Should I have an MRI first?

When most people have an injury, especially if it involves the neck or low back, they feel they need an MRI right away. Also, if a person is ordered to come to physical therapy after their injury without getting an MRI or some sort of advanced diagnostic testing they question why. These patients are usually fearful and hesitant to start physical therapy for fear that something is being missed about their condition and they might get worse or injure themselves more.

Many studies have have been done to show if there is any value of ordering an MRI or advanced diagnostic test following an injury. Unless it is a very serious injury there is very little correlation between positive findings and the relationship to level of pain.

Physical therapy is always the best conservative approach to any type of musculoskeletal injury. Early intervention is key to the overall healing process. Starting treatment early reduces the risk of the injury turning chronic. This can also help save you and your insurance company time and money. Unnecessary testing can get very expensive and this is what we are trying to avoid.

As physical therapists we are trained in detailed evaluations. I can guarantee that my evaluation will be more detailed than just about any health care professional that you will see. Education is a big part of what we do during our evaluation. We are able to find “red flags” and if something doesn’t add up we refer you out to another health care professional. There are clinical tests that we perform to determine what tissues are effected and if those are positive then we take the next step into treating them.

Advanced diagnostic testing is not necessary to have before starting physical therapy treatment. Sometimes, waiting to get a test before starting can delay the healing process of your injury. Physical therapists evaluate and treat a wide variety of injuries and can help with pain reduction and prevention of future injuries.

Can your discs actually slip?


You were doing yard work all day, went to lift that last bag of topsoil and felt a pop in your back and pain down your leg. You hobble into the house, sit down, pop a few Tylenol and put some ice on it. The next day you can barely get out of bed so you go to your physician. You come out of the appointment with all kinds of information. Everyone asks what happened and you say I have a slipped disc in my back. This term has been used for a long time. Is it really possible for one of your discs to slip in your back? Is that even a medical term? Is it something that we should be concerned about?

A disc can’t physically slip. The term is not accurate. Discs are attached to adjacent vertebrae with tough, ligamentous fibers, so discs can’t “slip”. These discs are very flexible in nature and allow for spinal movement and shock absorption. However, over time discs break down with wear and tear. A disc can move, bugle and completely rupture, ultimately expanding past it’s normal position of comfort.

The term slipped disc is often used interchangeably, and most of the time incorrectly, with bulging and herniated discs, but there is a difference in the terms. The anatomy of a disc helps to understand how the they are defined.

Disc Anatomy:

Annulus fibrosus – is the outer layer of the disc and is composed of a fibrous layer helping protect the inner portion of the disc.

Nucleus pulposus – is the inner layer of the disc and is composed of a gel like substance.

There are many layers in your back that help protect the disc. You have muscles and multiple ligaments along your spine that are the front line defenders. If any or all of those layers are weakened the annulus is all that is left before the nucleus. When a disc bulges the nucleus pushes into the annulus and causes the disc to lose shape and push into the spinal canal. This can cause a nerve to be pinched and cause symptoms down the leg. When a disc herniates the nucleus is now not contained in the annulus and leaks out into the canal causing pain and sometimes numbness or weakness.

Looking at these two terms and knowing how they are defined tells us there is no way that a disc can physically slip out of place. The term is widely used around the health care field. We just need to understand what it is being used for.

Is physical therapy going to be painful?

Before I leave the room after all of my evaluations I always ask my patients if they have any questions. I also ask, if what I just explained to them makes sense? At least 50% of the time, if not more, I get “ is this going to hurt? It is a very good question considering the majority of people have no idea what to expect from physical therapy. When people are already in pain to start the last thing they want is to have more pain. Also, at this point, people can be fearful of movement. Therefore, it can become challenging trying to explain what to expect. Let’s talk about this question of pain and if it’s really something to expect when you go to PT.

I absolutely hate when people say that I love putting them in pain! I also get very upset when patients and PT’s alike will state PT stands for pain and torture. Or a PT is a physical terrorist. Really? Is that what most people think we are and do to people? Let’s get one thing straight. My job is to promote movement, function and mobility using your own body to heal itself. I am not here to try and put you in the most pain possible. I have no desire to try and increase your pain nor do I get excited when I do. This is a misconception that a lot of people have and it needs to stop.

Yes, there are times that you may have some discomfort from certain movements, activities and treatments. Take the shoulder for example. A patient that has RTC surgery is going to have pain during PT because you have to move the joint in order for you to gain motion. The shoulder is healing from surgery and that is another reason that it is going to be painful. Any time you have limited motion you are going to experience some sort of pain/discomfort because the joint is not moving properly. It’s not a sign for me to see how much pain I can put you in. It’s just a guarantee that you will be in some sort of discomfort because of the limited motion the joint has.

Will you experience some sort of pain during PT? Depending on what you are coming for the answer is yes. Other times PT can and should be very relaxing and calming. General soreness from activity and exercise is not what I consider pain. It’s just your bodies way of telling you to move your ass more often and you wont feel this way. If you are seeing someone that calls themselves a pain and torture expert or refers to themselves as s physical terrorist I suggest you find a different place to go.

When things get tough will you quit?


As most of you know that read my posts my son plays travel baseball and I’m a coach on the team. Lately it has taken over my life, and I’m okay with that because I enjoy it so much! But I keep finding different reasons to talk about it because these kids show me something different each week. As with all 9 year olds there is an up and down attitude about them each day, week and month. One day they look like super stars out there and nothing can stop them. The next day they look like they are back in T-ball again. This past weekend was one of those weekends where you wondered how they would respond after the events that took place.

We played in a tournament called the Battle of the Boarder in Youngstown Ohio. Leading up to the weekend we knew that competition was going to be very good. 2 teams in particular were going to be there. Beaver Valley Red and West Hills. The last time we played West hills they beat up on us pretty badly. By about 13 runs to be exact! It wasn’t pretty, but our kids had bounced back in the next tournament they played in to take 2nd place. We were in a different bracket then either team and were set to face 2 teams we had never played. The day before the tournament started one dropped out and our schedule changed. Now we were scheduled to play Beaver Valley. I was excited to see how our kids matched up against them since we had never played them before. Once the kids heard that was who they were playing that’s all they talked about. They obsessed about it actually! And it was not in a good way. The game started and we walked the first batter, not a good start! Nerves were probably going crazy for most, but we managed to get 2 outs and the score was only 1-0. Then all hell broke loose! We committed 6 errors giving up 12 runs in the first inning! After the first inning it was 12-0! How does this happen? Little things like catching the ball before trying to throw it. Balls going through their legs, and coming in on fly balls instead of stepping back first. All things our kids do very well most of the time. Their nerves got the best of them. Needless to say the game ended in 4 innings after losing 18-1. We lost the second game 12-6 against another team we had never played mostly due to mistakes and kids just not being in the game. It was tough to watch and hard to talk to the boys afterwards. Sunday would tell us what type of team we have and how they respond.

The next morning the kids warmed up and you could tell they were more lively and upbeat. They started out strong and lead most of the game until the bottom of the 5th giving up 2 runs to be down 5-4. The kids battled that last inning but couldn’t find a way to get another run. We lost that game, but showed great resilience and determination to come back after getting the crap beat out of us the day before. It was great to see how our boys responded.

I wanted to share this with you all because there are always going to be times in life and in physical therapy that you are going to want to quit. Things are just going to get too hard for you and giving up seems to be the easiest thing to do. I know because I have felt like quitting before. My first 2 weeks of PT school I almost quit! I felt that it was going to be too hard and too much for me to handle. I was sick of school at that point and now I was going to have to go for an additional 3 years! I went home that weekend and thought about it a lot. I kept telling myself I could go and get a job for a little while and figure it out. Then I realized that I committed to doing this and this was what I felt passionate about. I’m so glad that I decided to continue my journey. Just know that it’s normal to want to just give up when things are tough and not going your way. It’s the way you respond and show resilience that makes all the difference.

My experience with custom orthotics, and will they work for you?


A while back I wrote a blog about how even physical therapists need treatment sometimes. I went over my experiences with a foot problem that I developed over a few summers ago. I wanted to do a follow up post on my current situation and how it has taught me something that I teach my patients on a daily basis.

To summarize my experience I started to get some foot discomfort in the fall of 2015 after a long season of tournament baseball. I used to wear spikes when I coached because it made it easier to do things with the players. That Thanksgiving I played in a Turkey bowl and wore those same spikes and the next day I could barely walk. It took about 2-3 months of self treatment and taping methods to finally get some significant relief. It would still bother me from time to time, but I could deal with it. Well, summer came in 2016 and I decided to get a new pair of spikes thinking that it was just the brand the they were a few years old. At first it felt fine, but as the season wore on I could feel my foot slowly hurting again. I finally just started wearing regular running shoes and that seemed to help, but never completely. I finally bit the bullet and went to see a foot specialist. I was diagnosed with nothing more than over pronation of my forefoot and in turn my arch was collapsing causing significant pain. This is honestly nothing that I already didn’t know. I just wanted to make sure I didn’t have a stress fracture. To my relief I was recommended to get custom orthotics done so I obliged. I didn’t receive a call for a few months and by that time my pain was gone so I never called back.

Fast forward to April 2017 and baseball season had been in full swing since Thanksgiving indoors of course here in Western PA. We were just getting outside and I started wearing my spikes again…bad move. They hurt so bad that I decided to get some turf shoes most coaches wear. I also decided to call the foot specialist again to pick up my orthotics. I made an appointment and within 10 minutes of being there I was walking out with orthotics in my shoes. The initial feeling was a little different. I wasn’t sure what to think really. I just knew that I needed to give them a shot. I always tell my patients with any type of change in footwear whether it’s new shoes or orthotics do it in steps. So I wore them for an hour for the first week. Just one hour a day, then bumped it up to 3 hours and so on. I now wear them all day when I’m at work because I am on my feet most of the day. I have to say that since wearing them I have not experienced foot pain at all!! It’s amazing what a difference they do make and I’m very happy I made the decision to get them.

My advice to my patients with foot problems is always try orthotics, especially if they have a flat foot. I usually tell them to try an over the counter version to see. Some insurances don’t cover them and it can be expensive. So before they go full out I tell them to go the cheaper route first. Now that I have had such a positive experience with orthotics it will drive me to be more aware of patients that will benefit from this.

If you have any questions about your foot problem or any musculoskeletal issue that you may be experiencing please don’t hesitate to contact me! 

nicksivrichpt@gmail.com

Can wearing a back brace do more harm than good?


31 million Americans experience low back pain at any given time. It is the number one cause of disability worldwide. Also, low back pain is one of the most common reasons for someone to miss work and the second most common reason for someone to go to the doctors. Really? That many people have back pain? It is that common for them to go to their primary care doctor for it? Why are they not coming to physical therapy first? That’s a topic for another day, but seriously low back pain is a huge issue that a lot of us deal with on a daily basis. I see it first hand every day as I treat patients frequently with this problem. Some are strains, disc herniations, fusions, fractures and just general arthritis symptoms. It’s inevitable that I will get the question: “Do you think a back brace will help me?” “My friend’s brother has worn a brace for years and says he thinks I need one.” So I decided to share my opinions and some general facts about back braces to hopefully help you make that decision.

What is the back brace being used for? This should be the first question anyone should ask. The type of injury or problem that you are having will be a key factor whether you will benefit from a brace or not. When do you plan on wearing it? Is this something that you are planning on wearing all day? Do you want to use it while you are doing house work or working out at the gym? Are you planning on wearing it while you sit? These are some key questions that you need to focus on in order to see if this is right for you.

In my opinion, I never recommend for a patient to wear a back brace. This is usually what I tell them. I don’t recommend that you get a back brace. I feel you would not benefit from it and here is why. Your back is already vulnerable in the fact that you are injured and you are in pain. Your muscles are not working to their full potential and are weak. If you were to put a brace on, chances are that you would get some relief initially, but you would only be hurting yourself. Think about it this way, once you put that brace on your muscles are going to say to themselves, I don’t have to work as hard as I was before because I have this trusty brace doing most of the work. So as your muscles decide to take a nap they are also shrinking which is called atrophy. Now they are not as strong as they were before. After using this brace for the past several weeks you start to feel a bit better. You think, “Hey I feel pretty good let’s try going without the brace today.” Within 30 minutes you feel worse than you did before. And now you put the brace back on because that’s the only way it feels better. See, the brace is doing most if not all of the work for your core and those muscle decided that they wanted to be lazy and not work. Sure it helped take away your pain temporarily, but in turn it was hurting you in the long run.

Now, here is when I feel you can and should wear a brace.

When you are weight lifting or power lifting: weight lifters have been using belts and back braces for years. These are only used for a very short period of time and are taken off so your back is only being assisted for a short amount of time.

When your job requires you to lift a lot throughout the day: I see Home Depot workers wearing braces all the time. And as soon as they are done with the lift they take of the brace. This is fine because you are not allowing the brace to carry the load all day long.

Scoliosis: This type of brace is used to stop the progression of Idiopathic Scoliosis. This brace must be used in order to prevent the curvature from getting any worse.

It can be very confusing a to when you should or should not wear a back brace. I suggest that you take into account what you are trying to use it for and ask your Physical Therapist or other licensed health care provider. Braces can be a life saver, but they can also leave you worse than when you started.

Putting in the work and staying consistent always pays off!

I am one of the coaches of my son’s travel baseball team. My son is almost 9 and it’s his first full year of kid pitch travel baseball. He has played with most of the kids on his team since he was 4. They all started out on a rec team together. Year to year you can see the improvement. Constant practice and playing for most of the year is our life right now. It’s so much different than when I was a kid. I played a lot of baseball, but only from April till August. These kids started in November and will play until the end of summer. Constant practice and games keep these kids consistent. They stay focused by doing things on a regular basis and it shows. Most of the things that we succeed at in life are done on a regular basis. We make a habit of them and they become a constant.

This past weekend we had another tournament for baseball. We played very well in pool play to earn the second seed to start the playoff/championship round. Sunday afternoon we were set to play the same team we beat the day before 5-4. It was a close game, but we played flat that game. The kids seemed pretty upbeat at the beginning of this game, but it didn’t start out the way we wanted it to. My son started the game pitching and was a little off with his location. He ended up giving up a 2 run home run in the 1st inning. Luckily we got out of it without going down by any more runs. He was down, but his teammates encouraged him as well as all of the coaches after getting out of the inning. The kids were off and losing most of the game. We entered the second to last inning down 7-3. The kids battled this inning getting timely hits and staying disciplined at the plate scoring 4 runs to tie it up! We would have scored 1 more if it wasn’t for me running my son into an out at third after a nice 2 run double. The last inning comes and the other team scored 2 runs to make it 9-7. Things just were not going our way. The rain came off and on and it was just a miserable feeling. The kids did not seem defeated though. They have been in this situation before! This is what they practice for each and every week. We ended up with bases loaded and 2 outs, a situation every athlete wants to be in! As a kid we always played and yelled out 2 outs bottom of the 9th bases loaded down by 1!. So who steps up to the plate? My son steps into the box ready and focused. First pitch is thrown and he swings out of his shoes! He was pumped up for this! I yell down from 3rd where I was coaching and tell him to relax, because a hit scores two! Next pitch comes and boom! He smokes this ball high in the air towards left center field. I knew it was gonna at least score two right? Then it keeps going and going and I yell “GET OUT OF HERE!” And the ball sailed over the fence! You would have thought I hit the ball because I was jumping up and down like a little kid screaming! As my son rounded 3rd he had the biggest smile on his face and it’s a moment I will never forget and cherish forever! I’m getting chills right now just typing this! The kids went crazy and it was just a great moment to be a part of! They won the game!


These kids never cease to amaze me! They showed me something that day that will always stick with me. Putting in the work and staying consistent will always pay off in the end. They never gave up on each other and they never quit. Even when my son gave up a home run in the first inning he kept his composure and stayed focused. Every single one of them contributed to that great victory!

I always like to bring things back to a situation related to physical therapy or situations in life in general. If we stay consistent with anything in life we are going to make our situation better. If we practice at something or make a habit of doing something on the regular it’s proven that you have a better chance of success. If you are trying to be more healthy then make a commitment to stick with a new way of eating and doing some sort of physical activity weekly. Do these things at the same time and same day to make a habit and stay consistent. When you make an appointment to come to physical therapy stick to it and commit to the full length of treatment sessions. Do your program at home and stay consistent. It’s proven to work because I saw it first hand this past weekend.

I treat PAIN all day every day

Throughout the week 10-20% of my patients cancel. It’s a given. Anywhere you go, regardless if it is a medical facility or not, cancels happen. I have cancelled things on occasion as well. Something comes up and you don’t have a ride, you have to work late or you just plain forgot. Things happen in life and that’s why we prepare for these types of things to happen. Sometimes, the reason for cancelling is actually the reason you should be coming in.

I have heard a lot of different reasons for cancelling over the years. Some are pretty standard as you would expect. Some are off the wall and I just shake my head. But whatever the reason is I’m okay with because you had the courtesy to call me and let me know. There is one reason though I have a hard time dealing with. “ I’m calling to cancel my appointment today.” “ Is everything okay?” “Yes, I am in a lot of pain today and need to cancel.” “I called my doctor and they gave me some pain meds.” Wait a minute what? They cancelled because they are in pain? Isn’t that the reason they came here in the first place? They were lifting something heavy and injured their back. Now they are dealing with back pain and need my help. Why would someone cancel because they are in pain?

As a physical therapist I am a musculoskeletal specialist. I help people get back to things they want to do by developing a program that puts them in the best position to win. I treat pain all day every day without the side effects of a pill! I don’t give you long term use effects by damaging your liver nor do I cause an addiction. I help people get back to the life they once lived without having to rely on me all of the time. I lead them to independence. I make decisions for them to guide them in the right direction. PAIN is usually a very common symptom of most of my patients.

So why would someone cancel if they are in pain? Early on in my career I had no idea and just attributed it to a patient being lazy. Sometimes that is the case, but most of the time it is just that the patient is misinformed. I didn’t do a good enough job explaining to them exactly what my plan was and what it was going to take in order for them to get better. Now, some patients just don’t pay attention and that’s on them. But I can always do a better job at communicating. So, if you are currently going to PT or are planning on going know that at times things might get flared up. You might get worse before you get better. You might experience more discomfort than you did before, but pain should not be a reason to cancel. I always want to see my patients if they are in pain. It ‘s what I am here for!

The benefits of warming up before exercise

I see it all the time at the gym. People come in, check in at the front desk, hang their keys on the board and go right to the bench press. Are they going to warm up at all? How many of you reading this right now have done that? I know I used to be one of those people in the past. I would just get in there and start full throttle not having a clue as to what I was doing to myself and the potential injuries I could have caused myself. Warming up is very important for a few reasons. It absolutely can aid in preventing injuries during your workout. It can also help enhance your performance during your workout. In fact the more intense your workout is going to be the more important a proper warmup is.

When you start a new workout routine or you are starting a new program your body is just getting used to those specific exercises. Nobody ever tries to run a marathon without first warming up. So why would we just jump right into something without really getting our body in a state of warmth? Working out is one of many elements involved in losing weight and leading a healthy life style. If you are not used to working out, a warm up is crucial to help your body ease into it.

Warming up before exercise slowly loosens your muscles at a better pace than just jumping right into a routine. Studies have suggested that warming up before a exercise regimen can prevent injury. Here are some of the specific benefits of a proper warm up:

Increased muscle temperature: A warmer muscle tends to contract more forcefully and relax a lot faster. This decreases the probability of overstretching and causing injury.

Blood vessel dilation: This can reduce the resistance to blood flow and have a little less stress on the heart.

Increased body temperature: This increases muscle elasticity and reduces the risk of strains and muscle pulls.

Increased blood temperature: Temperature of blood increases when it travels through your muscles. As that rises the binding of oxygen to hemoglobin decreases so oxygen is more readily available to your muscles. This can improve endurance.

Improved range of motion (ROM): As your muscles increase in temperature so do your joints. In turn this helps increase the available ROM that you have and this helps improve performance.

A typical warm up should start out slow with a gradual increase to what you are trying to accomplish. If you are a runner you should be jogging a bit mixing in a few sprints to engage fast and slow twitch muscle fibers. For those of us that like to strength train you should be starting out with light weight for a few sets gradually working your way into the exercise you are trying to accomplish. I personally like to run about 2 miles before I strength train. By the time I’m done. I’m very warm, loose and ready to start my workout. Another point I would like to make is that the best time to stretch is after a workout or after your warmup. This way your muscles are loose and more pliable and at less risk for injury.
Keep in mind that each person’s warmup is different. It can be very individualized and only comes with experience, practice and experimentation. I recommend trying various ways at a slow pace to find what works best for you.

REFERENCES:

https://www.verywell.com/how-to-warm-up-before-exercise-3119266

Why does my neck crack?

“Why do I feel a cracking in my neck?” “When I turn my head I hear snap, crackle pop why?” I hear these questions all the time in my clinic and it’s a valid question to have considering a lot of people experience this at some point. Cracking and popping in joints throughout the body are normal and we have a lot of joints in our neck. However, if cracking is accompanied by pain or some sort of swelling then it may be time to get it looked at by a health care professional.

Have you ever heard of crepitus? Crepitus refers to any type of noise or sensation such as a cracking, snapping, cracking, popping or grinding sound heard when a joint is moved. This symptom is common in your knees and usually does not accompany pain. The underlying cause of crepitus in the neck is not fully understood. Here are a few reasons why we tend to here those cracking sounds in our joints.

Synovial joint fluid pressure changes:

There are various studies that have been done to find out what actually causes the sound of cracking in our joints. Some say that it is the bursting of a gas bubble the joints synovial fluid. Others say it is the sound of the bubble being formed. Either way the cause and sound can come from either or.

Ligament or tendon moving around a bone:

Another reason for the cracking to happen is the possibility of a ligament or a tendon rolling over top of a bone. This can happen around all types of joints in the body not just the neck.

Bone on bone grinding:

Although this is the most uncommon reason, bone on bone grinding can cause a sound to be produced in your neck or joints. Once the articular cartilage wears away there is nothing left to prevent the bones from rubbing together. This in turn, can cause the sound of cracking or popping at times. This condition is called osteoarthritis. This condition usually happens gradually, but can accelerate if you experience an injury or surgery to the area. This type of cracking is usually accompanied by pain, limitation of movement and the cracking will happen with every movement.

Although there are many reasons people experience cracking, I always suggest getting yourself evaluated by a physical therapist or another health care professional to see what can be done for prevention of injury or symptoms.