#IFOMPT2016 SoMe Team: Jack Chew, Rachael Lowe, Laura Ritchie, Jesse Awenus, Steve Nawoor and Alex Chan

#IFOMPT2016 SoMe Team: Jack Chew, Rachael Lowe, Laura Ritchie, Jesse Awenus, Steve Nawoor and Alex Chan

It’s been a week since I got back from #IFOMPT2016 and I purposely waited this long to write my review of the conference because I needed some to time to take in the plethora of information that I was exposed to. I won’t dive too much into any one specific talk because the fabulous SoMe team did an excellent job doing detailed reviews of all the keynote lectures for you to read at your leisure. This will be my personal thoughts about the weeks events.

First off, I am so proud to call myself a physiotherapist. The amount of brilliance that lies within this profession both locally (Go Canada!) and abroad is astounding. The shear number of PhD physiotherapists breaking down walls and answering the question of “why does what we do help? (or not help)” is astounding. IFOMPT had researchers talking about such things as best practices for those with knee OA, to ischemic pain from static postures, to the psychosocial elements of pain. There is a shift in our profession and I think if you keep reading below you will begin to understand what I mean.

Dichotomy within the profession: Hands on vs. Hands off

IFOMPT is a conference with the term ‘manual therapists’ in the title. By this fact alone one would assume there would be a huge contingency of manual therapy presentations at this conference. This couldn’t be further from the truth. In fact, to my knowledge there was not one talk out of the 5 days that focused specifically on and only on manual therapy. I did not hear the words PIVM, PAIVM, or PAM once while there. There was no talk on rotated innominates, shifted ribs, or fixated joints. Well, there was but only to say that these are not diagnosis’s we should be giving to our patients.

Here is a perfect explanation of the dichotomy of opinions at this conference: Brian Mulligan vs. Lorimer Moseley
On the final day of the conference I attended a 90 minute workshop hosted by Brian Mulligan. This is a man that created mobilizations with movement and at the tender age of 83, was still as passionate and exuberant about his techniques as I’m sure he was when he first started. His talk was standing room only, meaning delegates has to be turned away at the door because of the amount of people who wanted to hear him speak. His presentation was very pathoanatomical in nature. He had one guy come up with a 20+ year history of back pain who had pain with extension. After a few quick spring tests to determine the joint levels at “fault” he did literally 3 minutes of mobilization with movement to open up the facets (which he diagnosed as the pain generating structure) and then re-tested extension, which was in fact much better then before. The crowed clapped and he was labelled as a miracle man by the man who was now out of a 20 year history of back pain. There was no talk of any psycosocial factors, no discussion around this man’s beliefs around his pain and no real differential. Suffice to say, those in attendance were quite impressed…well, some were. It was essentially a smoke and mirrors show to wow the audience.

I noticed the vast majority of younger PT’s (like myself) spent that morning at Mulligan’s course, while the older facet of the profession was at a more academic talk on the mechanisms behind the manual therapy we provide. It became apparent that there were many new grads in attendance who simply want to “fix” people. They want to provide an immediate result to the patients chief complaint, which is usually pain. Brian Mulligan did a very grand before and after show, bringing up live patients (including myself) to the front to demo techniques that he assures will fix pain problems within minutes. To quote Brian “I don’t need any rubbish study to tell me what I’m doing works, all I need are the testimonials of my patients”. This sentiment resonated with many in the very full room he was teaching in.

What is our therapy truly doing?

On the other hand, there were several talks by prominent PhD Physiotherapist Lorimer Moseley who discussed the biopsychosocial nature of pain, how complex it is, and how many different treatments have very similar effect sizes when done under randomized control trial. He spoke about the brains capacity to determine what is threatening to the body and what isn’t. He mentioned how discs cannot slip, pelvis’s cannot up slip or down slip and that thoracic rings cannot shift. And if they could, we would be pretty bad at detecting it with any reliability. Basically, he used actual data to explain why perceived anatomical abnormalities are not always pain generating issues. This was a stark contrast to the Mulligan talk about jammed facet joints and rotated innominates causing sacroiliac pain. Is it any wonder the novice clinician is confused?!

We went into this profession to help others. I will speak for myself when I say that I firmly believed going in that if I learned the right techniques of assessment and treatment I could use my hands to fix peoples pain. I would be a star! I even did a fellowship in manual and manipulative therapy in order to boost my ‘manual game’. I fortunately learned, quite begrudgingly I might add, that my hands were not “magical” as I so desperately wanted them to be. IFOMPT’s central theme was that listening to our patients, understanding their goals and concerns, and applying our hands to facilitate independent movement and not to align anything is what has been shown effective to date.

However under the radar this opinion was, there was still a huge subset of delegates who want desperately to believe that they can use their hands to detect joint faults and correct them to aid in pain reduction. I honestly believe many were scared to voice their pathoanatomical beliefs because of how ridiculed that model was being made out to be at the conference. What I did find funny was that the biggest theme of IFOMPT was the  BPS/neurocognitive approaches to treating pain, yet the 2 big award winners were primarily manual therapy based clinicians/studies (Josh Cleland for this study and Brian Mulligan). There seems to be the knowledge that our hands aren’t doing what we think they are, but we are desperate to believe manual therapy can fix people’s pain. I think we are in a bit of a identity crisis within the profession….if we can’t fix people using our hands, then why are we labelled manual therapists? No one will admit it, but many still hold MT as the central keystone in their treatment intervention and are unwilling to let that go. That was evident by all the 1-1 chats I had with delegates around the conference.

The last thing I wanted to touch on was the fact that no one discussed the economic realities of practice that underpin much of what was discussed at the conference. The time it takes to employ a BPS model, desire for repeat business (elephant in the room), need for cultural authority in the msk domain are realities that I still feel are too taboo to be discussed at such a prestigious conference. I believe a HUGE barrier to widespread implementation of a more BPS model has to do with the fact that clinicians do not want to make the patient feel 100% independent with their problem. Many physiotherapists are business owners and if all their staff are seeing patients only 3-4 times and mainly giving exercise and advice to self manage conditions, a lot of money stands to be lost. I am genuinely curious if the economic impact of the implementation of a BPS has been studied. It’s much more lucrative to tell someone they need weekly therapy to fix their imbalances then to reassure someone and tell them to do generalized exercise for their pain on their own.

IFOMPT 2016 was the biggest and most evidence backed conference I have ever been to. The calibre of the keynotes combined with the fantastic social program makes me giddy for what IFOMPT 2020 in Melbourn, Australia has in store. I for one will not be missing it. I suggest you try and do the same.

Signing off from my blogging duties for now. I hope to meet many readers in 4 years time.

Enjoy being a physiotherapist, it’s still one of the best gigs in town!

Dr. Greg Lehman Interview

Posted: May 4, 2016 in Uncategorized

Do you get confused on how to integrate the biopsychosocial (BPS) model into a busy orthopaedic practice? I know as new grad desperately trying move someone’s L3 on their L4 to fix their low back pain I had no clue how to use the BPS in my practice. In this interview Dr. Lehman breaks down why manual therapy can help back pain, how to integrate pain science into a busy orthopaedic practice, and if modalities such as needling have a roll in treating pain.

Have a listen, you won’t regret it.


To learn more about Greg and to attend one of his courses you can go to www.greglehman.ca to see when he is in your city next. He also provides TONS of free content that you would have to pay for elsewhere.

Enjoy!

Dr. Stuart McGill Interview

Posted: April 14, 2016 in Uncategorized

I had the pleasure of interviewing a true leader in the field of low back disorders. In this interview we discuss:

  •  Is there a “best exercise” those with back pain can do in the gym?
  •  Is there a role for manual therapy in the treatment of back pain? You will be surprised at what he says on this topic
  • Is neutral spine really any safer then a flexed spine during loaded activities?
    Can we really use pig spine model studies to learn how our own discs work? Is it generalizable to the pubic?
  • How does bioemechanics reconcile all the emerging evidence showing the psychosocial components to back pain? This was a VERY interesting question for him to answer
  • Why Rory Mcilroy will have the same fate as Tiger Woods when it comes to back pain…

And so much more!

You can purchase his books or see when he is in your city for a course by going to http://www.backfitpro.com

I hope you enjoyed listening to this as much as I enjoyed making it.

Below is a video of what I am calling a side plank hip thrust that has been working very well in clinic as a quick “trick” to help those suffering from anterior hip and or knee pain. If someone comes to you complaining of an anterior pinch with squatting or pain behind the patella, this exercise can work quite well at reducing that pain almost immediately.

I think it works so well because it provides a non threatening stimulus to the hip and knee that does not involve direct weight bearing through those joints. I’m sure it could also be effective for those with back or even shoulder pain for the same reason.

This exercise is kind of a lower body all in one movement. It targets both gluteus medius, gluteus maximus, the QL and obliques in both concentric and isometric contractions. So if a patient is low on time and eager to get better, be sure to prescribe this as part of a hip and knee mobility and stability program. I am under no false illusion that any pain relief felt from doing this in the clinic will be short lived if it’s not followed up with other tools to get the patient moving in other non-threatening ways. This is just another cool exercise that most patients can”feel” working right away.

Credit for this goes to Dr. Craig Liebenson.

This was shot in my living room, sorry for the sub-par quality! It’s hard finding cameramen in a busy clinic while at work so this one was done at home on my floor🙂

 

FullSizeRender

#GoRaptors

Last weekend I had the opportunity to attend Dr. Craig Liebenson’s seminar for the second time. I first saw Craig over 4 years ago in Toronto and that review can be found HERE. It was funny reading my old review because much of my thoughts on the course and its content have not changed except for a few key details.

When I first took his seminar I was less than 2 years in practice and was still very new to a lot of the concepts being taught. This time, with more years under my belt, I was better able to understand the concepts being presented and had a firmer grasp on how to apply what works for me and leave behind what doesn’t. Unlike 4 years ago, this time I was actively thinking about patients in my practice that would benefit from the concepts taught without overwhelming myself with minutia. I felt better able to appraise what was being taught, both the good and the not so good.

First of all, this course is almost impossible to review based on its concepts because it doesn’t really have any specific method or model to it. This course was a mishmash of content derived from many other schools of thought. The course notes, I must admit, aren’t fantastic as they are mainly filled with quotes, pictures, and charts without much context as to why they are there and how to decipher their applicability to what we do in our practices. This makes going back to review the material challenging as there is minimal framework as to why certain slides are put into the manual. In short, the manual is hard to follow.

Here is a sample of what was touched on

  • The inactivity criss (obesity, diabetes, low back pain prevalence etc)
  • Postural “dysfunction”and our culture of sitting
  • Exercise as the best medicine
  • Traditional vs functional approach
  • The “Mag 7” functional exam (Toe touch, wall angel, overhead squat, single leg balance, single leg squat, single leg bridge, respiration/belly breathing)
  • Stuart McGill’s “Big 3” (Bird dog, curl up, side bridge)
  • Kettle bell exercises
  • Core activation drills (wall press dead bug, side plank hip thrusts, stir the pot, plank rolls)
  • Crawling patterns and the developmental sequence

While sitting in the audience listening to the course content I made a list of what I liked about the course and what I really thought could have been done without or at least modified. I will share a few pros and cons as I saw them.

Pro: Craig is fantastic at getting his audience to change their gestalt on patient care. He challenges course participant to incorporate more active care into the assessment and treatment of each patient. He is very good at giving tips and “tricks” to help patients see the value of active care over a passive care. I talked to a few people in attendance who really wanted to try more active care in their practices after this course and I think that’s fantastic.

Con: Many times on the course he would use a demo who had pain doing a task such as a squat and would do an exercise drill with them, often targeting the core or another area of the body far removed from site of symptoms and then re-assess their pain in front of a crowd of at least 75 people. Each time the participant would say they felt better and was better able to do the functional test they had issues with before the exercise intervention took place. No one ever said what Craig did with them didn’t help (I personally never bat 100, do you?) This smoke and mirrors show wowed me 4 years ago, but now I kind of take it with a grain of salt as anyone when pressured  by a course instructor in front of a huge crowd of peers would say they felt better due to confirmation bias. Dr. Andreo Spina has an excellent video explaining why he doesn’t use demo’s in his course. Basically, you can temporarily trick the CNS into “better” movement but the results are often very short lived. I think without knowing it, he may have made it seem like a simple corrective exercise is a cure-all, when we know it’s not. One other point that needs mentioning is that when he was instructing participants on how to do the exercises, he made it look easy. The problem is that most clinicians aren’t treating healthy and fit 20-30 year olds with awesome body awareness, which is what the crowd demographic was. We are treating chronic pain patients with huge gaps in motor control and exercise capacity. This fact alone makes applying the concepts much more challenging then was let on in the course.

Pro: I liked how Craig was able to introduce the audience to many other approaches such as SFMA, DNS, McKenzie etc without bashing any one approach, stating many times that they each have value and are all tools that can be used depending on the patient in front of them. Many times I have found course instructors need to bash another course or instructor in order to legitimize their methods/ideas. This manufactured controversy might appeal to contrarians (like me) , but it also looks unprofessional. I like Craig for his non-guru approach to functional medicine and does a fantastic job of letting people know their are “many roads to Rome” as he liked to say.

Con: This next point is just a personal opinion, but I found the lecture components to be quite preachy at times. At one point I counted over 25 quotes, one after the other, in his power point slides. He literally read quote after quote, which I think only served to dissuade the audience from paying attention because it started to feel more like a church sermon then a rehab course. Only this time it became quite confusing as to how and why certain quotes fit into the topics we were discussing.  I personally could have done without the excessive number of quotes used to drive home points.

Pro: Simply put, I got some pretty awesome corrective exercise ideas that help with “buy in”. Since the course I have incorporated some of his exercises like the side plank hip thrust as a post test “re-set” and have had great results. For example, I had a new patient who had ++ knee pain with single leg squatting. I had him do it 3-4 reps, each time being sore. I then had him to the side plank hip thrusts with the painful leg on the downside and after about 10 reps we re-tested his single leg squat and he literally said “holly shit, how did you do that!?” because his pain was virtually gone. Now, I know that won’t last and there is a lot he needs to keep doing, but nothing beats that kind of buy in for patients to trust what I am saying and the motivation to comply with the home program. I am also sure a number of other drills would have worked, but hey..I can’t argue with those results. In all fairness, there have been a few other cases where the corrective drills didn’t make a change and I needed to think of other things on the fly. The course just gave me more ideas that really help the patient see the need to do exercise to help with their pain complaint. For this reason alone the course was well worth the time.

In all honesty I took this course again to help motivate me to keep pushing active care in both my assessment and treatment. I found myself “succumbing” to patient preferences for passive care and as a manual therapist it was easy to do that. It’s a huge challenge in a service industry (and yes, private physio is just that) to not cave to what the patient wants. I always give exercises based on what I see as being issues, but I found myself being more lax with patient compliance. I needed a kick in the butt to get creative to find ways to get better buy in because I am a firm believer that passive care is great and helps with symptoms, but it will not provide the fix patients need if exercises isn’t the staple of the program. And I know I get so much more job satisfaction if patients get better quickly and their goals are met. That just doesn’t happen nearly as well with passive care (manips, mobs, needles, soft tissue therapies etc). This course was great at giving that push I knew I needed.

Overall, I would recommend this seminar for it’s inclusiveness for other ideas in the rehab world and as a way to get your feet wet in the “functional” approach if you are growing tired of a structuralist model of looking at the body. You can find out when Dr. Liebenson will be in a city near you by clicking HERE.

Please feel free to ask me any more specific questions you have about this course in the  box below🙂

The tight hamstring debate

Posted: January 6, 2016 in Uncategorized

 

How many people think they have tight hamstrings? Ca’mon, raise your hands, I know you think your hammies are stiff. I hear this from my patients all the time. When I ask them to do multisegmental flexion (touch their toes) many will automatically say ” I haven’t been able to do that in years” or “my hammies are way too tight to do that!” I’m here to say that yes, some people can have a physiological contraction of sarcomeres causing a shortened resting position of the hamstrings, which is what we classify as a truly “tight” muscle. However, it is my contention through clinical observation that most of the time this is not the case. I know this because I am often able to change their ability to touch their toes in a single session…something I would never be able to do if they truly had physiologic hamstring shortening.

A few weeks ago I had the pleasure of meeting up with my friend Erson Religioso while he was teaching in Toronto. Some of you might know him from his epic blog, The Manual Therapist…(if you don’t, please make yourself familiar by clicking on the link). On the course we used PNF type movements of the anterior chain to help increase length of the posterior chain. Some might call this reciprocal inhibition, other might say it’s simply a novel input to help reduce perceived threat thus allowing the nervous to relax it’s hold on the hamstrings. I am more inclined to believe that latter.. my explanation for why the following manual technique and subsequent exercise works is by reducing threat. I believe that hamstrings are generally felt to be tight to protect the lumbar spine, as many people with “tight” hamstrings also suffer from low back pain. The nervous system deems maximal lumbar flexion to be threatening to the spine so it creates neurologically mediated tone of the hamstrings to prevent full lumbar flexion…all in an effort to “protect” it. This might be good for those with an acute symptomatic disc bulge, but for many it’s overkill.

Here is a video demonstrating a pretty neat little technique you can readily do in the clinic to help ease tension in the hamstrings without having to stretch them (which might actually make the problem worse!).


If this technique works to help increase toe touch, the following home exercise is a fantastic way to help the patient maintain their newly found hamstring length…ahh the freedom!


Hope these tips help you in your clinical practice. Enjoy!

Let’s say you have two people who walk into your clinic with an acute episode of back pain after they fell off their bikes in very similar ways. Their pain location is the same as is their initial pain intensity. Both seemed to have muscle strains after physical assessment. After a few sessions, patient A is doing much better…pain is down and he is well on his way to a full recovery. On the other hand, patient B seems to be doing worse…pain is not going away and it’s starting to affect other aspects of daily life. This is peculiar to you because both had very similar objective findings when they first arrived to see you and both sustained very similar
injuries….what gives?!?!

This brief and overly simplistic story is common. The question that has been on my mind for the last several months has been what factors predispose one person to have chronic pain and another person to get better in a matter of weeks? Why do similar injuries lead to often very different outcomes despite good care?  What traits or factors do different people posses that lead them down the wrong road into the land of chronic pain?

In the world of social media where rehab gurus rein supreme, I would expect that some “expert” would give an intricate pathoanatomical explanation as to why patient B didn’t get better. I might hear such things as I should assess their rolling pattern, or that a certain muscle has become inhibited in the (insert random body part here). I would be told that I need to take this or that course to learn the next “game changer” technique to be better at my job. While con-ed is great and learning from peers online has been a blessing for me, I would say that what is not talked about are the less sexy causes for pain…the stuff we can’t assess with a movement screen or strength test.

I took a course a few weeks ago by a professor out of Western University that addressed the prognostic factors that lead to chronic spinal pain. Dr. Dave Walton might not be a social medial celebrity in the world of rehab/therapy, but that’s probably because he is too busy conducting real research out of his lab, The Pain and Quality of Life Integrative Research Lab.  This course, entitled “Prognosis- based approach to assessment and treatment of acute neck and low neck pain” was a 1 day seminar discussing the evidence behind the very question I ask on a daily basis….what causes chronic pain?

We talked about the roughly 25% of people who suffer an acute injury that becomes chronic and what similarities they had.  For whiplash:

High confidence of risk factors for chronicity 

High confidence of no effect on outcomes

High pain intensity >6/10 Angular deformity of the neck
High neck-related disability Impact direction
Post-traumatic stress symptoms Seating position
Catastrophizing Awareness of collision
Cold hypersensitivity Head rest in place
Mechanical hypersensitivity (distal >local) Older age
Vehicle speed

(Walton et al. 2013)

I find it funny that many of the more anatomical categories such as position of neck and impact direction have very little to do with the onset of chronic pain. This continues to beg the question of the relevance of biomehanics in the treatment of the chronically pained patient.

For lower back pain, the results of a large scale meta-analysis from 2010 by Chou and Shekelle,  which was published in JAMA showed the following

Current evidence for LBP

Strong evidence of risk Moderate evidence of risk No clear evidence of risk
Nonorganic signs (Waddell’s signs) Non-supportive work environment History of prior LBP
Maladaptive coping behaviours High baseline pain Demographics (age, sex)
High self-report functional impairments (e.g RMQ) Presence of radiculopathy
Presence of psychiatric comorbidities
Low general health status

The conclusion of this article stated:

The most helpful components for predicting persistent disabling low back pain were maladaptive pain coping behaviours, nonorganic signs, functional impairment, general health status, and presence of psychiatric comorbidities.

The other key aspect of this course was the introduction of evidence backed outcome measures for pain and disability. These are used so we can actually measure objective change in pain and disability over time without the subjective conjecture of “oh you’re getting stronger and moving much better”. Having validated measures to use such as the Brief Illness Perceptions Questionnaire, the LEFS or Neck Disability Index (NDI) are great ways of helping us get a clearer picture of the patients pain and how it specifically effects their day to day life. It also helps us understand the patients beliefs around their pain and why they think they have it and how optimistic they are about recovery. Knowing this information going into an initial assessment really helps me get a clear picture of what I need to do with the patient. Maybe they believe their doomed to lifetime pain or maybe they have very few yellow flags. Knowing this drastically changes how I communicate and even what I do with the patient on the initial visit.

Overall, my tune has changed quite a bit over my 5 years of practice in that I used to be very quick to label peoples pain as anatomy related…”your back pain is due to your locked S.I joint or you have a twisted pelvis creatng muscle spasm”. I now cringe at thinking all the ways I scared patients and made them feel fragile and broken. As it stands now, my practice strives to rule out the bad reasons for pain (the red flags) and to find ways of modifying my patients pain to hopefully help them see that they have the ability to get better without excessive treatment. Education is a cornerstone of my practice…sometimes I think I talk TOO much to my patients about how robust their bodies are!

To hear from a physiotherapist I strive to emulate please take the time to  watch this interview from Prof. Peter O’Sullivan, a world renowned expert in treating chronic pain:

                          Let’s go Raptors!

A few weeks ago I had the pleasure spending the weekend immersed in something that has increasingly become a fascination of mine since I left PT school. It was a course run my a former classmate and friend of mine, Dr. Greg Lehman. Greg has a very unique perspective on the rehab profession at large because of his triple threat training as a researcher (did a masters of biomechanics with Pr.Stu McGill), a chiropractor and a physiotherapist. Coming into and directly out of physio school I must admit that I did not give much thought to the nature of pain. I knew people had it and I thought I would acquire all the tools in the world to fix it. I would mobilize stuck joints, release tight muscles, and give exercises to strengthen peoples cores. I would CURE people! I took courses in manual and manipulative therapy (Canadian System), acupuncture, soft tissue courses etc…all in an effort to get rid of peoples pain. Whenever I helped someone in a single session I thought I had the magic touch…what an idiot I was😉

In my attempt to keep this prelude brief, I will say that as I moved forward in my practice and kept a skeptical mind about what I was doing and what I was taught, I began to realize that I could do any number of different techniques and people would still get better. I reasoned that it was just as much as what I said to my clients as it was what I did that made all the difference. It was then that I realized I needed to become better at what I said was the cause of peoples pain. I needed a way that didn’t make patients feel dependent on me to align them or make them feel like they’re fragile. I used to do that… a lot. I struggled mightily with this paradigm shift because it’s SO EASY to tell somebody they have a rotated pelvis causing their back pain. It’s tempting because it necessitates more therapy and it’s easy for the patient to understand. It also makes the therapist look like a genius for finding this flaw that can be fixed. The problem for me came when I was forced to realize that twisted pelvis’s, stuck cuboids, or tight muscles were not the sole cause for peoples pain. In fact, they were actually relativity minor players in the pain game. The PhyisoFundamentals course was about talking about the other players in the pain game…namely The biopsychosocial model.

Instead of giving a bullet point list of what was discussed, I think it would be far better to do this as a small case study to demonstrate how the content of this course would change how I handled a patient with good old fashioned knee pain.

Mr. Jones is a 65 y.o male with insidious onset medial knee pain on the right of 4 months duration, He thinks he developed this pain from playing “too much” tennis over that time period and has since stopped playing due to pain and fear of making it worse. He owns a large manufacturing business, which is quite stressful for him to manage. He complains of pain with prolonged sitting >30 minutes and with any pivoting motions. He saw his GP who ordered him an X-ray showing moderate to severe osteoarthritis of the medial compartment, which he now believes is the cause of his pain. 

Based on this quick history, we could go several routes in both or physical exam and subsequent explanation of the cover page of pain workbookcondition. We could relate his knee pain to his twisted pelvis, creating a leg length issue thus placing more strain on the joint…how cool would that be if it were true?!?! Or we could do the following:

1) Explain that structure does not dictate function and that misalignments in the body have never been shown to cause pain. Our bodies adapt and there are many people out there with all sorts of anatomical peculiarities that don’t have any pain. This provides hope for the patient..he is not doomed to be in pain by his posture or alignment

2) We would NOT assess his pelvic orientation, how his L3 moves on his L4 or his inner unit timing and then relate it to the cause of his pain. What we would do is explain that while certain activities like tennis might make his pain worse, this is more of a neurologically mediated protection response than it is any knee specific problem. The brain interrupts the twisting motion as a threat and thus relays the message of pain to the brain. Slowly building capacity and confidence in the ability to move without pain will allow him to get back to tennis. We do this by manual therapy to desensitise angry nerves, explaining that he is not broken and the robustness of the body, and by graded exercise prescription specific to the tasks he wants to achieve.

3) We would be wary of making any correlation between his knee pain and his imaging findings. In fact, we would explain that he probably has the same amount of degeneration on his other knee and that many people get this and don’t have pain. Explaining how just as we age on the outside with wrinkles and grey hair, we age on the inside with degeneration and arthritis, This is a very important falsehood to correct because we know that if you believe the idea that your body is “degenerating” then you will naturally fall into behaviours that protect you. These “protections” are lack of use, hypervigilance and increased sensitivity to the area in questions…all things that promote the pain response.  Giving the patient the power to see past a static diagnostic image is both evidence informed and ethical. Personally, I question any healthcare professional who uses an X-ray finding to keep his/her patient coming back over and over again in the hopes of correcting whatever perceived misalignment or degenerative changes the image shows.

This course was unlike any I have ever taken before. There were no specific techniques taught and it was heavily based on language and evidence as opposed to palpation and guruism that so many other courses endorse. Greg made the strong point that we don’t have to change what we do with our patients on a day to day basis. If you like cracking backs, keep cracking. If you like prescribing the McGill big 3 or “releasing” muscles with an instrument, go nuts! All this course sought to do was re-frame the how and the why behind what we already do so well. And this is something I can get behind.

My personal comment: 
This course will be a hard sell for a lot of newer grads because they, like I used to, crave the “fix”. They went into the profession to help people and the promise of instant gratification is a powerful thing. There are many courses that promise quick fix techniques that seem very sure of themselves. The pain science movement doesn’t make itself out to be the panacea that many other courses seem to and this is why it might be hard for newer grads to reconcile. We want to believe we have magic hands and can move the body like a mechanic moves pieces of a car around to get it running perfectly again. This courses challenges those beliefs and might be a hard pill to swallow for some.

Overall I recommend this course to anyone who treats people in pain. We can do better and I think the content this course provides will help. I know it is still a work in progress for me to integrate all of this into my practice, but I will keep trying and make sure to assess my own interactions with each new patient I see.

Have a great week!

We see it all the time, especially over social media. Success story after success story. We see blog posts and facebook status updates detailing how a patient was miraculously cured of a chronic ailment in a single session because the practitioner was able to find what no one else was able to see. Often times when questioned about the assessment and treatment method employed to help such patient the inevitable response is usually “you must take my course to find out”. This blog post will be in direct contrast to that. This will be a quick case summery of a failed treatment of a patient I thought I could “fix”. We learn more from our failures than we do our successes so here’s hoping I’ve learned something from this.

About 2 months ago a new assessment came my way, referred to me by the Physiatrist in the clinic I work at. He was a 27 year old male with a chronic history of idiopathic low back pain. He walked into my office and I literally thought he was a neurological patient due to the sever antalgic and shuffling gait pattern. He was so far laterally shifted that he was losing balance while walking. In all honesty, once I realized he was a back pain patient I started salivating,..”this will be a great success story” I thought to myself. The more acute they are, the more of an instantaneous change I can usually make. It’s the chronic low grade back pain patients that take more time to see results. He explained to me that he has had multiple instances of his back going “out” on him over the past 5 years, but usually got better in a few days. This time was different in that he was in severe pain for over 2 weeks before seeing me.

Here is a bullet form list of what his exam findings were:

  • Severe lateral shift (pictures below…don’t worry, I got permission before posting this)
  • SLR of 20 degrees on right
  • +ve crossed SLR with pain only into the contralateral side of the low back
  • Absent right S1 reflex
  • Dermatomes within normal limits
  • No complaints of bowel or bladder signs, but had pain down to the right heel
  • Lumbar flexion to 20% of normal…couldn’t get his hands past his upper thighs
  • Lumbar extension to about 40% of normal
  • Basically all lumbar movement was classified as a DP (dysfunctional and painful)

Most other standard testing was not done due to the aggressive nature of his pain. At this point my diagnosis was in keeping with a severe right L5-S1 disc herniation compressing the L5 nerve root. He was already under medical management for this so I didn’t deem it prudent to send him for medical follow up. We started treatment with the idea of de-facilitating his sympathetic response. He was pretty wound up (understandably) so my clinical judgement lead me to work on crook lying diaphragmatic breathing, which did help slightly. For the first 1-2 sessions he couldn’t stay in any one position for more than 2-3 minutes before he had to move…suffice to say he was a challenge to treat. What he did respond to was aggressive lumbar traction in side lying. I had to use everything I had to traction his lumbar spine, which was exhausting for me but abolished his pain when maximum force was used. I basically just did this for another session or two, but results did not last at all. He would get off my bed as shifted as ever and in the same amount of pain as when he walked in. Many things were tried with him such as soft tissue release to his paraspinals and sciatic nerve pathway, thoracic spine manipulation, cervical traction, lumbar spine unloading tape jobs, side glides with over pressure, and many forms of self traction. He would always feel better after treatment, but the shift did not change and the results were very temporary. This was unacceptable to me. This client was talking time out of his busy day to see me and paying good money for my care…he should get at least some benefit from each session.

Homework consisted on breathing exercises, side glides in standing, crook lying core contractions, and self traction exercises of various degrees.

I treated him for 8 sessions using pain science education, traction and every type of self care exercise I could think of. With some initial progress but not enough, when he came in for his final session with me even worse than he had been before, I decided to throw in the towel and refer him back to our Physiatrist. At that point he was taking 12 percocets a day (!!!) and couldn’t work (even from home). The hard part was that he had no hard neuro signs and when we told him to go to the ER, they gave him pain meds and told him to come back if he had signs of cauda equina syndrome. He was stuck in limbo…too much pain to achieve therapeutic benefit and not enough to warrant a surgical opinion. He was given an MRI, which did show a large right sided disc herniation compressing the L5 nerve root. On a side note, it’s patients like these the remind me that imaging findings DO matter some of the time in that his pain was directly correlated to what his MRI showed. This is undeniable to all the pain science people out there.  This was a young man who desperately wanted to get better. He did everything that was asked of him and more. He just wanted to get back to work and resume his life. I can safely say this was a patient that kept me up at night thinking how else I could help him.

Our Physiatrist sent him to a pain clinic for injections in his back. The first one he had worked well and he achieved an 80% reduction in pan, but he went back for a second round the next day for more shots, which actually made him worse ($hit!). He was in agony again and back to square one. We are waiting for his symptoms to calm down a little before re-starting rehab and he is in line for a surgical opinion (finally).

This was written to remind you that there are just some patients we can’t help, despite doing everything we can. There is a tendency in the rehab/exercise social media setting to glorify outcomes, which I think make us as rehab professionals feel like we should be able to cure everyone who walks through our doors. As much as we want to, this is just not possible. But never stop trying and continually elevate your game to help as many people as possible. But also know that throwing in the towel is nothing to be ashamed of, as I feel It shows professional responsibility and a patient centred model of care. If I couldn’t help him, I wanted to find someone or something that could. I feel like I would enjoy reading this type of post if nothing else but to remind me that clinicians all over the place are working hard and not always getting the results they want. If you are struggling with some patients, seek out others for advice. Personally, I spoke over the phone with my friend and trusted colleague Erson Religioso about this case and he gave me some excellent advice. I went on a rehab group message forum to get suggestions from such people and Craig Liebenson. Just reach out and ask for help. It will serve both you and the patient well.

Here are the pictures of my patient so you can get a sense of how shifted he was:

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If you have any questions about this case (I know I didn’t give too many details) or any suggestions please do let me know. I think sharing troubling cases like this makes for an excellent learning opportunity and I hope you do too.

Thanks for reading

I’ve been asked to collaborate with a business in the U.K on this infographic about posture, pain and self help tips. The information is mine and the graphics were done by them. I think it uses best evidence that is easily understandable to the public. Any input would be great! I’m excited about this project and think it provides the public with an entertaining way of understanding how to self manage back pain from sitting too much…. And who doesn’t do that?

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