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Reflections on “The Alchemist” Part VII

“My heart is a traitor… It doesn’t want me to go on.

Naturally it’s afraid that in pursuing your dream, you might lose everything you’ve won.

Well then, why should I listen to my heart?

Because you will never again be able to keep it quiet.”

I have a couple of big picture drivers in my life.

1. Have no regrets

2. Don’t do anything that would bring shame to my dad.

In 2008, my brother died. He died from an overdose of Benedryl…(I hear it all the time, I didn’t know it was possible…me neither).

He had his demons…we all do. He was a great guy, but again, he had his problems. He had been imprisoned for DUI and just got out. He started joining me at the gym and he was making great progress in the gym. He couldn’t squat more than me, but that bastard deadlifted 405 on his first attempt. (I say that out of love because it took me years to lift 405).

Anyway, we would have conversations about serious things every once in a while (we shared a room growing up. I worked overnights and was going to school and at the time he wasn’t working, so the bed was his at night and mine during the day).

Aside: those that know me, know that I am like a tornado. Wherever I go, I organize things so that they make sense to me. This usually means a bunch of separate piles with very clear distinctions between the piles. (It works for me!) Mike, on the other hand, was just a slob! He loved candy. It wasn’t uncommon for me to come home after working overnights and going to school in the morning, only to find a ton of wrappers in the bed and a full cup of coke on the floor. It was like living with a big kid at times (usually that’s one of the ways I get described, but Mike took it to an extreme). I used to think that if I just pushed it all on the floor that he would clean it up…Nope. Just a new pile of wrappers the next day! I miss my brother. He was a good person and was very good to me growing up. I’m going to keep reminiscing a little because…why not?

I used to love to sing Karaoke and was actually a DJ for a while. It paid good money, but I’m glad I stayed in school because: who goes out to sing Karaoke anymore? Mike had a problem with alcohol. I’m not saying anything bad about him, it was just true. It didn’t make him a bad person, but like I said, he had demons. We went out to the bar (mind you, I didn’t drink at the time), after working out (the bar was right next door to the gym). I sang some songs, bought him a Long Island iced tea (I had no clue what this drink was prior to that night) and he listened to me sing a couple of songs. The car ride home (I’m the little brother, obviously not by size). He said, bro I’m proud of you. You grew up in the same house we all did. You can go out to the bar and drink orange juice and have a good time. You work full time and go to school. You’re going to be great at anything you do. (This memory always brings tears).

I was a new grad physical therapist. Not even practicing for a year when my mom called me in the middle of the night to scream through the phone that “I lost my baby!” Those words and that conversation is burned in my brain. That whole night at the hospital was like a haze. Hard to believe.

What’s harder to deal with is that 10+ plus years have passed and how much he’s missed out on. He was great with kids. He would’ve loved my kids. I think of all that he could’ve done and seen. He always wanted to go to Alaska. I made a copy of one of his pictures and carried it with me while we honeymooned in Alaska. I miss my brother.

I learned one thing…life is very short and don’t have any regrets.

The second big picture ideology that I try to live by is to not bring shame to my dad.

You’ll hear me say it frequently that my dad is my Superman. He knows that, which was very important for me to make sure that he knows I’m proud of him and the life he lived and continues to live.

He served as a medic for the 101st Airborne, the Screaming Eagles, in Vietnam. He stated in Vietnam longer than he had to in order to ensure that his younger brother didn’t have to go to Nam. He came home and worked in the family business (construction) for 30+ years. He divorced my birth mom (whom I have no contact with, which is why I say birth mom) and took care of all the kids as best he could. He and Aida worked hard to move us to a quieter area with less shootings. They made the decision to send me to Providence. Essentially, all of the good things I have came from that man.

I disappointed my dad one time. I was 13 and was a shoplifter. I would steal anything just to see if I could.

I got caught at the old Cub Foods on Larkin Ave. I was stealing magazines and baseball cards. I was with my cousin at the time (and I still believe that he got caught, but water under a bridge). I was fined $2,000 and was out in handcuffs, but wasn’t arrested.

I got home that night (understand that my dad typically would wake up at 3 AM to prepare for work) and it was about 11 PM. My mom told him what happened. I was never really punished (aside from paying back $2000, which at the age of 13 wasn’t easy to make…thanks to Norm Fanning for getting me a job shoveling manure). He said that “I’m disappointed in you son”.

I worked my tail off to pay back the fine by the end of summer.

It’s been 25 years and I’d like to believe that I haven’t done anything since that day to bring shame to my dad.

The moral of this story is twofold.

1. Have no regrets.

2. Have a role model in which to look up to and live up to.

Thanks for reading.

I got to go see a man about a horse.

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Don’t live inside you’re own head

The Mask

Why does my world Keep on tumbling down

I love my life with a smile because I’m afraid to frown

People see my smile and think everything’s okay

I live the way they want me to, never my own way.

Why do I let their words change my life

They only bring me pain and unwanted strife.

Is my life worth living is a question that I ask

Taking my own life is a complicated task.

I don’t want to die, I just want to kill the man you see

Because under all this happiness lies the real me.

Hey all,

I’m okay. This is the start to my next blog, which was inspired by today’s Gary Vaynerchuk episode with Kevin Love.

I was diagnosed as bipolar when I was 20ish.

it was on/off, run/sleep. I once put a car on a credit card. It’s just the way that I lived. Go hard and then shut down.

In 2015ish. I had a panic attack and seriously thought I was going to die. The worst part of it for me was that it happened at work. Work had always been my safe place. I was always a rock at work.

Thinking you’re going to die causes you to quickly establish priorities. The only people that I thought about at the time was Ania and Lenna. I thought about how they would make it without me.

This event caused me to make some changes in life because I realized my priorities.

Since that time, I have made decisions to most positively affect my family. I stopped putting as much stress on myself and I started having fun again.

No different than playing 3 on 3 as a kid. No different than Kairos.

I just Let Go and Let God.

Since that time, I’ve talked to a therapist and am having more fun in life almost 40 than I have in a long period of time.

If you are having issues that seem overwhelming and you are having trouble shaking…talk to someone.

Reflections on “The Alchemist”

“But I’m afraid that it would all be a disappointment, so I prefer to just dream about it.”

How many people never live their dream?

Golden handcuffs, fear of failure, fear of success, letting others dictate your actions, lack of self confidence, lack of self awareness are all possible reasons why a person may avoid chasing a dream.

When I started at Palos Health, I asked as many people as possible if they loved their job.

Everyone loved aspects of the job, like the pay (which was slightly better than average), the retirement plan (which was slightly better than average), health insurance (which was much better than average), and vacation time (which was slightly better than average).

There were a lot of reasons to stay in that position, but no one said they loved the job itself.

I never wanted to be in a position because I couldn’t afford to leave. This was the case for many people that continued to work there.

This is the definition of golden handcuffs.

I think we all have fear of failure or rejection. Me included. Can we overcome that fear of action, also known as paralysis of analysis?

The answer is yes. Just jump!

Failure is a possibility. It’s always a possibility.

Sears was around forever…until it wasn’t.

Toys R Us was around forever…until it wasn’t.

Montgomery Wards, Woolworths, Cub Foods, arcades, etc.

Even the largest companies can fail.

Failure is something to plan for, because it’s a possibility. I am not saying it’s something to hope for. There always has to be an exit plan.

One way to create a constant exit plan is to always work with integrity, try to make everyone around you better, work more productively than everyone else on the team, and to be nice.

You’d be surprised how much integrity, teamwork, hard work and good spirits can lead to opportunities.

I say it to all my students and many of those that I interact with as a mentor. I am not special.

It’s unfortunate that in the modern times, just exhibiting those above traits makes one appear special.

It’s not hard to stand out from the crowd, you just have to put a little more in than the next guy or gal. Fortunately for me, the bar has always been set a little lower than my work ethic, which makes me seem like I stand out.

It’s that scene from any armed forces comedy. When the leader asks for one person to step forward and everyone else steps back, that leaves one person out in front.

That’s how I feel sometimes.

Response to Gifford 2002

I was given this article to read by a Physical Therapist that I respect. This article was meant to educate me on the concept of centralization. For those that have spent time with me know that I am all for being educated.

I struggled with this article because it was full of opinion and anecdotal evidence. Also, the article was written 17 years ago. Much has been published since this piece was written. I will write this one exactly how I have written previous blog posts, but will go a little more into depth utilizing evidence instead of my experience, which I typically do in my other posts.

“For patients with back pain fear of movement, and bending in particular, could well be generated by clinicians whose own beliefs and fears about bending being “dangerous” are passed to patients.”

I completely agree with this. There is no reason to fear a movement, for most people. In all my years as a therapist, there has only been one patient that I was hesitant to move. After her history, I just had her slouch and sit up tall. Both positions created sharp sensations into her legs and she noted that when this happens her legs go weak. I had her lie on her belly and on her back and any movement again caused that sharp pain into the legs. After that, I asked her daughter (patient was non-English speaking) if there was any imaging that was done. Of course there was!

The daughter said that she didn’t want to start with the images because every doctor that her mom has been to said that she needed surgery.

I looked at the images and here’s what I want you to imagine:

Imagine playing Jenga with a 5 year old. You are doing your best not to let the tower fall, but it’s all over the place. Some pieces are half put into place, others have been slightly knocked out before moving onto another piece…You get the picture!

The patient eventually had a fusion…and her pain was completely resolved!

After the fusion, she was able to perform ½ Turkish get ups, chair squats, floor transfers, and speed walking without symptoms! Fusions aren’t for everyone, but then again conservative care doesn’t help everyone either.

With that said, there is never reason to be afraid of movement, but it has to be honored.

“However, management strategies, like the McKenzie system or approach, whose traditions predominantly seek to avoid bending may be part of creating a greater problem than is necessary”

This is a half-truth. With Mechanical Diagnosis and Therapy, there are some movements that are temporarily minimized. Patients are classified into one of three categories with this method, assuming the presentation matches a classification.


 

If you would like to read more about the system from my previous posts, click here https://movementthinker.org/?s=mckenzie.

The system does not try to avoid bending. This is a misunderstanding of the system. A patient can be classified into one of the three subgroups: derangement, dysfunction, and postural syndrome. They could also be classified into a category called: other, but to simplify things, we will only speak of the derangement syndrome.

With the derangement syndrome, a patient is issued movements, postures and positions that have proven, in the clinic, to reduce the patient’s symptoms or to improve their mechanical baselines (range of motion, reflexes, strength, dermatomal sensation, or special test). The patient is then issued this movement for the home program, with the instructions to minimize activities that increase stiffness, reduce strength or increase symptoms (pain, numbness, or tingling) further away from the spine.

If this means that the patient should minimize forward bending…so be it. It may also mean that the patient should minimize backward bending (think painting ceilings or other overhead type movements). The goal is to minimize the movements that aggravate symptoms and introduce movements that improve symptoms…TEMPORARILY!

I haven’t read too much research to contradict this last sentence, meaning there isn’t anything that I have read in 12 years that states we should continue to perform movements, postures or positions in the presence of worsening symptoms. I’d love to read it if it’s actually out there. You can email it to me a vincegutierrezpt@icloud.com.

“It is my belief that around 20 years of propaganda based on the disc derangement model and the concept of centralization of pain relating to dubious biomechanical models for back pain has led to an unprecedented therapist fear of flexion that is passed on to patients.”

I won’t completely disagree with the premise of the statement. A therapist that is poorly trained in the method, meaning one that hasn’t completed the credentialing process, should not be the basis of one’s opinion regarding the method. https://www.jospt.org/doi/abs/10.2519/jospt.2018.7876 A therapist that is properly trained no longer utilizes the disc model to educate the patient. The disc model has fallen out of favor, quite possibly for the reason stated above.

Also, we know that the disc model is not 100% accurate, as demonstrated by https://www.ncbi.nlm.nih.gov/pubmed/19841611 Zou et al.

“In other words, flexion, way back in Williams’ time (50’s and 60’s), was not a feared movement and patients still got better.”

I would challenge this with more research that has come out since publication of Gifford’s blog post.

 

INTERVENTIONS – FLEXION EXERCISES: Clinicians can consider flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking, for reducing pain and disability in older patients with chronic low back pain with radiating pain. (Recommendation based on weak evidence.)

This is straight from the Clinical Practice Guidelines for Low Back pain, which can be found at https://www.jospt.org/doi/pdf/10.2519/jospt.2012.42.4.A1. 

I put this first, but another summary statement in the same guideline shows: 

INTERVENTIONS – CENTRALIZATION AND DIRECTIONAL PREFER­ENCE EXERCISES AND PROCEDURES: Clinicians should consider utilizing repeated movements, exercises, or procedures to promote centralization to reduce symptoms in patients with acute low back pain with related (referred) lower extremity pain. Clinicians should consider using repeated exercises in a specific direction determined by treatment response to im­prove mobility and reduce symptoms in patients with acute, subacute, or chronic low back pain with mobility deficits. (Recommendation based on strong evidence.)

I’m just saying. 

This isn’t to say that using flexion based exercises won’t help patients, but based on research by Stephen May, it may only help a small percentage of patients, as seen in this article: https://www.sciencedirect.com/science/article/pii/S016147540600217X

“Clearly restoration of flexion is part of the McKenzie approach, but it is usually after some form of extension and introduced with caution.”

As therapists, we should know that words mater and I take offense to the portion that states “introduced with caution”, but I digress. 

A return to function is one of the steps in a recover, when classified into the derangement syndrome, but also for all patients that present to the clinic with symptoms. What is different about MDT is that return to function occurs after the patient has reduced symptoms and is able to maintain that reduction independently. Those that practice MDT do not start with return to function before the other two categories, although this is common to see in clinics with non-credentialed PT’s. 

A therapist will return a patient to extension, flexion and lateral motions over time. This is expected. When discussing with patients, I will typically say “we would like to return to pain-free movement through all planes that you can move through and then progress confidence with movement over time and utilizing different loads”. 

FLEXION IS NOT SPECIAL! Unfortunately, other therapists (including those that say they utilize MDT) believe flexion to be a dangerous movement, which would then make Mr. Gifford’s comments true. 

“When are physical therapists going to stop forcibly extending patients”

This comment was said to be made by an anesthesiogist. Surprisingly, I would agree with this because the wording is very specific. Therapists that are credentialed in MDT rarely “forcibly extend” anyone. There is a progression of forces built into MDT, which adds a layer of patient empowerment to the system. Before a PT performs manual therapy, the patient must perform the movement independently. This article specifically measures the fluid movement when performing extension based movements, both independently and with PT assistance. https://www.jospt.org/doi/full/10.2519/jospt.2010.3284

Utilizing MDT, a patient must first perform a movement (flexion, extension or lateral movement) independently for many repetitions (usually 10-15 every 2-3 hours at home) without a worsening of symptoms in order to ensure that the correct exercise was given. If the patient’s symptoms stop improving with the movement, then a version of force progression is pursued. Force progression takes many forms, such as increased repetitions, increased ROM, decreased time between sets, AND PT assistance utilizing manual therapy. Ideally, there is no “forcible extension” beyond patient’s own abilities unless the patient absolutely requires it to reduce symptoms. 

“Having to face patients who one moment have simple back pain and then later rapidly develop leg pain and a neuropathy is not nice and something I would preferred to avoid”

This is a fear tactic to besmirch MDT. If a PT is credentialed in the method, then this is not expected to happen. Having used this method as my base for 12 years, I have never personally seen this happen. 

Again, the research consistently supports utilizing a specific direction (key) to unlock the patient’s pain. Please, if you are interested in these topics, read the following two studies: https://www.ncbi.nlm.nih.gov/pubmed/15564907and https://www.researchgate.net/publication/41420157_Specific_Directional_Exercises_for_Patients_with_Low_Back_Pain_A_Case_Series

These articles are very informative to read, in that the first article is a randomized controlled trial (supposedly a strong design) and the second is a case series utilizing the patients that worsened from the first article. It was a novel series of studies. 

“My clinical observation is that it is very rare for common back pains to want to only move in one direction-except when they are fearful of a particular movement”

I would agree with this. Not all patients require a structured program and many can improve without physical therapy. This is not news based on the previous publications of the STartBack Screening Tool https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208163/

Many patients improve just from moving and returning to normal activities…but some do not. 

“My stance is that it is always best to start easy, comfortable and relaxed, pain free if possible, build confidence slowly and then gradually move into range and greater repetitions over time”

Again, just speaking of the derangement syndrome, I would say that MDT is not much different from his views. A patient that benefits from extension, which seems to be the movement most related to MDT although there are many other options that a patient may benefit utilizing, will start by simply lying on his/her stomach. I am not sure what could be more comfortable or relaxed than just lying down. If this is tolerated and there is no worsening of symptoms, then the patient is progressed to lying on the stomach, but propped up on elbows. This actually satisfies Mr. Giffords stance. The only aspect that opposes Mr. Gifford’s stance is that this is done over one or a couple of visits. Mr. Gifford would apparently prefer that this progression from lying on your belly to actually propping yourself up on your elbows should take “a few days, occasionally many weeks”. That is an area of disagreement from my clinical experience. 

“Using pain response (lessening/increasing, shifting location) with movements as the main guide to treatment ‘direction’ needs a note of caution.”

A common misconception is that pain response is the only aspect that is reassessed during a treatment with a credentialed MDT professional (could be either a physician, chiropractic physician or physical therapist). 

Pain location and response are important aspects to pain attention to after movements. For instance, patients that do not experience centralization are more likely to require an invasive procedure as noted by Skytte https://www.researchgate.net/publication/7812658_Centralization_Its_Prognostic_Value_in_Patients_With_Referred_Symptoms_and_Sciatica

Patients that demonstrate centralization within 7 visits are more likely to have a favorable outcome based on work by Werneke https://journals.lww.com/spinejournal/Abstract/1999/04010/A_Descriptive_Study_of_the_Centralization.12.aspx

“No, for me (Gifford), the more you tangle with a stirred up pain, whatever the direction you gor for, the most common outcome is ‘pain worse and worse’”

I don’t necessarily disagree with this, but this patient would not be classified utilizing MDT. About 5 pages ago, I mentioned that there was another category called: other. This patient would be classified as “other” and most likely would be classified better utilizing another method, such as the Pain Mechanism Classification System as follows: https://www.scholars.northwestern.edu/en/publications/validation-of-a-pain-mechanism-classification-system-pmcs-in-phys

“Repeated movements may e injuring neural tissue that nly starts to generate nociceptive activity and become sensitized much later on”

I agree with the statement, although he again is using a fear tactic to prove a point. When this happens, something was missed. This is an error by the PT, because this patient is no longer classified as a derangement syndrome and again is better off with the PMCS and treated accordingly. 

There is nothing wrong with having a patient not utilize MDT principles if they are not appropriate. The issues occur when a PT utilizes the treatment principles with a patient that was classified incorrectly. This again stresses the point of seeing a therapist that is credentialed or Diplomaed. 

I hope that this comes across as respectful as there is no ill intent in the writing. I only hope to expand the discussion. 

In the end, the professional has to choose what courses to take in order to feel comfortable treating patients with symptoms originating from the spine. I included personal experiences with research in order to give the reader more than just an anecdotal reports. 

I would appreciate it if you could share this with friends.

On the road

Everyone that knows me knows that I listen to a lot a podcast during my commute. One of the things that I find more enjoyable than listening to a podcast, his actual interaction. Over the past month, I have spoken to about eight therapist from all over the country regarding clinical aspects of care and classification of symptoms. An excellent conversation this morning for about a half an hour, my commute is about 45 minutes to an hour, so I have plenty of time to chat. And we discussed research we discussed therapeutic alliance, we discussed patient’s expectations, we discussed chronic pain, We discussed classification of pain, and we just discussed clinical presentations that we commonly seen in the clinic.

I absolutely love dialogue!

Considering a nursing home after surgery

“Moreover, older adults who are hospitalized are 60 times more likely to develop a disability than those who are not. ”

This is HUGE!

We know some of the common statistics such as an adult over 80 years that falls and breaks a hip has a high likelihood of death within one year.

There is some research about reserve capacity and the body’s ability to withstand a major obstacle such as a fall or hospitalization. Reserve capacity is essentially the amount of ability that a person has that exceeds daily needs.

For instance, if you typically walk 2.5 mph, but have the ability to walk at 5 mph, the reserve capacity would be the difference between usual speed and RESERVE gait speed.

“… recovery of function during a SNF stay is inadequate under usual care”

I’ve worked in a SNF and will attest to this based on experience. I stuck out like a sore thumb during my time in the SNF.

I got many of my patients up and walking. I would stand next to the patient to motivate, encourage and correct any safety issues that I noted during a movement or exercise.

Many of my “peers” were sitting at computers about 20-30 feet away from patients barking out directions from across the gym. The atmosphere was more party like for the roles of professionals, in which many conversations revolves around personal lives of the therapists, instead of the patient.

“The 2017 Medicare payment advisory commission reported no change in functional outcomes as measured by a patient’s ability to perform bed mobility, transfers, and ambulation.”

This is crazy! A patient goes to a rehab unit in order to rehabilitate to a safer functional level. If there are no changes in outcomes…why bother!

I did some research on total knee replacements when creating the protocol for our outpatient facility and there was much research showing that patients that went home after surgery did better than those that went to a “SKILLED” nursing facility.

Again…why bother!

There may be some lower level patients that need the nursing care at a facility like this, but we really do need to do a better job of planning a patient’s discharge from the hospital.

“specifically in SNF’s, annual expenditures comprise 50% of the $60 billion US allotted to post acute care. The discrepancy between high levels of spending in SNF’s and sub optimal outcomes strongly suggest the need for innovative clinical research designed to advance models of care delivery and assert the value of SNF rehabilitation therapists”

☝️ 🤔🤑

Leaving this one to stand on its own.

“… hospital discharge patterns away from SNF towards less costly home health or outpatient services.”

This makes sense and we are seeing this happen for some orthopedic cases that would previously be sent to a SNF. It took incentivizing hospitals and physicians to get them to change the way they treat patients.

“Nursing home literature suggests patient motivation to participate in treatment, such as physical therapy is linearly correlated to patient perceptions of and satisfaction with support from peers, family, and staff.”

Wonder why some patients may not be motivated to work with staff?

Read this article.

Excerpts from:

Gustavson AM, Boxer RS, Nordon-Craft A et al. Advancing Innovation in Skilled Nursing Facilities through Academic Collaboration. PTJ-PAL. 2018;18(3): 5-16

A Penny saved is a penny earned

We’ve all been there! That place in which we are sinking instead of swimming. You ain’t alone.

Hear my story below.

Check out my episode “A penny saved is a penny earned” from Movementthinker: a physio’s perspective on Anchor: https://anchor.fm/vincent-gutierrez/episodes/A-penny-saved-is-a-penny-earned-e298p5