Make PT Your First Stop for Rehabilitation, Wellness, or Athletic Performance Needs: #GetPT1st
Here is a fantastic short video done by Jimmy McKay, a physical therapy student at Marymount University. He also is part of a podcast for therapists and PT students at www.ptpintcast.com. Great to see the up & coming in our profession getting involved in this way -- the future is of the PT profession is looking bright!
Check out this video on why you should Get PT First, and be sure to follow the movement through the various social media outlets using the #GetPT1st or visit the website at www.GetPT1st.com for lots of great information.
Contact Athletes Physiotherapy to #GetPT1st in Las Vegas & Henderson, Nevada.
Let's discuss how we can help you meet your goals, whether you are looking to eliminate pain, be able to keep up with the kids, return to sport after an injury, or are looking to improve your general fitness or performance for an athletic event.
Managing Persistent Shoulder Pain
4 Possible Reasons Your Shoulder Pain is NOT the Fault of Your Shoulder!
Shoulder pain is a common problem with much variability. Shoulder pain can come in many forms across a wide range of sports, and can have a variety of causes. When coupled with the complexity of the shoulder itself and the required balance between mobility and stability it is easy to understand why it can be difficult to initially pinpoint the cause of an athletes shoulder pain. Certainly we traumatic shoulder injuries in sports like football, hockey, MMA, or wrestling where an athlete ends up with a dislocation of the humeral head, a "separated shoulder" or sprain of the AC joint, etc. These types of traumatic injuries are fairly easy to identify and understand.
For the purpose of this discussion, we are going to focus on the non-traumatic injuries. The chronic, achy, nagging pain that seems to develop over time, or the sharp, pinching pain that occurs with certain movements or positions. These are the descriptions most often given by our athletes. They may or may not have an event to attribute them to, and usually have not responded to the athlete's self-management strategies of ice, ibuprofen, self-soft tissue work with a foam roll or tennis ball. These are the low to moderate level pains that seem to creep up out of nowhere with each workout or as the training volume increases. Sometimes the athlete has had a label slapped on it: rotator cuff tendonitis or tendonosis, impingement, bursitis, rotator cuff strain. While these may be the tissues that are painful and irritated, focusing treatment only on the painful area will rarely yield a lasting result. You may achieve the initial goal of pain relief in the short run, but most often there are other variables to consider which may be contributing to the athletes shoulder pain, and they are not a the local painful area.
"Wait, so you're saying my shoulder pain may not be because of my shoulder? Because, I had an MRI, and they said that clearly my rotator cuff is 'inflamed'. And my shoulder is what hurts! Isn't that the shoulder's fault?"
Yes. That is exactly what I am saying. No, it may not be 'the shoulders fault' (though statements like that will be the topic of future discussion, as the shoulder is a body part, not a separate outside entity for which blame or other qualities can be asserted...).
Certainly chemical pain at the tissue level needs to be addressed, but what the MRI doesn't tell us is WHY the rotator cuff is so 'inflamed'. What is causing that tissue be respond in such a way? Sure pain is an output from the brain, so what is it that's tripped the threat alarm and gained the brain's focused attention?
First let's dive into 4 possible variables that may be contributing to your symptoms, the potential Source of the problem, which may be presenting as pain and irritation of the rotator curff, the Site of the problem.
4 Possible Contributors to Shoulder Pain
1. Inadequate Scapular Stabilization
The scapula, or shoulder blade, is a key component of the shoulder girdle. It is a point of attachment for muscle that connect scapula to humerus, scapula to thoracic spine & rib cage, scapula to cervical spine, and scapula to strenum. It is also provides the stable base and dynamically controls and positions the glenohumeral joint during movement. The rhythm or coordination of motion which takes place between the rotation of the humeral head & glenoid (the ball & socket) and the rotation of the scapula itself has been the topic of much attention over the years.
Inadequate scapular stabilization, usually seen as weakness or deficiency of function of the serratus anterior, middle & lower trapezius, rhomboids, also puts the rotator cuff at a disadvantage by preventing optimal activation and force production of the rotator cuff. Clinically, chronic tension in muscles like the levator, upper trapezius, cervical & thoracic paraspinals, pec minor, and rotator cuff muscles are often seen as a compensation for inadequate stabilization of the scapula. This may also be a contributing factor in issues related to lack of motion in the cervical and thoracic spine. Often times it is not stretching or mobilization that needs to occur at the thoracic or cervical spine, but rather strengthening & development of neuromuscular control to improve scapular stability.
2. Inadequate Thoracic Mobility
Your scapula, discussed above, has a rather intimate relationship with the thoracic spine. The scapula must be able to slide and rotate on the thoracic spine and rib cage, so a quicker way of discussing this is simply saying: 'Posture & position matters.' The skeletal relationships between the spine, rib cage, and scapula can change the available range of motion at the glenohumeral joint, and places tissues in on stretch or slack which creates insufficiency. These deviations in both joint mobility and tissue extensibility can limited the available motion of the scapula, which then places the glenohumeral joint at risk. This concept has been researched and discussed in the analysis of a tennis serve, volleyball serve, and with overhead throwing / pitching in baseball (though the mechanics are different in throwing).
Note also that we are saying 'inadequate thoracic mobility' and not 'inadequate thoracic extension.' Certainly lack of thoracic extension can be a common finding, and has received a lot of attention with mobility drills aimed at mobilizing and moving into extension or rotation. It is also important to recognize that there are instances where an athlete is actually living in thoracic extension, so adding more extension is unlikely to be helpful...or pleasant for the athlete. These are the athletes that often present with very flat thoracic curves, increased tone of the thoracic paraspinals, and visible winging or tilting of the scapula. The winging or tilting may not be a result of weak serratus anterior, but perhaps is a positional fault by having a curved scapula on a flat thoracic curve which decreases the congruence of the articulation.
3. Inadequate Lower Extremity Mobility.
Keep in mind that athletic movement requires integration of the entire kinetic chain. For an overhead athlete, transfer of force from the lower extremity, through the trunk, and through the upper extremity is necessary to achieve the goal of trowing a 100+ mph fastball or serving in tennis or volleyball. Lack of mobility at the hips, knees, and even foot & ankle have been shown to contribute to increased stress at the shoulder. The same can be said for a highly rotational sports like hockey, golf, tennis, and baseball / softball.
Without repeating what has already been said earlier, assessment of the entire kinetic chain should be performed to identify potential areas that are contributing to the increased stress on the shoulder via a lack of mobility or stability. Studies have shown that lack of mobility at the hip or knee can increase stress on the shoulder in throwing athletes. Additionally, we must look at joints both above and below meaning that limitations at the wrist and elbow can have just as much impact as issues at the lower extremity. This is easy to conceptualize in sports like weightlifting, where lack of wrist and elbow motion may be easier to see when the athlete is trying to achieve the rack position in a clean, but perhaps less so in a combat athlete with sports like judo.
4. Your Program Sucks.
You can't out rehab a poor strength & conditioning program. If with every workout the athlete is continually popping up with shoulder, hip, or back pain and the variables discussed in 1-3 are a non-issue, then it's time to look at the training program itself. What's your volume like? Is there a balance between pushing & pulling? Are you doing multi-joint, multi-planar movements and gaining ownership of the transverse plan? What kind of work/rest cycle are you using for the intensity & goal of the exercise? What are you doing for recovery?
Two focuses here:
1) Form matters. Whether you are doing push ups, working with light dumbbells, working with bands, performing explosive med ball throws, or moving big weights overhead in a movement like the snatch, one thing is certain -- form is everything. If you can't get your body into the proper position to perform an exercise, then there is no point in loading that movement with external resistance as this will just drive compensation and open you up to development of problems over time. Poor form may not stem solely from lack of mobility, but can also come from a lack of neuromuscular control, inexperience with the exercise in question, or onset of fatigue. In any case, continued loading through both load or volume with poor form may lead to injury sooner than later.
2) You need to have balance. Balance between Right and Left sides of the body, balance between pushing and pulling motions, and a balance in strength to offset the forces or loads that the body will have to endure.
Here's a real example of a past patient, we'll give you the short version: High school softball player, potential D1 candidate as a catcher, with a cannon for an arm. She developed shoulder pain in her throwing arm with confirmed small infraspinatus tear and labral pathology via MRI. Went through a course of PT and was no better. Was referred to me by her Orthopedic Surgeon. On evaluation she had a number of finds, a few of which included a significant deficit in Total Range of Motion and presence of GIRD on her affected shoulder as compared to the non-throwing shoulder, deficits in thoracic mobility, and deficits in ankle mobility.
One piece of information I wanted to gather was what kind of strength & conditioning program was she or her team doing. The response was, unfortunately, one we hear all too often -- they had a program that they were given to do in the weight room. Minimal supervision, and obviously created by someone without a S&C background. She walked me through her basic program, which consisted of chest press, lat pull down, chest flies, bicep curls, triceps extensions, a bit of shoulder external rotation with a theraband, and leg work consisting of your basic machine based leg press, leg extension, and leg curl.
Hmmm. No rowing? "Nope." No rear delt or reverse flies? "Nope". No side laying external rotation with a dumbbell? "Nope." You see the pattern emerging...
Their program sucked. All pushing and mostly internal rotation dominant exercises. Very little focus on external rotation or eccentrics, no real scapular stability exercises, and no pulling. No amount physical therapy will combat a program like that...unless you change the program, and that is what we did.
Get Yourself Assessed!
It is worth recognizing that these are just four of many possible contributors to shoulder pain. As an athlete, the first step should be to recognize there is a problem. If your are stretching, massaging, foam rolling, lacrosse ball mashing and taking a regular regimen of vitamin I, yet still having the same pain each day and with each workout over a period of weeks or months --- it's time to get assessed, preferably by a healthcare professional who understands your sport and needs as an athlete. Seeking out this type of clinician is about to get much easier for athletes & coaches, and I am excited for what is to come, so be on the lookout for our announcements during the next week!
A thorough evaluation and movement assessment will yield a great deal of information on how to best address what is affecting your performance. Targeted interventions can then allow you to minimize lost training or practice time, improve your overall movement capacity, and allow you maximize the results of your strength and conditioning program.
Feel free to get in touch with any questions by emailing me at firstname.lastname@example.org or contact me through our website here.
Athletes Physiotherapy, Las Vegas, NV
I won't call it a trend, because I think we are far too quick these days to slap a label on something that has been around for years and dub it as a 'trend' just because it now has a catchy title to spread around the various media circles.
Instead, we'll just call it a 'repeating scenario.'
And here's how this scenario has generally been playing out lately:
Scene 1: Research & Contact: Prospective New Patient calls or emails to get the details of my practice. They are frustrated with the fact that they have been through the system for a long while, they have seen various Physician specialties and numerous rehabilitation and wellness practitioners. Some express seeing some improvement, others not so much, but all have a continued problem with pain. Along this journey they have now amassed numerous diagnostic testing, reports, and varying opinions. They are now confused. The various practitioners they have seen have all given them different explanations -- if they gave any explanation at all -- and they have been given a conflicting list of absolutes. Orthopedic surgeon says there might be something to operate on, but the imaging is not conclusive. Therapist 1 says "never do X, Y, and Z, and in these scenarios keep your glutes tight and your core tight tight and keep that pulled up feeling." Therapist 2 says "no, don't keep that tight, instead stretch these muscles, like this....and make sure you never do A, B, or C, and avoid D every other Thursday".
Like a house guest who's long overstayed their welcome, the presence of pain has them frustrated, irritable, and bordering on hopelessness. The conflicting information between various medical & non-medical advice they are receiving has them confused to the point where they are now at a stand still. They don't know what to do, they are still in pain, yet they continue searching for their answer. Their search has now pointed them outside the 'normal' insurance-based system, and find my practice. Or they find yours - let's be honest, there are others working in similar model to mine, but we certainly are not the majority.
Scene 2: The Initial Visit: Prospective New Patient phone call has now become New Patient Evaluation, as the patient arrives to the clinic. New patient paperwork has been filled out in it's entirety, and along with it comes a stack of reports the size of a local Yellow Pages phone book (that's like the paper version of the internet for phone numbers in your local area, if there area any millennials or younger reading this who've never seen a Yellow Pages phone book and didn't get the reference!). They are very concerned with the content of their various reports, why one doesn't reflect what the other says, "and home come X shows up on this scan but there's no mention if it on this one..." They don't understand why they have pain. They want to know what tissue is at fault, what movement or activities should they stop doing, and what things can they do to take it away and prevent it from coming back.
To this point, this is just all normal initial patient visit stuff. Nothing special, nothing we as clinicians haven't been experiencing our who careers. It's this piece that has been new for me:
Scene 3: The Struggle for 'Who Knows Best':
As a Clinician -- you've gone through the schooling. You've obtained the degree, and hopefully the clinic experience to make you an effective clinician. Hopefully you've also been diligent about continuing education, and not just doing the bare minimum required by your state to maintain you license. You go into these initial patient interactions feeling that, clearly, you know best.
Problem is, so did every other clinician this patient has seen. Yet here they are. Still in pain. Still frustrated. Still unable to do all of the things they want to be doing.
As a Patient -- we often hear a variety of statements pertaining to self-awareness: "I know my body better than anyone else." "I have a very high pain threshold." "I know what I need or think will help but nobody seems to be listening."
Can we argue with these statements? Not really. After all, if pain is an output based on perceived threat to the body, would it not be right to think that the same brain will need to process a context in which the threat is removed. Ultimately, it's the brain at a subconscious level that makes that decision - not the Clinician, not the degree, not the certification or approach, and not even the treatment. Sure, those may all be variables, but driving that ultimate decision is the brain itself.
"But wait, that sounds like placebo?"
Maybe. Maybe not.
Can you say with 100% certainty that the manual therapy technique, exercise, tape application, ultrasound, mono-filament needle are the sole reason for why the patient experienced a reduction of symptoms?
You're sure? Can you really?
Because, I don't think any of us really can. From a mechanistic view point, sure, you can rationalize and theorize how the application of your treatment worked. You may even be right some of the time. The ultimate question still is -- WHY? Not in a Simon Sinek "Start With Why" sort of way, though that is now the case in much of what I do, and is a blog post for another time. I'm simply looking for the 'why' an intervention worked or didn't. And lately, the more I look and the more I search for the answers to that question, the more I am left wanting.
I agree with needing evidence and a solid literature base behind what works and what doesn't. I just wish we had a more meaningful literature base that gave us more 'WHYs' and less 'HOWs'. Because when you really look at it, even the current Clinical Prediction Rules are still 'HOWs' -- you have patient with Low Back Pain, they fit these criteria, you can be confident that manipulation will be successful. WHY?
And here's another not so secret truth -- Our patients are also seeking out the WHY. Unfortunately for both them and us, they have access to the internet, the medical & non-medical opinions of their friends, family, and co-workers. They come from a place of often diluted information and Dr. Oz ridiculousness.
To Be Continued... Clearly, there is much to be done in our world of research and evidence-informed treatment, so there won't be a final scene to this story, but a continuance. I would say there are a few suggestions that I have learned over time that have helped ease the initial patient scenario and help to guide them through a successful outcome:
1. Listen to your patient. Let them have a voice - you may end up being the first and only clinician to do so.
2. Listen to understand, evaluate, and come up with the best course of action. Don't simply wait for your turn to talk so you can spout your opinions.
3. Disagree professionally. This may sound like semantics, but if you disagree with the information they have been given by prior clinicians, do not disregard the information and do not criticize or talk down on the clinician who provided it. Simply share where your view lies based on your training and experiences.
4. Explain what you are doing and why you want to do it. Yes, it can be a difficult task if we don't know all the WHYs behind treatment effect, but you at a minimum should have a strong, science & experienced based theory to work from (note the lack of emphasis between science & experience, they both matter!). The more a patient is aware of what you are doing and the direction you intend to lead them in, the more likely they are to go there.
5. Going along with #4: The patient must be the responsible, active party in the process. This is not a 'fix me' mentality that we foster here, it is one in which the patient recognizes that it is their body, and they have the power & control to improve their situation.
6. Educate, Educate, Educate. That doesn't mean a list of absolutes that they can or can't do. It means teaching the patient to be self-aware, to recognize what they need to do to manage & improve symptoms, prevent symptoms, and improve their function. It means giving them up to date information, and helping them shift their paradigm away from chronic illness and into health & wellness.
Looking forward to your thoughts and feedback!
Athletes Physiotherapy - Las Vegas
In reading and coming across different information and opinions, I find that taking some time to read, think it over, and process the information before conveying my own opinions seems to work best for me, and allows me to be more objective and less emotion-based. That being said, I received an interesting email a few days ago from the American Academy of Manipulative Therapy (AAMT), since I am on their email list and working through their course offerings. The email was a blog post titled "APTA's Vision 2020: Was it abandoned in 2013?" It's a fairly short read and was nice to see someone else connecting the same dots.
If you are not familiar with the original 'Vision 2020' check out the post referenced above. My initial reaction to the new-and-improved updated statement was "Good Lord, how are they going to build public awareness by utilizing a more vague and vanilla vision statement?" The answer it seems, is that they are not. Building public perceptions regarding Physical Therapy - What it is, What we do, Who & What we are capable of treating - seems to very much lay in the lap of each individual Physical Therapist. This is a double-edged sword, and a tangent to the original motivation for this post, so perhaps more on that later!
Anyway, the AAMT email was timely because I had just spent the previous few minutes reading another blog post entitled "Are Physical Therapists Really Frauds?" This was a recent post by Dr. Scotty Butcher, Assistant Professor at the University of Saskatchewan and co-owner of BOSS Strength Institute, and was in response to an article written by Mark Rippetoe a while back. This was good read for me because it brings to light a few problems that exist within both fields of Physical Therapy and Strength & Conditioning. While Rippetoe's article can be viewed as fairly inflammatory and the short-sightedness of some of his thoughts are readily apparent, he does bring out a few good points that the Physical Therapy profession should take note of and take to heart. If you haven't read his original article, it's worth taking a look at.
I also want to clarify that Rip is an expert in his craft, and my intention is not to disagree with or discredit what he is saying. When I say some of his thoughts are short-sighted, I mean that there is no context to some of the statements.
Here's what I don't like about his stance:
Let's start with the car analogy he opens with. Certainly focusing on one part of a car, in his analogy the alternator, without the rest of the car makes that particular piece useless. But on the flip side - you don't tune up a car by simply revving the engine and ramping up the RPM's for a period of time with the breaks on. Saying just load the system and the system will figure it out doesn't always work. It may if your client is an athlete or power-lifter, but odds are that person's system is finding pathways for compensation versus strengthening and engaging the areas of weakness.
His discussion also does not take into account the presence of pain and the neurophysiological changes that have been well documented in the literature. Pain is a game changer. It affects the body's ability to recruit muscles and use motor patterns. It changes the biochemical & hormone profile in the system. If pain is present, simply loading the system and using a "Suck it up Buttercup, You're just weak" attitude won't get it done. This has been well explained in models like the FMS / SFMA where pain is it's own bucket, and is deemed a medical problem warranting medical assessment and treatment.
The other part of the article that is short sighted is the apparent view and assumption that "All PT's are created equal." Despite him giving credit to a "Better than average DPT" who's qouted stating a verbatem comment that I was taught over 10 years ago by a pretty fanstastic PT in the Pilates world, it seems there is this idea that all PT's use tiny correctives with small weights and are heavily based on passive modalities like E-stim, heat, cold, ultrasound, etc. There sad reality is that this is the prevalent view of what PT is and all that it has to offer. And you can thank the 'Big Box,' high volume, insurance-based clinics that accept shitty contracts for $25 per visit and drive volume to make up the difference for this phenomena. The truer reality is that there are quite a number of Physical Therapist who care about what they do, use methods and modalities that are effective and result in actual improvements that push their patients into a post-PT strength & conditioning program.
In his article he asks: "Why do the arbiters of all things exercise – the members of the physical therapy profession – insist that injuries must be rehabbed in a way that's completely different from the way that the uninjured component functions?
Why must they divide the body into its constituent components, figure out a way to make that isolated component function all by itself, and then base their rehabilitation exercises on this faulty analysis?"
I agree with the idea that we should thing systems not individual components, the answer comes in a lot of ways. Let's take low back pain. Is the answer to just teach them how to properly squat and dead lift, just go heavier & heavier, and eventually the person will get strong and the back won't hurt anymore? Eh, Maybe. Or, perhaps you will instead drive that client to get a hip replaced sooner because their back hurts because the hip doesn't move properly. I have seen many clients who's back pain resolved once we teach them how to move from their hips, maintain positioning of lumbar spine and pelvis, intervene with manual therapy focused on the hip, and then once they are pain-free work on loading the system in a way that I think Rip may approve of.
But here's the thing -- If we don't break down those pieces, we don't ever see where the dysfunction lies. If you don't know what's at fault, how are you going to intervene? I think there is danger in saying "Just get strong" at all cost without first going through the steps necessary to allow getting strong to happen in a way that won't be detrimental to the system. Perhaps I am being short sighted in assuming Rippetoe isn't evaluating in this way, but based on his original article, I feel that's a fair trade off.
Here's what I do like, and clearly you will see that, in as much as my initial tone seems down on Rip's article, there is more that I like than that I dislike:
The article brings to light a large disparity that exists between what physiologically & functionally makes sense, and what is sometimes done in the clinic. Too often PT, from an exercise standpoint, is very rudimentary and basic. I had a conversation a while back where the comment was made that "Corrective exercise should be must that -- corrective. It should make the desired change quickly, and we should be then moving on accordingly." This makes total sense to me. If you are doing the same corrective exercises with the intention of rehabbing an issue, I would venture to say you're either not hitting the root cause of the issue, or you are not progressing to the next phase of what is needed for long lasting change to take place. This does not apply to correctives that are used within a dynamic warm up, or as a maintenance/recovery program to keep your body tuned up, as I believe this is a different intention.
Traditionally PT never gets to the heavy lifting. Too often we see Outpatient physical therapy clinics who do not have a dumbbell over 12#. They have no cable columns. They have no barbells or kettlebells. They don't do body weight training beyond supine bridging, prone extension, quadruped, or the occasional front or side plank on a plinth...yet they advertise and promote specialties in Sports Medicine. How do the athletes get back to playing and ready to take on the stresses of their sport given all they have had is manual therapy, heat/ice, E-stim, and a few basic theraband exercises?
The answer too often is -- They Don't.
Not that they don't return to sport, they just usually see a personal trainer or strength coach who works to make up the difference. Why is this? Well, physical therapy is too often controlled by the insurance carrier. If the athlete has full range of motion, is mostly pain-free, and is deemed to have "good 5/5 strength" by means of crappy break testing, then they are discharged. At that point the physical therapist's hands are tied and the patient is discharged. Being in a non-traditional setting, this is not the norm for out athletes. We are able to intervene to get them out of pain, work to improve the things that require improvement -- soft tissue mobility, joint mobility, neuromuscular control, etc. and the work on reloading the system through strength training. Or, in cases where they have Strength & Conditioning and Skills Coaches, we can work with those professionals in a team approach to fill in the gaps.
I also do like the awareness brought to the idea that muscles work in systems and subsystems, not just in individual isolation. The rotator cuff and hip rotators do much more than rotate the shoulder and hip. How often are you training the stabilizing functions of these muscles as opposed to just concentrically & eccentrically loading them?
Last bit -- I believe that pointing out problems without proposing solutions is really just complaining. Rather than just pointing out the issues seen within the physical therapy profession, it would have been nice to see some suggestions beyond garbage advise like "Think twice before you listen to a physical therapist or rely on his weenie "corrective" exercises" or "You know how to get strong, so stop taking the easy way out and justifying it with big words and questionable science." I'd rather build bridges between professions than walls, but I'm sure that kind of thing doesn't get as may Facebook likes or T-Nation Article views. Inflammatory titles and bold claims get readers and keep attention. Hopefully if you're still here by now, I've managed to do a bit of both. My suggestion is two-fold:
1) Physical Therapists need to get better at strength training and building true strength versus just neuromuscular adaptations. This is certainly limited by time frames and insurance restrictions, which leads to the next point,
2) The Physical Therapy profession at large needs to do a better job of breaking insurance carrier control over care, and improve the public awareness about what we do and how well we often can do it -- provided of course, that it is being done well, and too often it's not.
3) The Personal Training and Strength & Conditioning world needs to be able to identify quality Physical Therapists and other medical professionals who speak their language to build working relationships with. There certainly is a ton of benefit that can be gained by both partied and their clients when the two disciplines work together
In summary, the Physical Therapy profession is in an interesting place, at least in the arenas of Outpatient Orthopedics and Sports Medicine, which is where much of this conversation applies. As health insurance costs rise, patient's out of pocket responsibilities rise, the pressure will be put on the Physical Therapist to be able to make effective, lasting change quickly. The consumer will demand it, and the system is rapidly evolving.
A recent systematic review by Ojha et al. found that a lack of public awareness and limited third party reimbursement were the two primary barriers preventing physical therapists from seeing patients directly without referral by a medical physician. In short, the public doesn’t know what physical therapists treat or how we go about treating it.
Athletes Physiotherapy - Las Vegas, NV
Kristopher Bosch, PT, DPT, ATC, FAAOMPT is a practicing physical therapist and athletic trainer in Las Vegas, NV where he founded Athletes Physiotherapy. Located in Henderson, Athletes Physiotherapy specializes in Orthopedic & Sports Physical Therapy with a niche in High Performance.
Physical Therapy for Temporomandibular Joint Dysfunction, aka 'TMJ' or 'Jaw Pain'
Jaw Pain. TMJ. TMD.
All are ways of describing the same thing -- pain associated with the Temporomandibular joint. It is estimated that about 15% of the American population suffers from some kind of cranio-facial pain which can be in the form of Temporomandibular joint pain, facial pain, headaches, and even ear aches.
Interesting enough, this condition affects women twice as often as men, and is the most frequent non-dental cause of chronic facial pain. Symptoms may result from an injury such as car accident, direct blow to the jaw, or collision during a sporting event, or it can come on without history of trauma.
Patients with TMD often describe a variety of symptoms: local pain at the TM joint itself, clicking when opening or closing mouth, pain or joint noise when eating hard or chewy foods or yawning, headaches, ear aches, ringing in the ear, difficulty opening their mouth wide, deviations or shifting of the mandible when opening/closing their mouth, and pain or stiffness with waking which is often attributed to them 'grinding their teeth.'
How Can Physical Therapy Help TMD?
Good question. And one I generally get immediately after telling someone that physical therapy can help their TMD. There are a number of variables that may contribute to or effect the TM joints. As with anything, we start first with a thorough evaluation. We are not just looking at the TM joints alone as the site of pain -- we want to get to the source of it. What is causing the TM joint or joints to be painful? A thorough evaluation would have the following components:
1. Postural assessment: Looking at the entire body, how is the individuals sitting and standing posture.
What is the orientation of the cranium on the cervical spine, cervical on thoracic, scapula on thoracic,
2. Examination of the jaw: A local examination of the TM joints is done to assess ROM, joint mobility,
and motor control.
3. Examination of the cervical spine, with particular emphasis on upper cervical region.
4. Examination & screening of motor control and movement patterns.
From here, we should have a good idea of what is contributing to the presentation of TMD. Especially in cases where there is not mechanism of injury, odds are compensations or changes in the system over time have lead to the restrictions in joint mobility, motor control, and postural organization that are seen during the evaluation.
Okay, so we confirm what the patient said coming in "I have jaw pain!" Hopefully we have an indication of what we need to work on to get the patient out of pain and back to their normal life routine, so now what?
There are a number of treatment options that we utilize in the quest for a successful outcome. Treatment options include:
1. Education: Educating the patient serves a number of invaluable purposes. First, we attempt to
decrease the perception of threat and intervene to minimize the persistence of pain. Second, we get
the patient to become aware of things that provoke symptoms, thing that relieve symptoms, and how
the move and carry their body on a daily basis. Third, we teach them how to avoid provocative
maneuvers, perform things that provide relief, and improve their sense of control over their health
and outcome. A fourth benefit that hopefully ensues for the first three is increased patient buy-in and
compliance with the treatment plan, which will help yield a positive outcome.
2. Manual Therapy: Manual therapy can be performed to improve soft tissue and joint mobility, and
can be aimed at restrictions found during the evaluation. Often times patients will present with limited
OA and upper cervical motion, restrictions in posterior soft tissues such as suboccipitals, and may
have limitation in thoracic motion and scapular stability.
3. Exercise: Exercise is utilized to help improve motor control, restore joint mobility and improve
postural organization, and provide a positive movement experience where the patient is able to move
with little to no pain and/or achieve pain relief through exercise.
4. Dry Needling: Dry needling is a very effective way to manage headaches and tissue tension, and
manage pain. This is a modality that I am using more often and much earlier in treatment of TMD,
and so far has been quite beneficial in making change quickly.
If you or someone you know living in Las Vegas or Henderson is experiencing symptoms of TMD, or you have been diagnosed with TMD but have seen a physical therapist, then I encourage you to contact our office and schedule your initial physical therapy evaluation. Let's see what we can do to get you out of pain and back to your normal routine!
Contact us today at (702) 930-8155 or BOOK YOUR APPOINTMENT ONLINE HERE!
Athletes Physiotherapy - Las Vegas, NV
Sports Physical Therapy, Performance Enhancement, and Athlete Development for Las Vegas & Henderson, Nevada
Falling of Deaf Ears - The Communication Barrier in Healthcare
There seems to be a rather common communication barrier in Medicine/Healthcare.
Day in and day out, I see patients who express a common pattern of frustration -- a lack of communication between them and their healthcare practitioner. This may be a Primary Care Physician, it my be a Specialist or Surgeon, it could be their last Nurse while in hospital, or it could be their last Physical Therapist or Chiropractor. Being an out-of-network provider, by the time the get into my door, most have been through the system and are seeking something different. I am by no means the only physical therapist in Las Vegas practicing in a small, boutique practice and seeing patients one-on-one, let alone across the country, but our style is certainly not the majority.
The common complaint is that the patient does not feel their voice was heard. They do not feel like what they were conveying was listened to, understood, or they many not have even had the opportunity to ask their questions or voice their concerns. Many patients state that their wait for the appointment was long, sometimes multiple hours depending on the office, and their actual time with the Provider is a matter of minutes. Others complain that they didn't get to actually see their Provider but instead saw their support staff or extenders. While these extenders may be great and provide the same high quality of care, perception once again rules.
With the continued trend of ever declining insurance reimbursements, many offices are seeing a higher & higher volume of patients and the Practitioners may simply have less time to spend with each patient. As Physical Therapists we have a unique position in that our patients are generally with us for an entire hour or half hour. We start by listening, by asking for their take on what their issues are, what their goals are, and what they feel is going to work for them. We can often alleviate a lot of anxiety and misunderstanding just by answering their questions and explaining what we are doing and how we can help them.
Far too often clinicians discount the value of the patient's take on what they think is going to work. Sure, you do occasionally get the patient that answers "I don't know, you're the one that went to school for this" -- touche -- but most have some idea of what they perceive as beneficial. Often times, they are right. Put another way, as an individual we often say "Well no one knows my body the way I do, because it's my body and I am conscious of it every day." Okay. So why is different for our patients? Would the same stance not apply to them?
Communication is key, and is coupled with Education. What you say, how you say it, and what the patient's perceptions are can make all the difference in the world. A patient who understands the plan, what you are attempting to accomplish, and why it can benefit them is far more likely to buy into the treatment plan and be compliant with their home program.
If we as Healthcare practitioners are going to effectively and efficiently help anyone, it would seem that the first thing we would do is listen to what the patient or client's problems are and what they are wanting to overcome or get back to doing. It is a bit ironic, given the first step in any clinical appointment is the history taking interview. It seems that this would be the first place where the patient would get to voice their needs.
Additionally, setting Patient Goals are an important part of treatment planning, and will ultimately help the clinician to establish Treatment Goals, both of which should be reflected in programming. If the goals of the patient do not align with the goals of the clinician, there may be resistance from the patient. Likewise, if the goals of the patient simply are unrealistic then certainly a conversation needs to be had on why the clinician feels their goals are not realistic. Take our average mid-40s office worker who tears their ACL and has to undergo reconstruction surgery. If the patient feels they are recovering too slowly based on the fact at Adrian Peterson returned to playing so quickly after he had his reconstruction surgery -- we may have some unrealistic expectations.
As Healthcare Practitioners, the last thing we want is for our patients to feel like their voice is falling on deaf ears. I find that looking back on past experiences, it seems that there are some offices who have found a way to make it work. One Orthopedic Surgeon had a Patient Care Coordinator who basically was the go-to person that could answer the patients questions and provide a direct line of communication. Other offices utilize a nurse or MA for this role, and in most cases these offices had a rather low rate of patient complaints. Again, the Practitioner may have provided great care and done everything they should have and more, but if the patient feels they were not heard or they do not understand why they are scheduled for a certain procedure or why certain test was not ordered, their account of the visit may not be as positive as it should be.
At the end of the day our goal is to help as many people as we can, as much as we can, and to the best of our ability. Mindset of the Practitioner is also another key variable. Clinicians who are overworked, stressed out, and frustrated themselves will often find the encounter with the patients clouded by it as well. Even when trying not to let it show, if the Practitioner is thinking about the other 3 exam rooms that have patients waiting to see them, they will not be present with the patient currently in front of them. Being present, in the moment, and aware of the encounter occurring at that time will often yield a much more fulfilling experience for both the patient and the Practitioner.
The business side of healthcare will most likely always exist, and it is understandable that there has to be balance as it is after all a business. Hopefully we can continually work to listen to our patients, provided them a level of services greater than what they expect, and have a business that is rewarded for quality more than volume. Either way, it begins and ends with communication.
Athletes Physiotherapy - Las Vegas, NV
f you are an athlete or coach curious about how Athletes Physiotherapy can help you get out of pain, get over an injury, maximize your training, and improve your performance, then get in touch by calling 702-907-5107, email to email@example.com, or schedule your initial visit here: BOOK MY SESSION
Sports Physical Therapy, Performance Enhancement, and Athlete Development for Las Vegas & Henderson, Nevada
Movement Screening & Athlete Management: Athletes Physiotherapy & Van Hook Sports Performance -- A Team Approach to Physical Therapy & Performance Training in Las Vegas, NV.
Movement Screening & Athlete Management
There is a lot of talk and controversy surrounding the use of Movement Screening. While there are a number of ways that you can screen movement, I think the more commonly utilized & discussed are the Functional Movement Screen (FMS) & Selective Functional Movement Assessment (SFMA). For detailed information on these two programs, see the folks over at functionalmovement.com as there is a plethora of information! Here's my disclosure -- I don't have any financial incentive to refer you to their site, it simply is the easiest way to shorten this post provide you with resources to answer questions you may generate.
That being said, these two systems are separate but interrelated. The FMS is often looked at as the Fitness Screen, ie it can be used by anyone who deals with movement in absence of pain. This includes personal trainer, yoga & Pilates teachers, martial arts instructors, physical therapists & chiropractors, etc. The SFMA is looked at as the Medical Counterpart to the FMS. There are a number of ways to use the FMS in practice:
As an example, let's say "Joey MMA Figher" comes in to train in preparation for their next fight. He is put through the Functional Movement Screen and is found to have hip pain during a few of the tests. If it is the Strength Coach performing the screening, he then punts to the Physical Therapist and says 'Hey, "Joey Fighter" has Left hip pain during the Overhead Deep Squat, Left Hurdle Step, and Left In-line Lunge.' This should trigger 3 things to happen:
For information on Screening and Athlete Management, check out the Athletes Physiotherapy Website or contact us by phone at 702-907-5107 or email to firstname.lastname@example.org
Treatment & Training Packages are available, and for the month of January 2015 Athletes Physiotherapy is offering FREE FUNCTIONAL MOVEMENT SCREENING. Contact us today to schedule your Screening Session!
Athletes Physiotherapy is a physical therapy clinic located in Henderson, NV in the southeast portion of Las Vegas. Our focus is on High Performance Physical Therapy with an emphasis on sports, dance, and orthopedics. We provide one-on-one, individualized care for rehabilitation and performance enhancement.
You Are Not Your MRI
When the discussion of an MRI comes up, I hear two main complaints from patients. One is the patient who is frustrated and doesn't understand why they have not yet had one, and how we as Physical Therapists can treat them without it. The other is the patient who has had one, and now is convinced that they will not improve because of what the films showed, as if somehow the pathology is a separate live entity which is free to do what it will to their body's. These are the patients who start conversations with "my disc herniation won't let me..." or "my sciatica doesn't want to..."
While your MRI may be an image of your own anatomy, it is imperative to understand that you are not your MRI. Presence of something that differs from the "norm," be it degenerative changes, disc bulge or herniation, increase or decrease in angle of lordosis, etc are all just that -- presence of something that differs from the norm. Certainly there are times when the pathology is severe, correlates with symptoms, and does not respond to conservative therapy. The point is that presence alone is not enough.
So often I hear patients express that their ability to heal, progress, or return to all the activities they enjoy is somehow not possible because of what their MRI films show as per the "my physician said this was the biggest disc herniation he/she has ever seen, and couldn't believe I was still walking."
REALLY? Act responsibly much???
As a healthcare practitioner, we must be mindful of our words and what we tell out patients. While there are varying opinions on this topic, there are many who view the MRI as doing more harm than good. Absent any 'red flags' that would trigger an immediate MRI being performed, there are many insurance carriers who have in their back pain protocols a stipulation that a course of physical therapy be completed before an MRI is obtained. Why?
Take this test: I want you to identify from the MRI images below which of the 3 patients is having low back pain currently and which has no pain and actively participates in all activities?
It's okay. Take your time, review them thoroughly, and I'll be here whenever you are ready to take a guess.
Because trust me, all you can do is guess.
There is no way to know who has pain and who doesn't just by looking at an MRI. Don't take my word for it, the research is pretty conclusive on this. Pain is an output, not an input. If there is no perception of threat by the brain, the then will not be presence of pain. Perhaps that is why some patients have "terrible" MRI films and have no pain, and others have "normal" or "clean" films but are in severe pain and can't function.
Is there a place for the MRI? Of course there is. But, let's try and be responsible. Let's evaluate the patient thoroughly and order diagnostic testing to confirm your suspicions or rule out others. Too often we see 'Reactive Medicine' being practiced where a battery of tests are ordered, and then a diagnosis is established. I have conversed with many MD/DO's of the 'old school' who will tell you that is absolutely backwards. Let's perform a good physical examination, with a solid orthopedic examination and movement testing (assuming the other system screens and neurological exam are normal) to identify movements that increase or decrease symptoms. Let's education the patient as to how pain works, and how based on the educated clinical decision you have come up with, physical therapy can help them (assuming that is the case, of course). If the conclusion is that physical therapy will not be helpful, or the patient warrants additional work up or another professional's skill sets, the educate the patient as to why you have come to that conclusion.
Here are a few pieces of literature to check out on a rainy day!
Living in pain is difficulty, it can also be unnecessary. If you are continuing to experience back pain or unresolved pain after an injury and you're in Las Vegas or Henderson, Nevada, then give Athletes Physiotherapy a call. If you haven't yet had physical therapy, this may be the conservative treatment option to get you out of pain and back to your normal routine. If you have already had physical therapy in Las Vegas or Henderson, but saw little lasting change, or were unhappy with the services you received then give Athletes Physiotherapy a chance and experience the difference first hand. Call 702-907-5105 or schedule directly from our website at www.athletespt.com.
Athletes Physiotherapy - Las Vegas, NV
Athletes Physiotherapy: specializing in High Performance Physical Therapy, Sports Physical Therapy, Dance Physical Therapy, Orthopedics, Athletic Training, and Performance Enhancement. Helping athletes, dancers, and active individuals in Las Vegas, NV & Henderson, NV get out of pain, move better, and achieving more!
7 Myths About Physical Therapy - via MoveForwardPT.com & the APTA
You can view the whole list in detail HERE, it's a good read and many of these are things that I have commented on in recent past.
Here are the 7 Common Myths as they have listed them. Comments below each listed are my own, and I encourage you to read the Fact responses to each at the link above:
1. Myth: I need a referral to see a physical therapist
Nevada is a Direct Access State, meaning that a physician's referral is not required to see a physical therapist. HOWEVER, there is still a level of control held by the insurance companies in which most will require you to obtain a physician's referral in order to cover it. If you are not billing insurance (as we do not), then you do not need to obtain a referral for PT, in most cases saving you the trip to your primary care physician and allowing you to start PT faster!)
2. Myth: Physical therapy is painful.
You often start physical in pain. The goal of physical therapy is to get you out of pain, and able to move and function without it. The first step in the process is discussing what pain is & is not, where pain comes from, what purpose it serves, and how we can get you beyond it.
3. Myth: Physical therapy is only for injuries and accidents.
You can see a physical therapist for an injury, after an accident, after a surgery. You can ALSO see a Physical Therapist for all of your wellness needs. Wellness to most people means exercise & nutrition, so it is important to seek out a physical therapist who is knowledgeable in these areas or works in a team setting to get you the best results. You can also be seen for general maintenance - we change the oil & rotate the tires on our car to keep it moving and performing well, why would we not treat our bodies the same? A combination of good orthopedic manual therapy, dry needling, and tailored exercise can keep you moving and performing at your best. Why wait to see a physical therapist because you have an orthopedic problem when you have the option of avoiding the orthopedic problem all together!
4. Myth: Any health care professional can perform physical therapy.
All health care professionals can not perform physical therapy. If they are not a licensed physical therapist, they are not performing physical therapy. Please remember that physical therapy is a Profession, it is not just a collection of thermal & electo-modalities. What that means is Physical Therapy is not heat/ice, ultrasound, electrical stimulation and massage. In fact, if this is essentially the treatment you are receiving in a clinic, you need to RUN, not walk, RUN to another provider. I often here patients tell me they received physical therapy in their physicians office, only to find out that it was one or two of the above mentioned modalities. Surprised that after a few 'in-house' treatments they were still in pain and dealing with the same issues -- I'm not.
5. Myth: Physical therapy isn't covered by insurance.
This is the only Myth/Fact I would be careful on. Physical therapy coverage is highly dependent on the insurance carrier you have. They set the rules in your plan, so verification of benefits before you start treatment is recommended. Again, Athletes Physiotherapy is an out-of-network provider, so we do not deal in this realm often. Our patients can submit a claim to their insurance in many cases, but what & if you get reimbursed depends on all of the same details - do you have an out-of-network deductible/copay/coinsurance??
6. Myth: Surgery is my only option.
There is a growing body of literature suggesting that physical therapy may be at least as good as surgery for many orthopedic conditions. The best plan is usually to exhaust all conservative care measures first, and if there is no response and surgery is recommended, then in some cases that is the only option. However, these cases are far less frequent that one might imagine. There are certain 'Red Flags' that are looked for when your physical therapist or physician first evaluates you, which may be an indicator that surgery is required as the immediate treatment option. In this case the physician will explain what they are finding and why surgery is necessary. It is not uncommon in clinic to have patients who are told they need surgery, for example on their shoulder, but are referred to physical therapy and make significant improvement to where they did not end up having the surgery. We don't treat your MRI or x-ray films, we treat you - the person. That's a whole other topic altogether!
7. Myth: I can do physical therapy myself.
Ah, yes. While a 'Can Do' attitude is a great thing in most cases, this is not one of them. Seeking out evaluation and treatment from a qualified practitioner is the best way to ensure a speedy & full recovery. Understand that I am not taking way a person's ability to be active in their own care, the responsibility is yours as the patient. What I am suggesting is that you look at it like a coaching relationship. Even Tiger Woods and most Pro Athletes who have been in their game for decades still have coaches to help them improve. You may be able to do much of your PT program on your own (many of my patients only see me 1x/week) but having the evaluation/screening and foundation built, and receiving guidance on where to put your efforts -- these are the things that are missing when we go it on our own!
Hope that helps to start clearing up the misconceptions that exist around physical therapy. It is a big topic, with lots of variables!
~ K. Bosch
Athletes Physiotherapy - Las Vegas, NV
If you haven't read it yet, I would suggest checking out the recent post by Dr. Moseley as that is one of a number of things that got me thinking this week about Clinical Decision making. Here is a link to his post:
First, do no harm - by Lorimer Moseley
I do 100% agree with Dr. Moseley and his NOI / BIM group colleagues, as these brilliant clinicians and scientists are really leading the pack when it comes to the concepts we utilize in clinical practice related to pain science and the neuroplasticity of the brain. In no way am I challenging what is being said.
I do have a number of questions, however, and hopefully by posing them here to the world I can dialogue and gain some clarity.
My personal beliefs and biases are not set in one system versus another, but rather doing what works, is in the best interest of the patient/client, is in line with the patient/client's goals & beliefs, and makes the most lasting change in the shortest time possible while minimizing their risk of adverse events.
Tall order, I know....
My questions are not based in the dogma of 'doing because that's how it's been done', or in defense of a bias toward manual therapy & exercise interventions and the biomechanical mechanisms that have been beaten into my head over the years. Rather, they are an attempt to decipher where & how all these things fit together -- because my personal thought is that they can, and do, exist together every day.
(Sidenote - I have not yet watched MedBridgeEducation's Pain:Where Does Biomechanics Fit, it's on my short list, so don't hate on me too much about that!)
Sometimes I get sucked into blog posts, more the comments than the posts admittedly, when topics of pain, structure, function and the dreaded Evidence-Based Practice are thrown at each other. Clearly there are some with very strong beliefs one way or the other, which is cool. I mean really, we all have to believe in something. We wouldn't be doing what we do if we didn't.
'The Old School' was the Biomechanical/Postural/Structural Camp. The 'New School' seems to be the Pain Science & Movement Camps, and they are very separate and distinct camps. Sprinkled between & within these groups you have a good mix of the (Soft tissue & Instrument Assisted soft tissue) Mobilizers, the Manipulators, the (Dry) Needlers, the Screeners, the Tapers, and the Hands-offers. I guess there still are a few Shake & Bakers, but they don't often get into conversations like these.
Often with the changing of Schools, the pendulum swings from too far in one direction, to too far into the opposite direction. I'd like to maybe slow the swing and see if can land somewhere in the middle in an attempt to have the greatest reach and help the most people in the process. I venture to think that each School is correct, and each has their place. Yes, it's true and I am not ashamed -- in the Chiro world I would be a Mixer.
So if you bare with me, these are in no special order. Maybe some of you have had similar thoughts, maybe my thinking is on point, or maybe I am just out in left field somewhere...
1. All pain starts as acute. True. However, we base this definition solely on chronicity - pain that lasts beyond our definition of acute (first 2-3 days) & subacute (2-3 weeks) and is "beyond the time of normal tissue healing" is dubbed chronic (greater than 3-4 weeks). Where does "chronic-acute" fit into our definitions, and is that a concept clinicians are looking at.
I am not questioning the timelines or definitions. What I do question is the idea that chronicity and tissue healing are the only things at play here. The idea of chronic-acute as I was taught it, was that a person has an issue, say low back pain as an example. They have an episode, it lasts a few days, within a week it's gone and the patient is back to doing everything. Two months later, it happens again, and again, and again. The patient may get sick of the recurrence and see out medical advice. Or, the pain may stick around "longer than it normally does" which prompts them to see a medical professional.
Certainly the brain is perceiving a threat, which is why the patient has pain. But why repetitively. Why does someone make what seems like a full recovery only to repeat the cycle. Is it not plausible to look at things like biomechanics and movement patterns to identify a potential influence or cause of these chronic-acute episodes of pain?
2. Biomechanics Doesn't Matter -- is essentially what I am hearing and seeing from those who pounce on the idea that they do. I get this is probably a small population, but it has a big voice, so the question is made. It usually goes something like "the research says;" "pain is the brain, not the joint/muscle/tendon/fascia;" "manipulation is neurophysiological,it's all the brain." And on, and on.....
So, can we all just agree that the brain rules the roost, that nothing happens without it making it so, and that in every & all instances pain is as it is defined" the brain's perception of threat to the body."
It's an output, yes. Very well, I agree & understand -- But how does that discount or some how negate mechanics/structure and impact that clinical tools like movement assessments or manual therapies have in successfully treating patients every day? Just because a study's conclusion of " 'X' intevention versus 'Y' intervention yielded that neither was found to be superior to the other" doesn't mean we discount one or both. Perhaps we need to start asking better questions. Perhaps we need to tighten up our research design.
I know - big talk from a non-academic who isn't doing the research. But -- pehaps that's also part of the problem. Perhaps we as clinicians need to get a bigger voice and start posing the questions.
3. Terminology Sucks: Agreed. And I gather this is at the heart of what Dr. Moseley is getting at. Maybe it's not the looking at variables like structure that is the problem, perhaps it is the way in which we communicate the what we are looking for and why we feel it is relevant that is the issue. Is it relevant? Maybe, maybe not.
Someone can't rotate their neck due to pain and restriction, you apply manual intervention (really don't care what in this instance, MDT, soft tissue mobilization, joint manipulation, dry needling) and they then can move there neck and rotate with no pain, to me the structure mattered.
With regard to terminology: I kid you not, as timing would have it, I had a patient today who had a Nerve Conduction Study done yesterday by their Neurologist. Patient has been doing great. Long history, and without violating HIPPA what I will say is after being in pain for 12 months, having no relief with 'shake & bake' out patient physical therapy, we had them pain-free most of the time within 4 visits and when they had pain it was rated as 3/10 as opposed to the 8-10/10 they had been dealing with. (And when I say We, I refer to the patient & I - it's a team approach, we as clinicians don't 'fix people').
Today: 7/10 pain. Why? Because they were told they had a pinched nerve, and was shown diagnostic proof. The patient even recongnized and identified this as the trigger without any prompting or suggestion. They were then presented with the referral to pain management, which they refused, being the smart patient they are. "Why should I do that when PT has gotten me so far is such a short time? Wouldn't it make sense to do a few more visits and see if there is any pain left to even manage? (Right! It's great when they get it!)
Terminology, explanation, rationale. All of the communicating we do with our patients matter. This is where we fail. We also fail when we take things away from patients with our absolutes: 'Never bend over;' 'Never squat;' 'Never deadlift; 'Never run,' but that is another blog post all of it's own!
So now that we have gotten that out, here is the last question which kind of is the Grande Finale of sorts, as it comprises the first 3:
4. How are clinicians treating in clinic if mechanics, manual therapy, & exercise don't matter? And how we will we as a profession continue to exist if the majority of what we do is considered fodder based on the pain science explanation and EBP literature?
I will tell you, as I admitted earlier, that I am a mixer. In working with said patient above, I can tell you we did do the explanation of pain and where it comes from/what it is talk the first day along with the evaluation. And upon next visit -- they still had pain. Their sessions also included breath work, manual therapy, and exercise. Can I say definitely what 1 thing made the difference? No, I can not - at least not you your approval or that of the research which demands reproducability. Tricky thing that reproducability, as we have yet to reproduce two exactly the same human beings who act, feel, and experience exactly the same, even among twins. So why are we so bent on reproducible results when the next person is not the same as the last?
Yes, I still worked at correcting perceptions that I think are incorrect or not optimal related to pain, where it comes from, and should it be provoked (patients come up with the darnedest things!)
So how should it be done. Should each visit simply be a discussion of pain neurobiology? Is it the act of discussing it that makes the difference? Is it really that simple? If it were wouldn't Psychology be having far greater 'wins' in this realm if it were? I have seen many patients seeing the "Pain Psychologist" who still had chronic pain despite all of those sessions. Is perhaps the act of seeing the "Pain Psychologist" by title a reinforcement of the somatoemotional component of pain? (yeah, I went there!)
I know -- more questions than answers, welcome to the world of my brain.
Placebo. There is also the argument that manual therapy, exercise, etc. work, 'but not in the way we think they work.' No kidding. And we wonder why PT has an identity problem...again, topic of another post.
Back to Placebo. If we can show that placebo makes an impact as seen in brain imaging studies. And explaining the pain neurobiology also has an impact as seen in brain imaging studies. And manual therapy & dry needling also have impact as seen in brain imaging studies...is it super far fetched to ask whether the conversation ie counseling that you are giving patients about pain is also a placebo?
Is it possible that one patient's brain perceives threat differently than another patient's, which is why one patient responds to one intervention, and one responds to another, and both have a positive outcome?
Things that make you go Hmmm....
Oh, and despite all the questions and the elementary nature of some of them, I really have read a lot of the literature on the topic. Perhaps I'm just not looking at it through the right lens...
I'll cut it off there.
Love to hear feed back, criticism, or just your two cents.
Athletes Physiotherapy - Las Vegas, NV
Thank you for stopping by the Athletes Physiotherapy Blog! Kristopher Bosch founded Athletes Physiotherapy in Las Vegas, NV. He is a Father, physical therapist, athletic trainer, pilates teacher, & perpetual student!
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