Whatcha lookin at? Part II

Whatcha lookin at? Part II

 

7.”Physical wellness is the positive perception and expectation of health…the ability to effectively meet daily demands at work and to use free time”

This is what my job mostly entails.  As a PT, I get to give people their physical wellness back.  Typically, we see patients because some aspect of their life is giving them pain and therefore preventing them from living their life as they would like.

  1. “Spiritual wellness is the belief in a unifying force between the mind and body…establish values and act on a system of beliefs as well as to establish and carry out meaningful and constructive lifetime goals”

When things get put into this perspective, it means more than simply religion.  What is your end-goal? We have a beautiful family with a daughter and hopefully many more on the way.  My end-goal is to leave a legacy that my family can be proud of.  I look at my dad, Sal Gutierrez, and see my Superman.  I want my kids to be able to look at me and say, “There goes my Superman.”

I want to leave my mark on this world.  The words that I write today will outlive me by centuries.  This is my journal.  Although this article is much different than the previous ones, this is much more enjoyable to reflect upon than simply the cause and treatment of back pain.

  1. “Social wellness is the perception of having support available from family or friends in times of need and the perception of being a valued support provider…establish meaningful relationships that enhance the quality of life for all people involved”

I think back to the book “The Prince” by Machiavelli (sp?).  A leader can either be feared or be loved.  I think of my family (by either blood or experience) and know that if they ask me to jump, I will ask when, where, and how high.  This is out of love, but not fear.  I know that I have family that will do this, as evidence by our wedding and people flying across the country at short notice.  I hope that I am the same type of family to those that I surround myself.

  1. “Psychological wellness is a general perception that one will experience positive outcomes to the events and circumstances in life…positive outlook about life…qualities of optimism, determination, and hope”

This one is huge.  I have had many patients tell me that the most important thing that I give in the treatment is hope.  This is emotional for me because although it is great to be able to change someone’s pain, it is much better to be able to change someone’s outlook.  Hope, determination and optimism.  I think of how the tale of two lives.  Growing up on the East side of Joliet, life wasn’t white picket fences. My life could have turned out completely different, but thankfully my parents were determined to give me better and we moved to a small farming community.  The nature vs nurture debate couldn’t have been stronger internally.  As much as I like to think that I did the whole bootstrap thing, I have to fully acknowledge that the environment I was in allowed for hope and optimism.  Thankfully, I have a circle around me that also shares in these traits.  Many have said it, from Tim Ferriss to Dave Ramsey, ” we are an average of the 5 people that we choose to spend our time with”. I am grateful my 5 guys made me better instead of brought me down.

  1. “Emotional wellness is the progression of a secure self-identity and a positive sense of self-regard, both of which are facets of self-esteem…ability to cope with daily circumstances and to deal with personal feelings in a positive, optimistic and constructive manner”

I think of this portion of wellness frequently. It is not uncommon that I am treating a child with a parent present or an elderly parent with a middle age child present. The patient may not be able to cope with the situation that brought them into the clinic, but the caregivers can either break or heal the situation. Some caregivers come across as apathetic, which makes sense as to why the patient doesn’t want better for him/herself. No offense if you are a caregiver, but please step outside of the situation and look into the situation with a fresh perspective. If you were watching as a third party, would you be proud or ashamed of how you act?

Some people don’t have the capabilities to deal with daily circumstances. Like I said previously, my brother died of a drug overdose. His life was full of obstacles…whose isn’t. Just my opinion, but I don’t think that it is a major event that causes people to lose hope and spiral downward, but more of a “straw that broke the camel’s back”. I think that there were too many straws in my brother’s case. Looking back though, as his brother, there is shame and guilt that I didn’t see this coming. Think of how this comes full circle. One person’s emotional wellness, or any wellness for that manner, can affect those that are in close proximity (either physically or emotionally). When at work, I do my best to ensure that my wellness is overpowering to those around me in order to bring up the other person’s wellness aspects. When there is a patient whose emotional, physical or social wellness overpowers my own…I sit back and allow that person to bring me up.

Good story. I had a patient that was in his 90’s. He was coming to therapy for balance issues. He noted that his “balance wasn’t what it used to be”. I agreed and said that my balance probably isn’t as good as it was 10 years ago. He then proceeded to stand on one foot for two minutes and stand on one foot with his eyes closed for a minute. My jaw dropped. At this point, I realized that this guy didn’t need me. If anything, I needed to learn from him. I asked him; “What did you do for a living and how did you get to be in this good of shape at your age?” He gave me a history lesson and noted that the year the Olympics were boycotted by the US, he was in the trials for the 100 m dash. He trained and trained for years in order to qualify for the Olympics, only to have his dreams squashed that year. He then quit sports and went on to a physical job as a track coach. He was still performing sprints into his 80’s. This also reminds me of another athletic relic in our country, Zygmunt Smalcerz. Look him up now! I’ll wait.

  1. “Intellectual wellness is the perception of being internally energized by an optimal amount of intellectually stimulating activity…not so overwhelming that there is no time for mental repose…includes a person’s ability to learn and use information”

This is very important in our society today. Everyone speaks of the watering down of higher education, in that you have more difficulty obtaining work with a BA/BS today than you did 30 years ago. More students are moving on to MA/MA or DPT’s (in my own case) than ever in the history of our country or my profession. The reason for this is that a job is not waiting at the other end. Our current kids (mine included) has more screen time than any generation previously. This screen time, although we can rationalize why it is good for our child, is really a way to allow for us to have a cheap babysitter.

  1. “Howard Clinebell” introduced other dimensions of well-being with the addition of the relationship, work,play and well being of our world dimensions.
  2. “Relationship Well-Being Dimension represents the most important factor for our healing and general wellness…need for nurturing and love, for giving and receiving, for empowering others, and for creating interpersonal bonds”

It has been said by Dave Ramsey that next year we will the same person as we are this year except for the people that we meet and the books that we read. People change us. I meet some patients at work that just completely upset me and make me make changes due to some of their perceptions on life. I meet others, like that track star, that make me think there is no reason not be healthy as an elder…other than decisions that we make in our younger years.

I try my best to be a positive influence to those people that I come in contact with, but sometimes it is not easy.

Everyone needs love in his/her life. Personal Story: My parents divorced when I was young. I don’t remember my mom much as a kid because my dad took care of us, and he did an awesome job with me…in my opinion. Again, my superman. Back to the point, when one is devoid of love, a cynical or angry perspective of the world can seep into our being. I was angry for a very long time because I stopped having contact with my mom when I was still young. She walked away. I was angry and had trust issues for a very long time. Think about it…if the person that you are inherently supposed to be able to place all of your trust into does something so terrible as to destroy that trust, then who can you trust. In the words of Stone Cold Steve Austin DTA. It took me over 2 decades to come to terms with the situation that happened when I was still a kid. Life is good now and I very much understand the concept of the “need for nurturing and love”

Excerpts taken from the following:

 

Thompson CR. Prevention Practice: A Holistic Perspective for Physical Therapy. In: Prevention Practice: A Physical Therapist’s Guide to Health, Fitness, and Wellness. Thorofare, NJ: SLACK Incorporated:2007.

Stay tuned for part III

WHAT YOU LOOKING AT?

WHAT YOU LOOKING AT?

 

We all have a story. Sometimes our story is embarrassing. Some stories are sad. Some stories are full of success. Some stories are empty. The point is…we all have a story and it is OUR STORY. My story is no different than many others. Life, death and taxes. Sometimes more death than life and other times more life than taxes.

 

I decided to do this one a little different than previous posts.  These are taken from the textbook regarding health and wellness, instead of a research article.  You will learn a part of my story.

 

 

  1. “Health is derived from the Old English term hal, meaning sound or whole. Health is essentially the purpose of Medicine”

We as a society are becoming confused with the terms healthy and lack of illness. To be healthy is to be whole. This is a huge change of perception and a paradigm shift that is still occurring in healthcare. We all know that there is not much money to be made in making someone “whole”, but we charge a ton of money for cancer care. The easiest way to determine how much money is being made is to look at the size of the building. Dave Ramsey says, the tallest buildings are either owned by banks, oil companies, or car companies. There are major profits in these businesses. I can’t wait for the day that the biggest buildings are owned by companies like Crossfit, Primal Blueprint, Barbell Shrugged, Paleo Solution, etc. I doubt that it will happen in my lifetime, but it would be nice for our society as a whole…to make it whole.

 

  1. “Medical professionals have experienced a shift in their health care paradigm perspective from one emphasizing illness to one stressing health, function, quality of life, and well being…The importance of supportive environments for producing lasting change cannot be overemphasized”

Again, when we are “sick” we go to the doctor to feel better. Doctors do a good job of treating sick people. If we are not “whole” like in the above statement, then we need to see a doctor because, because in essence we are…SICK! Think about this, can you say that you are WHOLE? That your life is great? If not, why not? Who in the medical field would be best to talk to about your emptiness, or sickness.

Personally, I have been to a psychologist and it was one of the greatest things that could have ever happened to me. I had a patient die in my arms. It is the worst experience that I ever had to experience and I can still see the patient and can recall the entire event until the point that I started chest compressions. I took lessons from that psychologist and applied them to life. That advice has completely changed my life. LISTEN TO ME! My life is changed because of that encounter…only for the better! As a society, we tend to stigmatize going to doctors or other professionals as less macho than handling things on our own. Look, I suck at fixing a car. I can put gas in the car and turn the key. After that, I am like the kid from the Christmas Story…OH FUDGE. People pay me to help them become healthier…whether this means to be pain-free or to move better, this is all part of becoming a better, less sick or whole, person.

I find that our profession is being asked to make this paradigm shift in the face of profit being made from treating illness. This is as much a personal business decision as it is societal ethical decision. We again need to see healthcare as a business and then we can understand why setting up fitness programs is not as profitable as setting up cancer treatment centers.

Getting back to supportive environments…Crossfit understands this. When talking to Crossfitters, the chief word to describe the “box” is community. This is why the model is so successful. They can sell you the workout, but anyone can do the movements…but not everyone will be inspired to do the movements day in and out alone in a garage.

 

  1. “…the National Academy of Sciences found that musculoskeletal disabilities in the workplace cost the United States more than $1 trillion per year in total costs”

HOLY CRAP! We are unhealthy! We get hurt daily. At any one point in time, there are 5 million Americans with back pain. This gets expensive. Think about how your not showing to work affects your co-workers or business as a whole. I know that if I call in sick to work and my patients don’t get seen, it costs me money, but it costs the business at least $1,000. I can’t afford to be hurt or sick.

 

  1. “A rising trend in poor health reported in the United States indicates an immediate need for preventive care in order to reduce medical conditions that lead to disability…a trend toward increasingly limited activity and poor health over the last decade”

Until we make health care and promotion of “whole”ness more profitable than sick care, I don’t see this happening. We as a society are becoming less healthy over time. This could have many factors depending on who is speaking. I hear groups say that it is the high-fructose corn syrup, it’s the GMO’s, it’s the gluten, it’s the technology, the lack of recess, the wussification of America. There are any number of reasons, but the result is still the same. We are becoming, in the words of Ravishing Rick Rude, a society “of fat, sick, lazy, overweight slobs”. God I wanted his abs. Secret man crush.

 

  1. “a variety of unhealthy lifestyle behaviors commonly developed early in life often lead to disability, chronic disease, and ultimately, premature death”

Basic stats reported in the media. The new generation of kids will be the first generation to not outlive the parent’s generation. WTF! Why are our kids more sick than we were/are? This should be enough to make every American sick and every parent take action. Kids should not be type II diabetic! Kids should not shy away from play! Dang it…I was always and continue to be the “big kid”, but I will play with the crossfitters, the powerlifters and the strongman groups and every once in a while I will go to the park and do the monkey bars, slide down the slide and run the bases. We need to introduce…no reintroduce…our kids to activities that don’t involve a screen. This is the type of lifestyle that will lead to “premature death”. It just got real.

 

  1. “According to the National Wellness Institute (it does exist), ‘wellness is an active process of becoming aware of and making choices toward a more successful existence’…wellness in an active, lifelong process…integrates mental, social, occupational, emotional, spiritual, and physical dimensions of one’s life”

Wellness is actively seeking out a successful existence. Let that one soak. Our time is precious and our time is relatively short all things considered. First, congratulate yourself…you are still here. Many are not. Many have lost the fight of existing. Personal story: My brother died of a drug overdose about 8 years ago. Purposeful or accident…only one person knows for sure and we will never know the answer. Why does it take death to put things into perspective. Every morning we wake up we have a choice. Do I want to be an active seeker of a successful existence, or will I allow external forces to manipulate my being and time. There are many cogs in the wheel of wellness, but even I focus only on a few spokes at a time. We can’t all be perfect. With regards to the mental, I used to be such an OCD person. My psychologist told me that I lived my life so compartmentalized and each compartment was perfect. It was good that way, but life sucked. When I started incorporating more than just reading medical journals, life improved. When I started taking advantage of the social aspect life blew up…in a good way. Loving family, friends that I would jump for at the drop of a hat (out of love, not fear), spending less time on social media and being more social in life. Time is short. I have been a meathead for the past 15 years and focused so much on the “physical dimensions” of my life that it overpowered the other dimensions. I remember working at Sam’s club (8298 represent) and being so engrossed in school, work or gym that I was inept socially. I couldn’t have a conversation unless it revolved around one of those three topics. I was so far removed from any culture, either pop or otherwise that I was socially uncomfortable.

 

 

 

I will continue to edit this post over time, as this chapter requires more time devotion than previous studies.

Excerpts taken from the following:

 

Thompson CR. Prevention Practice: A Holistic Perspective for Physical Therapy. In: Prevention Practice: A Physical Therapist’s Guide to Health, Fitness, and Wellness. Thorofare, NJ: SLACK Incorporated:2007.

TENDINITIS…TENDONOSIS…TENDINOPATHY…O MY!

TENDINITIS…TENDINOSIS…TENDINOPATHY…O MY!

 

Many people have had Achilles tendinitis, or tendinosis depending on your doctor’s education level. The modalities for this are outdated and although I don’t go into detail, this paper does state that performing exercise (you doing something) is better than passive modalities (other people doing things to you). We are animals and need to move!

 

  1. “This isolated eccentric loading paradigm has since gained considerable popularity and is now widely regarded as the treatment of choice, although there is a lack of convincing evidence that it is the most effective exercise regime”

For tendinopathies, eccentric lowering based exercises are given very frequently in the clinic, although this may not be the only way to treat the tendon. As a quick review, tendons connect muscles to tendons and ligaments connect bone to bone. Picture eating a chicken leg… when you get towards the handle portion of the chicken leg, there is that hard ropy part that we all spit out or try to eat around. That is the tendon. Thick, ropy and attaching the delicious chicken meat to the bone. Tendinopathies are injuries to the tendon that haven’t seemed to heal correctly.

Eccentric contraction is the type of contraction performed when the muscle becomes longer. For the meatheads, this is considered the negative portion of the lift. I remember being in PT school and describing the exercise as the positive portion, static portion and negative portion. Meatheads will understand this terminology. My professor said “Vince, we don’t use those terms here. We use concentric, isometric, and eccentric” respectively. I was instantly smarter because of this. (Sense the sarcasm). Every profession has it’s own language and these languages is why healthcare is so expensive. We have come up with smarter ways of saying the same thing that gym rats say everyday.

 

  1. Paraphrasing: After exercising, there are physical changes that occur: increased blood flow, collagen formation, bigger muscles/tendons. This occurs from varying the intensity of exercise, which can be done as follows: force or weight of the load to be moved, range of motion through which the muscle is contracted, contraction type (see above)speed of contraction, number of repetitions, and rest between sets.

For anyone that has ever read FLEX or Muscle and Fitness, these are all basic tenets of exercise. We can all agree that to make an exercise harder, we can always add weight. This one is easy and all of my PT students say this answer first when asked how to make an exercise harder. That’s great, but PT students are now considered doctors and I can get the same advice from my Dad, who was a laborer. We as medical professionals have to be able to give better advice than our patients can get from their neighbors.

Range of motion is considered how far we are moving our joints while moving weight. If you have ever been to the gym and watched someone squat, you already understand range of motion. One guy almost always does the set and says “did I go deep enough?” If the question has to be asked, the answer is always no. Anyways, it is obvious that the person that just unlocks his knees and stands back up is doing much less overall work that someone that lowers their butt until it is just inches above the floor (aka A$$ to Gra$$). We all know that the first guy didn’t do the same amount of work as the second guy, even if he used heavier weight. For some reason though, no one ever tells him this…I don’t get it.

Speed of contraction is huge. Dr. Squat (Fred Hatfield PhD…if you are a lifter and don’t know this name…stop and google him right now! I won’t be offended if you don’t read the rest of this but come back asking for an explanation of compensatory acceleration) used to talk about the speed in which we transition from the eccentric to concentric phase. In many people, it looks like a smooth wave…NO GOOD! He wants it to look like a checkmark, with the least amount of time needed to transition from one type of contraction to another. Getting back to the point, speed is another way to change the intensity or power output of an exercise. The faster you move a certain weight or body part, the more power output you have compared to a slower movement. For instance, the snatch is one of the most powerful movements in sports, but most people in the US only think derogatorily with this word (shame on you…you know who you are.) MORAL: The faster you move, the more power you produce. The heavier you lift, the stronger your tissues. The smaller the range of motion in a squat…douche.

 

  1. “It is well known that the tendon cells (fibroblasts) respond to mechanical stimuli in the form of strain, and that depriving them of strain (relative tissue deformation) leads to degeneration and apoptosis (cell death).”

In other words, if you don’t want your cells to die, then you have to do something strainful to the tendon. In other words: Get up off the couch and move! Or your cells will die. What happens to the body when the cells start dying? That’s why I get paid the big bucks, I know the answer. DOH! I’m giving away the answers.

 

  1. “…the evidence suggests that increased time under load, increased number of load cycles, and increased loading rate result in a positive adaptive response”

Simply put, spending some time under the bar (time under load) with multiple repetitions (load cycles) frequently (loading rate) is good for you (positive adaptation). You don’t need me to say this, but I will anyway. The stronger person is always more functional than the weaker person…all other things being equal. As we age, we lose the ability to be powerful. Think of it…even Arnold doesn’t look like AHNOHLD anymore. Start today. Get bigger, stronger, faster. You may never beat Bolt, but you can always beat the you of yesterday.

 

  1. “slow loading may therefore produce particularly strong cell stimuli that can be beneficial to the tendon if the strain is sufficient”

Okay, we are much smarter today than our ancestors…or are we. There is a guy by the name of Arthur Jones (again…Google him. This guy may not be able to squat as much as Fred Hatfield, but my Lord this guy is way more interesting…Why are you still reading…GO GOOGLE!). That’s right, he carried a gun almost everywhere he went. Jones proposed last century the benefits of slow training. He knew inherently that it made the tissues stronger. We now know he was right.

 

  1. “…imply that given a sufficiently high force (and resulting strain on the fibroblast), the contraction mode is inconsequential”

WHO CARES WHAT TYPE OF EXERCISE YOU DO! PUT YOUR HAND ON THE SCREEN..GO FORTH AND EXERCISE AND YOU WILL BE HEALED! (I say this, all the while picturing the grey haired preacher, from the 90’s on tv) We have overcomplicated treatment of tendon injuries. We just need to make the tendon stronger. We can do this through negative or positive lifting, assuming that there is enough weight to actually make a difference. Now let me retract slightly because I typically follow MDT paradigms. In Mechanical Diagnosis and Therapy, a tendinopathy would be classified as a contractile dysfunction. Robin, in the 1980’s thought that we just have to get the tissue stronger (remodeled). In this method, the patient is told to lift the weight just enough to reproduce the symptoms (pain) and then perform this repeatedly multiple times per day. When this no longer produces pain…go heavier. I know! He was such as genius!

 

  1. “Therefore, collectively, there is no firm evidence to support the notion that eccentric loading is more efficient than concentric or other loading regimes”

Do I need to elaborate?

 

MORAL: The person that doesn’t move will die (apoptosis). Movement heals all (general overstatement) and the type of movement is not as important as simply moving.

“They” say it’s not accupuncture

DRY NEEDLING? WHAT’S OUT THERE?

 

  1. “Myofascial pain syndrome is characterized by the presence of one or more symptomatic myofascial trigger points (MTrPs) located in skeletal muscle. Myofascial trigger points are palpable, localized areas of hyperalgesic muscle tissue typically located in a taught band of fibers”

Myofascial pain syndrome is pain believed to be originating from the myofascia. I feel like Webster’s dictionary at this point. You know what I mean? For instance when you look up a word such as ambulation and the first definition is: The act of ambulating. Thanks wise guy!

Let’s start with myofascial. There are two types of fascia spoken of in the research. The first is superficial (superficialis) fascia and the second is deep (profundus) fascia. There is this awesomely boring book to read about fascia if you are ever having trouble falling asleep (Fascia: The Tensional Network of the Human Body: The science and clinical applications in manual and movement therapy). I only recommend it if you are really interested because it is very long and very boring. I guess that we also have to start with “What is fascia?” In school we didn’t learn much about this tissue. For those that graduated before 2012, we were only taught that it is the white stuff that we have to cut through in order to see the muscles. It was more of a nuisance than an actual tissue to pay attention to. Boy, have things changed! If you have watched any of Kelly Starrett’s videos or read the book: Supple Leopard (which I highly recommend to most of my athletic patients), then you will see many ways in which the fascia can be moved and “loosened”. Fascia is a very tough tissue that helps to give us shape and encompasses the entire body. It covers our muscles and even covers the small structures that make up an entire muscle. Big picture: it’s everywhere. The research on it is still young and we don’t know its full purpose yet, but are starting to understand that when it is angry…it let’s us know.

These MTrPs are palpable, meaning that we can feel them if we attempt to feel you up. They are the “knots” that most people complain about. Some of these “knots” are like small marbles and others are like small sausage links. Either way, they are hyperalgesic, which means…for a lack of a better term…angry.

 

  1. “In addition, research indicates active MTrPs have greater concentrations of inflammatory and nociceptive agents, as well as a lower pH, compared to non-pathologic muscle fibers”

There are some details hidden this sentence. The first is the description of “active” trigger points. If some are active, then others are inactive. These are historically called latent trigger points. This type of trigger point has the same palpable nature of a trigger point, but doesn’t cause pain. I don’t know of any research that looks at the pH of latent trigger points. Think about it though. The only way that we can really know if a trigger point is active or inactive is to play with it and see if it hurts.

 

  1. “It has been suggested that TDN (trigger point dry needling) hyperstimulates the pain-generating area and thereby normalizes the local sensory inputs. Another hypothesis suggests that TDN causes natural opioid-mediated pain suppression by stimulating local alpha-delta nerve fibers.”

The take home point from this is that we have no idea how this may work! There are theories as to the why it works, but there are articles showing that it works. Put this in perspective…I consistently say that our profession is in its infancy regarding research, but I really should say that we are in our toddler stage. I have a young daughter and am just waiting for her “Why” stage. As a curious father myself, I always want to answer the question when I can, but at the same time I know that I will (through no fault of my own, as it appears to be a genetic trait of parents) answer her question with “because I said so”.

 

  1. “Trigger point dry needling is administered by inserting a thin, solid filiform needle directly into the palpable trigger point…then incrementally manipulated within the tissue in order to elicit a localized twitch response (LTR) and removed once the MTrP has been released”

Picture a pincushion…enough said! I like why’s, but there aren’t many with this regards. I can remember during a clinical, the clinical instructor was teaching me acupressure techniques in which you hold a force downward onto the knot and wait for the patient’s pain response to change or hold for 90 seconds, whichever comes first. This just seemed so arbitrary to me. What I saw was that I was going to dig my thumb into a patient and wait for them to tell me that it doesn’t hurt as much. People aren’t dumb. In the words of Dr. House… all people lie. If I tell you that I will push into your skull with enough force to cause you pain and that I will stop when your symptoms are better…what will you do? I think I’d be fixed.

There are too many vague descriptions for me with regards to this technique. “Incrementally manipulated”? What does this even mean? I can see a session lasting for hours and coming into the room every 10 minutes to “release the muscle”. This technique may work, but we still don’t have enough information to make this type of treatment standard yet.

 

  1. “Moderate to severe adverse events causing significant distress or further medical treatment (e.g., fainting, headache, nausea) occurred at a rate of <0.04%”

This means that 4 in 10,000 will have an adverse reaction. Hypersensitivy to aspirin is between 1-2 in 100. Overall, this appears to be a safe intervention, but we still have yet to see if it is effective.

 

  1. “TDN is more effective than stretching and percutaneus electric nerve stimulation, and at least equally as clinically effective as manual MTrP release and other needling treatments”

This means that dry needling has more promise than basic stretching, but is no better than many other techniques to reduce pain.

 

  1. “It appears that TDN, as performed and measured in each study, does not influence strength, variably improves ROM and function and frequently decreases pain”

We know that it helps pain. We don’t know how it helps pain. There are two major theories for affecting pain: the bottom-up theory and the top-down theory. The bottom-up theory is using an external stimulus to reduce your painful complaint. Again, if I put an ice pack on your painful area or hit a separate area with a hammer, your initial pain will reduce. The top down theory is not spoken of in the research very often. This is using your brain to reduce your pain, such as with meditation. It is also called the endogenous (internal) opioid (cocaine) theory. Aside from pain relief, there appears to be little evidence that it helps any other complaints. Since a majority of patients are coming to therapy for pain complaints, this could be used as an adjunct to mechanical (movement based) therapy in order to reduce pain complaints. (As of today’s date, I have absolutely no training in this treatment).

 

  1. “TDN treatment may allow for improved tolerance to other interventions, such as manual therapy and therapeutic exercise, with potential for overall accelerated progression and more lasting positive results”

This statement sums up my thoughts on this type of treatment approach. It can be used as an adjunct to get the patient back to where the research is strong…exercise. I will have to look into the legalities of performing this type of intervention in our state, as each state has it’s own rules regarding invasive procedures for PT’s.

 

MORAL: Using dry needling techniques can be useful for pain reduction, but has no other effects. This could be an intervention in order to return the patient back to functional activities assuming the patient has demonstrated that he/she will be a non-responder to a mechanical (movement based) intervention program.

 Functional Therapy and Rehabilitation 

(Now part of Goodlife PT)

903 N 129th Infantry Dr

Joliet IL

8154832440

EXCERPTS TAKEN FROM:

Boyles R, Fowler R, Ramsey D, Burrows E. Effectiveness of trigger point dry needling for multiple body regions: a systematic review. JMMT.2015;23(5):276-293.

 

Paint by number

I recently finished my transitional Doctorate of Physical Therapy degree.  There was long hours involved and lucky for you, I saved all (well…maybe most) of my work.  Here is an oldie, but a goodie (voice of Kasey Kasem)

 

A Critical Appraisal of Clinical Practice Guidelines for Low Back Pain (LBP)

 

P: For patients with back and/or leg pain

I: what is the level of evidence regarding varying interventions, outcome measures, risk factors, and assessment processes

C: throughout the profession of physical therapy

O: that can be used in the course of care of individual patients

 

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

 

Search:

Ovidsp with title terms “low back pain” and “guidelines” with keyword of “physical therapy”. The results were limited to articles published in the previous two years.   Seven citations were found.

 

Date of Search: March 1, 2014

 

Citation:

Delitto A, George S, Van Dillen L, et al. Low Back Pain: Clinical Practice Guidelines Linded to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. JOSPT 2012;42(4):A1-A57.

 

Summary:

 

The purpose of this guideline is to provide physical therapists with information, based on strength of the current evidence, regarding risk factors, clinical course, diagnosis/classification, differential diagnosis, examination, and interventions in the treatment of low back pain, with or without leg symptoms.

 

Content experts, appointed by the Orthpaedic Section of the American Physical Therapy Association (APTA), researched the above information. The authors independently searched the following databases: MEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews to initially acquire the content matter. The articles were limited to articles published prior to 2011 and the authors searched the reference list of each article in order to prevent the omission of a relevant article. The articles were leveled according to the criteria from the Centre for Evidence-based Medicine and were then were issued a grade of recommendation as previously described in the research.

 

The authors provided a comprehensive list of both International Statistical Classification of Diseases and Related Health Problems (ICD) Codes 10 and International Classification of Functioning, Disability and Health (ICF) codes.

 

The authors determined that based on lesser quality studies that data does not support a cause of LBP and risk factors are weakly associated with LBP.

 

Based on lesser quality studies, the data supports performing interventions that reduce the likelihood of transitioning from acute to chronic LBP and reducing the likelihood of recurrences.

 

Based on evidence from high quality studies, it is recommended to sub-classify patients based on signs and symptoms, such as the Treatment Based Classification System. Based on moderate evidence, the following signs and symptoms are useful in classifying patients based on the ICF and ICD-10: mobility impairment in the thoracic, lumbar or sacroiliac regions, referred or radiating pain into a lower extremity and generalize pain.

 

Based on evidence from high quality studies through expert opinion, it is recommended based on moderate evidence to consider performing a differential diagnosis to when serious medical conditions are suspected.

 

Based on high quality studies, there is strong evidence to recommend utilizing the Oswestry Disability Index (ODI or the Roland and Morris Disability Questionnaire (RMDQ) in order to monitor change pre-post intervention.

 

Based solely on case control studies, it is recommended based on opinion that clinicians should assess activity participation limitations.

 

Based on multiple high quality studies and few case studies, the authors provide strong evidence for recommending manipulative therapy in the treatment of LBP. These recommendations are only provided for patients with symptoms above the knee.

 

Based on high quality studies, the authors recommend performing trunk coordination, strengthening and endurance exercises to reduce pain and disability with patients ranging from subacute to chronic and also patients status post microdiscectomy. This recommendation is based on strong evidence.

 

Based on both high quality studies and case control studies, the authors recommend utilizing repeated movements or procedures, in a specific direction, to promote centralization. This is based on strong evidence.

 

Based on lesser quality evidence and case controlled studies, the authors recommend flexion exercises, combined with other interventions, for reducing pain in older patients with chronic symptoms. This is based on weak evidence.

 

Based on lesser quality studies and case series, the authors recommend lower quarter nerve mobilization procedures to reduce pain in patients with subacute and chronic LBP, with lower extremity symptoms. This is based on weak evidence.

 

Based on research ranging from high quality studies to expert opinion, it is recommended that clinicians avoid educational techniques based on pathoanatomy and extended bed rest. Recommended advice is centered on the inherent strength of the spine, the neuroscience explaining pain, the overall favorable prognosis of LBP, the use of active (as compared to passive) coping mechanisms, and early return to activity. This is based on strong evidence.

 

Conclusion:

Based on the Clinical Practice Guidelines above, the following is recommended based on strong evidence: utilizing an outcome measure such as the ODI or RMDQ, manual therapy, trunk coordination, strengthening and endurance exercises, promoting centralization, and performing patient education.

If you have back and want to be seen by a therapist that reads research for fun, come see me at 

FUNCTIONAL THERAPY AND REHABILITATION

now a part of the Goodlife family

903 N 129th Infantry Dr. 

suite 500

Joliet IL

8154832440 

 

 

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 

Do you run loudly?

Shhhhhh…quiet. Tread lightly and land softly. May your joints forever feel young.

  1. “Several of these programs instruct participants to land softly in an attempt to teach proper landing technique and reduce impact forces. Mandelbaum et al reported an 88% decrease in anterior cruciate ligament injuries in 1041 female subjects using soft landing cues”

Are you thinking what I’m thinking? Seinfeld? Mandelbaum seriously?! This was the family of old guys in the hospital with Jerry that kept hurting themselves trying to lift the t.v. I thought it was funny.

What the above is saying is that the sound of your landing can directly indicate your injury risk. Don’t go jumping off buildings to test this theory! I won’t be held liable.

 

  1. “13% decrease in peak vGRF during a drop-landing task when 80 adult recreational athletes were instructed to listen to the sound of their landing…reduced by 24% in a stud in which 12 female recreational athletes were asked to land softly…”

What this means is that the softer you land the quieter you land. vGRF is vertical Ground Force Reaction (some people really hate it when I mix up the letters, but oh well…You know who you are!). This is it this way. For every action, there is an equal and opposite reactions. This means that if you land with a heavy load, the ground pushes back up at you with an equal load. If you absorb some of the load with your joints by bending, then the ground doesn’t push back as hard. Think of dropping a stick vertically from a specific height. The stick will actually bounce a little after it hits the ground, because the ground pushes back. Now do the same experiment with a wet noodle and you will get a totally different result. This may not be an exact science, but at least it makes sense to me. When you land quietly (wet noodle), you don’t get the jarring force from the ground as when you land loudly.

  1. “Initially, the participants were instructed to perform drop landings (with no instruction) to obtain a baseline, normal sound amplitude of landing…then instructed to …create a quieter or louder sound from this normal landing condition”

For those of you that perform high-intensity exercise of varying modes under time domains-based exercises, (I am unsure that if I use the word crossfit that I may be sued like those before me) such as box jumps, that this study will apply to you.

  1. “quiet-landing instruction results in significantly greater joint excursion at the ankle and knee when compared to a normal landing sound instruction”

Essentially, the quieter that you try to land, the more that you perform a squatting based movement on the land. The stiffer you land, the louder you are. The louder you are, the more force (think jarring) that your joints have to endure.

MORAL: Be quiet! Tread lightly!

Excerpts taken from: Wernli K, NG L, Phan X, et al. The Relationship Between Landing Sound, Vertical Ground REaction Force, and Kinematics of the Lower Limb During Drop Landings in Healthy Men. J Orthop Sports Phys Ther. 2016;46(3):1945-199.

If you would like a running assessment or are experiencing pain during running, come see me at:

Functional Therapy and Rehabilitation

(Now part of the Goodlife family)

903 N 129th Infantry Dr

Joliet IL

8154832440

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

FORGHETABOUTIT!

FORGHETABOUTIT!

 

Stachura J. The testing of frontal plane movements in the loaded position in the absence of a lateral shift-A case study. International Journal of Mechanical Diagnosis and Therapy. 2009;4(3):17-23.

 

  1. “It is estimated that 80% of the adult population will experience low back pain at some time during their life. During a typical year, 40% of adults will experience back pain.”

I realize that this statistic gets thrown around so often, but it is only because 8/10 people will have the pleasure of being a back pain statistic. Very few people will live their life without going through an episode of back pain. Like Lavar Burton would say…”The more you know”.

 

  1. “It has been reported that up to 90% of patients referred for low back pain cannot be given a specific anatomical diagnosis”

Think about this. Most people that I see just want to be educated. How would you feel about going to your doctor to better understand what your problem is and being told you have back pain. DUH! “I came to the office to tell you that I have back pain and all you can tell me is what I told you!”. That is the best we can do in most situations. Everyone wants to know about the exploding disc or the pulled muscle or the DUM DUM DUM…ARTHRITIS! Typically there is not one cookie cutter answer to your pain and 9/10 times we can not state with certainty what is the problem tissue causing pain. 

  1. “The MDT model involves a movement examination in which single and repeated end range movements are performed and the patient’s response to these movements is assessed.”

In order to figure out how your symptoms respond and to better understand your symptoms, you will have to be moved while in our presence. This statement above does a good job of explaining MDT, AKA the McKenzie Method. You will be moved, not once, but tens to hundreds of times in order to determine what makes you better and what makes you worse. Once this is figured out, the rest is easy. Avoid what makes you worse and continue what makes you better. I spent almost $80K to learn this! It’s a little more complicated than this, but not much, which has been part of the stigma against this method: “It’s too easy”. Look, would you rather I looked very pensive and gave you 20 exercises and treated you for months on end, or would you rather I smiled with the thought that “I got this!” and then only treated you for 6-8 sessions? 

  1. “When a specific movement or combination of movements results in the patient’s symptoms being centralized, reduced or abolished, it is said that this is the directional preference of movement for the patient. If a directional preference is found, this determines the treatment intervention strategy…allows the MDT trained practitioner to make a provisional classification…then drives the principle of management.”

I wrote all of this out because I can’t stress the importance of all of the above. We have a ton of research since Donelson came out the term directional preference over 20 years ago. To make this very simplistic, many back pains are like a locked door. When we find the one movement that makes your pain better, it is like the key to open the door. Many patients, about 49%-64%, with back pain can be unlocked with the right key. If the therapist is trained to find the key, then it’s like solving a rubix cube. If a therapist doesn’t even understand the basic principle of directional preference, there will be a lot of attempts to open the door with CORE TRAINING (buzz word), massage, manipulation, rest and relaxation and heat or ultrasound. Not many of these have great evidence (albeit manipulation is growing in the research) of turning off back pain.

  1. “ A lateral shift was not detectable with visual inspection”

Let’s start with “lateral shift” and what it is vs. isn’t, because not every therapist can agree on this. https://www.youtube.com/watch?v=Gvk4TGw4ba8 I have absolutely no problem advertising for someone else if it also aids in educating the patients that I treat. A lateral shift literally means that the patient, when attempting to stand upright and straight, leans to one side or another due to pain and is unable to attain an upright position.

FUNNY STORY: I had a patient years ago that walked in with a lateral shift. There are some rules to determine whether or not the person’s crooked posture is relevant to the symptoms, but as a young know-it-all, I knew that it had to be relevant. Anyway, I treated this shift for over 40 minutes trying to get this person to walk straight and his symptoms weren’t changing nor was his posture improving. I called his wife back to the clinic and asked her to watch him walk. I didn’t tell her what I was looking for and just asked “what’s the most obvious thing that you see”. She said “he looks like he always looks like that” WHAT?! “Look at the guy…he’s crooked”. She followed with, “now that you mention it, he is crooked, but he’s always been that way.” I essentially let my eagerness to play the hero override the basic premise of ensuring that his being crooked actually has something to do with his symptoms. I was WRONG! Note this date, because I don’t say it often. Anyway’s, a few press-ups (look up a video of repeated extension in lying) and this crooked patient was pain-free, but still crooked.

  1. “Single movements were tested…demonstrated a major loss of lumbar flexion, moderate loss of lumbar extension, and a minimal loss of side gliding”

What this means is that the patient was unable to bend forward, had much difficulty bending backwards and sidegliding was not blocked much. Most patients don’t know what side gliding is, and don’t feel bad because many PT’s don’t know it either. This is a movement of shifting the hips like 1. You are holding a baby on your hips or 2. You are trying to hip check someone into the glass. This movement is important because it is more likely to test the problem area than just sideways bending. If your therapist has you bend sideways instead of side gliding, try your best to educate the therapist (You heard right!) and if the PT still doesn’t understand…walk out.

  1. “ A stud by Feinberg on 2320 patients with low back pain demonstrated that the most common site of disc pathology was the L4-L5 and L5-S1 level in combination followed by L5-S1 alone. Side glide in standing has been demonstrated to better isolate the lower lumbar segments than side bending”

Again, this relates to the above statement. Most people have back pain originating from the bottom two segments of the low back. Think about it, the lowest portions of the spine have to carry more weight than any other portions of the spine. It makes sense that they will be screaming for help at some point. To the point, side gliding affects these two segments moreso than sidways bending affects the bottom segments. Follow me for a second. Ninety-five percent of problems happen at these segments. If I am not testing the segments, then what am I doing?! It’s akin to me asking you move your arm in order to determine what’s wrong with your ankle. I understand that it’s an extreme example, but the theory is still the same. If you have a back problem that looks and smells like it could be coming from the lowest segments, we should be looking at the lowest segments in the best way possible. You will know more about this than most new graduates after reading just this segment of the blog. 

  1. “While there is no evidence to support the following, this author believes that the loaded position (standing) is more functional and therefore, should be fully tested before testing unloaded (lying) positions.”

This guy just took a huge leap. Okay, when practicing MDT it is taught, no drilled into us, that we should always follow the form. The author of this study is no longer following the form. That is not a bad thing. This guy is able to give a rationale for why we test some things in standing and some things in lying. The biggest picture item to understand about this method is that we will continue testing you to determine what helps you compared to what hurts you. For me and many other practitioners, our primary goal is to understand how your symptoms respond to certain movements. When we see patterns or certain “phenomenon” after moving you, we can start to play your symptoms like a fiddle. This means that we should be able to accurately predict what will make you worse and better. I personally like to test this to see if I am right. It will put the patient through a little more symptoms than they have to be, but so be it. (I really am a nice guy though). From my experience with patients, therapists aren’t doing this and the patient’s may never experience a cause and effect moment during the entire therapy episode, or even worse, traditional therapy may create a cause-effect relationship in a negative way and actually make the patient worse. It’s not the patient’s fault.

FINAL STORY: I had a patient back in 2009 that came walking into the clinic on crutches. Her diagnosis was sciatica and I couldn’t figure out why the crutches? I asked and she said that she walked in to a local clinic and needed crutches in order to leave the clinic. The PT was performing hamstring stretches. RANT: I hate seeing the traditional picture of the therapist in the Polo shirt stretching a patient’s hamstring. I never look that good stretching a patient! END RANT. The patient in question responded rapidly (good book: Rapidly Reversible Back Pain by Dr. Ron Donelson) to lumbar extension and not only did she not need crutches after the first session, but she had no pain whatsoever. Forghettaboutit!

 

MORAL: Not all therapists have the same knowledge even though we all have the same baseline education. Educate yourself in order to be better informed when going to see your healthcare practitioner.

If you are experiencing back pain or know someone that would benefit from an evaluation to determine how rapidly the symptoms can be resolved give them my name. I can be found at

Functional Therapy and Rehabilitation

Now part of the Goodlife family

903 N Infantry Dr

Joliet Il

60435

815-483-2440