Post 72

Not all press-ups are created equal
“Low back pain (LBP) is a common medical condition that affects p to 80% of the population and can have a profound impact on a person’s everyday life”

This statistic gets used so often that it should be common knowledge at this point that 8 out of 10 people will experience back pain at some point in his/her life. It is almost as common as the cold and it has overtaken respiratory issues for reasons to seek health care.
“LBP was ranked the greatest contributor to global disability and sixth for overall daily burden…in 57% to 89% of people with LBP, no specific etiology can be identified”.

This is huge! Think about this way, LBP is the biggest reason for people to become disabled, but only in about 10% of the cases, can a medical professional tell you the cause of your problem. Might as well play spin the bottle with ten different options. The likelihood of your doctor coming up with the cause of your back pain is as likely as the bottle landing on the cause of your back pain. This is not the doctor’s fault though because not all back pain is the same. If it is not all the same, then it should not all be treated the same. It should be classified, either in a sophisticated manner such as with Mechanical Diagnosis and Therapy or in an unsophisticated manner such as your “core is weak”.
“…subjects with LBP moved more in the lumbar spine during the early phases of forward bending, and that the lumbar spine and hips contributed equally during midranges, similar to controls…when rising from a forward bend, subjects with LBP moved more in the lumbar spine during the first 25% of the movement”

This is getting nit-picky. The easy way to say this is that people with back pain move from the spine in a different way than those without back pain. Depending on which school of thought you listen to, the lumbar spine should remain stable and all of the movement should happen at the hips. If this is the case, then any movement at the lumbar spine would be unacceptable. I don’t fall into this school of thought…but sometimes they are right, especially under load such as a 500# bar or a bag of dog food. Whatever best resembles your lifestyle.
“Three of the more common approaches include the Movement System Impairment (MSI) classification system, the McKenzie approach, and the treatment-based classification system (TBC), with associated clinical prediction rules (CPRs)”

I have a problem with this right off the bat. The Mckenzie approach is formally described as Mechanical Diagnosis and Therapy (MDT). There has been stigma against this approach due to the man that started the approach by “accident” and through careful observation and experimentation the approach has been validated time and again in the hands of those that are qualified. The fact that the authors call it the lay term “McKenzie Method” instead of the official MDT makes it hard for me to not comment.
The TBC is based on clinical prediction rules that have yet to be validated, this is of course aside from the manipulation category. We all know, by now, that manipulations are a powerful tool for all PT’s and Chiro’s to use with patients.
“…the LBP group displayed significantly less lower lumbar extension than did the control group”

If your PT notices this…kudos. What I tend to see is that the upper lumbar spine will extend and then the patient’s pelvis will come off of the table. This has been called “end-range” in some circles, as the lumbar spine has no room left to move and therefore the additional movement happens at the hip. What’s interesting is that I have seen this improve within a session, so the concept of reaching end-range because the pelvis has left the table doesn’t sit well with me. This could be the result of nuclear migration within the annulus, soft tissue accommodation based on the principle of creep or motor learning. I’m sure that there are other possibilities; I just don’t have them at the tip of my tongue (or fingers). Be that as it may, the extension mobility can clear up relatively quickly.
The take home message is that those with back pain don’t move the same way as those without back pain. It sounds like common sense, but it is only common sense when it is proven by people that get paid to tell us…DUH!
Excepts taken from:
Mazzone B, Wood R, Gombatto S. Spine Kinematics During Prone Extension in People With and Among Classification-Specific Low Back Pain Subgroups. JOSPT 2016;46(7):571-579.

Manipulation of the ankle joint

Manipulation of the Ankle Joint.
Now this will be a learning experience for all of us, except for maybe some chiros that follow the research or some professors that teach manipulation. For those of us that aren’t doing manipulations (or grade V mobilizations depending on the state that you live in) on a daily basis, this information is interesting. It will be a learning experience for me to type about it and I may not be able to give a strong background on the information, as I continue to learn about this type of information over time.
“Joint mobilization is delivered as a low-velocity sustained or oscillatory force, while joint manipulation is often defined as a hight-velocity thrust.”

For the most part this is true. Joint mobilizations are graded from I-V (Roman numerals like in Star Wars seems to provide more credibility than simply writing 1-5). Grade five is defined as the rapid thrust that is described in the manipulation aspect.
RANT: The APTA, in its white paper on mobilizations and manipulations, prefers that only PT’s perform these movements because students will become proficient in these movements through schooling. I call BS! I have only met one student in 8 years as a clinical instructor that could walk into the clinic and perform all of the manipulations without error. Most students have difficulty performing basic mobilizations. That’s okay, I am not judging the students (well really I am, as the CI, but I won’t knock the grade because they can’t perform the manipulations). The point is…most PT’s become proficient at the manual aspect of the profession outside of schooling. With all of that said, I don’t agree that PTA’s can’t perform mobilizations as a treatment, assuming the PT is there to assess prior and post manipulation. It is really arguing semantics, as it is not applicable in most situations.
“A number of researchers have demonstrated changes in the excitability of motor pathways following manipulation of the spine”.

When the article speaks of manipulations, the authors are describing the high velocity thrust technique. Performing these techniques causes changes in pain pressure threshold in some patients (think that you could tolerate more pain following the manipulation). In real world sense, it would theoretically require a greater stimulus to create the same pain that you felt prior to the manipulation. There is good work by Stephen (sp) George out of Florida regarding this concept.
“Existing research utilizing transcranial magnetic stimulation (TMS) has also indicated an increase in corticospinal motor excitability following manipulation to spinal joints, but not following low-velocity end-range positioning.”

I’ll be honest, I had to go look this one up. Neuro is not my strong point. I know that we have a brain…the end. Okay…I know a little bit more than that, but not much. I tended to fall asleep during the neuro portion of PT school and would dream about orthopedics. Oh well. Live and learn, it’s actually important.
The basic of the article is that the brain dictates the muscle action. There’s that old saying that “if you see it, then you can be it”. It’s something like that. The brain can increase electrical input to a separate muscle group and the brain can shut down the impulse to muscle groups through imagery, but it can also happen through manipulations, as seen in the article that I am quoting.
“Measuring modulation of corticospinal excitability with active contraction is important, because such changes would suggest an alteration in voluntary recruitment”

This is big for me, as a meathead, because if I can get my brain to send out more electrical impulses, then I, as a meathead can theoretically lift more weight. That’s all that really matters. Unfortunately, there is not a lot of research on this in the PT world, so more to come later when our profession starts to look into athletic performance.
“Individuals in the control group received the hand placement used for a caudal talocrural thrust manipulation only…Individuals in the intervention groups received a caudal talocrural mobilization or thrust manipulation.”

I won’t describe the technique because… “Kids, don’t try this at home”. Just know that it is fairly easy to perform for someone with experience performing manipulations. The manipulation is performed at the foot/ankle complex.
“Our findings indicate that thrust manipulation increased corticospinal motor excitability of the tibialis anterior approximately 30 minutes following thrust manipulation directed at the talocrural joints…there was no significant change in ankle dorsiflexion or dynamic balance following either of the interventions”

Big picture…a manipulation may make you stronger at contracting a muscle, but there doesn’t appear to be functional carryover in this report. It is still big news because there may be other manipulations that not only make your stronger, but also has functional carryover. This will be the fountain of youth once found. A stronger person is a more functional person, assuming that the person has adequate ability to move.
Quotes from:
Fisher BE, Piraino A, Lee Y, et al. The Effect of Velocity of Joint Mobilization on Corticospinal Excitability in Individuals with a History of Ankle Sprain. JOSPT 2016;46(7):562-570.

Lateral shift deformity

Crooked patients 

1. “A lumbar lateral shift (LLS) is defines as a lateral displacement of the trunk in relation to the pelvis…repeatedly associated with discogenic pathology…McKenzie reported that 90% respond rapidly to manual correction.”


In school we learn the theoretical aspect of the shift, but when you see your first patient that is shifted the though process immediately goes to a mixture of “oh shit and piss on yourself excitement”. The shift can be extremely painful and students, if not treating this in a clinical, may not be prepared for a patient in a true 10/10 pain status. After so many years in practice, it is just another puzzle to solve now. The excitement has gone away and lucky for the patients, so has the “oh shit” response.  


Patients come into the clinic “crooked”. Scott Herbowy once said it is like looking around the corner to see if the dog is hiding.  


2. “…prevalence of LLS is difficult to establish, but estimates range from 5.6 to 80% of patient with low back pain (LBP).


This statistic is so far away from informative, that it shows that it is present in any where from 5-80 out of 100 patients with back pain. I don’t see it in 80% of the patients, but 5% may be more applicable to my population in the clinic.


3. “Lumbar spinal fusion, perhaps the most invasive of these (surgical) procedures, is increasingly common in the United States. However, its effectiveness is questionable…”


If you are going to have a fusion, go so someone that is either certified or diplomaed in MDT first. Some things can’t be undone, and this is one of those things. Make sure that there are no other options of getting relief prior to undergoing something that may not be effective and can not be undone.


4. This article is a case study of a patient that has a lateral shift deformity in the presence of an “X-stop” device, which is typically used to prevent lumbar extension in the case of spinal stenosis. The patient centralized with side gliding mobilizations and was issued side gliding against the wall in order to close the affected side. The patient responded well to this motion within the initial 4 visits and the final 4 visits were used to improve functional performance without the return of the lateral shift. The X-stop makes this case interesting because typically patients that are post-surgical are excluded from most research.  


5. “The rapid centralization of symptoms observed in this patient is similar to that reported in previous case reports describing a lateral shift correction. Centralization or peripheralization during repeated movement testing has been positively correlated with pain provocation during lumbar discography.


Centralization phenomenon is something that trained clinicians are looking for during examination of the spine. When noted, the results are typically great, but if the peripheralizes (opposite of centralization), then the patient’s results are typically poor, at least if it happens with all movements tested.  


First point to make from this is that if you have back pain, seek out a trained therapist in order to address your symptoms. Always start conservative before going invasive for pain based symptoms. If you have progressive weakness or have a loss of bowel and/or bladder function go the doctor immediately, but aside from this stay conservative first.  


Second, people get crooked. If the crooked is not associated with pain, it may be that the person has always been crooked. Not all crooked people need therapy.  


Excerpts taken from:


Peterson S, Hodges C. Lumbar lateral shift in a patient with interspinous device implantation: a case report. JMMT. 2016;24(4):215-222.

Keeping the customer/patient happy


“…owners and managers an no longer rely solely on the relationships they have built with referral sources to grow their practices”


Look at the drug companies…they know how to peddle their wares. Once it became mainstream to advertise directly to the consumer we have what is now known as the “opioid epidemic”. If we can advertise directly to the consumer, and give the consumer what they want…business will boom. We have to know what the consumer wants first though. Don’t try to sell them what we have, know what they want and then create the product. We know that patient’s primarily want education first. Give them a taste of the education during a seminar and then tell them that they have to schedule an appointment in order to get the rest of the information. It’s funny. I remember working for Bill Curtis at PT and Spine and he would refer to the magic treatment. In that patients are looking for that magic so that way they can take control of their own issues. If one is the owner, we want to give the patient the magic…but not on the first day. If we got paid for outcomes and not for the patient coming to the clinic, there would be more incentive to help fix the patient at the initial visit and not carry it on for the national average of 8-16 visits for the average orthopedic issue.  


“Even five years ago physicians largely dictated our referral patterns…hospital-based clinics and physician-owned practices are aggressively attempting to keep their patients “in-house”.  


Everyone in business wants money. THEY WANT YOUR MONEY! There is incentive to keep you going to the same company for every service performed. If you need an MRI, X-ray, PT, sports physical, etc it is very convenient if it is all under one roof. Now, who is making the money? I’m going to make it easy. If your mechanic finishes looking at your car and then says that you need $10,000 dollars worth of work, but he can do it all at once, what are you going to say? What if I say that you need $20,000 worth of work? How high do I have to take that number before you realize that it may not be legitimate needs to continue? The doctors/hospitals that own all of the above “services” may be doing the same thing, but you never see the costs because the insurance “covers” the cost.


“We are aware that patients can choose to receive therapy wherever they would like…”


Are the patients aware of this? If you go to the doctor and get a referral for therapy (it’s like a referral to any other practitioner), but the referral has the name of a specific clinic on it, does the patient realize that they can still go anywhere? IF YOU ARE A PATIENT AND ARE READING THIS…YOU CAN GO TO ANY THERAPIST THAT YOU WANT TO GO TO! Not all PT’s have the same training or even the same specialty. If you don’t see progress with your therapist after 6 visits, and you are given the words “it just takes time”, find a new therapist. Some things do take time, but hear it from 2-3 different therapists before you actually believe it.  


“We are not here to ‘fix’ a patient; we are here to partner with them in their rehab”


This is huge. I don’t fix you…I help you fix yourself. I play the role of cheerleader, teacher, listener, advisor, but at no point am I the “fixer”. When I see you for 2 hours per week, there are so many hours throughout the week in which you have to help keep yourself fixed by what you learn in the clinic.  


I realize that I can come across as negative with regards to the business of healthcare and unfortunately it is more of a realistic view than either pessimistic or optimistic. I have had discussions with those that audit clinics, researched the Department of Justice website for healthcare fraud, shadowed/worked/observed in unethical clinics and have heard patient stories from their times in other clinics. My view is personal, but real. When I say get a second or third opinion, it’s because you may have to go through that many different clinics before you find one that has your intentions at the forefront.  


Excerpts taken from: Stamp K. Happy Customers: How to create a positive patient experience. IMPACT. July 2016:31-32.