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Start Back Screening Tool

“Lifetime prevalence for LBP (low back pain) has been reported to be between 60% and 95% and 34% of the participants in a large population study in Norway reported to have had LBP last week”

These numbers are scary, but are consistent with other published research that notes about 80% of the population will have back pain at some point in life. Think of how lucky you would have to be to go an entire lifetime without having back pain based on these numbers?

It can happen, as I’ve seen patients in their 80’s with a first time occurrence of back pain.

The part that is sad for me, as a PT, is that less than 10% of these people will ever get in to see a PT for back pain.

“Due to the lack of diagnostic tests that can identify objective signs of the condition, most of the patients are characterized as having ‘non-specific LBP'”

If you’re not familiar with the numbers, it has been said that any diagnosis trying to name a specific tissue (disc herniation, arthritis, spondylisthesis, spinal stenosis etc) is only correct about 10% of the time. The more severe the diagnosis the more likely that the specific tissue is the correct diagnosis (such as a tumor, spinal cord injury, infection).

Because of this, a majority (90%) of back pain is just labeled as “non-specific low back pain”. The problem with this is that the treatment for a non-specific problem tends to be…non-specific.

Don’t get me wrong, a majority of back pain doesn’t need much treatment, if any at all, and tends to improve over the course of 6 weeks. Some pains from the back require a specific treatment and a treatment outside of this Specific treatment can worsen symptoms.

This means that we have to actually attempt to classify a patient’s presentation. Understand please that a classification is not a diagnosis but instead more of putting the symptoms into a non-specific “bucket” that most resemble that presentation. For instance, there could be a bucket for fast changing, slow changing and unchanging. There could be buckets for a primarily psychosocial component, chemical component or a bio mechanical component.

“Based on the SBT (Keele Start Back Tool) scores, patients can be categorized into three subgroups: patients with low, medium, or high risk for developing persistent LBP and activity limitations….the low risk group should receive minor attention from health professionals and self management strategies are recommended for these patients. The medium risk group should be offered physiotherapy. For the high risk group more psychologically informed interventions are recommended”

This statement may upset some of my colleagues in PT, but we aren’t always needed for patients that experience back pain. For instance, it is advocated to see a PT if you have pain lingering more than a couple of Days. I’m not sure I completely agree with this, as much back pain reduces spontaneously. The last thing you, as the patient should want is to pay for unneeded treatments. The last thing that I want to do as a PT is to take a patients money if I am not needed at that time.

Again, don’t get me wrong there is a group of patients, with back pain, that should be treated by a Physical Therapist. These patients will score higher on the Start Back Screening Tool.

With that said, it is important that the patient be classified correctly within the first 6 weeks of experiencing symptoms. Some research demonstrates an early classification is beneficial and others demonstrate that it should be done within 6 weeks of symptoms. The reason for this is that the patient may benefit from more psychologically informed interventions, which should be performed by someone with

“To be useful as a screening tool in physiotherapy practice, it is important that the SBT-scoring is reliable and that the allocation to risk groups reflects the severity of the patients back problems.”

There are two things that we look at in terms of performing testing. One, is the test valid. This means does the test actually tell us what we think it tells us.

The second thing is reliability. This means that if I have multiple therapist from different settings performing the same exact task, would I get similar or exact scoring if performed on the same exact patient by different therapists.

“The SBT consists of nine items; referred leg pain, comorbid pain, disability, bothersomeness, catastrophizing, fear, anxiety, and depression…. The total score range from 0 to9, with nine indicating worst prognosis. The last five items are summarized into a psychosocial sub scale with five as the maximal score, indicating high risk for development of chronic LBP”

For more information about scoring, I personally like to use the Shirley Ryan website of outcome measures found here.

“Patients with a total score of 0-3 are classified as low risk (minimal treatment, eg self-management strategies).

I use this tool frequently in PT. I rarely have patients score a 3 or less, but this may be because they are already filtered out by the physician in primary care.

I recently had a patient score a 3 and lo and behold his symptoms were abolished in 6 weeks without intervention.

It’s a small sample size, but it seems to match the research.

To summarize: the STarT Back Screening Tool is an option to utilize in practice in order to determine if a patient

1. Requires little/no intervention and will return to prior level of function (PLOF) through regression to the mean (time > interventions).

2. Requires PT/Rehab only

3. Requires a more psychologically intensive approach to care.

Click here for original research article.

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Clinical Practice guidelines for Bell’s Palsy

Let me start by saying that I have seen few cases of Bell’s palsy comparatively. I can say I’ve seen no more than 10 cases in 12 years and reading this practice guideline, I can understand why it’s not a large percentage of patients seen in the clinic.

This post will be linked to the next blog post on Bell’s palsy because there are some conflicting recommendations, but not dramatically different.

“Bell’s Palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mononeuropathy…most common diagnosis associated with facial nerve weakness/paralysis”

I enjoy history. I didn’t know about Sir Charles Bell and I found this piece informative. Whenever a new disease or species is found, sometimes the discovered of the new xyz gets to name the new xyz. It is one way to keep their name alive. It could’ve also been described according to the actual dysfunction, as facial nerve palsy would indicate to everyone what is happening to the patient.

Once you see a patient with Bell’s palsy, it is never forgotten. The dysfunction can have dramatic effects on patients in terms of livelihood and willingness to go out in public.

People close to me know that I am a huge wrestling fan. One of the greatest, if not the greatest announcer in the history of professional wrestling is Jim Ross. His was the first time that I can remember learning of Bell’s palsy and it’s possible that his diagnosis cost him his job. It’s at least written about in other forums that there is a relationship. It was a long time before I got to hear about slobberknockers on tv again. Jim is back to work and his disease is visible to those that look close enough at his face.

“…rapid unilateral facial nerve paresis (weakness) or paralysis (complete loss of movement) of unknown cause.”

I have seen this run the gamut from barely noticeable to unable to close the eye or mouth. At the worse end of the spectrum, the person had major issues with drinking because there was incomplete mouth closure, which caused liquids to spill out of the mouth. Also, the same person was unable to move the eye or cheek muscles. An eye patch was required.

“…may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential injury”

With issues of mouth and eye closure, imagine how hard it is to keep the eye moist. Blinking assists in lubricating the eye, not to mention that the eye has difficulty producing moisture from the gland in the corner of the eye in the presence of Bell’s palsy.

“Treatments are generally designed to improve facial function and facilitate recovery”

The patients that I have seen, remember only a handful, I believe that only one person improved. At no point in time do I take credit for that, as a majority of patients improve over the course of 3 months. This patient was referred to me at the 6 week mark and time may have been more important than anything I did regarding the patients recovery.

“…the following should be considered:

-Bell’s palsy is rapid onset (<72 hours)”

I’ve had patients associate Bell’s palsy with a cold breeze blowing on them at night. They say this because the onset is so quick that some literally woke up with it. The patients attempt to find answers for why things happen. As a healthcare provider we have to do our best to educate and reassure the patient that it was nothing that they did to cause this phenomenon.

-“Bell’s palsy is diagnosed when no other medical etiology is identified as a cause of the facial weakness”

This is a diagnosis of exclusion. As mentioned at some point in this article, differential diagnosing needs to be performed in order to ensure that there is nothing sinister or other diagnosis causing this problem.

-“bilateral Bell’s palsy is rare”

I have personally never heard of bilateral Bell’s palsy and have obviously never seen it with my low level of experience treating this issue.

-“Currently, no cause for Bell’s palsy has been identified”

This has to be stated to patients. They will matrix and try to come up with a cause, which can create a change in behavior and the spreading of “old wives tales”. The most common one I hear is that the window being open caused a breeze while sleeping, or a fan was blowing on my face causing a breeze, to cause the symptoms.

-“other conditions may cause facial paralysis, including stroke, brain tumors, tumors of the parotid gland or infratemporal fossa, cancer involving facial nerve, and systemic infectious diseases including zoster, sarcoidosis, and Lyme disease”

These are all major issues that require a thorough history and possible imaging to determine if Bell’s palsy is the true diagnosis or if there is something obvious causing symptoms.

-“Bell’s palsy may occur in men, women, and children, but is more common in those 15-45 years old; those with diabetes, upper respiratory ailments, or compromised immune systems;or during pregnancy”

It affects both genders (I’ve seen both men and women), a wide age spectrum (I’ve never seen anyone older than 50) and multiple comorbidities can increase risk.

“…paresis/paralysis typically progresses to its maximum severity within 72 hours of onset of the paresis/paralysis”

This is good to know as a PT. It’s rare for us to see these patients in the acute, or immediately after it starts, stage. Because of this, should we see a progressively worsening condition, it would be prudent to refer the patient back to the physician in order to rule out any other medical concerns.

“Facial paresis or paralysis is thought to result from facial nerve inflammation and edema”

This is one of the explanations, but again there is no known cause.

“The facial nerve carries nerve impulses to muscles of the face, and also to the lacrimal glands, salivary glands, taste fibers from the anterior tongue, and general sensory fibers from the tympanic membrane”

This can cause the corners of the mouth to droop. The person may be unable to fully close the mouth to suck out of a straw.

The lacrimal glans is the little pink thing on the inside of the nose-side of the eye. This gland is responsible for keeping the eye moist.

“…may experience dryness of the eye or mouth, taste disturbance or loss, hyperacusis, and sagging of the eyelid or corner of the mouth”

Because it also supplies “power” to the tastebuds, this can affect taste. I’ve known many patients of those that I treated that lost weight because food was no longer appetizing.

“Most patients with Bell’s palsy show some recovery without intervention within two to three weeks after onset of symptoms, and completely recover within three to four months”

This is a very important statistic. Without knowing this, a patient referred to PT within days of the diagnosis, whom shows improvement within weeks, may lead the PT to believe that physical therapy has more significant effects than actually occurs.

“… facial function is completely restored in nearly 70 percent of Bell’s palsy patients with complete paralysis within 6 months and as high as 94% of patients with incomplete paralysis”

This information must be highlighted with patients. The effects of this diagnosis can be dramatic the first few weeks and hope needs to be restored in these patients.

Good ol JR is back to announcing wrestling!

“…as many as 30% of patients do not recover completely”

This needs to be addressed, but the education needs to be flipped to show that 70% recover partially or fully.

“Long-term, the disfigurement of the face due to incomplete recovery of the facial nerve can have devastating effects on psychological well-being and quality of life”

Two patients that I have treated in my past avoided going outside. Not to paint them in a negative light, but they lived like the Hunchback of Notre Dame. These two needed positive reinforcement in order to return to a life outside of the home.

I felt bad that these two have excluded themselves from the community because they wanted to return to normalcy, but didn’t want to be stared at in the process.

“…patients with facial paralysis can have impaired interpersonal relationships and may experience profound social distress, depression, and social alienation”

“The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell’s palsy”

As a PT, I will only discuss the information that is relevant to my profession or scope of practice.

1. “Clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute onset unilateral facial paresis or paralysis”

A thorough history is important regardless of the ailment. When paralysis is the end result, a thorough differential needs to happen in order to rule out other factors that could affect the facial nerve.

For instance, using the objective portion of the examination can help to rule out a stroke. The history can help to rule in cancer.

As a PT, ensure that you are taking a good history and physical exam in order to ensure that nothing is being missed.

2. “Clinicians should not obtain routine laboratory testing in patients with new onset Bell’s palsy”

“Risk: Missing a potential cause of Lyme disease, which is considered based on a thorough history.

Benefit: avoiding unnecessary testing and treatment, false positives and cost savings”

This is outside of the scope of PT and I will defer.

3. “Clinicians should not routinely perform diagnostic imaging for patients with new onset Bell’s palsy.”

“Benefit: avoidance of unnecessary radiation exposure, incidental findings, contrast reactions and cost savings”

“Risk: missing other causes of facial paresis”

“Opportunity for patient education”

4. “Clinicians should prescribe oral steroids within 72 hours of symptom onset for Bell’s palsy patients 16 years and older”

“Benefit: improvement in facial nerve recovery, faster recovery”

“Risk: steroid side effects and cost of therapy

Exceptions: diabetes, morbid obesity, previous steroid intolerance and psychiatric disorders.”

5. “clinicians should not prescribe oral antiviral therapy alone for patients with new onset Bell’s palsy”

“Benefits: avoidance of medication side effect, cost savings”

Risks: none

6. “clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell’s palsy”

Benefit: small potential improvement in facial nerve function

Risks: treatment side effects, cost of treatment

Patient preference: “significant role for shared decision making”

Exceptions: same for corticosteroid use

6. “clinicians should implement eye protection for Bell’s palsy patients with impaired eye closure”

Eye protection is standard of care.

Risks: costs of eye protection implementation, potential side effects of medication.”

This falls into the plan of care for PTs. Sometimes the amount of time that the patient has with a physician is less than 10 minutes. (I’ve read that an average patient physician visit is 11 minutes).

Because of this, the patient may not fully understand what to do once diagnosed with Bell’s palsy, and this can be within the role of the PT.

7. “Clinicians should not perform electrodiagnostic testing in Bell’s palsy patients with incomplete facial paralysis”

8. “Clinicians may offer electrodiagnostic testing to Bell’s palsy patients with complete facial paralysis”

Benefit: provide prognostic information for the clinician and patient, identification of potential surgical candidate

Risks: patient discomfort and cost of testing

8. “no recommendation can be made regarding surgical decompression for Bell’s palsy patients”

“Concerned about the facial deformity may make it some patients willing to pursue a major operation for a small increase in the chance of complete recovery while others may be more willing to except the chance of poor outcome to avoid surgery”

“The group was divided as to whether the evidence supported no recommendation, or an option for surgery. This difference of opinion derived from controversy regarding the strength of evidence”

9. “No recommendation can be made regarding the effect of acupuncture in Bell’s palsy patients”

“The GDG was divided regarding whether to recommend against acupuncture, or to make no recommendation.”

10. “no recommendation can be made regarding the effect of physical therapy in Bell’s palsy patients”

There are conflicting statements regarding varying clinical practice guidelines.

I have only had one patient with Bell’s palsy that demonstrated significant improvement greater than 90 days since the diagnosis. Is it possible that time had a strong let effect than PT…sure…it’s possible.

Typically, the recovery would’ve taken place by three months, but the patient made progress while in therapy.

Don’t get me wrong, I don’t think that PT is the end all be all for many diagnoses or patients, but I do believe that the interventions had an effect on this particular case.

There may be some patients that could benefit from therapy. In saying this, my experience would tell me that it is a small percentage of patients.

“patient may benefit psychologically from engaging in physical therapy exercises”

11. “clinicians should reassess or refer to a facial nerve specialist those Bell’s palsy patients with 1. New or worsening neurologic findings at any point, 2. Ocular symptoms developing at any point, or 3. Incomplete facial recovery three months after initial symptom onset”

“Identifying alternate diagnoses in the absence of recovery, and potential assessment for rehabilitative options…However based on the natural history of Bell’s palsy, the majority of patients will show complete recovery three months after onset.”



Click to find the Article.

Technique < Knowledge

For about a decade, I read all of the research surrounding the McKenzie Method, also known as Mechanical Diagnosis and Therapy.

I felt confident in seeing a patient on the first day and being able to discern, from the details of the history and movement exam, what was happening regarding the person’s pain experience.

This could only be done through an MDT lens. I couldn’t treat post-surgical patients well because protocols weren’t my cup of tea. Protocols required little thought and I believed that a 🐒 could do that type of treatment.

I couldn’t do chronic pain because I didn’t feel comfortable not having an answer to the questions.

All these years later, I’ve become better versed in treating patients with chronic pain, stinkin thinkin, poor health and post-surgical.

The problem was never in the patient, but instead in how I perceived the patient and subsequent treatment.

Having spent hundreds of hours learning about these types of patient presentations, I feel that I can relatively effortlessly slip from MDT classification to a pain based classification, and do all of this within a protocol if it is required.

Spending time in the trenches to learn your craft will allow you to use many different weapons of choice when enacting you’re craft.

Courage to act

Image: Kaufman SF. The Martial artist’s Book of Five Rings: The Definitive Interpretation of Miyamoto Musashi’s Classic Book of Strategy

This holds true in many forms.

I will continue to relate these quotes to those passions that I have such as Physical Therapy.

In the field of physical therapy, it is not uncommon to be asked/told to perform unethical and illegal acts.

As an employee, one has a decision to make:

1. Do said unethical/illegal activity, make my boss happy and possibly lose my professional license

2. Don’t do said unethical activity, go against the corporate line to protect my license and run the risk of losing my job.

You can see how this plays out in a day to day world if you work in healthcare.

I’ve met many that don’t understand the rules of the insurance that they are billing and therefore have no issues doing the company’s bidding because…they don’t know any better.

Once they know better, then it becomes an ethical dilemma. The job keeps food on the table and a roof over the head. Does anyone really want to risk that?

Many don’t and unethical and illegal activities continue to happen.

Every once in a while, someone speaks up and decides that they won’t toe the line.

This decision takes a couple of forms.

1. The employee flat out says no and that he/she won’t compromise integrity

2. The person goes to a higher authority and informs them of what is actually happening in the clinic.

Here is an example of the second example.

If you are a patient, know that these decisions are being made behind closed doors.

As a PT, do you have the “courage” to “act”?

Ankle strength

Some people have lost strength in the ankle due to a litany of issues such as:

Nerve damage

Muscle strain

Shin splints

Ankle fracture

Etc

Getting a stronger ankle joint doesn’t have to be complicated.

Some people have the ability to get stronger, but others may not have that ability.

Check with a licensed professional to see if the nerves are working properly before starting a structured exercise program for the ankle.

This is a basic exercise and is intended for general education.

Great teachers build students to be great

Image: Kaufman SF. The Martial artist’s Book of Five Rings: The Definitive Interpretation of Miyamoto Musashi’s Classic Book of Strategy

I have had many students over the course of my career as a PT.

It is not hidden that I practice with a base of MDT (Mechanical Diagnosis and Therapy). This is the base from which I begin every new patient evaluation. It allows me to keep information in an order that makes sense to me and keeps me thinking systematically.

When I take students, I don’t dictate how they practice. I want for them to learn about what is their passion within this profession.

Everyone has to follow his/her own dreams and goals.

I frequently get students that ask me how did I get to where I am at in this profession.

I tell them about reading textbooks, thousands of pages, two to three times in order to understand the words. The students go from feeling great about the energy that I bring and the mentoring and teaching that I have done through the clinical to telling me that they don’t think they can do it.

I DON’T CARE!

You do you. Don’t try to do the things I’ve done in my career. Becoming better at anything takes work. I can feed you my information and this can put you a little further in your quest for information, but you will never own the information in the same way that I own the information. It takes time and work to own the topics.

I only hope that the students can take from me an inspiration that this profession has a lot to offer. Each professional could be great at any one niche AND there would still be enough information, topics, niches for everyone to be great at something.

In the end, the responsibility is on the person…the student.

It is not on the teacher, for the teacher has already paved his/her own way.

The student must choose the path and forge forward.

What path have you taken as a student…professional?

Training for game day…everyday

Image: Kaufman SF. The Martial artist’s Book of Five Rings: The Definitive Interpretation of Miyamoto Musashi’s Classic Book of Strategy

There is so much to unpack here.

First, don’t do as I do because you may have different goals than I.

When I worked at Sams Club, I could have two conversations: gym stuff and Sams stuff. I was so single minded. I would go to school in undergrad and read Ironmind, Flex, Powerlifting USA and books by authors such as the great Mel Siff, Mike Menzter, Fred Hatfield and others.

I wanted to make myself better at the things I enjoyed and school was just something I had to do in order to eventually make money.

I became employee of the year at Sams Club in 2003 and quit the same year to go work at a gym making half that money and to start PT school.

Once in PT school, I still devoted my time to learning about lifting. I went deeper into methodologies and theories of exercise.

Once I graduated from PT school, I devoted all of my free time to becoming a better physical therapist. I want to be the best (warrior) at this craft (physical therapy) that I could attain.

This is not necessarily healthy. I want to start by saying this because it’s been told to me my entire career.

I studied research between sets at the gym. I read textbooks multiple times over. I sacrificed personal relationships to become better…I won’t even say good, but better than the day before.

I’m glad I put all of that time in during those first ten years.

This does not conform to the thought of work-life balance. Again, I’ve heard this my entire career.

When looking at balance, it has to be what makes you happy. Not everyone has the same definition of happiness. When I go to work, I’m sure my patients are grateful that I sacrificed a decade of my life to get better at my craft. When I believe in something I give it my attention. In giving it my attention, I give my time. In giving my time, I am giving my life.

I understand that not everyone is devoted to their craft, but I would hope those depending on that craft can see the difference between those who do and those who don’t.

Guard your ears

Patients want to know why they hurt. 🤷‍♂️🤔🙏

They want to know what we can do to help them get rid of their pain to get back to life. 🌈☀️

They want to know that movement is safe. ❤️👊

They want to know that nothing serious is wrong. 🚩

How many healthcare practitioners are answering the first one with a definitive answer of “xyz” is why your experiencing pain

AND

then goes on to put limitations on the patient

AND

tells the patient that it will take 3X/week for 4-8 weeks in order to get better 💵💸

😂😔🤔❌👎🤯

Patients, YOU NEED TO KNOW THAT IT IS RARE TO BE ABLE TO DETERMINE THE EXACT CAUSE OF YOUR PAIN!

There are many factors that can have a role in pain that for me to give you a single answer may do more harm than good.

I will tell you possibilities and we can have a discussion of how you think these possibilities ply a role in your symptoms, but even then we will not narrow it down to a specific tissue.

What we won’t do is

1. Increase your fear of movement

2. Create a restriction to specific movements without a timeline to reintroduce movements.

3. Overtreat you because we have created a fear of movement, taken away your mobility and then told you that you need to see me for 36 sessions.

If you are spending any money on your health care, don’t you want to see the person that keeps you for fewer visits, listens to your complaints, comes up with solutions to your issues and has a heart of a teacher.

Any 🐒 can take your money, but not every professional can provide you the help you’re paying for.