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How far do we have to go still in order to educate the public?

When people think back pain, they don’t think of physical therapists. When people think concussion, they don’t know where to turn.

As a professional, I do all that I can to educate the public, but in the end still have to apologize for our profession’s apathy.

We have no brand…better yet we have a brand, but not a consistent one.

I believe it was Therapy Insiders that did an episode of asking people on the street what they thought of when they heard the term physical therapy. Our roles in the SNF and acute care hospitals seem to be cemented in people’s mind because these answers were given, but we weren’t the first ones thought of for pain or back pain.

We have to do a better job folks. Get out there and educate the public on SoMe, in person, small groups or online. Every little bit helps. Let’s hope that if this same survey were done again in a year that the number would be far less.

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Online presence

I think that this sums it up. If we aren’t posting online on our personal websites, on social media (SoMe) or on a work website then we are missing out on contact points with over a third of the population. Our role has to grow larger than treating the patient that walks in the door with a referral. We, as a profession, have to go out there and educate the public, medical doctors, podiatrists, dentists, laborers, plumbers, and at times other therapists.

We don’t get to sit in our offices anymore and wait for patients to come to us, but we have to go out and educate!

How are you establishing a presence in your community, your workplace and your profession?

Leave comments below.

Do you suffer from knee pain?

Do you “suffer” from knee pain?

“Within this new paradigm, overweight and obesity contribute to OA through biomechanical (increased joint load) and inflammatory mechanisms.”

​There is newer research that indicates body fat can release inflammation. Think about this, inflammation can cause pain and there has been the old wives tale that being overweight can be the cause of pain, but now there is research to back up the claim that excess body fat can be a factor in having increased pain.

“Years lived with disability due to high body mass index have also increased markedly for males and females aged 15-49 years since 1990, emphasizing the potential contribution of rising obesity levels to global OA (osteoarthritis) burden among younger people”

​Being obese takes a toll on health. This is not a surprise. The heavier a person is, the more energy and work required in order to just move. Pair this with increased pain sensation and movement may actually decrease over time.

“Research has shown that the greatest risk factor predicting the development of knee OA in young an middle-aged people is a previous traumatic knee injury”.

​If you injure your knee traumatically, the research covers ACL surgeries and meniscus surgeries, then there is a high likelihood of developing knee osteoarthritis.

“Radiographic findings are not well correlated with symptoms and are unlikely to alter the management plan or predict future disease progression”

​THIS MAY BE THE MOST IMPORTANT MESSAGE FOR PATIENTS TO UNDERSTAND. Just because an X-ray shows “degeneration”, “osteoarthritis”, “joint narrowing”, “bone spurs”…so on and so forth…doesn’t mean that this is causing pain. What we now is that these findings are common as we age. There’s an analogy that these findings are similar to wrinkles on the skin, they are just wrinkles on the inside. Not too many people worry about skin degeneration in the form of wrinkles. The same should hold true regarding some of the results of an X-ray or MRI.

“Overuse of MRI is costly for health systems and may lead to unwarranted surgical intervention.”

​The most important part of this is that MRI’s may lead to surgeries that aren’t needed. Let’s go back to the wrinkle analogy. Just because something doesn’t look young and supple…like it does in the textbooks, doesn’t mean that everyone should have a surgery to remove wrinkles. The same holds true for wrinkles on the inside.

“…comprehensive assessment of young patients should include 3 key components: 1. A patient-centered history; 2. Physical examination, including performance-based tests; and 3. Administration of appropriate patient-reported outcome measures (PROMs).”

​I challenge this sentence in that it is only limited to young patients. This 3 step process should be performed on every patient, REGARDLESS OF DIAGNOSIS! Every patient should be treated as an individual and not as a diagnosis. Everyone has a different story. Every patient has different needs. Every patient has different goals that are specific to that patient in front of you. The only way that this can be learned by the therapist is by performing a patient-specific evaluation.

​The only way that we know if a patient is actually improving, aside from simply asking them, is to perform tests and measures. When your internet isn’t going as fast as we think it should, we can always run an internet speed test. This is an unbiased way to test the thought that it is running slow. We need the same types of tests and measures in physical therapy. These should be performed by your PT within the first 2 visits.

​Finally, there is a patient reported outcome. This is a way for the patient to answer questions in order to determine if the patient actually believes that they are better or not. The questions have been validated by some research and the form should be universally known.

“…education about the neurophysiology of chronic pain and contribution of emotional and social factors to the pain experience may be relevant for some patients.”

​Many people still believe that an injury happens and therefore there must be pain. It doesn’t quite work this way. The brain can overcome any of those “inputs” that theoretically can cause pain. For instance, we’ve all heard the story of a person performing feats of strength like lifting a car off a child, but few people hear about the injuries that tend to happen after this feat of strength. The brain can overpower the body’s ability to feel pain. On the flip side, the brain can cause pain without injury. This is a little known fact by many PT’s unfortunately. This type of pain requires a completely different type of treatment than someone that is actively experiencing an injury. This is more complex than can be described in this article, but there will be future posts to describe this phenomenon.

“…exercise can reduce pain and improve physical function for knee and hip OA…Muscle strengthening can play a role in managing symptoms…Neuromuscular training programs can address sensorimotor deficits often associated with knee injury, including altered muscle activation patterns, proprioceptive impairment, functional instability, and impaired postural control”

​This is a mouthful. To summarize, there is rarely a reason not to “get stronger”. Being strong enables people to do more than being weak. Don’t get me wrong, there are multiple ways to get strong, but there are also multiple ways to get injured while getting strong. Please, if you have little/no experience with strengthening exercises, see a PT or CSCS in order to obtain quality information prior to starting the program.

​Neuromuscular training can be replaced by balance activities. This can teach patients how to utilize the “somatosensory system”, which is the communication that takes place between the muscles, bones and brain in order to remain in a certain position.

“…neuromuscular exercises can improve knee cartilage quality (glycosaminoglycan content) in middle-aged adults following partial meniscectomy.”

​Every once in a while I learn something new when reading orthopedic research. (just kidding, I am learning every day from the stuff I read). This is a new concept to me. This means that by performing balance training, we can improve the quality of the knee cartilage (meniscus). This is huge because as a health professional, we were always taught that the cartilage has poor blood flow and we can’t really impact healing of this tissue. Who know that balance and exercise were good for you?

“..combining strengthening exercise with exercises aimed at increasing aerobic capacity and flexibility may be the best exercise approach for managing lower-limb OA”

​This has been challenged in the research lately. There is an article by Richard Rosedale (JOSPT 2014) that demonstrates that using MDT can provide superior results. The original advice of diet, exercise and balance is probably still the best advice until more research comes out to show that specific exercises are better than others.

Hope this synopsis was helpful. If you are experiencing knee pain or have been told that you have arthritis, there are options. Come see me at FTR in Joliet, now a member of the Goodlife Family.

Dr. Vince Gutierrez, PT, cert. MDT

903 129th Infantry Dr.

Unit 500

Joliet, IL 60435

815-483-2440

QUOTES TAKEN FROM:

Ackerman IN, Kemp JL, Crossley KM, et al. Hip and Knee Osteoarthritis Affects Younger People, Too. J Orthop Sports Phys Ther 2017;47(2): 67-79.

Get PT 2nd

“out of 137 patients, 100 had been recommended for spinal fusion. After evaluation, the group advised 58 of those patients to pursue a non operative plan of care”

There’s a slogan going around social media saying “GETPT1ST” I don’t know if I completely agree with the saying, but I can’t disagree with that either. The saying could just as well be get PT second. At some point a second opinion has to come in to play for a patient’s dysfunctions or pain. That second opinion, in my belief, has to come from someone without a financial stake in the surgery. This could be a physiatrist, PT, or a separate surgeon, which was done in the study cited.
The take home point is that 58% of those recommended for spinal fusion were recommended to seek a separate form of care, thus advised to avoid the surgery initially. What this means for the patients is that a second opinion should always be sought out, because the person advising a plan of care is advising it from their perspective. I’d love to say that everyone has the patient’s best interest in mind, but I can’t. In that case, the patient must become more educated and advocate for him/herself. For instance, a surgeon does surgery, a physical therapist does physical therapy and a physiatrist does physiatry. We see problems from different lenses and therefore will advise different plans of care for varying presentations. Some patients need surgery and some don’t. Some patients need physical therapy and some don’t. We can’t say PT first because PT is not magic and can’t fix everyone’s issues.
“As clinicians, we bring our own biases into the treatment plan for patients”
Want to decrease unnecessary surgeries? Have a multidisciplinary team do evaluations, researchers say. PT in Motion. April 2017:46.

Comparing McKenzie to a cognitive behavioral treatment strategy

Got back pain?

 

This is a study that compares two different treatment approaches head to head. Bout damn time that we are looking at two approaches and comparing them in a study. We (health care researchers) typically compare one treatment against no treatment. This is good and all, but then we believe that all treatments work and work equally. These are the types of studies that need to come out, so that as a health care provider, I am providing the best treatment to help your problem.

 

  1. “A recent UK survey estimated the (1-month period) prevalence of spinal pain to be 29%”

 

This means that during any one month period about 1 in 3.5 people are experiencing back pain, over on the other side of the pond. Think about that! If you have one person on each side of you, one of you will have back pain during the month.

 

  1. “The lifetime prevalence of these conditions is also high—it is estimated that »70-85% of the population will experience some spinal pain during their lifetime”

 

Again, 8 out of 10 people will have back pain during their lifetime. This is starting to sound grim. Pain is not normal. What are we doing to ourselves? Why do we keep having back pain at such an alarming rate? I have my opinions, based on some research, but it hasn’t been fully substantiated yet. I will pull out the research at a later date of course.

 

  1. “In 1998, the cost of lower back pain alone to the UK National Health Service was estimated at 1 billion (pounds), with over 200 million (pounds) being spent on physiotherapy”

 

So…what’s this got to do with us? That’s the UK. The numbers aren’t too far off of what we are spending on back pain. See the link from a previous post in which I discuss monetary figures.

https://movementthinker.org/2016/03/17/a-little-bit-of-crazy/

 

  1. “guidelines state that in the first instance patients should be encouraged to remain active, with the prescription of anti-inflammatory drug and/or analgesia where required.”

 

There is an opiod epidemic spreading world wide. I realize that opiods and anti-inflammatories are a long ways away from each other, but to think that back pain will be fixed with medication only is dreaming. NSAID’s are not always the answer either. http://www.aafp.org/afp/2002/0401/p1319.html

 

Robin Mckenzie states in his textbook (paraphrased): a mechanical problem needs a mechanical answer and a chemical problem needs a chemical solution. The first question has to be: is the pain mechanical or chemical?

 

To remain active is the same advice that I could get from my dad. You’ve heard the advice countless times I’m sure…especially if you’ve ever been hit by the ball while standing in the batter’s box…”walk it off”. Hell, my dad was a laborer. He didn’t go to medical school, but gives the same advice. I pay for better than that. I can get the advice for free back in Elwood.

 

  1. “Physiotherapy treatments aimed at alleviating the physical causes of back and neck pain include: advice, exercise programmes, massage, mobilization and manipulation”

 

Some big takeaways from this sentence are what was left out of the sentence. At no point did the authors talk about ULTRASOUND!, ELECTRICAL STIMULATION!, TRACTION!, VAX-D (sp)! CUPPING! or any of the other passive fads that make clinics money for doing thoughtless work. Look…if the above (in capital letters) makes up a part of your treatment, you have to question your practitioner as to why and what are the expectations of the intervention. I know what my expectations are…lining the owners pocket with greenbacks.

 

  1. “a new type of intervention for treating back and neck pain has recently been developed, triggered by growing awareness that psychosocial factors play an important role in musculoskeletal complaints. These behavioural interventions have different compositions depending on the specific theory underpinning the approach.”

 

To think that the “biopsychosocial” approach is new is a fallacy. It is a newer concept to put a name to it, but even those that simply have “mechanical” training understand that in order to use “mechanical” training, we have to get through the psychosocial constructs of each patient.

 

  1. “elucidating whether a treatment offers good value for money in terms of cost vs benefit must also be considered”

 

This is an interesting topic that is finally coming to the forefront in healthcare. I’m going to go to the extremes to make a point. Let’s say that you have a heart problem and a surgery that costs 100,000$ will keep you alive for decades, but a surgery that only costs $1,000 can keep you alive for a year. Which would you take? Costs vs benefits become very apparent in this scenario. This article will scale the topic down to back pain.

 

  1. “The trial compared two physiotherapists delivered interventions for musculoskeletal back and neck pain, which aimed to promote return to normal activities…Solution Finding Approach, was a brief physiotherapy intervention based on cognitive behavioral principles…a patient-centred view and, in this context, aims to help patients identify reasons for their pain and to provide solutions and long-term management strategies”

 

This essentially says: this approach consists of few physical therapy visits in order to help you figure out why you have pain and to provide solutions to long term management of your pain.

 

Remember this because it is important for the next section.

 

  1. “The second approach was the more traditional biomechanical approach used by physiotherapists, the McKenzie approach, which involves classification of patient’s spinal condition and the prescription of specific therapeutic exercises.”

 

This one states the following: The therapist will help you figure out why you have pain, through a classification system, and issue solutions (exercises) in order to provide long term management of your pain.

 

Sounds fishy…I don’t know if I like either method since they both sound so similar. Those that know me, know that I am biased. I am certified in the McKenzie method, formally known as Mechanical Diagnosis and Therapy.

 

  1. MeKenzie approach…has been clearly documented…commonly used by physiotherapists…conducted a biomechanical assessment using repeated movements of the spine and, based on these findings, prescribed specific exercises for the patients to work on repeatedly themselves…relies on active compliance with the exercises and advice.”

 

MDT (McKenzie method) was created a long time ago. I know the history like the back of my hand, but it seems like too much to type out here. Look up his biography, “Against the Tide” to read how this man revolutionized the way spines and now extremities are treated…by those that have studied the method. In a time in which not many believed him, and many went so far as to ridicule his methods, it took almost 50 years to confirm his thoughts through science.

 

Anyway, we use repeated, sustained, resisted and speed based positioning in order to elicit a change in symptoms. Manual techniques can also be used to elicit a change. Once we see a change that is documented with having good results…we stop there and send you home with the exercise, position or movement.

 

  1. “All the physiotherapists delivering the McKenzie approach were experienced in this method and had undertaken McKenzie Institute training (courses A-D).”

 

This is important. Scott Herbowy, one of the highly trained professors of the method, published a study in the recent years regarding the training and outcomes of those using the methods. It seems realistic to believe that someone that has taken courses A-D would have the same reliability and outcomes as someone that has taken the same courses and passed a competency exam. This is not true though. Those that have not yet passed the test appear to be inconsistent in classifying patients using MDt. See the study below to learn more:

 

http://www.ncbi.nlm.nih.gov/pubmed/24253786

 

  1. “…both the McKenize and Solution Finding approaches lead to improvements in patient outcomes over time, with no significant differences between the two treatments.”

 

Both treatment ideas provide similar improvements over time. This indicates that just in terms of improvements, it doesn’t matter which method is used (albeit neither group of therapists were highly trained in using the intervention attempting to be studies). I liken this to asking an auto mechanic to work on a Boing Jumbo Jet. Yes…the mechanic understands engines, but there’s a difference in specialties.

 

  1. “The McKenzie treatment required on average, one extra subsequent visit to the physiotherapist”

 

This means that seeing a therapist semi-trained in MDT will cost you an extra $100 dollars compared to seeing someone semi-trained in the Solution Finding Approach. Is this a bad thing? We will see.

 

  1. “the Solution Finding Approach is slightly cheaper than the McKenzie approach but confers marginally lower benefit”

 

Dave Ramsey has a free radio show about finances. One of his taglines is “the advice is worth what you pay for.” Obviously he’s kidding, but we all know that the better stuff in life isn’t free. When it comes to your health, how much more are you willing to pay? Are you willing to pay “slightly” more?

 

  1. “The policy maker needs to decide whether she or he is willing to invest additional health care resources funding the McKenzie approach”

 

Look, you need to find someone that has this certification or diploma training if you have back pain. Countries are debating whether or not more money should be put into training therapists in this method. Some of us have paid for the training out of pocket in order to become better therapists, with the end goal of providing great care to patients.

 

  1. “the additional cost associated with the McKenzie treatment is worth paying, given the additional benefit it provides”

 

NEED I EXPAND ON THIS SENTENCE? This benefit is from people that aren’t even “minimally competent” to provide this service. Imagine how much more benefit or less cost that you would have from someone that is competent in using the method.

 

This study was performed in the UK. There is no reason for me to believe that back pain differs that significantly from those experiencing back pain in the US. I have to correlate that those seeing a McKenzie Credentialled therapist will see even better results or spend less money over the long haul than that those seeing someone using cognitive behavioral therapy.

 

Quotes taken from: Manca A, Dumville JC, Torgerson DJ, Moffett JAK, et al. Randomized trial of two physiotherapy interventions for primary care back and neck pain patients: cost-effectiveness analysis. Rheumatology 2007;46:1495-1501.

Get PT first?

 

We all like to think of ourselves as important. “No one can do my job as good as I can.” We all think like this, or at least I hope we do.

 

  1. “One successful strategy for reducing the backlog of patients, developed in the United Kingdom, is for physiotherapists to screen patients referred by GPs before a first consultation with an orthopaedic surgeon.”

 

I wouldn’t have thought that this was possible in the US when I first entered the profession of PT, but now I at least think that it is plausible. There are many hurdles to overcome, and the first is money. If a surgeon is not seeing a patient, then the surgeon is not making money. The ideal of this scenario is to have surgical candidates see the surgeon and for non-surgical candidates to see non-surgeons.

 

On the flip side, therapists will have to become owners of the profession. I have worked with many PT’s that really enjoy the “paint by number” system, otherwise known as protocols, but protocols don’t necessarily fit in an environment like the one described. We have to be able to think independently and assess patients either using pattern recognition or using something like the Hypothesis Oriented Algorithm for Clinicians.

 

  1. “gatekeeper role for physiotherapists is supported by the growing body of evidence that it is effective, and that physiotherapy is an appropriate treatment for many musculoskeletal conditions”

 

As much as I agree with the statement that PT is effective, I don’t know if this statement supports the use for PT’s as a gatekeeper. I envision the role of gatekeeper as more of an assessor instead of a “treater”.

 

In the case of back pain, there are assessments that can be used prior to treating the patient in order to determine how much “help” the patient will need. When assessing the patient, there are odds ratios to determine a patient’s need for surgical intervention compared to conservative interventions.

 

These are the themes that a therapist must know in this type of setting.

 

  1. “In the UK, the initiative has resulted in reduced and more appropriate referral to orthopaedic surgeons, more timely interventions for those unlikely to benefit from surgery, and a shorter waiting time for appropriate care for all patients.”

 

This is very important. Just imagine that you need a back surgery for something very serious, such as an infection or cauda equina (just know that it is serious), but you have to wait in line to see the doctor because someone has a “pulled muscle” (not very serious). If those that are definite surgical candidates can get to see the surgeon faster, this would reduce the need for the surgeon to screen the patient in order to determine the next step.

 

In other words, if you have back pain, it is classifiable in about 80% of cases. Roughly 70-80% of those cases could be treated appropriately with PT initially. This would prevent about 56-64% of patients needing to see the orthopaedic in order to initiate treatment.

 

  1. “receives an average of 150 new referral each month to the orthopaedic outpatient department. Three orthopaedic surgeons and a registrar are available to screen 10 new and 18 review patients each week in one 3-hour clinic session…the waiting list for non-urgent care patients…waiting time of 164 weeks until their first appointment”

 

AND WE THOUGHT WE HAD TO WAIT A LONG TIME TO SEE THE DOCTOR! Think about this. If you had to wait over 3 years to see the doctor, would you rather wait that long or see a PT in a much shorter time? We are not at that point yet in our country, but it is coming. You will notice that you are seeing less of your MD and more of your PA’s and APN’s. There are not enough physicians to take care of all of the patients that want to see the doctor. The net question is would your rather see an expert or non-expert for your problem. There was a study, that I will go back and find to write about at a later date, that shows in terms of minimal competency, only orthopedic surgeons and PT’s pass a basic test for musculoskeletal conditions. Again, why would you want to see any one other than these two professionals for a musculoskeletal problem?

 

  1. “Conditions considered for inclusion were musculoskeletal-related knee, shoulder or back pain (with or without leg pain)…excluded if their subjective history suggested any sinister disorder requiring urgent medical attention, or if they had psychosocial issues that contribute to symptom chronicity”

 

This study essentially compared a PT’s ability to assess patients to that of an orthopedic surgeon. I don’t know how much I agree with this because we are calling the orthopedic surgeon’s assessment the gold standard, but for lack of a better tool…it will have to do. To be fair, it was the only profession that scored higher than PT’s in terms of musculoskeletal competency.

 

  1. “The physiotherapy screening appointment involved a comprehensive assessment, a provisional diagnosis and the development of a management plan in consultation with the patient…reported to the patient’s GP by letter in the same week, and a copy of the letter was filed in the patient’s medical record.”

 

This is where the rubber meets the road. The PT’s had to assess the patient nd diagnose the patient. Good luck with that in the states. Until we have a greater influx of DPT’s the idea of diagnosing is more like a dream. We have been pre-programmed that the physicians (MD’s, DO’s) diagnose and we give a “physical therapy diagnosis”. WTF! We have the knowledge, but not the cajones! Instead, we tell you what the problem is, but won’t tell you for fear of stepping on toes.

 

Because our profession is not a direct access profession, such as chiropractic care, we depend on physicians’ referrals to physical therapy. If we upset the physicians, we may see those referrals decrease in overall number.

 

  1. “ Principal outcome measures of the preliminary study were:

-proportion of new referrals not needing to see a surgeon;

-the level of agreement between the physiotherapists and the orthpaedic surgeon on diagnoses and management decisions, and

-the patients’, GP’s and surgeon’s level of satisfaction with the physiotherapist-led screening initiative”

 

In my opinion, this is also listed in terms of order of importance. If we can cut down on the number of referrals not needing to see the surgeon, then we will effectively make the health care experience more efficient. This is the new buzzword in healthcare.

 

If we can agree with the surgeon’s diagnosis, that is good, but we are making the assumption that the surgeon is correct.

 

Finally, is the satisfaction of all involved in the study. This may be biased, as a doctor may not be satisfied with another professional taking point on a medical case.

 

  1. “The orthopaedic surgeon agreed with 74% of the management decisions made by the physiotherapists…differences only in differentiating back pain of mechanical or nerve root origin, and knee pain of cartilage or articular origin.”

 

This is good, but not great. This only states that we both agree with each other. The good thing is that there is not much of a difference between seeing the therapist or the surgeon in regards to the diagnosis.

 

  1. “experienced, well qualified physiotherapists can competently and safely undertake screening of patients referred to public hospital orthopaedic outpatient clinics with non-urgent musculoskeletal pain”

 

This bodes well for our profession and health care in general, especially the financial aspect of health care costs. Unfortunately, giving PT’s full, unrestricted access to patients is not on the horizon in the US.

 

  1. “In the current climate of health care workforce shortages, there is a growing interest in allied health professionals undertaking additional tasks in extended roles. Two-thirds of the patients screened in this trial did not need to see a surgeon at the time of referral, but required non-surgical care, predominantly physiotherapy and exercise.”

 

With the shortages of MD’s, there is an increased need for other professionals to fill that gap. Physical therapy is one profession that can manage the orthopedic aspects of the MD shortage.

Sales in heathcare

 

This is a quick statement of sales. In healthcare, we are preprogrammed by administration, or bosses, to take your money. It doesn’t always sound this sinister, but it may sound like one of the following:

  1. Make sure that we don’t have a waitlist. We don’t want people to have to wait to get in for an appointment. This sounds very altruistic, but what we could hear if we fine tune our frequency is: don’t let this patient get better over time or make sure that this patient doesn’t hang up and go somewhere else.
  2. If you have something else to work on, make sure that the patient is completely satisfied with their stay. This could also mean that you haven’t treated the patient for enough visits to make as much money from the patient as the doctor has enabled us to make. For instance, if the prescription says 3x/week for 4 weeks, but you are better after 3-5 visits, then any visit not seen up to 12 is considered loss of potential revenue.
  3. There is nothing wrong with making patients feel good in order to get them to do what we want them to do. I hear: modalities are easy to apply and we can get paid to do them so…why not?

 

  1. “A good salesperson works hard to ensure the answers are all just different shades of ‘yes’”

 

If you want something, don’t take no for an answer. As much as I agree with this, I also have to disagree with this. You have to be willing to establish how important it is to “sell” your wares. For instance, regarding physical therapy that “ware” that we are selling is the new evaluation. It pays the most and leads to many additional visits. We have to ask ourselves if we are willing to sacrifice and what are we willing to sacrifice in order to get that new evaluation? Are we willing to sacrifice a lunch break? Are we willing to pay our employees overtime (most companies have gotten around this by going salary)? Is the employee willing to stay late? Are we wiling to sacrifice patient care by double booking a patient? We have to establish our priorities, so sometimes it is okay to say no if it doesn’t “make the boat go faster”. Again, Google this phrase…it’s that important.

 

This was a quickie, but still needs to be said.

 

Excerpts taken from:

 

Quatre T. WHY THEY BUY: Because They Cannot Say No. Impact: Private Practice Section of the American Physical Therapy Association. 2016;May:13

Socialized what?!

 

We all have our own opinions regarding socialized medicine, but let’s just look at some of the research from countries that provide socialized medicine.  This article is based on the system in Australia.

 

  1. “…34-year old male referred by his GP (primary physician) to the orthopaedic outpatient department…carpal tunnel” The PT referred the patient back to the GP and “suggested that the GP organize nerve conduction studies to confirm carpal tunnel syndrome, before the patient would be offered an appointment with a surgeon…seeing a physiotherapist to help clarify the diagnosis and see if the symptoms would respond to conservative treatment”

This is a mouthful. Let’s start with some of the major differences between the Australian system and the US system. The PT is the gatekeeper to see the surgeon. The PT’s opinion or consultation was taken seriously and the patient was sent back to the primary physician to order the tests before seeing the surgeon. Keeping it simple. Therapists do therapy. Chiropractors do chiropractic. Surgeons do surgery. It is wasteful to send a patient to a surgeon if the patient does not need surgery. It is not efficient to send a patient to a surgeon to order more tests. Also, the PT would help to clarify the diagnosis. For a long time, therapists in this country have been treated like technicians, only capable of performing the treatments that the physicians deemed appropriate. This is simply not the case anymore. We are a doctoring profession. Not that this in and of itself places us on a pedestal, but some of us continue to expand our knowledge base and have become professionals at both movement and classification of patients. This is to be respected, sought after and rewarded…not necessarily monetarily, but at least with more opportunities to demonstrate our abilities.

 

  1. “initially assessed by another outpatient phsyiotherapist…computer worker with a four to five year history of altered sensation in the left upper limb;including numbness, pins and needles and pain in the hand and thumb, and, pain around the lateral aspect of the elbow…gradually worsening…using his left hand less in everyday activities.”

By the by, this was session one, which we will call day one. Again, the body is a roadmap. Symptoms that are referred to the hand can come from anywhere that sends information to the hand. Let’s break it down in laymen’s terms. When you flip the switch on the lamp and the light doesn’t turn on, what’s the problem? First, the light may be burned out. This is akin to the muscles not working appropriately or a problem at the location of the visual or perceived problem…in this instance the hand. The problem could also be the power cord. This is similar to a problem coming from a nerve that travels from the hand up to the neck. Any of the nerves that supply the hand could be “frayed”, for lack of a better term. Finally, the cord could be unplugged. In this case, the electricity isn’t even making it to the power cord. This is similar to a problem with the neck. If the brain can’t send the signal appropriately to the power cord, then the hand won’t work correctly.

This is obviously becoming a problem for this particular patient, as he is slowly de-emphasizing the use of his left hand.

 

  1. “full active and passive range of motion. Left shoulder flexion produced pins and needles in the left hand”

When a patient raises his arm overhead, most people can see how the muscles work and that the shoulder joint must be moving somehow. What people don’t see is how this plays on the nerves of the body. When a patient reaches forward, this pulls on the nerves of the body and sometimes can increase a patient’s symptoms.

 

  1. “Session two (two weeks later): non-dermatomal distribution of hand symptoms…the presence of night pain that consistently disturbed the patient’s sleep”

Red flags. Think of the JAWS theme music when you here these words. Red Flags are BAAAD! Non-dermatomal patterns means that the symptoms don’t match the road map of the spine. If a problem is coming from one location, it would typically refer to one location in the hand. If it is coming from multiple locations, then it would refer to multiple locations in the hand. Ever heard of the phrase “Occam’s razor”? This means that the simplest solution is typically the correct solution. Two separate lesions in the spine occurring at the same time is not a very likely solution. This indicates that there could be a space occupying lesion (AKA SPINAL TUMOR!). Second, the patient is waking during the night due to symptoms. This is also a red flag for…CANCER!

This is two weeks later and the suspicion of non-mechanical pain (AKA spinal tumor) is introduced. This is where timeline starts to play a role between socialized medicine and US healthcare.

For those that don’t know, this topic is close to my heart, as I am currently working on a paper for submission regarding a similar topic.

 

  1. “After 10 repetitions full active ROM had been restored in all directions. ULTT was pain free and full ROM with both median and radial bias”

MDT is known as Mechanical Diagnosis and Therapy. The Mechanical portion of this means, “what happens to the patient when we move the patient?”

In this case, the patient’s mechanics (ability to move) improved in all directions. ULTT (upper limb tension tests: pulling on the nerve to test their irritability) had improved after performing retraction and extension. When we see that a patient is improving with a treatment, we first assume that whatever we did actually helped the patient. I mean why wouldn’t it? It’s not like we think that we are special, but we do our best to be objective and not bias the patient to say that this treatment made me better. If the patient improves, then The puzzle is solved. If the patient tells me that they improved, but actually didn’t, then I did a poor job of establishing patient alliance! There has to be openness between the patient and therapist. Some research actually shows that patients will tell the therapist what they want to hear instead of what is true. I hope that this doesn’t happen to me, but then I would be fooling myself. As a therapist, I can’t help you 100% if the patient is not 100% truthful.  Okay, now back to our regularly scheduled broadcasting.

 

  1. “Session Three (one week later)…reduced elbow pain during the day and no elbow pain at night, fewer pins and needles, but the numbness in his fingers was unchanged…(at the end of the session) Numbness in the hand remained unchanged”

At this point, we are at three weeks and the third session. Don’t get me wrong, I like this style of therapy in which the patient is given a homework assignment and then return to the clinic for the PT to problem-solve the symptoms. Our current system has the patient coming to therapy 2-3 times per week for 4 weeks. I’m sorry, but if we look at normal healing for most musculoskeletal issues, it is six weeks! Think about that. We know that it could take up to 6 weeks to treat an injury and you will be coming to therapy for up to 12 visits and still not enough time has passed in order for an injury to heal. We know this, but as I stated in previous blog posts, healthcare is big business.

The patient’s numbness is unchanged at the end of the session, but all else is better. At this point, the therapist has to start to think that the numbness is non-mechanical and start doing differential diagnosis internally as to why the numbness remains unchanged.

 

  1. “Session four (two weeks later)…’bad week’ as he (the patient) had intermittently increased left arm pain “after sneezing and coughing”…numbness was unchanged.”

We are now at 5 weeks and the patient is unchanged. One of the red flags that is in the research is no improvement following 30 days of treatment. At this point, medical assessments should be advised and the patient should be scheduled for that surgical consultation.

 

  1. “Session five (four days later)…’better’ after the previous session…ongoing numbness in his left fingers…an appointment was arranged with an orthopedic surgeon…requested that an MRI of the cervical spine (neck) to investigate the possibility of spinal canal/foraminal narrowing and to examine the possibility of a compressive lesion or space-occupying lesion”

We are now at 6 weeks. In America, this would be about 12-18 sessions instead of 5 sessions. We would still be at the same end-point, but the cost savings would equate to about $1,300 over the course of the episode. Healthcare is a business, so return on investment has to be looked at. We get reimbursed roughly 100$/session from Medicare. It makes sense that the cost of healthcare continues to increase when a patient is coming into therapy based on traditional treatment paradigms instead of current evidence or even best practice.

Now this patient is moved along in the healthcare system. Something to note is that the PT can request the MRI in order to look for foraminal narrowing (STENOSIS) or space occupying lesion (TUMOR).

 

9 “Session six (two weeks later)…symptoms were generally worse in the evening and better during the day…numbness and pins and needles in the hand were intermittent”

Two months out and the patient is waiting to see the surgeon and get the MRI. This is a downfall of the socialistic medicine. If this is something very serious, then the patient has waited 2 months for the MRI. Is there a right answer? I don’t know, but I know that our healthcare system is broken and a shift to a more conservative type of healthcare may be worth a shot.

 

  1. “surgeon’s clinic approximately three and a half weeks after his last physiotherapy session. MRI of neck and nerve conduction studies of the left arm were ordered…MRI four weeks later…”abnormality of the entire cervical cord”…solid, cystic mass within the cervical cord from C4-C6…excision of tumour approximately four weeks later”

This guy had a huge tumor. This accounts for symptoms extending in such a large location, as the tumor affects the nerve roots (think multiple electrical outlets) from varying locations. This would explain the widespread symptoms in the hand. Again, let’s look at the time table: we are now about 3 months out from session one and the patient is finally in surgery.  I have seen a similar presentation in practice a couple of times and not all were favorable outcomes. I say this from experience, as I have had two patients that died from a similar presentation, which was caught well before 3 months after the initial assessment. The patient in the case survived and his symptoms improved after the surgery.

  1. “The wait to see the surgeon was a reflection of the large caseload within the orthopaedic surgeons’s outpatient clinic. The wait for the initial MRI was due to the prioritization system used by the medical imaging department, to manage demand for so called ‘non-urgent musculoskeletal’ MRI’s”

When everyone has the same insurance, everyone has the same access to healthcare. When everyone has the same access, there are not enough practitioners to go around and systems need to be developed to handle the overload of patients coming into the health care system. We are starting to see this impact of “Obamacare”. There are so many more patients coming into the system the past two years that it is not uncommon to have a 2 week wait to see the therapist for the initial evaluation.

MORAL: When everyone has the same right to health care, then no one has the same freedoms as they did previously, unless they choose to pay a portion of their healthcare out of pocket. This is doing what’s best for society at the cost of the individual. More people will be insured and have access to treatment. If I am the person that has a spinal tumor though and has to wait for 3 months for treatment…I don’t think that I am agreeable to this type of system.

Let me know what you think? Are you in a country with free healthcare, how does it affect you personally?

Excerpts taken from:

 

Schoch P. Cervical spine tumor presenting as unilateral upper limb symptoms. IJMDT. 2009;4(3):24-29.

For more information or to receive an MDT evaluation from a credentialed therapist, I can be found at:

Functional Therapy and Rehabilitation

903 N 129th Infantry Dr

Joliet Il

815-483-2440

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

Louw A, Puentedura EJ, Zimney K, Schmidt S. Know Pain, Know Gain? A perspective on Pain Neuroscience Education in Physical Therapy. J Orthop Sports Phys Ther. 2016;46(3):131-134.

 

  1. “Pain is a normal human experience and essential to survival”

This portion is rarely spoken of in PT school and we spend our time in school learning how to shut down the pain, either in an ideal way of dealing with a mechanical problem or in a way in which we “trick” the brain of not seeing the pain for a short period of time. When working with patients, I often describe the gate control theory as the “Three Stooges” way of treating pain. For instance, if you have a headache and I hit your foot with a hammer, what happened to your headache. I stole the example from my dad, because this is how he would always respond if I told him my arm was sore after baseball practice. This was way back in the 1980’s and he was a laborer by trade. The gate control theory makes sense to most people, but we can also see the example and understand that it is probably not the best way to fix a problem, as we end up with a broken foot from the hammer.

 

  1. “The pain neuromatrix explained our knowledge and understanding of the functional and structural changes in the brains of people suffering from chronic pain”

To simplify, we have pain because our brains tell us that something is painful. This could be due to past experiences, actual painful stimuli eliciting Nociception, super excited nerves , so on and so forth.

 

  1. “biomedical models may induce fear and anxiety, which may further fuel fear avoidance and pain catastrophization”

It is very common for a patient to come into the clinic and say that he/she is avoiding a particular activity because of a history of a herniated disc. There is research that shows that a herniated disc can become “unherniated” (for a lack of a more layman’s term) over the course of 6 months. The patients are never educated regarding this point. Once a herniation, always a herniation is just not true. This biomedical or pathoanatomical (patho=bad and anatomical = body parts) model of health care is outdated and simply is not as useful to use with the general public because research demonstrates that the patient may become “sick listed” and from there stop participating in previously enjoyable activities.

 

  1. “a plethora of papers have been dedicated to a mere 20-millisecond delay of abdominal muscle contraction, yet despite the enormous amount of time, money and energy spent on this science, clinically it has yet to provide results superior to those of any other form of exercise for low back pain”

Doing the vacuum pose while lying down is no better than doing a general squat or learning how to utilize your diaphragm during breathing mechanics. As the layperson, there are many people that want to take your money in the health care industry. (I hate to say it like this, but healthcare is a huge business and the public needs to see it as so.) When the new fad comes out to solve back pain, don’t buy into the infomercial and as a matter of fact, turn off the t.v. and go get a book from the local library. You will spend hundreds of dollars less than what is proposed on the infomercial and be better off after having read the book. Nothing beats knowledge and the smarter you are at taking care of yourself, the better armed you are when you actually get in front of a health care practitioner. Remember, it is a business and we all want your money if you will give it to us. A better use of your time is to come educated so that I don’t have to teach you the basics of posture for 30 minutes, but can instead can teach you how to perform more high level movement patterns instead of sitting properly to reduce your pain. Oh wait, pain is normal. I’d lose my job if I sold this to all of my patients, but instead the patients need to be educated between hurt and harm.

 

  1. “In all health care education, be it smoking cessation, weight loss, or breaking addiction, the ultimate goal is behavior change.”

Speaking as a physical therapist, I can’t stress to the patients enough how the therapy experience is a team. Smart people call it therapeutic alliance, but I’ll settle for team. My part is to educate the patient and attempt to solve the puzzle of the patient’s pain, but it is the patient’s job to take the information that they have gained during the session and go home and apply it to their daily lives. For a patient to do nothing at home, AKA make no changes in behavior, and come to the following session thinking that the pain will go away is similar to :

 

https://spencergarnold.files.wordpress.com/2013/01/snatch-miracle.jpg

 

Patients may come hoping for a miracle, but it is not to be. The patient and therapist have to work together to attempt to solve the pain problem. If one side of the team is not doing their part, then the PT has to be willing to discharge the patient or the patient has to be willing to fire the PT.

 

  1. “…when PNE (Pain Nueroscience Education [pain is a normal human response]) is paired combined with either exercise or manual therapy, it is far superior in reducing pain compared to education alone”

From this I take that teaching the patient and then moving the patient is better than just teaching the patient. We can all agree that low level exercise is good for people. If we don’t agree with this, then we are saying that it is safer long term to live like a slug then to get up and walk around the living room. It just isn’t so. People will refuse to get up and walk around the living room when they start experiencing low back tightness, leg fatigue, or the dreaded “Fran cough” (look it up and btw I am an advocate professionally speaking). We as a society have to start moving more and learn about how our body is supposed to work. This can not be done from infomercials that have pictures of pulsating backs or frowning stomach fat.

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