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
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
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.
Yes, it matters if you had surgery last week. It may or may not matter if you had surgery years ago. It also matters if you fell last week, if you had the flu, if you have vertigo, if you have an inflammatory disorder, and so on. Your entire history can matter - and your surgical history is simply one piece of that history I consider when I determine the most appropriate questions to ask you as well as the appropriate ways in which to move you. Given how people often have lots of things going on health-wise, it takes expertise to know what is relevant and not get bogged down with extraneous minutiae (which can eat up your precious time with patients quite quickly).
The biggest overarching error I see with clinicians treating patients specifically for postsurgical rehab is that they assume the surgery indeed addressed the true problem. Resultingly, they fail to both ask questions and move patients in ways that are diagnostic in nature. I make my own diagnosis - which may be a straightforward diagnosis of “postsurgical” - and treat accordingly. There are a lot of postsurgical patients out there whose surgeries did not resolve their underlying issues, which makes this way of thinking imperative if you want a successful outcome. --Laura
Given how often I see patients whose non-spinal pain is related to their spine, I make sure to investigate the spine as a possible contributor or cause. As I’ve said before, that investigation varies in time based on the case.
If I read a study on patients diagnosed with “patellofemoral pain syndrome” or “shoulder impingement” and there is no mention of clinically looking into the effect spinal movements have on the person’s complaints, I take that study with a grain of salt. I use the word “clinically” on purpose: you cannot rule in or out spinal involvement solely with an image. At least 25% of people’s shoulder and knee pain I see is actually a spine problem, addressed with moving the spine.
I also say “probably” in this post on purpose. If an orthopedic study looks at people who have traumatically fractured their tibias, that is a different ball game. Most orthopedic problems, however, aren’t obvious traumas. -- Laura
Elbow pain with push-ups does not mean doing push-ups created the problem. Knee pain triggered by squatting does not automatically incriminate squats. While we usually have to avoid triggers temporarily in order to heal, that is not to say we avoid them because they caused the problem to begin with. Triggers, once the cause of the problem is correctly addressed, cease being triggers. Sometimes a trigger is the same thing as the cause, but in my experience that is not common.
Hamstring pain is posterior thigh pain. Quadriceps pain is anterior thigh pain. IT band pain is lateral thigh pain. Adductor pain is groin pain.
Of course it fits that people who aren’t clinicians would label pain using structures they know. And it’s obvious most people can name big muscle groups! My issue is when clinicians inappropriately do it.
If the patient uses this language, in an effort to create rapport, I may use it with interactions with that patient as well. Mimicing language can be a nice therapeutic tool that is easy to implement. (I typically will adopt the patient’s word for describing his or her own symptoms, for example; my favorite instance being my patient who referred to his radiating leg pain as his “lightning bolt.”) I’d prefer, however, to use the correct language if possible since accurate patient education regarding his or her problem is key to a successful outcome.
I do not use these terms to refer to these parts of the body outside of that specific patient context, though. Yes, if the patient has true hamstring, quad, ITB, or adductor pathology, these words are clearly apropos. But those patients (especially among non-athletes) are rare. In most cases a patient’s posterior, anterior, or lateral thigh pain or groin pain is referred pain from the spine or hip. --Laura
Certain diagnoses create constant symptoms. Certain diagnoses create consistent symptoms. Constant numbness, tingling, pain, etc. means it’s there every waking moment. It may vary in intensity, but it’s there regardless of your activity or position. Consistent is similar to predictable. Each and every time I jump my knee hurts. Each and every time I bend to put on my shoes my calf feels like it’s on fire. Each and every time I play golf three days in a row my shoulder acts up. As a clinician, I need to know which questions to ask and then how to interpret the patient’s answers to accurately diagnose.
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