Get PT 2nd

“out of 137 patients, 100 had been recommended for spinal fusion. After evaluation, the group advised 58 of those patients to pursue a non operative plan of care”
There’s a slogan going around social media saying “GETPT1ST” I don’t know if I completely agree with the saying, but I can’t disagree with that either. The saying could just as well be get PT second. At some point a second opinion has to come in to play for a patient’s dysfunctions or pain. That second opinion, in my belief, has to come from someone without a financial stake in the surgery. This could be a physiatrist, PT, or a separate surgeon, which was done in the study cited. 
The take home point is that 58% of those recommended for spinal fusion were recommended to seek a separate form of care, thus advised to avoid the surgery initially. What this means for the patients is that a second opinion should always be sought out, because the person advising a plan of care is advising it from their perspective. I’d love to say that everyone has the patient’s best interest in mind, but I can’t. In that case, the patient must become more educated and advocate for him/herself. For instance, a surgeon does surgery, a physical therapist does physical therapy and a physiatrist does physiatry. We see problems from different lenses and therefore will advise different plans of care for varying presentations. Some patients need surgery and some don’t. Some patients need physical therapy and some don’t. We can’t say PT first because PT is not magic and can’t fix everyone’s issues. 
“As clinicians, we bring our own biases into the treatment plan for patients”
Want to decrease unnecessary surgeries? Have a multidisciplinary team do evaluations, researchers say. PT in Motion. April 2017:46. 

Does taping in addition to PT provide increased benefits?

 

This is a look at a popular form of taping using in the PT profession. This was popularized in the Summer Olympics years ago and has increased in usage in the PT profession, regardless of what the evidence states.

 

  1. “Low back pain is a significant public health problem that affects approximately 39% of individuals worldwide at some point in their lifetime”

 

This is like beating a drum. If you follow the blog, I have written many times over the year regarding how expensive back pain is in the developed countries. One aspect that surprises me is how low this number actually is. In other articles, it talks about the lifetime prevalence rate between 70-80%. I would have to surmise that “worldwide” changes this number. I don’t have the reason why, but I have my guesses. I would guess that those “undeveloped” countries are spending less time on their kiester and more time either in a deep squat or standing position.

 

  1. “Several interventions commonly used by physical therapists, such as manual therapy techniques and exercises, are endorsed in most guidelines as effective treatments for patients with low back pain…”

 

Moving is better than not moving (in most cases). It’s funny because when I was a personal trainer (many, many years ago) I used to think of Physical Therapists as overpaid personal trainers. I completely disagree…sometimes. Don’t get me wrong, there are some PT’s that only prescribe 3 sets of 10 repetitions because it is traditional and for those PT’s I would agree that they are overpaid personal trainers. When prescribing exercise, we always have to think; “what’s the goal”. If the goal is pain reduction, than 3 sets of 10 may not be appropriate. If the goal is absolute strength or power or endurance, then 3 sets of 10 may not be appropriate. If the goal is hypertrophy…you got me…it may be appropriate for some patients for some muscle groups. In the end, 3 sets of 10 for everyone is no better than 3 sets of 5.

 

This isn’t meant to blast the PT profession, but if you are being treated in PT…Look around! If you are doing the same exercises as everyone else, then you have to question whether you are exactly like everyone else?

 

  1. “Kinesio Taping method was introduced at the Olympic Games in Athens and has since gained in popularity”

 

We have seen these tapes for the most part. The colorful tape worn on shoulders or backs of athletes. In the summer games, especially for women’s volleyball (I’m sure other sports have them, I just seem to watch more of this than anything else except for weightlifting), these colorful tapes are apparent. I use the tape, not for the reason indicated, but it makes for a great thumb wrap when using the hook grip in weightlifting.

 

  1. “The evidence of the benefits that Kinesio Taping can provide for patients with chronic low back pain is still scarce”

 

I could sell a cup of water to a drowning person in the ocean. I could easily sell Kinesio taping to my patients and others in the athletic arena, but I have yet to read a well-performed study that shows it is better than not using Kinesio tape. It’s the modern day ultrasound…It works until it doesn’t.

 

  1. “There is no current evidence to support the use of this method.”

 

This is not to say that it doesn’t work…yet, but of the studies performed thus far…it doesn’t work. One of two things will happen over time: 1. The company(ies) that sell the tape will continue to publish their own case studies to show the efficacy and/or 2. The peer reviewed journals will stop publishing all of the negative studies because academia will stop performing studies that consistently give the same results.

 

  1. “…the objective of this randomized controlled trial was to compare the effectiveness of adding Kinesio Taping to a physical therapy program in patients with chronic nonspecific low back pain.”

 

This is a well-performed study. Randomized doesn’t mean that the study is done randomly or half-assed, but the people in the study (guinea pigs) are separated in a scientific manner.

 

6a. Misc: There is a bunch of instructions for how the study was actually performed in the Methods. This is boring to the non-medical reader, and sometimes boring for those of us that read research. I will spare you the details. Just know that the study is well-performed.

 

  1. “The group that received physical therapy plus Kinesio Taping had the elastic tape applied to the lower back at the end of the sessions”

 

Essentially, if the tape is to provide greater benefit than exercise alone, this group should outperform the exercise-alone group in the data measured.

 

  1. “The corresponding author is certified by the Kinesio Taping Association International and provided training to the therapists on how to apply the Kinesio Tape”

 

This is important. If there is a method to perform on a patient, but the participating therapists are not certified in the method, then it could be that the practitioner doesn’t know the method well enough to perform the method. Since at least one of the authors is certified, it would make this a moot point.

 

  1. “After 5 weeks of treatment, the between-group comparisons showed no advantage of using Kinesio Taping in these patients for all primary outcomes…the addition of Kinesio Taping to physical therapy did not enhance treatment outcomes at any point in time.”

 

Crickets chirping………….Enough said.

  1. “Our data corroborate the results of 3 previous randomized controlled trials that do not support the application of Kinesio Taping in patients with chronic nonspecific low back pain.”

 

This means that if you want to tape your thumbs in order to lift weights, then go ahead, but using this type of tape (there are many different manufacturers of this type of tape) for back pain may not be ideal.

 

QUOTES TAKEN FROM: (Also, the initials of the first author is actually MAN, that’s awesome)

 

Added MAN, Costa LOP, De Freitas DG, et al. Kinesio Taping Does Not Provide Additional Benefits in Patients With Chronic Low Back Pain Who Receive Exercise and Manual Therapy: A Randomized Controlled Trial. J Orthop Sports Phys Ther. 2016;46(7):506-513.

Frozen shoulder: when it doesn’t move

frozen-shoulder1Frozen shoulder, when it doesn’t move.

 

Frozen shoulder is a common diagnosis in the clinic. I have seen this problem treated in so many different ways that some PT’s are able to drive Escalades. The problem is that not all treatments are created equal. Educate yourself on what the problem is and how it can and should be treated. It’s your body…understand it at least.

 

  1. “Frozen shoulder, or adhesive capsulitis…painful and limited active and passive range of motion…reported to affect 2% to 5% of the general population”

 

To be frank, frozen shoulder means your shoulder is frozen…it doesn’t move. Adhesive capsulitis is the medical term for…your shoulder doesn’t move! If you take something that does’t move and you try to move it…it is painful. It is not as common as everyone would like to believe and honestly I rarely see it in the clinic. You can have a stiff shoulder and not necessarily have “frozen” shoulder. It affects those that are diabetic more often than those that aren’t, but aside from this, the reason for it is still not certain.

 

  1. “The absence of standardized nomenclature for frozen shoulder causes confusion in the literature”

 

We know some things for certain. Your frozen shoulder will go through stages from start to end, what we aren’t certain of is how many stages, and what do we call these stages?

 

  1. “Secondary frozen shoulder was defined by 3 subcategories: systemic, extrinsic, and intrinsic…secondary frozen shoulder related to insulin-dependent diabetes are more likely to have a more protracted and difficult clinical course”

 

If you have frozen shoulder because of some other problems, this is classified as secondary. If that problem is due to a body disease, extrinsic is due to an injury outside of the shoulder and intrinsic is a known problem of the shoulder.

 

  1. “another classification system based on the patient’s irritability level (low, moderate and high) that we (the authors of the journal article) believe is helpful when making clinical decisions regarding rehabilitation intervention…Patients with low irritability have less pain and have capsular end feels with little or no pain; therefore, active and passive motion are equal and disability lower…typically report stiffness rather than pain as a chief complaint…high irritability have significant pain resulting in limited passive motion (due to muscle guarding) and greater disability…pain rather than stiffness…”

 

This is very easy to follow…walk with me. Your irritability is literally that, when you move how irritating is it? If it is not that painful and you have a capsular end-feel (only to be determined by someone that has moved thousands and thousands of shoulders so that it can be determined if the joint is normal or not very moveable), then it is lower on the scale of irritable. If your shoulder feels like a hot poker stabbing you in the eye and twisted every time you move the shoulder…it’s probably highly irritable.

 

  1. “recent evidence identifies elevated serum cytokine levels as part of the process. Cytokines and other growth factors facilitate tissue repair and remodeling as part of the inflammatory process…sustained inflammation and fibrosis…although the initial stimulus is unknown.”

 

This is HUGE, for those that are nerdy regarding physiology. Tendonitis…doesn’t exist. That’s a lie, but not far off. When you think that you have a tendonitis, by the time you see a doctor, it is probably a tendinosis. This means that after a short period of time, there are no longer inflammatory markers (chemical of inflammation) in the tendon. The fact that there is sustained inflammation is…NO GOOD! Think about having constant cycles of inflammation going on in your body. It sounds painful. It is! Others have challenged the premise of adhesive capsulitis, in that the capsule itself doesn’t have the inflammatory markers. At this time, it is semantics, because the shoulder is still painful.

 

  1. “3 sequential stages: the painful stage, the stiff stage and the recovery stage” others have described “4 stages…the preadhesive stage, the acute adhesive or freezing stage…the fibrotic or frozen stage…the thawing phase” these phases may take 12-18 months and “mild symptoms may persist for years”

 

Although we can’t fully agree on how many stages and how to describe the stages, we know that this is will take a long time in order to become fully functional.

 

  1. “A full upper-quarter examination is performed to rule out cervical spine and neurological pathologies”

 

I can’t stress this enough. Just because your shoulder hurts, doesn’t mean that your shoulder is the problem. I refer to the spine as the great chameleon. It can mimic damn near any symptom that you experience in the periphery. If you don’t fully evaluate the spine…or at least take a quick peek…then you may be treating the wrong thing!

 

  1. “typically reveals significant limitation of both active and passive elevation, usually less than 120 degrees”

 

Quick lesson, active elevation is your ability to raise your own arm. Passive elevation is your ability to allow me to raise your arm. Those with rotator cuff tears or issues typically have horrible active elevation, but passive elevation is much better and may be normal.

 

  1. “Scapular substitution frequently accompanies active shoulder motion…” and “Cyriax described a capsular pattern he believed diagnostic for adhesive capsulitis…it is not consistently seen in patients with frozen shoulder when objectively measured.”

 

Scapular substituion is elevating the shoulder blade in order to perceive that your are raising your arm further overhead. I tell patients to look at the space between your shoulder and your ear. If there is a huge change in that space when raising your arm overhead, then something is wrong. Patient’s will understand this visual. Have them do it with their “healthy” side so that they can see how much space change actually occurs and then do it with the problematic side to compare.

 

Cyriax, think Alfred Hitchcock look-alike, is one of the greats that provided many thoughts in the infancy of our profession. His theories are still taught in school and we still have to memorize his paradigms for examinations. In real practice though, we don’t always follow his teachings because…they aren’t always right. Each therapist will learn through seeing thousands and thousands of shoulders, that his patterns aren’t always right, but aren’t always wrong.

 

  1. “Although authors of textbooks have described patients with frozen shoulder as having normal strength and painless resisted motions…revealed significant weakness of the shoulder internal rotators and elevators.”

 

In school we learned that frozen shoulder doesn’t affect strength. I am not sure if it is still being taught, but I have to believe so because the boards (think OWL exams from Harry Potter) are based on the text books and not on recent research. Regardless, theses patients do demonstrate weakness. In my opinion, this weakness may be related to disuse due to pain or pain inhibition, but that is a story for another day.

 

  1. “Significant loss of passive external rotation with the arm at the side, as well as loss of active and passive motion in other planes of movement, differentiates frozen shoulder from other pathologies…Early frozen shoulder may be difficult to differentiate from rotator cuff tendinopathy because motion may be minimally restricted and strength testing may be normal”

 

Big picture…frozen shoulder will present with multiple losses of motion in many planes. Early frozen shoulder will still have ROM limitations, but not as bad as those that are in the second stage, which may make it difficult to see at first. The therapist/MD may not immediately recognize frozen shoulder and the treatment may be inconsistent with what is needed.

 

  1. “The definitive treatment for frozen shoulder remains unclear…Establishing treatment effectiveness is also difficult because the majority of patients with frozen shoulder significantly improve in approximately 1 year; therefore, natural history must be considered”

 

In other words, we think we know how to treat it, but even if we don’t you will get better over time. Is it possible that you don’t need to come to therapy…of course! Will you benefit from therapy…of course! Even if the therapist is providing stuff that doesn’t work…like ultrasound…the therapist should be spending adequate time with you in order to educate you regarding the condition and the overall prognosis. If your health care provider is not doing this…walk away! There are therapists on almost every corner if you look hard enough. Find one of quality.

 

  1. “Explaining the insidious nature of frozen shoulder allays the patient’s fear of more serious diseases…prepares the patient for an extended recovery…because daily exercise is effective in relieving symptoms”

 

This is my primary job…education. I gave up a career, as a teacher because I felt the system was broken. It is too hard to teach a group of kids when I had to cater to lowest common denominators. In this profession, I am still a teacher, but I only have one student…the patient in front of me. If I can teach you everything you need to know in one visit and you will go out and be the perfect patient, I may never have to see you again…for this at least. Most patient’s can’t absorb everything and may not be overly compliant after the first visit, so more visits will be needed. My hope is that the frequency of our meetings will decrease over time as the patient takes more ownership over lifestyle changes and exercise performance. Alas…sometimes it never happens.

 

  1. “Little data exist supporting the use of frequently employed modalities such as heat, ice, ultrasound, or electrical stimulation.”

 

If this comprises a majority of your therapy…”Houston, we have a problem”. I’ve said it before and I’ll continue to stand on the soap box. Health care is a business. All businesses need to keep the doors open and it would be nice if there was a profit at the end of the day. This means that you will be charged for unsupported treatments because of the following reasons: 1. Patients expect this, as this has traditionally been sold as physical therapy 2. It feels good 3. It pays well.

 

  1. “Gursel et al demonstrated the lack of efficacy of ultrasound, as compared to sham ultrasound, in treating shoulder soft tissue disorders”

 

It is no better than a placebo! If you would pay for it out of pocket, then I would rub some lotion over you with an ultrasound and then tell you that it is not effective. Would you still pay for it? If the insurance covers it though…why not? I will tell you why not…it takes up valuable time that I could be focusing on something more effective.

 

  1. “The basic strategy in treating structural stiffness is to apply appropriate tissue stress…think of the total amount of stress being applied as the ‘dosage’, in much the same way that dosage applies to medication…adjusting the dose of tissue stress results in the desired therapeutic change”

 

Tissue stress is anything that stresses the tissue. I know that it sounds simple…DUH. It is. I can stress the tissue by squeezing the tissue, stretching the tissue, forcing the tissue to contract against an outside force, but in the end, I need to provide the “appropriate tissue stress”. If the tissue is shortened, then it needs to be lengthened. This occurs by stressing with stretching. You will have to follow a prescribed set and repetition scheme at a specific interval frequency, which will be given by your therapist. Typically this is performed no earlier than every 12 minutes and no later than every 3 hours.

 

  1. “Three factors should be considered when calculating the dose…intensity, frequency and duration.”

 

Think of these as variables. Any good scientist knows that the best way to find the variable most important is to only change one variable at a time. If the patient presents to therapy and is not making progress, then I can change any of the three variables. I will choose to change the variable that 1. Best fits with the patient’s schedule 2. Gives me the lowest chance of making the patient worst 3. Gives me the predicted best result. All in this order. If I give you an exercise that you can’t do, then it doesn’t matter if I believe that it will help you. For instance, if I give you an exercise that needs to be done lying, but you work in a sewer system, you may not like me after the exercise.

 

  1. “Aggressive stretching beyond the pain threshold resulted in inferior outcomes in patients…tissue stress is progressed primarily by increasing stretch frequency and duration”

 

Going to therapy 3 days per week and expecting the therapist to get you better is a pipe dream. If you only go to the therapist for stretching, then the intensity will be high. This will result in an inflammatory effect, in which you will not want to/be able to move your shoulder. At this point, the stiffness will worsen. Be smart and move to tolerance. If you are worse for more than 20 minutes after stopping, you made a mistake and went too intense (there is research to support this timeline, but I don’t have it onhand).

 

  1. “Patients with the worst perceptions of their shoulder before treatment tended to have the worst outcomes.”

 

Butterflies and rainbows. If you think you are disabled, then you are. Please move. PSA.

 

  1. “Many authors and clinicians advocate joint mobilization for pain reduction and improved ROM. Unfortunately, little scientific evidence exists to demonstrate the efficacy of joint mobilization over other forms of treatment for frozen shoulder.”

 

I can easily spend 20 minutes mobilizing your shoulder and small talking about the weather, politics and religion. How else are we going to talk for 20 minutes?! That’s a long time for me to hold your arm. I need something to pass the time. The evidence is conflicting regarding me pressing on your shoulder to try to free up some room. I do mobilizations sparingly. They are good to know and if nothing else is working, then sure…why not do them? If something else works better, then that’s why I don’t do them often.

 

  1. “improved extensibility of any portion of the CLC (joint capsule) results in improved motion in all planes.”

 

I love using this example in the clinic: There was an episode of Seinfeld in which George and Jerry were staying in a fancy hotel. George went on this rant regarding tuck vs no tuck. Big picture…when the sheet is tucked in too tight, it is impossible to move your feet. You have to loosen up the sheets by kicking at them. Once you’ve loosened it up a little, it seems to free up a ton of room everywhere. This is the circle concept of the shoulder.

 

When we loosen up on aspect of the capsule, then the laxity that is created just moves around the capsule through additional mobilizations. We don’t actually stretch out the capsule in multiple planes.

 

  1. “At 7 weeks, 77% of the patients treated with injections were considered treatment successes, compared to only 46% treated with physiotherapy.”

 

Hell, this stat makes me want to advise patients to do this first before seeing me…or start gambling for the night. Does anyone else see the 777?

 

  1. “The core exercises include pendulum exercise, passive supine forward elevation, passive external rotation with the arm in approximately 40 degrees abduction in the plane of the scapula and active assisted ROM in extension, horizontal adduction and internal rotation”

 

We spend a fair amount of time discussing this diagnosis in PT school. I wish they had just covered this type of study so that we would know the way to treat this type of patient, instead of all of the theories and possible ways to treat this patient. It is good to have understanding, but it is better to have successful outcomes.

 

Excerpts taken from:

 

Kelley MJ, Mcclure PW, Leggin BG. Frozen Shoulder: Evidence and a Proposed Model Guiding Rehabilitation. JOSPT. 2009;39(2):135-148.

Is Your Therapist an Expert?

Experts…at least on paper.

 

I was very impressed with the Jensen article. I appreciate the historical analysis of experts. To believe that an expert simply knew more and was able to solve problems better than anyone else is disheartening. I work with others that are certified in MDT and though we go about treatment strategies in similar fashions, we compete against each other with paper patients. One strategy that we use to refine our skills in a group setting is a version of 20 questions. One therapist will create a case study and each therapist is attempting to ask the fewest questions in the history section in order to create a hypothesis to solve the patient’s puzzle. Though there are varying degrees of experience in this group, the therapists that consistently attend the study group are typically able to solve the case puzzle within 3-5 questions, whereas others may take 10-20 to create a hypothesis. I agree with the statement that experts are able to recall meaningful, selective knowledge. I can appreciate the next generation, which describes recall of patterns. This is extremely important for orthopedics. Patterns take much time to learn, but once a pattern is consistently witnessed, the therapist can be confident in the treatment approach.

I find the “necessity of self-monitoring through self assessment” to be extremely important in my practice. The saying “if all you have is a hammer, then everything looks like a nail” comes to mind. There are many therapists that force extension because it is the most common pattern, although the patient may not be an extension responder. I have had to step back many times to reassess my rationale for a treatment approach in order to ensure that I am not just following a preconceived bias.

 

The fact that the therapists were videotaped is interesting. There is one point in the paper when the therapist changed demeanor from clinical to personal while doing soft tissue mobilization prior to traction. I wonder if the therapist was taught this somewhere along the educational spectrum or if this is inherent. This skill has to do with “reading” reading the patient. I am reading a book called Telling Lies by Paul Ekman in order to better understand body language. This therapist either learned or inherently knew to change the approach at that time. To me, this is interesting.

I subscribe to the paragraph on page 34, “The expert therapists in this study shared…”. This is a central component to MDt. At no point do we utilize the word compliance, but instead emphasize therapeutic alliance. In other words, a team approach to fix the patient, with the patient’s preferences, judgments, and decisions having as much importance as the clinician’s knowledge of the problem.

Bill Curtis, PT, cert. MDT lectured to our class about MDT and at the time I had a hard time believing that spine symptoms could be fixed in days. I called, pardon the language, bullsh_t. I spoke to Bill after the lecture and because he did not have any research to back his claims, I had a hard time believing him. That was the greatest thing to have happened to me as a therapist, because he challenged me to do a clinical with him. I learned more in the 8 weeks as to how to fix people than I ever did in school. At that time I knew that I had to work with him in order to continue learning the secrets to solving the puzzles. I see some of my colleagues struggling with spines, and think that I would’ve been in the same boat if I didn’t seek out a mentor with more experience and abilities than I had at the time.

I like the statement that the OC made “you made a lot of mistakes”. I actually feel bad for some of the early patients that I treated. It’s one of those situations that if I knew then what I know now. Some of those patient’s wouldn’t have needed 15-16 visits in order to be back to 100%.

 

I thought that it was common sense that listening to patients is vital for proper classification and treatment. Apparently I was wrong. This is a skill that has to be learned and practiced in order to master. When working with PT students, I ask them to follow along and just write down on the form the information and we compare forms after the evaluation. Initially, the students miss so much relevant information, but by the end of the clinical are able to catch all relevant information and information that may not be as relevant to the case as much as relevant to the patient.

 

It is interesting that therapists are classifying patients, although they do not classify formally. Anthony Delitto stated in one of his papers that a clinician will attempt to classify all the patients. The NC stated that he/she “form opinions pretty quickly about certain patterns” and the OC stated “I constantly try to make sense to see how certain clinical pictures behave”. At this point, they are initiating a rudimentary classification process. Also a strong theme in this paper is therapeutic alliance. It comes up many times in the article.

I like that the experts used little equipment and gave few exercises. I tell patients that I can give them a book of exercises to do at home or I can give them one or two that will fix their complaints, which I also learned from Bill.

 

All therapists “set high standards and were driven to stay current in their specialty area”. As much as I agree with this statement, this statement also disheartens me. As professionals, I would expect this mentality from all of my colleagues, not just “experts”.

 

I love this article and am not speaking to all of the points of the article, just those that I find interesting or of differing viewpoints than those taught in school.

The comment on page 41, “If expertise in physical therapy is some combination of knowledge…can clinical practice and education be designed in a manner to address these multiple dimensions of professional competence?” I think that the first question to be asked is does everyone desire to be an expert. The desire to be an example and set an example for other PT’s to follow has to come before attempting to teach the skill set of an expert, in my opinion.

 

Another great question posed was “Why do some therapists continue to develop into expert clinicians, while others lapse into mediocrity?” Can this be detected during the interview process for PT schools? This question is very thought provoking in that it may be possible to create a profession of experts if we choose the right students.

 

Again, I loved the article and found certain elements as basic, such as caring and compassion being cornerstones of experts, while I believe that the other concepts, indirectly described in the article, are intriguing.

 

 

Excerpts and opinions based on the following article:

Jensen GM, Gwyer J, Shepard KF. Expert practice in physical therapy. Phys Ther. 2000;80(1):28-43.

 If you are in need of physical therapy or would like to talk to a therapist about the benefits of PT, I am more than happy to accommodate. 

FUNCTIONAL THERAPY AND REHABILITATION

now part of the Goodlife family

903 N 129th Infantry Dr

Suite 500

8154832440