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Category: Written Blogs

Problems with back pain

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Problems with back pain

Too often people experiencing back pain become a number instead of a person.

It becomes about checking boxes and jumping through hoops laid out within the broken medical system.

I tell many of the people I come in contact with: “give me 2-3 weeks to see if we can help you”

That’s it…two to three weeks.

I hear about patients having seen multiple doctors, pain specialists, acupuncturist and having gone through 4 months (yes 4 months!) of PT only to be lighter in the wallet without any more answers or relief than prior to all of the medical treatments.

I average 7 visits for patients with back pain. Mind you, 7 visits may be spread out over months because patients get homework.

If a patient is doing the homework and not responding, then why come to therapy 3x per week for more of the same that didn’t work in the first place!? 🤷‍♂️

I understand that people want relief and many of them are willing to spend thousands on relief and hope that the professionals are right when they say “it just takes time”, but how much of your life are you willing to wait through in order to get relief?

Waiting for relief is not the only answer.

There is a bell curve for all professions, I’m sure yours also.

Not all professionals are rockstars at their job.

Don’t get me wrong, you can like their personality, the professional can be “nice” or a “good person”, but is that what you want to pay for?

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Outpatient Therapy Services Payment System

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Outpatient Therapy Services Payment System

Physical therapy services are performed by someone licensed in the physical therapy profession. This can either be a licensed physical therapist (either a Bachelor, Master, or Doctor of Physical Therapy) or a licensed Physical Therapist Assistant (Associate degree).

Aspects of our profession that are performed in the clinic are as follows:

therapeutic exercise: exercises performed in order to help a patient improve function, strength, endurance, range of motion and/or reduce pain

Neuromuscular re-education: training movement patterns, balance, coordination, kinesthetic sense (where the body is at in space during movement), posture, and proprioception (where the body is at during one moment in time)

Manual therapy: using ones hands or tools to perform massage, joint mobilization (moving individual or groups of joints), traction, passive ROM (using hands to move a joint through its range) in order to improve pain, range of motion, swelling or other restrictions

These are the most common interventions used in my clinic. Other interventions used are modalities (which may or may not have evidence to support the intervention and may or may not be covered by an insurance plan). Some are as follows:

Ultrasound

Electrical stimulation

Heat/cold

Mechanical Traction

Iontophoresis

Laser therapy/light therapy

This is still a grey area for many Physical Therapists (PTs). Although the rules are very straightforward, some clinicians never read the rules that insurance companies impose to the clinicians. When a clinician is treating a patient and is in-network with the insurance company, the PT is accepting the rules imposed by insurance companies. Medicare will pay for medically necessary services.

It is up to the PT to establish this necessity in the documentation. The PT the. Needs to have a physician or other allowable non-physician provider (think nurse practitioner) sign off on the initial documentation, which establishes the PTs plan of action/treatment/care. This plan of action must establish a few details and is valid for up to 90 days.

Let’s talk numbers. Our spending on outpatient therapy services (occupational therapy, speech therapy, physical therapy) is more than many countries spend to run the entire country. This is a very large number and insurance companies, both public and private, are trying to cut down on the total expenditures over time.

It makes sense, because expenses have increased by 6% year to year for the previous years.

It may come as a shock to many patients, but “outpatient” benefits can be used in an inpatient setting 🤫.

If you were in a nursing home, they may have used your outpatient benefits to pay for part of your rehab. This may not be the best use of your funds as seen Here and Here.

Surprisingly hospital outpatients use fewer funds than I suspected. It has been documented that many physicians are pressured to keep a patient “in-house”. This means that physicians are not “supposed to” refer a patient out of the hospital network. This keeps all of the money within the hospital to find profits. This was highlighted in a previous news Article

In a way, I’m not surprised that private practices see such a large amount of the Medicare pie, as it’s been noted how many are abusing the system for large payouts. Such as this company that settled for $7M for performing abusive practices. These practices are very common to see in the field of PT.

Patients with Medicare are only to be billed for non-group services (which by the way pay at a much lower rate), when they are actually seen one-one.

Also, patients are only to be seen by licensed professionals. This means that technicians (techs) or aides are not allowed to guide a patient through their exercise program, at least if the company plans to bill for these services. Don’t believe me…here’s another Example.

So I guess that I am not surprised by how much money is spent in outpatient settings.

Many patients don’t understand that sessions are typically billed by the “15 minute rule”. This essentially means that for every 15 minutes, or at times the better half of 15 minutes (8 minutes), that the patient will see a charge on their explanation of benefits or receipt for services.

For example, a patient may see 3 separate charges for a session if the patient was seen in the clinic for 45 minutes. It can get messy if this is not explained to the patient.

The amount of money that Medicare reimbursed is different for different areas of the country. This is based on how much the cost of performing business is within a certain locale.

Those that have Medicare have to pay 20% of accepted/fee schedule amount.

This is where things can get confusing. For instance, I’ve seen an average visit (1 hr) be charged from $360-$1200 to the insurance company. This is a huge range in charges, which is also a problem with our healthcare system because it makes it difficult for patients to understand the actual charge.

Out of the charge for an hour, Medicare will allow close to $100 depending on how that hour was broken up into charges. The other $260-1100 is written off as an “adjusted” amount based off of insurance “savings”. (This savings number is also arbitrary to make it look like you get a great deal from having insurance).

Of the $100 that is allowable, the patient is responsible for 20% of that charge. The patient can choose to have another entity, a Medicare supplement or secondary, pay the other 20%. Of course the patient has to pay a monthly premium, unless on state aid, for that other 20%.

This is a way for business to start gaming the system. They will start to shorten session lengths so that they don’t lose as much money per session. There are three separate components that go into what is allowable by Medicare. They cut one of the three components by 50%.

Companies are then shortening sessions to the least allowable to maximize charges, such as shortening sessions to 25 or 40 minutes in order to maximize their reimbursement per session. They will then keep the patient coming in for more sessions per week in order to maximize payment.

Sometimes it’s what’s best for the patient, but many times it’s only what’s best for the company.

Those companies that charge more, or are in the upper tier of chargers in our profession. For instance, in our state their was a company that was audited and asked to pay back over $600K to Medicare due to inappropriate charges.

The article can be found Here

Start Back Screening Tool

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Start Back Screening Tool

“Lifetime prevalence for LBP (low back pain) has been reported to be between 60% and 95% and 34% of the participants in a large population study in Norway reported to have had LBP last week”

These numbers are scary, but are consistent with other published research that notes about 80% of the population will have back pain at some point in life. Think of how lucky you would have to be to go an entire lifetime without having back pain based on these numbers?

It can happen, as I’ve seen patients in their 80’s with a first time occurrence of back pain.

The part that is sad for me, as a PT, is that less than 10% of these people will ever get in to see a PT for back pain.

“Due to the lack of diagnostic tests that can identify objective signs of the condition, most of the patients are characterized as having ‘non-specific LBP'”

If you’re not familiar with the numbers, it has been said that any diagnosis trying to name a specific tissue (disc herniation, arthritis, spondylisthesis, spinal stenosis etc) is only correct about 10% of the time. The more severe the diagnosis the more likely that the specific tissue is the correct diagnosis (such as a tumor, spinal cord injury, infection).

Because of this, a majority (90%) of back pain is just labeled as “non-specific low back pain”. The problem with this is that the treatment for a non-specific problem tends to be…non-specific.

Don’t get me wrong, a majority of back pain doesn’t need much treatment, if any at all, and tends to improve over the course of 6 weeks. Some pains from the back require a specific treatment and a treatment outside of this Specific treatment can worsen symptoms.

This means that we have to actually attempt to classify a patient’s presentation. Understand please that a classification is not a diagnosis but instead more of putting the symptoms into a non-specific “bucket” that most resemble that presentation. For instance, there could be a bucket for fast changing, slow changing and unchanging. There could be buckets for a primarily psychosocial component, chemical component or a bio mechanical component.

“Based on the SBT (Keele Start Back Tool) scores, patients can be categorized into three subgroups: patients with low, medium, or high risk for developing persistent LBP and activity limitations….the low risk group should receive minor attention from health professionals and self management strategies are recommended for these patients. The medium risk group should be offered physiotherapy. For the high risk group more psychologically informed interventions are recommended”

This statement may upset some of my colleagues in PT, but we aren’t always needed for patients that experience back pain. For instance, it is advocated to see a PT if you have pain lingering more than a couple of Days. I’m not sure I completely agree with this, as much back pain reduces spontaneously. The last thing you, as the patient should want is to pay for unneeded treatments. The last thing that I want to do as a PT is to take a patients money if I am not needed at that time.

Again, don’t get me wrong there is a group of patients, with back pain, that should be treated by a Physical Therapist. These patients will score higher on the Start Back Screening Tool.

With that said, it is important that the patient be classified correctly within the first 6 weeks of experiencing symptoms. Some research demonstrates an early classification is beneficial and others demonstrate that it should be done within 6 weeks of symptoms. The reason for this is that the patient may benefit from more psychologically informed interventions, which should be performed by someone with

“To be useful as a screening tool in physiotherapy practice, it is important that the SBT-scoring is reliable and that the allocation to risk groups reflects the severity of the patients back problems.”

There are two things that we look at in terms of performing testing. One, is the test valid. This means does the test actually tell us what we think it tells us.

The second thing is reliability. This means that if I have multiple therapist from different settings performing the same exact task, would I get similar or exact scoring if performed on the same exact patient by different therapists.

“The SBT consists of nine items; referred leg pain, comorbid pain, disability, bothersomeness, catastrophizing, fear, anxiety, and depression…. The total score range from 0 to9, with nine indicating worst prognosis. The last five items are summarized into a psychosocial sub scale with five as the maximal score, indicating high risk for development of chronic LBP”

For more information about scoring, I personally like to use the Shirley Ryan website of outcome measures found here.

“Patients with a total score of 0-3 are classified as low risk (minimal treatment, eg self-management strategies).

I use this tool frequently in PT. I rarely have patients score a 3 or less, but this may be because they are already filtered out by the physician in primary care.

I recently had a patient score a 3 and lo and behold his symptoms were abolished in 6 weeks without intervention.

It’s a small sample size, but it seems to match the research.

To summarize: the STarT Back Screening Tool is an option to utilize in practice in order to determine if a patient

1. Requires little/no intervention and will return to prior level of function (PLOF) through regression to the mean (time > interventions).

2. Requires PT/Rehab only

3. Requires a more psychologically intensive approach to care.

Click here for original research article.



STarT Back Screening tool revisited

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on STarT Back Screening tool revisited

“…changes in psychosocial risk factors during the course of treatment may provide important information for a patient’s long-term prognosis”

As professionals, we should be performing repeated assessments of patients during the plan of care (POC) and not waiting until the patient is ready for discharge (either because their benefits have been exhausted, the insurance company dictates that an assessment needs to be performed or the patient self-discharged). Performing repeated assessments throughout the POC allows us, as professionals, to understand if the patient is improving, worsening or remaining unchanged with care and to assist us in modifying the POC.

The STarT Back Screening Tool is one method of assessing psychosocial factors that may impede rehab potential.

“… repeated assessments during an episode of care can also provide valuable information about changes in a given variable that can be used for treatment monitoring”

Utilizing a standardized approach to assessing a patient will enable the professional (PT in my case) to determine if a patient is catastrophizing, losing hope, or requires the assistance of a more psychologically focused treatment approach.

“The STarT Back Tool (SBT) is a Screening questionnaire consisting of nine items related to physical and psychosocial statements that are used to categorize patients based on risk (low, medium, or high) for persistent LBP-related disability.”

Here is a copy of the tool in question.

“Wideman et al found that early changes in SBT scores were predictive of four month treatment related changes in several relevant psychological and clinical outcome measures.”

This is a little different than what is expected from an outcome tool. For instance, many tools are utilized to tell the clinician where the patient is at currently and if this patient Hs a risk of developing chronic pain.

When we utilize multiple scores instead of a standalone score, this is indicative of how a patient will progress over the course of time.

“all patients (in this study) were referred for physical therapy by a physician and did not seek physical therapy services through direct access… this setting was considered secondary care.”

This is an important topic. For instance, the previous blog post indicated that the tool gives us information when read minister over a 4-week time period. This indicates that there are changes that occur over the course of 4 weeks.

Many complaints of low back pain improve independently over the course of 6 weeks. If a patient is issued this test at the first visit and classified as low, medium or high, this may lead to an inaccurate classification. Seeing as this study issued the tool to patients in a secondary care (meaning that the patients were referred by a physician) indicates that the patient is not being seen within the first few days of injury.

“1. Aged 18-65 years,

2. Seeking physical therapy for LBP (symptoms are T12 or lower, including radiating pain into the buttocks and lower extremity), and

3. Able to read and speak English”

“treatment was not standardized or tracked in this study and was provided at the discretion of the physical therapist.”

This may also be an issue, as there is a newer study that indicates the treatment interventions may have a role in the patient’s scoring.

Please see the previous post about how to utilize this tool.

“…123 patients (84.2% of the entire sample) who completed the SBT at intake and 4 weeks…The percent of patients for each SBT risk category who were classified differently at intake and four weeks was 81.8% for SBT high risk, 76.0% for SPT medium risk and 11.3% for SBT low risk.”

This indicates that a patient’s initial score should be interpreted with caution because there is a high probability that it will change over the course of 4 weeks.

“most patients either improved (48.8%) or remained stable (40.6%) based on changes in SBT categorization.”

“Thirteen (10.6%) patients were categorized as worsened based on changes in SBT categorization, with six of those patients categorized as SB team high-risk at intake and four weeks later.”

This is interesting to me. Typically, in PT, a therapist will cite regression to the mean. This essentially states that given time the patient will transition from an extreme score towards a more moderate score. This doesn’t account for those that transition from a moderate score towards a more extreme score. To me, this indicates that the episode of care had an effect, albeit a negative effect, on this patient encounter.

Primary findings of this present study were as follows:

1. At over 4 weeks, approximately 11% of patients worsened SBT risk;

2. Clinicians should be less confident in the stability of an intake SBT categorization of high risk than that of medium and low risk;

3. Prediction of 6-month pain intensity scores was not improved when considering intake or 4-week change for SBT categorization; and

4. Prediction of 6-month disability scores was improved when considering intake, 4-week, and 4-week-change SBT categorization”

This indicates that the first measurement may not be a good indication of what will take place with the patient regarding disability over time and some patients can be made worse with therapy. We already knew the second part from previous blog posts.



Excerpts from:

Beneciuk JM, Fritz J, George SZ. The STarT Back Screening Tool for Prediction of 6-month Clinical Outcomes: Relevance of Change Patterns in Outpatient Physical Therapy Settings. J Orthop Sports Phys Ther. 2014;44(9):656-664.

Clinical Practice guidelines for Bell’s Palsy

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Clinical Practice guidelines for Bell’s Palsy

Let me start by saying that I have seen few cases of Bell’s palsy comparatively. I can say I’ve seen no more than 10 cases in 12 years and reading this practice guideline, I can understand why it’s not a large percentage of patients seen in the clinic.

This post will be linked to the next blog post on Bell’s palsy because there are some conflicting recommendations, but not dramatically different.

“Bell’s Palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mononeuropathy…most common diagnosis associated with facial nerve weakness/paralysis”

I enjoy history. I didn’t know about Sir Charles Bell and I found this piece informative. Whenever a new disease or species is found, sometimes the discovered of the new xyz gets to name the new xyz. It is one way to keep their name alive. It could’ve also been described according to the actual dysfunction, as facial nerve palsy would indicate to everyone what is happening to the patient.

Once you see a patient with Bell’s palsy, it is never forgotten. The dysfunction can have dramatic effects on patients in terms of livelihood and willingness to go out in public.

People close to me know that I am a huge wrestling fan. One of the greatest, if not the greatest announcer in the history of professional wrestling is Jim Ross. His was the first time that I can remember learning of Bell’s palsy and it’s possible that his diagnosis cost him his job. It’s at least written about in other forums that there is a relationship. It was a long time before I got to hear about slobberknockers on tv again. Jim is back to work and his disease is visible to those that look close enough at his face.

“…rapid unilateral facial nerve paresis (weakness) or paralysis (complete loss of movement) of unknown cause.”

I have seen this run the gamut from barely noticeable to unable to close the eye or mouth. At the worse end of the spectrum, the person had major issues with drinking because there was incomplete mouth closure, which caused liquids to spill out of the mouth. Also, the same person was unable to move the eye or cheek muscles. An eye patch was required.

“…may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential injury”

With issues of mouth and eye closure, imagine how hard it is to keep the eye moist. Blinking assists in lubricating the eye, not to mention that the eye has difficulty producing moisture from the gland in the corner of the eye in the presence of Bell’s palsy.

“Treatments are generally designed to improve facial function and facilitate recovery”

The patients that I have seen, remember only a handful, I believe that only one person improved. At no point in time do I take credit for that, as a majority of patients improve over the course of 3 months. This patient was referred to me at the 6 week mark and time may have been more important than anything I did regarding the patients recovery.

“…the following should be considered:

-Bell’s palsy is rapid onset (<72 hours)”

I’ve had patients associate Bell’s palsy with a cold breeze blowing on them at night. They say this because the onset is so quick that some literally woke up with it. The patients attempt to find answers for why things happen. As a healthcare provider we have to do our best to educate and reassure the patient that it was nothing that they did to cause this phenomenon.

-“Bell’s palsy is diagnosed when no other medical etiology is identified as a cause of the facial weakness”

This is a diagnosis of exclusion. As mentioned at some point in this article, differential diagnosing needs to be performed in order to ensure that there is nothing sinister or other diagnosis causing this problem.

-“bilateral Bell’s palsy is rare”

I have personally never heard of bilateral Bell’s palsy and have obviously never seen it with my low level of experience treating this issue.

-“Currently, no cause for Bell’s palsy has been identified”

This has to be stated to patients. They will matrix and try to come up with a cause, which can create a change in behavior and the spreading of “old wives tales”. The most common one I hear is that the window being open caused a breeze while sleeping, or a fan was blowing on my face causing a breeze, to cause the symptoms.

-“other conditions may cause facial paralysis, including stroke, brain tumors, tumors of the parotid gland or infratemporal fossa, cancer involving facial nerve, and systemic infectious diseases including zoster, sarcoidosis, and Lyme disease”

These are all major issues that require a thorough history and possible imaging to determine if Bell’s palsy is the true diagnosis or if there is something obvious causing symptoms.

-“Bell’s palsy may occur in men, women, and children, but is more common in those 15-45 years old; those with diabetes, upper respiratory ailments, or compromised immune systems;or during pregnancy”

It affects both genders (I’ve seen both men and women), a wide age spectrum (I’ve never seen anyone older than 50) and multiple comorbidities can increase risk.

“…paresis/paralysis typically progresses to its maximum severity within 72 hours of onset of the paresis/paralysis”

This is good to know as a PT. It’s rare for us to see these patients in the acute, or immediately after it starts, stage. Because of this, should we see a progressively worsening condition, it would be prudent to refer the patient back to the physician in order to rule out any other medical concerns.

“Facial paresis or paralysis is thought to result from facial nerve inflammation and edema”

This is one of the explanations, but again there is no known cause.

“The facial nerve carries nerve impulses to muscles of the face, and also to the lacrimal glands, salivary glands, taste fibers from the anterior tongue, and general sensory fibers from the tympanic membrane”

This can cause the corners of the mouth to droop. The person may be unable to fully close the mouth to suck out of a straw.

The lacrimal glans is the little pink thing on the inside of the nose-side of the eye. This gland is responsible for keeping the eye moist.

“…may experience dryness of the eye or mouth, taste disturbance or loss, hyperacusis, and sagging of the eyelid or corner of the mouth”

Because it also supplies “power” to the tastebuds, this can affect taste. I’ve known many patients of those that I treated that lost weight because food was no longer appetizing.

“Most patients with Bell’s palsy show some recovery without intervention within two to three weeks after onset of symptoms, and completely recover within three to four months”

This is a very important statistic. Without knowing this, a patient referred to PT within days of the diagnosis, whom shows improvement within weeks, may lead the PT to believe that physical therapy has more significant effects than actually occurs.

“… facial function is completely restored in nearly 70 percent of Bell’s palsy patients with complete paralysis within 6 months and as high as 94% of patients with incomplete paralysis”

This information must be highlighted with patients. The effects of this diagnosis can be dramatic the first few weeks and hope needs to be restored in these patients.

Good ol JR is back to announcing wrestling!

“…as many as 30% of patients do not recover completely”

This needs to be addressed, but the education needs to be flipped to show that 70% recover partially or fully.

“Long-term, the disfigurement of the face due to incomplete recovery of the facial nerve can have devastating effects on psychological well-being and quality of life”

Two patients that I have treated in my past avoided going outside. Not to paint them in a negative light, but they lived like the Hunchback of Notre Dame. These two needed positive reinforcement in order to return to a life outside of the home.

I felt bad that these two have excluded themselves from the community because they wanted to return to normalcy, but didn’t want to be stared at in the process.

“…patients with facial paralysis can have impaired interpersonal relationships and may experience profound social distress, depression, and social alienation”

“The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell’s palsy”

As a PT, I will only discuss the information that is relevant to my profession or scope of practice.

1. “Clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute onset unilateral facial paresis or paralysis”

A thorough history is important regardless of the ailment. When paralysis is the end result, a thorough differential needs to happen in order to rule out other factors that could affect the facial nerve.

For instance, using the objective portion of the examination can help to rule out a stroke. The history can help to rule in cancer.

As a PT, ensure that you are taking a good history and physical exam in order to ensure that nothing is being missed.

2. “Clinicians should not obtain routine laboratory testing in patients with new onset Bell’s palsy”

“Risk: Missing a potential cause of Lyme disease, which is considered based on a thorough history.

Benefit: avoiding unnecessary testing and treatment, false positives and cost savings”

This is outside of the scope of PT and I will defer.

3. “Clinicians should not routinely perform diagnostic imaging for patients with new onset Bell’s palsy.”

“Benefit: avoidance of unnecessary radiation exposure, incidental findings, contrast reactions and cost savings”

“Risk: missing other causes of facial paresis”

“Opportunity for patient education”

4. “Clinicians should prescribe oral steroids within 72 hours of symptom onset for Bell’s palsy patients 16 years and older”

“Benefit: improvement in facial nerve recovery, faster recovery”

“Risk: steroid side effects and cost of therapy

Exceptions: diabetes, morbid obesity, previous steroid intolerance and psychiatric disorders.”

5. “clinicians should not prescribe oral antiviral therapy alone for patients with new onset Bell’s palsy”



“Benefits: avoidance of medication side effect, cost savings”

Risks: none

6. “clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell’s palsy”

Benefit: small potential improvement in facial nerve function

Risks: treatment side effects, cost of treatment

Patient preference: “significant role for shared decision making”

Exceptions: same for corticosteroid use

6. “clinicians should implement eye protection for Bell’s palsy patients with impaired eye closure”

Eye protection is standard of care.

Risks: costs of eye protection implementation, potential side effects of medication.”

This falls into the plan of care for PTs. Sometimes the amount of time that the patient has with a physician is less than 10 minutes. (I’ve read that an average patient physician visit is 11 minutes).

Because of this, the patient may not fully understand what to do once diagnosed with Bell’s palsy, and this can be within the role of the PT.

7. “Clinicians should not perform electrodiagnostic testing in Bell’s palsy patients with incomplete facial paralysis”

8. “Clinicians may offer electrodiagnostic testing to Bell’s palsy patients with complete facial paralysis”

Benefit: provide prognostic information for the clinician and patient, identification of potential surgical candidate

Risks: patient discomfort and cost of testing

8. “no recommendation can be made regarding surgical decompression for Bell’s palsy patients”

“Concerned about the facial deformity may make it some patients willing to pursue a major operation for a small increase in the chance of complete recovery while others may be more willing to except the chance of poor outcome to avoid surgery”

“The group was divided as to whether the evidence supported no recommendation, or an option for surgery. This difference of opinion derived from controversy regarding the strength of evidence”

9. “No recommendation can be made regarding the effect of acupuncture in Bell’s palsy patients”

“The GDG was divided regarding whether to recommend against acupuncture, or to make no recommendation.”

10. “no recommendation can be made regarding the effect of physical therapy in Bell’s palsy patients”

There are conflicting statements regarding varying clinical practice guidelines.

I have only had one patient with Bell’s palsy that demonstrated significant improvement greater than 90 days since the diagnosis. Is it possible that time had a strong let effect than PT…sure…it’s possible.

Typically, the recovery would’ve taken place by three months, but the patient made progress while in therapy.

Don’t get me wrong, I don’t think that PT is the end all be all for many diagnoses or patients, but I do believe that the interventions had an effect on this particular case.

There may be some patients that could benefit from therapy. In saying this, my experience would tell me that it is a small percentage of patients.

“patient may benefit psychologically from engaging in physical therapy exercises”

11. “clinicians should reassess or refer to a facial nerve specialist those Bell’s palsy patients with 1. New or worsening neurologic findings at any point, 2. Ocular symptoms developing at any point, or 3. Incomplete facial recovery three months after initial symptom onset”

“Identifying alternate diagnoses in the absence of recovery, and potential assessment for rehabilitative options…However based on the natural history of Bell’s palsy, the majority of patients will show complete recovery three months after onset.”



Click to find the Article.

Ankle strength

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Ankle strength

Some people have lost strength in the ankle due to a litany of issues such as:

Nerve damage

Muscle strain

Shin splints

Ankle fracture

Etc

Getting a stronger ankle joint doesn’t have to be complicated.

Some people have the ability to get stronger, but others may not have that ability.

Check with a licensed professional to see if the nerves are working properly before starting a structured exercise program for the ankle.

This is a basic exercise and is intended for general education.

Great teachers build students to be great

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Great teachers build students to be great

Image: Kaufman SF. The Martial artist’s Book of Five Rings: The Definitive Interpretation of Miyamoto Musashi’s Classic Book of Strategy

I have had many students over the course of my career as a PT.

It is not hidden that I practice with a base of MDT (Mechanical Diagnosis and Therapy). This is the base from which I begin every new patient evaluation. It allows me to keep information in an order that makes sense to me and keeps me thinking systematically.

When I take students, I don’t dictate how they practice. I want for them to learn about what is their passion within this profession.

Everyone has to follow his/her own dreams and goals.

I frequently get students that ask me how did I get to where I am at in this profession.

I tell them about reading textbooks, thousands of pages, two to three times in order to understand the words. The students go from feeling great about the energy that I bring and the mentoring and teaching that I have done through the clinical to telling me that they don’t think they can do it.

I DON’T CARE!

You do you. Don’t try to do the things I’ve done in my career. Becoming better at anything takes work. I can feed you my information and this can put you a little further in your quest for information, but you will never own the information in the same way that I own the information. It takes time and work to own the topics.

I only hope that the students can take from me an inspiration that this profession has a lot to offer. Each professional could be great at any one niche AND there would still be enough information, topics, niches for everyone to be great at something.

In the end, the responsibility is on the person…the student.

It is not on the teacher, for the teacher has already paved his/her own way.

The student must choose the path and forge forward.

What path have you taken as a student…professional?

Training for game day…everyday

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Training for game day…everyday

Image: Kaufman SF. The Martial artist’s Book of Five Rings: The Definitive Interpretation of Miyamoto Musashi’s Classic Book of Strategy

There is so much to unpack here.

First, don’t do as I do because you may have different goals than I.

When I worked at Sams Club, I could have two conversations: gym stuff and Sams stuff. I was so single minded. I would go to school in undergrad and read Ironmind, Flex, Powerlifting USA and books by authors such as the great Mel Siff, Mike Menzter, Fred Hatfield and others.

I wanted to make myself better at the things I enjoyed and school was just something I had to do in order to eventually make money.

I became employee of the year at Sams Club in 2003 and quit the same year to go work at a gym making half that money and to start PT school.

Once in PT school, I still devoted my time to learning about lifting. I went deeper into methodologies and theories of exercise.

Once I graduated from PT school, I devoted all of my free time to becoming a better physical therapist. I want to be the best (warrior) at this craft (physical therapy) that I could attain.

This is not necessarily healthy. I want to start by saying this because it’s been told to me my entire career.

I studied research between sets at the gym. I read textbooks multiple times over. I sacrificed personal relationships to become better…I won’t even say good, but better than the day before.

I’m glad I put all of that time in during those first ten years.

This does not conform to the thought of work-life balance. Again, I’ve heard this my entire career.

When looking at balance, it has to be what makes you happy. Not everyone has the same definition of happiness. When I go to work, I’m sure my patients are grateful that I sacrificed a decade of my life to get better at my craft. When I believe in something I give it my attention. In giving it my attention, I give my time. In giving my time, I am giving my life.

I understand that not everyone is devoted to their craft, but I would hope those depending on that craft can see the difference between those who do and those who don’t.

Cervical myelopathy: how to test clinically

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Cervical myelopathy: how to test clinically

“… The onset is often insidious with long periods of episodic, stepwise progression, and may present with a vast array of clinical findings from patient to patient.”

Cervical myelopathy is like neck pain to the extreme. It isn’t just a neck issue, but it ends up encompassing anything below the neck. It can cause arm symptoms, leg symptoms, difficulty walking, weakness throughout the body, spastic robot-like walking, and breathing issues.

This is a neck problem that needs to be addressed ASAP!

Let’s take a look at some of the research on this problem, what your therapist should check, and when it’s time for the patient to be sent back to a physician for imaging to determine if the patient is a candidate for surgery…it is that important.

Some quick stories (or not so quick).

I’ve had two patients with cervical myelopathy. One patient had symptoms of this, but also had arm problems from a previous injury. Because of this, the CSM (cervical spine myelopathy) was delayed in diagnosis until the patient demonstrated abnormal gait…10 months later!

The second case was picked up in the clinic immediately on the first day. I performed this cluster, to be learned later, on the patient and he was very positive. We had a conversation about the need for imaging and a consult with a neurosurgeon. The patient essentially said…thanks but no thanks.

Unfortunately this patient lost use of his hands and developed a walking pattern that was very abnormal before he decided that surgery was the right choice.

Here’s a quick Video describing CSM.

“May involve lower extremities first, weakness of the legs, and spasticity”

Spasticity is an issue that could be seen in walking for some people, but is testing using movements under speed like in this Video

What we will see is that the body reflexively slows down or stops the movement from happening rapidly.

“lower motor neuron findings in the upper extremities such as loss of strength, atrophy, and difficulty in fine finger movements, may present”

This means that we may see generalized weakness, loss of muscle mass (smaller muscles) and difficulty with picking up pennies and buttoning buttons.

“neck stiffness, shoulder pain, paresthesias in one or both arms or hands, or radiculopathic signs”

Neck stiffness is self explanatory. The neck movement may not be fluid or it may be restricted due to pain. There may be symptoms such as pain, tingling or numbness radiating into the shoulder(s) regions, arm(s) region or down to the hand(s) region. We may also see changes in sensation or reflexes.

“An MRI is most useful because the tool expresses the amount of compression placed on the spinal cord, and demonstrates relatively high levels of sensitivity and specificity.”

There is little reason for a PT to recommend an MRI, unless there are specific conditions found during the evaluation. The type of presentation notes above is one reason for a PT to recommend an MRI to the referring physician or the patient’s primary care physician.

X-rays do not do a good job of demonstrating any soft tissue (muscle/spinal cord/disc/ligaments/tendons) abnormalities.

Mind you, this presentation is not common and for the most part, an early MRI is not indicated for neck or back pain.

“The tests, when used alone, are not overtly diagnostic and may lead to a number of false negatives and in rare occasions, false positives”

It is recommended that, when CSM is suspected, the physical therapist use the cluster (groups) of testing in order to strengthen the likelihood of this suspicion. One test used alone is not enough to consider other testing.

“in reality, the diagnosis of CSM involves MRI findings and clinical findings, with equal weighting of both results”

Because the clinical exam is so important for this diagnosis and subsequent imaging, it is important that the PT and physician be familiar with the testing described.

“Of the 10 variables included in the regression modeling, the tests of Babinski and Hoffman’s signs, the Inverted Supinator sign, gait Abnormality, and age > 45 years were retained.”

I’ll be honest. In my first 10 years, I never tested for the inverted supinate sign or Hoffman’s sign until I read this paper. This is a testimony to continuing one’s education beyond taking courses. I don’t recall (those that know me know that I have a pretty good memory) ever learning this cluster through any of the coursework that I took since 2007.

After reading this article, I practiced these tests on a bunch of healthy individuals, those with neck pain in which I didn’t suspect a spinal cord issue, so that I could get better st the test and understand the normal response. This way, I learned the test mechanics and felt confident performing the test on anyone. It enabled me to understand the difference between the “healthy” patients on which I tested this specific cluster and the few in which had a positive test.

Rant: I hear it from so many students and new grads that they feel like they haven’t learned how to perform the tests or what to see as a result of the test because they only get to test healthy individuals. Having gone through the mechanics of this cluster for years, I hope that students understand that they must become confident at performing the mechanics of the test (kinesthetic learning) and know how a healthy response looks. One may go his/her entire career without ever seeing this presentation, but that doesn’t mean that one can’t perform the test and understand a normal result. I bring this up because I hear the same type of arguments regarding vestibular testing and ocular testing.

Every patient that has a history of stroke gets a vestibular-ocular exam because there may be lingering positive testing after the neurological event. This again strengthens my ability to perform the test and increases my likelihood that I will see positive testing…so I know what it looks like for future patient evaluations that may come in off of the street through direct access.

“A finding that included three of five positive tests yielded a positive likelihood ratio of 30.9 and a post test probability of 94%”

Even if you’re not a statistician, this is important information.

A positive likelihood ratio greater than 10 is an indication that your testing is giving a result that increases the chances of that being the diagnosis.

A post-test probability of 94% indicates that there is less than a 10% chance that the diagnosis or classification is incorrect after testing.

This is a much better percentage than we have of most orthopedic issues.

“”this study found that selected combinations of clinical findings that consisted of (1) gait deviation; (2) + Hoffman’s sign; (3) inverted supinator sign; (4) + Babinski test and (5) age > 45 years were affective in ruling out and ruling in cervical spine myelopathy.”

If you are a student and plan on treating patients…you must know these tests.

If you are a therapist treating these patients…you must know, be confident administering and understand the repercussions of a positive test.

If you are a patient…know that not all therapists have the same training and some may not even know these tests exist. I hope this makes you take a more thoughtful approach in choosing your next PT.

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Reflections on “The Alchemist”

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Reflections on “The Alchemist”

“The shop is exactly the size I always wanted it to be. I don’t want to change anything, because I don’t know how to deal with change. I’m used to the way I am.”

This is nothing like me, but we have met all types.

I personally thrive on change. I haven’t held a single position for more than a couple of years. One of the reasons I really enjoyed working for a larger company was that I could move through the company relatively easy and learn other jobs, without sacrificing my place in the company or benefits.

When I worked at Sam’s club, I started as a “cart boy” (man do I miss Don and Howard). I moved to cashier, where I held the title of Big Dog (only those that worked their would get it, but it was the person who scanned the most items per hour) many times. I worked at the service desk, as a cashier supervisor, overnight stocking, tire and battery center and freezer cooler.

Those that know me, know that I don’t know a damn thing about cars. Over time, I could do a set of 4 tires in less than 15 minutes from the time the car hit the lift to the time the tires hit the ground.

My first day in TMA resulted in me needing a drug test! Got to love Bill Foster for saving my job that day. I was told to drive a large older ford into the garage. What they didn’t tell me was that I had to take the turn wide using a three point turn. I took it tight (I had no clue), and I was scraping the side of the truck against the brick building for about 1/2 the bed. The truck was so loud that I couldn’t hear it.

Bill Foster comes running out giving the stop sign like a third base coach. I hopped out without a clue of what had happened.

He sold me as an incompetent idiot to the owner of the truck, as it being my first day on the job…and let me tell you that I was very grateful to be called that because the guy totally calmed down and was happy to get a new paint job. It was the first and only time that I had to be drug tested for being an imbecile.

If you live in Joliet and know Bill Foster, thank him for saving my job that day.

Don’t be afraid of change…what’s the worse that can happen?

A new paint job.