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Part I: TBCS revision

“In order to optimize the treatment effect, patients with LBP should be classified into homogeneous subgroups and matched to a specific treatment. Subgroup-matched treatment approaches have ben shown to result in improved outcomes compared with nonmatched alternative methods.”

There is more information coming out over time that demonstrates certain patients do well with specific treatments related to that particular patient.

Looking at the broad scale, there are many people with LBP across the world.  Not everyone with LBP has similar symptoms or will respond to the same treatment.

For instance, if your pain gets worse with repeated or prolonged bending, prolonged sitting an standing slouched, your treatment will look differently than someone that gets better with the aforementioned activities.

This is what is meant by subgrouping patients into groups.  We take the patient’s presentation and history and match that to an intervention that tends to work well for that group.

One such method of subgrouping can be found here.

This article will highlight a different approach to subgrouping, the Treatment-Based Classification System. This is a post that I previously wrote on this system.

“There are 4 primary LBP classification systems that attempt to match treatments to subgroups of patients using a clinically driven decision-making process: 1. the mechanical diagnosis and therapy classification model described by McKenzie, 2. the movement system impairment syndromes model described by Sahrmann, 3. the mechanism-based classification system described by O’Sullivan and 4. the treatment-based classification system described by Delitto et al.”

I won’t hide from my deficiencies.  I am well versed in the MDT system and fairly well versed in the treatment based classification system.  I am not well versed in the MIS or the MBC.  I will limit my advice to that which I am knowledgeable.

Yet, these systems-without exceptions- have 4 main shortcomings:

  1. No single system is comprehensive enough in considering the various clinical presentations of patients with LBP or how to account for changes in the patient’s status during an episode of care.
  2. Each system has some elements that are difficult to implement clinically because they require expert understanding in order to be utilizied efficiently.
  3. None of these classification systems consider the possibility that some patients with LBP do not require any medical or rehabilitation intervention and are amendable for self-care management.
  4. The degree to which the psychosocial factors are considered varies greatly among these systems, which runs contrary to the clinical practice guidelines established by the American Physical Therapy Association (APTA) that advocate using the biopsychosocial model as a basis for classification.”

I will address these points regarding my knowledge of MDT and TBC.  I will not address the MIS or the MBC due to my lack of knowledge regarding these systems.

1. No single system is comprehensive enough or accounts for changes in status during an episode of care.

First, I can’t fully agree with this statement.  Yes, there is no system to date that can account for every patient that walks through the door.  This is true.  This is why a therapist must be well versed in multiple systems.  For instance, MDT is a system that doesn’t take into account non-movement based pain presentations.  When paired with an approach that takes this patient presentation into account, it makes for a great pairing.

The TBC does not account for change during the patient’s episode of care.  Once a patient is classified and the intervention is applied, there is no algorithm for further improvement or progression.

This is not true though for MDT.  For instance, a patient can be classified into one of three categories.  The first two categories have built in progressions, regressions and modifications to movement.  The third category is a category that doesn’t require much intervention aside from advice.

With the first category, derangement (another way to say this would be rapidly changing) there is a clear progression.  Let’s start with the term derangement.  No one likes this term to be used for patients.  It’s a long running joke that we should never tell patients that they have a derangement. Words do matter and the patient’s perception of this term may be just as important as our expectations for the patient.

Now, moving on to the important part of the post.  When a person is classified as a der…I mean a rapidly changing presentation, here is what the progression looks like in the clinic:

  1. Reduce the der…Dangit! I almost did it again.  Make the symptoms better quickly.
  2. Make sure that the patient can maintain the reduction in symptoms.
  3. Return to the functional activities that the patient would normally do during the day without reproducing symptoms
  4. Teach how to prevent the symptoms from returning

That seems like a fairly simple strategy when bringing patients through a program in PT, but unfortunately this simple construct is lost on a lot of professionals.

 

Why you ask?

 

Thanks for asking.

 

Because unfortunately, there is no profit in getting people better.  Shhhh….You didn’t hear it from me.

 

Regarding the second category of Mechanical Diagnosis and Therapy: Dysfunctional tissues, it also comes with a game plan that is easier to follow than the first, but not as fun to implement.

Also, the name dysfunction is another term that I have gotten away from in the clinic.  Again, patients don’t want to be deranged or dysfunctional, although if given the choice, I would much rather have a derangement.  They want to know is it going to improve and if yes, what’s the timeline.

These issues are like hamstring or achilles problems…they tend to get better if left alone until….WHAM! You goin for a quick sprint to keep your child from running out of the door at the grocery store.  OR you run down the stairs because you are feeling froggy.

It let’s you know….DUFUS! YOU NEVER CORRECTED THIS PROBLEM!

This tissue issue (say that 5 times fast!) needs to be loaded to the point of pain and then allowed to recover before it is loaded again.

Like one of my mentors Annie O’Connor says in her courses “No pain… No gain…No guts…No glory”

This example is rarely used in therapy, but this is one case in which this example is fitting.  Ideally, this tissue is loaded consistently.  I have seen research that states the achilles tendon should be loaded about 1200X/week.  That’s a whole hell of a lot of repetitions.

As a matter of fact, if you would like to read more about this, you can find a previous article that I commented at this link.

  1. “Each system has some elements that are difficult to implement clinically because they require expert understanding in order to be utilized efficiently.”

I would wholeheartedly agree with this statement.  There is research that demonstrates good reliability when MDT is applied by those that have taken, and passed, the credentialing exam.  It has been shown multiple times, but here is one of the more current articles.

The systems are not easy to use, nor should they be easy to utilize.  It irritates me to no end when I hear about a therapist “using the McKenzie exercises” even though he/she has no idea regarding the wrongness of the statement.  Open mouth…insert foot.

There has to be something sacrificed in order to learn a method or system.  Time, money, life…these are all things that I sacrificed in order to get to where I am at in my career, which much to learn remaining.

 

“None of these classification systems consider the possibility that some patients with LBP do not require any medical or rehabilitation intervention and are amendable for self-care management.”

Again, can I disagree with these statements.  At one of the MDT conferences (they blend together), Nadine Foster presented on the STarTBack screening tool.  MDT is advancing to keep up with the research.

Those that keep up with the research or attend MDT-based conference, understands that not all patients require follow-up, or even an evaluation!  Some patients do get better with time.

To follow-up with this, there is still one classification that I didn’t describe yet. This is the postural syndrome. In this syndrome, the patient has no signs or symptoms of a problem…unless he/she maintains one position for too long.  Once the patient moves from that position…the symptoms disappear.  It’s like Wizzo (it’s a Chicago thing).  I bet you didn’t know that you were going to get a history lesson.

“The degree to which the psychosocial factors are considered varies greatly among these systems, which runs contrary to the clinical practice guidelines established by the American Physical Therapy Association (APTA) that advocate using the biopsychosocial model as a basis for classification.”

I agree with this, in that MDT or the TBCS doesn’t appear to utilize psychosocial factors in classifying patients.  There is another classification that appears to be paired well with MDT.  Check out this podcast with Annie describing this system.

This will be continued in the next article that goes more into depth on TBCS.

If you would like to read the article highlighted above, you can find it at this link.

Thanks for reading.  For those that gained a little knowledge from this article…please share so others can learn about classification of low back pain.

 

 

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A novel case study

I was just speaking about this case to one of the PTs that works with me this week, and felt it a good learning opportunity to post to the inter webs.

78 year old male was referred to me from another PT. The patient underwent 6 weeks of PT with another therapist also certified in MDT.

I helped train that PT and she felt that the patient should be referred to me to see if there was anything missed during the appointments.

The patient had an extrusion at L3, affecting quad strength. He also had a loss of light touch sensation at the anterior thigh.

His only complaint was pain that would wake him up at 2 AM, which was very intense. He would take a Norco and walk for 30-45 minutes to reduce his pain. He could sleep until 6 or 7 AM, which is when the excruciating pain would return. Again, he would take a Norco and walk. The pain would go away and not return the rest of the day until 2AM. He was very active with Tai Chi and Kung Fu over 10 hrs per week.

His only complaint was pain in the middle of the night.

I couldn’t provoke his pain during the evaluation.

He had already been through 6 weeks of PT without change, so I was only trying to figure out his sleep issue.

I had a working hypothesis

1. Overnight, the disc imbibes fluid and increases in size.

2. It was possible that the change in fluid content was increasing his pain since the pain went away when he was up walking during the night

3. If I could prevent the disc from taking on fluid, his pain might shut off

That was my only thought pattern that made sense for his symptoms.

I had him sleep in a recliner and to call me in 2 days with the result.

He was painfree in the recliner and did not wake at all.

Because he already had 6 weeks with an MDT trained clinician, I didn’t feel that bringing him into the clinic was going to be productive, so I followed by phone.

After two weeks, which is how long it is expected to see results if given the right direction and load, he was able to return to bed without waking.

This patient returned to therapy for a different issue a year later and we had a conversation about his back (he was seeing a different therapist). His strength recovered and he didn’t require surgery.

Moral of the story:

1. Sometimes you have to think outside of the box

2. Don’t let the image dictate treatment

3. Only treat the patient if we can improve their lot in life

4. Always develop a relationship with the patient you are treating.

Hip impingement? Is there a place for PT?

“surgical rates for correction of FAI have escalated, despite limited evidence to support a cause – and – affect relationship between FAI and hip pain.”

It is said that there is an 18X increase in procedures over the decade Studied.

The fact that this surgery has increased at such a dramatic rate may be a result of who the patient sees for the problem.

Physical Therapists do physical therapy.

Surgeons do surgery.

Pain management do management of pain through chemical means.

Chiropractors do chiropractic medicine.

Acupuncturists do acupuncture.

It’s a very easy equation to figure out. Who you see to manage your symptoms will dictate what is done for your symptoms.

“… The evidence from these studies is mostly level four (low level), the reported results are short term, and at least one studies suggest a notably lower level of sport activity at three years surgery. Currently, there are no high – quality randomized studies examining the effectiveness of surgery for FAI”

This makes it difficult to make a broad statement due to the lack of controlled research. For instance, a sham surgery (a surgery in which the patient is cut, but nothing else is done) compared to an actual surgery would start to give us information on the value of the surgery.

Looks like the study is in the process of being Completed.

I personally like case studies and case reports because sometimes a “classic study”, such as a randomized controlled study, may not capture the characteristics of the patient in front of the health care professional.

“75% of surgeons believe that FAI surgery prevent future osteoarthritis, although 62% of the surgeons were either unsure of or did not believe there was an optimal debridement of SAI lesions to prevent future osteoarthritis”

A belief plus 5 dollars will buy a coffee at Starbucks.

Not a fan of these types of studies because it demonstrates the bias of the profession. The shocking statistic is the reverse. The fact that 25% of surgeons don’t believe that surgery prevents future OA is cool. Unfortunately, we don’t know the education level, outside of the fact that the people polled were surgeons, of each person in the poll. For instance, if it’s the best of the bell curve that believe surgery has no effect on OA, then I may side with that opinion. We just have to think critically when reading these numbers.

“… The fact that 34% of both pediatric and adult patients diagnosed with FBI stated that they I knew they wanted FAI surgery (21% not willing to try conservative therapy for six months) suggest that orthopedic/sports patient has a propensity for overconfidence in surgery as the gold standard treatment.”

We are all salespeople for our profession.

Don’t believe me…just check out how many people are selling PTs education on Sales tactics and marketing.

It seems that surgeons are doing a great job of sales in that 1 in 3 believe that surgery is the answer.

As PTs, many of us are learning how our language affects the patient, both positive and negative.

It would be easy for me to convince a patient that they are weak and need us, but I don’t know if that is doing more of a service or disservice st that point.

“We think we could all benefit from learning from our past, when, despite similar increased endorsement of surgical intervention (746% increase in shoulder arthroscopy for impingement over a ten-year span), surgical patients fared no better than those treated conservatively.”

Yup.

Another way to say conservative = non surgical.

I’m going to leave this final quote from the article as the final statement. 👇

“Stop accepting morphology as pathology”

Link to the article

Life purpose and changes

“If you want to change the world, you have to enroll others in your plans and vision.”

Adam Robinson

About 2 years ago I started a blog. It was just for fun and the premise behind the blog is this “the only knowledge wasted is the knowledge not shared”. I saw this quote on a t-shirt; a blog was born.

My goal is to provide high quality content to readers through this blog in order to assist them with making decisions regarding choosing a health care practitioner. The secondary goal is to educate physical therapists at least up to the point of at patients. It sounds cynical that I believe that some patients have more knowledge than the PT, but I also believe that the patient has more to lose and more at stake than the PT.

The PT only has a paycheck at stake, maybe a reputation. The patient has life limitations and issues that may prevent them from truly experiencing life. That way more at stake than the PT has on the line. In this fashion, I have seen patients becoming smarter over the years through forums, FB groups, reading blogs and watching videos.

The reason why I say high quality content is because there are a lot of lies and misinformation on the World Wide Web (internet). Healthcare professionals prey on the weak and ignorant to take their money using scare tactics and unrealistic hype.

I ain’t got nothing to sell you other than making you a better human through work. Nothing ventured, nothing gained.

I have increasing demands on my time with a family, managing multiple clinics, treating patients and community involvement.

My posts will become fewer and fewer as I try to fit them into my life instead of fitting my life around my work.

Love your life or change it

Dr. Vince Gutierrez, PT

It’s like the Gamler by Kenny Rogers

“If you must play, decide on three things at the start: the rules of the game, the stakes, and the quitting time.”

Chinese proverb.

This is a lesson that learned later in life. I entered into an agreement under one pretense (set of rules) and after entering the agreement and quitting my job, the rules changed. At that point, I had to ride out the decision that I had made to quit and try to make the best of it.

I wasn’t fully aware of the rules; they changed during the game.

After making the decision to leave my current job, in order to open a clinic with a friend near where I created my following, it was decided that the clinic would be 35 miles away! This was a major blow because now I was starting completely fresh and had no following (although a few patients chose to make that drive). I was able to get in front of over 1,000 pairs of eyes in person and 160,000 pairs of eyes through social media and newspapers.

Unfortunately, I still didn’t know all of the rules until well into the game and at that point my wife and I realized that I couldn’t win the game and we started to discuss quitting time.

Luckily for me, I busted my ass to build my following in this new area. A local business wanted both my skills and my work ethic. The fact that I was able to bring new faces to the clinic was a bonus.

The clinic needed another PT within a few months and through hustle and blessings, I was also able to build a following among PTs, so finding another PT that wanted to work with me wasn’t difficult.

I am now making more money working fewer hours and learning more about the business of health care than I had during the previous 12 years of my career.

I had to learn the lesson the hard way.

Whenever you are entering into an agreement, both sides need to understand the rules of the game, the risks and rewards and when to call it quits.

“You got to know when hold em; know when to fold em; know when to walk away; know when to run.”

Rehabilitation after a shoulder replacement: What’s the norm?

“There is growing belief among orthopaedic providers that how much formal physical rehabilitation a patient receives is influenced by the patient’s insurance and its willingness to pay for various postoperative therapies.”

This makes sense. Many patients aren’t aware of how much their insurance will cover regarding physical therapy. For example, Medicare will cover 80% of physical therapy after the deductible is met. The deductible is $183. In our state, average coverage of physical therapy is about $90/session. This means that the patient would be responsible for 20% of the $90, or $18/session. This makes the assumption that the patient does not have a secondary insurance that may cover the 20% that Medicare doesn’t cover.

Medicare will cover all PT that is considered medically necessary and cases that go above $3,000 are subject to a manual medical review. This would be about 33 visits per year. Speak to your PT about this in order to verify this information. Each clinic charges a little differently than others and these are the averages in my experience.

Unfortunately, many people that have Medicare as their primary insurance do not understand the physical therapy benefits associated with this insurance.

“A recent study challenged the need for formal physical rehabilitation after anatomic total shoulder arthroplasty (TSA), finding that a home-based, physician-guided therapy program provided similar results with lower costs.”

If a patient can get better without going to PT, we should all be in support of this.

This study tracked patients with Human, which included 20.9 million people. This is a huge sample size. This information was compared with a 5% sampling file of patients utilizing traditional Medicare. The study collected data for a long period of time, from 2010-2015 and the patients had to undergo a TSA or RSA (reverse shoulder arthroplasty). Rehablitation visits were tracked for 6 months after surgery, by tracking charges that are traditionally utilized in rehabilitation. Any date that a specific charge was utilized was counted as 1 visit.

The grouping was paired as follows: 0 visits of rehabilitation, 1-5 visits of rehabilitation, 6-10 visits of rehabilitation, 11-15 visits of rehabilitation, 16-20 visits of rehabilitation, 21-25 visits of rehabilitation, 26-30 visits of rehabilitation and greater than 30 visits.

“The study included 16,507 patients”

This was a huge number of patients. This strengthens the reach of the research. The more patients that are included in a research study, the stronger the statement can be made (regardless of the statement) at the end of the study.

“In general, the Humana cohort had higher overall physical rehabilitation utilization than did the Medicare population across all factors.”

Patients with Medicare are not treated in physical therapy as much as non-Medicare patients.

“The Humana and Medicare populations had a similar percentage of patients with 0 visits.”

“The Humana population had a higher percentage of patients in all visit categories above 1 to 5 visits”

“…with the Midwest having significantly less physical rehabilitation utilization, which is best demonstrated by 69% of patients in the Midwest undergoing only 5 or fewer physical rehabilitation visits, compared to only 54% of patients in the Northeast and 53% of patients in the West.”

This is the anomaly that I would like to know more regarding. Why do patients in the Midwest choose to not utilize PT? This could be poor education of patients regarding the importance of PT. It could also be that PT’s in the Midwest are following more of a HEP based protocol and only having patients return to update the HEP.

“the possibility of patient-directed rehabilitation at home having equivalent outcomes to formal office-based physical rehabilitation was brought to the forefront after Mulieri et al demonstrated equivalent outcomes after TSA when comparing the 2 therapy programs.”

This is a study that I will attempt to get in the next couple of weeks. If a patient does not need PT services in order to improve function, then Boo Hoo for our profession, but we have to do what is best and right by the patient. Should this study demonstrate that PT’s aren’t able to provide additional value beyond not performing therapy, then patient’s should not seek out PT.

I’d like to believe that we have a place in the rehabilitation process post TSA, but I also don’t think that our place is one of > 20 visits.

Excerpts taken from:

Wagner ER, Solberg M, Higgins LD. The Utilization of Formal Physical Therapy After Shoulder Arthroplasty. J Orthop Sports Phys Ther. 2018;48(11):856-863.

 

One piece of equipment that may benefit your rehab process after a shoulder surgery is the following:

https://amzn.to/2BHMpX7

I find that over the door pulleys are easy to use and quick to install.

 

Plantar Fasciitis and Ultrasound: questionable at best

“The plantarfascia is a thick, nonelastic, multilayered connective tissue crossing the plantar part of the foot. Plantar fasciitis is the main cause of pain in the plantar surface of the heel.”

The plantarfascia is located at the bottom of the foot, between the heel and the toes.   It is very thick and a tough band.

A part of physical therapy school includes dissecting the human body.  Some people find this disgusting, but it is actually an honor.  We were told that only 5% of college students will ever be able to dissect the human.  The bottom of the foot is very intricate. There are multiple layers of muscles, but the plantar fascia is a very taut band that requires a scalpel in order to tear.  In other words, it is very strong tissue.

“In the United States, more than 2 million people are treated for plantar fasciitis every year…the most common signs for identifying plantar fasciitis are pain and tenderness in the medial …heel bone, as well as an increase in pain when taking first steps in the morning and pain in prolonged weight bearing.”

First, plantar fasciitis is mostly diagnosed through a patient’s history.

Second, there are a lot of people with plantar fasciitis that seek out treatment.

This leads us to the next statement from the article

“…researchers have not determined the most effective combination of treatments due to the dearth of high quality research in this area.”

Feel good about this condition yet? So many treatment options are available, but few with solid research to back them up.

If you are interested in learning more, check out this  Link

“One of the most widely used electrical devices among physical therapists in Israel and worldwide is therapeutic ultrasound…Yet there is insufficient high quality scientific evidence to support the clinical use of therapeutic ultrasound in treating musculoskeletal problems.”

I find it funny that PT’s should know this information and yet they act opposite of what the evidence indicates.  There are running jokes that using ultrasound may be just as effective turned off as when turned on.

If your PT continues to utilize ultrasound, ask why?

Sometimes the answer may simply be: it is easy, it can be charged and it will do no harm.

Treatment:

Both groups were given stretches for the Achilles/calf and the plantar fascia.  One group was issued ultrasound at a higher intensity in order to create a thermal effect and the other group was given ultrasound that was low intensity and not postulated to have any physiological effect, as the intensity was low and the depth of treatment was considered more superficial.

There was no significant difference in the number of treatments per group.

Result: There was no additive effect of ultrasound on the treatment of plantar fasciitis for pain, function or quality of life.

There are reasons to use ultrasound from a business perspective, but the more and more that I read research I find fewer reasons to perform the intervention medically.

Reference:

Yigal K, Haidukov M, Berland OM et al. Additive Effect of Therapeutic Ultrasound in the Treatment of Plantar Fasciitis: A Randomized Controlled Trial. J Orthop Sports Phys. 2018;48(11):847-855.

ACL rehab

“At 13 months post ACLR (Anterior Cruciate Ligament Reconstruction), individuals exhibited average knee extensor moments that were 17% smaller in the surgical limb during a bilateral squat against body-weight resistance”

ACL injuries tend to be noted in some non-contact sports such as soccer and basketball. Contact sports, such as football, also have ACL tears noted during contact, such as a tackle that makes the knee buckle inwards.

The patient with an ACL tear will typically opt for surgery if he/she plans on returning to some type of sporting activity. There is a debate as to whether or not to have the surgery if there will be no return to sporting activity.

After the ACL surgery, the research above notes that patients are less likely to use the surgical side during a squatting activity (think getting up from the toilet) and will push more with the non-surgical side.

This makes sense to me. After the surgery, the patient is in a locked long leg brace and is unable to move fluidly on the affected leg. The patient will not spend as much time on the surgical leg because of this and will transfer the weight to the non-surgical side. It becomes a learned habit to transfer the weight to the non-surgical side, but this is just my opinion.

 

“The persistence of under-loading is concerning, as asymmetrical limb loading during landing tasks has been linked to increased risk for anterior cruciate ligament (ACL) reinjury”

This is important! If we never get the patient to load the leg in order to improve strength and motor control (ability move in the way that the brain dictates), then the patient is at a higher risk of future injuries.

Let me clarify: if you squat and allow your legs to go wet noodle during the squat, it will look like a knocked-kneed version of a squat. This is not inherently horrible, but when asking the body to absorb a large load in this positon, when not trained to absorb this load, may lead to an injury. It all comes down to progressively loading specific positions in order to learn how to hold this position.

This is a major component of Olympic weightling compared to powerlifting. In the performance of the snatch (the most explosive movement in sports), maintaining proper position is extremely important for completing the lift. In powerlifting, the position may be able to be off a little and the athlete can overcome the small error in position.

With regards to ACL rehabilitation, it is important that we ensure that the patient is able to have enough strength to maintain positions without the load (bodyweight jumps, external weight, etc) dictating positional changes.

 

“…the bilateral multijoint nature of a squat allows for compensations that can shift the task demands to the nonsurgical limb (interlimb compensation) or to adjacent joints within the surgical limb (intralimb compensation) to reduce knee extensor moments.”

The bodyweight squat can be performed differently and switches the load from either the hip to the knee.

If you watch someone squat (recommended for all people that will attempt to squat), the person should both watch the knee and the hip. If you look at opening and closing, this will be much easier.

  1. Watch the knee to see how much the knee “closes” or how much the angle changes from the calf to the hamstring
  2. Watch the hip to see how much the hip “closes” or how much the angle changes from the trunk to the thigh

Which joint moves more?

This will help the reader to understand whether the knee joint muscles or hip joint muscles will be the dominant movers during the squat. Those that have knee issues will tend to move the hip joint muscles more than knee joint muscles.

I’ll make a video on this at a later date.

 

“…individuals 1 month post ACLR performed bilateral sit-to-stand tasks with a 38% reduction in vertical ground reaction forces (vGRFs) in the surgical limb”

This very simply means that the person is pushing less with the surgical leg than the non-surgical leg.

This means that the surgical leg is taking less force through it and will not be able to generate the same amount of power. Also, it is typical to see the patient weight shifting towards the non-surgical leg.

“reduced knee extensor moments have been found along with increased hip extensor moments…may rely on interlimb compensations to unload the knee during early rehabilitation but adopt intralimb compensations as they progress through rehabilitation.”

This goes back to the differences in a powerlifting based squat and an Olympic weightlifting based squat. The more upright the torso, the more that the knee takes a load and the less upright the torso, the more the back and hips will take the load.

I am having this exact conversation with a patient currently following an ACLR, attempting to get the patient to increase the load on the knee.

“During early rehabilitation, strategies for restoring symmetrical weight bearing during bilateral tasks should be emphasized and reinforced even during submaximal tasks…efforts should be made to continue to focus on sagittal plane knee loading and avoid compensation with the hip extensors.”

I tend to use a mirror for visual feedback in order to allow the patient to see the weight shift between the legs. This tends to fix the problems for weight shifting. We then progress to doing the squatting motion away from a mirror in order to build in positional awareness without the need for visual cues.

In order to improve the knee to hip ratio regarding which joint moves more, the cues will switch from sitting back on a chair (similar to a box squat which is hip hinge emphasizd) to emphasizing sitting between the feet (similar to an overhead squat) which is more knee joint driven.

If you don’t have a PT that understands how to squat, this may be a difficult movement to restore with physical therapy alone.

It may be prudent to ask your PT to describe a squat prior to starting therapy in order to ensure that your therapist has at least a baseline knowledge of squatting.

If the therapist doesn’t start describing multiple techniques for squatting based on body shape, then the therapist may not be well versed in the movement.

If you have any questions about squatting or ACLR rehabilitation…comment below.

Article: https://www.jospt.org/doi/abs/10.2519/jospt.2018.7977

 

You can find me at Primarycarejoliet.com and wherever you subscribe to podcasts at A physio’s perspective: movementthinker.

Second opinion

How many people will choose to get a second opinion before going in for a major surgery?

I would hope 💯%!

I had an awesome conversation about 10 years ago when I was visiting Canada. There was a guy that traveled to Canada in order to get an opinion regarding back surgery. He was from San Diego. That’s a pretty far trip to see if he needs back surgery.

I asked him why travel that far for an opinion and he said that he wanted to reduce any bias on the doctor’s part regarding whether he was a candidate. For instance, the doctor in Canada would not be performing the surgery and it was unlikely that the doctor giving the opinion would be able to benefit from recommending surgery, since the patient would have surgery in California.

He avoided going for the opinion in California because the hospital system would profit from the surgery. The surgeon may have an arrangement with the hospital to ensure that the hospital gets a percentage of the money. We know that the hospital will make money during a surgery. Many people stand to profit from a surgery and the patient would do well to get an opinion from someone that doesn’t stand to benefit.

This brings me to my rant for now. 👇

Why don’t patients get a second opinion regarding physical therapy?

1. It’s not a huge expense

Physical therapy, on average will cost the insurance company about $1200 per episode of care. If the patient is paying 20% for the coinsurance, then it will only cost the patient $240/episode. This works out to about $50/week.

That’s relatively inexpensive compared to a large surgery. The question is: why not spend an extra $25 to see if a second therapist agrees with the first? If there is a disagreement in how treatment should be performed, then the cost may not be the chief factor.

This leads us to 👇

2. All therapists do the same thing

Not all PTs are trained the same! Don’t let a non-PT (such as surgeon or family doctor) tell you that it’s all alike.

Not all surgeons have the same reputation and skills. Not all PTs have the same reputation and skills. The only way that you, as a patient, will know about other’s skills and reputation is to ask and try.

If you are absolutely in love with your PT or MD, then so be it. Sing from the rooftops so that the reputation gets built. If you’re not…try someone different.

Sometimes the grass IS greener.

3. Convenience

I get it. A drive around the corner is much easier than a drive for an hour. It makes sense.

If we believe that not all therapists have the same training or passion for treating a specific issue, then we must also believe that these therapists are worth the drive.

Follow this example:

1. Patient A decided to go to a therapist close to home or work (we know that regarding gyms most people won’t drive more than 15 minutes from work/home). The therapy session costs the patient $240 out of pocket and the insurance pays $1000.

Let’s also say that the patient is being seen for low back pain or sciatica, since this is the number one reason to seek PT. The patient is seen in a clinic in which the therapist is there to punch a clock and see as many patients as possible because that’s how 💰 is made.

The patient doesn’t get much better and then returns to the doctor for a series of shots (more money and time). The shots are a 50/50 chance of working.

Half of the patients will then still have pain and now be shuffled to the next step, either pain management or surgical consult.

2. Patient B spent a little time to search for the therapist in a 20 mile area that best treats low back pain or sciatica. The patient makes an extra 20 minute drive. The therapist decides that the patient would ben for from 8 visits of PT over 6 weeks and the patient gets better because the therapist enjoys the job and works well with patients having this diagnosis.

The patient made a little more of an effort up front, but saved 💵 and ⏳ by choosing the right therapist instead of moving further along in the medical system.

Want a second opinion, send me a message.

Back pain using MDT

“Low back pain is the worldwide leading cause of years lived with disability, with an estimated point prevalence of 9.4% and a lifetime prevalence of up to 39%”

If three people are sitting together, the odds are that one of those three had back pain, has back pain or will have back pain. That kind of sucks, unless your the one of the people without pain.

Point prevalence means that any one point in time about 10% of the population will have back pain. There are about 320 million-ish adults in the US. This means that about 30 million adults have back pain at any one point in time.

It’s a great time to be a PT, if we can educate the public that we are well trained and capable of treating back pain.

For patients reading this, not all PTs are equal and just like with a surgical procedure, you’d probably get a couple of opinions before making a decision on YOUR Guy or Gal (after you gain trust in the person all of a sudden they become YOURS). I get it! Some people call me their guy, but I’d like for more people to call me their guy.

***tangent: patients are paying more for healthcare. This could be in the form of a higher deductible, copay, coinsurance or straight cash based. As a patient, you should be looking around for the person that gives you the best value for your dollar. If you ever have questions regarding your treatment, feel free to message me and ask me questions in a free conversation. I have a long commute daily and love having these conversations, which have become a weekly occurrence. You can find me Here

“The presence of centralization is associated with good prognosis in patients with low back pain…recent studies have shown that directional preference and centralization, when I matched with adequate MDT treatment, result in better patient outcomes and then treatment with general range of motion exercises”

Centralization?🤔 I wonder what that is?

If you’re new to this page, you can go back and read my old posts on centralization here

Just know that centralization has been called the trump card to helping patients with back pain…it’s that powerful that it darn near always wins for the patient.

“The level of MDT training should also be considered, as it may impact interventions and risk-adjusted functional outcomes.”

Studies have been Published questioning the reliability of using MDT. I believe that these studies need to be looked at in depth because this particular study shows that those not certified in the method may not be the most reliable in noting a particular “syndrome” in the patient’s presentation. The level of training appears to play a role in the therapist’s ability to assess a Patient.

“only trails in which of therapists were MDT trained were included. To be considered MDT trained, therapist were required to have participated in at least one course offered by the McKenzie institute international focused on applying MDT to patients with LBP”

Based on the above research links, just using therapists that have taken courses in MDT decreases the likelihood that a reliable classification took place, therefore reducing the likelihood that the patient was treated according to the proper principle and finally leads me to believe that I was wasting my time in reading the remainder of the article….I digress. I read it anyways to hear what’s being talked about regarding MDT, both good and bad.

“review were’s screen 354 abstracts and selected 51 articles for fall text review. After review, 17 articles were retained for the meta-analysis; however, of these 17 studies, four did not provide sufficient data to be included in the statistical analyses”

This is part of the problem that I have with systematic reviews and meta analyses. So much of the research gets discarded and not used in the actual article, that we then start to see researcher bias based on the question asked and how the researchers go about obtaining information. Think of it, only 5% of the actual information that they found on their initial screen actually makes it to the cutting room floor.

“MDT versus manual therapy plus exercise: there was moderate evidence of a significant difference in pain after the intervention, with results favoring MDT…There was moderate evidence of no significant difference in disability after the intervention period between MDT and manual therapy plus exercise.”

I think this is 👌. Understanding that MDT is the assessment first and treatment second one must also understand the components of MDT. MDT incorporates manual therapy, exercises, postures and positions. This means that there is something specific to the way that manual therapy and exercises are prescribed in MDT that has a greater affect on pain that just manual therapy and exercise together.

No effect on disability or function over a time period is also not surprising for me. It’s well known amongst those of us that use this method that returning a patient to function is not well taught in MDT, as there are many other courses and methods that speak to this. MDT follows a certain paradigm, with returning to function as part of the paradigm, but because it varies widely from patient to patient, it is best learned from other resources.

“this study found that MDT plus first – line care resulted in significant, but small, improvement in pain intensity compared to first – line care only.”

This is significant! But small. For anyone going to an ED for back pain, they are in significant pain. I’ve spent part of my career working in an ED for this exact population. In the time I worked in the ED, only one patient was unable to find a position, movement or posture that provided relief. This is significant because these patients were able to receive the right care through an outpatient means instead of being admitted to the hospital for “non-specific low back pain”.

These patients didn’t receive the rapid MRI, which in some cases may actually make the patient worse over time. These patients didn’t have a hefty hospital bill and these patients were able to recover in their natural environment thereby reducing the risk of infectious disease acquired in the hospital.

This is significant!

“One study included in the review, despite lacking data for analysis, compared MDT to education and found no significant between – group differences for changes in disability.”

This is not too shocking for me. If the pain is acute (started recently), we know that many with back pain will get some relief over time. Education is powerful in and of itself and a large part of MDT is education based.

If both utilize education as the base for acute pain, then the outcomes may not be much different. No shock here!

“There was moderate evidence of a significant difference in pain after the intervention period, with the results favoring MDT. ”

MDT is a patient response system. This means that after every movement, position or posture the therapist is asking the patient if it reduced symptoms. If the answer is yes, then the PT will typically issue this for a home program. 🙄

It’s no wonder that the system is pretty good at reducing pain in a specific classification; the therapist is giving exercises that have been shown to reduce pain/symptoms.

“Two studies included in the review, which lacked sufficient data to be included in the meta-analysis comparing MDT to modalities, found significant between-group differences for changes in pain, favoring MDT.”

Again, comparing an active intervention (patient takes part in the intervention) to passive interventions (treatment is done to the patient) is expected to lead to an outcome favoring the active intervention. There are multiple reasons for this, but one may simply be interactions with another individual during the session.

“Three studies compared the effects of MDT to combined manual therapy plus exercise in participants with chronic LBP…There was moderate evidence of no significant difference in pain after the intervention period between interventions…There was high quality evidence of no significant difference in disability after the intervention period between interventions.”

Again, this is not too difficult. As a treatment strategy MDT is literally manual therapy plus exercise. It’s comparing two similar interventions, with similar results.

“One study had 2 comparison intervention groups consisting of either MDT exercise in the opposite direction as the directional preference or midrange lumbar/stretching exercises. Only this latter group was included as the comparison to MDT in the current analysis.”

This is the part of the analysis that I don’t quite understand. Why bother 🤷‍♂️ comparing the interventions if one of the treatment groups is removed?

This article is cited frequently by PTs trained in MDT and you can read my analysis of the article Here

Removing one of the groups, specifically the opposite directional preference group, greatly changes how that article impacts the reader.

“There was high quality evidence of a significant difference in disability after the intervention period, with the results favoring MDT.”

Even with removing the group of patients that had a high dropout rate and poorer outcomes, the article still favored MDT over “evidence based” interventions.

“Also, MDT does not explicitly account for pain systems theory, specifically differentiating between pain that is central or peripheral in origin, and for a wider spectrum of psychological factors that could be present in patients with chronic low back pain. ”

This is a good point and those that are well versed in the system would state that there are other classification systems out there that would include this pain system. If you are interested in these systems, I highly encourage readers to take a course by Annie O’Connor, author of A World or Hurt.

You can learn more about Annie by following this Link

Thanks for reading.

Since my last post, I’ve gone through a major job change. I can now be found at PCJ

What would it take to convince you as a patient to give a PT with an MDT certification a chance?

What would it take to convince you as a PT to take an MDT course?

Link to article