Month: February 2018

McKenzie Method and back pain

I recently just read a case study, which I will be referencing a lot in the future paragraphs, regarding the use of MDT in the treatment of a patient with pain.  This is not uncommon, but what makes it special is that that the patient has a diagnosis of recent transverse process fractures in the spine.  Hope you find it interesting also!

 

First, Mechanical Diagnosis and Therapy (MDT) is also known informally as the McKenzie Method.  You can read more about the method with this link.  Also, this method is used by therapists all across the world as seen  here. Finally, if you are looking for more in depth information on the method, it can be found here.  There is so much information out there regarding MDT that there is no need for me to go back and explain it all again.  Read the previous stuff that I did. 

Patient characteristics

  1. 24 y/o female referred with left sided back pain
  2. 10 week previous involved in accident in which she was hit by a car while walking
  3. Transverse processes fractures from L2-L4
  4. Evaluation occurred about 10 weeks following accident

Examination:

  1. PT and MD agreed to patient generated forces only
    1. This is important! The most important part of this statement is the communication that is taking place between the PT and the physician prior to the patient entering the clinic. Also of importance to note is the trust that the physician has in not only the therapist, but also the method, as the patient was specifically referred for an MDT assessment. 
  3. Left low back tightness and numbness constantly
    1. Pain was intermittent
  5. Sometimes worse with sitting and tenderness when sitting against a hard-back chair, sometimes worse with activity and waking a few times per night due to pain
    1. The above is also important as this indicates high irritability as the symptoms can be constant and pressure can increase the symptoms. Also, the patient is waking during the night, which is historically correlated to an inflammatory process, but can also be position related. 
  7. The patient was better with standing, walking and lying
    1. This could mean that the patient has a directional preference for extension, prefers to be unloaded or is better with movement. The only way to figure out how these variables play a role in her symptoms is to start playing/manipulating the variables and watch the outcomes.  This is no different than any other science-based projects.  We have the opportunity to work with patients that trust us.  We have a responsibility to work with the patient in order to educate them as to the process of attempting to narrow down the variables at play regarding the symptoms.  Once the patient is agreeable to working together, we can change the inputs to the brain and assess the outputs in terms of physical changes and perceived changes from the patient. 
  9. Worse with postural correction, but no worse with using a lumbar roll.
    1. Postural correction, when performed according to the book is a hands-on technique and in doing so may be too much for the patient to tolerate. The fact that the patient is no worse with a lumbar roll means that extension, in and of itself, may not be bad but increasing the range in a loaded position may not be preferable at this time.
  11. Patient was issued back bends, repeated extension in standing, after the first session due to her complaints with flexion based movements and improving with standing and walking.
  12. Visit 2 overall unchanged and the patient was instructed to lean against a countertop to provide a fulcrum to lean against during the movement. This is, theoretically, to allow for increased force during the movement.
    1. The worst response to any movement that I can see in the clinic is “no overall change”. If we can’t change the patient’s symptoms or movement patterns, or strength, then it is hard to predict if the patient will respond to therapy over the course of care.  If the patient gets worse during the evaluation, it is not good/bad, just a response.  The thought is that if the patient is able to change for the worse, then the PT should be able to create a change for the better.  It’s simplistic thinking, but in the presence of a mechanical and not chemical issue, it is a common response to see in the clinic.
  14. Patient was better with either the countertop version of backbends or when doing pressups
    1. This is a version of progression and alternative versions of the same exercise. For example, the thought is that during a pressup, the patient is able to move further into the range of extension than during a back bend.  This may be because of eccentric loading of the global flexors or because of gravity assistance during the pressup on the lumbar spine.  I haven’t seen any research that definitively states why, but these are the thoughts.
  16. By the third visit, the patient reported 80% improvement with no pain.
    1. This is very common to see when a patient presents with a mechanical response and is categorized as a derangement (see all of the links above). It’s not uncommon to reduce symptoms in less than 7 visits. 

 

The big picture lessons from this case are:

  1. Don’t be afraid to assess a patient systematically.
  2. Communicate with other members of the health care team.
  3. Be willing to change your plan when something isn’t progressing accordingly.

Elenburg JL, Foley BS, Roberts K, Bayliss AJ. Case Report: Utilization of Mechanical Diagnosis and Therapy (MDT) for the treatment of a lumbar pain in the presence of known lumbar transverse process fractures: a case study. JMMT. 2016;24(2):74-79.

If you are having back pain and want to be evaluated by a certified MDT therapist, you can find me here.

What’s it mean to be a PT part I

 

 

As professionals, we are all supposed to practice in accordance with the core values and within the Code of Ethics.  Having conversations with PT’s all over the country regarding unethical situations makes me think that some in the profession could use a refresher.  Especially those (me included) that may not have been paying close attention to this information while in school.

Principle #1: Physical therapists shall respect the inherent dignity and rights of all individuals.

It’s unfortunate that there are people that make bad decisions in life.  There are cases of PT’s acting inappropriate with patients. Here’s a recent article regarding a PT that was found to act inappropriately by his state board.

Moral of the story: patients have inherent rights as people.  Although we are in a position of trust, we must never do anything to compromise that trust that patients place in us.  Patients are coming to us at a vulnerable time in his/her life and we must acknowledge that.

  1. Physical therapists shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability.
    1. It’s been published that some students receive lower grades during a clinical correlating with race.
    2. PT students may not feel comfortable treating the older patient with the same principles as the younger patient per this
    3. Another study speaks to the disparities among races for receiving medical care for knee

 

I guess that I have been naïve all of these years.  As a minority that comes from a blue-collar family, I never paid attention to this and have not seen it personally.  We have to take into account our  implicit bias at all times.  For instance, I recently attended a health fair at the local Spanish Community Center and the people were so surprised that a Mexican from “the neighborhood” was able to earn the title of Doctor.  This type of bias affects every generation that gets infected with this negative thinking.

  1. Physical therapists shall recognize their personal biases and shall not discriminate against others in physical therapist practice, consultation, education, research, and administration.
    1. I thought that a lot of these principles were common sense and part of being a good person, but apparently there are a lot of people who have these biases in healthcare.

 

 

THIS IS THE FIRST IN A SERIES OF POSTS THAT I WILL BE DOING ON THE CODE OF ETHICS AND CORE VALUES.  FOR SO LONG, I’VE ATTEMPTED TO LIVE THESE CORE VALUES OF OUR PROFESSION, BUT THEN I HAVE COME TO REALIZE THAT SO MANY OF MY STUDENTS COULDN’T RECITE THEM.  TO ME THIS MEANS THAT THEY HAVEN’T BEEN INTERNALIZED.  AS PROFESSIONALS, WE NEED TO ACT LIKE PROFESSIONALS AND AT LEAST BE AWARE OF OUR CORE VALUES AND CODE OF CONDUCT.

A personal synopsis of the Monk and the Merchant

My take on the Monk and the Merchant

Let me first say that I read through the first 30% of the book and got nothing from the book.  I was tempted to put the book down and just be done, but remembered that it was recommended by Dave Ramsey for a reason and just continued to trudge through it until the book piqued my interest.

This was my first lesson from the book: If I can build up my reputation and gain the trust of people, I will be able to lead them.  Had I not trusted in the words of Dave Ramsey, the author of many books and a highly ranked  podcast, I would have stopped reading.  If I can gain the trust of people in my immediate area and truly am altruistic in my teachings and business, then I can also achieve this type of success.

“Principal one: work hard and God will prosper you”

Hard work has never been an issue. As the son of a laborer, who never missed a day of work unless he had a fractured bone, work is expected. I never thought of work as performing God’s will. We were given the ability to bless those around us with our talents and through those blessings we receive thanks in the form of dollars. This aligns with Rabbi Daniel Lapin‘s theory that those that are paid much are only paid much because they affect many people. Watch the video here.

“It’s easy to have an idea. But it’s another thing to commit time and effort to it. “

This very much describes me. I have the attention span of a squirrel. If it can’t be done in 20 minutes, it’s probably not going to be done. Doing things like writing the blog, scanning paperwork into the computer system at work, creating presentations etc. etc. are not my strong points. In an average day I have so many ideas that it’s hard for me to even capture them. Acting upon those ideas is where I have difficulty. If anyone has ever listened to Barbell Shrugged I can very much relate with Mike Bledsoe. If you haven’t listened to it, I highly recommend it.

“… There are a lot of great ideas. But if we allow the negative influences of others to stop us, then we will never accomplish anything.“

This one is a great quote but doesn’t necessarily apply to me. Naysayers and negative influencers provide more fuel for me to perform the activity that they’re telling me that I’ll fail at. I think that if a person is so easily swayed by a negative influence, then the idea that they have is not very convincing. It’s easy to fight for something that you internalize, but hard to defend a fleeting thought against pressure from those held on high.

“So, the first principle is basically, ‘Seek God and decide what you want to do, and then do whatever it takes to make it happen.’ Oh, and work hard at it.”

I like that the quote mentions seeking counsel in God.  A long time ago as a student at Joliet Junior College, I was torn between going to medical school and becoming a teacher.  My prayers were answered in that I was to go to school to become a teacher.  During these prayer meditations, God spoke to me not to just become a teacher, but to also follow the path that it takes me to have an impact on many people.  At the time, I assumed that this meant that I would be able to affect many at once with my time as a teacher, but alas, I was wrong.  The path from studying education led me back to healthcare as a PT.  In this field I have influenced over 18,000 people with a blog, over 60 students, thousands of patients and multitudes of people through volunteering my time in this profession.

By the way…none of that would’ve happened without hard work in the process.

“Principle two: Financial prosperity is often connected to soul prosperity”

It’s so simple.  It doesn’t have to be difficult. Find that thing that lights up your heart and follow it.  It will not let you down!

I’ve never had a single position for more than 7 years and even that’s a stretch if you consider how many times I left that position and return.  Again…squirrel.

I have an obsessive demeanor.  I do that what I enjoy and do the hell out of it.  At some point, the joy dissipates and then goes away altogether.  At that time I go find something else that lights up my heart.  Some people love challenges; some people love helping others; some people love to be recognized; some people love to be paid.

Go find that thing that makes you smile. I find it incredible how many people that I come in contact with that do not know what makes their heart sing.  It must be hard to live like that.  How can one ever be satisfied? Happy? Complete? If one never finds that “thing” that makes their eyes shine, heart sing, and face light up, how hard must life be?

There are many ways to help people. Many ways to be challenged. Many ways to be recognized etc.  Once I feel completed at one version of helping others it’s time to move to a different version of the same theme.

It does become harder as one has more responsibility because each move affects more than just you.  For instance, it was easy to transition from pushing carts at Sam’s club (helping people) to putting on tires (helping people) because I had no responsibilities to anyone other than myself.  It was a much harder decision to go from a financially lucrative position at a local hospital to a private company with less financial incentive.  I had to have a conversation with my wife and we discussed how it would affect our family.  In the end, this change has allowed me to help more people than I ever could had I stayed at the hospital.

“Principle three: A man must do whatever he can to provide for his family”

This goes hand-in-hand with the last principle.  I have to provide for my family and that ranks right up at the top with personal satisfaction.  Because of the decision to leave the financial stability of the hospital, I’ve taken on a second job to try to narrow the gap between what I used to make and what I make now.  Again, work is not the problem, but other problems do arise.  For instance, it is now one additional day that I am away from my family.  One additional day that I don’t get to recharge.  One additional day in which I have responsibilities outside that of just my family.

We must question our decisions and determine if we are on the right track.  I am sure that I made the right decision to take the job at the lower paying position, but not sure if I need to keep the second job or choose a different path.

“Many men have robbed themselves of their destiny because they have allowed discouragement to rob them of their dreams”

I’ve been blessed throughout my life.  A good friend, Mary Jones, described my life like this. It goes beyond me though.  I’ve been blessed with a support system that treated me fair and always encouraged me to just keep going forward.

Not everyone has been as blessed and we all start the race at a different starting line, but we all must run.

Principle four “Trials develop your character, preparing you for increased blessings.”

As long as you don’t stay down, you will grow stronger and more resilient.  When you become stronger, more people will follow.  I’ve had many trials in life but was too dense at the time to know that quitting was an option.  I was too dense to know that there were other possibilities and that failure was an option.

These trials and difficulties, we all have them, have led me down the path.  We all have fears and skeletons in our closets that push us or create chips on our shoulders.

 

HOW one responds to those fears, skeletons, and chips will define WHO one becomes in life!

Excerpts from The legend of the Monk and the Merchant