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.

Pinky and the Brain

 

shutterstock_266981183We 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.

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

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

 

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

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

 

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

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

 

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

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 This biomedical or pathoanatomical (patho=bad and anatomical = body parts) model of health care is outdated and simply is not as useful to use with the general public because research demonstrates that the patient may become “sick listed” and from there stop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

 

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

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

 

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

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

 

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

 

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

 

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

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

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

Functional Therapy and Rehabilitation 

(Now part of the Goodlife family)

903 N 129th Infantry Dr. 

Joliet Il 60435

815-483-2440