Category: non-professionals

Considering a total knee replacement?

knee-replacement

Considering a total knee replacement?

 

There are increasing numbers of total knee replacements performed yearly. Medicare is initiating a bundled payment initiative for all facilities in 2017 and many are participating for the previous 2 years. What does this mean for the patients? Theoretically, it means more efficient care, with better outcomes, because patients will be more closely monitored. For instance, the hospital, and those employed by the hospital, stands to profit moreso than normal when patients have great success rates with more efficient care (see fewer visits performed).   From my perspective it is about 2 things: 1. Improve patient’s outcomes 2. Do this with less expense. Our country spends a large percentage of our money on healthcare, but when looked at from a broad perspective, we do a poor job of keeping our people healthy. Whatever the reason, this needs to change.

 

Those of us in healthcare understand that the insurance company drives the type of treatment that a patient can receive. Most patients, in my experience, will not pay out of pocket for care that they feel entitled to and will stop care when the entitlement is exhausted. We, as healthcare professionals, have to do a better job of demonstrating value to patients. I spend, like many people, over $1,500/year in order to have a cell phone with internet access. This amount of money would pay for 1 visit of PT per week for almost 6 months, if the patient paid out of pocket. BLASPHEMY! Why should I pay for something that the insurance company will cover?

 

The insurance companies are becoming more aware of our downfalls as a profession. One major downfall is one of the deadly sins…GREED! When patient’s have to take more responsibility for their own health care and have to share more of the costs of health care, then the patient will become more aware of how his/her dollars are being spent…or go broke in the process. Gratefully, I work for a company that doesn’t push profit as much as it pushes “right patient, right time, right treatment”. Patients need to see that not all therapy is the same and sometimes…just sometimes…the patient can have both high quality therapy at a low cost.

 

Bringing us to today’s post. Come and knock on our door…we’ve been waiting for your…and the kisses are hers and hers and his…three’s company too. When I think of single leg stance, I think of the flamingo stance. When I think of the flamingo stance, I think of terri/torrie/cindy (blond from the show) standing on one leg while at the zoo. Moral of the story is: patients with better balance do better overall. Patients can achieve better balance by working on the skill over time. Depending on the source, the NIH reports that it takes upwards of 50 hours of practice to improve balance. Go practice now.

 

Can you stand on one foot?

Can you do this with eyes closed?

Can you do this equally on both sides?

Can you do the eyes closed version for at least half as long as the eyes opened version?

 

If not, go see a PT. You can look at the APTA website or your state’s local website (Illinois Physical Therapy Association) in order to find a provider.

 

Piva SR, Gil AB, Almeida GJM, et al. A Balance Exercise Program Appears to Improve Function for Patients With Total Knee Arthroplasty: A Randomized Clinical Trial. Phys Ther. 2010;90:880-894.

 

Intro: 37% of TKA’s still have functional limitations p one year. Diminished walking speed, difficulty ascending/descending stairs, inability to return to sport are chief functional complaints. During TKA surgery several tendons, capsule, and remaining ligaments are retightened to restore the joint spaces deteriorated by the arthritis. Some of the knee ligaments are removed or released, which may affect mechanoreceptors/balance.

 

PURPOSE:

  1. To determine the feasibility of applying a balance exercise program in patients with TKA
  2. To investigate whether an F (functional) T (training) program supplemented with a balance exercise program (FT+B) could improve function compared to FT program alone
  3. To test the method and calculate a sample size for a future RCT with a larger sample size

 

METHOD: Double-blind pilot RCT (very strong evidence)

Inclusion: TKA in the previous 2-6 months (meaning not eligible for study if the TKA was before 2 months previous)

Exclusion: 2 or more falls in the previous year. Unable to ambulate 100 feet with an AD or rest period, acute illness or cardiac issues, uncontrolled HTN, severe visual impairment, LE amputation, progressive neurological disorder or pregnant (interesting exclusion criteria).

 

All went through a quadriceps muscle-sparing incision (cuts through the fascia of the patella instead of the quadriceps) this may be a factor in reducing rehab stay.

 

See the appendix for the protocol (6 weeks).

 

Testing measures:

  1. Self-selected gait speed (interesting, but probably not feasible for our clinic)
  2. Timed chair rise test (5 repetitions): easily added to our testing.
  3. single leg stance time: easily added in
  4. LEFS
  5. WOMAC

 

RESULTS:

  1. Adherence for both groups is 100% and the HEP adherence was similar (filled out logs)
  2. walking speed continued to improve over the course of 6 months for the FT+B group and was 25% better than the FT only group.
  3. The interesting fact is that improvement continued up to 6 months, when previous literature describes 3 months and done.
  4. Single leg stance: FT+B improved (as expected due to SAID), but the FT group either maintained or worsened on speed and balance.

 

DISCUSSION: FT+B demonstrates clinically important differences in walking speed, SLS, stiffness and pain, without adverse events. Subjects in the FT+B could balance on average 4 seconds longer than baseline. This may be important for weight bearing during the stance phase of walking. Performance-based measures should be used in place of subjective measures.

 

TAKE HOME: Patients will benefit from the addition of balance exercises post-surgically. It may be prudent to discuss with the surgeons of increasing the length of stay in therapy and decreasing the number of visits per week, as progress continues to occur past the 3 months initially surmised. Each patient should be tested with one or more of the following:

  1. SLS
  2. Chair rise test
  3. Gait speed: important indicator of function/independence/death
  4. Balance test (excluding Tinetti due to possible ceiling affect when the patient no longer needs an AD).

OREO COOKIE FRACTURES

ht_oreo_cookie_jef_120301_wmainOREO COOKIE FRACTURES

 

Osteoporosis is a common malady to see in the clinic. Most patients diagnosed with the bone weakening disease don’t know much about the disease. I would think that if a patient was diagnosed with cancer, then they would want to know how to beat it…I don’t tend to get that same sense of urgency from my patients initially. Like the old commercial…”the more you know…” and the patients seem to want to know everything once they hear the basics.

 

  1. “Osteoporetic fractures, including vertebral compression fractures are associated with significant mortality, morbidity, and low quality of life”

 

Osteoporosis is the gradual demineralization of bone, typically seen in elderly women. Fractures due to this condition are called osteoporetic fractures. The most common areas of fracture are thoracic spine, hip and wrist. When the bones are so weak, they start to crumble due to the weight that they have to hold.

 

Think of a compression fracture as an Oreo cookie. The cream filling is the disc and the cookie is the bone of the spine, known as vertebra. If you squeeze the cookie together just to the outside of the filling (because we all know that the little circular filling is never the same size as the cookie) the cookie breaks. This is the same type of predicament that happens to patients with osteoporosis. Their cookie breaks. Mmmm…cookie.

 

  1. “…physical therapy-related treatment that emphasize exercises to reduce fall risk, back strengthening exercises, and proprioceptive postural training”

 

If your bones are weak and you fall, to cite Robbie O’Shea, “bummer for you”. You are looking for a fracture and the ground will help you find it. Weak bones don’t like to be jostled. If we can prevent a fall, we can at least prevent a fracture caused by a fall.

 

Why do we want to give back strengthening exercises? Think hunchback of Notre Dame. That’s what many patients with osteoporosis look like over time. The thoracic spine develops so many fractures that the patient is now looking at the floor for money all day long. The spine loses it’s “normal” curve and now the patient is unable to look at the stars or reach into high cabinets. No good.

 

  1. “Up to 67% of OVCF’s (osteoporetic vertebral compression fractures) are asymptomatic and the associative pain pattern in patients with symptomatic conditions is often inconsistent”

 

In a previous post, I noted that problem with imaging. The image can only tell you what the abnormal issue is, but can not tell you what is causing your pain. I had a patient once that had multiple compression fractures…some old and some new…but prior to this new fracture had never experienced pain. Not all fractures cause pain. This is an interesting concept to me because if something is so far off that it breaks, I expect pain to be present. This is another case in which what we believe to be true…isn’t.

 

  1. “Clinical findings or clusters of findings may improve the manual physical therapist’s ability to indentify OVCF before treatment and when imaging is unavailable”

 

In therapy, we want to know when it is safe for us to treat you. If you have a history of osteoporosis, we are traditionally taught to stay hands-off of the patient. We run a risk of actually causing additional fractures. Of course, there is evidence to counter this, but traditionally speaking we are taught to treat you like you have the plague. If we can predict which patients may have osteoporosis, we can make a more informed decision as to whether we should touch you.

 

  1. “The most diagnostic combination included a cluster of: (1) age > 52 years; (2) no presence of leg pain; (3) body mass index </= 22; (4) does not exercise regularly; (5) female gender…a finding of two of the five positive tests demonstrated the lowest LR-, providing value to rule out an osteoporosis compression fracture or wedge deformity. A combination of four of five tests yielded a LR+ of 9.6…Five of five was always associated with a fracture.”

 

If the patient does not meet at least 2 of the 5 scenarios, then the patient likely (Likelihood Ratio negative) does not have a compression fracture. If the patient has 4 of 5 of the scenarios, then the odds of the patient having a compression fracture increase from 2.4% to 20%. This number is still small, but applying the above scenarios allows the therapist or patient to have a better idea of the chances of a vertebral fracture.

 

EXCERPTS TAKEN FROM:

 

Roman M, Brown C, Richardson W, et al. The development of a clinical decision making algorithm for detection of osteoporotic vertebral compression fracture or wedge deformity. JMMT.2010;18(1):44-49.

Feelings…about back pain

Feelings…Nothing more than, feelings

 

This weeks article speaks to the importance of choosing your provider. Writings may be few and far between, as I am getting married the afternoon of this writing. Because we will be taking our honeymoon soon, there will be a pause in publishing more articles. FEAR NOT! I will return.  Thanks for reading

 

  1. non-specific “LBP (low back pain) where it is not possible to diagnose a specific cause”

 

This accounts for about 90% of back pain issues as stated in previous research. When a doctor tells you “you have a herniated disc”, “you have arthritis”, “you have spondylolisthesis” (sorry, I wanted to sound smart), they are simply telling you what another doctor saw on an image. What does this mean? It means that you have lived a life on this Earth and are no different than a majority of the population…okay the spondylolisthesis is not that common. Aside from telling you that you are normal compared to most people, they are telling you that your picture on an image (x-ray, MRI, CT scan) is not the ideal that is in the textbooks. The picture alone can not tell you with certainty that this is what is causing your pain. In other words, your pain is not specifically coming from anywhere, but it may be coming from any structure that senses pain and refers pain to that area.

 

Think of a heart attack. I picture George Costanza (Cant standja) from Seinfield. His imagined heart attack was complete with left arm pain and chest tightness. This is what we mean by referred. The heart, when upset, can send pain signals to other portions of the body…even though there is nothing wrong with the left arm or jaw or any other location that the heart tells the brain.

 

  1. “…experts have questioned whether the current paradigm is flawed”

 

We are right about what structure is causing your pain in about 10% of the cases..do you think that there is a flaw in the system somewhere? The first flaw is that the structure causing the pain actually matters. I know…I know, you want to know why you feel a knife slicing your spine in half or ants crawling on your skin, but in the end, if we turn off the pain…Does it matter?

I think the primary flaw is trying turn non-specific low back pain into something specific. There is plenty of research that demonstrates this: once you have an “answer” to the cause of your pain, you are quite willing to start blaming all of your problems on your disc or stenosis or arthritis or spondylolisthesis. “Sorry honey, can’t do the dishes…my disc bulge is acting up.” Actually…I may need to use this later. I RECANT ALL I JUST SAID. Joking of course…don’t take anything I write seriously.

 

  1. “Guidelines for the rehabilitation of patients with persistent NSLBP (that non-specific low back pain thingy from above) highlight the importance of practitioners encouraging patients to remain at work and stay as active as possible, with a key focus on self-managing their condition”

 

I of course will tell you that back pain will not kill you. It could in a very small percentage of the population be something so serious that it will kill you, but in reality it’s probably not you. (again, I am not a medical doctor, but a doctor of physical therapy, so if you think your back pain will kill you…go see your medical doctor). I can understand that some people just want a break from work. If this gives you good reason to take a break from work…Shhh…I won’t tell. Aside from the mental health days that you may want to take, don’t let back pain keep you from working. You are highly unlikely to make it any worse, or better for that manner, by working. Back pains due to disc herniations (bulges) are not the result of one massive injury, but the result of multiple small injuries over time. It’s like the old saying, “the straw that broke the camel’s back” (HAHAHA…it literally fits).

 

  1. “It is not known why physical therapists do not follow guideline advice”

 

This is my complete opinion here, but the patient’s don’t know any better. If the patient’s can’t tell the difference between good therapy and bad therapy, and if we then let the cat out of the bag and say that bad therapy pays more than good therapy, why don’t YOU think that the guidelines aren’t followed? There are some therapists that know the guidelines like the back of there hands, such as myself. You can see a previous blog in which I summarize the guidelines for low back pain, but there are other therapists altogether that don’t know that these guidelines don’t exist. I make this statement in a general sense and I extrapolate it from previous research that states that older therapists don’t have either the time or expertise to find a research article. If they can’t find it, then like the tree in the forest…it didn’t happen.

On an aside, I have to keep touching on the bad therapy pays more than good therapy situation. Our profession has historically been paid for what we do to you. Meaning if we give you an ultrasound…cha ching$$$. If we give you e-stim…cha ching$$$. If we give you a rub down…cha ching$$$. If we have you do exercise (whether we are watching you [the ethical thing] or a high school graduate aide is watching you [the pay is the same]…cha ching$$$. If we do all of the above and add traction…$$$. You get the point. We are finally starting to move to a system that if you have a knee replacement, then we will get paid a specific amount, regardless of what we do to you in that process. You will slowly start seeing all of the above disappearing over time because the effect is questionable and we would then be getting paid less per treatment approach that we use. ITS ALL ABOUT THE BENJAMINS BABY!

 

  1. “Practitioners’ attitudes and beliefs about LBP have been shown to influence their advice and treatment recommendations”

 

What this tells me is that we are treating based on tradition instead of the current evidence. Again, if you go to multiple doctors, you will get multiple opinions. The same thing holds true for PT’s. If you see a myofascial specialist…then you have a myofascial problem. If you see a manipulator…then you have a facet (back joint problem). If you see a MDT specialist…then you have a disc problem. We as practitioners have to know more than one system, but we better be good using at least one of the systems; otherwise we will just start mixing and matching systems.

 

  1. “Results have shown that practitioners’ professional group and practice setting appear to be associated with their attitudes, beliefs, and advice”

 

$$$$$$$$$!

If the practice setting values money over results, then the people working in that setting will have to reflect the values of their employers. It’s rough out there in this profession because it is hard to figure out which employer you are walking into until it is too late. There is such a huge pressure financially to make a living and pay off the hundreds of thousands in student loan debt, that the new graduate doesn’t know the difference between an awesome environment and one of financial manipulation.

 

  1. “ I would probably explain to her that it was most likely postural strain…there could be an underlying facet joint degenerative problem evident”

 

How confident are you in this practitioner’s opinion of your problem. It could be this or it could be that? I don’t really have a good reason for either, but “Hey, it’s usually this or that…so why not now?”

 

  1. “They believed that patients who exercises and kept active were more likely to avoid future episodes of NSLBP”

 

For future reference, please read Audrey Long’s article about the right exercise.

What if I told you that your therapist could be making you worse? If we don’t keep up with the research…it is possible. Not all exercise is good exercise. More on this in another blog.

 

  1. “Empowerment through education and pain control were clear subthemes…”

 

People…IT’S YOUR BODY! TAKE CONTROL. We can hold your hand, coach you, be compassionate towards you, but WE CAN NOT FIX YOU! You have to play a role. We can give you the tools to fix yourself, but if you don’t use the tools then WE failed TOGETHER. I didn’t fail, you didn’t fail…BUT WE FAILED!

 

  1. “’passive attitudes’…Therapists found working with these patients demanding, as from their perspective, patients with these attitudes were difficult to communicate with and, therefore difficult to educate and empower”

 

Please see # 9.

 

Excerpts taken from:

Jeffrey JE. Foster NE. A Qualitative Investigation of Physical Therapists’ Experiences and Feelings of Managing Patients with Nonspecific Low Back Pain. Phys her. 2012;92:266-278.

 

As an aside, I just saw that Nadine Foster is one of the authors. I absolutely adore this lady. I had to opportunity to hear her talk at the MDT conference in Austin. I really adore smart people, and she was impressive.

 

Medicine’s dirty little secrets

This is another paper from my previous doctorate program.  This is long and can be complex at times, just know that medicine and health care is a business.  In this business, the end goal is to take your money, otherwise known as making a profit.  Everyone can see that the shady car salesman is trying to take the money from your pocket and place it into his.  For some reason, we have trouble seeing the shady little scientists doing the same thing.  Picture Pinky and the Brain.  Pinky and the Brain…Pinky and the Brain…One is a genius, the other’s insane.  Welcome to the healthcare.

 

Couglin SS, Barker A, Dawson A. Ethics and Scientific Integrity in Public Health, Epidemiological and Clinical Research. Public Health Reviews. 2012;34:1-13.

 

“It can be intrinsically unethical because it may involve activities held to be wrong in themselves such as deception, misrepresentation and falsification. It can also be extrinsically unethical because such actions can cause direct harm to individuals and populations where such research is relied upon, negatively impact public trust in and support for research and result in wasted research resources.”

I appreciate the first quote as it discusses the basic ethical principles, as we have already discussed these in the course. There has been little discussion thus far as to how these discussions could affect future research trial that attempt to replicate the original research.

 

“narrow…way. On this model we might think of integrity as abiding by the relevant research ethics rules or regulations”

This is a very narrow way of looking at integrity. There may be many practicing, which according to the narrow way, do not practice with integrity. Some of the written rules do not account for the “internalistic account”. For example, some insurances only pay for up to ten sessions of traction, whereas there is a sub classification of traction, which will typically only respond well to traction initially, for LBP. For this group, it go against my internal integrity to not provide the treatment in which the research reports the best results.

 

“…rather than it being quickly concluded that a piece of research is unethical because it does not meet a presumed requirement, such as the need for informed consent.”

This is an excellent statement. It is up to the reader to be able to critically analyze research and come to his/her own conclusions regarding the ethics of the research. If a written informed consent is not applied, but a verbal is implied, is this unethical? We all practice with verbal consent (when we educate and then proceed) and sometimes we practice with an implied consent (when we apply what seems to be a benign treatment such as postural correction).

 

“…integrity need not always be about following the rules, as much as being able to see that different kinds of moral considerations are important, often conflict, and that sometimes difficult decisions have to be made about priorities.”

This article is excellent in that it places the autonomy of decision in the practitioner’s/researcher’s hands.

 

“Honest error or scientific differences in the design and conduct or research or interpretation of study findings do not constitute scientific misconduct”

This is a great statement, although I don’t necessarily agree. As professionals, we should attain for the least amount of error. When a grievance is performed, it would be hard to prove that it was performed intentionally.

 

“When properly executed, study protocols ensure the integrity of the process used to answer a single research question or a series of questions. However, when not adhered to, negative consequences, such as the inability to reproduce a study in order to verify its validity or the loss of confidence in research findings, can ensue”.

I wonder how often studies reproduced, and published, in the field of physical therapy? Rarely is a study reproduced in my readings, but studies typically utilize protocols performed in previous studies. This is discussed at length with clinical prediction rules for the spine. These studies are created utilizing characteristics that are the most common for treating/classifying patients, but follow-up studies to reproduce (confirm) the original study is rarely performed.

 

Sax JK. Protecting Scientific Integrity: The Commercial Speech Doctrine Applied to Industry Publications. American Journal of Law & Medicine. 2011;37:203-224.

 

“…companies will publish positive results of their clinical trials. They tend not, however, to disclose negative results of clinical trials in scientific publication, or they down-play the negative results…No regulation requires that industry publish negative results…”

The article is staring with an obvious bias against pharmaceutical companies. At no point in my career have I heard about other industries such as physical therapy being reprimanded for not publishing negative results. Beyond the fact that negative results are not submitted for publication, it is possible that a negative result would not be published in a peer reviewed journal to begin with, as this has been previously documented and is also covered later in the article. “Previous studies demonstrate that industry publications have a bias in that they tend to report positive results of clinical trials.” This initial paragraph sets the tone of attacking the establishment of “big pharm”.

 

“…(s)tudies funded by pharmaceutical companies were nearly 8 times less likely to reach unfavorable qualitative conclusions than nonprofit-funded studies and 1.4 times more likely to reach favorable qualitative conclusions.”

The author states this as if we, as the readers, should be surprised. As a class, we have already discussed COI, and when those that stand to profit from the results fund the study, we should not be surprised by the favorable results.

 

“Instead of subjecting themselves to peer review, some members of industry will skirt around this system by creating their own publications, such as symposium issues, which allows them to promote their products without having the academic and scientific community review the research prior to publication”

Although I find this to be unethical, I must say that it is an ingenious way to get around the establishment in order to make a profit. Unfortunately, that profit may be the result of harm. Although I wouldn’t make the same decisions, the decisions are understandable in a profit driven society.

 

“The tobacco industry also wrote review articles, citing their own work. Policymakers often rely on review articles because they are supposed to provide a summary of the most up-to-date data. Another tactic utilized included suppressing or criticizing research that did not support the tobacco industry’s position”

Again, these statements demonstrate the articles purpose of demonizing portions of the pharmaceutical companies practices. To compare pharmaceutical companies with the tobacco industry, the author is essentially comparing a company that the reader may not have a strong feeling towards to a company that most in America can rally against.

 

“…the FACT Act did not become law.”

This is shameful. There were good ideas implemented in the FACT Act, that would have allowed the reader to make individual conclusions, instead of taking the authors word regarding the conclusion.

 

“If the expected value of noncompliance is positive, then the rational pharmaceutical company will ignore the regulation and violate the law because the incentives create a regime where it is cheaper for them to ignore the law”

Although this makes sense, applying a larger financial penalty in order to obtain results does not historically work. For instance, the price of cigarettes continues to rise, but there are still smokers. Obviously there is more than finances at stake with this example, but the authors opened the door by introducing tobacco companies in the argument. The tobacco industry is the reason why this rationale does not work.

 

“[u]ntruthful speech, commercial or otherwise, has never been protected for its own sake…a state may regulate commercial speech that is provably false, deceptive, or misleading.”

This forces the burden of proof on the state that the company was knowingly being deceptive and misleading. These cases that are proven are the landmark cases, such as the teenage antidepressant case presented in the study. There are few landmark cases presented in the article. On a side note, the teenage antidepressant study was so influential that an episode of Law and Order was created similar to the case.

 

Rohr JR, McCoy KA. Preserving environmental health and scientific credibility: a practical guide to reducing conflicts of interest. Conservation Letters. 2010;3:143-150.

I had little vested interest in this article, so there are fewer quotes that I found to comment.

 

“Perhaps the most commonly used strategy to avert undesired environmental and public health decisions is to manufacture uncertainty”

This is not necessarily an evil concept in my opinion. If the evidence is lacking, then “manufacturing uncertainty” is easy. If the evidence is overwhelmingly in support of a specific action, such as the earth circles the sun, then manufacturing uncertainty is impossible. I find the burden for this to be on those in support of those attempting to preserve the environment. For instance, in 2007 the Illinois chiropractors were trying to take mobilizations away from physical therapists. We had ample evidence to demonstrate that we not only owned the technique (thanks to Mary McMillan), but also owned the wording. Because of the evidence cited over the previous century, we were able to prevent this loss.

 

“…delay regulations that might be necessary to protect environmental health.”

This is an opinion of the author and seeing as how this paper is meant to be a persuasion based paper, it should be omitted or cited if there is evidence to support this.

 

“Some authors have even argued that conservation science, with its mission of advancing the sience and practice of conserving the Earth’s biological diversity, is normative and biased and thus can be perceived as having a conflict of interest.”

I can appreciate the authors providing this statement and research in the article, because while reading the article I can only think of the conflict of interest that has been established by those attempting to preserve the environment. If one has a vested interest in the outcome of the research, I find it hard to believe that the research is performed without bias.

Core stability and Swiss Balls

MORAL: Boys, put your balls away. Nothing more to add

 

  1. “Developing core strength has been emphasized as a valuable component in general and sports conditioning programs in addition to active rehabilitation programs for individuals with low back pain (LBP).”

 

What is the core? We all see the late night infomercials talking about core strength and see people with washboard abs. Is this core? Not exactly. Picture this: the strike zone in baseball. Not the MLB, because that strike zone is almost non-existent, but little league baseball. The old middle of the thighs to the letters of the jersey, that’s the strike zone. Now, picture all of the bones and muscles that are in this area. Do the same thing for the side of the body and the back of the body. Most everyone neglects the back and sides. We all want that beach body you know. Unfortunately, that beach body is all show and no go.

 

Core stabilization is more of a communication thing than an Incredible Hulk thing. The muscles of the “core” (strike zone) have to be able to transfer the amount of force that your legs are generating and apply it to something that your arms want to do. All of the body by Jakes or ab rockers won’t get you there. They will do a great job of strengthening your target muscles for that specific exercise, but they won’t do anything for making you a better athlete or better person for that matter.

 

  1. “Numerous studies have placed individuals on trunk exercise programs that in turn resulted in a greater increase in endurance and decline in reports of LBP episodes”

 

If you are a couch potato, than doing anything may be better than doing nothing. If this is you, then stop reading because the ab rocker is waiting for the next set. If you aspire to more than just couch potato, then doing unweighted trunk strengthening exercises may not be enough for you.

 

  1. “It is apparent that training while under unstable conditions does increase the activity of these (trunk) muscles”

 

Enter the Bosu ball or the Swiss Ball. This one statement has created rooms of balls in gyms and has spawned people marching in place while sitting on a ball in the physical therapy clinic. If you are one of these people and really think that you are being uber effective, then this article may be offensive. PUT YOUR BALLS AWAY!

 

But I can already hear you say: “increased activity” blah, blah, blah. Look, being busy is not the same as being productive. Increasing activity does not lead to increasing strength, unless you are increasing the load as well. When I say load, I mean weight. The kind of stuff of the legends of Paul Anderson, Franco Columbo, Kaz (he is so legendary that he only needs to go by his nickname). Look these people up. I can say with certainty that they weren’t training on balls.

 

  1. “Behm et al had subjects perform various trunk-stabilizing exercises with stable and unstable (Swiss ball) conditions. Results indicated that the abdominal stabilizers, LSES (back muscles) and ULES (upper back muscles) exhibited significantly greater activity with the unstable conditions. The 2 most effective exercises for trunk activation were the side bridge and superman”

 

Again is you are weak than doing anything is better than doing nothing. If you have weak muscles, then lifting a spoon is difficult and your muscles will get activated. “Only the strong survive.” I don’t want to activate, I want to get jacked. Why? Because someone that is strong will be able to get their butt off of the toilet at the age of 80, without the use of handrails. Someone that is jacked will not have difficulty getting off of the floor and being a stereotype like on the commercial. People…it is not about turning on muscles. I can turn on my butt muscles by squeezing my ass cheeks together. Activation does not equal functional and surely doesn’t mean strong.

 

The Swiss ball is one of the worst things to be introduced into our profession. That’s right…I said it! We as a profession spend way too much time training unstable situations when the patient needs to get stronger. I can hear the PTs arguing now: “What about balance patients? What about patients that need to walk on unstable surfaces?” Great! Do Swiss ball stuff for this purpose, but stop selling the unstable training as a means to get stronger. I am saying “I AGREE WITH YOU”! Ok, now get rid of the Swiss ball for all other purposes. We are doing the patient a disservice. The logic made sense years ago, but the research just isn’t there.

 

On a side note: I want as many patients as possible to read this blog. This way the patient can be armed with facts to go into the PT with in order to question the activities that are being performed in the clinic. If I can’t give a good reason for why I am doing what I am doing, then fire me! We are in a day and age in which results will be the driver of our profession. This is already starting to happen with “bundled payments for total joints” ( I highly suggest that you educate yourself on this also. I may or may not write about this soon). We need to make sure that as health professionals that we continue to get smarter and better at what we do. Patients need to continue to educate themselves about their health for two reasons 1. IT’S YOUR BODY! 2. You will challenge your health care provider to either get better or get lost.

 

The two most effective exercises for trunk activation are the side bridge and superman, said no strongman, crossfitter or strongman ever!

 

  1. “Swiss balls have been incorporated into strength training programs on the belief that a labile surface will provide a greater challenge to the trunk muscles, increase the dynamic balance of the user and possibly help to stabilize the spine in order to prevent injuries”

 

Coming soon: Humans on Mars. Same kind of statement. The above quote starts by talking about beliefs. Look, are we a faith or are we a science? We can’t have both. If we believe something to be true…it also has to be true. For a long time, the world was flat. We believed it to be true, so it was true. We have come a long way since Galileo. We actually have to test our beliefs to see if it is worth using.

 

I am a meathead. Swiss balls are fun to play tug-o-war or work on balance (such as advocated by Paul Check), but they are not good for building stability. To be stable is to be the opposite of mobile. We need to make our trunk opposite of mobile. We can do this by resisting a heavy load.

 

  1. “…one must ensure that their training regimen incorporates training specificity”

 

Joe Weider. The name brings back memories of the old Weider barbell sets sold at Sears. We had the concrete filled plastic weights. My how far we have come…and yet the same principles still apply. If you want to get better at throwing a punch, don’t work on kicks and if you want to be a better swimmer, don’t practice skydiving. If we want to be strong and stable (i.e. immobile), then we need to practice on being strong and stable.

 

  1. “The practical application of training the trunk stabilizers from a supine or prone position may not transfer effectively to the predominately erect activities of daily living”

 

If we pair point 6 and point 7, then there’s only one real reason to practice exercises in a horizontal position…you know what I mean (wink, wink).

 

Anyway, the new buzz words are functional fitness. The above statement is essentially saying that doing exercises that are not similar to what you would do during your day may not be functional. You hear the old joke about 12 oz curls, yeah I’ve heard it too. If all you do all day is drink grape nehi, then you don’t need to do anymore than that. It’s functional for you.

 

  1. “Perhaps a combination of relatively high-intensity resistance using free weights (light to moderate instability) can provide greater activation than the very popular instability exercises commonly used today”

 

DUH! Anyway, the authors are finally talking about a quantity of activation. There is no doubt that lifting a beer bottle will activate your arms and trunk muscles, but I’ll take the guy that is lifting kegs for fun if I was a betting man.

 

  1. “The 80% 1RM squat exercise exhibited significantly greater LSES EMG activity than all other exercises…exceeding the body weight squat, deadlift, superman, sidebridge exercises by 56, 56.6,65.5 and 53.1% respectively”

 

When compared to dead lifting, side bridging and superman, the squat is THE KING OF ALL EXERCISES! For lumbar spine muscles. Hear that all you bird-doggers! Hear that all you supermanners! There is nothing better than loading a heavy barbell with 45 pound plates and squatting down and standing up. I miss the sound of the 45 pound plates vibrating next to each other when you walk the bar out. I use bumper plates nowadays. Not as much testosterone as the steel, but a hell of a lot safer for my garage floor if I have to dump the weight.

 

Put it into perspective, this exercise is 50% better than most popular exercises. Everyone can squat. Everyone has to get off of the toilet. If you don’t, you will end up in a home because no one wants to help you off of the toilet and wipe your behind for free.

 

  1. “The 80% 1 RM deadlift exercise exhibited significantly greater ULES EMG activity than all other exercises”

 

There is a reason why powerlifters have such thick backs. They specialize in the 2 exercises that work both the lower and upper lumbar muscles.

 

  1. “…it may be unnecessary to add calisthenic-type instability exercises to a training program to promote core stability if full-body, dynamic, upright exercises are implemented in the program”

 

Time to turn off the t.v. Stop buying all of the infomercial crap and just get up off the couch…now sit down…stand up…sit down…stand up…sit down. Now go do the same thing while holding a can of soup. You are now stronger than you were yesterday.

 

Excerpts taken from:

Hamlyn N, Behm DG, Young WB. TRUNK MUSCLE ACTIVATION DURING DYNAMIC WEIGHT-TRAINING EXERCISES AND ISOMETRIC INSTABILITY ACTIVITIES. Journal of Strength Conditioning Research. 2007;21(4):1108-1112.

 

 

Whatcha lookin at? Part III

Whatcha lookin at? Part III

 

The topic of the day is overall wellness of the individual and of society as a whole. I have some strong opinions regarding this and if you disagree with what I right, that’s your prerogative. Please leave a comment stating why you disagree.

 

  1. “ Work Well-Being Dimension satisfies the thirst for purpose…need for fulfilling a purpose in ones’ vocation”

 

This is important. Think of all of the people on disability, whether short or long-term. If there is no purpose, then how empty are we? This reminds me of a story: My dad…my Superman retired in 2005-ish. When he retired, he asked me about some symptoms he was having. Coughing up blood and difficulty sleeping. He attributed it to getting kecked by a horse in the previous week. I saw red flags. One thing led to another and he was initially thought to have lung cancer. The man didn’t smoke and as long as I can remember never smoked. After retirement, he spent his time sitting around watching Bonanza. He had a surgery and removed a mass from his left lower lobe, which was non-cancerous, but was due to a bacterial infection. This is a moot point, because the bacterial infection would have killed him also. Anyway, after the surgery, my brother bought him a horse. He found a new passion…a new purpose. My dad is healthier now than I have seen him in a long time. My mom doesn’t particularly like his spending time with the horses, but he has a purpose. My mom still searches.

 

We all need a purpose…we all need a why. If you don’t have one, keep looking because someone we all have talents and can all be helpful to someone else if we take the time.

 

  1. “Play Well-Being Dimension acknowledges that play provides the individual

with laughter, cheer, energy, and balance”

 

From the work well-being to the play well-being. I think that we have confused busyness with work and/or play. For instance, many of us say that we are busy when asked how we are doing, as if busy-ness implies that we are working. This is not always the case. I am way more productive when I am not busy. Play is difficult for many people because we, I , forgot what it means to be “unbusy”. This time of laughter and cheer. Having a daughter has greatly helped, a I recently went down a sslide for the first time in a long time. If you know me, then you can image “big guy in a little coat”. That’s how it felt going down the slide.

 

  1. ‘Well-Being of Our World Dimension reflects an individual’s perceptive on living in a healthy environment and protecting natural resources…broad overview of the world…responsibility, justice, an earth-caring lifestyle, a desire of well-being for all”

 

I don’t know if I agree with this dimension totally. As much as I am for a “green” environment, I don’t know how much someone’s throwing away electronics affects me personally. I won’t judge someone taking plastic over paper. Short story: While in Poland, we went to the grocery store weekly. We had to pay for every bag that we used. It was about a nickel in US dollars. Although it wasn’t much, remember that people there don’t make as much as we do here, so this is a major sacrifice in order to carry the groceries out of the store.

 

  1. “Even when a individual presents with signs and symptoms of pathology, education of secondary complications prevents further signs and symptoms leading to disability”

 

I see many patients with low back pain. Most of these patients come into the clinic looking for one thing (and research shows this is the number one thing that patient’s want): education. They want to know why they are experiencing symptoms and how can they go about fixing themselves. If we can educate patients or society as a whole regarding normal compared to abnormal experiences, there may be less disability.

 

  1. “Prevention practice encompasses health care designed to promote health, fitness, and wellness through education and appropriate guidance designed to prevent or delay the progression of pathology”

 

Those promoting health should also demonstrate a healthy lifestyle. Without a doubt, if I passed you on the street, you may ask “Do you even lift bro?”, but I can squat with the best of them (drug free of course). Many therapists don’t allow for time in their day to exercise and to me this is hypocrisy, seeing as exercise is the intervention charged the most in our profession.   It’s like a Doctor telling you to quit smoking though you see the stains on the fingernails. Hypocrisy!

 

  1. “Preventive care also includes instruction to minimize or eliminate injurious forces throughout daily life. This instruction includes recommendations to optimize conditions for performance, whether the performance is related to simple activities of daily living, work activities, leisure activities or activities related to competitive sports”

 

Robin McKenzie, Shirley Sahrmann, Stuart McGill, Brian Mulligan, Florence Kendall, Geoff Maitland, Stanley Paris: These are the giants of the previous century. They took therapy and principles of health to the health care practitioner. Giants of today are: Grey Cook, Kelly Starrett, Quin Henoch, Therapy Insiders, Barbell Shrugged guys, because they are taking healthcare to the patient.

 

As a PT, I can affect one patient per hour. Writing this blog, I have already affected twice as many people and I only hope for exponential growth.

 

Excerpts taken from the following:

 

Thompson CR. Prevention Practice: A Holistic Perspective for Physical Therapy. In: Prevention Practice: A Physical Therapist’s Guide to Health, Fitness, and Wellness. Thorofare, NJ: SLACK Incorporated:2007.

 

Whatcha lookin at? Part II

Whatcha lookin at? Part II

 

7.”Physical wellness is the positive perception and expectation of health…the ability to effectively meet daily demands at work and to use free time”

This is what my job mostly entails.  As a PT, I get to give people their physical wellness back.  Typically, we see patients because some aspect of their life is giving them pain and therefore preventing them from living their life as they would like.

  1. “Spiritual wellness is the belief in a unifying force between the mind and body…establish values and act on a system of beliefs as well as to establish and carry out meaningful and constructive lifetime goals”

When things get put into this perspective, it means more than simply religion.  What is your end-goal? We have a beautiful family with a daughter and hopefully many more on the way.  My end-goal is to leave a legacy that my family can be proud of.  I look at my dad, Sal Gutierrez, and see my Superman.  I want my kids to be able to look at me and say, “There goes my Superman.”

I want to leave my mark on this world.  The words that I write today will outlive me by centuries.  This is my journal.  Although this article is much different than the previous ones, this is much more enjoyable to reflect upon than simply the cause and treatment of back pain.

  1. “Social wellness is the perception of having support available from family or friends in times of need and the perception of being a valued support provider…establish meaningful relationships that enhance the quality of life for all people involved”

I think back to the book “The Prince” by Machiavelli (sp?).  A leader can either be feared or be loved.  I think of my family (by either blood or experience) and know that if they ask me to jump, I will ask when, where, and how high.  This is out of love, but not fear.  I know that I have family that will do this, as evidence by our wedding and people flying across the country at short notice.  I hope that I am the same type of family to those that I surround myself.

  1. “Psychological wellness is a general perception that one will experience positive outcomes to the events and circumstances in life…positive outlook about life…qualities of optimism, determination, and hope”

This one is huge.  I have had many patients tell me that the most important thing that I give in the treatment is hope.  This is emotional for me because although it is great to be able to change someone’s pain, it is much better to be able to change someone’s outlook.  Hope, determination and optimism.  I think of how the tale of two lives.  Growing up on the East side of Joliet, life wasn’t white picket fences. My life could have turned out completely different, but thankfully my parents were determined to give me better and we moved to a small farming community.  The nature vs nurture debate couldn’t have been stronger internally.  As much as I like to think that I did the whole bootstrap thing, I have to fully acknowledge that the environment I was in allowed for hope and optimism.  Thankfully, I have a circle around me that also shares in these traits.  Many have said it, from Tim Ferriss to Dave Ramsey, ” we are an average of the 5 people that we choose to spend our time with”. I am grateful my 5 guys made me better instead of brought me down.

  1. “Emotional wellness is the progression of a secure self-identity and a positive sense of self-regard, both of which are facets of self-esteem…ability to cope with daily circumstances and to deal with personal feelings in a positive, optimistic and constructive manner”

I think of this portion of wellness frequently. It is not uncommon that I am treating a child with a parent present or an elderly parent with a middle age child present. The patient may not be able to cope with the situation that brought them into the clinic, but the caregivers can either break or heal the situation. Some caregivers come across as apathetic, which makes sense as to why the patient doesn’t want better for him/herself. No offense if you are a caregiver, but please step outside of the situation and look into the situation with a fresh perspective. If you were watching as a third party, would you be proud or ashamed of how you act?

Some people don’t have the capabilities to deal with daily circumstances. Like I said previously, my brother died of a drug overdose. His life was full of obstacles…whose isn’t. Just my opinion, but I don’t think that it is a major event that causes people to lose hope and spiral downward, but more of a “straw that broke the camel’s back”. I think that there were too many straws in my brother’s case. Looking back though, as his brother, there is shame and guilt that I didn’t see this coming. Think of how this comes full circle. One person’s emotional wellness, or any wellness for that manner, can affect those that are in close proximity (either physically or emotionally). When at work, I do my best to ensure that my wellness is overpowering to those around me in order to bring up the other person’s wellness aspects. When there is a patient whose emotional, physical or social wellness overpowers my own…I sit back and allow that person to bring me up.

Good story. I had a patient that was in his 90’s. He was coming to therapy for balance issues. He noted that his “balance wasn’t what it used to be”. I agreed and said that my balance probably isn’t as good as it was 10 years ago. He then proceeded to stand on one foot for two minutes and stand on one foot with his eyes closed for a minute. My jaw dropped. At this point, I realized that this guy didn’t need me. If anything, I needed to learn from him. I asked him; “What did you do for a living and how did you get to be in this good of shape at your age?” He gave me a history lesson and noted that the year the Olympics were boycotted by the US, he was in the trials for the 100 m dash. He trained and trained for years in order to qualify for the Olympics, only to have his dreams squashed that year. He then quit sports and went on to a physical job as a track coach. He was still performing sprints into his 80’s. This also reminds me of another athletic relic in our country, Zygmunt Smalcerz. Look him up now! I’ll wait.

  1. “Intellectual wellness is the perception of being internally energized by an optimal amount of intellectually stimulating activity…not so overwhelming that there is no time for mental repose…includes a person’s ability to learn and use information”

This is very important in our society today. Everyone speaks of the watering down of higher education, in that you have more difficulty obtaining work with a BA/BS today than you did 30 years ago. More students are moving on to MA/MA or DPT’s (in my own case) than ever in the history of our country or my profession. The reason for this is that a job is not waiting at the other end. Our current kids (mine included) has more screen time than any generation previously. This screen time, although we can rationalize why it is good for our child, is really a way to allow for us to have a cheap babysitter.

  1. “Howard Clinebell” introduced other dimensions of well-being with the addition of the relationship, work,play and well being of our world dimensions.
  2. “Relationship Well-Being Dimension represents the most important factor for our healing and general wellness…need for nurturing and love, for giving and receiving, for empowering others, and for creating interpersonal bonds”

It has been said by Dave Ramsey that next year we will the same person as we are this year except for the people that we meet and the books that we read. People change us. I meet some patients at work that just completely upset me and make me make changes due to some of their perceptions on life. I meet others, like that track star, that make me think there is no reason not be healthy as an elder…other than decisions that we make in our younger years.

I try my best to be a positive influence to those people that I come in contact with, but sometimes it is not easy.

Everyone needs love in his/her life. Personal Story: My parents divorced when I was young. I don’t remember my mom much as a kid because my dad took care of us, and he did an awesome job with me…in my opinion. Again, my superman. Back to the point, when one is devoid of love, a cynical or angry perspective of the world can seep into our being. I was angry for a very long time because I stopped having contact with my mom when I was still young. She walked away. I was angry and had trust issues for a very long time. Think about it…if the person that you are inherently supposed to be able to place all of your trust into does something so terrible as to destroy that trust, then who can you trust. In the words of Stone Cold Steve Austin DTA. It took me over 2 decades to come to terms with the situation that happened when I was still a kid. Life is good now and I very much understand the concept of the “need for nurturing and love”

Excerpts taken from the following:

 

Thompson CR. Prevention Practice: A Holistic Perspective for Physical Therapy. In: Prevention Practice: A Physical Therapist’s Guide to Health, Fitness, and Wellness. Thorofare, NJ: SLACK Incorporated:2007.

Stay tuned for part III

WHAT YOU LOOKING AT?

WHAT YOU LOOKING AT?

 

We all have a story. Sometimes our story is embarrassing. Some stories are sad. Some stories are full of success. Some stories are empty. The point is…we all have a story and it is OUR STORY. My story is no different than many others. Life, death and taxes. Sometimes more death than life and other times more life than taxes.

 

I decided to do this one a little different than previous posts.  These are taken from the textbook regarding health and wellness, instead of a research article.  You will learn a part of my story.

 

 

  1. “Health is derived from the Old English term hal, meaning sound or whole. Health is essentially the purpose of Medicine”

We as a society are becoming confused with the terms healthy and lack of illness. To be healthy is to be whole. This is a huge change of perception and a paradigm shift that is still occurring in healthcare. We all know that there is not much money to be made in making someone “whole”, but we charge a ton of money for cancer care. The easiest way to determine how much money is being made is to look at the size of the building. Dave Ramsey says, the tallest buildings are either owned by banks, oil companies, or car companies. There are major profits in these businesses. I can’t wait for the day that the biggest buildings are owned by companies like Crossfit, Primal Blueprint, Barbell Shrugged, Paleo Solution, etc. I doubt that it will happen in my lifetime, but it would be nice for our society as a whole…to make it whole.

 

  1. “Medical professionals have experienced a shift in their health care paradigm perspective from one emphasizing illness to one stressing health, function, quality of life, and well being…The importance of supportive environments for producing lasting change cannot be overemphasized”

Again, when we are “sick” we go to the doctor to feel better. Doctors do a good job of treating sick people. If we are not “whole” like in the above statement, then we need to see a doctor because, because in essence we are…SICK! Think about this, can you say that you are WHOLE? That your life is great? If not, why not? Who in the medical field would be best to talk to about your emptiness, or sickness.

Personally, I have been to a psychologist and it was one of the greatest things that could have ever happened to me. I had a patient die in my arms. It is the worst experience that I ever had to experience and I can still see the patient and can recall the entire event until the point that I started chest compressions. I took lessons from that psychologist and applied them to life. That advice has completely changed my life. LISTEN TO ME! My life is changed because of that encounter…only for the better! As a society, we tend to stigmatize going to doctors or other professionals as less macho than handling things on our own. Look, I suck at fixing a car. I can put gas in the car and turn the key. After that, I am like the kid from the Christmas Story…OH FUDGE. People pay me to help them become healthier…whether this means to be pain-free or to move better, this is all part of becoming a better, less sick or whole, person.

I find that our profession is being asked to make this paradigm shift in the face of profit being made from treating illness. This is as much a personal business decision as it is societal ethical decision. We again need to see healthcare as a business and then we can understand why setting up fitness programs is not as profitable as setting up cancer treatment centers.

Getting back to supportive environments…Crossfit understands this. When talking to Crossfitters, the chief word to describe the “box” is community. This is why the model is so successful. They can sell you the workout, but anyone can do the movements…but not everyone will be inspired to do the movements day in and out alone in a garage.

 

  1. “…the National Academy of Sciences found that musculoskeletal disabilities in the workplace cost the United States more than $1 trillion per year in total costs”

HOLY CRAP! We are unhealthy! We get hurt daily. At any one point in time, there are 5 million Americans with back pain. This gets expensive. Think about how your not showing to work affects your co-workers or business as a whole. I know that if I call in sick to work and my patients don’t get seen, it costs me money, but it costs the business at least $1,000. I can’t afford to be hurt or sick.

 

  1. “A rising trend in poor health reported in the United States indicates an immediate need for preventive care in order to reduce medical conditions that lead to disability…a trend toward increasingly limited activity and poor health over the last decade”

Until we make health care and promotion of “whole”ness more profitable than sick care, I don’t see this happening. We as a society are becoming less healthy over time. This could have many factors depending on who is speaking. I hear groups say that it is the high-fructose corn syrup, it’s the GMO’s, it’s the gluten, it’s the technology, the lack of recess, the wussification of America. There are any number of reasons, but the result is still the same. We are becoming, in the words of Ravishing Rick Rude, a society “of fat, sick, lazy, overweight slobs”. God I wanted his abs. Secret man crush.

 

  1. “a variety of unhealthy lifestyle behaviors commonly developed early in life often lead to disability, chronic disease, and ultimately, premature death”

Basic stats reported in the media. The new generation of kids will be the first generation to not outlive the parent’s generation. WTF! Why are our kids more sick than we were/are? This should be enough to make every American sick and every parent take action. Kids should not be type II diabetic! Kids should not shy away from play! Dang it…I was always and continue to be the “big kid”, but I will play with the crossfitters, the powerlifters and the strongman groups and every once in a while I will go to the park and do the monkey bars, slide down the slide and run the bases. We need to introduce…no reintroduce…our kids to activities that don’t involve a screen. This is the type of lifestyle that will lead to “premature death”. It just got real.

 

  1. “According to the National Wellness Institute (it does exist), ‘wellness is an active process of becoming aware of and making choices toward a more successful existence’…wellness in an active, lifelong process…integrates mental, social, occupational, emotional, spiritual, and physical dimensions of one’s life”

Wellness is actively seeking out a successful existence. Let that one soak. Our time is precious and our time is relatively short all things considered. First, congratulate yourself…you are still here. Many are not. Many have lost the fight of existing. Personal story: My brother died of a drug overdose about 8 years ago. Purposeful or accident…only one person knows for sure and we will never know the answer. Why does it take death to put things into perspective. Every morning we wake up we have a choice. Do I want to be an active seeker of a successful existence, or will I allow external forces to manipulate my being and time. There are many cogs in the wheel of wellness, but even I focus only on a few spokes at a time. We can’t all be perfect. With regards to the mental, I used to be such an OCD person. My psychologist told me that I lived my life so compartmentalized and each compartment was perfect. It was good that way, but life sucked. When I started incorporating more than just reading medical journals, life improved. When I started taking advantage of the social aspect life blew up…in a good way. Loving family, friends that I would jump for at the drop of a hat (out of love, not fear), spending less time on social media and being more social in life. Time is short. I have been a meathead for the past 15 years and focused so much on the “physical dimensions” of my life that it overpowered the other dimensions. I remember working at Sam’s club (8298 represent) and being so engrossed in school, work or gym that I was inept socially. I couldn’t have a conversation unless it revolved around one of those three topics. I was so far removed from any culture, either pop or otherwise that I was socially uncomfortable.

 

 

 

I will continue to edit this post over time, as this chapter requires more time devotion than previous studies.

Excerpts taken from the following:

 

Thompson CR. Prevention Practice: A Holistic Perspective for Physical Therapy. In: Prevention Practice: A Physical Therapist’s Guide to Health, Fitness, and Wellness. Thorofare, NJ: SLACK Incorporated:2007.

Do you run loudly?

Shhhhhh…quiet. Tread lightly and land softly. May your joints forever feel young.

  1. “Several of these programs instruct participants to land softly in an attempt to teach proper landing technique and reduce impact forces. Mandelbaum et al reported an 88% decrease in anterior cruciate ligament injuries in 1041 female subjects using soft landing cues”

Are you thinking what I’m thinking? Seinfeld? Mandelbaum seriously?! This was the family of old guys in the hospital with Jerry that kept hurting themselves trying to lift the t.v. I thought it was funny.

What the above is saying is that the sound of your landing can directly indicate your injury risk. Don’t go jumping off buildings to test this theory! I won’t be held liable.

 

  1. “13% decrease in peak vGRF during a drop-landing task when 80 adult recreational athletes were instructed to listen to the sound of their landing…reduced by 24% in a stud in which 12 female recreational athletes were asked to land softly…”

What this means is that the softer you land the quieter you land. vGRF is vertical Ground Force Reaction (some people really hate it when I mix up the letters, but oh well…You know who you are!). This is it this way. For every action, there is an equal and opposite reactions. This means that if you land with a heavy load, the ground pushes back up at you with an equal load. If you absorb some of the load with your joints by bending, then the ground doesn’t push back as hard. Think of dropping a stick vertically from a specific height. The stick will actually bounce a little after it hits the ground, because the ground pushes back. Now do the same experiment with a wet noodle and you will get a totally different result. This may not be an exact science, but at least it makes sense to me. When you land quietly (wet noodle), you don’t get the jarring force from the ground as when you land loudly.

  1. “Initially, the participants were instructed to perform drop landings (with no instruction) to obtain a baseline, normal sound amplitude of landing…then instructed to …create a quieter or louder sound from this normal landing condition”

For those of you that perform high-intensity exercise of varying modes under time domains-based exercises, (I am unsure that if I use the word crossfit that I may be sued like those before me) such as box jumps, that this study will apply to you.

  1. “quiet-landing instruction results in significantly greater joint excursion at the ankle and knee when compared to a normal landing sound instruction”

Essentially, the quieter that you try to land, the more that you perform a squatting based movement on the land. The stiffer you land, the louder you are. The louder you are, the more force (think jarring) that your joints have to endure.

MORAL: Be quiet! Tread lightly!

Excerpts taken from: Wernli K, NG L, Phan X, et al. The Relationship Between Landing Sound, Vertical Ground REaction Force, and Kinematics of the Lower Limb During Drop Landings in Healthy Men. J Orthop Sports Phys Ther. 2016;46(3):1945-199.

If you would like a running assessment or are experiencing pain during running, come see me at:

Functional Therapy and Rehabilitation

(Now part of the Goodlife family)

903 N 129th Infantry Dr

Joliet IL

8154832440

I AM an N of one! (superman pose)

 

If I care more about you than you do…we got a problem. If you live with chronic pain, you may not have to. Seek out a qualified healthcare practitioner, versed in research, and participate in your own health care.

 

  1. “…researchers and clinicians have come to understand patients as a heterogeneous group…One of the first classification schemes was created by McKenzie.”

Not all patients with back pain have the same back pain from the same source. Meaning one patient may have pain from the disc, one may have pain from the spine joints, one may have pain from pressure on the posterior longitudinal ligament and one may have a muscle sprain/spasm. That last one gets used a lot, but I have yet to see a true muscle sprain/spasm in the clinic. The point of this is that we first have to classify a patient when they come into the clinic. Another phrase for classifying is to make a “best guess” as to what is causing the problem. I worked with a well-respected physiatrist Dr. Ron Mochizuki and while we were presenting at a community event he stated, “When we know what fixes your problem, then we will know what caused it.” After hearing this, it made a lot of sense. Unfortunately, everyone wants an answer to the “WHY do I have pain?” question, but the answer is not that easy.

Mckenzie…where do I start? Robin was innovative and passionate. This guy, dearly departed, imparted more influence into our profession than any other practitioner in the previous century! For all of the PT’s that may actually read this, think about this. Readers of the Journal of Sports Physical Therapy voted the likes of Sahrmann, Paris, Mulligan, McMillan, Kendall, Maitland, and Robin as the most influential PT of the previous century. Robin bucked the trend in therapy at the time and was seen a cult leader. We now know that he was well ahead of his time. He was our House MD, both revered for his knowledge and sometimes mocked for his lack of servitude to the traditional treatment paradigm.

 

  1. “Centralization has been consistently associated with a good prognosis for both pain and function, and can direct appropriate treatment”

Centralization (Look it up! It’s that important if you have back pain) trumps depression, trumps yellow flags (You’ll hear more about these later) and again is the “TRUMP CARD” as previously stated in the literature to treating back pain.

 

  1. “This case study describes the assessment and treatment of a patient with a 20-plus year history of constant low back and bilateral leg pain, presenting with multiple yellow flags and verbalized fear avoidance…seen for a total of five visits over seven weeks”

A case study is a study with an “n” of 1. This means that this describes one patient. The “n” of one concept is being touted as very relevant in the popular podcasts such as the Tim Ferriss Show, Barbell Shrugged, The Paleo Solution Podcast, etc. What does this mean? In science, a case study is relegated near the bottom of the Totam pole. Why? If something works for one patient…So What?! It was only one patient. We think that a study should help thousands of people before we can claim it as helpful. This is horrible to think. It reminds me of a good story and then a personal story.

 

http://avalouise.net/wp-content/uploads/2015/08/Starfish-Story.jpg

 

The first time that I heard this story was while I was in PT school. There was a guy, I apologize for not remembering his name. We were at Rush Hospital in Chicago and there was a recipient of a double lung transplant telling this story. He is the “n” of 1 and the transplant saved his life. The point of this is that a case study can be just as important as the big time studies if the person in the study gets a life saving treatment or intervention. His story inspired me to be a bone marrow donor. One of the hardest decisions that I ever had to make… and forever I will be a bone marrow donor. Forever I will have to have every other year interviews in order to educate me of the possible side effects that weren’t known at the time of my donation. My life is forever changed, but I am just an “N” of 1.

Back to the story…the patient had a 20-year history of back and both leg pain, with yellow flags. Any therapist reading this knows that we do not like seeing this patient in the waiting room prior to day one. They typically color in the entire body when asked to fill out the body diagram. They tend to color outside the lines on the body diagram. Really!? We know you have pain. Coloring outside the lines gets our attention, but not in a good way. A person with a 20 year history of pain is no good. I’ve seen many a therapist throw up their hands saying, “What am I going to do with this guy?” Needless to say, it still is a business and these patients tend to get put on a “shake and bake” “one-size-fits-all” program. Now on top of that, add in yellow flags and this has the makings of a disaster. Dave Ramsey has a saying that some people have “Eyeore” as a spirit animal. This is a quick summation of yellow flags. 

 

  1. “Her score on the Modified Oswestry Low Back Disability Index was 56%”

This is a questionnaire that allows the patient to self describe how symptoms limit lifestyle. This score would correlate with severe disability.

 

  1. “Management following Initial Assessment: Self Management provided: repeated extension in lying; repeated extension in standing; slouch/overcorrect in sitting…educated about the excellent prognosis in the presence of centralization”

Remember what I said about the “Trump Card”? Even in someone that has experienced pain for > 20 years and shows up to the clinic looking like Eyeore, there is still hope! At least if the therapist is well versed in the research and doesn’t default to “shake and bake”.

Repeated extension in lying is similar to the cobra pose in Yoga. This exercise has been synonymous with McKenzie forever, but MDT is more than just this exercise. Postural correction? Wait…posture is important? For some people, changing postire can turn off pin and increase confidence. 

  1. Visit Two (one week later)…Pain has reduced from 4/10 to 3/10. “She reported a consistent decrease in pain with the performance of her exercise…posterior-anterior mobilization of the lumbar spine (was added this session)”.

Not a huge change in pain intensity from visits one to visit two, but there was a huge change in perception. Once a patient understands that he/she has the power to change the pain, it’s over. The patient has to see that cause and effect. I don’t care if the pain has been there for 1 day or 20 years. I never tire of seeing the patient’s face when they start seeing the same patterns that I see. I love the look when they realize that the pain was within their control. That is awesome! P-A mobilizations are when the therapist puts his/her hands on the patient’s back, while the patient is lying face down. The therapist applies a downward force and the patient typically says “Ah…that feels good”. This may be no good (more to come later).

 

  1. Visit three (one week later): “initiating treatment with sustained extension in lying…head of the bed elevated for five minutes…performed to accommodate the patient’s reports of wrist pain with repeated extension in lying…symptoms were fully centralized”

Story Time: This is the famous story regarding Mr. Smith. Take yourself back to the 1950’s. Non-conformists weren’t looked upon in high regards. Robin was a non-conformist. Everyone at that time believed that if you bent a person backwards you would sever a person’s spine and cut the nerve roots in half! Seriously?! This is how they thought back then. Enter Mr. Smith…from here I will say go out and buy Robin’s book “Against the Tide”. It’s a great story from a great clinician and I can’t do this story justice because it is not my story.

 

  1. “Visit Four: pain level of 1/10…primarily centralized to the low back…avoiding passive treatment is consistent with promoting patient independence…hurt vs harm”

This patient is much better than previous visits at this time. A patient with 20 years of pain is starting to see the value of mechanical care. It’s funny I recently had a student that came into the clinic and said “I don’t plan on being a MDT based therapists when I graduate”. After this student left, I don’t think that he will be able to see treating a patient in any other way, as the results can be rapid…even in patients with 20 years of pain.

Passive treatments are any treatments in which the patient is not actively participating. This is the “Shake and Bake” described earlier. Passive treatments are as follows: massage, ultrasound, electrical stimulation, moist heat and some would say manipulation. Believe it or not, that is a strong statement. There are many therapists that built their careers on using passive treatments. These treatments require very little thought and the business gets reimbursed well for using these types of treatments. Our professional organization, the APTA, has come out strongly against the use of passive treatments and McKenzie was very much against passive treatments, as they foster dependence on the therapist instead of the patient taking ownership of the problem. I do physical therapy. I have a doctorate of PT. I can explain all of the same benefits that our profession uses to sell the continued use of these and then I can tell you that this research is old and there is little current research to show the benefit of the above list. We all want to help patients, but there is a huge chasm between traditional physical therapy and current therapy based on research.

Hurt vs. harm: If you have ever worked out, you understand soreness. Some coaches may have explained this as are you hurting or are you injured? Harm is no good, but hurt is normal. I have a two year old daughter and I am constantly stepping on small toys. It hurts…bad sometimes actually, but it doesn’t harm me. When a patient does something out of the ordinary, they will feel things out of the ordinary. This is not always harmful, but if that feeling lingers for a period of time (20 minutes based on research), then the hurt pain becomes harm pain. Stay out of harms way, but seek pain. This is the only way to become bigger, stronger, faster and the bigger, stronger, faster person tends to have a better quality of life than that of the smaller, weaker, slower person.

 

  1. “Visit Five: (one month later)…denied pain…patient scored 2% on her Modified Oswestry Disability Index…no longer fearful”

Twenty years of pain…GONE! This is a frequent occurrence in the clinic, but the therapist has to be trained in treating this type of patient. This a change of 10% is considered significant on the Oswestry, and this patient’s change was 5x significance! Of value, the patient’s belief system changed and was no longer afraid of movement!

 

  1. “several yellow flags…depression…inability to describe any relieving postures or activities besides rest; self-limiting…external locus of control”

This is Eyeore. Depressed, never excited, wants to rest and relax and believes that this is the best for symptoms, and external locus of control. This is the woe is me patient. Everything is out of the patient’s control and the world is against the patient. Think of the old joke about the country song…My dog died, my wife left me and the truck broke down. Never mind you didn’t feed the dog, love your wife or put gas in the truck. IT’S NOT MY FAULT! This is external locus of control.

 

MORAL: Don’t be Eyeore. Take control of your health. Go out and get bigger, faster, stronger.

 

Functional Therapy and Rehabilitation

903 N 129th Infantry Dr

Joliet IL

815-483-2440

 

Excerpts taken from:

 

Sheets C. Resolution of a 20-year history of chronic low back and leg pain with direction-specific exercise and focused pain education. IJMDT. 2009;4(3):30-36.