PhysioWorks, Sports and Wellness https://physioworkshsv.com High quality, individualized and evidence-based Physical Therapy for Huntsville, Madison, and North Alabama Mon, 22 Jan 2018 16:33:47 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.4 https://physioworkshsv.com/wp-content/uploads/2015/10/cropped-favicon-32x32.png PhysioWorks, Sports and Wellness https://physioworkshsv.com 32 32 I Want a Scan Doc! https://physioworkshsv.com/i-want-a-scan-doc/ https://physioworkshsv.com/i-want-a-scan-doc/#respond Fri, 19 Jan 2018 21:24:10 +0000 https://physioworkshsv.com/?p=4373 When we have an injury or pain it is very tempting to want to know exactly what is wrong!

“Why can’t I just have an x-ray or MRI so that we are certain it is only a sprain!”

I understand this wish, but if we imaged every little pain or injury, our medical care would be even more expensive than it currently is. There are even circumstances where imaging can have negative consequences! So, the gatekeeper to imaging needs to be responsible and judicious. This blog we’ll look at the main types of imaging that are used in orthopedics and sports injuries and give you some idea of when and why they are used.

Radiograph (aka, X-Ray)

People often use the term X-Ray interchangeably with a radiograph. You are having an X-Ray in the sense the body absorbs X-Rays, but the image we see at the end is a radiograph. The different structures of the body absorb certain amounts of X-Rays which gives us the nice (or nasty!) picture. This is a simple 2-dimensional picture and can be taken in different positions to give us the view we want.

Radiographs simply show bone and space. With contrast (injected or consumed solution), they can show other things, such as blood vessels and food traveling down the esophagus (In the form of a live x-ray called a fluoroscopy).  

Normal knee radiograph xray medial and lateral compartments

Image 1: A normal knee- green line marks the joint line of the femur (thigh bone), the two blue lines the joint line of the tibia (shin bone). You can clearly see good space there, indicated by the two marron vertical lines. The two yellow and purple vertical lines demark the lateral and medial (outside and inside) compartments.

Sometimes I hear people say that they had an X-Ray and were told they have worn cartilage – this is not really true as you cannot see cartilage on an X-Ray; instead they are making an inference that there is less space and therefore less of the soft tissue (cartilage) that should be there. While this might be true if you opened up the knee, it may not be the most helpful thing to tell the patient. They walk away from the appointment thinking they have a horrid arthritic knee when in fact, that may not be the cause of their pain! X-Ray has become a formality in medical and chiropractic care when it should not be. X-Rays are harmful, so they should be used only when necessary. In musculoskeletal care, they should be used when there is a concern of fracture or other significant pathology. If someone likely has a soft tissue injury, e.g. muscles, tendon, ligament, or disc, it likely is not appropriate. This principle has been considered with ankle sprains in the form of rules to help decide if there is a risk of a fracture and benefit of a radiograph (see our blog on this here). It has also been looked at by professional groups as part of the Choosing Wisely campaign which many countries take part in. The in 2017 as their first contribution to this campaign stated:

 

Chosing wisely on imaging

*(Red flags are symptoms of significant pathology that need an immediate intervention – e.g. include neurological deficit such as weakness or numbness, any bowel or bladder dysfunction, fever, history of cancer, history of intravenous drug use, immunosuppression, steroid use, history of osteoporosis or worsening symptoms.)

 

As you will see in these example of imaging and low back pain there is a consensus amongst the medical, chiropractic, and physical therapy organizations that certain things need to be met in order for imaging to be ordered and be useful. Some of you will read this and may realize that you have had imaging that is unnecessary. I have seen this in my patients, which is why I think it is good to publicize the result of these campaigns. I have even had patients who have had recent good quality X-Rays that were taken elsewhere, who have gone on to visit a local doctor and be told by support staff they need to have a new X-Ray using their equipment… The doctor might not be aware of this, but the X-Ray was ordered without a doctor having seen the patient! Rant finished, let’s look at the other imaging options that are out there:

Nuclear Medicine Imaging (CT, PET, SPECT scans)

In a Computed Tomography (CT) scan, many X-Ray measurements are taken to provide us with slices or a cross-sectional representation of the body. Positron Emission Tomography (PET) and Single-Photon Emission Computerized Tomography (SPECT) scans are also forms of CT scans, but use different forms of radiation than an X-Ray. Each of these technologies has their use in various types of medicine and industry. In orthopedics, CT scans are typically used for imaging fractures that are more complex and will require surgical fixation. Whereas a radiograph gives us a 2D view of the fracture, the CT scan gives us a 3D view which can be viewed in 2D or can be looked at in a 3D model. This allows us to see the route(s) that a fracture takes through the bone. In a fracture that is fragmented (comminuted) it helps visualize the fragments of bone and helps the surgeon plan how they will put it back into a normal anatomic position and what hardware they will need to use. Like X-Rays, nuclear imaging may also use contrast dyes to help identify other issues. These scans are used in other conditions in medicine from cardiology to oncology.

 

Bone scan tibial stress fracture

Image 2: A bone scan (Scintigraphy) of a stress fracture of both tibia!

Acetabular fracture CT scan

Image 3: The arrow on this CT scan shows a fracture to the acetabulum (the socket of the hip). This a 2D slice of the body a little below the waist looking from the head to the toes.

3D acetabulum CT

Image 4: A 3D model using CT data of an acetabulum fracture – we can see a complex fracture with lines in the front and the back of the socket.

Magnetic Resonance Imaging (MRI)

MRI uses a magnetic field, radio waves, and computation to determine the alignment of hydrogen atoms in the various tissues of the body. NOTE, there is no radiation involved! The main risks are if someone has metal objects or implants in their body, so they should make sure they tell their provider about this as this might make this an inappropriate scan. The alignment of hydrogen atoms is detected as a signal, and the differences in the signals give us our image. Some signal differences also indicate a pathology. As with CT scans, a contrast agent can be used to help better visualize/diagnose certain issues. MRI scanners in human medicine are typically either 1.5 or 3 T (Tesla), which denotes the strength of the magnet. The stronger 3T magnets give better resolution (detail) of the scan. One of the challenges of MRI scan is that they take significantly longer than X-Ray or CT scans and are performed in a tunnel which can be claustrophobic. To help those who struggle with claustrophobia, open-sided MRI machines have been developed, but they have weaker magnets, so the images are less detailed. To reduce the time the MRI takes, slices can be thicker, but this can also lead to things being missed if they are between slices. When scans are being performed, various sequences are taken. These sequences are produced by altering parameters such as the time between radio wave pulses and the time for the pulse to be sent and the echo to be received. Two of the most common sequences are T1 and T2. T1 sequences are typically very good for looking at anatomy. T2, on the other hand, is great for looking at pathology as fluids show up as a bright signal or hotspot.

MRI shoulder cyst and rotator cuff tear

Image 5: This T2-weighted MRI shows high signal (white in the scan) showing a rotator cuff tear (infraspinatus tendon – white arrow) and a cyst (white arrowhead)

 

People are often aware that MRI gives a really good view of a person’s anatomy and pathology, so this is often the scan people want their doctor to send them for! As we have seen for the choosing wisely campaign, radiographs and MRI are not indicated for people with acute, non-specific low back pain without red flags. Although we want to know, it is not indicated, and may even have a negative effect. The reason it may have a negative effect is threefold:

    1. Significant numbers of pain-free people have MRI findings such as disc bulging and degenerative changes.  Disc Bulges in people with no back painWe might be more likely to have surgery or recommendations based on imaging that might not have been necessary. One example is a 2016 case study in the New England Journal of Medicine1.  that showed an MRI of a large lumbar disc herniation and then a repeat MRI 5-months later that showed it had spontaneously (i.e. no surgery) resolved. We see this in people who have a degenerative meniscal tear diagnosed by MRI, have a knee scope and the statistics show are no better off at two years than if they had not had surgery and worse find they will end up having knee replacement sooner (see our blog on this!).
    2. There is actually a significant variability in the reading of an MRI. This paper2 found that a lady with back and leg pain was sent to 10 different imaging centers over a week and there was large variability in the findings/readings of the scans!…Among the 10 reports, there were 49 distinct findings, and not one was found in all 10 reports! On average, each radiologist made about a dozen errors, seeing one or two things that weren’t there and missing about ten things that were! In the UK I saw many more scans and am by no means an expert in interpreting them, but I have caught miss-readings myself and been in hospital rounds where surgeons have disagreed with the radiologists’ findings.
    3. The nocebo effect – When you are told something about your body it can be positive (placebo), or negative (nocebo). If you are told that you have spinal degeneration that can negatively affect your beliefs about your spine. For this reason, there are actually descriptors that might be more beneficial to use, e.g. “We saw nothing more than the equivalent of wrinkles of the spine on your scan”.

When it is appropriate, MRI is a superb imaging option. In the US, physical therapy programs teach image interpretation, but there are very few situations (military being one) that PTs can order them. In the UK, after the requisite courses, PTs can order all types of imaging and I have been on the side of ordering images out of concern of cancers, fracture, ligament and tendon rupture, which has led to appropriate treatment.

Conclusion:

Seeing inside the body is amazing and under the right circumstances, it is very necessary. However, we do not always need to see inside. What a patient tells us provides most of a diagnosis, the physical examination confirms things and imaging is only needed when something more concerning is going on that needs some type of intervention (surgery, chemotherapy, radiotherapy, etc). In many cases, even in the case of imaging findings that we might call a pathology, physical therapy can be successful in helping people return to activity and resolve pain. If you have an issue, don’t be too eager to jump to imaging, consider if physical therapy might help. Feel free to contact (e-mail, or phone) me to see if physical therapy would be a good option to consider.

 

References:

  1. Hong J, Ball PA. IMAGES IN CLINICAL MEDICINE. Resolution of Lumbar Disk Herniation without Surgery. N Engl J Med. 2016;374(16):1564.
  2. Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J. 2017;17(4):554-561.

Images:

  1. Beattie KA, Duryea J, Pui M, et al. Minimum joint space width and tibial cartilage morphology in the knees of healthy individuals: a cross-sectional study. BMC Musculoskelet Disord. 2008;9:119.
  2. Kurklu M, Ozboluk S, Kilic E, Tatar O, Ozkan H, Basbozkurt M. Stress fracture of bilateral tibial metaphysis due to ceremonial march training: a case report. Cases J. 2010;3:3.
  3. Flanigan DC, De smet AA, Graf B. Magnetic resonance imaging in traumatic hip subluxation. Indian J Orthop. 2011;45(3):272-5.
  4. Fornaro J, Keel M, Harders M, Marincek B, Székely G, Frauenfelder T. An interactive surgical planning tool for acetabular fractures: initial results. J Orthop Surg Res. 2010;5:50.
  5. Awh MH, Stadnick ME. MRI challenge. Sports Health. 2009;1(2):180-3.
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How Much?! Typical PT Costs in the High-Deductible Era https://physioworkshsv.com/how-much-typical-pt-costs-in-the-high-deductible-era/ https://physioworkshsv.com/how-much-typical-pt-costs-in-the-high-deductible-era/#respond Wed, 10 Jan 2018 21:26:13 +0000 https://physioworkshsv.com/?p=4360 How much is physical therapy care in huntsville and madison county physioworks sports and wellness inc

We recently went through open enrollment for our family health insurance.  We had been on a traditional PPO plan, but over the past three years, we have also had the alternative option of a high-deductible health plan (HDHP) tied to a health savings account (HSA). This year the HDHP became more attractive due to bigger contributions from my wife’s employer, so we revisited our decision. This required going back and looking at past healthcare expenses and trying to predict future ones. As we look at our situation (a family of four), even with two family members having conditions that require ongoing specialized medical care and imaging, the high deductible plan looks to now be a better fit. So, starting this year, we have a much greater incentive to be informed of the true costs of our healthcare decisions.

I know that many of you are making the same decisions – increasingly, employers and individuals are moving to high-deductible plans with HSA accounts. Even on PPO plans, the trend is for higher and higher deductibles. PT is definitely one of those healthcare expenses that can hit you in the pocketbook! So, now that we have more incentive to ‘price-shop’ our healthcare, how can we do that without sacrificing our health and quality of care?

I believe that being a smart consumer is positive for both the patients and the employer. Historically, consumers haven’t given too much thought to the provider they use or the pharmacy that they fill their prescription from a cost perspective. In our case, we usually had a $5 copay for a 30-day medication supply, so unless we looked at our insurance explanation of benefits (EOB), we had no idea what the medication cost, what insurance paid, and even then we had no idea of cost differences between pharmacies. However, more tools are starting to become available to help us as consumers make informed choices. One that my family will be using this year is GoodRX, which lets you price compare your prescription medications between different local pharmacies – we found a $100+/month difference in the price of one medication that one of my family members is on!

In the physical therapy world, it is harder to price compare. First of all, under the traditional in-network model, the PT will have no way to tell you exactly what codes will be billed to your insurance until you have been examined. The amount charged from visit to visit may also vary, especially if you see more than one provider due to the way clinic scheduling works. Also, what pricing information is publicly available is fragmented making it difficult and time-consuming to check prices. However, as an insured person, my insurance company does provide me with a tool on their member site that can at least help. Some insurers have tools that are publicly accessible and others are inside member sites, so hopefully, your insurer can provide you with some data. This tool had been promoted in open enrollment to help employees price shop, and doing so for physical therapy I was amazed how great the variation is from clinic to clinic. However, even with that information, there are still things that make it hard for a consumer to understand. So, here is a breakdown and some notes that might help. (Note: These numbers are hypothetical estimates informed by average pricing information that I found through internet searches; they are intended to give a ballpark idea of the price ranges for PT, not exact pricing for any specific providers or negotiated insurance rates. The numbers provided here are intended to reflect negotiated rates; i.e., the amount due after the bill has been processed by your insurance company.)

 

Physical Therapy Average Costs, evaluation, therapeutic exercise, electric stimulation, manual therapy

Notes:
1. Evaluations are untimed codes, which means that that the above amounts could get charged for any amount of time the therapist spends doing the evaluation. The quicker the evaluation, the more time there is to provide other treatments whose codes are typically timed. These codes are typically billed when a certain time is spent on a service. Many insurances follow Medicare billing principles, so with exercise, 1 unit could be billed after 8 minutes, and a second could be billed after 23-min, so essentially 15-min of exercise averages $88, 30-min would average $176. Some insurances do not follow Medicare rules which allow for more aggressive billing.
2. The electrical stimulation that most people get at the end of therapy is classed as “unattended” which means the patient can be hooked up and left on it, while the therapist sees another patient (and bills both!). Theoretically, all the above are supposed to be skilled procedures by a physical therapist, so although an aide can set up the basics (e.g. getting the patient comfortable and positioned), the therapist should be the one performing any of the above treatments. This also means that legally an aide should not be taking someone through an exercise program, which is then billed to insurance.

 

With that knowledge, let’s compute the cost of a hypothetical evaluation (first PT visit) as performed in many clinics around the country. The patient will be with the therapist 40-45 minutes and will be in the clinic for 60 minutes. Evaluation (the talking and the physical examination) takes 20min, the therapist does 10min of manual therapy, 15min of exercise and puts them on electric stimulation (during which they might write notes, or in many clinics will move on to treat someone else):

Physical therapy evaluation cost example

 

Let’s also consider a follow-up appointment where 15min is spent on manual therapy, 30min on exercise (2 units) and the session is completed with 15min of electrical stimulation (unattended):

 

physical therapy follow up costs

 

Assuming you only need evaluation and a follow-up it would total $780. With the shift to high deductible plans, you may not have hit your deductible (The average individual deductible across the US is $1,696 for any sized company, and is $1,205 in Alabama)! The policy my family is moving onto has a $3000 family deductible that has to be met before it will then pay 80% of the charges (coinsurance). Typical PT in the US is 2-3 x a week for 4 weeks, so with evaluation costing $410 and follow-ups costing $370 each, you may have been billed somewhere in the range of $3000-$4480. For anything more than 2x a week for 4 weeks I would have hit the deductible with the increased visits being subsidized by coinsurance. Even with insurance paying some of the cost at that point the larger amount for 2x a week for 4 weeks would have only been reduced to $3296. Visits add up quickly and when you are seeing the dollar amount instead of a copay you might be shocked! It is even more shocking when you consider there is no research showing superior results being seen over so many visits in such a short space of time.

I often hear HR departments and insurance companies tell people that it is cheaper/better to stick with in-network providers. This is not necessarily true as it makes an assumption that out-of-network and in-network providers will do the same things. This is not the case and is why PhysioWorks is an out-of-network provider! Knowing some of the numbers from my time working as an in-network provider for a large local company, I set my cash rate at what I considered to be a fair value for my clients and for myself. At $135 for 60-minutes, if I saw someone for 12 visits it would only total $1620, but I do not typically see people on those schedules! On average, I see my patients 5-6 visits over a 6-month period using a highly tailored plan of care. Using those numbers, my patients’ out-of-pocket costs for a plan of care likely average ~$800.

 

physical therapy cost in madison huntsville alabama physioworks versus the rest

The table uses the numbers in our other examples; your actual numbers may be different.

 

The differences in these numbers are huge! However, with the assumption that it is cheaper to stay in-network, the first question I am asked when people call me is: “ Are you in-network with my insurance?” If people give me the chance to explain things and also look at our reviews they start to see our business model is very different and that it yields results. Once our clients experience the highly-tailored personalized care that we provide, they often tell me that they see our service as a fantastic value at a bargain price! If you are considering physical therapy or any other form of healthcare, do not just look at the dollar value. As with any other decision (car purchasing, restaurant choice), consider the overall value of the service. I hope the above helps you to consider the value of physical therapy! If you have any questions send me an email or call.

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Medical Misinformation – Be Careful What You Read & Trust! https://physioworkshsv.com/medical-misinformation-be-careful-what-you-read-trust/ https://physioworkshsv.com/medical-misinformation-be-careful-what-you-read-trust/#respond Wed, 03 Jan 2018 21:10:37 +0000 https://physioworkshsv.com/?p=4352 Does coffee cause cancer?

Put down that cup of coffee! A recent research study says….

No, wait. It’s ok. Coffee is actually good for you; a new study showed….

But EGGS – eggs are bad. Will ruin your cholesterol…

Oh, hold on, the latest research shows that eggs are ok after all….

I’m sure all of this sounds very familiar – medical “information” is constantly coming at us, on the news, social media, our favorite TV show host…and it will make your head spin if you try to listen to it all. We’ve all noticed the constant yo-yo on whether certain favorite foods and activities are “good” or “bad” for our health. What is going on?

Medical misinformation careful what you read and trust!

If you have met me or been reading my blog for long, you will know that I read a lot of research papers and that I try to back up my medical decisions and advice with research. That is why I take the time to include the relevant references in my blog posts! But with all the conflicting advice out there, how do I know what to believe and what to ignore?

There are many papers out there; In fact, the National Library for Health has some 17 million trials tagged “human”, and a further MILLION articles are added each year. Much of this research is useless, creates misinformation, or worse, can be used to push certain agendas. It is challenging to look at papers in an unbiased manner and assess their quality; their study design, the appropriateness of their conclusions and recommendations. There is no way that I, or any medical professional or researcher, can stay on top of ALL of that information, but it is important to at least be able to evaluate the quality and reliability of the medical research that we do consume and allow to shape our practice. This is what I try my hardest to do so!

A recent paper1 looked at this issue. It came up with 4 major problems we have with research publication which is shown in this graphic

Four issues of Medical Missinformation

In order to evaluate the quality of a particular research paper, one needs a knowledge in research statistics and how to properly design an experiment. For instance, factors such as the sample size, length of the study, whether a good experimental control was in place are crucial. Also relevant is whether the research was carried out on lab tissue, humans, or animal subjects. Sadly, many times those attention-grabbing headlines touting the latest “cancer-causing” (or cancer-curing) food, etc, don’t tell you any of those things – if you dig deep you might find out that the research was in rats, at much higher dosage levels than human normally would (or even could) experience, or that the research was simply some cells responding in a petri dish and may be decades away from actually being a conclusive result that anyone should base their decisions on!

This is why I take my professional reading seriously and strive to be careful about evaluating the quality of the research that I bring to you on my blog. My educational background has equipped me with the basic knowledge and tools I need to critically review sports-medicine research, and my goal is to break that information down into something useful and applicable for my clients and my readers!

Do you have any questions or topics that you wish I could cover in a future blog? Let me know! I would love to hear from you and report back on the current state of the research. No matter where you find your health information, I would encourage you to consider it with a critical eye; before you let the information coming at you from all directions start to change your lifestyle decisions, consider the source and the quality of the underlying research behind the headline!

Reference:

  1. Ioannidis JPA, Stuart ME, Brownlee S, Strite SA. How To Survive the Medical Misinformation Mess. Eur J Clin Invest. 2017;
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Gloria’s Story – Elbow Pain Gone Naturally: No Injections, or Surgery! https://physioworkshsv.com/glorias-story-elbow-pain-gone-naturally-no-injections-or-surgery/ https://physioworkshsv.com/glorias-story-elbow-pain-gone-naturally-no-injections-or-surgery/#respond Thu, 07 Dec 2017 23:19:04 +0000 https://physioworkshsv.com/?p=4337 Gloria came to see me because she had been struggling with pain on the inside and outside of her elbow for over a year. These problems are often referred to as “tennis” or “golfer’s elbow”, as tendon pain in these areas is commonly seen in these sports. However, in Gloria’s case, her elbow pain was preventing her from doing her gardening, and some of her fitness routine (pilates and weight-lifting). She went to see an orthopedic surgeon, who prescribed an oral steroid,  referred her for physical therapy, and scheduled a follow-up for 5 weeks. If she was not better by then, he planned to give her a steroid injection. After reading our online reviews, Gloria contacted me. We discussed her case over the phone and she scheduled an evaluation.

On examination, Gloria was found to have a full range of motion through her neck, shoulder, elbow, wrist, and hand. Nerve testing was negative, but all tests for lateral and medial elbow tendinopathy (tennis and golfer’s elbow) were positive. The insertions of these tendons at the elbow were also quite tender. I could not detect any notable weakness except when the arm was raised above the horizontal, which was consistent with her history as she struggled with heavier, fast loads in positions distant from the trunk.

Typically, if left untreated, the average recovery time for tennis elbow is about a year. But at the time I first saw her, Gloria had had the problem for more than a year and it persisted, so it seemed unlikely that the problem was going to resolve on its own. Research indicates that exercise is helpful for tendon pain, but our understanding of how to treat tendon pain is rapidly evolving, and often we don’t yet have a definitive answer for how to best treat a specific tendon injury. But thankfully, a recently published paper1 gives some guidance on the best practice for tennis elbow. Long combinations of isometric, eccentric and concentric exercises were found to be effective compared to other exercise combinations 8-weeks after treatment had started (longer-term data is not yet available; rest assured I will be keeping an eye out for any updates as new research is published!)). So, I recommended we start with these exercises specifically targeting the elbow tendons. Gloria also had weakness in the shoulder above the horizontal, so it made sense to also strengthen the shoulder and trunk. I also recommended heavy load strengthening exercises for these.

During the evaluation, I tried a manual therapy technique called a “mobilization with movement” (MWM) and it gave some instantaneous relief. When a client has been experiencing debilitating pain for a long time, it can be hugely relieving to experience the instantaneous reduction or even elimination of pain that manual therapy treatments can sometimes provide. However, the relief they provide is only short-term – still helpful to provide comfort and reduce potential need for medication or injections while the body heals, but they do not actually heal the injury in and of themselves. Gloria and I discussed the need to avoid her becoming dependent on passive treatments like manual therapy and that true long-term recovery would come from an active, exercise-based approach. This empowered Gloria to be in control of her own recovery, rather than dependent on frequent appointments with me.We also discussed that having had pain for a year, recovery could be slow and would be influenced by changes in how her body processes pain (not just structural tendon tissue changes at the elbow).

Gloria also asked about the injection the doctor had proposed doing only five weeks after starting therapy. Current evidence does not support injecting steroids into or around the elbow tendons as an early treatment and could lead to worse outcomes. If she was significantly further down the road and had tried other less risky conservative options the potential risk of a steroid injection might be worth considering. But given that we were just starting a physical therapy plan of care that I expected to take at least a matter of months, I recommended that she delay any injections until we determined whether PT was helping her to recover.  You can read my summary of some recent research2 on this topic below in the footnote* below, but here is a spoiler: “The physical therapy group had less use of pain and anti-inflammatory medicines, and had the lowest level of recurrence at 1 year (Recurrence of 5% for physical therapy, 20% for placebo injection, and 55% for corticosteroids)”.

Gloria returned 3 more times, for a total of 5 visits over a period of 5months. At discharge, she felt 98% better. Her only pain was occasional and was in a motion that she did not often experience and was not that notable, and will likely resolve as she continues to be active and improve strength.

If you have a problem that has persisted and is keeping you from living your life the way you want, send me a message or give me a call! If you are on the fence about physical therapy due to doubt, or past experience, we offer no-risk FREE screenings where we can meet and I will do some brief examination to determine if I can help you. If I can’t help I provide recommendations on which health professionals you might want to consider seeing.

Footnote:

*We have blogged about tendinopathy before, and the research is pretty clear that many of the “quick fixes” don’t address the true issue, or can even be negative. Current physical therapy research does not support the use of traditional treatment such as ultrasound, friction massage, and in some cases stretching (compressive tendinopathy). The research is also against more modern treatment such as assisted soft tissue mobilization (using a metal tool on the tendon to scrape already degenerative tissue!). In medicine, steroid injections have often been used because tendinopathy had been considered an inflammatory problem. However, these injections have not been found to be very effective as tendinopathy is a problem of cellular degeneration due to poor load management. The main degenerative change is to the collagen within tendon cells (We want healthy collagen as it makes tendons stiff so they can withstand load). The reason steroids are not particularly helpful is that when injected, they slow down the turnover (regeneration) of collagen cells. It seems that steroid injections are actually not good for tendons! A recent study2 compared steroid injection with placebo injection or physiotherapy. They found that 1 year following steroid injection patients had worse outcomes than those who had a placebo injection. Those who had the steroid injection were also more likely to have a recurrence of symptoms. The physical therapy group had less use of pain and anti-inflammatory medicines and had the lowest level of recurrence at 1 year (Recurrence of 5% for physical therapy, 20% for placebo injection, and 55% for corticosteroids).

References:

  1. Stasinopoulos D, Stasinopoulos I. Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. J Hand Ther. 2017;30(1):13-19.
  2. Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461-9.
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From Failed ACL Reconstruction to Podiums and Mountaintops! https://physioworkshsv.com/from-failed-acl-reconstruction-to-podiums-and-mountaintops/ https://physioworkshsv.com/from-failed-acl-reconstruction-to-podiums-and-mountaintops/#respond Tue, 24 Oct 2017 22:31:28 +0000 https://physioworkshsv.com/?p=4315  

2017 Heel and Crank - Number 1 in age group post ACL - way to go Jeremy!

Number 1 in age group – way to go Jeremy!

Do you know someone who has had an injury or surgery and has not fully recovered? Have they been unable to do what they could before, or do the things they want? Sadly, it is my experience that there are many people who are in this boat and have not found a solution. The reason for this is likely to be different in each case, with some assuming it is their lot, or worse being told that the lack of progress was a risk of their surgery.  I have seen many of these people and, with the freedom, my practice at PhysioWorks provides, have been able to step back, review the case holistically, and take a different approach. In many cases, this has helped them to progress further than they had previously, and in the best instances make a full recovery.

In this blog, you will get to hear the story of Jeremy, a 33-year-old who had an ACL tear, surgery, PT, a second surgery, more PT, yet was still unable to get back to the things he loved – running, cycling, hiking, and weight training. When I first saw Jeremy, he was part of the 20% of ACL reconstruction patients who had not returned to sport. Over the course of nine PT appointments, spread over a year, Jeremy has returned to doing all the things he loves, even placing 32nd and making the top of the podium in his age group in his first ever duathlon – the Heel and Crank in April 2017! He then went on to complete the Assault on Mount Mitchell, a 102 mile, 10,000ft ascent!

The video below shows Jeremy’s progression with running. You can really see how his biomechanics have improved over time, making him a stronger, faster runner, with less future injury risk.

 

 

As you read Jeremy’s story, you might wonder about an old injury that has bothered or restricted you – email me about it! I would be happy to listen to your story and explore whether my approach can help you.

 

Completed the 2017 Assault on Mount Mitchell - Go Jeremy! Post ACL rehab success!

Completed the 2017 Assault on Mount Mitchell – Go Jeremy!

 

A More Detailed History:

 

The Injury And Surgery:

Jeremy was an active 33 year old – he cycled, ran, hiked, and rode dirtbikes. Unfortunately, in January of 2014 he came off of his dirtbike and hurt his knee. Examination and MRI revealed an ACL rupture and meniscal tear. Shortly after, he had an ACL reconstruction (ACLR), using the central third of his own patella of the same knee (technical term: patella autograft). This patella tendon tissue over time turns into ligament tissue that very closely matches that of the original. The meniscus was torn in the outer third, in the so called red-zone, which meant it was repairable with two anchors. The red zone means there is good blood supply and it will heal, versus a tear in the white zone of the meniscus, which is considered irreparable and  is typically trimmed off. The surgeon must have also found an area of cartilage damage, where the bone was essentially bare, because a microfracture procedure was also performed. Microfracture involves small holes being drilled into the bone to stimulate bleeding, the release of stem cells and subsequent cartilage regrowth.

 

Post Surgery, a second surgery, and post surgery again!

Jeremy followed the typical ACL rehab protocol at another local PT clinic associated with his surgeon. He did well with respect to basic normal activity (i.e. walking, stairs, slopes) and felt good enough to try some hiking that same August. However, following the hike, his pain levels started to increase and he started to have issues getting his knee fully straight, had pain going from sitting to standing, and also pain when walking on slopes. Going hiking at this stage should have been ok if the strength and range of motion is available, so it is likely that one of these was not quite where it needed to be (but I cannot travel back in time and see!). A year after the initial surgery he continued to have issues, so he underwent a scope of the knee to remove scar tissue. He did therapy as recommended by the doctor, saw some improvement, but still could not return to running or sports – meaning at that time, he was part of the 20% of people who had not returned to some form of sport.

I’ve written before about ACL injuries (here and here) because we’ve seen such a dramatic increase in them in youth sports in recent years, and because the sad fact is that many athletes do not make a full recovery after ACL rupture. Typically, recovery back to normal activity (walking, stairs, etc) is fairly uneventful. This is normally as far as your insurance-covered PT treatment will take you. But return to sport after ACL reconstruction is challenging – even many professional athletes don’t make it back to their pre-injury performance. Statistics show that about 80% of ACLR patients return to some form of sport, 65% return to the same sporting level and only 55% return to sport at a competitive level within 1-2 YEARS post ACLR1

 

Two Years Later – Jeremy’s Assessment at PhysioWorks

Jeremy was unwilling to accept this outcome, so in April 2016, he contacted me and came to the clinic for an evaluation. As I do with every patient, we began with me listening to Jeremy’s story and understanding his goals and frustrations with his current lack of progress. In fact, some of this process started before Jeremy walked into my clinic – my online paperwork system meant that I had already read about his history and goals before we met for his first appointment, and I could immediately zero in on the key issues, ask clarifying questions, and quickly develop an in-depth understanding of not only where Jeremy was at that moment, but the entire history of his injury and recovery to date. Sometimes patients can become frustrated as they move from provider to provider, having to tell their story again and again, and over time the accuracy of the story they tell may reduce. This can be a big problem in an on-going case like Jeremy’s, where small clues about what was going on even before an injury can really be helpful in understanding the big picture and the underlying issues that will need to be corrected for a full recovery to be possible. Taking the time to understand a patient’s issues and where they’re at in terms of processing and dealing with injury, pain, and loss of function is incredibly important. For this reason, it is not uncommon that half of my 45-minute examination time is spent talking to the patient. In many cases you can do most of your diagnosis by talking, and the physical examination is just a confirmation. I find that this approach is particularly helpful for people with complex problems, and they often tell me they have not really felt anyone has truly listened to them before. (As a healthcare professional, hearing this always makes me sad!)

In Jeremy’s case, this approach led not only to understanding the history of his injury, but also of his history of chronic low back pain since 2003 that could have some connection to his poor recovery. The persistence of back pain had been diagnosed as coming from his sacroiliac joint (SIJ). He would have flare ups from time to time, which were significant and disabling, even affecting his confidence in exercising and doing what he wanted to do in the gym or in rehab.

During our initial conversation, I told Jeremy the findings from a couple of questionnaires I had him complete. These questionnaires are validated to help understand the full effects that ACL injury can place on an individual, and both showed that there was a significant affect on not only his sporting interest, but his life in general. One showed that instead of what should be a normal 0%, he had a 44% on the emotion score. This does not mean he was a blubbering wreck! Instead in the ACL literature, emotional aspects of ACL injury can include feelings of loss, physical dependency on others, fear of re-injury, lack of self-confidence, and mood swings2. Often people are unaware of the impact that such an injury and surgery can have. Thankfully, Jeremy was not willing to accept where he was at; he realized the issues it could have for his lifestyle and he wanted to make progress.

Only once I had a clear understanding of Jeremy’s history and goals did we move on to physical examination. My primary findings were gluteal (butt) weakness, quad tightness on the injured side, and persistent loss of muscle mass and control/balance in the leg that was injured. He also still had soreness at the patella tendon incision, indicating that there was a tendonapathy, even two years past the surgery!

All of these issues could be successfully addressed through a tailored home exercise program. When possible, this is always my preference, as it requires the patient to be an active participant in their recovery, as opposed to potentially becoming dependent on passive “hands-on” therapy treatments like mobilizations, manipulations, stimulation, etc. Creating a situation of dependence is not something we wish for and is particularly harmful when there is a persisting problem where the individual is desperate for a solution. Also, I knew that with a case like Jeremy’s, the recovery would likely stretch over months, even a year, rather than weeks. Prescribing the right therapeutic exercises would allow his therapy appointments to be spaced out rather than every few days, keeping the treatment affordable and not overly intrusive into his time and life. I expected each session would consist of progression of exercises and tapering of visits. Jeremy and I discussed that in order to be successful, he would have to work hard and be committed. This may sound like a no-brainer, but to commit to changing how you do things for an extended period and changing habits can be difficult! During the last 15-minutes of our hour-long evaluation, I walked Jeremy through about half a dozen exercises. I explained how to progress them over the next couple of weeks and to contact me if he had concerns. Instructions for the exercises were given via an online portal which had videos, photographs, and suggested ranges of repetitions and sets. (Click this link to see what this looks like!) This form of delivery has proven to be popular and helpful as many patients have told me about their frustration of being given stick figure drawings or simple picture print-out that they then lose or do not understand.

 

Jeremy’s progress:

I will not detail each of the follow ups, but Jeremy saw me a further eight visits through March of 2017. The chart below gives some highlights of the visits:

First three visits post ACL

At this point Jeremy was very happy with the progress and decided to write us a review! However, he had more goals he wanted to meet, including comfort on century bike rides and running. Our rehab continued along the original plan.

Further visits post ACL and return to running and cycling

The Final Result!

As you can see, at his last appointment (March 2017) Jeremy had made excellent progress. He had met all of his goals and has a very good approach for continuing to move forward. He is also very pleased that his back pain has not flared up recently which he would have expected it to do so. None of his sporting interests require a significant change in his plan, but I feel confident given his strength and previous hop testing that he should be able to do these as long as they are approached sensibly (i.e. the way all people should approach a new sport – gradually!)

As we already showed in the summary Jeremy was able to place 32nd out of 295 people in his first ever duathlon and then was able to make a a 102 mile, 10,000ft mountain ascent on a bike! He does not feel any particular restriction in his activity and is able to pick and chose what he wants to do rather than having his life dictated by an old injury.

Have you been struggling with an injury, or from a surgery that you cannot get over? Do you need a different and more tailored approach? Send me an email if you have questions about your problem; I would love to help you!

 

References:

  1. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543-52.
  2. Olofsson L, Fjellman-Wiklund A, & Soderman K. From loss towards restoration: Experiences from anterior cruciate ligament injury. Advances in Physiotherapy. 2010; 12: 50- 57.
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Up close and personal: Total knee replacement in the US vs. the UK https://physioworkshsv.com/up-close-and-personal-total-knee-replacement-in-the-us-vs-the-uk/ https://physioworkshsv.com/up-close-and-personal-total-knee-replacement-in-the-us-vs-the-uk/#respond Thu, 19 Oct 2017 16:02:17 +0000 https://physioworkshsv.com/?p=4302 knee replacement components

This is what goes in the knee!

One month ago, I had the opportunity to return home to England for a week to help my mom as she recovered from knee replacement. Of course, I was concerned (as surely any son would be!) about her undergoing major surgery, but my concern was also based on seeing a variety of outcomes for people after knee replacement. I wanted to go and make sure everything went well; I joked with her that I was going to make sure she was behaving herself!

From hearing the experience of friends and family, you may have mixed opinions about total knee replacements (TKR/TKA). They are typically a good surgery, but I have seen some that recover in a very straightforward manner and others that really struggle. TKA should be undertaken when quality-of-life is being significantly affected by pain, difficulty in function, and has not improved with rehabilitation. This was certainly the case for my mum. When someone decides to have a TKA they are expecting a significant improvement in quality-of-life. Many find this, but imagine what it would be like to struggle to get the knee moving after surgery, or have ongoing pain. I have seen patients like this and it feels to them like they have swapped one problem for another. There are a myriad of reasons for this from medical complications, surgical errors, to poor rehab and patient compliance. My goal was to make sure Mum did not struggle and was able to reap the rewards I know are possible with TKA.

From the media, most of you will know something about the health system in the UK; It is a socialized system called the National Health Service (NHS). Getting a TKA in this system can take a long time (12 months +), which is not much fun when you are in pain. Fortunately, following retirement, my parents had maintained private health insurance for this very reason and were able to schedule surgery when they wanted. So, her experience in scheduling the surgery was the same as someone in the US. I’ve lived in the US for 10-years, but before that I lived and worked in the UK both in the NHS and private practice, so am familiar with the typical post-surgical treatment of a TKA in each country and setting. In the US, patients would typically experience daily physical therapy while in the hospital and then would start outpatient or home health therapy 2-3 x a week for anywhere from 4-8 weeks or more. This has become the norm and is relatively encouraged by the way insurance and reimbursement works. However, there is no evidence to show that this approach to rehab works any better than others. Obviously, it has been a while since I worked in the UK, but watching Mum’s rehab reminded me how different approaches can work and explains the beliefs I have on rehab and why I have structured my practice the way I have.

Traveling to London

The long process of international travel, but well worth it 🙂

 

After 20 hours of traveling, I arrived in London Heathrow, picked up the rental car (think stick shift and the other side of the road) and drove the 60 minutes to the hospital. I arrived at the hospital the day after her surgery (I spoke with her the day of the surgery via wifi while transatlantic! Pretty cool!). She was doing well, sitting up in the bedside chair, and the biggest problem she was having was some nausea. She had PT daily, working on a simple set of exercises and her mobility. She left the hospital three days after the surgery having proven that she could walk with a pair of crutches and go up and down the stairs. She was discharged with a set of instructions, including exercises, and she was then at home on her own with Dad and I for a period of a week and a half until she started her first therapy appointment. During that period we encouraged her to do her exercises and brought her ice when she wanted it. I did try to see if I could help her move her knee, but she couldn’t relax enough to make it worthwhile so I left the work to her! Essentially, we were glorified cheerleaders. I dovetailed with a visit from my sister (Also a PT!) who stayed with them for a few days, and a week and a half after discharge she went for her first outpatient PT appointment. The therapist was impressed with how she was doing.  They worked a little on improving her walking gait using one crutch and gave her a progression of her exercises. She continued to work at home and had a follow-up PT appointment two weeks later. When I spoke to her today, Oct 17th 2017, four weeks after the surgery, my sister had visited with her family (Easier for them to visit from Scotland!) and Mum had walked 1.5 miles with her one crutch! I am obviously a little biased, but I think that her progress has been exceptional!

 

Mum doing great following knee replacement

My Mum doing great after surgery. First trip out! Also, a rare chance for us all to be together as we live so far away!

 

Obviously, this is only one case, so it does not prove that one approach is superior to another. However, having worked in both countries, I do not feel like I have seen more superior results in the US. The difference in care in the UK, in this case, is not due to the socialized healthcare as some might claim; for example, all of Mum’s care was at a private hospital. (I do acknowledge there is room for improvement in both systems and you are always welcome to ask my opinion!) Instead, the philosophy is different. In the US, most people’s experience of going for PT following TKA involves 2-3 time a week of the therapist making them do the repetitious exercises, the therapist bending their knee, and some electric stimulation and some form of ice therapy. There is a lot of hand-holding and, to be honest, I see overtreatment which can have negative consequences. I see patients who have been pushed too hard by PTs who are worried about a stiff knee, but the aggressive therapy creates pain that itself leads to stiffness! In the UK, the more spaced out appointments ask the patients to be more responsible for their progress. Certainly, there is some risk with this approach when a patient does not report concerns/problems. Even though I am aware of this risk, I still favor an approach that is more similar to the UK approach with all of my patients, as I believe that my patients are smart, able, and don’t need their hand held all the way through rehab. Many of my patients are busy professionals and do not have the time for multiple visits per week! I make sure that there are adequate ways to communicate with me to reduce the risk of unintended consequences occurring between appointments. I believe that where the patient is more involved, they will see more lasting/resilient results. I will qualify this by saying that everyone is different and some people will want the hand-holding, and I am fine with that initially if it is truly needed. However, I feel it is incumbent upon me, and a professional/ethical responsibility, to promote self-efficacy and self-reliance.

When you have been practicing/working any job for a period of time (in my case 15 years now) you can’t always understand why you do everything the way you do. I have tried as a professional to stay up to date on the latest research and that is the biggest guide to my practice. But, my experiences have also guided me, and mine are quite different from most PTs having worked in two countries, various practice settings, and under two healthcare systems. If you think my approach might be a good fit to help you with any pain, injury, or rehab needs, please do send me a message. You can contact me via email or phone. I am always happy to chat!

 

Image Credits:

  • Hirschmann MT, Hoffmann M, Krause R, Jenabzadeh RA, Arnold MP, Friederich NF. Anterolateral approach with tibial tubercle osteotomy versus standard medial approach for primary total knee arthroplasty: does it matter?. BMC Musculoskelet Disord. 2010;11:167.
  • Google Maps
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CrossFit – Are You Crazy?! https://physioworkshsv.com/crossfit-are-you-crazy/ https://physioworkshsv.com/crossfit-are-you-crazy/#respond Tue, 03 Oct 2017 20:55:15 +0000 https://physioworkshsv.com/?p=4257 I have recently started doing CrossFit at a local box (CrossFit gym), and from the reaction I’ve received from pretty much everyone I’ve told (including my own wife!), it seems that the first thing many people think of is ‘injury’! I’ve received many admonitions to ‘be careful’, and warnings about CrossFit causing shoulder injuries, knee injuries, back injuries….you get the picture. I have wondered if many of those warning me are thinking, “Surely as a PT you should know better!” Certainly, I have seen and rehabilitated some CrossFit injuries over the years, but as a form of exercise, it can provide a great base for people to enjoy life and perform better in their sports. But is it really true that CrossFit is inherently more dangerous than other sports? If it is, why is that? If it’s not, why is there a perception that it is?

Well, thankfully I’m not going into this blind! A few months ago, I had the fortune of meeting Scott and Lori Bean, owners of CrossFit Nomad. Very quickly I was impressed with the care that Scott and Lori expressed for their members. They want to do everything they reasonably can to keep injuries to a minimum. My focus on injury prevention and risk reduction resonated with them, as well, and so we have agreed to partner together to support each other in our goals! I’m now available to Nomad members at the box several times throughout the week (or anytime by phone/email!) to answer injury-related questions, screen potential injuries, and provide guidance on injury risk reduction. In return, I am working out at Nomad as any other member would, working on improving my own fitness (which I have sadly neglected while raising small kids and starting my own business!). This is really allowing me to truly understand and appreciate CrossFit! I want to tell you a little more about CrossFit Nomad in particular, but first let’s look a little more closely at what CrossFit is, and what the research says about CrossFit and injuries in general.

 

Picture of Andrew Walker, Physical therapist doing box jumpat CrossFit

Hard work, great fun, seeing results!

 

CrossFit – What Is It, and Who Is It For?

CrossFit is a form of cross-training exercise – meaning that it is a mix of cardio and whole-body strength and flexibility training. Many of the exercises are a little unusual or maybe things you wouldn’t have imagined yourself doing (or doing again) – like headstands, rope climbing, jerry-jug carries, sled pushes…along with some more traditional weight lifting moves like squats, clean-and-jerks, dead-lifts, pull-ups….

So maybe you’re thinking – good grief, that stuff was hard in high school, I can’t-do that? Stay with me! One of the great things about CrossFit is that all of the workouts can be scaled to your current ability level – and you will still get a great workout. That said, there is definitely the possibility of injury when you’re starting a new exercise routine, so what is the real injury risk with CrossFit?

CrossFit Injury Compared to Other Sports

A recent systematic review found that CrossFit’s injury rates are lower or comparable to those for Olympic lifting, distance running, track and field, rugby, football, ice hockey, soccer, and gymnastics. With respect to most commonly injured body part, 25% are shoulder, 14.3% and 13.1% were lower back and knee, respectively. The quality of the research available is not of the highest caliber, but is also not the worst!

What can CrossFit do to Keep Injury Rates Reasonable?

The above research noted that it appears that injuries occur more where supervision is not always available to the athlete, or they do not actively seek supervision. I had often heard from CrossFit athletes that some boxes don’t have great supervision and have more injuries. Some boxes and athletes may even wear pain and even injury as a badge of honor! The paper quotes other research showing that in CrossFit males were less likely to seek help from coaches. That Y chromosome and our testosterone do seem to make us a little more likely to plow onwards without such regard for technique and safety. I have seen this in other sports as well, so I feel pretty confident it is not isolated to Crossfit! Even though males are perhaps less likely to seek supervision, perhaps the mark of a good CrossFit box is one where the coach is paying good attention to those who are not seeking it!

CrossFit Nomad’s Approach to Injury Risk Reduction

 

2nd session – I felt this pale after weighted sled pushes! 200lbs x 40yd repeats! Nauseating, but good sweat!#crossfit…

Posted by PhysioWorks, Sports and Wellness, Inc on Tuesday, August 29, 2017

 

If supervision is key to reducing CrossFit injuries, then Nomad is definitely on the right track. Each new member attends 3-6 private personal training sessions, where you learn the basics of the various techniques employed in CrossFit workouts (or “WoDs” – workout-of-the-day). The focus of these sessions is technique rather than any weight or achievement. (Though, I can attest that they are still really good workouts – I was drenched with sweat from head-to-toe after each one!) I really enjoyed the personal training sessions as although I was broadly familiar with CrossFit I did not know all of the different exercises. So before you ever go to a regular workout session, you are laying a good knowledge foundation to be able to safely progress.

 

Now that I’m going to the regular WoD classes, I continue to be impressed with all the coaches and their attention to detail. The coach who is leading the workout is constantly keeping an eye out on everyone’s form (not doing the workout themselves!). Also, the coaches themselves come to classes for their own fitness and I have noticed them helping even when it is not their class. As a male, I acknowledge that perhaps I am slightly more likely to plow onwards even when wrong, so I have been happy to see that I have received coaching input both when I have looked for it and when I have not! In the past, my natural competitiveness has caused me some injuries, so I am glad that although there is the encouragement to perform and better myself, there is no push for me to do stuff I am not comfortable with.

Exercise for Everyone!

 

 

Overall, I’ve found working out at CrossFit Nomad to be a great experience of challenging workouts and a fun community. If you’re looking for a new way to get in shape and have fun, with a little more variety than your typical “weekend warrior” sports, I would encourage you to check out CrossFit. In fact, whether your thing is running, golf, tennis, soccer, softball, CrossFit is a great way to improve your strength base and improve at your primary sport. Whatever your reasons for starting, just make sure the box you’re at is providing you adequate guidance as you learn the workouts, and don’t push through pain – give me a call or schedule a free injury screening if you have concerns. My experience so far makes me excited to be doing CrossFit and I look forward to seeing where it takes me!

 

Reference:

Klimek C, Ashbeck C, Brook AJ, Durall C. Are Injuries More Common with Crossfit Training than other Forms of Exercise?. J Sport Rehabil. 2017;:1-10.

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Fighting For Your Goals https://physioworkshsv.com/fighting-for-your-goals/ https://physioworkshsv.com/fighting-for-your-goals/#respond Wed, 13 Sep 2017 20:59:34 +0000 https://physioworkshsv.com/?p=4232 What brings you to see me?

One of the first things I ask a current or potential patient is “what brings you to see me?”. People often say what they think I want to hear (pain, stiffness, etc), but the question is aimed at teasing out a much broader answer. What are their goals? How is life is being affected? What do they want to achieve? More than feelings of pain, or stiffness, these are often what our patients really care about, but how often are they given the opportunity to express themselves? Taking time to understand the patient’s true goals ensures that we don’t get to the end of the plan of care with me thinking I am great because they have no pain, while the patient is frustrated because they can still not pick up their grandson, play ball, or whatever the case may be. Asking this question gives us the opportunity for true success! Sometimes the goals of my patients are ambitious and may take significant time to achieve. But, as long as they are realistic, we will discuss how long they might take to achieve and what interim goals we can set to gauge progress. Today’s blog is an example of how understanding my client’s true goals made all the difference in his treatment and outcome.

Pearson’s Story

 

When Pearson came to see me he was 23, had a small lawncare company, and looked like a fit, well-built, and healthy guy. However, he actually was very frustrated because of a long history of shoulder problems that were stopping him from confidently working out his upper body and pursuing his passion of boxing and MMA. Six years ago, he suffered a dislocation of his shoulder. Although the joint spontaneously relocated, he had ongoing pain and feelings of instability. Three years went by, and he went to an orthopedic surgeon – MRI showed a labral tear and a Hills Sach lesion (a small divot in the cartilage on the humeral head). He underwent a surgical repair, followed up with physical therapy, but he continued to have the same problems. I first saw him over a year following the surgery and he was still struggling with the same symptoms. He had returned to the surgeon, but he found visits were relatively short, without any real answer, until they eventually said he had probably torn something else or damaged the initial repair. They wanted to get another MRI and expected him to need another surgery. Given his experience thus far, Pearson was understandably reluctant to go for another surgery. He decided to try something different and reached out to me.

One of the first things that was very evident was that he desperately wanted to get back to MMA/Boxing and was not so concerned with a little pain. However, he was also concerned about causing additional damage to his shoulder and the potential long-term consequences for his future health. This was a perfect segway to discussing his beliefs about pain, how he could monitor pain, and what the potential was for further injury and success.

 

Pearsons Shoulder Problem

 

Moving into his examination, I found he had full shoulder and elbow range of motion. With him laying on the table, I took hold of his arm and passively moved his shoulder joint and found that he had a lot of mobility into external rotation When I did this, there was a look of apprehension on his face. We call this an “apprehension test”, and it suggests some instability of the shoulder. The test is a slow and careful motion, giving a sensation of instability, but in real life, a quick and forceful movement in that direction at the very least might be painful and concerning, but could also cause subluxation or dislocation. The test has an additional portion where I put my hand on the front of the joint and gently push down, providing a relocating force. The relocation portion of the test removed the pain. I then tested shoulder strength and found he was significantly weak in flexion and external rotation of the shoulder. This is quite a helpful finding as we now know that two of the rotator cuff muscles, the supraspinatus, and infraspinatus, should be very active in these two movements. Weakness in these two muscles could explain some if not all of the instability, as the major job of the rotator cuff is to provide stability to the shoulder joint. So I was able to explain that it is entirely possible that the instability he had been experiencing was more likely due to weakness in the rotator cuff than a new or old labrum tear that needs more surgery. I  learned that Pearson did not feel his rehab had gone well prior to or subsequent to surgery, partly due to his attitude at that time, and also due to his experience of in-network physical therapy. As I asked questions about his rehab, it was very apparent that it had never stressed him to the level that he needed to return to boxing and meet his goals.

Given all of this information, I was able to formulate a hypothesis of why Pearson had continued to struggle with shoulder problems – he had weakness in his rotator cuff muscles. I also knew there was a possibility that he could have a labrum or rotator cuff tear, but even if he had a scan showing a tear, research shows that surgery is not necessarily required. I discussed all of this with him and explained that we needed to load the shoulder to strengthen the rotator cuff and build load tolerance to the activities he wanted to do. I instructed him in a simple set of strengthening exercises, provided him with electronic instructions at the PhysioWorks portal, and booked him a follow-up three weeks later. If you have done PT before you may be used to 2-3 x a week, but in my opinion, this is typically not needed. In Pearson’s case, he had been struggling with this injury for several years, and he needed time to reverse the muscle loss. I made sure he had all the tools and information he needed to make progress during those three weeks and kept in touch via phone and text in-between appointments.

 

Pearsons Shoulder Success!

 

After the evaluation, Pearson came for a total of four follow-ups over a five month period. At each visit, we reassessed and progressed the loading exercises. We saw progress at each appointment, and after the second follow-up, we started to add exercises that mimicked boxing and MMA motions (e.g. grappling). The feeling of instability went away, and he was able to get back into training at the boxing gym. Progress wasn’t always a linear progression with each day being a little better – there were some very good days, average days and even some days where it felt like things backslid. However, the overall trend was progression month on month. At the beginning of the year Pearson was in the process of moving out of state, so we held off on any visits and he would contact me when back in town for a period. At the beginning of June, I got a call asking if I would be able to meet him in the boxing gym. One of the great flexibilities my practice brings is the ability to go outside of the clinic and see athletes or workers in their environment, so I was happy to go! I went to Rocket City Rocks Boxing Gym and had the opportunity to review his shoulder and then watch him workout and then spar. His shoulder felt solid and above all, he was able to hit hard. A year before he came to me with a shoulder that felt fragile, and now he had confidence. There were still a couple of areas that felt weak, and we discussed that he just needed to continue to build strength and build load tolerance in those positions. I was great to see Pearson enjoying the sport he is so passionate about! His dream is to take it to a higher level, even to go pro, and his coaches say he has a shot at it! I will be cheering for him all the way!

 

We can help you:

 

If you have a goal that is unmet, an injury that is still an issue, or a surgery that has not given you the results you want, give me a call or an email. I would love to help you!
 
 

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What is The Difference Between Physical Therapy and Chiropractic? https://physioworkshsv.com/what-is-the-difference-between-physical-therapy-and-chiropractic/ https://physioworkshsv.com/what-is-the-difference-between-physical-therapy-and-chiropractic/#respond Wed, 30 Aug 2017 18:16:51 +0000 https://physioworkshsv.com/?p=4223 I recently came across an article by a chiropractor who stated that he practices ‘chiropractic physiotherapy’ and ‘rehab’. Now, the rules about who can call themselves a physical therapist/physiotherapist vary state-to-state, but he does have a point: there is a good deal of overlap between both the conditions that physical therapists and chiropractors treat and the techniques they use to treat their patients.

For instance, both treat patients with back pain and other types of musculoskeletal pain. Both might employ manual therapy techniques to reduce pain, such as trigger points, Graston, or ART. So what is the difference, and why should you choose one over the other?

The article I mentioned earlier provided a list of the treatments that this chiropractor describes as ‘physiotherapy’. I could not help but notice one crucial treatment that was not included in his list – because it is my favorite treatment technique for addressing the root cause of my clients’ injuries and pain! So what is it?

Every treatment on the list was passive – meaning it is something the chiropractor does to you. These treatments don’t really require anything of you other than to show up for your appointment (and pay the bill!) While they can be effective at relieving pain, none of them are more than a temporary band-aid treatment; they are incapable of addressing the root cause of the issue. For some types of pain and injury, this might be all that is needed – the body is well on the way to healing itself, and all you need is a little pain relief in the meantime. Some of this relief may even be using the placebo effect. But many of my clients have been struggling for months or even years with lingering injuries that just won’t go away, or pain that is stemming from an underlying issue in their biomechanics. Until the root cause of the issue it identified and corrected, the pain will not go away, and you will continue needing those passive therapy techniques forever! A great example of identifying the root cause and treating using therapeutic exercise is seen in the video review below. I believe that my clients want and deserve full healing, not just temporary relief.

My goal with every client is to seek to identify and resolve the underlying factors, including the biomechanics, that led to their pain and/or injury. Because of this, my favorite treatment technique to use with my clients is therapeutic exercise. By working with my clients to help get better strength and control in their muscles, we can resolve the cause of the injury in the first place. PLUS – the best-kept secret about therapeutic exercise is that it can actually be an effective pain relief technique in and of itself!! How awesome is that? By teaching my clients appropriate exercises for their condition, I can help them manage their pain AND strengthen their body so that it can heal and overcome injury! Plus, this is pain management that doesn’t require drugs, needles, gadgets, or additional expense. They don’t even need to come into my office multiple times each week; just enough for me to check on their progress and adjust their exercises as they become stronger. Another added bonus is that in some cases it can be the start of more general exercise that they had not been doing before and can have a huge impact on their general health (See past blog for more discussion on this!)

I believe in this type of treatment because I have seen it work for so many of my clients. From the marathoner who hasn’t been able to run more than 10 miles in years due to knee pain, to the MMA fighter who was told he was facing shoulder surgery (he didn’t, by the way; PT has him back stronger than ever!), to the swimmer whose shoulder never quite recovered after rotator cuff surgery years ago – therapeutic exercise was the missing piece to helping them get back to doing what they love.

I use and recommend manual therapy and other passive treatments as tools to relieve pain and allow my client to begin to move, heal, and strengthen the affected area. But I never want my clients to become dependent on visits to my clinic, or even passive treatments done at home. I want you, and all my clients, to become healthy and strong so that those nagging injuries and pain are banished once and for all, setting you free to pursue your lifestyle and fitness goals!

So, which type of treatment would you prefer? 😉

If you are struggling with pain that is holding you back from the activities you enjoy, give me a call to schedule a FREE screening exam. I would love to discuss the issue with you and explore whether physical therapy might be the answer you are looking for.

 

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Do Your Knees Hurt? https://physioworkshsv.com/do-your-knees-hurt/ https://physioworkshsv.com/do-your-knees-hurt/#respond Tue, 15 Aug 2017 20:54:26 +0000 https://physioworkshsv.com/?p=4216 Most knee pain is anterior or patellofemoral. Find out more about it and how to treat it!

 

Do your knees hurt? If they do, the odds are that you have anterior knee pain (AKP). AKP goes by many different names, including patellofemoral pain syndrome, chondromalacia patella, and runner’s knee. Recently a group of experts met and produced a consensus paper1 to better define the diagnosis and treatment in AKP.

 

There are many different types of knee pain, but AKP is the leading type; up to 74% of knee pain is AKP! What’s worse, it is a type of pain that tends to stick around – up to 40% of people with AKP report that they haven’t fully recovered 12 months after their diagnosis2 and 70% to 90% have recurrent or chronic pain3. This may be because AKP can be challenging to treat; the causes of this pain are not only found local to the knee, but also the back, hip, and ankle. For athletes, overtraining, training too much or too hard, or not allowing enough rest can also contribute to AKP. The fact that pain can persist beyond the typical healing time also tells us that there is likely some degree of psychosocial component – e.g. factors such as work stress, lack of sleep, etc affecting intensity and ease of provocation of pain.

 

Historically, the approach to AKP has been rather near-sighted, with a focus on the knee itself. Doctors know that when a patient has pain, they typically would like to have a named diagnosis for the pain they are struggling with. Given the time pressures that providers are under, often a patient will receive a specific knee diagnosis, and any subsequent may be focused solely on that diagnosis. If your provider does not address all contributing factors, including the biomechanics of the entire kinematic chain and possible training and lifestyle contributors, you may be left with the dissatisfaction and residual or recurrent problems described above.

 

Recommendations for Diagnosis:

The main indication for this diagnosis is pain behind/around the patella elicited by weight-bearing activity that loads the patellofemoral joint (e.g. squatting, stairs, jogging, running, hopping. You may also see crepitus/grinding, tenderness on the edges (facets) of the patella, small effusion (swelling), or pain on sitting, rising from sitting, or straightening the knee following sitting. People who have had full or partial dislocations are a subgroup of people suffering from AKP. The best physical test to make a diagnosis (positive in 80% of people) is AKP on squatting. No other testing is particularly helpful for diagnosis. Initial diagnosis does not require imaging, however, this may become necessary in cases where the pain is not changing over time and it’s going to be helpful in potentially planning surgery.

 

Recommendations for Treatment

  • Treatments were assessed for effectiveness in the short (6-month), mid (6-12-month) and long term (12+ months).
  • Exercise Therapy has been shown to reduce pain and improve function in the short, mid, and long term.
  • Combined hip and knee targeted exercise therapy is better than knee targeted exercises alone for both pain and function in the short, mid, and long term.
  • Combined interventions of exercises and taping, bracing and orthoses provide benefit in the short and mid term.
  • Foot orthoses are recommended for the short-term.
  • It is uncertain if acupuncture, or taping on their own provide relief.
  • Joint mobilizations (a form of manual therapy) to the knee or back are not recommended.
  • Electrophysical agents are not recommended (e.g. e-stim, ultrasound).

 

I underlined the final two items because these are oftentimes performed in clinics around the country as standard practice, and many PTs truly think it benefits their patients. Some might even look at these recommendations with disdain. However, the reason the study group listed these treatments as not recommended is that good quality studies have found that they provide no meaningful improvements. Some will read this and say “I had stim on my kneecap and I felt better after, these people are wrong!”, and I can understand that, as stim certainly feels good. However, feeling good and perhaps providing a few hours of pain relief is different than getting 6 or more months of benefit. When a healthcare professional is doing stim as part of a program that includes other treatments such as exercise, and the former is the most enjoyable part, it is understandable that people assume it is effective. However, the best research which we call a randomized control trial does what it says and controls the variables used so that we can work out which ones are truly effective. Stim, ultrasound, joint mobs to the knee have been shown to not be effective. The reason that acupuncture and taping are listed as uncertain is that there is not good quality evidence for or against yet. As such they should not be first choice treatments, even if anecdotally the therapist thinks they work. So, spending your and/or your insurance company’s dollars, wouldn’t you rather invest in treatment that provides proven longer relief?

 

Here’s the really awesome part: EXERCISE not only helps your body heal and be pain-free in the long-term, it can actually provide short-term pain relief, which is the only benefit that stim and ultrasound (and maybe acupuncture) provide. But, unlike stim/ultrasound, exercise doesn’t require a PT office visit or any special equipment. Once your PT has prescribed your exercises and taught them to you, you can do them anytime, anywhere, whenever you need pain relief! AND, they are also helping you to get better, not just masking your pain! How great is that?!

 

Summary of AKP diagnosis and treatment:

  • Exercise therapy that targets the hip and knee will help in the short, mid, and long-term if you have pain in the front of your knee that is worse with weight-bearing activity.
  • Bracing/taping and an orthotic in addition to exercise may help In the short and mid term
  • Traditional treatments of stim, ultrasound, and manual therapy to the knee are not beneficial.
  • Acupuncture and taping on their own have an uncertain benefit and should probably not be used as a first line treatment.

 

So, do you have knee pain? Contact me if you feel you have not had the right treatment in the past and are still struggling.

 

References

  1. Crossley KM, Van middelkoop M, Callaghan MJ, Collins NJ, Rathleff MS, Barton CJ. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). Br J Sports Med. 2016;50(14):844-52.
  2. Collins NJ, Bierma-Zeinstra SM, Crossley KM, et al. Prognostic factors for patellofemoral pain: a multicentre observational analysis. Br J Sports Med 2013;47:227–33.
  3. Powers CM, Bolgla LA, Callaghan MJ, et al. Patellofemoral pain: proximal, distal, and local factors, 2nd International Research Retreat. J Orthop Sports Phys Ther 2012;42:A1–54.

 

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