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Advanced Injury Treatment Center Blog

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October 2014
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“Choosing your healthcare provider wisely will save you both time and money.”

The rising cost of healthcare has made it increasingly difficult for employers to provide benefit packages for their employees that don’t include high out-of-pocket co-pays and/or deductibles. Self employed individuals may find that it is nearly impossible to afford a low out-of-pocket plan. This rise in costs to the patient is forcing many people who may have injuries or ailments to delay treatment or to completely forego the treatment they may desperately need. As a physical therapist/chiropractor I have witnessed this first-hand in my practice. I commonly see patients who have just reached the point that they can’t withstand the pain or they can no longer do an activity they may enjoy. They have waited until the pain or disability becomes too great to bear. A perfect example of this is a runner who can no longer run. For many running is not only their exercise of choice for the physical benefits but also a form of mental therapy. Let pain take this ability away and you have one very unhappy patient. What if you could seek early treatment to be able to continue the activities you enjoy? What if there was a way to make necessary care less of a financial burden to you the patient?

Now more than ever consumers have to make educated decisions and be their own advocate when it comes to choosing their healthcare provider. If you need services such as physical therapy or chiropractic care and you haven’t done your homework, you could end up spending both time and money you don’t need to. In these tough times when many are struggling financially, patients should seek out care that is both effective and efficient. What many don’t realize is that there are vast differences in treatment approaches amongst different providers which can make all the difference in treatment length and cost of care when it comes to successful resolution of your injury or ailment. You can’t assume that just because providers have the same degree or initials after their name that they are using the same techniques or following the same protocols. This is a very important distinction.

Here are some tips for choosing your healthcare provider:

1. Ask friends and family. There is nothing better than good testimonials from others when making your decision.

2. Check the clinic websites. The website should provide you with the backgrounds of each provider as well as the clinic’s treatment approach.

3. Interview the provider. I am speaking to folks by phone and responding to e-mails prior to seeing them in my office. This is a great way for patients to get preliminary questions answered and get a feel for the provider. If the provider is not willing to do this, I would be concerned.

We at the Advanced Injury Treatment Center located in Bedford, NH ( strive to separate ourselves by providing by the highest level of care in manual medicine and rehabilitation. Our mission is to restore the highest level of function in the shortest period of time saving you both time and money. The treatment is always one-on-one and with the same provider to optimize continuity in care. We are a small, privately-owned clinic whose success is largely based on satisfied patient to patient referrals.

2 Simple Exercises to Help Reduce Your Knee Pain


Brian Looney, DPT, DC, Terry Srokose DC, Joshua Cleland, PT, PhD, Cesar Fernandez-de-las-Penas, PT, PhD

This study conducted at The Advanced Injury Treatment Center was just published in the peer reviewed Journal of Manipulative Physiological Therapeutics.  I would like to thank the above co-authors for all the help.  I couldn’t have done it without them.

Objective: The purpose of this prospective case series was to describe the outcome of a set of patients with plantar
fasciitis treated with Graston Instrument Soft Tissue Mobilization techniques (GT) and a home stretching program.
Methods: Ten patients with a primary report of plantar heel pain completed self-report questionnaires including the
Global Rating of Change Scale (GRC), the Numeric Pain Rating Scale, and the Lower Extremity Functional Scale.
Patients were treated with GT directed to the triceps surae, soleus, plantar fascia, and medial calcaneal tubercle.
Participants received a maximum of 8 treatments over a time frame ranging from 3 to 8 weeks at a frequency of 1 to 2
sessions per week. Each patient was instructed to perform the stretching program at home 3 times daily. Patients
completed all outcome measures at baseline, sixth visit (GRC), and at discharge or the eighth visit. The number of
successful outcomes on the GRC was examined using a binomial test. Dependent t tests were used to examine if a
significant difference existed in secondary outcome measures of pain and function.
Results: The subjects had a mean duration of symptoms of 32.4 weeks (SD, 31.1). Patients were treated for
an average of 6.9 visits (SD, 1.3). There was a statistically significant difference between the number of patients
who did and did not achieve a successful outcome (P = .047). There was also a significant improvement
from baseline to follow-up for the Numeric Pain Rating Scale (P = .002) and Lower Extremity Functional
Scale (P = .017).
Conclusions: The group of patients selected for this case series who were treated with GT and home stretching
experienced clinically meaningful improvement. (J Manipulative Physiol Ther 2011;34:138-142)
Key Indexing Terms: Plantar Fasciitis; Physical Therapy; Pain

Should Endurance Athletes Strength Train?

Strength training for endurance athletes continues to this day to be a hot topic of a debate. This question may pose vast differences of opinion depending on whom you ask. I personally feel that it is a critical part of any endurance athlete’s training program. The intention of this blog is to present a research-based perspective to allow you, the runner, to make an informed decision as to whether or not it is right for you.

In order to understand the benefit of strength training for the distance runner you must recognize the physiological demands that running places on the body. Unlike most sports, which require strength, speed, and power to be successful, distance running is primarily limited by the delivery and use of oxygen. This then brings us to the question: “Does strength training actually help increase endurance?” Currently there are no studies showing that strength training actually increases oxygen delivery from lungs to muscles. However, the way that strength training can make you faster is by improving your running economy. This means by increasing your muscular strength you will also increase your muscular power, which is the product of force (strength) and speed. The key to a runner’s strength training is to get his/her muscles to increase their rate of force production so that they can have stronger muscle contractions in a shorter time.

Current research supports that power training and plyometric exercises are most effective for enhancing economy and endurance performance by increasing muscle power production. This means that runners should be strength training like football players. Heavy weight training focuses on the strength component of power, and plyometrics training focuses on the speed component. The result is you will be stronger, quicker, and more powerful, translating into better running economy.

The bottom line is, if you have already increased your running volume and intensity as much as you can, or cannot handle the physical stress of more miles, strength training and plyometrics can help get you to that next level. If you are planning on adding strength training to your program, be sure to focus on high-intensity, low-repetition exercises. Examples include squats, hamstring curls, calf raises, power cleans, and dead lifts. Also, use specific periods of the year to focus on endurance training or strength, speed, and power.

The Advanced Injury Treatment Center in Bedford, NH specializes in the diagnosis and treatment of soft tissue injuries. We are also certified strength and conditioning specialists (CSCS). We utilize techniques such as Active Release Technique, considered to be the gold standard of soft tissue management systems, as well as Graston Technique, to break up scar tissue and enhance your recovery time from an injury. Advanced Injury Treatment Center can also assist in strength and conditioning program design, based on the needs and demands of your specific sport.

Treating Common Low Back Pain

Low back pain is one of the most common conditions I see in our office on a daily basis.  This is not shocking considering it plagues over 80% of the population at some point in their lives.  A significant contributing factor is the large number of people who work in a prolonged flexed position while sitting at the computer.  The human body is designed for movement and not for sitting at a desk for 8 hours a day.  This chronic posture creates muscular imbalances (such as tight hamstrings and hip flexors), decreases joint range of motion (limited hip extension), and ultimately increases mechanical stress on the structures of the lumbar spine.  Unless someone is regularly stretching and exercising to counteract this postural stress, their back does not function favorably when they turn into “weekend warriors” or just picking up a laundry basket for that matter!

At the Advanced Injury Treatment Center in Bedford, NH, we evaluate all contributing factors to a patient’s back pain.  That may entail excessive hamstring tightness, poor foot mechanics, or weak gluteal muscles to name a few.  Long-term relief of back pain requires a treatment plan that addresses all of an individual patient’s biomechanical faults.  Treatment may consist of Graston Technique or Active Release Technique to lengthen chronically tight soft-tissue, joint manipulation to restore joint mobility, and exercise prescriptions to strengthen weak/inhibited muscles.  Low back pain can be resolved but it takes a thorough treatment plan and a motivated patient.  Like I tell every patient, “if I see you back here in 3 months with the same symptoms, what have we really accomplished?”

Avoid Backpack Back Pain

As kids return to school this fall it is a great time evaluate what is on their backs.  Improper use of backpacks can be a major contributor to back pain in school-aged children, but following a few guidelines can significantly reduce the risks.

The weight of the pack and its contents should not exceed 10% of the child’s body weight.  Excessive weight causes the child to compensate their posture to carry the load.  This creates increased mechanical stress on the spine which can lead to muscle spasm, disc compression, joint irritation and ultimately pain.  Some studies have also shown that as little as 20% of body weight can begin to cause changes in a child’s breathing.  If the weight of your child’s pack cannot be reduced to a safe range than you should strongly consider a pack with waist belt.

Second to the actual weight is proper wear and fit of the pack.  Slinging a pack over one shoulder completely defeats the purpose of an ergonomically designed backpack.  The shoulder straps should be tightened so that the pack is snug to the child’s back as this will help evenly distribute the load and keep the contents from shifting.  Also, always place the heaviest items in the pack closest to the child’s back and lighter ones on the outside.  

If your child is still experiencing pain or discomfort after making these changes than they should be evaluated to rule out an underlying spinal disorder.  The Advanced Injury Treatment Center in Bedford, NH specializes in the diagnosis and conservative treatment of back and neck pain.

Why your tendonitis doesn’t get better!

Tendonitis is one of the more common conditions that I treat and some of the most difficult to resolve. I am lumping the following conditions under this heading, Lateral Epicondylitis (Tennis Elbow), Achilles Tendonitis, Medial Epicondylitis (Golfer’s Elbow) Plantar Fasciitis (Heel Pain), Patella Tendonitis (Jumper’s Knee), Illiotibial Tendonitis (Runner’s Knee). The plain and simple truth as to why these conditions take so long to heal is the fact they aren’t tendonitis. When people finally decide to seek treatment for that nagging pain they are way beyond “itis” and now an “osis”. This means the condition has progressed beyond the inflammatory phase and into a fibrotic state. The problem lies in the fact that tendons are generally avascular in nature which means they get no blood supply which results in very poor ability to heal.

Traditional treatments include steroid injections, NSAIDs, and physical therapy modalities such as ultrasound and iontophoresis revolve around reducing inflammation. Is it no surprise that these treatments generally don’t work? You are being treated for something that doesn’t exist! So the question is how we get blood supply to this area that is now fibrotic “scar tissue” and start the process of healing. The answer to this question is Graston Technique combined with eccentric exercises. Graston Technique is a highly affective soft tissue treatment which utilizes stainless steel tools to break up scar tissue. It works on a tendonosis by initiating inflammation and therefore stimulating the healing process. Eccentric exercises focus on the lowering end of the movement or “negative” to load the tissue and aid in proper remodeling of the tissue. These two treatments combined makes for highly successful treatment outcomes with time and do diligence.

The Advanced Injury Treatment Center is the only clinic in the Southern NH area offering this form treatment. If you are currently in treatment and getting limited results, or waiting for the pain to just go away, call us and set up an appointment. Our mission is to provide the highest quality of care and get you back to activities you enjoy in the shortest time possible!

Mechanism and Prevention of Common Shoulder Injuries due to Resistive Training.

Mechanism and Prevention of Common
Shoulder Injuries due to Resistance Training

The shoulder is one of the most complicated joints in the human body and this unfortunately makes it very prone to injury during resistance training. Some basic background of anatomy, physiology, and biomechanics of the region can go a long way in preventing injuries. This knowledge will help you understand the “Risk/Reward” ratio that is inherent in all forms of exercise. By this I mean that we want to place a specific and controlled stress on targeted tissues while minimizing excessive strain on other areas. I find that too often certain exercises are performed which greatly increase risk of injury when safer alternatives are available.

So what is a rotator cuff anyway? Many people envision it as an actual cuff of ligaments but it is 4 small muscles that stabilize the shoulder joint. The supraspinatus, infraspinatus, teres minor, and subscapularis lie deep to the much larger deltoid. Imbalance of the primary movers (pec/deltoid) and underlying stabilizers (rotator cuff) ultimately leads to impingement syndrome, anterior instability, and tendinopathy of the rotator cuff muscles.

What you can do
- Never perform lat pull-downs behind the neck!!
- Work rotator cuff/scapular stabilizers at least once a week
- Limit range of motion with chest press and fly
- Maintain proper posture and scapular retraction with upper body exercises
- Posterior capsule and chest stretches
- Consider alternatives for exercises that put shoulder at high risk

Upright Row Reverse Fly, Shrugs, Cable Pull (D2)
Close-Grip Straight Bar Bench Dumbbell Bench
Military Press High-Incline Dumbbell Press
Dips Any Tricep Exercise
Front Raise Thumb-Up Front Raise

Just following a few of these suggestions can go a long way in preventing unnecessary shoulder injuries. However, if you do find yourself experiencing shoulder pain then I strongly recommend an evaluation with an AITC health care professional located in Bedford, NH. We can properly diagnose your problem and then make appropriate treatment/rehab suggestions to get you back in action.

Why physical therapy and chiropractic treatment programs often fail.

Why do physical therapy and chiropractic treatment programs often fail? The answer to this question is simple “scar tissue”. Traditional physical therapy programs often jump right into stretches and strengthening exercises without first addressing the tissue dysfunction. This is putting the cart before the horse. You can not stretch and strengthen dysfunctional tissue and expect anything less than failure. The chiropractic algorithm is to “adjust” the joints to reduce joint restriction or free nerve interference depending on what camp you come from. The problem with this approach is that this is only helpful if the problem is true “joint dysfunction”, which in my experience is very rarely the case.

Scar tissue forms mostly in muscles, tendons, ligaments, fascia and joints. These dead fibrotic tissues can also be called adhesions. Scar tissue is formed from sustained muscle contraction (posture), repeated contraction (repetitive motion), a traumatic event (muscle strain) or secondary to surgical procedures. All of these mechanisms reduce blood flow to the tissue resulting in “hypoxia” or lack of oxygen. The body produces free radicals secondary to hypoxia which results in the production of tough, dense scar tissue in the affected area. This scar tissue binds up and ties down tissues that need to move freely. As scar tissue builds up, muscles become shorter and weaker, tension on tendons can cause tendonitis, and nerves can become trapped. This can cause reduced range of motion, loss of strength, and ultimately pain. If a nerve is trapped by this fibrotic tissue you may also feel tingling, numbness, and weakness.

So the question is what to do about scar tissue. There are two treatment approaches that are highly effective in the reduction of scar tissue. The first is a manual approach called “Active Release Technique”. I have found ART to be extremely effective especially with deeper structures. ART uses active motion with sustained pressure to break up scar tissue. The second approach is instrument assisted soft tissue mobilization such as Sound Assisted or Graston Technique. These techniques utilize specifically designed tools which are often easier on the therapist and can be more effective on superficial structures.

The Advanced Injury Treatment Center in Bedford NH is the only clinic in the greater Manchester area that utilizes both of these highly effective treatment techniques. If you have had limited success in the past or are currently in treatment and not progressing, we can help. You no longer have to “just live it.”

Sports Injuries Nonsteriodal anti-inflammatory medication NSAIDS: Why I don’t recommend them!

The unfortunate reality of society today is most people want immediate gratification and usually look for that quick fix. This is witnessed in all aspect aspects of life from weight loss to financial success to where I see it most personal healthcare. We are so quick to reach for that bottle of advil when we have an ache/pain, but do we really know how this is affecting our body. Set aside the approximately 18,000 deaths a year secondary to the use of NSAIDS from gastrointestinal complications, what most don’t know is these drugs have a significant negative impact on our body’s ability to heal following an injury.

The fact that NSAIDS actually delay and hamper the healing of all soft tissues including muscle, ligaments, tendons, and cartilage is overwhelming supported in numerous studies. In one study on muscle strains, a popular NSAID essentially wiped the entire inflammatory proliferative phase of healing (days 0-4). At day two there were essentially no macrophages (cells that clean up the area) in the area and by day four after a muscle strain, there was very little regeneration as compared to the normal healing process. The muscle strength at this time was about 40 percent of normal. Another study confirmed that at day 28 after an injury the muscle regeneration was still delayed.

The key question regarding the healing of sports injuries is what therapy speeds up the healing time by increasing fibroblastic cells (cells that lay down new tissue). The current literature supports a treatment called Graston Technique. Graston Technique is a treatment used to break down scar tissue and initiate healing by increasing fibroblastic proliferation. I have personally seen some amazing outcomes with even in the toughest of cases such as a chronic tendonosis. There are five certified practitioners in state of NH, two of which work out of The Advanced Injury Treatment Center in Bedford, NH. I personally have been using this technique for approximately 6 years and find it to be incredibly effective for resolving soft tissue dysfunction.

I hope this blog sheds some light on what not to do when you suffer an injury. Remember the next time that you go for the bottle of Advil that it will ultimately slow down the healing process and delay your return to activity. I would also recommend being evaluated by a healthcare professional if symptoms persist. Our goal at the Advanced Injury Treatment Center is to get you back to activity in the shortest amount of and enjoying the lifestyle you deserve!