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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

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If it hurts it must be bad, or good, or whatever.

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.