a lot of inherent stability and is exposed to significant forces during the golf swing. When a shoulder is moving properly and has sufficient strength, there generally is not a problem during the golf swing. Conversely, if there is a deficit in shoulder mobility or strength in a golfer, there is a good chance of eventually experiencing some shoulder pain while golfing. Here are some ways to check your own shoulder for rotational mobility:

INTERNAL ROTATION

Reach your arm behind your back: how high can you reach your thumb? Is it between your shoulder blades? Those with good mobility will reach to the level of T9 (the 9th thoracic vertebra) or higher, which roughly equates to bra strap level, or near the bottom corner of the shoulder blade. If your motion only makes it to the region of your low back or hip, that is a sign of reduced internal rotation mobility, with the most likely culprit being a stiff posterior capsule.

The shoulder capsule is a set of ligaments that blend together to form sort of a protective shell surrounding the “ball and socket” part of the joint. Anatomically, the socket isn’t particularly deep, allowing for more mobility, but at the cost of less stability. This is why the capsule is important, as it provides some joint stability while still allowing it to move through a large range of motion. When part of the capsule becomes stiff, it can adversely affect the mechanics of the joint, potentially leading to pain. This could manifest at the site of restriction itself or in other areas.

To stretch the posterior capsule of your shoulder, try the “sleeper stretch”. To stretch your right shoulder, lie on your right side with your elbow raised to shoulder level. Then take your left hand, grasp your right wrist, and guide the right arm to rotate downward toward your feet. Hold for 30 seconds. Click on the link below for a photo and further instruction of the sleeper stretch:

Sleeper Stretch

If the sleeper stretch is painful to perform, an alternative exercise to similarly improve shoulder mobility is the cross-body shoulder adduction stretch. The key to this stretch is that it should be felt behind the shoulder, without any pinching or sharp pain experienced in the front of the shoulder. 

Cross-Body Shoulder Adduction Stretch

EXTERNAL ROTATION

To check external rotation of your shoulder, raise your hand up to a “high five” position. Can you do this without pain? When you look at your forearm in this position, ideally it would be vertical, indicating roughly 90 degrees of shoulder external rotation. Some can rotate beyond 90 degrees, which is okay for most people. But remember, excessive mobility can come at the cost of stability. In other words, those with more mobility may need to compensate with additional strength surrounding the joint in order to ensure pain-free shoulder function. External rotation stiffness may be capsular or muscular, and there are some simple ways to stretch both.

Shoulder External Rotation Stretches

It can be helpful to remember that ideal shoulder function involves balancing both mobility and stability. If either of those are compromised, it could affect not only your ability to golf without pain, but also result in pain with day-to-day activities.

-Matt Kooy, DPT

Golf & Low Back Pain

Does your low back hurt at the end of your round? Does it hurt with every swing? Do you have low back issues that prevent you from playing at all? Over 80% of adults experience an episode of low back pain in their lifetime, with low back pain being a major cause of disability across the globe. The low back is the leading site of injury in golfers and could have any number of causes: irritated disks, facet joints, muscles, ligaments, etc. While there are many potential causes for low back pain, it is often helpful to look at the low back’s neighbors (the hips and thoracic spine) for mobility restrictions that might relate to the painful tissues in the low back.  

HIPS

The hips are highly mobile joints and hip mobility is critically important for the golfer during both the backswing and follow through. For a right handed player, the right hip internally rotates on the backswing and externally rotates on the follow through. Conversely, the left hip externally rotates on the backswing and internally rotates on the follow through. For left handed players, it’s the reverse. For many individuals (especially those with aging hips), there is usually more of a limitation with internal rotation compared to external rotation. While there are some stance modifications that may help while playing golf, such as increasing the amount of “toe out” at address, a better approach may be to identify where you are stiff and improve your baseline mobility in order to improve not only your golf game, but potentially day-to-day activities as well. 

THORACIC SPINE 

The spine is divided into three sections: the cervical spine (neck), thoracic spine (mid-back), and lumbar spine (low back). There are some distinct anatomical differences in each section and the shape of the bones and their connections can affect how far they are able to move in a particular direction. The neck moves well in all directions. The thoracic spine is mobile with rotation, but not as mobile with side bending or backward bending. The lumbar spine is mobile with forward & backward bending, but less mobile with rotation. It’s more important that the lumbar spine provide a stable foundation around which to swing, than to provide the rotational motion itself.

Since rotation is such a critical component of the golf swing, it is important to maximize the available rotation from the hips and thoracic spine so that we don’t place too much rotational demand onto the lumbar spine. If the hips and thoracic spine won’t fully rotate, the body might make up for it at the lumbar spine, an area without much rotation to give. See the exercises below to work on improving your hip and thoracic mobility and hopefully your golf game at the same time.

Hip & Thoracic Spine Mobility Routine For Golfers

-Matt Kooy, DPT