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Sometimes lots of exercise and activity is warranted, but not usually. It’s important to realize that the large majority of a patient’s recovery occurs outside of my office. That being said, we best utilize our time together figuring out what needs to be done when you leave. We investigate which movements or exercises are best for you to do on your own time. We also spend time discussing your prognosis, trouble shooting, reviewing how to self-assess, and so on. If a patient is under the impression that she goes to physical therapy to do her exercises and then does little to no work at home, that ensures very slow progress at best. I love going to the gym (I first joined Gold’s Gym way back when I was 17), but what I offer patients is more critical thinking and problem solving versus a place to work out. -- Laura
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Teaching is the most important part of my job. By teaching patients (versus simply treating), you’ll likely get better outcomes as well as better reduce future need for medical services. When a patient has a joint problem, for example, I want her to understand the full picture. That is, prevalence, common contributing factors, how repeated movement in one direction can yield improvement, how they differ from muscular problems, and so on. If a patient’s low back complaints respond to repeated extension, perhaps (hopefully!) if her knee hurts years later she’ll try repeated knee movements.
The overarching principles of treating joint derangements do not vary despite joints differing in degrees of freedom, anatomy, and demand. Most significantly, the best odds for success without expert help is moving the joint 1. in the direction it rarely goes or 2. in the direction opposite to how it’s stuck or 3. in the direction opposite how it was injured. -- Laura I look for direct cause and effect. In most cases, the cause. the intervention, is movement. Movement is usually generated by the patient, but I can use manual techniques if needed. Here’s a simple, common example of how I implement this in the office.
A patient presents with isolated pain on the right shoulder, lateral aspect. History: intermittent pain, pain usually with reaching, no pain at rest, can’t throw, present for 3 months, staying the same, no trauma, notices loss of flexion which can vary. Physical exam: no pain at rest and no cervical or thoracic loss of ROM or pain. Shoulder flexion: moderate loss with pain at end range. Shoulder internal rotation: minimal loss with pain during movement. Concordant pain with resisted abduction and pain-free weakness in external rotation (3+/5). All other shoulder baselines are normal. I don’t regularly do special tests. Now I want to investigate if there is a particular movement (directional preference exercise) that has a positive effect on those baselines. I test 10 reps of cervical retraction and extension with overpressure: no effect on baselines. I test 10 reps of right lateral cervical flexion with overpressure: no effect. I test 10 reps of thoracic extension with ball overpressure: no effect. I test 10 right shoulder internal rotations (hand behind back): shoulder external rotation improves to 4+/5 and flexion is less painful. We do 20 more internal rotations and flexion is now only minimal loss and there’s no more pain with resisted abduction. We have found a significant positive effect with the exercise repeated shoulder internal rotation. That will become the patient’s home program until the next visit. It’s about demonstrable cause and effect, not theories or guessing. It’s about being specific and not giving someone who needs one movement a program of seven things to stretch, strengthen, and retrain when it’s not needed. -- Laura My appointments are investigative - moving this way or that way and assessing the effect minutes or even seconds later - and then prescriptive. To my great curiosity, I’ve had patients respond positively to a movement/exercise (that is, symptoms or movements immediately improve) and state it was probably due to their recent injection or their pills. It doesn’t work quite like that. Cortisone from three days ago was a constant during our entire time together; the variable was the performed movement. The same goes if you've been on a Medrol dose pack for 5 days. While these may have an overall positive influence, they are not the variable we are experimenting with in the clinic.
I am deliberate in my clinical testing specifically so that we can establish cause and effect and not base decisions on probabilities. (Was it the medicine? Was it time? Was it therapy? Was it sleeping in a weird position?) Let's be as precise as possible. Just as I know how to anticipate the result of an intervention, the other clinician giving you the injection or prescription should also be able to tell you what to expect from the shot or pills. -- Laura Again, it boils down to function vs structure. Most problems are things not functioning well - not structural damage. Think thyroids under or over producing hormones, hearts not pumping blood efficiently, bacterial infections in the gut.
In the musculoskeletal system it’s often nerves misfiring, joints not moving well, muscles not activating. Movement testing reveals these. Structural musculoskeletal issues, though, primarily need imaging to be visualized; they’re hard to see with the naked eye. Those who believe musculoskeletal problems are largely due to structural damage (I do not) therefore usually rely on imaging. A glaring problem with imaging, however, is that people with no complaints will have structural changes upon imaging. That those “changes” become “damage” in the presence of complaints is an unsubstantiated leap. I use movement to test (and treat) the structure and function of people’s musculoskeletal system. In the event a relevant structural issue that will not respond to therapy is suspected, the individual is referred to the appropriate clinician. -- Laura This is a simple way to categorize approaches to fixing an orthopedic issue: surgically invasive, other invasive, and not invasive. You always want a diagnosis first, and since clinicians in orthopedics diagnose with different approaches, a second opinion is warranted if you are not pleased with your options or progress. (I diagnose primarily via a method of repeated movements, which, on the whole, is more helpful than diagnosing via imaging.)
We all know what surgery is. In my opinion it should be the last resort. Among the many reasons why, surgery (or intentional trauma) should be picked last because of the relative risk. The “other invasive” group includes prolotherapy, PRP, cortisone or any other injection, stem cells, dry needling, pharmaceuticals/supplements, and so on. Things that generally penetrate or enter a person’s skin/body. In the category of “not invasive” are movement, clinician techniques like mobilizations, various modalities such as heat and ice, and others. Each category has pros and cons. What I find encouraging in this day of costly high-tech alternatives is that an expert program based on movement will still fix most problems! -- Laura There is absolutely a time and place for joint replacements. While it’s every patient’s decision, I believe it’s best to explore conservative measures first - if for no other reason than risk alone. An individual’s determination should be based on a collection of facts and viewpoints.
It’s typically true that, when compared to replacement, therapy 1. poses less health risk 2. mandates less time off work 3. costs less 4. instills more self-efficacy 5. hurts less. Of course in the right patient group, it also provides superior outcomes. Within 5 visits I can usually arrive at a prognosis. With a poor prognosis (ie there’s too much structural compromise to improve), presenting the option of a surgical consult makes sense. If a patient explores therapy and a replacement is indicated, little time or money is lost in that endeavor if the therapist is skilled at arriving at a prognosis early. “How can a person with a given diagnosis of OA who’s been recommended a new knee do well with therapy?” I treat a patient with joint complaints just like everyone else. I diagnose the patient based on a history and movement exam and treat accordingly. Most diagnoses do well with therapy, but in some cases it becomes clear that surgery is needed. -- Laura If it's accepted that arm and leg pain can originate from the spine, it should be understood that joint pain can as well. I screen the spine with extremity limb and joint complaints. Forearms, thighs, arms, legs, hands, and feet are not entirely different from wrists, hips, elbows, shoulders, knees, and ankles. Limb (between joints) pain is more often coming from the spine than isolated joint pain, but it still happens frequently. Clinicians need to look for this referred and radicular pain. I use repeated movements of the spine to investigate if extremity joint pain is indeed spinal in origin, which could take anywhere from a few minutes to a few visits. -- Laura
Perhaps I am splitting hairs when I differentiate between load and force. However, I think it’s important to refute the common conception that fixing orthopedic problems is all about progressive loading, extreme effort, sweating hard. Most of my patient visits feel more like a visit to the doctor’s office than a visit to the gym. It’s about looking for a solution, devising a home protocol, and education.
While I use loading, what initially fixes most orthopedic problems is not loading in the truest sense. Yes, injured tendons/ muscles need load to remodel and repair. Yes, load is needed to return someone to prior levels of function if there’s been deconditioning. My experience, however, is that most problems involve a joint not moving well ... remedied quickly with movements (forces), usually requiring little muscle action at the problem site. If I diagnose a shoulder derangement, the top two movements I’ll use to reposition the joint are functional internal rotation with a belt (passive) and extension with the patient’s hand on an elevated surface (passive for the shoulder). I envision those more as different forces on the shoulder joint vs different loads. The words don’t really matter, but, to me, the implication does. -- Laura Being intentional with asking patients questions is important for two reasons. One, it saves time, thus making the process more efficient. Two, my thinking won’t be distracted or misinformed by extraneous, non-useful information. Asking questions with purpose takes practice, but is absolutely essential for both diagnosis and treatment. (When I take a patient’s verbal history, I typically only have 2 potential diagnoses in mind by the end thanks to effective questions.)
If the purpose of a question is to show interest in the patient’s story or to foster rapport, that is a fine purpose. Doing so, however, may confer to the patient that those answers are significant (when they aren’t). What I see novice clinicians frequently do is ask irrelevant questions about symptoms. For instance, differentiating if the pain is burning, hot, achy, or sore. While that may matter, it almost certainly doesn’t matter in the evaluation. Or if a patient says his knee clicks, the clinician dives deep into when it clicks. Again, in 99% of cases that doesn’t give you helpful information. Knowing which answers one needs and which one doesn’t is not easy - and comes with expertise. Once that skill is achieved, the process is streamlined and clinicians become more efficient at helping patients. --Laura |
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