If you have surgery to repair a broken foot and then it hurts or rebreaks after you decide to go jogging prematurely, does that mean the surgery was ineffective? If you have a wound cleaned out and you decide, against orders, to go for a swim and it gets infected again, does that mean the debridement wasn’t effective? The intervention is the surgery, but it’s also the instructions that come with it. The intervention is the wound debridement, but it’s also the accompanying directions.
With physical therapy interventions I tend to give patients 1-2 things to do as well as 1-2 things to modify or avoid. Could I give more things to do and more things to avoid? Yes. But people don’t tend to follow a longer list of instructions, so keeping things simple is key. Say, though, to fix your elbow pain you seem to need repeated elbow extension and you wake up one day and symptoms are worse. We need to be critical thinkers. Is it possible the intervention of elbow extension is wrong? Yes. But if you were good before bed and you woke up worse, it’s more likely that sleeping interfered with your intervention rather than the intervention is wrong. When sleeping, we adopt postures unconsciously. It’s quite likely your elbow was simply in a position that made it worse. We need to figure these kind of things out.
There are plenty of examples of things that can interfere. It’s hard to foresee and prevent ALL things that may impede an intervention from working. But when they arise, we need to recognize them for what they are and not simply disregard an intervention that has the potential to work if given the right circumstances. -- Laura
There are diverse opinions when it comes to orthopedics. And you should feel free to explore the myriad thought processes, approaches, opinions, techniques, etc. But when your goal is to fix something, you need to focus on one approach. Let one chef take over, even if just for the time being. Not only does that allow you to focus all your time and energy on the game plan in front of you, but it, most significantly, gives it the greatest odds of success.
If I want someone to repeatedly flex his spine, but another clinician wants him to repeatedly extend it - well, those are obvious contradictions. Doing both at the same time in this example would make zero sense and would preclude either approach from working. Outside of obvious examples, though, there are more subtle ways that things get derailed. For instance, if I tell someone she has a terrific prognosis if we follow these four steps, but her primary care physician keeps telling her therapy won’t help because the x-ray looks bad, then things often stall.
Research all the different options first if you really want to, but give just one approach, just one clinician, the title of head chef at a time. If it’s concluded that another perspective is needed, then you can move on. As the saying goes: we can't have too many cooks in the kitchen. -- Laura
Here are the top four reasons I can fix my orthopedic problems quickly. One, I address them as soon as they happen. Two, I know what to do. Three, I know what temporarily not to do. And, four, I have confidence in the methodology. I think the fourth reason is the most salient. I don’t get sidetracked by an uncle telling me to just get a shot. Or another clinician giving me his/her two cents. Or Google recommending medicines, oils, or any number of theories and movement programs. We all have aches and pains from time to time. By understanding orthopedics and how to approach problems methodically and effectively, even if I know my recovery will take some time, I know the prognosis, don’t have fear, and don’t waste time on unnecessary interventions. -- Laura
There is a reason some interventions need to be done frequently. When I diagnose orthopedic problems, the frequency of the intervention in the initial phase of rehab is paramount. We brush our teeth frequently throughout the week to keep our teeth clean. What I investigate with patients is: will frequent movement (specific movement) get your body healthy? Once we get it healthy, frequency, like with teeth brushing, is reduced to keep it healthy. -- Laura
Saying you treat pain is like saying you treat sneezing or itching - they're symptoms. You can manage pain, but you’re not, in essence, treating it. You treat the cause of the pain. When people ask me if I treat shoulder pain or jaw pain, etc., I know what they mean. The short answer is: I primarily evaluate to see if I can help with what is causing the pain.
Pain management strategies (such as ice, heat, unloading, medication, creams, gentle movement, and so on) have value, and I recommend them as needed. The goal, however, is to find and fix the cause of someone’s pain (musculoskeletal or other) just like you figure out why you’re sneezing or itching. Are there cases when a cause cannot be deduced? Sure; but they are rare and, by methodically eliminating diagnoses, you still should be left with only a few reasonable hypotheses. -- Laura
Proprioception relies on uninterrupted, efficient nerve conduction - for both input and output. So before you start training and (re-)programming nerves for speed, efficiency, and adaptability, you need to ensure their electricity is flowing uninterruptedly. Proprioception, often a component of physical therapy and training, is defined as the "perception or awareness of the position and movement of the body." (Oxford Languages) It makes sense to verify there are no kinks in the hose (nerve) before you try to fix the hose or optimize its ability to do its job. Nerve tension tests are very useful, but I also use repeated movement testing to gauge how well nerves are moving and working. This applies to so many things besides just proprioception. Almost all, if not all, functions in your body are powered by your nerves carrying electricity and information! For almost any complaint, this is my starting point. -- Laura
Let’s say I am helping someone fix her shoulder derangement. If I have the correct diagnosis, I expect significant improvement quickly with an exercise in a specific direction - and eventual 100% return to normal. Let’s say we figure out that direction (often it’s extension or functional internal rotation). By finding that positive response to that direction of movement, we confirm our diagnosis and therefore establish a reasonable prognosis.
Now, here are other factors that could affect the ability to get the problem 100% resolved: patient’s shoulder position at work, at play, while sleeping; patient’s compliance with the home program; patient’s performance of the exercise; stress level; diet; lifestyle factors (eg smoking); other health issues; environment; genetics; patient’s belief system/expectations; how the problem affects the patient’s life; and other people’s input/opinions.
For this reason, I often use the words “should,” “likely,” and “in most cases.” Yes, there are many problems that, in my head, I think are 100% fixable; but I know that, until something is 100% fixed, it’s not a given. There are numerous factors when it comes to addressing problems with the human body and mind. As a clinician, I set expectations based on interpreting all the available data. -- Laura
Most of orthopedics is getting joints moving better, getting nerves conducting electricity and moving better, and getting tendons functioning at full capacity. Rare is the case that true strength needs to be built in a muscle or muscles to resolve a problem. Those scenarios include when atrophy is creating problems (secondary to a number of possible factors) and when there has been injury to a specific muscle. While I often use general “strengthening” exercises as an adjunct to the primary intervention, the intent there is to get the musculoskeletal system moving and working again, not strengthening. Of course, muscular strength, which takes significant time to build, has myriad positive effects on the body, and I wholeheartedly support strength training in general. However, when problems arise, specific distinct solutions are typically called for. -- Laura
Once we find the direction a joint needs (its directional preference), we must establish the protocol. A rule of thumb is 10 repetitions every 2 hours, but it needs to be tailored to people’s specific situations. There are many parameters when it comes to the home protocol, mainly total volume, repetitions per set, sets per day, frequency, cadence, and time.
For me, frequency is the most significant - how regularly the exercise is performed throughout the day. Of course the other dimensions matter, but if I had to choose between 100 repetitions at 9:00am, 25 reps in the morning plus 25 reps in the evening, or 5 reps performed frequently (say every 3 hours), I would choose the final option. The reason is simply that in the intervening time people move their bodies, their joints, in all different directions. Doing the exercise regularly in effect “resets” the joint to the desired position. So if 6 hours or 3 days passes, when the exercise is revisited it’s more likely there’s more “resetting” to do. It’s as if the boulder rolled farther down from the top of the mountain and now there’s more to overcome. With high frequency, we want to keep the boulder from rolling down too far and eventually keep it set where it should be at the top of the mountain. This is not my exact mindset when I approach muscle, tendon, nerve, capsule, or other problems; however, for those I diagnose with joint derangements, frequency is almost always the number one priority for improvement. -- Laura
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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