Category: non-professionals

Socialized what?!

 

We all have our own opinions regarding socialized medicine, but let’s just look at some of the research from countries that provide socialized medicine.  This article is based on the system in Australia.

 

  1. “…34-year old male referred by his GP (primary physician) to the orthopaedic outpatient department…carpal tunnel” The PT referred the patient back to the GP and “suggested that the GP organize nerve conduction studies to confirm carpal tunnel syndrome, before the patient would be offered an appointment with a surgeon…seeing a physiotherapist to help clarify the diagnosis and see if the symptoms would respond to conservative treatment”

This is a mouthful. Let’s start with some of the major differences between the Australian system and the US system. The PT is the gatekeeper to see the surgeon. The PT’s opinion or consultation was taken seriously and the patient was sent back to the primary physician to order the tests before seeing the surgeon. Keeping it simple. Therapists do therapy. Chiropractors do chiropractic. Surgeons do surgery. It is wasteful to send a patient to a surgeon if the patient does not need surgery. It is not efficient to send a patient to a surgeon to order more tests. Also, the PT would help to clarify the diagnosis. For a long time, therapists in this country have been treated like technicians, only capable of performing the treatments that the physicians deemed appropriate. This is simply not the case anymore. We are a doctoring profession. Not that this in and of itself places us on a pedestal, but some of us continue to expand our knowledge base and have become professionals at both movement and classification of patients. This is to be respected, sought after and rewarded…not necessarily monetarily, but at least with more opportunities to demonstrate our abilities.

 

  1. “initially assessed by another outpatient phsyiotherapist…computer worker with a four to five year history of altered sensation in the left upper limb;including numbness, pins and needles and pain in the hand and thumb, and, pain around the lateral aspect of the elbow…gradually worsening…using his left hand less in everyday activities.”

By the by, this was session one, which we will call day one. Again, the body is a roadmap. Symptoms that are referred to the hand can come from anywhere that sends information to the hand. Let’s break it down in laymen’s terms. When you flip the switch on the lamp and the light doesn’t turn on, what’s the problem? First, the light may be burned out. This is akin to the muscles not working appropriately or a problem at the location of the visual or perceived problem…in this instance the hand. The problem could also be the power cord. This is similar to a problem coming from a nerve that travels from the hand up to the neck. Any of the nerves that supply the hand could be “frayed”, for lack of a better term. Finally, the cord could be unplugged. In this case, the electricity isn’t even making it to the power cord. This is similar to a problem with the neck. If the brain can’t send the signal appropriately to the power cord, then the hand won’t work correctly.

This is obviously becoming a problem for this particular patient, as he is slowly de-emphasizing the use of his left hand.

 

  1. “full active and passive range of motion. Left shoulder flexion produced pins and needles in the left hand”

When a patient raises his arm overhead, most people can see how the muscles work and that the shoulder joint must be moving somehow. What people don’t see is how this plays on the nerves of the body. When a patient reaches forward, this pulls on the nerves of the body and sometimes can increase a patient’s symptoms.

 

  1. “Session two (two weeks later): non-dermatomal distribution of hand symptoms…the presence of night pain that consistently disturbed the patient’s sleep”

Red flags. Think of the JAWS theme music when you here these words. Red Flags are BAAAD! Non-dermatomal patterns means that the symptoms don’t match the road map of the spine. If a problem is coming from one location, it would typically refer to one location in the hand. If it is coming from multiple locations, then it would refer to multiple locations in the hand. Ever heard of the phrase “Occam’s razor”? This means that the simplest solution is typically the correct solution. Two separate lesions in the spine occurring at the same time is not a very likely solution. This indicates that there could be a space occupying lesion (AKA SPINAL TUMOR!). Second, the patient is waking during the night due to symptoms. This is also a red flag for…CANCER!

This is two weeks later and the suspicion of non-mechanical pain (AKA spinal tumor) is introduced. This is where timeline starts to play a role between socialized medicine and US healthcare.

For those that don’t know, this topic is close to my heart, as I am currently working on a paper for submission regarding a similar topic.

 

  1. “After 10 repetitions full active ROM had been restored in all directions. ULTT was pain free and full ROM with both median and radial bias”

MDT is known as Mechanical Diagnosis and Therapy. The Mechanical portion of this means, “what happens to the patient when we move the patient?”

In this case, the patient’s mechanics (ability to move) improved in all directions. ULTT (upper limb tension tests: pulling on the nerve to test their irritability) had improved after performing retraction and extension. When we see that a patient is improving with a treatment, we first assume that whatever we did actually helped the patient. I mean why wouldn’t it? It’s not like we think that we are special, but we do our best to be objective and not bias the patient to say that this treatment made me better. If the patient improves, then The puzzle is solved. If the patient tells me that they improved, but actually didn’t, then I did a poor job of establishing patient alliance! There has to be openness between the patient and therapist. Some research actually shows that patients will tell the therapist what they want to hear instead of what is true. I hope that this doesn’t happen to me, but then I would be fooling myself. As a therapist, I can’t help you 100% if the patient is not 100% truthful.  Okay, now back to our regularly scheduled broadcasting.

 

  1. “Session Three (one week later)…reduced elbow pain during the day and no elbow pain at night, fewer pins and needles, but the numbness in his fingers was unchanged…(at the end of the session) Numbness in the hand remained unchanged”

At this point, we are at three weeks and the third session. Don’t get me wrong, I like this style of therapy in which the patient is given a homework assignment and then return to the clinic for the PT to problem-solve the symptoms. Our current system has the patient coming to therapy 2-3 times per week for 4 weeks. I’m sorry, but if we look at normal healing for most musculoskeletal issues, it is six weeks! Think about that. We know that it could take up to 6 weeks to treat an injury and you will be coming to therapy for up to 12 visits and still not enough time has passed in order for an injury to heal. We know this, but as I stated in previous blog posts, healthcare is big business.

The patient’s numbness is unchanged at the end of the session, but all else is better. At this point, the therapist has to start to think that the numbness is non-mechanical and start doing differential diagnosis internally as to why the numbness remains unchanged.

 

  1. “Session four (two weeks later)…’bad week’ as he (the patient) had intermittently increased left arm pain “after sneezing and coughing”…numbness was unchanged.”

We are now at 5 weeks and the patient is unchanged. One of the red flags that is in the research is no improvement following 30 days of treatment. At this point, medical assessments should be advised and the patient should be scheduled for that surgical consultation.

 

  1. “Session five (four days later)…’better’ after the previous session…ongoing numbness in his left fingers…an appointment was arranged with an orthopedic surgeon…requested that an MRI of the cervical spine (neck) to investigate the possibility of spinal canal/foraminal narrowing and to examine the possibility of a compressive lesion or space-occupying lesion”

We are now at 6 weeks. In America, this would be about 12-18 sessions instead of 5 sessions. We would still be at the same end-point, but the cost savings would equate to about $1,300 over the course of the episode. Healthcare is a business, so return on investment has to be looked at. We get reimbursed roughly 100$/session from Medicare. It makes sense that the cost of healthcare continues to increase when a patient is coming into therapy based on traditional treatment paradigms instead of current evidence or even best practice.

Now this patient is moved along in the healthcare system. Something to note is that the PT can request the MRI in order to look for foraminal narrowing (STENOSIS) or space occupying lesion (TUMOR).

 

9 “Session six (two weeks later)…symptoms were generally worse in the evening and better during the day…numbness and pins and needles in the hand were intermittent”

Two months out and the patient is waiting to see the surgeon and get the MRI. This is a downfall of the socialistic medicine. If this is something very serious, then the patient has waited 2 months for the MRI. Is there a right answer? I don’t know, but I know that our healthcare system is broken and a shift to a more conservative type of healthcare may be worth a shot.

 

  1. “surgeon’s clinic approximately three and a half weeks after his last physiotherapy session. MRI of neck and nerve conduction studies of the left arm were ordered…MRI four weeks later…”abnormality of the entire cervical cord”…solid, cystic mass within the cervical cord from C4-C6…excision of tumour approximately four weeks later”

This guy had a huge tumor. This accounts for symptoms extending in such a large location, as the tumor affects the nerve roots (think multiple electrical outlets) from varying locations. This would explain the widespread symptoms in the hand. Again, let’s look at the time table: we are now about 3 months out from session one and the patient is finally in surgery.  I have seen a similar presentation in practice a couple of times and not all were favorable outcomes. I say this from experience, as I have had two patients that died from a similar presentation, which was caught well before 3 months after the initial assessment. The patient in the case survived and his symptoms improved after the surgery.

  1. “The wait to see the surgeon was a reflection of the large caseload within the orthopaedic surgeons’s outpatient clinic. The wait for the initial MRI was due to the prioritization system used by the medical imaging department, to manage demand for so called ‘non-urgent musculoskeletal’ MRI’s”

When everyone has the same insurance, everyone has the same access to healthcare. When everyone has the same access, there are not enough practitioners to go around and systems need to be developed to handle the overload of patients coming into the health care system. We are starting to see this impact of “Obamacare”. There are so many more patients coming into the system the past two years that it is not uncommon to have a 2 week wait to see the therapist for the initial evaluation.

MORAL: When everyone has the same right to health care, then no one has the same freedoms as they did previously, unless they choose to pay a portion of their healthcare out of pocket. This is doing what’s best for society at the cost of the individual. More people will be insured and have access to treatment. If I am the person that has a spinal tumor though and has to wait for 3 months for treatment…I don’t think that I am agreeable to this type of system.

Let me know what you think? Are you in a country with free healthcare, how does it affect you personally?

 Excerpts taken from:

 

Schoch P. Cervical spine tumor presenting as unilateral upper limb symptoms. IJMDT. 2009;4(3):24-29.

For more information or to receive an MDT evaluation from a credentialed therapist, I can be found at:

Functional Therapy and Rehabilitation

903 N 129th Infantry Dr

Joliet Il 

815-483-2440

FORGHETABOUTIT!

FORGHETABOUTIT!

 

Stachura J. The testing of frontal plane movements in the loaded position in the absence of a lateral shift-A case study. International Journal of Mechanical Diagnosis and Therapy. 2009;4(3):17-23.

 

  1. “It is estimated that 80% of the adult population will experience low back pain at some time during their life. During a typical year, 40% of adults will experience back pain.”

I realize that this statistic gets thrown around so often, but it is only because 8/10 people will have the pleasure of being a back pain statistic. Very few people will live their life without going through an episode of back pain. Like Lavar Burton would say…”The more you know”.

 

  1. “It has been reported that up to 90% of patients referred for low back pain cannot be given a specific anatomical diagnosis”

Think about this. Most people that I see just want to be educated. How would you feel about going to your doctor to better understand what your problem is and being told you have back pain. DUH! “I came to the office to tell you that I have back pain and all you can tell me is what I told you!”. That is the best we can do in most situations. Everyone wants to know about the exploding disc or the pulled muscle or the DUM DUM DUM…ARTHRITIS! Typically there is not one cookie cutter answer to your pain and 9/10 times we can not state with certainty what is the problem tissue causing pain. 

  1. “The MDT model involves a movement examination in which single and repeated end range movements are performed and the patient’s response to these movements is assessed.”

In order to figure out how your symptoms respond and to better understand your symptoms, you will have to be moved while in our presence. This statement above does a good job of explaining MDT, AKA the McKenzie Method. You will be moved, not once, but tens to hundreds of times in order to determine what makes you better and what makes you worse. Once this is figured out, the rest is easy. Avoid what makes you worse and continue what makes you better. I spent almost $80K to learn this! It’s a little more complicated than this, but not much, which has been part of the stigma against this method: “It’s too easy”. Look, would you rather I looked very pensive and gave you 20 exercises and treated you for months on end, or would you rather I smiled with the thought that “I got this!” and then only treated you for 6-8 sessions? 

  1. “When a specific movement or combination of movements results in the patient’s symptoms being centralized, reduced or abolished, it is said that this is the directional preference of movement for the patient. If a directional preference is found, this determines the treatment intervention strategy…allows the MDT trained practitioner to make a provisional classification…then drives the principle of management.”

I wrote all of this out because I can’t stress the importance of all of the above. We have a ton of research since Donelson came out the term directional preference over 20 years ago. To make this very simplistic, many back pains are like a locked door. When we find the one movement that makes your pain better, it is like the key to open the door. Many patients, about 49%-64%, with back pain can be unlocked with the right key. If the therapist is trained to find the key, then it’s like solving a rubix cube. If a therapist doesn’t even understand the basic principle of directional preference, there will be a lot of attempts to open the door with CORE TRAINING (buzz word), massage, manipulation, rest and relaxation and heat or ultrasound. Not many of these have great evidence (albeit manipulation is growing in the research) of turning off back pain.

  1. “ A lateral shift was not detectable with visual inspection”

Let’s start with “lateral shift” and what it is vs. isn’t, because not every therapist can agree on this. https://www.youtube.com/watch?v=Gvk4TGw4ba8 I have absolutely no problem advertising for someone else if it also aids in educating the patients that I treat. A lateral shift literally means that the patient, when attempting to stand upright and straight, leans to one side or another due to pain and is unable to attain an upright position.

FUNNY STORY: I had a patient years ago that walked in with a lateral shift. There are some rules to determine whether or not the person’s crooked posture is relevant to the symptoms, but as a young know-it-all, I knew that it had to be relevant. Anyway, I treated this shift for over 40 minutes trying to get this person to walk straight and his symptoms weren’t changing nor was his posture improving. I called his wife back to the clinic and asked her to watch him walk. I didn’t tell her what I was looking for and just asked “what’s the most obvious thing that you see”. She said “he looks like he always looks like that” WHAT?! “Look at the guy…he’s crooked”. She followed with, “now that you mention it, he is crooked, but he’s always been that way.” I essentially let my eagerness to play the hero override the basic premise of ensuring that his being crooked actually has something to do with his symptoms. I was WRONG! Note this date, because I don’t say it often. Anyway’s, a few press-ups (look up a video of repeated extension in lying) and this crooked patient was pain-free, but still crooked.

  1. “Single movements were tested…demonstrated a major loss of lumbar flexion, moderate loss of lumbar extension, and a minimal loss of side gliding”

What this means is that the patient was unable to bend forward, had much difficulty bending backwards and sidegliding was not blocked much. Most patients don’t know what side gliding is, and don’t feel bad because many PT’s don’t know it either. This is a movement of shifting the hips like 1. You are holding a baby on your hips or 2. You are trying to hip check someone into the glass. This movement is important because it is more likely to test the problem area than just sideways bending. If your therapist has you bend sideways instead of side gliding, try your best to educate the therapist (You heard right!) and if the PT still doesn’t understand…walk out.

  1. “ A stud by Feinberg on 2320 patients with low back pain demonstrated that the most common site of disc pathology was the L4-L5 and L5-S1 level in combination followed by L5-S1 alone. Side glide in standing has been demonstrated to better isolate the lower lumbar segments than side bending”

Again, this relates to the above statement. Most people have back pain originating from the bottom two segments of the low back. Think about it, the lowest portions of the spine have to carry more weight than any other portions of the spine. It makes sense that they will be screaming for help at some point. To the point, side gliding affects these two segments moreso than sidways bending affects the bottom segments. Follow me for a second. Ninety-five percent of problems happen at these segments. If I am not testing the segments, then what am I doing?! It’s akin to me asking you move your arm in order to determine what’s wrong with your ankle. I understand that it’s an extreme example, but the theory is still the same. If you have a back problem that looks and smells like it could be coming from the lowest segments, we should be looking at the lowest segments in the best way possible. You will know more about this than most new graduates after reading just this segment of the blog. 

  1. “While there is no evidence to support the following, this author believes that the loaded position (standing) is more functional and therefore, should be fully tested before testing unloaded (lying) positions.”

This guy just took a huge leap. Okay, when practicing MDT it is taught, no drilled into us, that we should always follow the form. The author of this study is no longer following the form. That is not a bad thing. This guy is able to give a rationale for why we test some things in standing and some things in lying. The biggest picture item to understand about this method is that we will continue testing you to determine what helps you compared to what hurts you. For me and many other practitioners, our primary goal is to understand how your symptoms respond to certain movements. When we see patterns or certain “phenomenon” after moving you, we can start to play your symptoms like a fiddle. This means that we should be able to accurately predict what will make you worse and better. I personally like to test this to see if I am right. It will put the patient through a little more symptoms than they have to be, but so be it. (I really am a nice guy though). From my experience with patients, therapists aren’t doing this and the patient’s may never experience a cause and effect moment during the entire therapy episode, or even worse, traditional therapy may create a cause-effect relationship in a negative way and actually make the patient worse. It’s not the patient’s fault.

FINAL STORY: I had a patient back in 2009 that came walking into the clinic on crutches. Her diagnosis was sciatica and I couldn’t figure out why the crutches? I asked and she said that she walked in to a local clinic and needed crutches in order to leave the clinic. The PT was performing hamstring stretches. RANT: I hate seeing the traditional picture of the therapist in the Polo shirt stretching a patient’s hamstring. I never look that good stretching a patient! END RANT. The patient in question responded rapidly (good book: Rapidly Reversible Back Pain by Dr. Ron Donelson) to lumbar extension and not only did she not need crutches after the first session, but she had no pain whatsoever. Forghettaboutit!

 

MORAL: Not all therapists have the same knowledge even though we all have the same baseline education. Educate yourself in order to be better informed when going to see your healthcare practitioner.

If you are experiencing back pain or know someone that would benefit from an evaluation to determine how rapidly the symptoms can be resolved give them my name. I can be found at

Functional Therapy and Rehabilitation

Now part of the Goodlife family

903 N Infantry Dr

Joliet Il

60435

815-483-2440