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The low down on Hip Replacement

25.02.20

The low down on Hip Replacement

The current state of affairs

Hip replacements are becoming increasingly common. Currently 1.3 people in every 1,000 will undergo a hip replacement operation, and more than 1.2 million are carried out each year worldwide. The biggest risk factors for needing a hip replacement are age and arthritis, with 85% of people having a hip replacement, also having osteoarthritis. In terms of gender, women have a higher risk of needing a hip replacement (58%) compared with men (42%). Hip replacement surgery in patients aged 45-54 has also doubled in the past 10 years.

What can we do, to reduce the risk of needing a hip replacement?

Physical activity helps. Running decreases your risk of developing osteoarthritis by 18% and as osteoarthritis is present in 85% of people who undergo a hip replacement, this has a knock-on effect in reducing your risk of needing a hip replacement by 35-50%. And if you’re not up for running that’s OK, walking can also reduce the risk of needing hip surgery, although by a smaller percentage (23%). Almost half of the protective effective of being physically active comes from weight control. The higher your BMI, the greater your risk of needing a hip replacement.  

And what can you do if you’re already experiencing hip pain?

If you need a hip replacement then the sooner you have it, the better the outcome is likely to be and the quicker you will recover from your operation. This is because the more pain you suffer prior to having surgery, the more compensations and adaptations the muscles and soft tissues will have made around the joint, in an effort to try and protect it and you from that pain, and the harder that will be to re-train once you’ve had the operation. That’s not to say it can’t be done, it will just take a bit longer and need a bit more of an investment in your time and energy. The good news is that outcomes from hip replacements are very good. Developments in materials and surgical techniques, mean that the artificial hips are lasting longer, and success rates are very good, with more than 80% of people experiencing pain relief and functional improvement, meaning their daily lives become easier and they’re able to do more.  

We hope you find this information helpful and if you have any questions or queries, please feel free to get in contact with us 6676 4000 or 6676 4577.

We are running the GLA:D program as a preventative for surgery for hips and knees with osteoarthritis.

Follow this link to read more - GLA:D program Pottsville and Cabarita Physiotherapy.

 

Don’t Get into Deep Water with Swimming Injuries

10.12.19

Don’t Get into Deep Water with Swimming Injuries

Swimming is one of the most popular sports in the world. We swim in the sea, pools, lakes, streams, rivers and even ponds. And given 70% of the Earth’s surface is water, we’re not short of opportunities. And while swimming is considered a ‘low-impact’ sport due to the fact that the water supports a large percentage of, more than 84% of regular swimmers suffer from some type of overuse type injury caused by swimming. Why? The main reason is the high repetition number and forceful nature of the shoulder revolutions which takes our shoulder joint through its full range of motion (which is one of the greatest of all our joints), against resistance, over and over again. And as 50-90% of the power generated to propel you forward comes from the shoulders, you can see why they are the most frequently injured joint. However, swimming also puts stress on your back, to hold you level in the water; on the neck when raising your head out of the water to breathe and if you favour breaststroke as a stroke, there’s added pressure from the unnatural twisting motion on the knees. So, despite it seeming to be a low-impact sport, swimming actually carries a surprisingly high risk of injury. Let’s take a look at those injuries, why they happen and what you can do about them. Swimming injuries generally stem from two sources, and often these sources will combine:
  1. Muscle imbalances
  2. Stroke technique issues
Muscle Imbalances Our everyday posture, particularly if you spend a lot of time sitting at desk or in a car, or generally not moving around, creates all sorts of muscle imbalances from short hamstrings, tight muscles around the neck, back and shoulders. We unconsciously adopt a curved forward upper back, round shoulders and chin poke, which not only add to shoulder problems in swimmers but neck pain too. Poor posture is the biggest culprit of short tight trapezius and pectoral muscles and weak anterior (front) neck and upper back muscles. These muscles can be painful and develop trigger points which are hyperactive spots in the muscle, commonly referring pain and causing headaches. Tight muscles may also limit your neck movements. Good posture ensures good alignment of the joints and ligaments which allows for optimal contraction of your muscles and off-loads underlying structures. Stroke Technique This a big topic to cover because it depends what stroke you’re swimming mostly with and what kind of injury you may have but issues include: a wide, swinging arm recovery which requires excessive internal rotation, causing impingement on the joint; thumb in first with hand entry, which again causes excessive internal rotation in the shoulder and a dropped elbow or straight arm pull through which creates a long lever and overloads the shoulder. What does all of this mean to you? You shouldn’t swim? You should reduce your training or change your sport? The bottom line is that the benefits of swimming - whether it’s for general fitness and physical activity, the desire to win competitions, or just to find your quiet place for stress relief - far outweigh the risk of injury.

   

Is Osteoarthritis causing you hip or knee pain? GLA:D Evidence based treatment for hip and knee arthritis

29.03.19

Is Osteoarthritis causing you hip or knee pain?

GLA:D Evidence based treatment for hip and knee arthritis

GLA:D®, or Good Life with Arthritis: Denmark, is an education and exercise program developed by researchers in Denmark for people with hip or knee osteoarthritis symptoms.  

What does GLA:DTM involve?

This education and exercise program reflects the latest evidence in osteoarthritis (OA) research. It also includes feedback from people with OA and trainers on what works in the real world to help patients manage OA symptoms.

GLA:DTM Australia training consists of:

  • A first appointment explaining the program and collecting data on your current functional ability
  • Two education sessions which teach you about OA, how the GLA:D™ Australia exercises improve joint stability, and how to retain this improved joint stability outside of the program
  • Group neuromuscular training sessions twice a week for six weeks to improve muscle control of the joint which leads to reduction in symptoms and improved quality of life
  Pottsville and Cabarita have partnered with GLA:D to offer this program at our clinics. The education sessions are free. The cost of the program is $440 and includes an initial and post program individual Physio session and 12 group GLA:D exercise sessions. It is strongly recommended to participate in the supervised program for optimal results. However if this is not possible you can do individual sessions which cost $35 supplemented by a home program . You do not need a referral from you Doctor, however you may be eligible for a rebate from Medicare for some of the cost of the program, if deemed appropriate by your GP. All sessions are claimable through private health funds.

Can I Participate in GLA:DTM Australia?

GLA:D™ Australia is a program for all individuals who experience any hip and/or knee osteoarthritis symptoms, regardless of severity. You may participate in the GLA:D™ Australia program if you have a hip or knee joint problem that resulted in visiting a health care provider.

You may not be able to participate in the GLA:D™ Australia program if:

  • You have other reasons for your hip and/or knee pain, including; tumor, inflammatory joint disease, result of hip fracture, soft tissue or connective tissue problems
  • You have other symptoms that are more pronounced than the osteoarthritis problems (for example chronic generalized pain or fibromyalgia)
  • You are unable to understand and communicate in English
 

OA Treatment in Australia

OA is the most common lifestyle disease in individuals 65 year of age and older, but can also affect individuals as young as 30 years of age. Current national and international clinical guidelines recommend patient education, exercise and weight loss as first line treatment for osteoarthritis. GLA:DTM Australia program offers a proven and effective exercise and education based framework for the treatment of hip and knee OA.

Background of the GLA:D® Program

Research from the GLA:D® program in Denmark found symptom progression reduces by 32%. Other outcomes include a less pain, reduced use of joint related pain killers, and less people on sick leave. GLA:D® participants also reported high levels of satisfaction with the program and increased levels of physical activity 12 months after starting the program.  

This program is unique in that the education and exercises provided can be applied to everyday activities. By strengthening and correcting daily movement patterns, participants will train their bodies to move properly, prevent symptom progression and reduce pain.

   

Quick Facts

 
  • GLA:D has been proven to have dramatic effects in reducing pain of OA hip and knee by an average of 32%
 
  • The program is open to anyone with hip or knee OA, even if it is severe.
 
  • GLA:D has been shown to be far superior to other treatments such as anti-inflammatories, injections and arthroscopic surgery
 

Find out more about GLA:DTM

Pottsville and Cabarita Physiotherapy P: 02 6676 4000 E:  info@pottsvillephysio.com.au W: www.pottsvillephysio.com.au        

OSTEOARTHRITIS OF THE KNEE – Day to Day Tips

26.02.19

Day to day Tips 

 
  • Pace your activities through the day – don’t tackle all the physical jobs at once.
  • Wear low-heeled shoes with soft, thick soles (trainers are ideal). Thicker soles will act as shock absorbers.
  • Use a walking stick to reduce the weight and stress on your painful knee.
  • Use the handrail for support when climbing stairs.
  • Don’t keep your knee still in a bent position for too long, it will stiffen up.
  • Think about modifying your home, car or workplace to reduce unnecessary strain on your knee.
  • Learn to relax your muscles and let the tension out of your body.
  • Use heat/ice packs to help eases pain and stiffness.
  • Knee braces for osteoarthritis are available.
  • Speak to your doctor or therapist first for recommendations or referrals for any of the above.

Osteoporosis

15.10.18

Osteoporosis is a condition where bones are weakened so they are more likely to fracture.
This is due to bone tissue loss that is a result of ageing.  Gradual bone loss begins around 30-40 years of age.  The rate of loss accelerates for women at the time of menopause as oestrogen is protective of bone up to that time.
Lifestyle factors such as inactivity and inadequate dietary calcium and vitamin D all increase the risk of osteoporosis.
Loss of muscle strength and balance with age as well as disuse increase the risk of falling.  Many osteoporotic fractures (including over 90% of hip fractures) occur as a direct result of a fall. The spine, hip and wrist are the most common fracture sites but any bone can be affected.
Osteoporosis often remains undetected until a person suffers a fracture.  The standard accepted method to diagnosis osteoporosis is dual-energy x-ray absorptiometry (DXA), a very low-dose x-ray examination. Scans are usually performed at the hip and spine and provide a T-Score which indicates how an individual’s bone mass compares to the average bone mass of others of the same race and sex at age 20. Weight bearing exercise is the best way to prevent osteoporosis in those with normal or slightly low bone mass.

DXA Bone Density scan

A person with very low bone mass however is at increased risk of low trauma fracture and so should perform lower impact exercises such as Clinical Pilates, Tai Chi, line dancing, stair climbing, and low-moderate impact aerobics.
Exercises to strengthen the back muscles are beneficial, however correct technique should be emphasised.  
Any new exercise program should be initiated carefully, monitored closely and progress gradually.  Gains in bone from exercise in adulthood will be lost if the exercise is stopped.  High impact activities may not be practical for individuals with painful joints but gradual introduction is likely to be beneficial
Osteoporotic men and women should:  
  • Aim to exercise 4–5 times per week for 40 minutes
  • Engage in a variety of lower intensity exercises designed to optimise balance, muscle strength and endurance to prevent falls
  • Clinical Pilates based programme's  that include back muscle strengthening and balance activities like standing on one leg, heel-to-toe walking along a line, stepping sideways over objects and walking on tip toe are ideal

Winter Ski Slopes Strategies

03.08.18

Winter Ski Slopes Strategies

There’s no doubt about it, snow sports are fun. Whether you’re hurtling down the side of a mountain at 40 mph, or exploring backcountry terrain; snow sports always involve excitement, adventure and exhilaration. But snow sports are much more fun when you’re physically fit. There is nothing worse than having to limp in early from the slopes because you’re tired or sore (or even worse, injured). Snow sports are major workouts and if you’re not fully prepared physically for your holiday, not only will you be exhausted for most of it, but you’re also at a much higher risk of injury, let’s face it, nobody wants to come home in a plaster cast. So, the goal of this guide is to get you as fit as possible, in the shortest time possible, and give you the best chance to have an awesome, injury-free holiday. Snow sports demand a combination of both technique as well as muscle strength and flexibility to keep stay safe on the slopes, run after run. Decent stamina (aerobic fitness) is key if you’re going to have enough energy to last the day, and anaerobic fitness is needed for the downhill bursts of activity. So, if you’re spending your hard-earned cash on a trip to the mountains, it’s just a waste if you don’t prepare. Any preparation you can do in the weeks leading up to your holiday will improve your performance and enjoyment, as well as reduce your chance of suffering an injury. Here are our top six strategies for reducing the risk of injury while on the slopes.

Strategy 1  - Health

Anything that gets you out of breath will be strengthening your heart, and improving your lung capacity. Walking, running, stair climber, rowing, cycling and swimming are all great ways to work your cardiovascular system. Because snow sports involve stamina as well as short-burst aerobics, the most effective preparation is a combination of high-intensity training and longer, more sustained efforts called interval training. Interval training is the best way to build cardiovascular endurance; the key to the training is to maintain a high heart rate, concentrating on short sprints. Aim for two to three, 20-30 minute interval training sessions a week, working harder to increase the heart rate for one or two minutes, then working less hard to drop it right down for 2 – 4 minutes before repeating the same sequence, throughout the session. This routine can be incorporated into any of your favourite cardio workouts from running to swimming. Remember to build up the exercise slowly and incrementally. So, if you’re starting from a relatively low fitness level, have longer rest periods in between the sprints, and shorter sprint periods, and slowly build these up. If you’re not sure where to start, a physical therapist or personal trainer will be able to help you find a training schedule that will suit you. The other reason that good fitness is a major advantage is because ski resorts are usually found at higher altitudes than where you would normally live. This means there’s less oxygen in the air, meaning you need to breathe harder to get the same oxygen levels as you would at sea level and it can take a few days to acclimatise. Being physically fit can help combat side effects of a high altitude. A SESSION MIGHT LOOK SOMETHING LIKE THIS: 5 MINUTE WARM UP 1-2 MINUTES SPRINT (high heart rate) 2-4 MINUTES INTERVAL (lower heart rate) 1-2 MINUTES SPRINT (high heart rate) 2-4 MINUTES INTERVAL (lower heart rate) 1-2 MINUTES SPRINT (high heart rate) 2-4 MINUTES INTERVAL (lower heart rate) 5 MINUTE WARM DOWN

Strategy 2 - Strength

Skiing and snowboarding require a strong abdomen, and powerful legs, and in the case of snowboarding, good upper body strength too. The stronger you are, the less likely you are to get tired. If fatigue creeps in, your form can start to deteriorate, making it difficult to last the day as well as increasing your risk of a fall. Stronger muscles better support your joints, and absorb the forces from impacts and vibrations, and this can also help prevent injury. The quadriceps muscles (front of thigh) work in two ways on the slopes, helping as you both bend and straighten the knees. The controlled lengthening of the quadriceps from straight to bent is called eccentric training and is fundamental to snow sports. Squats, lunges, deadlifts and plyometric jumps are all good exercises to specifically strengthen your quadriceps and hamstrings (back of thighs) and glute (buttocks) muscles essential for snow sports. Good core strength (your deep abdominal muscles) is required to sustain postures for prolonged periods, maintain balance and control and support your back from injury. Planking exercises, bridging, using a Swiss ball, mountain climber and Pilates are all excellent exercises to improve core strength. Your physical therapist can give you specific skiing or snowboarding exercises to strengthen your legs and core

Strategy 3  - Balance

Balance is important in all aspects of snowboarding and skiing. Good balance will ensure better technique and efficiency when on the slopes but also help prevent falls and possible injury. Yoga and Pilates are two great forms of exercise for developing balance. Simple balancing home drills include: Stand on one leg with eyes closed for two minutes twice a day. When this gets easy, add some small movements, such as little knee bends or brushing your teeth. You can advance this by standing on something wobbly or uneven (a Bosu ball at gym or a soft pillow at home). Stand on one leg whilst swinging the other leg around with your eyes closed; or practice picking up small objects off the floor whilst balancing on one leg.

Strategy 4 - Warm up

Warming up increases blood flow through your muscles, preparing them to respond to the demands of snow sports, and reducing your risk of injury. Stretching as part of warm up also helps improve flexibility in your joints and muscles. Walking briskly, a jog, swinging your legs doing some walking lunges will all help. Warm up again following a lunch break or long wait at a ski lift when you’re out on the slopes. A cool down and light stretch helps remove lactic acid from your muscles and keeps them subtle, which will make getting out of bed the next day easier! Once you come off the slopes, before sitting at your favourite après ski spot, walk around for 5-15 minutes, and do some stretches.

Strategy 5 -  Equipment

Apart from physically preparing your body to cope with the demands of snow sports, some equipment can help protect it from injury. Helmets are designed to resist impact and absorb energy to minimize damage to the brain. Helmets have been shown to decrease head injury risk and severity by 2260%. Wearing a helmet really is a no brainer (pun intended!). Badly fitting bindings and rented equipment have been associated with increased injury risk. Make sure you have your bindings fitted and adjusted (even if you own your own equipment) by a certified technician. Ensure you also rent skis according to your skill level. Be realistic and don’t over estimate your ability as this may increase your risk of injury. The use of hip pads and wrist guards whilst snowboarding have been shown to be beneficial in lowering overall injury risk too.

Strategy 6 - Saftey

Experience and education are key. People with low skill levels are more likely to be injured but don’t assume that experience and skill level go hand in hand. If you’re inexperienced, lack confidence or feel a bit rusty – it’s worth taking the time to attend ski/snowboarding school or get some private instruction for the first few days of your holiday. Take time to re-familarise yourself with the snow, easing onto the green and blue runs before heading off to anything more challenging. A higher proportion of people are injured in the afternoon. This may be due to a wide range of factors, including fatigue, business on the slopes, heavy lunches, or alcohol intake, as well as changes in snow conditions. Take regular breaks through the day or carry snacks to keep your energy levels up. Ensure you stay hydrated. Just because its cold doesn’t mean you aren’t sweating from physical exertion. Dehydration can result in mental and physical fatigue. Staying hydrated can help combat the effects of high altitude. Finally, it’s your responsibility and behavior that can keep you safe on the Applying these six strategies will significantly increase your chances of returning from your snow sports holiday uninjured and intact. Keep an eye on our Facebook page for more snow sports fun and advice. And have a great holiday! slopes. Most injuries can be prevented, know the snow responsibility code and follow it: the snow responsibility code and follow it: 1.STAY IN CONTROL AT ALL TIMES 2.PEOPLE BELOW YOU HAVE RIGHT OF WAY 3.OBEY THE SIGNS LOOK BEFORE YOU LEAP 4.STOP WHERE ITS SAFE (ON THE SIDE OF THE PISTE),AND WHERE YOU CAN BE SEEN 5.STAY ON THE SCENE AFTER AN ACCIDENT Credit - Co -Kinetic Journal

Chronic Pain

28.06.18

Chronic Pain

Pain is NORMAL. It is the body’s way of alerting us to what it thinks is DANGER. The interesting thing about pain is that we don’t actually experience pain until our brain interprets a signal from the body as being pain. It is important to accept that YOUR PAIN IS REAL – IT IS NOT IN YOUR HEAD!! There are many things that contribute toward the brain signalling pain:  Thoughts  Fears  Past experiences  Family issues; My mother has cancer could this be what is happening to me?, Who will look after the family?  Work issues; Will I have to have time off? , How much money will I lose?  Anxiety/stress can increase the sensitivity of the nervous system  Exercise can help turn down pain signals by releasing chemicals that help to quieten the nervous system. All of these things make a difference as to whether or not your brain will interpret the signals from the body as pain. The important thing to understand is that the brain can still signal pain long after the original injury in the tissues has healed. When you initially have an injury, signals are sent to the brain to alert it to danger. The brain then interprets the signal, remember factors mentioned above will play a role in the brain interpreting the signal, and this is where the pain experience starts. This is all necessary so that you don’t go and do anything which may injure you further. However these messages can persist and lead to chronic pain.

Chronic pain is when you continue to experience pain long after the original injury has healed

This is due to central sensitisation. This is when the brain sends chemicals to the spinal cord to meet the signals coming from the tissues. These chemicals can be excitatory, which means they multiply the signals coming from the tissues and therefore send a much stronger signal to the brain then the original signal from the tissues. The brain can also send messages to the tissues to release more inflammatory substances – the body thinks it can heals faster this way, but doesn’t know when to turn off this inflammatory process. This type of inflammation is not helped by medication and explains why there can still be inflammation present many months later. This causes the nerves to become hypersensitive and send earlier and more signals to the brain, again this is an over sensitivity of the nervous system. Over time, the cycle continues which results in increasing sensitivity of the brain and therefore more and more pain. Pain can become a habit – your body anticipates and remembers it and it takes very little to trigger it, sometimes when things are really bad even thinking about moving can trigger the pain. The brain has lost its ability to differentiate between painful and non painful input, so just to be safe it triggers everything as pain. The brain has also lost its ability to distinguish between body parts so you may find your pain spreading or moving. The good news here is there is no damage in the tissues causing the pain, it is just that the brain is so used to feeling the pain that it continues to signal even though the damage has healed. It is the sensitivity of the nervous system that is causing this. The important things to understand is that PAIN DOES NOT EQUAL DAMAGE!! The solution is to make the brain understand that there is no longer any damage in the tissues and it is time to desensitise. We can do this through a graduated return to normal activity.

TAKE CONTROL

1. Any new injury or disease requires a prompt medical examination. 2. Understand any prescribed help. Ask for appropriate scientific evidence supporting what is offered to you. 3. Make goals that both you and your clinician understand. Aim for physical, social and work goals, which allow your progress to be measured.

Patello-femoral Knee Pain

16.04.18

Patello-femoral Knee Pain

Aching knees affect 25 % of the population and are commonly caused by dysfunction at the patella-femoral joint (under the kneecap). It is typically aggravated by bending movements such as sitting, walking up and down stairs or hills, jumping and running. It is also common during adolescence as the long bones are growing faster than the muscles, tendons and ligaments putting abnormal stress on the joints.

Causes

  • Unfortunately genetics have a part to play and this can’t be changes
  • Faulty bio mechanics due to muscle imbalances

Treatment

Treatment is very successful and we will look at correcting muscle imbalances throughout your lower back, hip, pelvis and leg. This is done by manual techniques to the knee cap, massage, acupuncture, exercise and taping.

Patellofemoral pain

06.11.17

Experiencing knee pain while walking, running, squatting, kneeling, going up or down stairs or slopes?

You may have a condition known as Patellofemoral pain syndrome.

Patellofemoral pain syndrome is one of the most common knee complaints of both the young active sportsperson and the elderly. Patellofemoral pain syndrome is the medical term for pain felt behind your kneecap, where your patella (kneecap) articulates with your thigh bone (femur). This joint is known as your patellofemoral joint Patellofemoral pain syndrome, is mainly due to excessive patellofemoral joint pressure from poor kneecap alignment, which in time, affects the joint surface behind the kneecap (retropatellar joint). Physiotherapy inventions help strengthen one’s quadriceps and hips, which subsequently aids in restoring the biomechanics of the patellofemoral joint. Physiotherapists are able to advise and design customised exercise programs to improve the strength of your knee and leg muscles and help you maintain good general fitness. If you are experiencing patellofemoral pain, or any pain in your knee and joints, it is important to have your condition assessed by a physiotherapist. Patellofemoral pain typically develops because of 1 of 3 different reasons 1. Excessive pronation of the foot (flattening of the arch). It doesn't matter if you have high arches or flat feet, it depends on how much your arch flattens from non-weight baring to weight baring. This can be addressed in the short term with the use of orthotics but a strengthening program of the muscles that support your arch is recommended. 2. Weak quadriceps (weak thigh muscles). The quads are the largest muscle group in the body that we use to extend our knee. Important for walking, running, squatting, and climbing stairs. We can test your maximum isometric contraction and compare it to your unaffected side to see if this is a contributing factor and address any deficit with an appropriate strengthening program. 3. Weak hip abductors (gluteal muscles). Gluteus medius and minimus help to keep our pelvis level while walking and running. If your opposite hip dips then the knee you are standing on will drift inwards causing poor alignment of the patellofemoral joint. This deficit can be picked up with good observation skills and strength testing.    

Osteoarthritis and supplements

08.10.17

Osteoarthritis and supplements

Osteoarthritis is a common inflammatory condition characterised by joint pain. See below example. osteoarthritis knee Osteoarthritis affects 2.1 million Australians.  The prevalence is higher in women and joint symptoms are experienced by more than 25% of people aged 65 years or older. Osteoarthritis is particularly burdensome, on individuals and on the healthcare system and is the main reason for knee replacement surgery.  This is of great concern considering the projected rise in the aging population.   In recent years, omega 3 fatty acids (from fish oil), glucosamine and chondroiten have increased in popularity. Research into these and osteoarthritis is showing some promising results, however more research is still needed.   Should you take these supplements if you have Osteoarthritis?? You can as there is some worthwhile evidence but it should form only a small part of your management plan. Score your pain on a scale of 1-10 before taking the supplement, then after 3-6 months score your pain again to see if there has been any change. If you are taking chondroitin it is recommended that you take a supplement containing 800mg such as BioOrganics glucosamine 750g and chondroitin 400mg.   There is much stronger evidence to show that dietary induced weight loss (>10% of body weight) and physical exercise such as strength training and aerobic exercise can have a moderate to large improvement in pain, function and quality of life.   In addition, learning effective pain – coping skills have been shown to have positive outcomes not only for pain but also for function, stiffness and disability.