Advertisements

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

Advertisements

Reflections from “The Alchemist” Part II

“Everyone seems to have a clear idea of how other people should lead their lives, but none about his or her own.”

Are you happy?

Do you love your profession?

Are you satisfied with the time you spend with your family?

Matthew 7:5

You hypocrite, first take the log out of your own eye, and then you will see clearly to take the speck out of your brother’s eye.

This is the first passage that comes to mind when I think of the above quote.

I’ve met many people in my life say I should’ve been a lawyer, I should’ve gone to medical school, I should’ve done this or that. A wise dumpster diver, turned scholar, turned flight attendant by the name of John Patrick Luby III used to say “Never should (shit) on yourself!”

All that really matters is that I’m happy in life and content with where I’m at as a professional. When I introduce myself and people say what do you do you I said I do physical therapy. I rarely say that I’m a physical therapist.

As much as I do for the profession and within the profession, I never want the profession to define me. I am a father. I am a husband. I am a son. I am my own person.

Lately, I have been spending time counseling others on clear pass. I try my best to stay unbiased and to not give my opinion as much as I try to receive answers and ask questions to those that are looking for their careers. I do my best to give an objective opinion regarding finances, regarding passions, regarding job stability, job, but most importantly happiness.

It’s not my job, nor my want, to try to push someone into a direction. I personally feel it’s my responsibility to help those that are seeking assistance in finding their own career path I never do this by pushing them in a direction, but instead help them to see where their passions may lie.

I’ve met many people that are dissatisfied with how their life is playing out, but what they fail to see is that it’s now until they’re no longer living, they are free to make choices to affect the outcome going to change their future is the president. Their past Cano want to change it, but the choices they make today will affect the outcome as of tonight and tomorrow. I making different choices they can choose to take a different path in life, but many have difficulties making those decisions. There are outside forces that may hold people in certain positions in life, such as golden handcuffs, family responsibilities, stature and such.

Ultimately, it is not my job to direct others, not other’s job to direct me.

Patients with Medicare using PT

“Services were required because the individual needed therapy services”

For a person to need therapy services, they must have a plan of care certified as necessary by a physician or other referring professional.

“A plan for furnishing such services has been established by a physician/NPP or by a therapist providing such services and is Eperiodically reviewed by a physician/NPP”

A PT is allowed to establish a plan of care for patients, but the insurance doesn’t necessarily have to pay for it. In order for Medicare to pay for a plan of care that is established by a physical therapist, a physician or other referring provider must sign off on that plan of care.

“Services are or were furnished while the individual is or was under the care of a physician…In certifying an outpatient plan of care for therapy a physician/NPP is certifying that the above conditions are met. Certification is required for coverage and payment of a therapy claim.”

If a physician/NPP provides a referral at the time of evaluation, this ensures that the patient was under the care of a referral source at the time of the evaluation. This becomes important because there are patients that will wait to start therapy for months or years after a referral was issued. There is not guarantee that the referral source will certify the POC at this later date. If this POC is not certified, then the treatment will not be covered by Medicare.

“Claims submitted for outpatient PT, OT, and SLP services must contain the National Provider (NPI) of the certifying physician identified for a PT, OT, and SLP plan of care”

Although this is a technicality, this may cause a denial of payment if the NPI number, of the referring professional, is not included on claims.

“Although there is no Medicare requirement for an order, when documented in the medical record, an order provided evidence that the patient both needs therapy services and is under the care of a physician. The certification requirements are met when the physician certifies the plan of care”

Again, this needs to be reiterated over and and over, the patient needs to be under the care of a physician when in physical therapy. The referral can serve to show that the patient was under the care of a physician at the time of the initial evaluation. In the end, the only thing that matters is that the physician/NPP signs off on the plan of care established by the PT.

“Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan”

Have you had enough of this yet.

Do you think that there is a reason this is spelled out so frequently in the documentation?

Some don’t follow the rules of the game.

“The services must relate relate directly and specifically to a written treatment plan as described…must be established before treatment is begun…written or dictated.”

We all know that a plan is required.

Some don’t know how to write frequency and duration.

Some don’t know how to write interventions, or some perform interventions not written.

They must be written and signed off on in order to perform.

“The signature and professional identity of the person who established the plan, and date it was established must be recorded with the plan”

No brainer…or is it?

Stamped signatures are not signatures according to CMS, and stamps are not approved.

“Outpatient therapy services shall be furnished under a plan established by:

A physician/NPP

The physical therapist who will provide the physical therapy services”

This is critical. A therapist doesn’t need to have a POC signed if the physician/NPP creates the plan and it is abided by the PT verbatim.

Also, the PT doesn’t need to be licensed if practicing under a physician.

“The plan may be entered into the patient’s therapy record either by the person who established the plan or by the provider’s or supplier’s staff when they make a written record of that person’s oral orders before treatment is begun.”

This is a formality, but it has to do with dictating a note. Treatment can not be started by anyone other than the PT or immediately supervised by the PT that created the plan, before it is entered into record.

“The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits.”

I tend to do one billable unit on the days of an evaluation. This is based on how much time you spend with the patient covering an intervention, or if an untamed intervention is performed.

“Therapy may be initiated by qualified professionals or qualified personnel based on a dictated plan. Treatment may begin before the plan is committed to writing only if the treatment is performed or supervised by the same clinician who established the plan”

This means that the PT or PTA can start treatment on the initial visit. The PT must be in the office supervising the PTA at this point.

Some people, like Anthony Maritato, use this method to establish a relationship between the treating therapist and the patient.

Others, like Rick Gawenda, find this to be a less efficient use of time.

“It is acceptable to treat under two separate plans of care when different physicians/NPP refer a patient for different conditions. It is also acceptable to combine the plans of care into one plan covering both conditions if one or the other referring physician/NPP is willing to certify the plan for both conditions”

I’ve seen some clinic totally prefer to treat the patient 2x/week for one ailment and 2x/week for another ailment.

Take a guess why…it sure ain’t for the patient’s benefit.

Medicare limits how many units can be charged in a session (essentially how much money can be paid in a session). If there is a way around this, you can bet that money hungry clinics will find this workaround.

“The plan of care shall contain, at minimum, the following information as required by regulation:

Diagnosis

Long term goals

Type amount and frequency of therapy services”

The evaluation doesn’t need much. It would be great if it established medical necessity, but is it required…NOPE!

The diagnosis can either be ICD codes or the written diagnosis since it is not spelled out.

“Long term treatment goals should be developed for the entire episode of care in the current setting”

This is something new to many therapists. Medicare doesn’t specifically require short term goals. If they are not required, do they need to be done? In school it is taught to set short term goals as a step towards the long term goal. In reality, every minute counts. The time spent creating and typing short term goals could be used elsewhere. Creating short term goals is literally robbing Peter to pay Paul, but Paul doesn’t need the money.

“…long term goals may be specific to the part of the episode that is being certified. Goals should be measurable and pertain to identified functional impairments”

Goals should be measurable and timely. They should relate to function. There is a lot of grey area in this portion. Subjective measurements are not the most reliable and maybe shouldn’t be used in goal writing.

I see frequently “to increase hip abduction strength to 4/5”

This goal is measurable, albeit loosely and has no tie to function.

I personally like to use outcome measures and specific functional testing in my goal writing. For instance, the patient will improve the (TUG, Tinetti, Berg, chair rise, single leg stance, lower/upper extremity functional scale, yellow flag risk form) in order to …

“…documentation should state the clinical reasons progress cannot be shown”

This is built into many EMRs now.

Sometimes I will write that the symptoms are not reducible through movement or modulation. Other times, I will write that the patient is not consistent with the HEP. Sometimes, it’s that it is a maintenance case and the patient is unsafe to perform exercises with an untrained professional due to fall risk, BP fluctuations or rapidly changing SpO2.

This is where it really pays off to have read some of the textbooks that were recommended in PT school. I particularly recommend the ACSM handbook.

“The amount of treatment refers to the number of times in a day the type of treatment will be provide…one treatment session a day is assumed”

In an outpatient setting, this is typically one. In an acute or subacute setting it may be BID (twice in a day) or even TID (thrice in a day).

“The frequency refers to the number of times in a week the type of treatment is provided”

I struggle with this one. Many therapists are putting 3 times per week for 4 weeks on all their plans. This isn’t being done because they believe it’s what is best for the patient, but because there is a corporate policy to get as many visits in per week as able.

I get frustrated with this type of plan. If you are a therapist and working in this setting, but only putting this plan down to keep from rocking the boat…you are abusing Medicare and should call CMS to report this activity.

Please and thank you.

“The duration is the number of weeks, or the number of treatment sessions, for THIS plan of care.”

This question is asked frequently. I will typically put down the number of weeks if I know that the surgeon only wants so many weeks of PT per a protocol. If it is not protocol based, the. I will typically put down the total number of visits expected for the episode.

Many of my patients (>80%) require an authorization and are typically given 12 visits to start. In this case, I will make the plan for 12 visits or 90 days, whichever comes sooner. I know that I have to do a progress note and get a recertification and ask for more visits at this time anyways.

“It may be appropriate for therapists to taper the frequency of visits as the patient progresses toward and independent or caregiver assisted self-management program with the intent of improving outcomes and limiting treatment time.”

Again, I frequently get 12 visits to start. I try to make these visits as worthwhile for the patient as possible. For some cases I will see 3 times per week, but for many I will see 1 visit per week or 2 per 10 days. This way we are able to see the patient for the timeline of change that is expected. For instance, strength usually occurs in the first 6 weeks due to neuromuscular changes and hypertrophy happens after this timeframe. If we are seeing the patient for 12 visits in 4 weeks, then we may have exhausted the benefits before noting the change.

To me, that is a waste. Many patients agree with me on this because we make the POC together based on their finances (copays need to be paid each day regardless of how many times you are seen per week), work schedules and need/expectation to change over a given time period.

Again…PTs, if you don’t have this autonomy to create your own Plan of Care, are you truly an autonomous practitioner or are you simply a technician that is doing what a higher figure is telling you to do?

“When tapered frequency is planned, the exact Number of treatments per frequency level is not required to be projected in the plan, because the changes should be made based on assessment of daily progress”

This is one of the aspects that I take advantage of in the plan. At this point, I will write 12 visits over 12 weeks or 12 visits over 6 weeks. This way I may start at 3 visits and taper down to one visit per week.

“The clinician should consider any comorbidities, tissue healing, the ability of the patient and/or caregiver to do more independent self-management as treatment progresses, and any other factors related to frequency and duration of treatment”

I had a patient that hadn’t walked in years. The person had fluctuating blood pressures with activity and at times therapy was halted due to elevated BP. This patient was not safe to perform gait training independently due to fall risk and intermittent cardiac crises. This patient was treated 1-2 times per week with gait training and performed a Nu Step at home. The interventions that were skilled were performed in the clinic and the unskilled interventions were issued for HEP.

“…optional elements: short term goals, goals and duration for the current episode of care, specific treatment interventions, procedures, modalities or techniques and the amount of each.”

As much as this says “optional”, I’m not sure it is fully optional. For instance, this report notes that a therapist did not have the type of intervention in his POC as one of many reasons for repayment.

“Changes to procedures and modalities do not require physician signature when they represent adjustments to the plan that result from a normal progression in the patient’s disease or condition or adjustments to the plan due to the lack of expected response unchanged. Only when the patient’s condition changes significantly, making revision of term goals necessary, is a physician/NPP’s signature required on the change.”

For me personally, when there is a major change in status that requires a change in goals and expectations, I phone the physician and alert the medical team to the change in status. I feel that it is important to relay this information to the physician personally, in addition to writing a progress note or re-evaluation.

“Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care… The date of the certification is signed is important to determine if it is timely or delayed”

This small detail is important. Although the physician may sign it, it also must be dated. I’ve had to send many evaluations back for a date.

“The physician/NPP’s certification of the plan satisfies all of the certification requirements noted above in (section) 220.1 for the duration of the plan of care, or 90 calendar days from the date of the initial evaluation, whichever is less.”

This is where things get confusing. If you set your plan for 90 days, then everything is good and no confusion.

If you set your plan for 6 weeks, then you would need to get another certification past 6 weeks.

I’ve seen some therapists just write the plan for 90 days on each evaluation in order to check the 90 day box. Don’t be that person. Put thought into your plan and don’t just set up your plan for 90 days because it’s the maximal allowable in one episode.

My duration varies from 4 weeks for acute back pain, 6 weeks for vestibular dizziness up to 12 weeks for neurological disorders. The only downside of doing this is that there is paperwork more frequently. The upside is that it forces a reassessment, which indicates whether or not a patient is responding to care.

“…the physician/NPP shall certify the initial plan as soon as it is obtained, or within 30 days of the initial therapy treatment.”

At my clinic, we have a spreadsheet that has the evaluation name, date and signature (yes/no). Once the signature is obtained, the name is removed from the spreadsheet.

Also, when discharging a chart we have a checklist of items that are expected to be in the chart. The signed evaluation is one of these items on the checklist.

“Evidence of diligence in providing the plan to the physician may be considered by the Medicare contractor during review in the event of a delayed certification”

Again, this is more of a standard operating procedure. When a note is faxed to a physician, the fax cover letter becomes a part of the record. This is done to demonstrate that due diligence was performed in attempting to get a note signed.

“Payment and coverage conditions require that the plan must be reviewed, as often as necessary but at least whenever it is certified or re-certified to complete the certification requirements. It is not required that the same physician/NPP who participated initially in recommending and planning the patient care certify and/or re-certify the plans”

This is also an opportunity for PTs. If a patient has a better relationship with the PCP compared to the orthopedic surgeon, it may be prudent to have the patient get the PCP to sign off on the recertification.

“If the physician wishes to restrict the patient’s treatment beyond a certain date when a visit is required, the physician should certify a plan only until the date of the visit.”

The evaluation template that we use from Theraoffice provides an area for the physician to change the plan if deemed appropriate.

“Certifications and recertification’s by Doctors of podiatric medicine must be consistent with the scope of the professional services provided by a doctor of podiatric medicine as authorized by applicable state law… Chiropractors may not certify or recertify plans of care for therapy services.”

This is huge. For instance, a podiatrist physician is only allowed to write a referral for their scope of practice. Seeing a patient from a podiatrist for an ailment that is outside of the scope of practice may result in a sticky situation, like Seinfeld encountered.

Also, Chiropractic physicians are not allowed to certify plans of care for PT. This applies to Medicare. You must be aware of the patient’s insurance in order to determine if other insurances have the same regulations.

“… The provider is precluded from charging the beneficiary for services denied as a result of missing certification”

This means that the provider or company that the provider work for will hound the physician’s office to get the evaluation or progress report signed. Otherwise, the amount paid was not approved to be performed.

The clinics are not allowed to charge the patient due to a lack of certification.

This is not meant to be legal advice, as this is my take on the Important passages from This manual regarding our profession.

If in need of more information on Medicare compliance, check out Nancy Beckley or Rick Gawenda

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

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.

Life purpose and changes

“If you want to change the world, you have to enroll others in your plans and vision.”

Adam Robinson

About 2 years ago I started a blog. It was just for fun and the premise behind the blog is this “the only knowledge wasted is the knowledge not shared”. I saw this quote on a t-shirt; a blog was born.

My goal is to provide high quality content to readers through this blog in order to assist them with making decisions regarding choosing a health care practitioner. The secondary goal is to educate physical therapists at least up to the point of at patients. It sounds cynical that I believe that some patients have more knowledge than the PT, but I also believe that the patient has more to lose and more at stake than the PT.

The PT only has a paycheck at stake, maybe a reputation. The patient has life limitations and issues that may prevent them from truly experiencing life. That way more at stake than the PT has on the line. In this fashion, I have seen patients becoming smarter over the years through forums, FB groups, reading blogs and watching videos.

The reason why I say high quality content is because there are a lot of lies and misinformation on the World Wide Web (internet). Healthcare professionals prey on the weak and ignorant to take their money using scare tactics and unrealistic hype.

I ain’t got nothing to sell you other than making you a better human through work. Nothing ventured, nothing gained.

I have increasing demands on my time with a family, managing multiple clinics, treating patients and community involvement.

My posts will become fewer and fewer as I try to fit them into my life instead of fitting my life around my work.

Love your life or change it

Dr. Vince Gutierrez, PT

ACL rehab

“At 13 months post ACLR (Anterior Cruciate Ligament Reconstruction), individuals exhibited average knee extensor moments that were 17% smaller in the surgical limb during a bilateral squat against body-weight resistance”

ACL injuries tend to be noted in some non-contact sports such as soccer and basketball. Contact sports, such as football, also have ACL tears noted during contact, such as a tackle that makes the knee buckle inwards.

The patient with an ACL tear will typically opt for surgery if he/she plans on returning to some type of sporting activity. There is a debate as to whether or not to have the surgery if there will be no return to sporting activity.

After the ACL surgery, the research above notes that patients are less likely to use the surgical side during a squatting activity (think getting up from the toilet) and will push more with the non-surgical side.

This makes sense to me. After the surgery, the patient is in a locked long leg brace and is unable to move fluidly on the affected leg. The patient will not spend as much time on the surgical leg because of this and will transfer the weight to the non-surgical side. It becomes a learned habit to transfer the weight to the non-surgical side, but this is just my opinion.

 

“The persistence of under-loading is concerning, as asymmetrical limb loading during landing tasks has been linked to increased risk for anterior cruciate ligament (ACL) reinjury”

This is important! If we never get the patient to load the leg in order to improve strength and motor control (ability move in the way that the brain dictates), then the patient is at a higher risk of future injuries.

Let me clarify: if you squat and allow your legs to go wet noodle during the squat, it will look like a knocked-kneed version of a squat. This is not inherently horrible, but when asking the body to absorb a large load in this positon, when not trained to absorb this load, may lead to an injury. It all comes down to progressively loading specific positions in order to learn how to hold this position.

This is a major component of Olympic weightling compared to powerlifting. In the performance of the snatch (the most explosive movement in sports), maintaining proper position is extremely important for completing the lift. In powerlifting, the position may be able to be off a little and the athlete can overcome the small error in position.

With regards to ACL rehabilitation, it is important that we ensure that the patient is able to have enough strength to maintain positions without the load (bodyweight jumps, external weight, etc) dictating positional changes.

 

“…the bilateral multijoint nature of a squat allows for compensations that can shift the task demands to the nonsurgical limb (interlimb compensation) or to adjacent joints within the surgical limb (intralimb compensation) to reduce knee extensor moments.”

The bodyweight squat can be performed differently and switches the load from either the hip to the knee.

If you watch someone squat (recommended for all people that will attempt to squat), the person should both watch the knee and the hip. If you look at opening and closing, this will be much easier.

  1. Watch the knee to see how much the knee “closes” or how much the angle changes from the calf to the hamstring
  2. Watch the hip to see how much the hip “closes” or how much the angle changes from the trunk to the thigh

Which joint moves more?

This will help the reader to understand whether the knee joint muscles or hip joint muscles will be the dominant movers during the squat. Those that have knee issues will tend to move the hip joint muscles more than knee joint muscles.

I’ll make a video on this at a later date.

 

“…individuals 1 month post ACLR performed bilateral sit-to-stand tasks with a 38% reduction in vertical ground reaction forces (vGRFs) in the surgical limb”

This very simply means that the person is pushing less with the surgical leg than the non-surgical leg.

This means that the surgical leg is taking less force through it and will not be able to generate the same amount of power. Also, it is typical to see the patient weight shifting towards the non-surgical leg.

“reduced knee extensor moments have been found along with increased hip extensor moments…may rely on interlimb compensations to unload the knee during early rehabilitation but adopt intralimb compensations as they progress through rehabilitation.”

This goes back to the differences in a powerlifting based squat and an Olympic weightlifting based squat. The more upright the torso, the more that the knee takes a load and the less upright the torso, the more the back and hips will take the load.

I am having this exact conversation with a patient currently following an ACLR, attempting to get the patient to increase the load on the knee.

“During early rehabilitation, strategies for restoring symmetrical weight bearing during bilateral tasks should be emphasized and reinforced even during submaximal tasks…efforts should be made to continue to focus on sagittal plane knee loading and avoid compensation with the hip extensors.”

I tend to use a mirror for visual feedback in order to allow the patient to see the weight shift between the legs. This tends to fix the problems for weight shifting. We then progress to doing the squatting motion away from a mirror in order to build in positional awareness without the need for visual cues.

In order to improve the knee to hip ratio regarding which joint moves more, the cues will switch from sitting back on a chair (similar to a box squat which is hip hinge emphasizd) to emphasizing sitting between the feet (similar to an overhead squat) which is more knee joint driven.

If you don’t have a PT that understands how to squat, this may be a difficult movement to restore with physical therapy alone.

It may be prudent to ask your PT to describe a squat prior to starting therapy in order to ensure that your therapist has at least a baseline knowledge of squatting.

If the therapist doesn’t start describing multiple techniques for squatting based on body shape, then the therapist may not be well versed in the movement.

If you have any questions about squatting or ACLR rehabilitation…comment below.

Article: https://www.jospt.org/doi/abs/10.2519/jospt.2018.7977

 

You can find me at Primarycarejoliet.com and wherever you subscribe to podcasts at A physio’s perspective: movementthinker.