If it hurts it must be bad, or good, or whatever. Vincent Gutierrez, PT, cert. MDT

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 This biomedical or pathoanatomical (patho=bad and anatomical = body parts) model of health care is outdated and simply is not as useful to use with the general public because research demonstrates that the patient may become “sick listed” and from there stop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.

And this is my two cents for the night.
If you are in need of physical therapy or would like to sign up for a complementary discovery session (a conversation to determine if therapy is right for you), contact me. 

Functional Therapy and Rehabilitation 

(Now part of the Goodlife family)

903 N 129th Infantry Dr. 

Joliet Il 60435

815-483-2440

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).

If you need therapy after a total knee replacement, you can contact me at the following location.
Dr. Vince Gutierrez, PT, cert. MDT

Functional Therapy and Rehabilitation (Now part of the Goodlife family)

903 N Infantry Dr.

suite 500

Joliet, IL

60435

815-483-2440