Category: PTs

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.

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

PHYSICAL THERAPY: The art is old, but the science is young.

By Vince Gutierrez PT, cert. MDT

 

Excerpts taken from the following article:

Thackeray A, Fritz JM, Childs JD, Brennan GP. The Effectiveness of Mechanical Traction Among Subgroups of Patients With Low Back Pain and Leg Pain: A Randomized Trial. J Orthop Sports Phys Ther. 2016;46(3):144-154

 

  1. “The cost of management for low back pain (LBP) in the United States is estimated at nearly $86 billion annually.”

Put these numbers in perspective. http://www.usdebtclock.org/state-debt-clocks/state-of-illinois-debt-clock.html. If we can come up with a better way in which to treat this epidemic, then we can decrease more than half of the debt from my home state. Performed year to year and we can theoretically reduced the debt load of each state within 100 years. I know that it sounds like it will take a long time, but so far there aren’t any better ideas. If nothing else, this number is humongous. It accounts for about 3% of all healthcare expenses.

 

  1. “Two commonly used interventions for these patients include an extension-oriented treatment approach (EOTA) and mechanical traction. The EOTA was popularized by the McKenzie examination and treatment system”

First there is a lot to say about these two sentences. One reason that MDT is so closely associated to extension based exercises is because of research articles such as this. This is not the case. The McKenzie examination and treatment system, AKA MDT, is a systematic assessment used to assess patient’s symptoms in order to classify the patient and lead to subsequent treatment. There are a lot of patients that respond to extension, but extension is not MDT. This has to be cleared up more because of a personal problem with patients being treated by a therapist that says “I use McKenzie in my treatment”, when actually the therapist has no more training than someone that has read this blog.

Next, we have to define EOTA. This basically means press-ups or cobra poses in yoga. This could also mean just standing up and leaning against a countertop with your butt pressed against the countertop for support. From this point, lean backwards as far as you can. One thing that separates MDT from EOTA is that MDT stresses mid-range (small stretch) to end-range (big stretch) with overpressure if needed.

Big point is this: MCKENZIE TREATMENT INCLUDES EXTENSION, BUT EXTENSION IS NOT MCKENZIE TREATMENT.

 

  1. “Many clinicians also report the use of traction for patients with low back and leg pain”

Some people may remember traction from old school hospital shows that has a person in a body cast with the leg suspended in the air with a weight pulling on the leg. The main thing to know is that traction is a shortened form of “DIStraction”, which means to pull apart. For low back pain, this hasn’t been used as much in the 2000’s as it has prior to this century. Previous research (performed by the same people that did this study) found that only a small percentage of people will be a good responder to traction. These people tend to have two characteristics, which will be talked about in a later point.

 

  1. “Experts generally agree that traction is most appropriate for patients with peripheral symptoms and signs of neurological compromise, for whom centralization of symptoms is a treatment goal”

“Peripheral symptoms” mean that the symptoms are in the periphery (think peripheral vision being around the outside of the eye), peripheral symptoms are around the outer limbs of the body. Centralization is moving the symptoms from the periphery to a more central location, think move the symptoms from the outer limb to the spine. [As an aside: if you see my picture, you can see that I have a two year old. She is actively pulling my arm at this time, so if I sound scatter brained, I blame her.]

 

  1. The patients that demonstrate improvement with traction in a previous study, “demonstrated at least 1 of the following: peripheralization of symptoms when moving into lumbar extension or a positive crossed straight leg raise”

Every profession has its own language. When I try to read legal documents, I fall asleep. When someone else tries to read medical documents, it can be overwhelming or intimidating. A crossed straight leg raise simply means the following: crossed (opposite leg of the leg that is having pain/numbness/tingling), straight leg (well, this one is kind of self explanatory, but keeping the leg straight), and raise (again self explanatory, but raising the leg while lying on your back).

 

  1. “This was a …longitudinal randomized trial”.

This means that the study was performed over the course of time from a start point and continued until some point in the future. Randomized means that the subjects in the study (think guinea pig) were randomly placed into one of two groups. This is like when in school and the teacher has to create groups. One of the ways to try to make the teams fair is to draw from a hat. (Another aside: In PT school there was a partner that I loved to work with because our styles totally complemented each other. She was very organized and I was [am] very much the opposite. Let’s just call her M FN Jones. Okay, she carried the team, but I can hold my own on the workload portion. Anyway, the teacher decided to pull our names from a hat on the last project after 3 years of having been allowed to work together (we partnered on almost everything we did up until that point). Needless to say, the teacher pulled our names out as the first group.) The point of that is we were randomly assigned to be in a group, which we would’ve picked in the first place…Moving on.

 

  1. Inclusion criteria is as follows: “between the ages of 18 and 60 years, presented with leg pain distal [further down the leg] to the buttock and signs of nerve root compression (positive straight leg raise [self-explanatory] or diminished dermatomes [loss of sensation at certain points in the leg], myotomes [specific weakness in the leg] or reflex…and reported moderate disability as indicated by an Oswestry Disability Index score of 20 or greater”

Here we go. Inclusion criteria means that only people that meet the specific requirements are allowed into the study. You would have to meet all of the above requirements in order to compare your self with the people in the study. The therapist that you are seeing should attempt to use research that best matches your presentation to that of what was read. For instance, it doesn’t make sense to use this article for someone that only has back pain. This article is not written for that type of patient.

Next, myotomes and dermatomes. I do a ton of patient education in the clinic. One thing to understand is that you are not special! Well, you may be special, but we are all alike in some aspects. Everyone has a spine (at least everyone that I treat, so as not offended those spineless people). The spine acts like a road map. Meaning if you have a nerve problem at L4-L5 or L5-S1 (think the lowest portion of your back), then your symptoms would travel down to the big toe or to the outer border/bottom of the foot. The reason why I use these points specifically is that about 95% of back problems come from these levels. These nerves can affect the knee jerk reflex or the foot jerk reflex (this reflex is less sexy, so gets less airtime on hospital shows).

If you have been to a therapist or doctor, I am sure that you were told to show up 15 minutes early to fill out paperwork. The Oswestry Disability Index is typically one of those paperworks that you have to fill out. It essentially gives us a starting point from which to judge how the symptoms affect your everyday life. The higher the score, the worse you are doing.

  1. “A series of active extension-oriented exercises were performed and progressed…(patients) were instructed to discontinue any activities and to avoid positions that could cause their symptoms to peripheralized or increase in intensity, and were encouraged to stay active.”

Extension oriented exercises are those that I described earlier: the cobra pose and back bending, in addition to prone lying (lying on your belly) and prone on elbows (propped up on your elbows like a kid watching t.v.). It sounds funny that lying on your belly is considered exercise, but if I can charge for it, then it must be exercise. Just kidding. People that lose the ability to bend backwards may be able to start with the lowest level of extension, which in this case is simply prone lying. This is progressed until the patient can perform repeated extension in standing (increasing the lordosis [hollow] in the lower part of the spine.

Participants were instructed to not make themselves any worse. This seems like common sense, but if the person doesn’t understand centralization and peripheralization, this request may not be followed, as sometimes the back pain is more intense compared to the leg symptoms experienced prior to performing extension based movements. The patient must understand that leg symptoms = bad and back symptoms = better.

  1. “The traction protocol was designed with guidance from expert clinicans who use traction frequently and was aimed at a population with lumbar radicular pain consistent with a disc herniation”

This one puzzles me as a clinician. What this says is: “we didn’t really have a good place to start, based on research, so we just called some people that use this treatment to see what they do”. This is the whole “art of science”, in that traction is a traditional based exercise, but its artsy because there’s not much science showing it works.

  1. “Treatments were provided by a licensed physical therapist trained in all study procedures during a 90-minute training session”

Obviously, the people doing the study are well respected and I have met 2 of them. It sounds more glamorous than it actually was-more of a handshake really-but it’s true. That’s my way of saying that these are also considered the “great gurus” of our profession. Now, after saying that…90 minutes?! Really? This is another part that I am frustrated with MDT being used as background information of this study. MDT trained therapists undergo over 80 hours of coursework before sitting for a test in order to be considered “minimally competent”. To say that the researchers learned the procedures in 90 minutes and then compare this to MDT is a travesty. “And that’s all I got to say about that.” A la Mr. Gump.

  1. “The mean +- SD number of treatment sessions was 10.1+- 2.7, with no difference between group.”

What this means is that the people in the study were seen for anywhere from 7-13 visits. Think about that. If you are going to a therapist for more than 13 visits and there has been no effect for back pain, maybe it’s not working.

  1. “…4 participants assigned to EOTA (switched to traction).”

Extension is not for everyone. If a treatment isn’t working or you are getting worse from extension (backward type movements), you should probably switch treatments or go somewhere else if the healthcare practitioner is not comfortable moving you in a way that doesn’t make you worse. There’s a couple of sayings that come to mind in this situation. When I was first learning MDT, many “experienced” therapists told me that to an MDT practitioner “everything looks like a nail, because all you have is a hammer”. This couldn’t be further from the truth and the statement only demonstrates the healthcare practitioner’s ignorance. Don’t get me wrong, I forgive ignorance, but not after having informed you of the total wrongness of the statement. Let’s also talk about experience for a second. I take many students, as I am a credentialed clinical instructor. By the time the student is done with the clinical, I hope for two things: one that he/she is a better clinician walking out compared to walking in and two that the student never becomes a practitioner of 20 years of work with only one year of experience as opposed to 20 years of experience. Moving on, the second saying that comes to mind is “trying to fit a square peg into a round hole.” There are MDT therapists that continue to do this, and the only reason that I know this is because it is still talked about at both courses and conventions. If you have a therapist trying to shove you into a hole you don’t belong in…find another one. Holes are uncomfortable and borderline scary. When you feel this with your healthcare practitioner, you’ll know.

  1. “In other words, matching traction treatment to those patients positive on the subgrouping criteria did not result in greater improvement in pain or disability.”

A long time ago, in a galaxy far far away, there was these researchers that found that a specific group of patients responded better to traction than others. One of the researchers that did the initial study was also an author on the current study. I am impressed when an author can publish a negative (the treatment doesn’t work) study. First, there is a publication bias against this type of study because it is also not as sexy as a study that cures back pain. Second though, this author states that there is a subgroup of patients that can be helped by traction and then later states that maybe there isn’t a subgroup.

  1. “This is consistent with a Cochrane review by Wegner et al that identifies low-to moderate-quality evidence that lumbar traction has little or no impact on disability and pain” and “For patients who are unresponsive to other treatments, using traction to determine if centralization can be achieved may be a reasonable approach, particularly when many medical alternatives include more costly interventions such as injections and surgery.”

Okay, this was a mouthful (imagine typing it all!). The Cochrane review just says that there is a lot of evidence showing that there is moderate evidence that it doesn’t help. Did you get that? We can state, with moderate certainty, that you shouldn’t get have this done to you. This is still prescribed on many physician’s scripts and performed by many therapists.   If your therapist is using this as the go to, then you are no longer ignorant and “Here’s your sign”.

The second aspect of this is more appealing to me and I appreciate the authors’ honesty in writing this. What it essentially says is that if you are a surgical candidate, meaning surgery is the only option, then the kitchen sink should be thrown at you in order to try to fix your problem. If the end result is laying you on a table and cutting you open, either removing a piece of your spine or placing rods and screws in your body, then I am all for traction!

 

In the end, you are a little more educated than you were after reading all of this. I am much more tired after typing all of this. We will all be better off for it in the long run.

Until next time.

If you have back pain, or you know someone that would benefit from an assessment, please pass this information on to them. 

Functional Therapy and Rehabilitation

903 N Infantry Dr. 

Suite 500

815-483-2440

If it hurts it must be bad, or good, or whatever.

Louw A, Puentedura EJ, Zimney K, Schmidt S. Know Pain, Know Gain? A perspective on Pain Neuroscience Education in Physical Therapy. J Orthop Sports Phys Ther. 2016;46(3):131-134.

  1. “Pain is a normal human experience and essential to survival”

This portion is rarely spoken of in PT school and we spend our time in school learning how to shut down the pain, either in an ideal way of dealing with a mechanical problem or in a way in which we “trick” the brain of not seeing the pain for a short period of time. When working with patients, I often describe the gate control theory as the “Three Stooges” way of treating pain. For instance, if you have a headache and I hit your foot with a hammer, what happened to your headache. I stole the example from my dad, because this is how he would always respond if I told him my arm was sore after baseball practice. This was way back in the 1980’s and he was a laborer by trade. The gate control theory makes sense to most people, but we can also see the example and understand that it is probably not the best way to fix a problem, as we end up with a broken foot from the hammer.

  1. “The pain neuromatrix explained our knowledge and understanding of the functional and structural changes in the brains of people suffering from chronic pain”

To simplify, we have pain because our brains tell us that something is painful. This could be due to past experiences, actual painful stimuli eliciting Nociception, super excited nerves , so on and so forth.

  1. “biomedical models may induce fear and anxiety, which may further fuel fear avoidance and pain catastrophization”

It is very common for a patient to come into the clinic and say that he/she is avoiding a particular activity because of a history of a herniated disc. There is research that shows that a herniated disc can become “unherniated” (for a lack of a more layman’s term) over the course of 6 months. The patients are never educated regarding this point. Once a herniation, always a herniation is just not true. This biomedical or pathoanatomical (patho=bad and anatomical = body parts) model of health care is outdated and simply is not as useful to use with the general public because research demonstrates that the patient may become “sick listed” and from there stop participating in previously enjoyable activities.

  1. “a plethora of papers have been dedicated to a mere 20-millisecond delay of abdominal muscle contraction, yet despite the enormous amount of time, money and energy spent on this science, clinically it has yet to provide results superior to those of any other form of exercise for low back pain”

Doing the vacuum pose while lying down is no better than doing a general squat or learning how to utilize your diaphragm during breathing mechanics. As the layperson, there are many people that want to take your money in the health care industry. (I hate to say it like this, but healthcare is a huge business and the public needs to see it as so.) When the new fad comes out to solve back pain, don’t buy into the infomercial and as a matter of fact, turn off the t.v. and go get a book from the local library. You will spend hundreds of dollars less than what is proposed on the infomercial and be better off after having read the book. Nothing beats knowledge and the smarter you are at taking care of yourself, the better armed you are when you actually get in front of a health care practitioner. Remember, it is a business and we all want your money if you will give it to us. A better use of your time is to come educated so that I don’t have to teach you the basics of posture for 30 minutes, but can instead can teach you how to perform more high level movement patterns instead of sitting properly to reduce your pain. Oh wait, pain is normal. I’d lose my job if I sold this to all of my patients, but instead the patients need to be educated between hurt and harm.

  1. “In all health care education, be it smoking cessation, weight loss, or breaking addiction, the ultimate goal is behavior change.”

Speaking as a physical therapist, I can’t stress to the patients enough how the therapy experience is a team. Smart people call it therapeutic alliance, but I’ll settle for team. My part is to educate the patient and attempt to solve the puzzle of the patient’s pain, but it is the patient’s job to take the information that they have gained during the session and go home and apply it to their daily lives. For a patient to do nothing at home, AKA make no changes in behavior, and come to the following session thinking that the pain will go away is similar to :

https://spencergarnold.files.wordpress.com/2013/01/snatch-miracle.jpg

Patients may come hoping for a miracle, but it is not to be. The patient and therapist have to work together to attempt to solve the pain problem. If one side of the team is not doing their part, then the PT has to be willing to discharge the patient or the patient has to be willing to fire the PT.

  1. “…when PNE (Pain Nueroscience Education [pain is a normal human response]) is paired combined with either exercise or manual therapy, it is far superior in reducing pain compared to education alone”

From this I take that teaching the patient and then moving the patient is better than just teaching the patient. We can all agree that low level exercise is good for people. If we don’t agree with this, then we are saying that it is safer long term to live like a slug then to get up and walk around the living room. It just isn’t so. People will refuse to get up and walk around the living room when they start experiencing low back tightness, leg fatigue, or the dreaded “Fran cough” (look it up and btw I am an advocate professionally speaking). We as a society have to start moving more and learn about how our body is supposed to work. This can not be done from infomercials that have pictures of pulsating backs or frowning stomach fat.

Rehab post TKA

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).