jessephysio

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:

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?

Last week on my blog I wrote about what I had learned in my 4th year of practice. One thing I mentioned was that I now use dynamic or rhythmic shoulder stabilization exercises much more then ever before. I now use them as much if not more than good old fashion concentric-eccentric cuff strengthening. This quick video post is going to explain this almost too simple to work exercise and why I think it helps.

The reason I like this so much is that the test becomes the exercise. If I do this band assisted stabilization exercise and it makes immediate changes in pain free AROM of the shoulder, I have instant patient buy in and then prescribe a variant of it for home use.  The next time you have a patient with a painful shoulder arch or too much upper trap activation with abduction, lay them on your treatment table and preform this exercise with them for 1-2 minutes  and then re-test their AROM. I have done this in clinic with some pretty great results. I love the “wow” factor patients have because something so simple and quick can change their pain…and the best part is that you don’t even have to do any manual therapy. I often complement this exercise with the explanation that if it helps it means the patient has full control over getting better and they don’t need any fancy manual techniques to improve. How liberating is that for the patient?!

I explain in the video why I think it works, but that is just an educated guess. If you have another explanation I would be more than happy to hear it!

Thanks and best of luck

It looks like it’s that time again. Time to summarize what my 4th year of practice has taught me. It’s been another busy year, but also a transformational year for my practice. I’ve settled into my clinic in Toronto, adjusted a few paradigms and am happy to report I still love what I do everyday. Being a physiotherapist is truly the best choice I have ever made.

So without further adieu, here are a few select things I learned in my 4th year as a physiotherapist:

1) Paralysis by analysis: reading too many blogs can be a bad thing: This might sound weird coming from a blog, but I have slowed down how many blogs I read (I say that every year, but this year was especially true). Reading 100 different opinions on any given topic can make you nuts. There have been times this year when assessing a patient I have a blog post from Reinold, Lehman, or Erson in my head and although I learn so much from all of them, it can still screw you up with the patient in front of you. Have a system and stick to it!

2) Quick clinical point that has really been great for me this year: Rhythmic stabilizations and reactive neuromuscular training is better that pure strength training for shoulder rehab. I have got MUCH better and quicker results by teaching the shoulder to resist movement by centrating it in the glenoid than I ever did with good old fashion side lying external rotations. Patient has pain at 120 degrees abduction before treatment, do 2 minutes of theraband assisted rhythmic stabilizations , and their pain is usually gone or at least better in most instances (not all, but always worth a shot). I will get a video up showing you what I do for this.

3) You can cherry pick research to justify pretty much anything in rehab. Anyone can use google scholar to find anything that validates just about everything…I’ve seen articles that validate some pretty wacky things. As a clinician, you have to take it upon yourself to have a cursory understanding of research methodology, statistical analysis, and levels of evidence. This helps you see through the bullshit.

4) Research has advantages over real life practice in that a patient in front of you in pain is not pre-screened using specific inclusion and exclusion criteria. It’s up to you to piece it together to help who comes to your door. As much as I love research and use it as much as possible, I have also come to learn that real patients don’t all fit into nice little boxes where we can do treatment ‘A’ and expect a certain result. Not everyone fits into a clinical prediction rule and we must treat the patient and not the condition.

5) Don’t feel bad for using treatments that many say don’t work. If I decided to stop doing all the treatments that such websites as sciencedbasedmedicine.org and saveyourslef.ca said are ineffective there would be very little I would be able to do as a physiotherapist. I really enjoy these sites and read them often, but I have come to learn that if something is of low risk and has some possibility of helping, it’s worth a shot. I’ve bashed craniosacral therapy before for its biological implausibility and lack of any research for its use. However, I also know there are subsets of patients who really enjoy it and respond well to it. I don’t for a second think the therapist is actually moving skull bones around or normalizing the flow of CSF, but I do think they are providing some great therapeutic touch, which we know down regulates the CNS, which can alter the sensitivity of the nervous system. The risk is small so I say live and let be when it comes to stuff like that. Just don’t say it can cure cancer okay? 😛

Great site! http://www.sciencebasedmedicine.org

6) As much as I hate this, I have realized that my goals for patients don’t matter because it’s what the patient wants that ultimately dictates treatment progression. For example, if I see a patient with reoccurring low back pain and my goal is to teach them strategies for decreasing the rate of recurrence, I will do an SFMA and work on their DN’s which may include some serious strength training. However, the patient may just want pain relief from this specific episode and not care about prevention strategies. I will always try and explain that they need to do x,y and z to get better and stay better, but if they choose not to listen I have to respect that and just help them with pain relief. I sometimes believe this involves economic factors that I have no control over as well. In summery, if a patient just wants pain relief then that’s all I’ll give them. Can’t want to help someone more then they want to help them self.

7) Patients need to know you have a plan for them and seeing patients more often is better for their outcomes. I used to think that patients respected you more when you wanted to see them less (and I still think that is true to a degree). However, to really integrate proper exercise into daily life or to calm down nervous system output in the form of manual therapy, a patient needs to be seen a little more frequently at the onset. I now see new patients at least once a week for 3-4 weeks, sometimes twice depending on the nature of the condition.

8) I don’t think we can make permanent changes to people’s static posture and I’m okay with that. I am WAY less posture oriented this year then I ever was before. I don’t completely exclude it as a source of pain, but I don’t think I am able to correct a kyphotic thoracic spine to any appreciable degree…and I don’t think it even matters that much anyway. I now teach the mantra “motion is lotion” when clients ask me the ideal posture…the best posture is the next posture!

saveyourself.ca

9) Lastly, we need to have a framework to treat patients. There has to be a standardized method used to assess and treat and it needs to be patient centred. This has proven challenging for me as many of the “frameworks” from which I was taught to view the human body have proven wrong in the world of evidenced based practice. For example, I was taught tests for SI joint movement and stability (gellet etc) and then was told to treat based off those assessment findings. This kind of structuralism methodology formed the bases of my physiotherapy education and much of my post-grad education. Now, a few years into practice I can safely say that I have almost had to relearn what I do for a living due to fact that I can’t ignore the massive amounts of research showing we can’t palpate multifidus, detect movement at the SI joint or ascribe the cause of back pain to a leg length discrepancy (these are just examples off the top of my head). Integrating pain science into my practice was and continues to be a challenge… Patients really want you tell them they have a fixable structural problem. They almost need it to help them feel like they got a thorough assessment. Changing patient’s expectations in this area is a work in progress to say the least.

Are we really doing what we think we are doing?

So there you have it. An inside look into what has been going through my mind this year. Hope you enjoyed it!

Research as shown that manipulation to the thoracic spine can be beneficial for neck and shoulder pain (see articles HERE  an HERE). So it only stands to reason that improving mobility at this crucial area of the spine can be helpful for a large group of orthopaedic complaints. Neurophysiological rational aside, getting more ROM through the thoracic spine has impact on areas upstream and downstream the body. If we look at the joint by joint approach, we see that the the cervical and lumbar spine are primarily designated areas of stability (sort of…), and the thoracic spine is the mobile area of the spine (again, kind of…). If we develop stiffness in the upper back, common sense tells that the areas above and below will have to compensate to achieve functional ROM. This is why so many people who drive a lot get neck pain…if you’re torquing out your neck to look at your blind spot because you can’t rotate through your upper back you will get neck pain.

I will be honest in saying that 99% of the people I treat will have their upper back mobility assessed via the SFMA model to some degree. Plantar fascists, PFPS, carpal tunnel…they all get their spinal mobility looked at. I may not always address it right away but it will be looked at. I just think it’s good clinical practice to get an overall sense of how someone moves and try to find non-painful dysfunctions before I jump into treating the painful area (yes, I treat the site of pain…and so should you!)

Here is a BRIEF video explaining how I assess upper back ROM using an SFMA framework.

For clients who have persistent lower back, neck or shoulder problems I usually send them home with at least one of these 3 exercises depending on what I find as being the biggest problem and what the patient can effectively do on their own. These are exercises that help maintain the gains made in therapy and for the most part, clients actually report the exercises “feel good” to do…which helps with compliance.

1) Open Books

2) Quadruped (on all 4’s) thoracic rotations with variations

3) Foam Roller Thoracic Extensions

I’m always looking for better and easier exercises that patients will like doing and that will help them with their chief complaint. I have had success with these 3 and hope to learn many more as time goes on. I hope these help you in your clinical practice. Please share what upper back exercises you like giving your clients as the best way to learn is through sharing knowledge.

Thanks for reading!

Earlier tonight I was watching an Inner Circle webinar from Mike Reinold. The webinar was discussing 5 common stretches we probably shouldn’t be doing and like anything else I’ve watched from Mike, it was a nice review with great content. During the Q & A part at the end, a physio asked if we are getting too fancy as new clinicians and favouring movement and neurodevelopmental approaches to assessment in favour of the basics? Are we jumping into Kolar and Yanda before understanding the basic work of Kendal, Magee, and Colby etc? In answering this young physios question, Mike stated:

“We’re seeing a lot of new grads coming out of PT school and they’re FMS certified, maybe SFMA etc. They’re doing PRI and DNS classes. They get all these funky things that they’re doing but they don’t know how to treat a joint. They can’t get people strong and mobile or much of anything else, yet they are trying to stimulate peoples diaphragms. It’s great to have the training in these things, but you must have the basics down first.”

– Mike Reinold, Inner Circle Webinar

I think this was an excellent reply from Mike as I also think social media has “pressured” us to take every con-ed course under the sun in the name of becoming “better”. But is taking seminar after seminar in the hopes of finding answers really making us better? Or is just making us more confused? I think taking con-ed is very important and have done my fare share, but I also think keeping the basics in mind is just as important. We have to understand stages of healing, true pathology, arthro and osetokinematics, normal ranges of motion and biopsychosocial care paradigms before we can start assessing crawling and rolling. These assessments are warranted and should be done, but not because we think we should to be “trendy”. They should be done only when you know exactly why you are doing it and how having that information will alter your subsequent treatment and exercise prescription. In talking to many therapists as of late, I have come to the sad conclusion that many do all kinds of movement’s screens and other fancy assessment techniques, but ultimately utilize the same interventions regardless of what their assessment tells them. Why? Because they don’t yet know what they should do with the information they have obtained. This could be because instead of truly mastering the basics, they have taken course after course but really don’t know what to do with the information they have been given. This may lead to confusion and frustration on the part of the therapist…sort of like paralysis by analysis. Personally I have chosen to slow down my course registrations per year because I believe it’s about quality, not quantity. I rather take a course and master it’s concepts to the best of my abilities before jumping into something else. I used to feel like I had to know it all now. I have a long career ahead of me and will take my time in getting these tools under my belt. I have actually found that I get better results when I stick with one form of care instead of jumping around from technique to technique in the hopes of finding that magic bullet.

I think having the desire to learn more is admirable and is something I can relate to. But I have come to learn that you can’t absorb it all right away. Learning through experiences via treating complex patients and even failing is what makes us better. As long as we are constantly being introspective about our practice and figuring ways to try and be better the next time I see nothing but a bright future for our profession!

Therapydia is once again doing their nominations for various physiotherapy related blogs. There are so many amazing webpages by dedicated therapists all around the world and I love being a small part of that world. If you enjoy what I put out and would like to show it, please take a second and nominate jessephysio.com for the chance to win a little reward!

You can access the nomination page here.  Also, be sure to sign up at bottom of page with your email so you can actually vote for the winner on April 14th!

Be better than a sit up…

‘Google’ core training and you will be inundated with all kinds of exercises, tips, “secrets”, and explanations on why any one method is superior to another. Now, I’m not here to say the way I like to do it and the way I give to my patients is best, but I do think it is well informed. Just quickly, the core does not just mean the 6-pack muscles. When I refer to the core for the purposes of this blog post I am referring to the rectus abdominis, transverse abdominis, internal and external obliques, multifidus, and diaphragm. The gluteal muscles can also be thrown in there but the exercises I show in the videos below don’t deal with that as much.

Research tells us that repeated end range flexion is bad for the spine. Professor Stuart McGill from the University of Waterloo has shown in his lab that there are a finite number of cycles of compression a lumbar spinal disc can go through before it herniates. This number is variable between genders and age groups, but it is something to keep in mind. Therefore, I have long done away with sit-ups and crunches as my core exercise of choice. Why speed up the prospect of getting a herniation with my exercise selections? Those exercises aren’t “bad” per se but there are just more optimal choices to train the core functionally and reduce the risk of future injury (notice I didn’t say eliminate the risk…that’s impossible). I have stated before and will again that I believe the true function of the core is not to create movement, it’s actually to resist it. For example, if someone side tackles you while playing football your core doesn’t work to induce movement, it’s working to stabilize and limit how much lateral excursion your body is placed under during the hit. This is what we call reactive core facilitation. The core is preventing spinal injury by limiting movement that might be dangerous for the spine. This ability is trainable and should be for all people from those suffering from back pain to those looking to get stronger for elite athletics. All 3 exercises I will link to are modifiable to make them easier or harder depending on the ability level of the person attempting them.

One big caution: These exercises and their subsequent regressions or progressions should be prescribed to you only after an evaluation has been carried out. Every exercise is a test and if you fail the test with one of these (which is fine), you should be afforded the opportunity to be given exercises better suited to you. A good rehab professional or strength coach can do this…we should at least TRY to make things specific to the client as we can people…maybe a rant on that topic at a later time 😉

So here are 3 anti-movement core exercises that I like giving select clients at my clinic. Each one serves a different purpose and can for the most part be done at home with a band  or weight if a pulley system is not available.  Anecdotally I also like these 3 because clients can “feel” what I’m trying to accomplish with them  if done correctly. This helps with buy in and adherence. Enjoy!

1) Palloff press:

2) Supine single arm chest press:

3) Half kneeling chops:

For those that are super interested, this is an excellent teaser video from Gray Cook talking about side to side asymmetries in the chop pattern of movement. If you are good going to your right, but not your left then something needs to be modified. This is where the help of an expert in rehabilitation/exercise prescription comes in. Showing an exercise is easy… It’s modifying it for the abilities of the person in front of you that takes skill.

Hope you enjoyed.

The Cheerleader 3x3x3 exercise

Photo cred to Mikereinold.com

This is a video of a very simple exercise to help promote scapular retraction that I learned from Mike Reinold . I like exercises that are easy to teach and the patient can feel working almost instantly. This is also just a great exercise to get people out of the anterior tilt and rounded shoulder posture we see with the desk working community. The patient can literally have a band by their desk and bang out a set every hour or two…get that reverse posturing going! Also helps with those with impingement issues related to poor shoulder positioning.

All you need is a theraband and you’re set. As stated in the video, you just take the band between your hands and pull it across your chest, making sure to get a nice scapular squeeze at the end range. After doing 3 reps in the horizontal direction turn the band on an angle and repeat the same motion 3 times. Then turn the band the other way and do it…you guessed it, 3 times! Why 3? I don’t know, I just like it cause I call it the 3x3x3 drill (3 reps in 3 directions for 3 sets = easy for client to remember). This exercise mainly targets the lower trapezius muscle and rhomboids in a reciprocal fashion to pull the shoulders back and tip the scapula posteriorly. It’s cool cause it works both sides at the same time (less time for the patient to worry about exercising)

Again, this is a good exercise for developing posterior chain strength and endurance in the upper body. To get the most bang out of your exercise buck, have your client return the band to the starting position VERY slowly…this will promote great eccentric posterior cuff and shoulder stability…and the client will get a nice burn going.

Enjoy!