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.

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.

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.

PIGEON TOES IN YOUR TOT

Pigeon Toes (Intoeing)

Children who walk with their feet turned in are described as being “pigeon-toed” or having “intoeing.” This is a very common condition that may involve one or both feet, and it occurs for a variety of reasons. 

Intoeing During Infancy 

Infants are sometimes born with their feet turning in. This turning occurs from the front part of their foot, and is called metatarsus adductus. It most commonly is due to being positioned in a crowded space inside the uterus before the baby is born. 

You can suspect that metatarsus adductus may be present if: 

• The front portion of your infant’s foot at rest turns inward. 
• The outer side of the child’s foot is curved like a half- moon. This condition is usually mild and will resolve before your infant’s first birthday. Sometimes it is more severe, or is accompanied by other foot deformities that result in a problem called clubfoot. 

This condition requires a consultation with a pediatric orthopedist and treatment with early casting or splinting. 

Intoeing In Later Childhood 

When a child is intoeing during her second year, this is most likely due to inward twisting of the shinbone (tibia). This condition is called internal tibial torsion. When a child between ages three and ten has intoeing, it is probably due to an inward turning of the thighbone (femur), a condition called medial femoral torsion. Both of these conditions tend to run in families. 

Treatment 

Some experts feel no treatment is necessary for intoeing in an infant under six months of age. For severe metatarsus adductus in infancy, early casting may be useful. 

Studies show that most infants who have metatarsus adductus in early infancy will outgrow it with no treatment necessary. If your baby’s intoeing persists after six months, or if it is rigid and difficult to straighten out, your doctor may refer you to a pediatric orthopedist who may recommend a series of casts applied over a period of three to six weeks. The main goal is to correct the condition before your child starts walking. 

Intoeing in early childhood often corrects itself over time, and usually requires no treatment. But if your child has trouble walking, discuss the condition with your pediatrician who may refer you to an orthopedist. A night brace (special shoes with connecting bars) was used in the past for this problem, but it hasn’t proven to be an effective treatment. Because intoeing often corrects itself over time, it is very important to avoid nonprescribed “treatments” such as corrective shoes, twister cables, daytime bracing, exercises, shoe inserts, or back manipulations. These do not correct the problem and may be harmful because they interfere with normal play or walking. Furthermore, a child wearing these braces may face unnecessary emotional strain from her peers. 

Nevertheless, if a child’s intoeing remains by the age of nine or ten years old, surgery may be required to correct it.

Source - 11/21/2015

Caring for Your Baby and Young Child: Birth to Age 5 (Copyright © 2009 American Academy of Pediatrics)

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.

RECOGNIZING CONCUSSIONS IN STUDENT ATHLETES

A concussion is a mild traumatic brain injury caused by a direct blow to the head, face, or neck. In the United States, an estimated 300,000 sports-related concussions occur annually.

In high school gender-comparable sports, girls have a higher concussion rate than boys. Female athletes have also been shown to have a greater recovery time in postconcussion symptoms as compared to males.

Signs of a Concussion

Concussion symptoms usually appear within minutes of the injury; however, some symptoms may take several hours to occur. Any athlete who has lost consciousness during a sports-related impact should be examined for a concussion or a spine injury. A headache is the most common complaint of an athlete with a concussion. If you suspect your child has suffered a concussion, they may exhibit the following symptoms, which may worsen with stress or activity:

• Loss of consciousness
• Headache
• Feeling in a “fog”
• Difficulty remembering
• Behavioral changes (irritability, rapid changes in mood, exaggerated emotions, aggressiveness, depression, decreased tolerance to stress, etc)
• Nausea/vomiting
• Difficulty with balance
• Pupils that are enlarged or not equal in size
• Double or blurred vision
• Slurred speech
• Difficulty falling asleep
• Excessive drowsiness

What to do if you suspect a concussion in an athlete:

• Do not allow them to return to any sporting event. 
• The athlete should be allowed to rest until there is a resolution of symptoms. This allows the brain to recover. Rest involves allowing time to sleep or take frequent naps. Minimizing distractions, such as television, Internet, reading, or phone use is important.  
• It is unnecessary to wake the athlete up every hour. This disturbs sleep patterns, which can interfere with the healing process of the brain.
• The athlete should avoid pain relievers, like aspirin or other anti-inflammatory medications. These may increase the risk of bleeding in the brain.
• The athlete should not be left alone following the injury. Symptoms should be monitored closely. If they worsen, the athlete may need to be evaluated in the emergency room to determine if a more serious brain injury exists.  

PT FOR ATHLETES

If you’re an athlete, you know that long periods of training followed by performing at peak levels can take a toll on your body. Whether you’ve experienced an acute injury or have become hurt as a result of overuse, the professional physical therapists from Champion Performance and Physical Therapy in Prairie Village, Kansas can help you get back in the game with their effective sports physical therapy programs.

If you’re an athlete considering sports physical therapy, take a look at some of the ways in which you could benefit from treatment at Champion:

• Less Downtime: Sports physical therapy helps athletes regain muscle strength without damaging the injured area further. This will help you proactively work to repair injured tissue and get back to your training or active recovery period faster and with less downtime.
• Better Odds For A Full Recovery: Instead of letting an injury “ride its course,” physical therapy takes a proactive approach to healing and thus increases your odds of making a complete recovery. Under the care of a physical therapist, you’ll also know exactly when you can resume your normal activity levels again, whereas athletes who don’t seek physical therapy often try to do too much too soon and risk re-injuring themselves.
• You’ll Receive Tailored Treatment: Some athletes make the mistake of trying to rehabilitate their injured body part on their own, but this approach overlooks the fact that each body and injury is unique. The professionals at Therapy Works utilize a number of different treatment methods and have the skills, knowledge, and experience to tailor their sports physical therapy program to the unique needs of each patient.

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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.

BRACHIAL PLEXUS PALSY

A brachial plexus palsy happens when the nerves of the brachial plexus have been damaged during birth. The brachial plexus is a set of nerves that control the muscles of the arm. Palsy means not being able to move muscles in an area (paralysis).

Nerves are soft, tube-like structures inside the body. They contain many small fibers (filaments), like a telephone cable or a thick electrical cord. These small fibers carry signals from the brain to control the muscles. Nerves also carry signals from the skin to the brain. This is how we feel things on our skin.

The nerves of the brachial plexus go out from the spinal cord under the collarbone and into the armpit. From there, they branch out into individual nerves that control the muscles in the shoulder, elbow, wrist and hand.

When nerves in the brachial plexus get damaged, signals cannot travel like usual from the brain to the arm muscles. So some or all of your child’s arm muscles may no longer work. When this affects only the shoulder and elbow muscles, it is called an Erb’s palsy. When it affects all of the muscles of the arm, hand and wrist, this is known as a total plexus palsy.

Brachial Plexus Palsy in Children

Brachial plexus palsies usually happen because of a stretch injury to your child’s head, neck and shoulder. This can happen during birth, especially when the birth is difficult or complex. Sometimes a child’s shoulder will get stuck against the mother’s pelvis. This can result in a stretch injury as your child is being delivered.

The brachial plexus may be injured if a baby's shoulder gets stuck on the mother's pelvis during birth.

In older children, a brachial plexus palsy can occur because of an injury where the neck and shoulder get stretched.

Many children with a brachial plexus palsy recover on their own. But if the condition does not completely resolve within 1 month, it usually has lasting effects. That’s why we encourage you to have your child assessed 1 month after their birth or injury if they have not fully recovered. If treatment is needed, it’s important to begin early and to have ongoing therapy.

Physical and occupational therapy can reduce problems with stiffness or other bone problems that can happen as a result of the injury. Some children need to wear splints to help position their joints while the nerves are recovering. Some need surgery to repair their nerves.