Archive for the ‘Uncategorized’ Category

 

I wanted to share a quick story about a new patient I had at my clinic a few weeks back. This 34 year old male came in as a new patient with a complaint of some “minor knee pain” after falling at work. He walked into my treatment room with what seemed like good control of his knee. I didn’t see a limp nor was his gait antalgic in the least. I figured it was a muscle strain or something of that nature. I get him on the bed to do stability testing and this is what I find:

 

At fist I thought it was an ACL tear but upon further investigation it was a PCL tear. I didn’t show it in the video, but his sag sign was very positive.

I then did another stability test and this is what I found:

 

 

This maybe a little harder to see but he also have extreme laxity of his MCL!!

So let’s review: This patients calmly walks into my clinic with very little pain after falling at work and hearing a pop. He looks stable in gait yet these orthopaedic tests tell us a very different picture…not sure I’m able to explain this clinically

I had him go back to his GP to get an MRI to confirm my diagnosis and it was in fact shown to be a full PCL and MCL tear. His surgeon does not want to do surgery as the PCL has a very poor recovery rate as her his words ( I didn’t know that at the time).

Any suggestions on how to treat this? Just curious to see what others might do?

Pretty interesting case, right?!

Thanks for readng

Me and Dr. Craig Liebenson

 

Over this past weekend I had the opportunity to see Dr. Craig Liebenson present a course at SPC in Toronto. In this blog I will write a review of the course with some interesting take home points.

For those that don’t know, Craig is a chiropractor from Los Angeles. He is what I would call a revolutionary chiropractor as he has taken concepts from so many discipline and formed his approaches based on the work of physicians  physiotherapists, strength coaches, etc. He is well known for his ability to make us look at the body as a unit and not as separate parts that need to be fixed in isolation. He is a master at corrective exercise prescription and he understands movement better than pretty much anyone else I have ever heard speak. He is a strong advocate for bridging the gap from rehab to fitness…meaning manual therapy and modalities are great, but we must also teach our clients to move right to empower them to be able to heal their own pain.  HERE is the link to his personal website  where he literally gives away tons of information and printable exercise  sheets for patients. It is refreshing to know that he doesn’t charge for everything, and he doesn’t seem like he is in it for the money at all.

Craig started the day on a rather interesting “rant”. He told us we are in the midst of a rehab renaissance and if we fall behind, we will be lost. He encouraged us to see Pr Stu McGill, Grey Cook, and take DNS, kettlebell FMS, and SFMA courses to make us complete practitioners. Personally, I found this strange at the onset as he never said “good work” for taking a weekend and spending hard earned money to take his course. Instead he almost made us feel bad for not taking other courses. Towards the end of the weekend he rectified  this by thanking us all and saying how much he appreciates us in Toronto for having him back for a third time.

After his initial rant he went on to discuss societies failure. We as a society have become super sedentary and it’s reeking havoc on our health. He brought up an interesting slide that looked like this:
Obesity, High BP, and sedentarism
GP’s- medication, imaging
Ortho Docs- Injections and surgery
Gold standard: Manual therapy and Exercise

Essentially, we has physiotherapists, chiropractors and personal trainers (minus the manual therapy) are well positioned to educate the world about how devastating inactivity is. Dr. Liebenson told us we must be at the front lines of batteling this. I agree with him 100%!

We talked about the postural conspiracy and how poor kyphotic postures are causing lower back, neck, shoulder pain along with headaches and so much more.

Back and neck pain..check!

Bruegger’s exercise

We reviewed the joint by joint approach and we talked about the importance of micro-breaks for our office worker patients. To break the code and get people moving better, we can’t have them go back to sitting in a hunched position for hours at a time. This defeats the goals of corrective exercise. HERE is an exercise sheet I give to ALL my desk worker clients, regardless of their initial complaint. Throughout the weekend Craig had us doing Cat-Camels, Reach the ceiling, and bruegger’s exercises to keep us limber…he is a man that definitely practices what he preaches.

 

We discussed the overhead athlete and how shoulder impingement might be due to a contralateral hip internal rotation deficit. If a pitcher can’t post on his lead leg when pitching due to a lack of hip IR, he will ultimately have to use more force through the throwing arm to get the acceleration he needs. This over time can lead to a tight capsule and impingement.  Moral of the story: we must look at each client as a whole and not just treat the site of pain.

Breathing was also big. Long story short: we must breath through our belly and not our accessory muscles of respirations (pec minor, scalenes, upper traps) as this can cause chronic neck pain/tension.

Dynamic knee valgus was also discussed as a leading cause of ACL injuries in women (nothing new there).

Exercises to mobilize the thoracic spine such as the T4-8 sphinx, foam roller extension, and child’s pose positions open books were all discussed as ways to self-correct the kyphotic postures our desk jobs put us in….I should probably do some sphinx exercises right about now! We talked about squat training and how to from a goblet squat to a sumo squat and then to a potato sack squat with a kettle bell to train for a weighted squat with a bar…this was an excellent progression as I am always looking for better ways to teach my motor moron patients better progressions to squats with.

There was so much talked about on this course that is it very hard to summarize everything. I will say that the biggest take home for me was HOW we get our patients to buy in to the corrective exercise framework of rehab. I asked this question on the course….I wanted to know how we convince a back pain client who wants to get passive care to buy into an exercise based approach. This is how we should integrate this into our practice:

1) Find out what hurts (movement, ROM, specific exercises, ADLs…whatever!)

2) Find out what movements the patient is bad at that do NOT hurt (non-painful dysfunction)

3) Pick an exercise that helps correct #2  , which should also help with #1. You can pick ANY exercise you want, as long as it helps with the patient’s initial complaint. If you know the principles of movement, the method doesn’t matter as much. Just get the patient feeling better and moving better and they should feel better. If by doing the chosen exercise for teh non-painful dysfunction helps with the clients initial complaint, they are MUCH more likely to buy in.

(With all that said, I still think it will be impossible to get some of my patients to exercise…they just have ZERO interest in active care which is both depressing and frustrating as they are essentially denying them self a pain free existence due to laziness)

NOTE: Being able to tease out the non-painful dysfunction and then figure out which exercise to give that will help that dysfunction and simultaneously decrease their pain is hard. It takes practice and is the art of what we as manual medicine providers do. We must learn as much as we can about why we hurt and how the kinetic chain can become compromised. Once we know that, it becomes easy (as Craig said).

We left the course with this amazing quote by Karel Lewitt:

I am always aware of how many things which I taught in my long past have since been proved wrong. The most important attitude is therefore to be constantly aware that what you are doing and teaching now you will have to modify and correct in view of new facts. Thus you must keep an open mind for new knowledge, even if it sometimes shows that what you believed and taught before was wrong

Here is a small clip just to see what it looked like at the course. Enjoy:

IFOMPT Day review

Posted: October 8, 2012 in Uncategorized

Thursday was my second day at the conference and it was my favourite of the 3 I was in attendance for. To start the morning off we had Gray Cook talk about how we look at movement screening, testing, and assessing movement patterns. I wrote a full blog post on his talk that can be seen HERE .

After a break with exhibitors, I attended a specialist master class  pertaining to complex cases presentations. The presenters all described a real case which served as a great clinical lecture with real take home messages for me. Dr Trudy Rebbeck from Sydney Australia talked about a very interesting case of 15 year old football player who suffered concussion like symptoms after being aggressively tackled in a game. Any movement of the neck produced numbness and weakness in the arms and legs (yikes!). He was sent for an MRI which was “negative”. After a course of therapy including DNF exercises, gradual return to play re-training and balance training he was cleared to go back to his sport. The one detail that astounded me was after the initial MRI was cleared, the Physiotherapist (Dr. Trudy Rebbeck) wanted to see it because his symptoms just didn’t make sense to her. After she reviewed it and asked another radiologist to look at it, they clearly found out that this young boy had incomplete fusion of the arch of the atlas and small tears in the alar ligament. The condition is called Spina Bifida Atlnato and was completely missed by the first radiologist.
Moral of the story: We must exercise clinical judgement and we can’t believe everything is fine with our patients even when they are cleared medically.

There were other case presentations that dealt with similar situations. The overall theme of this class was to think holistically at the body and always to think outside of the box when treating any one specific joint. I.E anterior shoulder pain might be an issue with the rotator cuff, LHB tendon, cervical spine, thoracic spine, serratus anterior or lower trap weakness…the list is long and we have to differentiate to get a a true clinical diagnosis.

After that class the conference gathered back in the main room to witness Robert Elvey get the Geoff Maitland award for clinical excellence throughout his 40+ year career as a physiotherapist. He has been dumbed the father of modern neurodynamic therapy and has taught 1000’s of clinicians the art and science of OMPT all over the world. He was not in attendance to receive the award due to health matters, but his acceptance speech read by a friend and colleague of his was excellent. Congratulations to Robert Elvey on this distinction.

The last presentation of the day was called ‘Manipulation in the Thoracic Ring’ by Dianne and Linda-Joy lee. Unfornately I arrived just as they started and was forced to stand for the 2+ hour lecture with about 30-40 other people in the back. I could not write any notes down as I had no space to do so. Even with that in mind, I still highly enjoyed their talk. If you’re a physio in Canada, chances are you have heard of the lee’s. Diane lee is synonymous with the pelvis and they have been vital in their work of the theoretical model of thorax biomechanics. In a very large summery of what they said, their 30+ years of clinical experience has lead them to believe that many common orthopaedic conditions can be traced back to the thorax. It is their contention that the ribs can shift to the right or left… envision the rib-vertebra-rib-sternum complex as one complete ring. Therefore we have 10 complete rings from rib 1 to rib 10 (last 2 ribs are floating and don’t constitutive a true ring). They believe that subtle shifts in these rings can alter our positioning, creating muscle imbalance, join compression, and really many different problems. They used videos to demonstrate their ring re-positioning techniques on their patients with what seemed like miraculous results. The lee’s really made this concept look like the missing link that integrates all forms of therapy into one conceptual model. They showed video of a rower with a long history of LBP with rowing and long periods of sitting. In their video they showed the rower long sitting (like a rower position) and we saw his lower lumbar spine shift sideways with each rowing movement. L.J Lee then placed her hands along the side of the thoracic wall (which 2 ribs i can’t recall) and ‘repositioned’ the rings and told the patient to do another rowing motion. After her force was applied, the rower had no more pain in his lower back. All in all I left this presentation with so many questions as I always am skeptical of techniques that are advertised as cure-all’s. I’m not saying they out right said their form of treatment can cure everything, but they did have an almost mystic-like tone to their presentation. To learn more about their very interesting model, click HERE

In summary: This day and really this whole conference has been about the connection between research and clinical experience. We must use research to guide our practice, but we can’t let it be everything. Like the Lee’s said: RCT’s will never encompass or be able to examine the therapeutic relationship we have with our patients…and this is a very valid point indeed. This conference has also really been about thinking about the regional inderdependence of the body and to view it in a holistic way. Surprisingly, I didn’t hear as much as a I thought about specific manual therapy treatment. I heard more about functional movement assessment, integrated systems model (Lee’s), and the biopsychosocial model of pain.

Thanks for reading,

Jesse Awenus

This is a case presentation that I knew I had to share with my readers as i’m sure you will be as shocked with the ‘results’ as I was.

A 23 year old girl presents to me with an acute onset of left groin/hip pain after sitting down in a car 3 days prior. She came to me after getting a massage from an RMT at my clinic and was in even worse pain. She reported that after the pain started she went to the ER where the attending physician diagnosed it as a hip flexor strain/spasm. There was no imaging done.

Her complaint was that of an anterior/medial groin pain that was worse with hip flexion but was in little to no pain at rest. Her flexion/adduction/internal rotation test was positive for re-producing her complaint. She also mentioned that she has a history of hip discomfort from time to time while skiing and biking. My mind immediately went into differential diagnosis mode…could it be femoroacetabular impingement, labral tear, hip flexor strain, ingunial nerve irritation, pelvic alignment issue…the list goes on.

I continued to assess her using palpation, movemnet screens and length tension tests for the adductors, hip flexors, glutes, and quads. I also noted a mild anterior innominate on that side (yes, I know the studies proving we can’t really tell blah blah blah). After reviewing in my head her MOI and her complaint of pain with hip flexion and how a massage made no changes in her pain, I gave her a preliminary diagnosis of FAI. I treated her with gentle mobilizations of the posterior hip capsule, thomas test hip flexor stretching  and soft tissue work to the adductors. She reported “feeling better” after the initial session.  Fast forward two weeks later…

She comes back to me two weeks later stating that she felt amazing for one week after my treatment, which obviously made me happy. BUT she had xrays in her hand that she wanted to show me. She went on to tell me that while at the gym doing squats one week later the same pain returned but even worse then before. She stated that she could barley move her leg without pain. She went back to the ER and this time they decided to do xrays….and you won’t believe what they found:

Sewing needle in her leg!!

Do you see the red circle? Well, that is a sewing needle that got logged into her adductor muscles right behind her pubic bone on the left side….SERIOUSLY?!?!

She told me that when she sat down in that car (when the pain first started) she felt an immediate bout of pain but had no idea why. She was moving apartments and apparently a needle was sticking up from the car seat and BAM…right in the leg. How there was no blood or sign of the needle for almost 3 weeks (from time of injury to time of xray) is astounding to me.  I also have no idea how my treatment abolished her pain for almost a full week…yes, she literally resumed her life pain free until squatting at the gym made her sore again.

Anatomically, let’s think of how lucky she was…aside from all the muscles she must had hit with that needle, she also has one more major anatomical structure she avoided…can you guess what it is?

The needle could have easily hit her femoral artery causing a whole host of other issues! Yikes!

Femoral artery anyone?

Although this is a freakish case, it does make me think about something quite important.  My mind was all about biomechanics, and finding the route cause of her pain and not simply treating  her symptoms.  This can possibly get us in trouble at times because if we are so caught up at finding what we believe is the “cause” of the problem, we might actually miss the real cause, which might be staring right in front of us. Now, I admit that I am VERY lucky my treatment didn’t make anything worse, but there was no way that from her history I would think she was impaled by a metal object! This case made me realize that anything can walk into our doors as physiotherapists and we have a duty to our patient to make sure their pain is actually within our scope of practice to treat instead of assuming it’s due to faulty movement patterns, motor controls issues or any other catch phrase term that is popular now.

Hope you found this as interesting as I did!

Oh yeah, the doctors took out the needle using local anesthetic and she was pain free 2 hours after the surgery…go figure!

 

 

This article is not going to be about manual therapy, exercise prescription or reviewing recent literature. Today I want to share with you some of the key concepts I have learned over my first 2 or so years as a Physiotherapist. This article was inspired by a bright young physio student (soon to be physio) named Dave Leyland… read his latest article for some motivation in case you feel like you might be lagging behind. In essence, this article will just be me talking about what I have changed and what I want to change as a physio since graduating almost 2 years ago.

I started practicing September 8th, 2010. I remember my very first patient like it was yesterday (to those who have been in practice 20 or 30 years, I bet 2 years ago does actually feel like yesterday!). Her name was Nancy and she had an MCL and medial meniscus tear. She was a great first patient to have started my career with…friendly, nice, open to having a newbie work on her…she was a pleasure. I treated her with “the best” care I knew how to provide at the time. She got better and I felt like a super star…. Until my 2nd patient! My 2nd patient (ever) was the son of a relatively famous former NHL hockey player. He had a full AC joint separation after being hit in the boards during hockey. I remember going home at night a researching “the best” rehab protocols for such an injury. UnlikeNancy, this young man had been to other, more experienced therapists and actually knew a thing or two about therapy. He questioned me insensately and his surgeon called me to inquire about exactly what I was doing, why I was doing what I was doing, and what were my objective outcome measure after each session…these are all valid questions, but as a new grad I was forced to be very on the ball… it was rough…it was then I realized that knowing what I knew was just not going to be enough…and the more I learned, the more I realized that what I knew was just not going to cut it in this field…not by a long shot.

Over the past 2 years I have made huge gains in my skill set. I am more confident as a therapist. I am better able to recognize clinical patterns, and I know I can help most anything that walks into my door. Here is a list of the most important concepts I have learned over the pat 2 years in practice.

Looks a bit like me after work some days

1) I learned nothing in physio school! Well alright, maybe that’s a bit dramatic… but in reality, coming out of physio school I knew just enough not to hurt anyone. I thought I knew a lot, but when what I was doing as a physio wasn’t providing consistent and positive results I realized I needed to step up my game. The second I embraced the fact that the learning only really starts after you get the degree was the second I became better at what I did.
 

 

2) “The foot bone is connected to the leg bone… the leg bone is connected to the hip bone”. Remember that song from back in the day? Well who would have thought it would form the basis for my philosophy as a therapist. I learned only after school just how interconnected our bodies truly are. The “joint by joint approach” or regional interdependence model of care is now a corner stone of my practice. Simply put, most times pain in one area has contributing factors from other areas as well. This sounds simplistic, but it has and will continue to take me years to figure out all the reasons why people develop pain.

3) Patients do not care about the letters after your name. They only care about results. I used to think that having “MSc.PT” after my name made me credible in the eyes of my patients. I now know that they couldn’t care less. They care about how much you know to get them feeling better. They want to feel taken care of and that their problems are meaningful to me as a therapist. I am currently in the manual therapy stream of courses held by the orthopaedic division of the CPA. Once I complete the entire syllabus system I will get the designation “FCAMPT”…and will a single patient care? Probably not. I do these things for my knowledge and skill set…if you do them to impress patients you will be surely disappointed.

4) Confidence is king. This relates to my 3rd point, but clients need to know that their therapists knows exactly what is going on and how they will “fix” them. They need a game plan to follow and someone to coach them along the way. This is hard to do as there are some times clients that walk in my door that have very odd conditions. And I for one will not lie to a client and make something up just to give them an answer. That would be the easier route, but I rather tell them I don’t know but will figure it out. Does that always work? I’m not sure, but at least I can go to bed knowing I’m 100% honest with all my clients. The #1 way I have learned how to gain confidence is to LEARN! Always read, ask questions and then read some more. So much info is out there…you just have to wade through the B.S to find it.

5) The over arching theme I have learned over the last 2 years is that I will never be comfortable knowing what I know and leaving it at that. The second you become stagnant is the second you become obsolete as a therapist. Having an internal drive to know more is a gift I guess. I force myself to stay up to date and read as much as time always. Blogs, books, webinars, articles…I always wind up getting something from everything I invest time into. What you get out what you put in is never truer than with my career as a physiotherapist.

6) This will be my “rant” point off the list. I have come to realize that treating clients who are unmotivated is both physically and emotionally draining! I want to cure the world and make everyone 100% better, but I have learned that just isn’t always possible. The greatest exercise means nothing if the client doesn’t care enough to do it. This is an epidemic these days with some clients. I could write an entire blog on how everyone wants the quick fix, but that’s not the point of this article. Essentially I have come to realize that if I care more about my patients’ well being then they do, I will burn out quick! So I make a point of telling each new client I see that they have to be committed to therapy for optimal results to be achieved…it’s a two way street. Passive care is great, but it can’t all be that.

Can’t be all about the money

7) Money will come. I used to think I wanted lots of money right away and many of my decisions were based on how much money I could make. I’m lucky to have realized very quickly that money will come when I deserve it. Being the absolute best therapist in my client’s eyes is what creates value. This is something that takes time to achieve…you know, the whole “always learning stuff” I keep talking about… that’s what makes money. When people deem you to be so essential that they will spend their hard earned dollar to have you work on their body…that’s when money will come (more money that is).
 

 

8) I am a puppet on a stage EVERY single day I go into work. My patients don’t care how tired I am or how bad my night was. They have their own problems to deal with and are paying me to worry about their issues…not mine! Each day I go into work I have to put aside any and all problems in my life and become 100% sympathetic to my clients needs. There are no off days for me. I can’t afford to be indifferent with even one client because you never know who that client knows and how they might help your career one day. This was a hard pill to swallow because lets face it…as much as I love my job there are definitely days where I MUCH rather be elsewhere. Learning how to “act the part” day in and day out was tough…but that’s just the way it is!

 

9) Customer service customer service customer service!  Writing down the names of my patients kids, their birthdays, when and where they went on vacation, what their favourite sports teams are…these are the little “tricks” that really help solidify relationships with my patients.  Think about it…wouldn’t you love it if the next time you walked into your doctors office and he or she asked you how your trip to ‘insert destination here’ was? That little extra care really goes along way. I make a habbit of emailing clients videos of exercises to make sure they fully get them. I call clients back ASAP if they have any questions. I always tell clients to call or email me when and if they need me for anything physio related. That kind of selflessness is what drives customer service. If you do just this I think you are ahead of the game.

Overall, I am happy to say that I love my job and I feel honoured to be able to do what I get to do each day. It can be a hard job, but it can also be immensely rewarding! I can’t wait to see what I learn in the next 2, 4, 10, 20 years!

What have you learned since becoming a therapist? What tips do you have for newer grads like me to ensure success in a demanding industry such as ours?

Have a great week!

2 BIG Announcements

Posted: May 23, 2012 in Uncategorized

Hello Blog readers. Today I have 2 very exciting announcements to make that I’m sure will be of interest to all of you wonderful people:

1) I have joined up with www.physioanswers.com to help write small articles on real life matters related to your health and wellness. This site is simple it nature–it is just a bunch of very smart professionals from across the world who have come together to make an easy to navigate site with great articles for your health. And it is 100% free!!

2) Have you ever wished you had access to easy to follow, professionally made exercise videos for either yourself or your patients? There are a bunch on youtube, but they are of sub par quality and don’t give the viewer all the tools to really understand how to do a simple exercise. Well in the coming months, me and my colleague (and friend) Scott Stanger are teaming up to produce a first class website with exercise videos. Professionally shot, with text, video and voice to help fully explain exercises. This site will be easy to navigate and will surely help your patients out with exercises…because really, are the pictures on paper showing exercises really helping our patients understand what to do? I think not. Scott and I want to change all of that. Our site will show rehab exercises from simple clam shells and side lying external rotation to more complicated movements like single leg deadlifts or turkish get-ups. More information on this to come as we develop and fine toon it for its big debut.

Please comment with any suggestions you have for either announcement and I will be sure to listen!!

VERY cool case presentation

Posted: March 9, 2012 in Uncategorized

This is my first case presentation on my blog…so exciting. I had a VERY interesting (and awesome) case at my clinic this week that I had to share with whoever wants to listen. I always feel hesitant to write about clinical cases  because I realize there are many ways to skin a cat and I’m sure another therapist will come along and tear apart my diagnosis and subsequent treatment. This case however, the results were unlike any I have experienced yet as a physiotherapist.

A 43-year-old woman presented to clinic 3 days ago suffering from a 3 year off and on again history of “heaviness in the ears”. This was accompanied by bouts of dizziness and a slight ringing in the ears as well…she has become VERY annoyed with this and stated it was messing up her life. At first my red light caution flag came up, so I did a very thorough history and exam. Her reported mechanism of injury was doing a dive in her pool, twisting her neck. I immediately thought “uh oh, vertebral artery issues”. So I asked her about the 5 D’s and 2 N’s which were all negative. Her BP was 128/85 (not bad). Her HR was 73 BMP. Even though the sensitivity and specificity of the vertebral artery stress test sucks, I did it anyways (why not, right?). It was negative as well. She had no recent trauma to speak of.

Does this look fun?? NO!

I then thought about BPPV (vertigo). I did the dix-hallpike test bilaterally which revealed no nystagmus or dizziness…does anyone like doing this test? I don’t like throwing my clients down to the bed repeatedly and I’m sure they don’t love it either…But I digress

I remembered reading an article  that talked about upper cervical spine restrictions leading to altered proprioceptive input to the brain leading to sensations of dizziness and ringing in the ears. So, I checked the craniovertebral area and BAM…barley any movement was noted at C1-C2 bilaterally into right and left rotation on accessory glide tests…yeah, yeah I know…PIVM testing is garbage and unreliable…but hey, this is what I felt…it just wasn’t moving. Since this was the largest clinical finding I found I made a decision to treat it. I started with mobilizations…I did that for about 3-4 minutes and it really didn’t change her accessory glide testing. Her upper cervical flexion test was also at about 30 degrees bilaterally (should be roughly 45 on both sides) . I asked my patient if she was alright with me manipulating her neck to free up the restrictions. I told her the risks and benefits and made her aware that if she was at all uncomfortable we could do other things. She was happy to let me do the manip. I put her in the pre-manip hold—zero pain noted by the client. I then did a HVLA thrust at C1-C2 on both sides. Cavitation was noted on first attempt…always nice when that happens.

After the manip, I had her stay on the table for a few minutes. She felt fine and proceeded to sit up. She sat on the side of my treatment table and started to smile…then laugh…and then cry. She stated “I have had this issue for ages and it’s gone…all gone”. It was a great feeling to have helped her with her issue. I saw her again the very next day for follow up. She said she was 90% better and very happy. I did myofascial work on her suboccipitals, scalenes, levator scapula, splenius capitus, and upper traps. I sent her home with chin tucks and scapula retractions as a home program. She called me today at the clinic saying she woke up this morning with zero symptoms….SWEET!

Suboccipital release Doesn't it just look great...

Ok, here is the moral of the story: I went on a hunch…did I know with 100% certainty that her issues was neck related…I’d be lying if I said yes. I went with my best guess and it paid off for me in this instance. Taking manual therapy courses and being an avid reader of the literature has afforded me the ability to know the risk-benefit ratio for the techniques I employ. I know the risk of neck manips (it’s minimal) and I cleared her for everything beforehand. I recalled reading a study (now I remember where I found it)… here’s the link  that showed a very high success rate with manipulative therapy to the neck with the symptoms my client presented with. I wouldn’t start maniping everyone with ear problems, but if you can differently diagnose and rule out issues, you’re well on your way to figuring out why your clients have pain. I don’t use neck manipulation very much as I think for many issues there are better treatments to give (muligan mobs, massage, traction, thoracic manip etc). But for the amount of restriction I felt, I just felt it needed to be done…and I’m happy it proved successful!

Hope this little case presentation was interesting. If anyone has any other ideas about treatment or differentials for this presentation I am very happy to learn!

Thanks for reading.

 

We'll see about that...

 

As some of my readers know, one of my blog posts has started a little bit of an argument over the philosophy some chiropractors abide by in their practice. Instead of responding to the chiropractors posts individually, I will try my best to show literature (no opinions) to explain why I have come to believe that subluxation theory has no place in today’s healthcare marketplace.

Before I start, I want to reiterate that I am a chiropractic supporter! I support any healthcare discipline regardless of the credential that incorporates current best practice evidence when treating their patients. For myself, as a physiotherapists who limits himself to the diagnosis and treatment of neuromusculoskeletal conditions, I feel I have a responsibility to my patients to seek out the best information I can on the most effective way to assesses and treat. I don’t rely on dogma or the thought processes of any one particular guru to guide my

The Guru...

clinical practice. I don’t subscribe to a single theory, or preach one entity as the cause of all (or most) disease. Like I said in my original post, I have many chiropractic friends who I look up to as colleagues and try to learn from. My father is a chiropractor in practice for 31 years and we are always learning from one another. I am not naïve to the profession as some of the chiropractors on my blog have inferred.

 For the rest of this post when I refer to chiropractic care I am referring solely to adjustments for subluxations. I am NOT referring to the other modalities evidenced informed chiropractors employ…so let’s look at the evidence:

There is questionable scientific evidence chiropractic works. Neither of two cochrane reviews support it, nor can the The National Center for Complementary and Alternative Medicine (the Federal Government’s lead agency for scientific research on complementary and alternative medicine) who state:

“Overall, the evidence was seen as weak and less than convincing for the effectiveness of chiropractic for back pain. Specifically, the 1996 systematic review reported that there were major quality problems in the studies analyzed; for example, statistics could not be effectively combined because of missing and poor-quality data. The review concludes that the data “did not provide convincing evidence for the effectiveness of chiropractic.” The 2003 general review states that since the 1996 systematic review, emerging trial data “have not tended to be encouraging…. The effectiveness of chiropractic spinal manipulation for back pain is thus at best uncertain.” The 2003 meta-analysis found spinal manipulation to be more effective than sham therapy but no more or no less effective than other treatments.” from: http://nccam.nih.gov/health/chiropractic/#9a

 The national center for complementary and alternative medicine, who’s purpose is to support CAM can’t in good conscious conclude that manipulation for “subluxations” works….interesting.

This review then necessitates to me that prudent healthcare practitioners use a multimodal treatment approach. No one therapy alone is sufficient! Just manipulating the spine without doing anything else will yield suboptimal results as stated in the literature.

The chiropractors that have commented on my blog have pretty much stated that the foundations for chiropractic are based on some of the most self evident truths of this universe and they fix subluxations because they feel universal intelligence clearly exists.

Now, no one is arguing against the existence of a supreme being. Nor are we suggesting that faith doesn’t play a role in health. What I do take issue with is the role of D.D. Palmer as high priest.

A quote from his 1910 book “The Chiropractor’s Adjuster” –

“I founded Chiropractic on Osteology, Neurology and Functions of bones, nerves and the manifestations of impulses. I originated the art of adjusting vertebrae and the knowledge of every principle which is included in the construction of the science of Chiropractic.”

and

“I am the originator, the Fountain Head of the essential principle that disease is the result of too much or not enough functionating. I created the art of adjusting vertebrae, using the spinous and transverse processes as levers, and named the mental act of accumulating knowledge, the cumulative function, corresponding to the physical vegetative function — growth of intellectual and physical — together, with the science, art and philosophy — Chiropractic. It is now being followed, more or less, by 2,000 Chiropractors, and its use is being attempted by several other methods. It was I who combined the science and art and developed the principles thereof. I have answered the time-worn question — what is life?”

Besides the obvious factual error (Palmer did not “create” SMT, it has existed in some form since before the time of Socrates), he claims to be the “fountainhead” of knowledge and to be able to answer to the question “what is life?”. There are others who have made similar claims over the years, including, but not limited to David Koresh, Rev. Jones, and General Idi Amin Dada…can you see why his god complex persona discredits him?

The second issue, how does a grocer (Palmer’s career in 1895) instantly become so well versed in “Osteology, Neurology, and the Fuctions of bones, nerves, and the manifestations of impulses” to found anything?

Third, how does Palmer so easily dismiss the thousands of years of evolution in medical knowledge that came before him? Peracles, Hippocrates, Socrates, Virchow, and Lister mean nothing? Palmer was smarter than the thousands of healers who came before him. He alone is the “Fountainhead”. Please.

Lastly, look at Palmer’s motivation (again from his book):

“One question was always uppermost in my mind in my search for the cause of disease. I desired to know why one person was ailing and his associate, eating at the same table, working in the same shop, at the same bench, was not. Why? What difference was there in the two persons that caused one to have pneumonia, catarrh, typhoid or rheumatism, while his partner, similarly situated, escaped? Why? This question had worried thousands for centuries and was answered in September, 1895.”

Actually, we now have the answer to this worrisome question, and it isn’t chiropractic. Our modern understanding of the immune system, down to the protein synthesis level, has specifically determined the answers in a very provable manner.

Very interesting book!

 More on subluxation theory:

Other chiropractors have declared its unproven status as an area that needs reform:

“Some may suggest that chiropractors should promote themselves as the experts in “correcting vertebral subluxation.” However, the scientific literature has failed to demonstrate the very existence of the subluxation. Until and unless sound research published in credible journals demonstrates the existence and reliable identification of vertebral subluxation, and vertebral subluxation is found to be an important public health problem, society at large will not care about its correction. Thus, “subluxation correction” alone is not a viable option for chiropractic’s future.”

(Murphy, et al.Bringing Chiropractic Into the Mainstream in the 21st Century – Part II“, Dynamic Chiropractic, September 1, 2005, Vol. 23, Issue 18)

 A Beth Israel Deaconess Medical Center article describes the mainstream understanding of vertebral subluxationheory:

Since its origin, chiropractic theory has based itself on “subluxations,” or vertebrae that have shifted position in the spine. These subluxations are said to impede nerve outflow and cause disease in various organs. A chiropractic treatment is supposed to “put back in” these “popped out” vertebrae. For this reason, it is called an “adjustment.”

However, no real evidence has ever been presented showing that a given chiropractic treatment alters the position of any vertebrae. In addition, there is as yet no real evidence that impairment of nerve outflow is a major contributor to common illnesses, or that spinal manipulation changes nerve outflow in such a way as to affect organ function.[32]

 (Robin Brett Parnes, MS, MPH, “Chiropractic Treatment: What You Should Know“, Beth Israel Deaconess Medical Center.)

And finally:

In 2009, four scholarly chiropractors (yes, chiropractors did this study!) concluded that epidemiologic evidence does not support chiropractic’s most fundamental theory. Since its inception, chiropractors have postulated that “subluxations” (misalignments) are the cause or underlying cause of ill health and can be corrected with spinal “adjustments.” After searching the scientific literature, the chiropractic authors concluded:

“No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal, this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability.”

 (Mirtz TA et al. An epidemiological examination of the subluxation construct using Hill’s criteria of causation.Chiropractic & Osteopathy 2009, 17:13, 2009)

 With this in mind, it is laughable to me that some chiropractors claim that through the removal of subluxations they have prevented heart surgeries, helped with ADHD or colitis…among other conditions. HOW can any rational healthcare practitioner espouse this? I mean, ca’mon! Let’s be real here.

Another great read

Instead of debating the chiropractors on my site point by point I have taken the time to find my sources. It was said that I am an “unarmed man” when it comes to research. I have just posted excerpts of studies showing you WHY I believe your theory for why you say you do what you do just doesn’t hold water. If anyone has any credible sources to prove subluxaions A) Exist and B) cause the problems some have said they create then please share. I am always up for learning and always ready to change my mind if presented with compelling information.

I realize that this post may have offended some and I’m sorry for that. I started my original post praising where chiropractic is going and by the comments of a few, I am sadly reminded that there is still so far for your profession to go. I find it funny how subluxation based chiropractors tell me that other chiros who do more than fix subluxations are “fake chiros”. These are the chiropractors that have taken it upon themselves to constantly learn more and demand the most from their profession. Are they doing exactly what Palmer said they should do? NO! And I commend them for it!

For a much better author on this topic please visit: http://www.sciencebasedmedicine.org/index.php/subluxation-theory-a-belief-system-that-continues-to-define-the-practice-of-chiropractic/

 Thanks for reading,

Jesse Awenus B.A (Hons) Kin, MSc.PT
Registered Physiotherapist

 

 

Great big toe mobility

If one link breaks,what happens to the rest?

 

As many of you know, the times of treating the site of pain are behind us (with exceptions of course). Through a paradigm shift in the rehab/training world we have come to appreciate the body as an integrated unit, where all it’s part never function in isolation but as a unified whole. This means that when a patient presents with knee pain as an example, the knee is very rarely the cause of the pain. The knee pain is simply the consequence of an issue at a joint either above or below the knee. Now that we have that out of the way….on to the topic at hand!

Low back pain (LBP) is an epidemic. We all know the stat that 80% of us will have back pain at some point in our life…I know I have! The problem then becomes an issue of treatment. Let me just say that I am not dead set in my ways and I know there are many ways to skin a cat..i.e many different treatments can fix the same problem…that’s only if the right problems are addressed. In this blog I will explain how a restriction at the big toe can ultimately lead to back pain…just something else to think about.

Hallux Rigidus can occur for many reasons. This condition presents itself as limitations in big toe extension

Heel strike, to 5th toe, to 1st toe

(dorsiflexion). Why does that really matter? Oh…it matters! Every step you take the big toe is working to create power for push off. We start off with heel strike, the subtalor joint moves us into inversion where our weight is placed on our 5th met head and then we have subtalor joint unlocking which allows the midfoot to fall into functional pronation allowing the big toe to come into contact with the ground. At this point, the big toe digs into the ground to create the push off we need to move forwards. In order for the big toe to flex into the ground to create momentum, it must first go into 45-60 degrees of extension to create the proper length tension relationship to allow the push off phase to occur. This is where problems start to set in.

If the big toe can’t dorsiflex, the body is going to compensate for that lack of movement by trying to shift the body weight medially to get that big toe to hit the ground…the body is smart and will always find a way to do things to keep moving. When we don’t get the movement from the big toe, the knee must go into valgus collapse (knock kneed) to try and get as much weight on that big toe as possible for push off. When the knee goes into medial collapse, the hip moves into internal rotation and the lower back compensates by shifting towards the side of hip internal rotation. When the low back shifts, you can get muscle shortening, facet joint impaction, degenerative changes etc…leading to back pain that started from a lack of big toe extension.

So here is the BIG question…WHY can’t the big toe extend? Arthritis is one reason but I won’t discuss that as again, I believe arthritis is just a consequence of a biomechanical imbalance elsewhere. Here is a big reason that I see clinically. If the flexor hallicus longus muscle becomes restricted, the big toe will not have the mobility to extend due to the muscle keeping it in a plantarflexed position. We sleep in a plantarflexed position so this muscle often becomes tight in some people. If the flexor hallicus longus is fine and patient still can’t dorsiflex the first ray with ambulation then I check peronius longus. Why? The peronius longus has the task of transferring weight from the 5th met head to the big toe during the gait cycle..it helps create that functional pronation I was talking about before. It also has a roll to play in plantar flexing the big toe to help with push off. So, if peronius longus is weak or tight it could be a cause of why the big toe can’t fully get the mobility it needs to create adequate push off power.

 In short, to treat this I mobilize/manipulate the first MTP using accessory and physiological glides. I do myofascial release of the flexor hallicus longus from the fibular origin to its insertion (probably getting a few other muscles at the same time…but that’s fine!). I stretch the foot into dorsiflexion, I work on peroneal strengthening (good one being heel lifts a with tennis ball squeezed between the ankles), and I of course work of glute strength…because everybody needs it! I also check the pelvis to see if there is an imbalance at the innonimate…that too can be one cause of big toe problems

Simple big toe self stretch:


Peroneal Exercise:

Are there other reasons for back pain? 100% yes without question. This article was just written to help therapists who have clients with nagging back pain to help think outside the box in terms of possible causes. I know I have been stuck with clients in my practice and have neglected to look at other factors…not so much because I didn’t want to, but more because I just didn’t know they could be issues in the first place. I guess the take away point is to be a detective with the body. Never think that a problem you see somewhere other than the site of pain is unrelated…it probably is. I’m the first to admit that I have been caught chasing symptoms to try and make the client happy. But I have found that if I take the time to explain why I’m wiggling their toe for their back pain, I gain credibility…because If I didn’t explain that, I’d be considered a voodoo therapist in their eyes hahaha

 Thanks for reading and happy new years!

 Jesse Awenus B.A (Hons) Kin, MSc.PT
Registered Physiotherapist

Research Review Service

I get asked this one question daily: What is the difference between a chiropractor and a physiotherapist? I often get asked this question after I perform spinal manipulation as most patients usually deem that to be chiropractic territory. My answer to them is never simple as I usually have to explain quite a bit to make my answer make sense. I also do this because I want to give my profession and the chiropractic profession their credit where it is due….and usually by the time I’m done with my answer I’m sure the patient has regretted asking the question in the first place 😉

I usually tell my patients that today’s physio and chiro practice very similar to one another. There are chiropractors that use soft tissue release, ART, acupuncture, modalities, exercise prescription along with spinal manipulation. There are also physiotherapists that do all that as well. I do mention that there are chiro’s that tend to use manipulation as their primary treatment technique and some even use it as their only treatment technique (Yikes!). I get into the philosophical differences between the two professions and how we as physiotherapists have generally been more evidenced based clinicians…but this is changing. However, I ALWAYS say that just as there are quacked out chiropractors, there are also worthless physiotherapists who use ultrasound and heat on anything that walks in their door.

I have many chiropractic friends and for those that don’t know, my own father is a chiropractor who has been in practice for 31 years. I have seen MANY sides of the profession and have done my research. I know the good, the bad, and the ugly of the profession. In all honesty, I am very pleased to see where chiropractic has gone in the past 10 or so years. The CMCC is producing quality, evidenced based neuromusculoskeletal therapists. They have all but done away with subluxation theory and are promoting patient self-care for the management of their pain. I learn a lot from some of the chiropractors I associate myself with and enjoy their take of the rehab profession as they see it. I LOVE how they are rallying against the subluxation based chiropractors in their own profession. They have realized that in order to gain mainstream legitimacy they must be evidenced informed clinicians who do not rely on 110 year old ideas about how the spine and nervous system function.

 

Physiotherapists and Chiropractors who practice using up to date research as their guide probably do things very similar most of the time. Are there differences in our training? Sure there are, but that does not mean one is better than the other…just different. Today, prominent physiotherapists such as Grey Cook and Mike Reinold are working side by side with amazing chiropractors like Craig Liebenson and and Perry Nickelston. Overall, it has become far less about the letters after your name and more about the quality of work you do that determine the kind of therapist you are.

It is essential that ALL rehab and exercise professionals read and stay current. Also, money should not be their soul purpose for doing what they do. These therapists exist and are doing fantastic work. If you ever need a recommendation for a good physio OR chiro let me know and I’ll be happy to assist.

Happy Holidays,

Jesse Awenus B.A Hons (Kin), MSc.PT
Registered Physiotherapist