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Tag: pain

Cervical myelopathy: how to test clinically

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

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

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

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

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

Some quick stories (or not so quick).

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

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

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

Here’s a quick Video describing CSM.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Medicare for all

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Medicare for all

Are you paying attention?

Medicare for all would not be a great option, since we can barely sustain Medicare for some.

Government has to get more and more creative in order to make the đź’° last longer.

Part of that creativity is to reduce output.

Another part of that will be to increase revenue to this system.

Reducing output is easy. They are simply paying less for services and taking less risk than previous years.

For instance, ACO (hospitals and other entities) are seeing less reimbursement than previous years for the same procedure.

Less income means that the hospitals have to find other ways to generate income or to become “leaner” in their operations. This may mean less one-one time for PTs.

What do you think the solution should be?

See some of the comments to understand why we are running into problems.

PT and tendons: where are we at?

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on PT and tendons: where are we at?

“Complicating matters further is the mismatch between reported pain (and disability) and imaging (and pathology), as well as evidence of widespread sensory nervous system sensitization in some tendonopathies.”

A little background. Pain is not always viewable. This is a large debate even among the highest level of pain organizations. The IASP (Thanks to Colin Windhu for catching a mistake) is looking to change the definition of pain to include tissue based problems, or at least perceived problems.

Not all pain has a tissue based component, as some have a cognitive and emotional based component. For instance, I treated a person that was so afraid of performing activities that this person developed a pain from the thought of movement. After establishing that movement was safe, this person more than 10X increased the ability on a functional test…in less than 6 weeks.

This person, and others that I’ve worked with, have a “stinking thinking” type of pain. This may not be the fault of the patient, but instead it may be the fault of the faulty medical system. One that drives fear.

How many people have heard a physician say

“This is the worst spine I have seen”

“You shouldn’t squat/run because it’s bad for your knees”

“You shouldn’t work with heavy weights because it’s bad for your back”

“Your knees/hips are bone on bone and you will need a new knee/hip in the future”

Your pain is because you have a rotator cuff tear/disc herniation/arthritis etc”

These types of interactions do more to hurt the patient than help the patient and can start the cycle of inactivity out of fear of breaking oneself.

Don’t buy into the hype. A little stat, when a physician diagnoses your back pain as a herniated disc, arthritis, muscle strain, stenosis, etc do you know that the diagnosis is only right about 10% of the time?!

People are hanging their health habits in a guess that has a worse chance of being right than flipping a coin. You would have better odds of getting 4 of a kind in Texas Holdem.

Let’s start by not placing too much weight into the diagnosis because it’s a best guess at best.

Here’s what we think may happen. Some pain can cause more pain. Nerves can communicate with each other.

It’s similar to an infection. Any nerve that comes in contact with the nerve that is irritated can then become infected (irritated). Hmm?

I’ve seen many patients that experience widespread pain even though “everything is healthy”.

Yet another reason not to hang your hat on one specific tissue problem.

“… A diagnosis of tendinopathy is reasonably easy to make clinically, on the basis localized pain over the tendon that is associated with loading of the tendon.”

If you hurt your biceps and you ask your biceps to work, it makes sense that it may not like that.

If you hurt/injured your biceps and it hurts when you make your ankle muscles work, we wouldn’t expect that to create a problem in the biceps if the problem is localized to the biceps.

Make sense?

In other words, when a tendon is injured, we expect specific behaviors like

1. Pain with contraction under load that may increase with increasing loads

2. Pain with compression of that area

3. Pain with stretching that specific area

4. No issues when that area is not moving.

If the symptoms operate outside of this narrow set of parameters, it may not be only a tendon issue. This is not to say there isn’t a tendon issue, but instead is meant to say that the tendon may only be a part of the problem and we have no idea how much of a part it is until more assessment is done.

“…management of tendinopathy should optimally involve addressing loading of the tendon”

A tendon connects a muscle to a bone. It doesn’t have a ton of blood flow and can be slow to heal.

It needs to work in order to get back to its normal function.

This is what it means to load the tendon. Make it work, but don’t irritate/create harm. As long as the tendon/pain is not worse following an activity…awesomesauce…no harm done.

“Management of load…usually commenced with complete removal of offending activities and the introduction of appropriate and graduated loading activities”

If you break your leg, you will expect to be on crutches. This is to allow the bone time to heal. This stage lasts anywhere from 4-6 weeks. Loading before then one is ready to accept load can result in worsening the injury. You would know this because the pain worsened or you would break it further.

Loading a tendon before it is ready to be loaded OR more than it is ready to accept will lead to increased pain in that area, pain that is lasting and worsening function over time.

These are the clues a patient needs to give their attention towards.

Sometimes you need to remove all load from a tendon to allow it to rest and others you can perform your normals daily activities, but any more would result in increased pain that lingers.

When the pain no longer lingers after an activity, it is time to do more activities and create a new norm.

It doesn’t have to be any more complicated than this. Some research shows that 1200 repetitions of calf raises should be performed weekly, but it doesn’t have to be this structured.

“…requires patient buy-in…involves the clinician educating the patient about the nature of the tendinopathy, its relationship to loading, and a likely recovery trajectory.”

This is by far and away the most important detail.

If the patient is not educated on how the body should respond AFTER performing the activity, then the patient may be reluctant to continue anything that creates transient (short-lived) pain.

This is one of those issues that only gets better with direct loading. It doesn’t “fix” with time because it needs to be strong enough to handle the loads that you would throw at it on a daily basis.

“This exercise program should be adequately supervised, reviewed, and progressed to ensure adherence and resolution of the tendinopathy.”

SOAPBOX: ADEQUATELY SUPERVISED DOES NOT MEAN THREE TIMES PER WEEK FOR SIX TO EIGHT WEEKS. THE PATIENT SHOULD BE PERFORMING THE HOME PROGRAM AND THE THERAPIST IS IDEALLY ONLY A PHONE CALL AWAY. THE PATIENT SHOULD RETURN IF SOMETHING U EXPECTED HAS OCCURRED OR THE PATIENT NO LONGER IS ABLE TO REPRODUCE THE SYMPTOMS WITH THE LOAD THEY ARE USING AT HOME.

“(a) symptom-guides management, (b) symptom-modification management (c) compressive versus tensile load (d) stages of loading through the rehabilitation process (isometric and isotonic strengthening, energy storage and release, return to play), and (e) what I will refer to as movement competency…in a way that does not provoke pain.”

This doesn’t need to be summarized and is great advice for most soft tissue disorders.

“In the lower limb (Achilles tendon, patellar tendon), it appears that pain up to 5/10 on a numeric pain rating scale during and after training is not harmful and may be desirable”

This is a little more aggressive than I go initially, but the patient’s response gets to dictate how hard we push.

If there is a 3 point change and the patient is no worse after repeatedly creating a 3-point change, the. They have earned the right to go to a 4-point change. At some point, we would predict that too much of an increase would lead to an inflammatory effect, but we just don’t know what that number is for that specific patient.

The only way we will ever know is to test it.

“The fad of giving all patients with tendinopathy an eccentric exercise program from the onset has largely abated; however, after adequate strength of the muscle has been achieved, it is necessary to use eccentric exercises to reinstitute the energy storage/return capacity of the musculotendinous complex”

Not sure if this is any different than just load the tissue. The tissue needs to be able to contract under load and stretch under load. That’s normal mechanics for a muscle.

“Movement competency…is mainly about the form and shape (posture and alignment) with which physical activity is performed.”

This is consistent with what Dr. Kelly Starrett has been preaching for years through his books, videos and interviews.

A squat should look like a certain shape and many things look similar, such as a lunge (squat with one leg), clean start position, deadlift start position, standing up from the toilet etc.

Of course I know there are nuances between the squat and deadlift regarding hip height and back angle, the clean and lunge regarding shin angle etc, but in the end the basic shape still applies (knee bent and hip bent with shoulders forward and back fairly flat with head looking straight ahead). The similarities are where most people need to function and the nuances are what make the exceptional athletes different.

Link to article

Part I: TBCS revision

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Part I: TBCS revision

“In order to optimize the treatment effect, patients with LBP should be classified into homogeneous subgroups and matched to a specific treatment. Subgroup-matched treatment approaches have ben shown to result in improved outcomes compared with nonmatched alternative methods.”

There is more information coming out over time that demonstrates certain patients do well with specific treatments related to that particular patient.

Looking at the broad scale, there are many people with LBP across the world.  Not everyone with LBP has similar symptoms or will respond to the same treatment.

For instance, if your pain gets worse with repeated or prolonged bending, prolonged sitting an standing slouched, your treatment will look differently than someone that gets better with the aforementioned activities.

This is what is meant by subgrouping patients into groups.  We take the patient’s presentation and history and match that to an intervention that tends to work well for that group.

One such method of subgrouping can be found here.

This article will highlight a different approach to subgrouping, the Treatment-Based Classification System. This is a post that I previously wrote on this system.

“There are 4 primary LBP classification systems that attempt to match treatments to subgroups of patients using a clinically driven decision-making process: 1. the mechanical diagnosis and therapy classification model described by McKenzie, 2. the movement system impairment syndromes model described by Sahrmann, 3. the mechanism-based classification system described by O’Sullivan and 4. the treatment-based classification system described by Delitto et al.”

I won’t hide from my deficiencies.  I am well versed in the MDT system and fairly well versed in the treatment based classification system.  I am not well versed in the MIS or the MBC.  I will limit my advice to that which I am knowledgeable.

Yet, these systems-without exceptions- have 4 main shortcomings:

  1. No single system is comprehensive enough in considering the various clinical presentations of patients with LBP or how to account for changes in the patient’s status during an episode of care.
  2. Each system has some elements that are difficult to implement clinically because they require expert understanding in order to be utilizied efficiently.
  3. None of these classification systems consider the possibility that some patients with LBP do not require any medical or rehabilitation intervention and are amendable for self-care management.
  4. The degree to which the psychosocial factors are considered varies greatly among these systems, which runs contrary to the clinical practice guidelines established by the American Physical Therapy Association (APTA) that advocate using the biopsychosocial model as a basis for classification.”

I will address these points regarding my knowledge of MDT and TBC.  I will not address the MIS or the MBC due to my lack of knowledge regarding these systems.

1. No single system is comprehensive enough or accounts for changes in status during an episode of care.

First, I can’t fully agree with this statement.  Yes, there is no system to date that can account for every patient that walks through the door.  This is true.  This is why a therapist must be well versed in multiple systems.  For instance, MDT is a system that doesn’t take into account non-movement based pain presentations.  When paired with an approach that takes this patient presentation into account, it makes for a great pairing.

The TBC does not account for change during the patient’s episode of care.  Once a patient is classified and the intervention is applied, there is no algorithm for further improvement or progression.

This is not true though for MDT.  For instance, a patient can be classified into one of three categories.  The first two categories have built in progressions, regressions and modifications to movement.  The third category is a category that doesn’t require much intervention aside from advice.

With the first category, derangement (another way to say this would be rapidly changing) there is a clear progression.  Let’s start with the term derangement.  No one likes this term to be used for patients.  It’s a long running joke that we should never tell patients that they have a derangement. Words do matter and the patient’s perception of this term may be just as important as our expectations for the patient.

Now, moving on to the important part of the post.  When a person is classified as a der…I mean a rapidly changing presentation, here is what the progression looks like in the clinic:

  1. Reduce the der…Dangit! I almost did it again.  Make the symptoms better quickly.
  2. Make sure that the patient can maintain the reduction in symptoms.
  3. Return to the functional activities that the patient would normally do during the day without reproducing symptoms
  4. Teach how to prevent the symptoms from returning

That seems like a fairly simple strategy when bringing patients through a program in PT, but unfortunately this simple construct is lost on a lot of professionals.

 

Why you ask?

 

Thanks for asking.

 

Because unfortunately, there is no profit in getting people better.  Shhhh….You didn’t hear it from me.

 

Regarding the second category of Mechanical Diagnosis and Therapy: Dysfunctional tissues, it also comes with a game plan that is easier to follow than the first, but not as fun to implement.

Also, the name dysfunction is another term that I have gotten away from in the clinic.  Again, patients don’t want to be deranged or dysfunctional, although if given the choice, I would much rather have a derangement.  They want to know is it going to improve and if yes, what’s the timeline.

These issues are like hamstring or achilles problems…they tend to get better if left alone until….WHAM! You goin for a quick sprint to keep your child from running out of the door at the grocery store.  OR you run down the stairs because you are feeling froggy.

It let’s you know….DUFUS! YOU NEVER CORRECTED THIS PROBLEM!

This tissue issue (say that 5 times fast!) needs to be loaded to the point of pain and then allowed to recover before it is loaded again.

Like one of my mentors Annie O’Connor says in her courses “No pain… No gain…No guts…No glory”

This example is rarely used in therapy, but this is one case in which this example is fitting.  Ideally, this tissue is loaded consistently.  I have seen research that states the achilles tendon should be loaded about 1200X/week.  That’s a whole hell of a lot of repetitions.

As a matter of fact, if you would like to read more about this, you can find a previous article that I commented at this link.

  1. “Each system has some elements that are difficult to implement clinically because they require expert understanding in order to be utilized efficiently.”

I would wholeheartedly agree with this statement.  There is research that demonstrates good reliability when MDT is applied by those that have taken, and passed, the credentialing exam.  It has been shown multiple times, but here is one of the more current articles.

The systems are not easy to use, nor should they be easy to utilize.  It irritates me to no end when I hear about a therapist “using the McKenzie exercises” even though he/she has no idea regarding the wrongness of the statement.  Open mouth…insert foot.

There has to be something sacrificed in order to learn a method or system.  Time, money, life…these are all things that I sacrificed in order to get to where I am at in my career, which much to learn remaining.

 

“None of these classification systems consider the possibility that some patients with LBP do not require any medical or rehabilitation intervention and are amendable for self-care management.”

Again, can I disagree with these statements.  At one of the MDT conferences (they blend together), Nadine Foster presented on the STarTBack screening tool.  MDT is advancing to keep up with the research.

Those that keep up with the research or attend MDT-based conference, understands that not all patients require follow-up, or even an evaluation!  Some patients do get better with time.

To follow-up with this, there is still one classification that I didn’t describe yet. This is the postural syndrome. In this syndrome, the patient has no signs or symptoms of a problem…unless he/she maintains one position for too long.  Once the patient moves from that position…the symptoms disappear.  It’s like Wizzo (it’s a Chicago thing).  I bet you didn’t know that you were going to get a history lesson.

“The degree to which the psychosocial factors are considered varies greatly among these systems, which runs contrary to the clinical practice guidelines established by the American Physical Therapy Association (APTA) that advocate using the biopsychosocial model as a basis for classification.”

I agree with this, in that MDT or the TBCS doesn’t appear to utilize psychosocial factors in classifying patients.  There is another classification that appears to be paired well with MDT.  Check out this podcast with Annie describing this system.

This will be continued in the next article that goes more into depth on TBCS.

If you would like to read the article highlighted above, you can find it at this link.

Thanks for reading.  For those that gained a little knowledge from this article…please share so others can learn about classification of low back pain.

 

 

A novel case study

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on A novel case study

I was just speaking about this case to one of the PTs that works with me this week, and felt it a good learning opportunity to post to the inter webs.

78 year old male was referred to me from another PT. The patient underwent 6 weeks of PT with another therapist also certified in MDT.

I helped train that PT and she felt that the patient should be referred to me to see if there was anything missed during the appointments.

The patient had an extrusion at L3, affecting quad strength. He also had a loss of light touch sensation at the anterior thigh.

His only complaint was pain that would wake him up at 2 AM, which was very intense. He would take a Norco and walk for 30-45 minutes to reduce his pain. He could sleep until 6 or 7 AM, which is when the excruciating pain would return. Again, he would take a Norco and walk. The pain would go away and not return the rest of the day until 2AM. He was very active with Tai Chi and Kung Fu over 10 hrs per week.

His only complaint was pain in the middle of the night.

I couldn’t provoke his pain during the evaluation.

He had already been through 6 weeks of PT without change, so I was only trying to figure out his sleep issue.

I had a working hypothesis

1. Overnight, the disc imbibes fluid and increases in size.

2. It was possible that the change in fluid content was increasing his pain since the pain went away when he was up walking during the night

3. If I could prevent the disc from taking on fluid, his pain might shut off

That was my only thought pattern that made sense for his symptoms.

I had him sleep in a recliner and to call me in 2 days with the result.

He was painfree in the recliner and did not wake at all.

Because he already had 6 weeks with an MDT trained clinician, I didn’t feel that bringing him into the clinic was going to be productive, so I followed by phone.

After two weeks, which is how long it is expected to see results if given the right direction and load, he was able to return to bed without waking.

This patient returned to therapy for a different issue a year later and we had a conversation about his back (he was seeing a different therapist). His strength recovered and he didn’t require surgery.

Moral of the story:

1. Sometimes you have to think outside of the box

2. Don’t let the image dictate treatment

3. Only treat the patient if we can improve their lot in life

4. Always develop a relationship with the patient you are treating.

Hip impingement? Is there a place for PT?

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Hip impingement? Is there a place for PT?

“surgical rates for correction of FAI have escalated, despite limited evidence to support a cause – and – affect relationship between FAI and hip pain.”

It is said that there is an 18X increase in procedures over the decade Studied.

The fact that this surgery has increased at such a dramatic rate may be a result of who the patient sees for the problem.

Physical Therapists do physical therapy.

Surgeons do surgery.

Pain management do management of pain through chemical means.

Chiropractors do chiropractic medicine.

Acupuncturists do acupuncture.

It’s a very easy equation to figure out. Who you see to manage your symptoms will dictate what is done for your symptoms.

“… The evidence from these studies is mostly level four (low level), the reported results are short term, and at least one studies suggest a notably lower level of sport activity at three years surgery. Currently, there are no high – quality randomized studies examining the effectiveness of surgery for FAI”

This makes it difficult to make a broad statement due to the lack of controlled research. For instance, a sham surgery (a surgery in which the patient is cut, but nothing else is done) compared to an actual surgery would start to give us information on the value of the surgery.

Looks like the study is in the process of being Completed.

I personally like case studies and case reports because sometimes a “classic study”, such as a randomized controlled study, may not capture the characteristics of the patient in front of the health care professional.

“75% of surgeons believe that FAI surgery prevent future osteoarthritis, although 62% of the surgeons were either unsure of or did not believe there was an optimal debridement of SAI lesions to prevent future osteoarthritis”

A belief plus 5 dollars will buy a coffee at Starbucks.

Not a fan of these types of studies because it demonstrates the bias of the profession. The shocking statistic is the reverse. The fact that 25% of surgeons don’t believe that surgery prevents future OA is cool. Unfortunately, we don’t know the education level, outside of the fact that the people polled were surgeons, of each person in the poll. For instance, if it’s the best of the bell curve that believe surgery has no effect on OA, then I may side with that opinion. We just have to think critically when reading these numbers.

“… The fact that 34% of both pediatric and adult patients diagnosed with FBI stated that they I knew they wanted FAI surgery (21% not willing to try conservative therapy for six months) suggest that orthopedic/sports patient has a propensity for overconfidence in surgery as the gold standard treatment.”

We are all salespeople for our profession.

Don’t believe me…just check out how many people are selling PTs education on Sales tactics and marketing.

It seems that surgeons are doing a great job of sales in that 1 in 3 believe that surgery is the answer.

As PTs, many of us are learning how our language affects the patient, both positive and negative.

It would be easy for me to convince a patient that they are weak and need us, but I don’t know if that is doing more of a service or disservice st that point.

“We think we could all benefit from learning from our past, when, despite similar increased endorsement of surgical intervention (746% increase in shoulder arthroscopy for impingement over a ten-year span), surgical patients fared no better than those treated conservatively.”

Yup.

Another way to say conservative = non surgical.

I’m going to leave this final quote from the article as the final statement. 👇

“Stop accepting morphology as pathology”

Link to the article

Plantar Fasciitis and Ultrasound: questionable at best

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Plantar Fasciitis and Ultrasound: questionable at best

“The plantarfascia is a thick, nonelastic, multilayered connective tissue crossing the plantar part of the foot. Plantar fasciitis is the main cause of pain in the plantar surface of the heel.”

The plantarfascia is located at the bottom of the foot, between the heel and the toes.   It is very thick and a tough band.

A part of physical therapy school includes dissecting the human body.  Some people find this disgusting, but it is actually an honor.  We were told that only 5% of college students will ever be able to dissect the human.  The bottom of the foot is very intricate. There are multiple layers of muscles, but the plantar fascia is a very taut band that requires a scalpel in order to tear.  In other words, it is very strong tissue.

“In the United States, more than 2 million people are treated for plantar fasciitis every year…the most common signs for identifying plantar fasciitis are pain and tenderness in the medial …heel bone, as well as an increase in pain when taking first steps in the morning and pain in prolonged weight bearing.”

First, plantar fasciitis is mostly diagnosed through a patient’s history.

Second, there are a lot of people with plantar fasciitis that seek out treatment.

This leads us to the next statement from the article

“…researchers have not determined the most effective combination of treatments due to the dearth of high quality research in this area.”

Feel good about this condition yet? So many treatment options are available, but few with solid research to back them up.

If you are interested in learning more, check out this  Link

“One of the most widely used electrical devices among physical therapists in Israel and worldwide is therapeutic ultrasound…Yet there is insufficient high quality scientific evidence to support the clinical use of therapeutic ultrasound in treating musculoskeletal problems.”

I find it funny that PT’s should know this information and yet they act opposite of what the evidence indicates.  There are running jokes that using ultrasound may be just as effective turned off as when turned on.

If your PT continues to utilize ultrasound, ask why?

Sometimes the answer may simply be: it is easy, it can be charged and it will do no harm.

Treatment:

Both groups were given stretches for the Achilles/calf and the plantar fascia.  One group was issued ultrasound at a higher intensity in order to create a thermal effect and the other group was given ultrasound that was low intensity and not postulated to have any physiological effect, as the intensity was low and the depth of treatment was considered more superficial.

There was no significant difference in the number of treatments per group.

Result: There was no additive effect of ultrasound on the treatment of plantar fasciitis for pain, function or quality of life.

There are reasons to use ultrasound from a business perspective, but the more and more that I read research I find fewer reasons to perform the intervention medically.

Reference:

Yigal K, Haidukov M, Berland OM et al. Additive Effect of Therapeutic Ultrasound in the Treatment of Plantar Fasciitis: A Randomized Controlled Trial. J Orthop Sports Phys. 2018;48(11):847-855.

Second opinion

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Second opinion

How many people will choose to get a second opinion before going in for a major surgery?

I would hope đź’Ż%!

I had an awesome conversation about 10 years ago when I was visiting Canada. There was a guy that traveled to Canada in order to get an opinion regarding back surgery. He was from San Diego. That’s a pretty far trip to see if he needs back surgery.

I asked him why travel that far for an opinion and he said that he wanted to reduce any bias on the doctor’s part regarding whether he was a candidate. For instance, the doctor in Canada would not be performing the surgery and it was unlikely that the doctor giving the opinion would be able to benefit from recommending surgery, since the patient would have surgery in California.

He avoided going for the opinion in California because the hospital system would profit from the surgery. The surgeon may have an arrangement with the hospital to ensure that the hospital gets a percentage of the money. We know that the hospital will make money during a surgery. Many people stand to profit from a surgery and the patient would do well to get an opinion from someone that doesn’t stand to benefit.

This brings me to my rant for now. 👇

Why don’t patients get a second opinion regarding physical therapy?

1. It’s not a huge expense

Physical therapy, on average will cost the insurance company about $1200 per episode of care. If the patient is paying 20% for the coinsurance, then it will only cost the patient $240/episode. This works out to about $50/week.

That’s relatively inexpensive compared to a large surgery. The question is: why not spend an extra $25 to see if a second therapist agrees with the first? If there is a disagreement in how treatment should be performed, then the cost may not be the chief factor.

This leads us to 👇

2. All therapists do the same thing

Not all PTs are trained the same! Don’t let a non-PT (such as surgeon or family doctor) tell you that it’s all alike.

Not all surgeons have the same reputation and skills. Not all PTs have the same reputation and skills. The only way that you, as a patient, will know about other’s skills and reputation is to ask and try.

If you are absolutely in love with your PT or MD, then so be it. Sing from the rooftops so that the reputation gets built. If you’re not…try someone different.

Sometimes the grass IS greener.

3. Convenience

I get it. A drive around the corner is much easier than a drive for an hour. It makes sense.

If we believe that not all therapists have the same training or passion for treating a specific issue, then we must also believe that these therapists are worth the drive.

Follow this example:

1. Patient A decided to go to a therapist close to home or work (we know that regarding gyms most people won’t drive more than 15 minutes from work/home). The therapy session costs the patient $240 out of pocket and the insurance pays $1000.

Let’s also say that the patient is being seen for low back pain or sciatica, since this is the number one reason to seek PT. The patient is seen in a clinic in which the therapist is there to punch a clock and see as many patients as possible because that’s how đź’° is made.

The patient doesn’t get much better and then returns to the doctor for a series of shots (more money and time). The shots are a 50/50 chance of working.

Half of the patients will then still have pain and now be shuffled to the next step, either pain management or surgical consult.

2. Patient B spent a little time to search for the therapist in a 20 mile area that best treats low back pain or sciatica. The patient makes an extra 20 minute drive. The therapist decides that the patient would ben for from 8 visits of PT over 6 weeks and the patient gets better because the therapist enjoys the job and works well with patients having this diagnosis.

The patient made a little more of an effort up front, but saved 💵 and ⏳ by choosing the right therapist instead of moving further along in the medical system.

Want a second opinion, send me a message.

Physio and whiplash

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Physio and whiplash

“Whiplash-associated disorders (WAD) is the term given to the variety of symptoms often reported by people following acceleration/deceleration injury to the neck.”

Most people understand the term whiplash is related to an auto accident. After the basics, everything else is like the teacher from the Charlie Brown An acceleration/deceleration injury is exactly what it sounds like.  I’m sure that if you have an older sibling you understand this concept.  My friends, I won’t say any names (Tom and Carl) used to brake abruptly to see if they could get someone to spill their drink.  It’s kind of like that, only more forceful.

When the car comes to an abrupt stop, the body will continue forward thanks to the laws of inertia.  It will typically be stopped by a seatbelt.  Some though, may be stopped by a windshield.

“Cardinal symptom is neck pain but neck stiffness, dizziness, paresthesia/anesthesia in the upper quadrant, headache and arm pain are also commonly reported.”

I have seen a plethora of patients after a motor vehicle accident (MVA).  Neck pain and stiffness seem to be the most common complaint anecdotally, but I have also seen the headache and arm symptoms.

Part of the problem with such diffuse symptoms is that not every professional will treat the patient, but instead will treat the situation.  This means that when a patient presents with symptoms that may not make sense, the professional then inserts individual bias and believes that the patient must be making up the symptoms.  I have seen this over the years in which the PT/PTA/PA/MD believe that the patient is FOS (not a medical abbreviation).  Be that the case, it is still our job to try to help that patient.  If the patient is exaggerating symptoms, we still have to sift through the exaggerations in order to determine what is organic (with a physical cause) and what is non-organic (without physical cause).

“…whiplash injuries comprise (about) 75% of all survivable road traffic crash injuries.”

Just this year I was involved in two MVA’s.  Neither of which were my fault.  As an aside, I have never met anyone that said an accident was his/her fault, in the clinic at least.  Luckily, both MVA’s that I was involved the other person admitted fault immediately.  The first accident involved me T-boning another car doing 45 mph (someone tried making a U-turn on a 4 lane highway). I experienced shock during the first accident and it took me a while to calm down.  I had back pain and neck pain, but as a professional, I knew that it would subside on its own.  This is exactly what happened, over the course of a month.  The best thing that I did was return to lifting and normal activities.  The second accident involved me being rear-ended with the other person going 40-45 mph.  Again, I had some back and neck pain.

Body heal thyself.  Father time is a powerful motivator and I was back to 100% within a couple of months.

“Consistent with international data indicate that approximately 50% of people who sustain a whiplash injury will not recover but will continue to report ongoing pain and disability one year after the injury”

There are so many variables that go into a person experiencing chronic pain.  Extent of tissue damage is not the only variable that needs to be assessed.  Sometimes people just feel wronged by life and this stress of life may contribute to symptoms.

We know that most tissue damage heals relatively quickly (at least quickly when relative to a lifespan).

“…recovery, if it occurs, takes place within the first 2-3 months following the injury with a plateau in recovery following this time point”

We know that most healing takes place over the course of weeks to months.  With this, we have to question the cause of this roadblock to recovery.  Is it truly tissue damage or is there something else at play?

“…good recovery, where initial levels of pain-related disability were mild to moderate and recovery was good, with 45% of people predicted to follow this pathway”

Glass half empty/Glass half full?

About half of the people with WAD will experience a good outcome.  Considering that not much has to be done with this group, I can see some healthcare providers taking responsibility for good outcomes.  I used to work for a clinic that tried to get people into the clinic as fast as possible with the idea being that if we don’t get the patient in fast enough, then the patient may get better on his/her own.

Think about that? We know that most things get better with time, so we want the patient to believe that it was us and our treatment that helped them the most.  As much as I can see this from a marketing perspective, from a global health perspective…it just ain’t right.

Sometimes the patients just need some advice to stay active and come back in 4-6 weeks if there is no change in symptoms.

I was in a course once talking to a PT and I asked that therapist, who also happened to be a business owner: “how do you know that you have had a successful episode of care?”

That therapist’s answer was: “The insurance has been exhausted”

Whether the therapist was joking or not, the fact that this perception is out there that the patient should be bled dry (at least monetarily) is disturbing.

Remember this when you are working in a clinic (if you’re a healthcare professional) or when you are going to see your healthcare professional.

“…initial moderate to severe pain-related disability, with some recovery but with disability levels remaining moderate at 12 months. Around 39% of injured people are predicted to follow this pathway.”

Now we are starting to play.  I use this term “play” as a measure of patient severity.  For instance, when playing basketball with my 4-year old, it’s not really playing the game as much as it is just toying around.  When playing the game against someone that I have never beaten before, I have to study the player, understand the player’s moves, his/her strengths and weaknesses, tendencies when under pressure, establish my game plan against their moves etc.  This is how I perceive a patient and symptoms when they enter the clinic.  I am studying that patient and the symptoms in order to best understand what that patient is experiencing.

I believe that only through understanding the tendencies of the symptoms are we truly able to help/assist the patient in this journey to reduce pain and return to full function.

“…involves initial severe pain-related disability and some recovery to moderate or severe disability, with 16% of individuals predicted to follow this pathway”

I love listening to this guy. He has a way of explaining severity of pain that is just not taught in most healthcare programs.  Understanding that pain is an experience is more important for the healthcare providers, because without this understanding, we can not explain this phenomenon to the patient.

“The most consistent risk factors for poor recovery are initially higher levels of reported pain and initially higher levels of disability.”

With this, the thought exists that we may be able to affect recovery with WAD if we can simply reduce pain.  We may be able to reduce pain in some populations through education.

Maybe we should attempt to use education as a means to reduce pain before we try other interventions such as heat, cold, manual therapy, etc.

It may go something like this:

Therapist: You know Mr. Smith, I have done my evaluation and there is some good news; you’re going to get better.

Mr. Smith: How do you know?

Therapist: There was nothing in my exam that showed that there was any major structural damage and we know that tissue injuries tend to improve on their own over the course of weeks to months.

Mr. Smith: That is good news!

“lower expectations of recovery have been shown to predict poor recovery”

This may be the factor that healthcare professionals should focus time trying to change.  As much as we speak to patients about tissue damage and injuries, we need to spend time in conversation understanding what they believe the barriers are to a successful recovery.

Taking the extra 10 minutes per session to have these conversations and together problem-solving ways to overcome these barriers may be more important than an extra 2 minutes on an arm bike or an extra set of banded rows etc.

Patients are people first and foremost and not a sum of body parts.  Breaking through perceived barriers is an important first step to providing the right interventions to patients.  Sometimes the intervention is only education and other times it may be more integrative of exercise, manual therapy and other modalities at our disposal.

“Some factors commonly assessed by physiotherapists do not show prognostic capacity. These factors include measures of motor and sensorimotor function such as the craniocervical flexion test, joint repositioning errors and balance loss”

We all learn tests and measures in school.  A great world would be inclusive of tests that actually mean something.  Testing balance and strength and positional awareness are all good tests to take time and give information to physicians or insurance companies, but in the end they don’t actually do much to tell the story of the patient.

We need to identify patients that will respond to therapy and those that may need for than just PT.  With that said, we also need to be able to identify those patients that will get better on their own.  Not all patients need to see a physical therapists, we just don’t have a way of telling one subset from another at this time.

“The QTF classification of whiplash injuries was put forward in 1995 and it remains the classification method still currently used throughout the world”

This is the Quebec Task Force Classification:

I No neck complaints and no physical signs
II Neck complaints of pain, stiffness or tenderness only and no physical signs
III Neck complaints and MS signs including 1. Decreased ROM 2. Point tenderness
IV Neck complaints and Neuro signs including: 1. Decreased or absent DTR 2. Muscle weakness 3. Sensory deficits
V Neck complaint and fracture or dislocation

“Current clinical guidelines for the management of acute WAD recommend that radiological imaging be undertaken only to detect WAD grade IV and that clinicians adhere to the Canadian C-Spine rule when making the decision to refer the patient for radiographic examination”

For those that are unfamiliar with, or forgot, the C-Spine rules (including myself), here is the link.

“…the same general examination procedures usually adopted for the examination of any cervical spine condition but with some additional procedures based on research findings of WAD”

When a patient presents to therapy, with complaints of neck pain, after a motor vehicle accident here are some things that a patient can expect (if you are a PT, then these are the things that we should be doing as an at least)

  1. Range of motion using a large compass
  2. Assessing strength in the arms/neck
  3. Assessing any loss of sensation
  4. Assessing loss of reflexes
  5. Assessing grip strength
  6. Assessing patient perception of symptoms using an outcome meaure
  7. Assessing joint integrity using special tests and symptom change
  8. Assessing nerve irritability

“…many patients with WAD will report diffuse symptoms of sensory loss or gain and generalised muscle weakness, both of which may be bilateral, but these findings do not necessarily indicate peripheral nerve compromise and may be a reflection of altered central nociceptive processes.”

Some clinicians think that if a symptom doesn’t match what was learned in school that the symptom must be made up.  We’ve all been around these clinicians that believe that patients must be “faking”, “malingering” or just out for the $$$ after an accident.

Truth is that we have no reliable way to tell if a patient is “faking”.  We may be able to tell if a patient is providing full effort during our examinations, but we can’t know anything beyond this.

The first thing that we need to understand is that the nervous system is complex.  Now, when I see a patient that reports increased sensitivity in an area, I report it as such.  Previously I would report a decreased sensation in the opposite side tested.  I didn’t understand, at that time, that a person could experience hypersensitivity in an area.

“…strong evidence for the presence of augmented central nervous system processing of nociception in chronic WAD and moderate evidence that cold hyperalgesia is associated with poor recovery from the injury”

The nervous system appears to be boss. When it is experiencing stress, it can drastically change how the person perceived different stimulus. I recently had a patient that was so sensitive that she noted her pain increased with the breeze from a ceiling fan.

Think of a car alarm set to really sensitive. We all have seen a car alarm that goes off from a sideways glance. This appears to be happening with the nervous system. The system has difficulty processing what is a real threat to the system and what is a normal stimulus.

Patients that have difficulty tolerating cold appear to have a heightened car alarm, which may indicate a poor overall recovery.

“The clinical course of WAD, where most recovery occurs in the first 2-3 months”

In my opinion there are too many of us in healthcare with big egos. We tend to use this basic rationale:

Patient got better. Patient was in physical therapy during this time of improvement. Physical therapy must be the reason the patient got better. 🤔

This type of logic is unfortunately mislead.

Other variables, such as time may have a role more so than the interventions performed during this time.

“The mainstay of management for acute WAD is the provision of advice encouraging return to usual activity and exercise, and this apprpach is advocated in current clinical guidelines.”

ADVICE!? That’s the mainstay?!

Not ultrasound?!

Not massage?!

Not electrical stimulation?!

How can this be?!

Body heal thyself. 💪🏼👊

“…recent systematic reviews concluding that there is only modest evidence available supporting activity/exercise for acute WAD. It is not clear which type of exercise is more effective or if specific exercise is more effective than general activty of merely advice to remain active.”

The 🥖 and butter of PT may or may not be affective for treating patients immediately post accident.

Lately, I have been seeing many of these patients and there is much education that goes into time based healing on the first few visits.

“…six sessions of physiotherapy was only slightly more effective than a single session of advice from a physiotherapist”

As much as it pains the many wallets of our profession, I definitely agree with this. Some patients that I have seen actually get some relief just from knowing the clinical expectations post WAD.

“…a graded functional exercise approach and advice demonstrated greater improvements in pain intensity, pain bothersomeness and functional ability, compared to advice alone.”

Think of those six sessions from above.  A traditional clinic may use 6 sessions in 2 weeks.  A clinic that understands the research may use those visits over the course of 6-8 weeks.

A graded functional exercise approach means that the patient is slowly performing more work load over the course of time in order to improve function.  This time period is probably no less than 6 weeks since we know that we see significant changes in strength and movement ability over the course of 6 weeks.

“…the recommendation to clinicians is that health outcomes should be monitored and treatment continued only when there is clear improvement.”

It’s unfortunate that this has to be said.  I have seen some patients treated in a clinic for months without appreciable improvements.  At some point, we have to do what is in the best interest for the patient first and foremost.  Having a patient continue to come into the clinic, in the absence of improvement, is a red flag that there may be something else causing symptoms.  Also, continuing to treat a patient may do more harm than good because the patient takes on attributes of a “sick” person.

It’s a case in which the medical system may actually cause problems through the use of treatments and information.  This type of change in the patient has been labeled as iatrogenic (caused by the medical system).

“Analysis revealed no significant differences in frequency of recovery between pragmatic (medication/physiotherapy/CBT) and usual-care groups at 6 months. There was no improvement in non-recovery rates at 6 months, indicating no advantage of the early interdisciplinary intervention.”

I read previously (I’ll have to go back and look for the article) that early aggressive therapy may actually increase symptoms of patients after a motor vehicle accident.

“Education and advice to return to activity and exercise will still remain the cornerstones of early treatment for WAD”

This year I was rear ended on the highway and T boned on another highway.

Excerpts from:

Sterling M. Physiotherapy Management of Whiplash-Associated Disorders (WAD). Journal of Physiotherapy. 2014;60:5-12.