PHYSICAL THERAPIST'S GUIDE TO BALANCE PROBLEMS

Balance problems make it difficult for people to maintain stable and upright positions when standing, walking, and even sitting. Older people are at a higher risk of having balance problems; 75% of Americans older than 70 years are diagnosed as having "abnormal" balance. Older women are more likely than older men to develop balance problems, although the difference between the genders is small. Balance problems increase by almost 30% in people aged 80 years or more. Mexican-Americans have the highest rate of balance problems among all Americans. Physical therapists develop individualized physical activity plans to help improve the strength, stability, and mobility of people with balance problems.

What are Balance Problems?

A balance problem exists when an individual has difficulty maintaining a stable and upright position. A range of factors can cause balance problems, including:

• Muscle weakness
• Joint stiffness
• Inner ear problems
• Certain medications (such as those prescribed for depression and high blood pressure)
• Lack of activity or a sedentary lifestyle
• Simple aging

Balance problems can also be caused by medical conditions, such as:

• Stroke
• Parkinson’s disease
• Multiple sclerosis
• Brain injury
• Arthritis
• Spinal cord injury
• Cognitive diseases
• Diabetes

Balance problems occur when 1 or more of 4 systems in the body are not working properly:

• Vision
• Inner ear
• Muscular system
• Awareness of one's own body position (called “proprioception”)

Poor vision can result from age, eye tracking problems, or eye diseases. Inner ear problems, also called vestibular problems, can develop from trauma, aging, poor nutrition, or disease. Body-position sense can become abnormal as a result of trauma or a disease, such as diabetes. Muscle strength and flexibility can decline due to lack of exercise, a sedentary lifestyle, or disease.

The brain coordinates impulses from the eye, inner ear, and body-position senses, and sends signals to the muscular system to move or make adjustments to maintain balance. If one or more of the senses is not sending correct signals to the brain, or if the muscular system cannot carry out the necessary movements, a person may not be able to maintain or correct their balance.

How Does it Feel?

A person with balance problems may experience tripping, swaying, stumbling, dizziness, vertigo, and falling. Although a person’s "static" balance may be fine when standing still or only performing a single task at a time, “dynamic” balance problems may become apparent when the person is moving about or trying to do more than 1 thing at a time (ie, walking, while turning the head to talk to another person), or when there is not much light (at night, or in a darkened room). If someone’s dynamic balance is abnormal, it can cause a fall and possible injury.

Balance problems can make a person fearful of performing simple daily activities. As a result, they may lose muscle strength and become frail because they avoid strenuous or challenging movements. A person who has balance problems may start to feel frustration about the condition, and become depressed.

How Is It Diagnosed?

If you see your physical therapist first, the physical therapist will conduct a thorough evaluation that includes taking your health history. Your physical therapist will also ask you detailed questions about your condition, such as:

• How often do you experience problems with your balance?
• What are you doing when you experience balance problems?
• Is your balance worse at nighttime or in dark rooms?
• Does the room spin, or do you feel off-balance?
• How many times have you fallen in the past year?
• Have you suffered injuries from falling?
• Have you changed or limited your daily activities because of your balance problems?
• What medications do you take?
• Have you had a vision or ear checkup recently?
• Do you have difficulty with any daily activities?
• How much, and what kind of daily exercise do you get?
• Do you have any other medical conditions or problems?
• Are you under the care of a physician?
• What are your goals?

Your physical therapist will perform tests, such as motion, strength, coordination, visual tracking, and balance tests, to help assess your overall physical ability. Your physical therapist may collaborate with your physician or other health care providers, who may order further tests to rule out any underlying conditions that may exist.

How Can a Physical Therapist Help?

Physical therapists offer numerous options for treating balance problems, based on each person’s needs. They are trained to evaluate multiple systems of the body, including the muscles, joints, inner ear, eye tracking ability, skin sensation, and position awareness in the joints (proprioception). Physical therapists are experts in prescribing active movement techniques and physical exercise to improve these systems, including strengthening, stretching, proprioception exercises, visual tracking, and inner ear retraining. 

Your physical therapist can help treat your balance problems by identifying their causes, and designing an individual treatment program to address your specific needs, including exercises you can do at home. Your physical therapist can help you:

Reduce Fall Risk. Your physical therapist will assess problem footwear and hazards in your home that increase your risk of balance problems or falling. Household hazards include loose rugs, poor lighting, unrestrained pets, or other possible obstacles.

Reduce Fear of Falling. By addressing specific problems that are found during the examination, your physical therapist will help you regain confidence in your balance and your ability to move freely, and perform daily activities. As you build confidence in your balance and physical ability, you will be better able to enjoy your normal daily activities.

Improve Mobility. Your physical therapist will help you regain the ability to move around with more ease, coordination, and confidence. Your physical therapist will develop an individualized treatment and exercise program to gradually build your strength and movement skills.

Improve Balance. Your physical therapist will teach you exercises for both static balance (sitting or standing still) and dynamic balance (keeping your balance while moving). Your physical therapist will progressively increase these exercises as your skills improve.

Improve Strength. Your physical therapist will teach you exercises to address muscle weakness, or to improve your overall muscle strength. Strengthening muscles in the trunk, hip, and stomach (ie, “core”) can be especially helpful in improving balance. Various forms of weight training can be performed with exercise bands, which help avoid joint stress.

Improve Movement. Your physical therapist will choose specific activities and treatments to help restore normal movement in any of your joints that are stiff. These might begin with "passive" motions that the physical therapist performs for you, and progress to active exercises that you do yourself.

Improve Flexibility and Posture. Your physical therapist will determine if any of your major muscles are tight, and teach you how to gently stretch them. The physical therapist will also assess your posture, and teach you exercises to improve your ability to maintain proper posture. Good posture can improve your balance.

Increase Activity Levels. Your physical therapist will discuss activity goals with you, and design an exercise program to address your individual needs and goals. Your physical therapist will help you reach those goals in the safest, fastest, and most effective way possible.

Once your treatment course is completed, your physical therapist may recommend that you transition to a community group to continue your balance exercises, and maintain a fall-proof home environment. Many such community groups exist, hosted by hospitals, senior centers, or volunteer groups.

Your physical therapist may recommend that you consult with other medical providers, including:

• An eye doctor, to check your current vision needs.
• An ear doctor, to check your outer and inner ear status.
• Your personal physician, to review your current medications to see if any of them may be affecting your balance.

Can this Injury or Condition be Prevented?

To help prevent balance problems, your physical therapist will likely advise you to:

• Keep moving. Avoid a sedentary lifestyle. Perform a challenging physical activity each day to keep your muscles strong and flexible, and your heart and lungs strong. Use your body as much as you can to walk, climb stairs, garden, wash dishes by hand, and other daily activities that keep you moving. If you work out or follow a fitness program, keep it up!
• Have yearly checkups for vision and hearing. Make sure your vision prescription is up-to-date.
• Carefully manage chronic diseases like diabetes, whose long-term side effects can include balance problems. These side effects can be greatly reduced by following the recommended diet and medication guidelines given to you by your physician.
• Monitor your medications. Make note of any medications that you think may be affecting your sense of balance, and talk to your physician about them.
• Report any falls to your physician and physical therapist immediately. They will evaluate and address the possible causes.

Your physical therapist will also prescribe a home exercise program specific to your needs to prevent future problems or injuries. This program can include strength and flexibility exercises, posture retraining, eye-tracking and vestibular exercises, and balance exercises.

Real Life Experiences

Margaret is a 70-year-old retiree. She and her husband have lived in the same house for 30 years. Margaret is as active around the house as ever, taking care of all the household cleaning and maintenance, growing vegetables in her garden, cooking, and tackling light landscaping.

One night recently, Margaret tried to close the bathroom window when it turned chilly outside. She didn't bother to switch on the bathroom light. In order to reach the window, she had to step into the tub with her right foot. She found that she had to push harder on the stubborn window, and lifted her left leg to place it in the tub. The next thing she recalled was explosive pain in her ribs. She realized that she was on her side, sprawled half in and half out of the tub. She did not recall falling. Her husband got her to the doctor.

Margaret's doctor x-rayed her ribs, shoulder, and toe, and found no broken bones. He instructed Margaret on how to care for her many bruises. He bandaged a torn toenail on her right foot, and told Margaret that she would not be able to wear a closed-toe shoe for awhile.

When her doctor asked Margaret if she had fallen before, she admitted that she had lost her balance while going upstairs recently. She admitted that she felt more off-balance in the dark. Margaret also mentioned that she and her husband attended ballroom dancing sessions each week, and joked that she never could learn to “spot a turn.” The physician, knowing that the dancer technique of “spotting a turn” requires inner ear and vision function, recommended that Margaret consult with her eye doctor, and her physical therapist.

Margaret met with her eye doctor and got her vision prescription updated; she noted that she felt somewhat more balanced with proper eyeglasses. She then met with her physical therapist.

Margaret's physical therapist took her medical history and performed a full battery of tests, assessing Margaret's muscle strength, balance, body-position sense (proprioception), eye-tracking ability, and inner ear (vestibular) function.

She noted Margaret's bruises from her fall. In addition, she found that Margaret lacked the ability to keep her eyes focused on an object while turning her head, and that her balance was severely affected when her eyes were closed. She asked what Margaret's personal goals were for therapy; Margaret said she wanted to avoid falling, return to her normal vigorous household activities, and attend her ballroom dance sessions 3 times per week.

Margaret's treatment began with simple eye-tracking exercises, and moved on to standing and walking balance exercises. Her physical therapist then added specific strengthening exercises to the routine. She also performed hands-on therapy, somewhat like massage, to increase the healing speed of the shoulder and rib muscles that were bruised and strained. She also applied electrical stimulation and cold packs to those areas to reduce swelling and pain.

Margaret continued her physical therapy sessions for 4 weeks, increasing her exercises as her strength returned. She learned about fall-proofing her home, including installing night lights in the bathrooms, and about wearing proper footwear.

At the end of her treatment program, Margaret was able to return to all her household tasks, and maintain a home-based exercise program designed by her physical therapist. She reported that she felt much more confident about maintaining her balance, even at night. She and her husband returned to ballroom dancing—and she was able to gently “spot a turn” for the first time in her life!

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat balance problems. However, you may want to consider:

• A physical therapist who is experienced in treating people with balance or vestibular problems. Some physical therapists have a practice with a balance or vestibular focus.
• A physical therapist who is a board-certified clinical specialist, or who completed special training in vestibular physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

• Get recommendations from family and friends or from other health care providers.
• When you contact a physical therapy clinic for an appointment, ask about the physical therapist’s experience in helping people who have your type of problem.
• During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

TIPS FOR CAREGIVERS

For those of you who have loved ones living with or near you that you help on a daily basis, or for those of you who are medically trained caregivers, THIS IS FOR YOU. Caregivers have a significantly larger risk of injury that do most professions, and a larger incidence of stress-related medical complications, such as high blood pressure and cardiac dysrhythmias. We, here at Champion, understand the physical and emotional toll your job has on you - and we, with the help of the APTA, are here to help. Below is a link provided by the APTA to help people like you thrive in your career. 

http://www.moveforwardpt.com/PatientResources/VideoLibrary/detail/caregivers-caregiver-safety-tips 

Description: 

Lisa Leach, PT, DPT, demonstrates techniques to keep caregivers and those that they care for safe in a variety of environments.

For more information, please visit us at kcchampionperformance.com 

ALZHEIMER'S DISEASE + PHYSICAL THERAPY

US population estimates indicate that 5 percent of people over age 65—about 5.2 million—and more than 40 percent of people over the age of 85 have Alzheimer's disease. Along with memory loss and other cognitive problems, people with Alzheimer's disease may have difficulty performing simple tasks of daily living. Physical therapists partner with families and caregivers to help people with Alzheimer's disease keep moving safely and delay worsening of the condition.

What Is Alzheimer's Disease?

Alzheimer's disease is a progressive condition that damages brain cells and affects how we speak, think, and interact with other people. It's the most common cause of dementia, a group of brain disorders that cause a decline in memory and the ability to perform daily activities. And it's the fifth leading cause of death among adults over age 65 in the United States, after heart disease, cancer, stroke, accidents, and respiratory disease.

The risk of getting Alzheimer's disease increases with age; it's rare to get it before age 60. Having a relative with Alzheimer's disease raises your risk of getting it, but most people with the disease do not have a family history of it.

One of the major symptoms of Alzheimer's disease is confusion. There are several other potential causes of confusion, some of which may be reversible if discovered early:

• If confusion comes on suddenly, schedule a visit with a physician or a neurologist immediately.
• If confusion occurs or gets worse after a fall or a head injury, immediately call 911 or emergency medical services (EMS) so that an ambulance can be sent.

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Signs and Symptoms

There are 10 important warning signs of possible Alzheimer's disease:

• Memory changes that disrupt daily life
• Difficulty making decisions, especially in planning or solving problems
• Difficulty completing familiar tasks
• Confusion about time and or place
• Trouble understanding visual images or the way things physically fit together (spatial relationships)
• Finding the right words to say when speaking or writing
• Misplacing items and losing the ability to retrace your steps
• Poor or decreased judgment about safety
• Withdrawal from work or social activities
• Changes in mood or personality

People with Alzheimer's disease also may get lost in once-familiar places. In the later stages of the disease, they might get restless and wander, especially in the late afternoon and evening (this is called "sundowning"). They may withdraw from their family and friends or see or hear things that are not really there. They may falsely believe that others are lying, cheating, or trying to harm them.

Along with these "cognitive" symptoms, people with Alzheimer's disease may develop difficulty performing simple tasks of daily living in the later stages of the disease. Eventually, they may need assistance with feeding, bathing, toileting, and dressing. The physical ability to walk is usually retained until the very last stage of the disease; however, due to confusion and safety concerns, people with Alzheimer's disease may need supervision or an assistive device to help them get around safely.

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How Is It Diagnosed?

The exact cause of Alzheimer's disease remains unknown and is most probably due to many factors, which makes diagnosis difficult. Researchers are getting closer to making a diagnosis by using brain imaging studies such as computed tomography scan, magnetic resonance imaging (MRI), positron emission tomography (PET) scan, or ultrasound. These tests can show abnormalities in brain structure or function. Mental function tests, cerebral spinal fluid tap, biomarkers, and genetic testing also can be used to help make a diagnosis. But a definitive diagnosis can be made only on autopsy.

Your physical therapists may play an integral role in recognizing early signs or symptoms of this disease. If they recognize you or your loved one is exhibiting signs or symptoms consistent with Alzheimer’s, they will make an appropriate referral to the necessary specialist.

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How Can a Physical Therapist Help?

For people with Alzheimer's disease, research shows that:

• Physical activity can improve memory.
• Regular exercise may delay the onset of dementia and Alzheimer's disease.
• Regular exercise may delay the decline in ability to perform activities of daily living in people who have Alzheimer's disease.

As the movement experts, physical therapists can design exercise programs for people with a variety of health conditions, including Alzheimer's disease.

In the early and middle stages of Alzheimer's disease, physical therapists focus on keeping people mobile and help them continue to perform their roles in the home and in the community. In the later stages of the disease, physical therapists can help people keep doing their daily activities for as long as possible, which reduces the burden on family members and caregivers. Physical therapists also can instruct caregivers and family in how to improve safety and manage the needs of a loved one with Alzheimer's disease. Physical therapy can help improve quality of life and possibly delay the need for institutionalization.

People with Alzheimer's disease develop other conditions related to aging, such as arthritis, falls, or broken bones. Physical therapists are trained to treat these conditions in people who have underlying Alzheimer's disease. Therapists take into account the impact of the disease on other health conditions, on general health, and on the individual's ability to understand important instructions.

The therapist may use various teaching methods, techniques to simplify instructions, and unique approaches, including:

• Visual, verbal, and tactile cueing - The physical therapist provides "cues such as pointing to objects or gesturing. For instance, lifting up both arms can signal the person to stand up. Cues can also be given verbally with short, simple, or one-step instruction. Tactile clues holding someone's hand to have them walk with you. Sometimes, 2 or 3 cueing techniques are used simultaneously.
• Mirroring - With this technique, the physical therapist serves as a "mirror," standing directly in front of the person to show them how to move. To help the person raise his or her right arm, the therapist's left arm would be raised.
• Task breakdown - Physical therapists are trained in how to give step-by-step instruction by breaking down the task into short, simple "pieces" to be completed separately. For instance, if the therapist wants to teach a person how to safely move from lying in bed to sitting in a chair, the therapist might have the person practice rolling to the side, then pushing up to sitting, then moving to a chair in separate steps.
• Chaining- The physical therapist can provide step-by-step instructions by linking one step to the next step in a more complicated movement pattern. This technique usually is used once task breakdown has been successful and unites the separate steps of moving from lying in bed to sitting in a chair, to make it one fluid movement.
• Hand over hand facilitation - The physical therapist takes the hand or other body part of the person who needs to move or complete a task and moves that body part through the motion.

Although people with Alzheimer's disease usually maintain the ability to walk well into the late stages of the disease, balance and coordination problems often lead to walking difficulties. The physical therapist will train the muscles to "learn" to respond to changes in the environment, such as uneven or unstable surfaces.

Train Family Members and Caregivers

The family and caregiver may need instruction in how to safely move, lift, or transfer the person with Alzheimer's disease to prevent injury to the caregiver as well as the person with Alzheimer's disease. In addition to hands-on care, physical therapists provide caregiver training to improve safety and to decrease the risk of injury. For instance, the therapist can show caregivers how to use adaptive equipment and assistive devices, such as special seating systems, canes, or long-handled reachers, and how to use good "body mechanics" (the way you physically move to do a task).

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Can this Injury or Condition be Prevented?

Although the answer to this question is still unknown, many research studies have found that people who are physically active are less likely than sedentary people—even in later life—to have cognitive decline or dementia as they age. Some research suggests that increased cardiorespiratory fitness might even prevent brain atrophy. Your physical therapist can design an exercise program to help you improve your odds for healthy aging.

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Real Life Experiences

Mr C is 76 years old and was diagnosed with possible Alzheimer's disease 2 years ago. Recently, he began having difficulty doing simple things he once took for granted, such as getting up from a chair and walking to the porch. His physical therapist will develop specific exercise programs to help Mr C keep his balance and decrease his risk of falling. His therapist explains to him that exercise programs also can help him improve his ability to participate in social activities, such as playing with his grandchildren. Exercise can lead to increased blood flow to the brain, which may help to improve his memory and other cognitive abilities.

Mr C's physical therapist will determine which assistive devices would improve Mr C's safety in the community. The therapist also will train Mr C's daughter in how to help Mr C make smoother movements when he rises from sitting to standing or puts dishes in the sink. The therapist also will develop cues to assist Mr C in completing more complex tasks.

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

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What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat conditions or injuries. You may want to consider:

• A physical therapist who is experienced in treating people with conditions related to aging. Some physical therapists have a practice with a geriatric focus.
• A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in geriatrics physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

• Get recommendations from family and friends or from other health care providers.
• When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have underlying Alzheimer's disease.
• During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

ARTHROSCOPY NOT RECOMMENDED FOR DEGENERATIVE KNEE DISEASE, PER NEW RESEARCH

A recent systematic review concluded that arthroscopic surgery for degenerative knee disease (including arthritis and meniscal tears) did not result in lasting pain relief or improved function. As a result, panelists strongly recommend against arthroscopy for patients with degenerative knee disease in most cases. 

The review (Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline- May 2017) was published in BMJ.

According to the review, about 25% of people older than 50 years of age experience pain from degenerative knee disease (the percentage rises with age), and costs for arthroscopies for this condition are in excess of $3 billion per year in the United States. Furthermore, only 15% of arthroscopy patients reported a small or very small improvement in pain or function at 3 months post surgery, and those benefits were not sustained at 1 year post surgery. 

In place of arthroscopy, panelists recommend effective alternatives including an individualized regimen combining rest, weight loss as needed, a variety of treatments provided by a physical therapist, exercise, and nonsteroidal anti-inflammatory drugs.

In an interview with the New York Times, Dr Reed A.C. Siemieniuk, a methodologist at McMaster University in Hamilton, Ontario, Canada, and chairman of the panel, said, "Arthroscopic surgery has a role, but not for arthritis and meniscal tears." The procedure, he elaborated, "became popular before there were studies to show that it works, and we now have high-quality evidence showing that it doesn't work."

7 STAGGERING STATISTICS

America's opioid epidemic is being felt nationwide.

Recent guidelines and consensus studies from The Centers for Disease Control and Prevention (CDC),  the American College of Physicians, and the National Academies (Health and Medicine Division) encourage health care providers to pursue safer alternatives, like physical therapy, for most non-cancer-related pain management. Choosing physical therapy is a safe and effective alternative to manage and treat pain, and can help you avoid the risks and side effects of opioids.

Statics from the CDC, the Substance Abuse and Mental Health Services Administration, the Agency for Healthcare Research and Quality, and the Henry J. Kaiser Family Foundation reveal the gravity of the problem.

1. In 2016, health care providers across the US wrote more than 214 million prescriptions for opioid pain medication, a rate that demonstrated 66.5 prescriptions per 100 people. Some counties had rates 7 times higher than that.

2. As many as 1 in 4 people who receive prescription opioids long-term for noncancer pain in primary care settings struggle with addiction.

3. From 1999 to 2015, more than 183,000 people have died in the US from overdoses related to prescription opioids.

4. While opioid abuse is down in younger Americans, it has risen among older adults. For adults aged 50 years and older, opioid abuse doubled from 1% to 2%.

5. Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids.

6. Veterans are twice as likely to die from accidental opioid overdoses as non-veterans.

7. Opioid-related hospitalizations among women in the US increased by 75% between 2005 and 2014.

Do you know someone in pain? Encourage them to talk to her or his physician or physical therapist about safe ways to manage pain.

The American Physical Therapy Association’s #ChoosePT campaign raises awareness about the risks of opioids and the safe alternative of physical therapy for chronic pain management.

9 THINGS YOU SHOULD KNOW ABOUT PAIN

1. Pain is output from the brain.While we used to believe that pain originated within the tissues of our body, we now understand that pain does not exist until the brain determines it does. The brain uses a virtual “road map” to direct an output of pain to tissues that it suspects may be in danger. This process acts as a means of communication between the brain and the tissues of the body, to serve as a defense against possible injury or disease.

2. The degree of injury does not always equal the degree of pain.Research has demonstrated that we all experience pain in individual ways. While some of us experience major injuries with little pain, others experience minor injuries with a lot of pain (think of a paper cut).

3. Despite what diagnostic imaging (MRIs, x-rays, CT scans) shows us, the finding may not be the cause of your pain. A study performed on individuals 60 years or older who had no symptoms of low back pain found that 36% had a herniated disc, 21% had spinal stenosis, and more than 90% had a degenerated or bulging disc, upon diagnostic imaging.

4. Psychological factors, such as depression and anxiety, can make your pain worse. Pain can be influenced by many different factors, such as psychological conditions. A recent study in the Journal of Pain showed that psychological variables that existed prior to a total knee replacement were related to a patient's experience of long-term pain following the operation.

5. Your social environment may influence your perception of pain. Many patients state their pain increases when they are at work or in a stressful situation. Pain messages can be generated when an individual is in an environment or situation that the brain interprets as unsafe. It is a fundamental form of self-protection.

6. Understanding pain through education may reduce your need for care.A large study conducted with military personnel demonstrated that those who were given a 45-minute educational session about pain sought care for low back pain less than their counterparts.

7. Our brains can be tricked into developing pain in prosthetic limbs. Studies have shown that our brains can be tricked into developing a "referred" sensation in a limb that has been amputated, causing a feeling of pain that seems to come from the prosthetic limb – or from the "phantom" limb. The sensation is generated by the association of the brain's perception of what the body is from birth (whole and complete) and what it currently is (post-amputation).

8. The ability to determine left from right may be altered when you experience pain. Networks within the brain that assist you in determining left from right can be affected when you experience severe pain. If you have been experiencing pain, and have noticed your sense of direction is a bit off, it may be because a "roadmap" within the brain that details a path to each part of the body may be a bit "smudged." (This is a term we use to describe a part of the brain's virtual roadmap that isn’t clear. Imagine spilling ink onto part of a roadmap and then trying to use that map to get to your destination.)

9. There is no way of knowing whether you have a high tolerance for pain or not. Science has yet to determine whether we all experience pain in the same way. While some people claim to have a "high tolerance" for pain, there is no accurate way to measure or compare pain tolerance among individuals. While some tools exist to measure how much force you can resist before experiencing pain, it can’t be determined what your pain "feels like."

TIPS TO RECOVER FROM A WORKOUT

Proper recovery following a workout is as essential as the workout itself. Whether you are beginning to work out for the first time or are altering your regimen, proper recovery is crucial to sustaining a long-term workout plan.

Why It's Important:

During exercise, the body undergoes a controlled amount of stress. Tissues in our bodies need this stress in order to improve their function and your performance. In fact, when you exercise, your muscles actually undergo “micro-trauma” due to the imposed demand of your activity. Recovery is your chance to build yourself back up stronger than before; it is the link between short-term, immediate benefit and long-term, lasting outcome.

The following tips can help you attain maximum benefit from your workout and reduce the risk of developing an injury.

Stretching

Stretching is an important part of recovery, but it rarely receives the time or attention it deserves. The purpose of stretching is to maintain the flexibility of tissues that are tight or stiff from an activity or prolonged position.

There are a variety of methods of stretching (using the hamstring muscle as an example):

• Static/Isolated Stretching: Static, or isolated stretching is holding a stretch position for a long period.  (Example: A static hamstring stretch would be when you sit on the ground with one leg pointing outward and you simply reach for your toes and hold for at least 30 seconds.)
• Dynamic stretching: Dynamic stretching is using movement to combine muscle groups. (Example: A dynamic stretch for the hamstring would be walking toe touches, as you bend down and grab your toe with every step for 2 to 3 seconds.)
• Foam Rolling: Foam rolling is a type of self-mobilization and massage. (Example: To foam-roll the hamstring muscle, you will simply put a foam roller under your legs and let your weight rest on top so the foam roller will push out any knots in your hamstring.)

A very general rule for stretching is dynamic stretching before exercise, static stretching after exercise, and foam rolling throughout. Utilizing various stretching strategies will allow you to maintain and improve your mobility.

Refueling (Hydration and Nutrition)

Proper fueling before exercise is important to optimize performance, but nutrition for recovery from exercise is often overlooked. Our bodies rely upon a well-balanced array of nutrients, vitamins, and minerals to aid in rebuilding the parts of our body that have been stressed during exercise. Refueling after a workout with a well-rounded set of carbohydrates, proteins, and healthy fats will help your body reap the most benefit from your hard effort

Water is also absolutely essential to overall health. In particular, following exercise, proper hydration is key to replace the fluids that you have lost during your activity. Water also helps regulate your temperature, maintain healthy joints, and eliminate wastes that build up in your system during activity. Pay special attention to your total water intake if you are exercising in extreme hot or cold climates or if you feel as though you may be getting sick. Make a habit of keeping a water bottle in your purse, gym bag, car, or workplace for easy, reliable access.

RICE

RICE stands for Rest, Ice, Compression, Elevation. If you find yourself having pain or swelling following exercise, particularly in a joint like your knee, ankle, or shoulder, you may consider using this four-part strategy to decrease inflammation and pain. If you continue to have symptoms several days following a workout, it may be important to seek the advice of a healthcare provider to further examine your complaints..

(See "The Difference between Soreness & Pain During Exercise" for more detailed information.)

Listen to Your Body

The only person who knows how your body feels after a workout is you. Allow yourself to listen to your body, and appropriately. This includes recognizing the signs of fatigue, pain or soreness and increasing recovery time between exercise bouts. This may also mean pushing yourself to work harder when you feel well. Don’t succumb to peer pressure at the gym. Trust yourself and what your body is telling you. When you are starting a new exercise program, don’t be afraid to ask your physical therapist for helpful hints on how your body may give you feedback after exercise, and how you should respond to that information.

Cross Training

Even if you love to run, your body may not like you running seven days a week. No matter what your exercise of choice may be (walking, running, swimming, cycling, weightlifting, yoga, recreational sports, etc.), you may considercan benefit from finding another form of exercise.

Cross training doesn't require a special shoe. It’s simply about challenging your body with different tasks so that certain tissues are not over-stressed, which often leads to overuse injuries. For example, a swimmer will benefit from strength training in addition to the hours spent in the pool in order to build different muscle groups and allow momentary rest for those that are used repetitively in the pool. Remember to do the exercises your body needs, not just the exercises you want to do. A physical therapist can help you determine where you have deficiencies or might be at risk for overuse injuries based on your workout regimen.

Planning Ahead

When life is busy, it’s hard to schedule enough time in your day to workout at all, let alone take care of yourself afterward. Try to plan your day or week so you have adequate time following each workout to implement the strategies above. This way you won't feel as rushed and cut out important recovery activities.

Sleeping

Often taken for granted, sleep is your body’s prime opportunity to recover.

When the body is at rest, the repair of our muscular, cardiovascular, skeletal, and immune systems can go to work. The CDC recommends that, in general, teens have 9-10 hours and adults 7-8 hours of sleep each day. These guidelines are especially important if you are demanding more of your body through regular exercise or stressful daily activities.

To get the most out of your shut-eye, strive for consistent bedtimes, avoid stimulating activities in bed (like TV and electronic devices), and a comfortable environment. You may find that you sleep better on days that you exercise, and will definitely notice a more effective, pleasant exercise experience if you are giving your body the rest it needs and deserves.

Fortunately, not only is your physical therapist trained to design an individualized exercise program for you, but she will also provide guidelines and strategies to ensure that you recover in the most effective way.

AMPLIFIED PAIN SYNDROMES: WHAT SHOULD YOU KNOW

Amplified pain syndromes (APS) is an umbrella term used to describe increased sensitivity to pain due to abnormal nerve connections in the nervous system. Diagnoses in children that fall under this umbrella term include juvenile fibromyalgia, central sensitization, and generalized chronic pain, among others.

In combination with a variety of factors, APS may be caused by:

• Injury
• Illness
• Psychological stress

 Individuals with APS may experience:

• Pain that is localized or widespread
• An onset of pain that is sudden or gradual
• Pain with an unknown cause
• Pain triggered by stress, illness, or prior injury, with pain continuing beyond a typical healing phase
• Pain described as achy, dull, sharp, shooting, burning, throbbing, and/or stabbing
• Pain that affects function and the ability to participate fully in daily activities
• Decreased school attendance, decreased involvement in sports, and disinterest in social participation

Signs and Symptoms

• Pain that is heightened in response to a normal event or minor injury that wouldn't typically be perceived as painful
• Impaired muscle endurance and weakness, poor cardiopulmonary (heart) endurance, poor posture, impaired balance, and/or impaired functional abilities
• Pain in response to a sensation such as a light touch, pressure, temperature, and/or vibration that would not normally provoke pain
• Swelling, temperature, and/or color changes to the skin of the affected area

Other common associated signs/symptoms may include: headache, blurry vision, memory problems, chest pain, heart palpitations, dizziness, abdominal pain, nausea, vomiting, diarrhea, constipation, abnormal limb movements, sleep disturbance, and fatigue.

Treatment

Physical therapists work with other medical professionals to provide physical therapy and education for people experiencing APS. Working one-to-one with individuals with APS, physical therapists teach exercises to decrease the fear of movement and apply exposure-based treatments to help desensitize painful areas. They aid in shifting focus from pain to function, encourage the use of stress management strategies, and help people recognize daily causes of stress.

Treatment may be provided in an inpatient or outpatient setting and may include:

• Exercise therapy: Daily strengthening and aerobic exercise to retrain the nervous system, decrease the fear of movement, and help people work through pain and discomfort and focus on functional improvements
• Desensitization: Daily repeated exposure to sensations that are perceived as painful in order to retrain the nerves' response to light touch, pressure, vibration, and temperature
• Stress education: Guidance about stress management, which may include recommended counseling services, relaxed breathing exercises, mindfulness training, and/or self-regulation strategies
• Decreased attention to pain: Education on how to limit discussion and decision makingdue to pain in order to decrease its importance to the brain, and return to normal daily activities.

Authored by: Brandi Dorton, PT, DPT, and Danielle Feltrop, PT, DPT, of Children's Mercy Hospital

VERTIGO + PHYSICAL THERAPY

Vertigo usually is described as a spinning sensation, whereas dizziness usually is described as "lightheadedness." Often, they have different causes and different treatments.

If you have vertigo accompanied by one or more of the following symptoms, immediately call 911 or emergency medical services (EMS) so that an ambulance can be sent for you:

• Double vision
• Difficulty speaking
• A change in alertness
• Arm or leg weakness
• Inability to walk

What Is Vertigo?

Vertigo is the sensation of spinning—even when you're perfectly still, you might feel like you're moving or that the room is moving around you. Most causes of vertigo involve the inner ear ("vestibular system"). A number of conditions can produce vertigo, such as:

• Inner ear infections or disorders
• Migraines
• Tumors, such as acoustic neuroma
• Surgery that removes or injures the inner ear or its nerves
• Head injury that results in injury to the inner ears
• A hole in the inner ear
• Stroke

You also might have:

• Nausea
• Vomiting
• Sweating
• Abnormal eye movements

One of the most common forms of vertigo is benign paroxysmal positional vertigo, an inner-ear problem that causes short periods of a spinning sensation when your head is moved in certain positions.

How Is It Diagnosed?

Your physical therapist will use your answers to the following questions to help identify the cause of your vertigo and to determine the best course of treatment:

• When did you first have vertigo (the sensation of spinning)?
• What are you doing when you have vertigo (turning your head, bending over, standing perfectly still, rolling in bed)?
• How long does the vertigo last(seconds, minutes, hours, days)?
• Have you had vertigo before?
• Do you have hearing loss, ringing, or fullness in your ears?
• Do you have nausea with the spinning?
• Have you had any changes in your heart rate or breathing?

Your physical therapist will perform tests to determine the causes of your vertigo and also to assess your risk of falling. Depending on the results of the tests, your therapist may recommend further testing or consultation with your physician.

How Can a Physical Therapist Help?

Based on your physical therapist's evaluation and your goals for recovery, the therapist will customize a treatment plan for you. The specific treatments will depend on the cause of your vertigo. Your therapist's main focus is to help you get moving again and manage the vertigo at the same time. Treatment may include specialized head and neck movements or other exercises to help eliminate your symptoms. Conditions such as benign paroxysmal positional vertigo have very specific tests and treatments.

If you have dizziness and balance problems after your vertigo has stopped, your physical therapist can develop a treatment plan that targets those problems. Your physical therapist will teach you strategies to help you cope with your symptoms:

• Do certain activities or chores around the house cause you to become dizzy? Your therapist will show you how to do those activities in a different way to help reduce the dizziness.
• Have simple activities become difficult and cause fatigue and more dizziness? Your therapist will help you work through these symptoms right away so you can get moving again and return to your roles at home and at work more quickly.

Physical therapy treatments for dizziness can take many forms. The type of exercise that your therapist designs for you will depend on your unique problems and might include:

• Exercises to improve your balance
• Exercises to help the brain "correct" differences between your inner ears
• Exercises to improve your ability to focus your eyes and vision

In addition, your physical therapist might prescribe exercises to improve your strength, your flexibility, and your heart health—with the goal of improving your overall physical health and well being.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat people with dizziness. You may want to consider:

• A physical therapist who is experienced in treating people with neurological problems. Some physical therapists have a practice with a neurological vestibular rehabilitation focus.
• A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in neurological physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

• Get recommendations from family and friends or from other health care providers.
• When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with inner ear injury.
• During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

WHO'S IN SURGERY WITH YOU??

Many of our patients have no idea who all is in the operating room with them when they go in for their procedure, and that's really no surprise. It's very common for multiple people who are not vital to the procedure to be present - some may even be there just to learn, or manage equipment being utilized. When you have surgery, a team of medical staff helps the surgeon during the operation. Who is on the team depends on the type of surgery. Most teams include the following professionals:

Surgeon

A surgeon has finished 4 years of medical school and 4 or more years of special training after medical school. Most surgeons have passed exams for board certification. The American Board of Surgery is the national group that gives this certification for general surgery in the U.S. Some surgeons also have the letters FACS after their name. This means they have approval of the Fellows of the American College of Surgeons (FACS).

Anesthesiologist

An anesthesiologist has finished 4 years of medical school and 4 years of special training in anesthesia. Anesthesiologists may get additional training in certain surgery specialties. This might be neurosurgical anesthesia or cardiac anesthesia. The anesthesiologist takes part in all 3 phases of surgery: before, during, and after.

Certified registered nurse anesthetist (CRNA)

The nurse anesthetist gives you anesthesia care before, during, and after surgery or labor and delivery. The nurse constantly watches every important function of your body. He or she can change the anesthesia medicine to make sure you are safe and comfortable. A nurse anesthetist has a bachelor's degree in nursing and at least one year of experience as a registered nurse in a critical-care setting. He or she also has at least a master's degree from a nurse anesthetist program. Nurse anesthetists must pass a national certification exam to become CRNAs.

Operating room nurse or circulating nurse

Registered nurses are registered and licensed by each state to care for patients. Some nurses focus on a certain field such as surgery. The operating room nurse helps the surgeon during surgery. Operating room nurses are certified in various areas of surgery. Nurses must pass an exam to be certified.

Surgical tech

Surgical techs assist with the surgery by setting up a sterile operating room. They get supplies and surgery tools ready. And they hand the surgeon the tools he or she asks for. They must pass an exam to be certified by the National Board of Surgical Assisting (NBSTA).

Residents or medical students

In many teaching hospitals, resident doctors in training and medical students may be a part of the surgical team.

Physician assistant

Physician assistants practice medicine under the supervision of a doctor. They may act as an assistant to the surgeon. Or they may close incisions with stitches (sutures) or staples.

Medical device company representative

Sometimes surgeons will have a representative from a company that makes medical equipment in the operating room. Such equipment might be artificial joints, spine stabilizers, or pacemakers. The representative can help the surgeon with sizing and function of the equipment.