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.

PT BEFORE SURGERY

Yes, please! 

Mild meniscal tears and moderate knee osteoarthritis send some people under the knife, when all they really need is physical therapy.

A recent study in the New England Journal of Medicine found no significant difference between individuals who received surgery and those who received physical therapy alone, thus avoiding the unnecessarily invasive procedure and related costs.

Dr Edward Laskowski, codirector of the Mayo Clinic Sports Medicine Center, told Men's Journal that physical therapy might prove equally effective for other knee injuries, including MCL, PCL, and cartilage tears (Try Physical Therapy Before Surgery - April 29, 2013).

"If you have good range of motion, physical therapy may very well settle down the symptoms over time," Laskowski said.

In a May 2, 2013, episode of Move Forward Radio, the lead physical therapist in the trial discussed the findings of the study.

Learn about physical therapist treatment of meniscal tears and osteoarthritis of the knee.

WHAT EXACTLY IS A PHYSICAL THERAPIST?

As described by the American Physical Therapy Association

Physical therapists (PTs) are health care professionals who diagnose and treat individuals of all ages, from newborns to the very oldest, who have medical problems or other health-related conditions that limit their abilities to move and perform functional activities in their daily lives.

PTs examine each individual and develop a plan using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability. In addition, PTs work with individuals to prevent the loss of mobility before it occurs by developing fitness- and wellness-oriented programs for healthier and more active lifestyles.

Physical therapists provide care for people in a variety of settings, including hospitals, private practices, outpatient clinics, home health agencies, schools, sports and fitness facilities, work settings, and nursing homes. State licensure is required in each state in which a physical therapist practices.

The Physical Therapy Profession

Physical therapy is a dynamic profession with an established theoretical and scientific base and widespread clinical applications in the restoration, maintenance, and promotion of optimal physical function. Physical therapists:

• Diagnose and manage movement dysfunction and enhance physical and functional abilities.
• Restore, maintain, and promote not only optimal physical function but optimal wellness and fitness and optimal quality of life as it relates to movement and health. 
• Prevent the onset, symptoms, and progression of impairments, functional limitations, and disabilities that may result from diseases, disorders, conditions, or injuries.

The terms "physical therapy" and "physiotherapy," and the terms "physical therapist" and "physiotherapist," are synonymous.

As essential participants in the health care delivery system, physical therapists assume leadership roles in rehabilitation; in prevention, health maintenance, and programs that promote health, wellness, and fitness; and in professional and community organizations. Physical therapists also play important roles both in developing standards for physical therapist practice and in developing health care policy to ensure availability, accessibility, and optimal delivery of health care services. Physical therapy is covered by federal, state, and private insurance plans. Physical therapists' services have a positive impact on health-related quality of life.

As clinicians, physical therapists engage in an examination process that includes:

• taking the patient/client history,
• conducting a systems review, and 
• performing tests and measures to identify potential and existing problems.

To establish diagnoses, prognoses, and plans of care, physical therapists perform evaluations, synthesizing the examination data and determining whether the problems to be addressed are within the scope of physical therapist practice. Based on their judgments about diagnoses and prognoses and based on patient/client goals, physical therapists:

• provide interventions (the interactions and procedures used in managing and instructing patients/clients),
• conduct re-examinations,
• modify interventions as necessary to achieve anticipated goals and expected outcomes, and
• develop and implement discharge plans.

Physical therapy can be provided only by qualified physical therapists (PTs) or by physical therapist assistants (PTAs) working under the supervision of a physical therapist.

POSSIBLE CAUSES OF THAT PAIN IN YOUR BUM

Sciatica is one of the most common diagnoses that we see in physical therapy. But what exactly is sciatica and how do physical therapists treat this complex diagnosis? The simple answer is the treatment is all dictated by the source.

Generally, Sciatica is a term that is commonly used to describe pain, weakness, numbness, or tingling that radiates down the back of the leg. Typically, the symptoms follow the distribution of the sciatic nerve, but there can be some confusion as to the source of the pain especially when the patient’s symptoms are referred. Our job as PTs is to determine the source of the nerve irritation or referral origin and treat it accordingly. This is often accomplished with a thorough musculoskeletal exam and typically without the need for costly medical imaging. Alongside misalignment caused as a result from weak musculature of the hip, below are the most common causes of sciatica seen in PT and how we typically treat them.

1. Disc Herniation:

The most common source of sciatica is pressure on the sciatic nerve from a herniation or protrusion of a spinal disc. This pressure on the nerve can create an irritation and inflammatory response causing symptoms to radiate down the leg following the path of the nerve that is compressed.

What can physical therapy do to help patients with sciatica caused by a disc herniation?

• Studies have shown that patients respond well to repetitive lumbar range of motion in improving sciatica symptoms related to lumbar disc herniation. Typically the direction that most patients report relief of their symptoms is lumbar extension. However, a thorough physical therapy assessment will help decide a patient’s specific “directional preference”.
• Core stabilization exercises in conjunction with lumbar range of motion are also effective at reducing sciatica symptoms. PTs tend to focus on strengthening the transversus abdominis and gluteal muscles in both static and dynamic activities.
• Patient education is probably the most important component of the rehab of disc herniation. Patients are educated on proper sitting and standing postures as well as proper body mechanics with lifting activities to avoid causing further disc herniation.

2. Stenosis:

Narrowing of the space where the spinal cord or nerve roots exit the spinal canal is called stenosis. If the space is narrowed, that can create pressure on the cord or the nerves causing pain to radiate down the leg.

Stenosis is typically seen in a condition called degenerative disc disease. Our discs are located between the bony vertebrates and over time they can start to lose some of their height. This loss of height causes the narrowing of space seen in stenosis.

Another cause of stenosis is tiny little bone spurs called osteophytes that can form in the spinal cord or nerve root space.

What can physical therapy do to help patients with sciatica caused by stenosis?

• Our goal in PT is typically to help improve ROM in the lumbar spine to help open up the narrowed space. Patients with stenosis often respond well to lumbar flexion or bending exercises, which is in contrast to the lumbar extension exercises often seen in disc herniation. However, a thorough physical therapy exam will help determine the appropriate stretches/range of motion exercises.
• As with disc herniation, core stabilization and posture/movement retraining are important for patients with sciatica caused by stenosis.
• Functional dry needling (i.e. Trigger point dry needling) is also very effective for patients with lumbar stenosis. By using tiny, hair thin needles, we can quickly decrease the muscle tightness of spinal muscles, resulting in decreased compression of the lumbar vertebrae. We will discuss dry needling more in the last section.

3. Piriformis Syndrome:

Deep in your buttock/gluts is a muscle that runs diagonally from the outside of your hip to the lowest part of your spine. This muscle, called the piriformis, can get short and tight or even be in spasm. In 85% of the population, the sciatic nerve runs just beneath the piriformis and in the other 15% it runs through the muscle. The sciatic nerve can become compressed and irritated when the piriformis is taught or in spasm creating symptoms of sciatica down the back of the leg.

What can physical therapy do to help patients with sciatica caused by piriformis syndrome?

• Typically, a physical therapist will prescribe a thorough home exercise program that includes stretches for the piriformis, hamstrings, and glute muscles (see linked video for example of a piriformis stretch).
• Sciatic nerve glides/flossing can be effective at getting the sciatic nerve moving again if it is trapped by the piriformis, especially in conjunction with the stretches above (see linked video for example of a sciatic nerve glide).
• A common theme with all of the causes of sciatica is core stabilization. Core and glute strengthening exercises will help to reduce the demands put on the piriformis muscle with daily and recreational activities (see linked video for an example of a core exercise).
• Trigger point dry needling has also been found to be very effective at quickly reducing the tension of the piriformis.

UNDERSTANDING BALANCE

Balance is a complex process involving the reception and integration of sensory input and the planning and execution of movement. It’s the ability to control the center of gravity over the base of support in any given sensory environment. Reflexes are automatic responses by the peripheral or central nervous system to help support postural orientation and maintain balance; they occur rapidly enough to not be under volitional control.

Balance is a result of the interaction of three separate systems in the body:

• The Visual System, which helps us see things in the environment and orient us to the hazards and opportunities presented.
• The Vestibular System (the inner ear), which provides the brain with information about the position and motion of the head in relation to gravity.
• The Proprioceptors/ Somatosensory Receptors which are located in joints, ligaments, muscles, and the skin to provide information about joint angle, muscle length, and muscle tension all of which is gives information about the position of the limb in space.

The brain needs input from all three systems to distinguish motion of the self from motion of the environment. Any mismatch in these inputs can produce nausea, vomiting and dizziness. Some common examples that we all experience are

• The sense of perceived motion when sitting in a car at a stop light and the car next to you creeps forward, causing you to slam on your brakes
• When on a boat, proprioceptors perceive a rocking boat under your feet, but your eyes see a steady horizon.

More long-term complications with balance can make an affected person feel persistently unsteady or dizzy. In fact, as many as four out of ten Americans will at some point experience an episode of dizziness significant enough to send them to a doctor. These issues can be caused by improper function of the systems mentioned above, health conditions, or as a side effect from some medications. In severe forms, a balance disorder can intensely impact day-to-day activities resulting in an inability to function and cause psychological distress.

TMJ DISORDER - JAW PAIN

Temporomandibular joint disorder, or dysfunction, (TMD) is a common condition that limits the natural functions of the jaw, such as opening the mouth and chewing. It currently affects more than 10 million people in the United States. It is sometimes incorrectly referred to as simply “TMJ,” which represents the name of the joint itself. TMD affects more women than men and is most often diagnosed in individuals aged 20 to 40 years. Its causes range from poor posture, chronic jaw clenching, and poor teeth alignment, to fracture or conditions such as lockjaw, where the muscles around the jaw spasm and reduce the opening of the mouth. Physical therapists help people with TMD ease pain, regain normal jaw movement, and lessen daily stress on the jaw.

What Is Temporomandibular Joint Disorder?

Temporomandibular joint disorder (TMD) is a common condition that limits the natural function of the jaw, such as opening the mouth and chewing, and can cause pain. The temporomandibular joint (TMJ) is a hinge joint that connects your jaw to your skull in front of your ear. The TMJ guides jaw movement and allows you to open and close your mouth and move it from side to side to talk, yawn, or chew. TMD can be caused by:

• Bad posture habits. One of the reasons TMD is so common is because many of us spend a great deal of time sitting at a desk, where we often hold our heads too far forward as we work. But there are many other kinds of bad posture. Sitting in the car for a long commute, working at a checkout station, always carrying your child on the same hip—all can place the head in an awkward position and cause jaw problems. The "forward head position" puts a strain on the muscles, disk, and ligaments of the TMJ. The jaw is forced to "rest" in an opened position, and the chewing muscles become overused.
• Chronic jaw clenching ("bruxism"). Many people clench their jaws at night while they sleep, usually because of stress. Some clench their teeth throughout the day as well, especially when dealing with stressful situations. This puts a strain on the TMJ and its surrounding muscles.
• Problems with teeth alignment ("malocclusion"). If your teeth are positioned in an unusual way, greater stress is placed on the TMJ when performing everyday jaw motions, such as chewing.
• Fracture. In a traumatic accident involving the face or head, a fracture to the lower jaw may result and cause TMD. Even when the fracture is fully healed, TMJ stiffness and pain may remain.
• Surgery. Individuals may experience a loss of TMJ mobility and function following certain kinds of surgery to the face and jaw.
• Trismus ("lockjaw"). This condition—where the jaw muscles spasm and the jaw cannot be fully opened—can be both a cause and a symptom of TMD. Other causes of trismus include trauma to the jaw, tetanus, and radiation therapy to the face and neck.
• Displacement of the disc or soft-tissue cushion located between the ball and socket of the TMJ, which causes popping or clicking of the jaw and, frequently, pain.
• Arthritis in the TMJ.

How Does it Feel?

The symptoms of TMD can be temporary or last for years. Jaw pain is the most common symptom.

CAUTION: Jaw pain also can be a symptom of heart attack. Seek medical care immediately if jaw pain is accompanied by: 

• Chest pain
• Shortness of breath
• Dizziness
• Left arm pain
• Numbness in the left arm
• Nausea

TMD can cause the jaw to lock or get stuck in a certain position. You may experience headaches, feel pain when chewing certain foods, or have difficulty fully opening your mouth.

TMD symptoms include:

• Jaw pain
• Jaw fatigue
• Difficulty opening your mouth to eat or talk
• Ringing in your ears
• Dizziness
• Headache
• Popping sounds in your jaw
• Neck pain
• Locking jaw

How Is It Diagnosed?

To identify the cause of your symptoms, your physical therapist may:

• Review your medical history, and discuss any previous surgery, fractures, or other injuries to your head, neck, or jaw.
• Ask you to describe your pain, including headaches, and observe any pain patterns in the neck and TMJ.
• Conduct a physical examination of your jaw and neck, including the soft tissue and muscles in the area.

Your physical therapist will evaluate your posture and observe how your cervical spine—the upper portion of your spine, situated in your neck—moves. Your physical therapist will examine your TMJ to find out how well it functions and whether there are any abnormalities in your jaw motion.

If, after the examination, your physical therapist suspects that your pain is a result of the position ("alignment") of your teeth, the therapist will refer you to your dentist for further examination.

How Can a Physical Therapist Help?

Your physical therapist can help you restore the natural movement of your jaw and decrease your pain. Based on your condition, your therapist will select treatments that will work best for you. Your treatments may include:

Posture Education. If you sit with your head in an increased forward position, you are placing greater strain on the muscles beneath your chin, causing the lower jaw to pull back and the mouth to be in an open position even when resting, increasing stress on the TMJ. You also might be overworking the jaw muscles to force the jaw closed so your mouth isn't open all the time. Your physical therapist will teach you to be aware of your posture so that you can improve the resting position of your jaw, head, neck, breastbone, and shoulder blades when you're sitting and walking.

Improving Jaw Movement. Physical therapists use skilled hands-on techniques (manual therapy) to gently increase movement and relieve pain in tissues and joints. Your physical therapist may use manual therapy to stretch the jaw in order to restore normal joint and muscle flexibility or break up scar tissues ("adhesions") that sometimes develop when there is constant injury.

Your physical therapist will teach you special "low-load" exercises that don't exert a lot of pressure on your TMJ, but can strengthen the muscles of the jaw and restore a more natural, pain-free motion.

Special Pain Treatments. If your pain is severe, your physical therapist may provide treatments, such as electrical stimulation or ultrasound to reduce it.

Referral to a Dentist. If your TMD is caused by teeth alignment problems, your physical therapist can refer you to a dentist who specializes in TMD, who can correct the alignment with special appliances, such as "bite guards" that create a natural resting position to relax the TMJ, relieve pain, and improve jaw function.

PT'S GUIDE TO PELVIC FRACTURES

A pelvic fracture is a break in 1 or more bones in the pelvis. It is sometimes referred to as a "hip fracture" or "broken hip" because it occurs in the bones that make up the hip area. A pelvic fracture causes difficulty walking or standing. It can also cause abdominal pain, bleeding from pelvic cavities, and difficulty urinating. Pelvic fractures in the United States are relatively rare, making up 0.3% to 6% of all fractures. Pelvic fractures are most common in people 15-28 years of age. In people younger than 35, males suffer a higher incidence of pelvic fractures than females. In people older than 35, females suffer pelvic fractures more often than males.

What is a Pelvic Fracture (Hip Fracture)?

A pelvic fracture is a crack or break in one or more of the pelvic bones, which are located at the base of the spine. The pelvis is often referred to as part of the hip. (When you "put your hands on your hips," your hands are actually resting on your pelvic bones.)

A pelvic fracture can result from a low-impact or high-impact event.

Low-impact pelvic fractures most commonly occur in 2 age groups: adolescents and the elderly. Adolescents typically experience fractures of the tips of 1 of the pelvic bones, resulting from an athletic injury (football, hockey, skiing) or an activity such as jogging. Pelvic fractures also can occur after minor falls in people with osteoporosis or even occur spontaneously when bones are weak. The elderly frequently suffer fractures of the thicker part of the pelvic bones. These "pelvic ring fractures" result from falling onto the side of the hip. These falls can be caused by balance problems, vision problems, medication side effects, general frailty, or unintended obstacles such as pets underfoot, slippery floors, or rumpled rugs. Low-impact pelvic fractures often are mild fractures, and they may heal with several weeks of rest. Physical therapy is very helpful in restoring strength and balance in these cases.

High-impact pelvic fractures most commonly result from major incidents such as a motor vehicle accidents, a pedestrian being struck by a vehicle, or a fall from a high place. These pelvic fractures can be life-threatening, require emergency room care, surgery, and extensive physical therapy rehabilitation.

How Can a Physical Therapist Help?

Pelvic fracture recovery often involves surgery or long periods of bed rest. In the case of athletes, avoidance of sport activities is recommended until pain has resolved. During these periods of rest, which are usually weeks to months, a person often loses strength, flexibility, endurance, and balance abilities.

Physical therapists can help you recover from a pelvic fracture by improving your:

• Pain level
• Hip, spine, and leg motion
• Strength
• Flexibility
• Speed of healing
• Speed of return to activity and sport

When you are cleared by your physician to begin physical therapy, your physical therapist will design a specific treatment program to speed your recovery, including exercises and treatments you should do at home. This program will help you return to your normal life and activities and reach your recovery goals.

The First 24-48 Hours

Your physical therapist may help you learn to use crutches so you can move around your home without walking on the leg of the injured side. This will more commonly apply to low-impact pelvic fractures, as in athletes. More severe pelvic fractures will require a wheelchair, in which your physical therapist can instruct your safe usage.

Reduce Pain

Your physical therapist can use different types of treatments and technologies to control and reduce your pain, including ice, heat, ultrasound, electrical stimulation, taping, exercises, and special hands-on techniques called manual therapy that gently move your muscles and joints.

Your physical therapist will choose specific activities and treatments to help restore normal movement in the leg and hip. These might start with passive motions that he or she applies to your leg and hip joint, and progress to active exercises and stretches that you perform yourself. Treatment can involve hands-on manual therapy techniques called "trigger point release" and "soft tissue mobilization," as well as specific stretches to muscles that might be abnormally tight.

Improve Strength

Certain exercises will benefit your healing at each stage of recovery, and your physical therapist will choose and teach you an individualized exercise program that will restore your strength, power, and agility. These exercises may be performed using free weights, stretch bands, weight-lifting equipment, and cardio exercise machines such as treadmills and stationary bicycles. For pelvic fractures, muscles of the hip and core are often targeted by the strength exercises.

Improve Balance

The hip area contains many muscles that are vital for balance and steadiness when walking or performing any activity. Your physical therapist will teach you effective exercises to restore strength and endurance to these muscles so that you can regain your balance.

Speed Recovery Time

Your physical therapist is trained and experienced in choosing the treatments and exercises to help you heal, get back to your normal life, and reach your goals faster than you might be able to on your own.

Return to Activities

Your physical therapist will collaborate with you to decide on your recovery goals, including return to work and sport. Your treatment program will be designed to help you reach these goals in the safest, fastest, and most effective way possible. Your physical therapist will use hands-on therapy and teach you exercises and work re-training activities. Athletes will be taught sport-specific techniques and drills to help achieve sports-specific goals.

Prevent Future Problems

Your physical therapist can recommend a home exercise program to strengthen and stretch the muscles around your hip, upper leg, and core to help prevent future problems, such as fatigue and walking difficulty. This program may include strength and flexibility exercises for the hip, thigh, and core muscles. Your physical therapist will also review with you and your family ways to prevent falls in your home. These fall-prevention strategies may include clearing the floors of loose obstacles (throw rugs, mats), using sticky mats or chairs in the shower, preventing pets from walking near your feet, and using non-slippery house shoes, as well as installing grab bars or rails for the shower, toilet, and stairs.

If Surgery Is Necessary

If surgery is required, your physical therapist will help you minimize pain, restore motion and strength, and return to normal activities in the speediest manner possible after surgery.

Can this Injury or Condition be Prevented?

Pelvic fracture can be prevented by:

• Warming up before starting any sport or heavy physical activity. Your warm-up should include stretches taught to you by your physical therapist, including stretches for the muscles on the front, side, and back of the hip.
• Increasing the intensity of an activity or sport gradually, not suddenly. Avoid pushing yourself too hard, too fast, too soon.
• Following a reasonable and safe nutritional plan. Nutritional factors can contribute to osteoporosis, which can put you at higher risk of pelvic fracture.
• Maintaining good balance skills. Balance problems can increase the risk of falling and thus increase the risk of incurring a pelvic fracture. Physical therapy can help maintain and improve balance ability, which can help prevent falls.
• Driving safely to avoid motor vehicle accidents.
• Clearing your house of obstacles that you could trip over, and eliminating slippery walking surfaces.

1/3 OF THE WORLD IS WHAT?

If you're overweight or obese, you're definitely not alone. In fact, new research shows there are billions of people just like you – and it's concerning the public health community.

A New England Journal of Medicine study, published Monday, finds that more than 2 billion people – or one-third of the world's population – fall into the obese-or-overweight categories, CNN reports. What's more: Their weight is causing them to endure health problems.

The New York Times reports the per capita death rate has ticked up 28 percent since 1990, and40 percent of these deaths occurred among overweight people not heavy enough to be obese. In 2015, extra weight was a factor in 4 million deaths from conditions such as heart disease and diabetes.

More than 710 million people are considered obese, which translates to 10 percent of the global population.

For the purposes of the study, being obese meant having a body mass index of 30 or higher, while being overweight was defined as having a BMI between 25 and 29. The Institute for Health Metrics and Evaluation at the University of Washington led the Gates Foundation-backed study.

The U.S. earned the dubious distinction of having the highest percentage of obese children and young adults relative to the overall population (13 percent), while Egypt had the highest percentage of obese adults, with nearly 35 percent.

Looking beyond percentages at the actual numbers: The U.S. was home to the most obese adults (79.4 million), and China was home to the most obese children (15.3 million).

These findings are unsettling to experts, who worry about the health consequences of the world's expanding waistline. "People who shrug off weight gain do so at their own risk – risk of cardiovascular disease, diabetes, cancer, and other life-threatening conditions," Dr. Christopher Murray, study author and director of the Institute for Health Metrics and Evaluation at the University of Washington, told CNN.

Researchers used data from the Global Burden of Disease study in their analysis, which included 68.5 million people tracked between 1980 and 2015. They reported that in 73 countries, the obese population had doubled since 1980. Women had higher obesity levels than men no matter the age group, a finding that echoes previous research.

So, what comes next?

"We need to control the consequences of obesity much better globally ... and help people who are obese to lose weight," Goodarz Danaei, a professor at the Harvard T.H. Chan School of Public Health who didn't work on the study, told CNN. "That's where we need research and public health interventions."

But such interventions could prove complicated, particularly when it comes to increasing access to healthy food. "Unhealthy foods cost less; healthier foods often cost more. People eat what they can afford," Adam Drewnowsk, director of the Center for Public Health Nutrition at the University of Washington, told The New York Times. He also didn't work on the study.

It remains unclear what rising obesity rates mean for children. "We don't really know what the long-term effects will be if exposed to high BMI over 20, 30, 40 years," Danaei told CNN. "It may be larger than we have already seen."

5 HYDRATION MYTHS BUSTED

1. Caffeine Dehydrates You

Let’s start these myths off on a positive note: Your morning cup of coffee can boost your hydration levels. While experts have long believed that caffeine, like that contained in coffee, acts as a diuretic to dehydrate the body, recent research published in PLOS ONE found that in people who drink up to four cups of caffeinated Joe per day, coffee is just as hydrating as H2O.

It's important to remember that hydration levels tend to be lowest in the morning, since you spend all night sleeping, not drinking. So if what you want first thing in the morning is a cup (or two) of coffee, go for it, says registered dietitian and board-certified sports dietitian Georgie Fear, author of “Lean Habits for Lifelong Weight Loss.”

2. You Need to Drink Eight Glasses of Water Per Day

There are multiple reasons why this well-meaning guideline falls short of guaranteeing good hydration. For starters, every person’s hydration needs are unique. Age and sex are two big factors: The National Academies of Sciences, Engineering, and Medicine recommends that while men and women ages 19 to 30 consume 15.6 cups and 11.4 cups of water per day, respectively, toddlers need as little as 4 cups per day. Climate, exercise as well as pregnancy and lactation all move the needle, too.

Here’s how popular functional waters, which promise benefits beyond hydration, stack up.

But this next part is also important: All of that water doesn’t have to come in beverage form. According to the National Academies, roughly 20 percent of the average adult’s water consumption actually comes from food. “If you eat more of a plant-based diet, it could contribute even more,” says registered dietitian Betsy Opyt, creator of Betsy’s Best. She notes that fruits and veggies such as watermelon, cucumbers, celery and star fruit are more than 90 percent water.

3. As Long as You Aren’t Thirsty, You’re Well-Hydrated

Think of thirst like sunburns – it doesn’t pop up until it’s too late. “People are typically dehydrated by about 2 to 3 percent of their body weight, which is enough to impact physical and mental performance, before thirst kicks in,” explains registered dietitian and board-certified sports dietitian Marie Spano. Plus, the body’s biological thirst mechanisms tend to become even more faulty with age, so it’s especially important for older adults not to count on thirst as a hydration gauge.

While many experts like to use the guide, “as long as your urine is pale yellow or clear, you’re well hydrated,” it’s important to remember that everything from medications and supplements to the foods you eat can influence your urine color, Spano notes. Her bathroom rule: If you need to pee once every few hours, you’re likely well-hydrated.

4. The More Water You Can Drink in a Day, the Better

“If you really push the fluids, you can dilute the concentrations of electrolytes in your blood." “Hyponatremia, or low blood levels of sodium, is a dangerous condition, even life-threatening. Some unfortunate deaths have occurred as a result of drinking a gallon of water as part of a contest, or among marathoners who drank too much water without taking in any electrolytes.”

While, fortunately, these tragedies are uncommon, the National Academies similarly notes that acute water toxicity can occur by drinking excessively more fluid than your body can excrete in a given timeframe – about 3 to 4 cups per hour.

5. Sports Drinks Are Always Superior to Water

Sports drinks are great for their electrolytes (think: calcium, magnesium, potassium, sodium, phosphate and chloride), helping to prevent issues such as fatigue, nausea, headache, impaired muscle function as well as severe hyponatremia – all of which are possible when you’re sweating out electrolytes and drinking plain ’ol water. Meanwhile, they also contain simple sugars and calories that are meant to keep the body primed with energy when you’re in the middle of a long endurance workout.

However, a quick jog around the block doesn’t qualify. “Unless you’re exercising for more than 90 minutes or in extremely hot and humid conditions, water will do,” says Fear, noting that downing sports drinks when you really don’t need them is why many people who take up running gain, rather than lose, weight.

SELF-REFERRAL FOR BACK PAIN IS CHEAPER FOR OUR PATIENTS

Patients who receive care from self-referring physicians for the treatment of low back pain (LBP) are more likely to be referred for some form of physical therapy, but that's just part of the story. According to newly published research, LBP patients who are self-referred receive fewer physical therapy visits and more ineffective passive modalities than patients who aren't self-referred—and all at a higher overall cost. The state of Kansas accepts self-referral for physical therapy! 

In the study, researchers analyzed 158,151 LBP episodes in private health insurance claims records for nonelderly individuals enrolled in plans offered by Blue Cross Blue Shield of Texas. They found that physicians who "self-referred"—that is, referred their patients to a business with which they have a financial relationship—referred 26% of their patients to physical therapy. That rate was 16 percentage points higher than among non-self-referrals. Overall physical therapy was referred at a rate of 14%. 

But the higher rate of referrals doesn't tell the whole story, according to the study's authors, who analyzed what happened next—and how much it wound up costing. Results of the study were e-published ahead of print in the Forum for Health Economics and Policy (abstract only available for free). 

What they found was that the self-referred patients received, on average, 2 fewer physical therapy visits and 10 fewer 15-minute physical therapy service units compared with treatments by providers who did not self-refer. And when self-referred patients did receive physical therapy, they were treated differently from their non-self-referred counterparts, with an increased use of passive modalities such as hot and cold packs, mechanical traction, ultrasound, and electrical stimulation—approaches authors describe as "ineffective" in treatment of LBP.

Looking more closely at Healthcare Common Procedure Coding System (HCPCS) records, authors found that about 46% of physical therapy services rendered during non-self-referred episodes included individualized exercises to develop strength, endurance, range of motion, and flexibility, compared with a 31.5% rate among the self-referred episodes. Significant differences were also found in the use of dynamic activities designed to improve function, which occurred at a 6.7% rate for non-self-referred episodes but in only 4.2% of the self-referred episodes. Conversely, electrical stimulation accounted for almost 9% of the physical therapy services in self-referring episodes. Among the non-self-referred episodes, use of that passive modality was 1.4%.

Authors write that the use of exercise and dynamic activities "implies that [LBP] patients treated by non self-referring providers received skilled one-on-one care," and that "patients seen by self-referring providers received higher proportions of passive treatments." According to the authors, these passive treatments "can be easily performed by non physical therapists (medical assistants or technologists) in physicians' offices," and billed as physical therapy services under the "incident to" rule.

And what about overall cost? It turns out that fewer physical therapy sessions and a greater use of passive modalities doesn't wind up saving money—in fact, the LBP episodes addressed through self-referral averaged $889 in insurer-allowed costs, compared with $602 for non-self-referred episodes—a 49% difference. As for spending on individual physical therapy services, self-referral episodes averaged costs that were double non-self-referrals—an average of $144 for the self-referring provider, compared with $73 for the non-self-referring provider.

Results of the study not only inform physical therapist practice, but they help to clarify issues that have been at the heart of a policy debate over the reach of the Stark law, a law intended to prohibit referrals to a business that has a financial relationship with the referring provider under Medicare. That prohibition applies to most in-office ancillary services, but there a few exceptions: physical therapy is one of them. APTA has made elimination of these exceptions one of its public policy priorities.

The new study also fills in some of the gaps left in a 2014 report from the US General Accountability Office (GAO), which looked at self-referral for physical therapy across all health conditions under Medicare. That report found a higher rate of referral to physical therapy (and fewer physical therapist services received) among self-referred cases, but was limited in its scope. Authors of the new study cite a number of "deficiencies" in the report, including its focus only on elderly patients, and the lack of any analysis of the types and quality of physical therapist services rendered.

“The results of this study further confirm what APTA has firmly believed for years now,” said APTA President Sharon L. Dunn, PT, PhD, OCS, in an APTA news release. “Referral for profit leads to health care practices that benefit the provider and remove the focus from where it should be; the patient. APTA has long advocated for the elimination of referral for profit for physical therapist services from health care.” 

For their part, the study's authors keep the focus on the ways in which the quality of physical therapy services differ between self-referred and non-self-referred episodes.

"An important contribution of this study is the finding that the composition of physical therapy services rendered to [LBP] differs between self-referring and non self-referring practices," authors write. "The care provided by independent therapists is comprised of more active, hands on treatments which appear to be appropriate in light of empirical evidence showing that passive procedures are not effective treatments for LBP."

The study was funded in part by the Foundation for Physical Therapy and the National Institute on Aging.