As a new physical therapist, I have been unsure of when to refer patient out for a serious pathology.  A weekend course with Dr. Boissonnault brought more clarity to my understanding.   This becomes especially relevant with direct access.  I’d like to share some pearls I learned from this class.  

1) Think about “what’s the worst thing that the patient can have?”.  Once I am aware of this, I will have a clear idea of what questions to ask to clear that condition.  Most of the time, a serious pathology can be cleared out pretty quickly.   Doing so will also help retain my knowledge for differential diagnosis. Because as the saying goes, if you don’t use it, you lose it.  

2) The screening process for PTs vs MDs are very similar.   For example, it's difficult to diagnose with a certainty that a tumor is causing patient’s low back pain.  However, we can screen to see if the patient is appropriate for further imaging or blood work studies.  Here are some examples.   PTs and MDs would use the cluster 1) history of cancer, 2) age> 50, 3) unexpected weight changes 4) failure of conservative treatment as a way to screen out cancer causing back pain.  Ottawa cervical spine rules can be used to determine if a plain film is indicated after a neck trauma.   This leads to my 3rd point because disease has its own schedule...

3)  If the patient is positive for screening (ex: back pain with history of cancer, weight loss, night pain), but has already seen their physician, then what?   Ask...

     a) Is the physician aware of these findings? 

     b) What tests have been done so far?  

     c) If they saw their physician a while ago (like 2 months ago), compare the symptoms now vs when they saw the physician.  Has it significantly worsened?  Are there new onset of symptoms?

If these questions are positive, and your objective testing doesn’t seem musculoskeletal,  then referral to physician is warranted.   

4)  A mechanical pain pattern (movements, posture relation to pain) does not rule out serious pathology.   It does help to differentiate visceral/systemic origins of pain because these are not affected by movement.  Early on, pathological conditions (skeletal cancer, RA, stress fractures) frequently present in a mechanical pain pattern.  They would use common musculoskeletal descriptors such as dull ache and intermittent. 

5) Determine how urgent the referral is: ASAP vs in a week vs  at the patient’s convenience.  For example, signs of DVT is an urgent referral as in they have to go to an ER now.  However, if you see an abnormal looking mole on your healthy patient with shoulder pain, you can recommend that they make an appointment and get that ruled out as soon as they can.  Certainly, it’s not an emergency here. 

6) As a rule of thumb, plain films (x-rays) are very specific but not sensitive tests for most of these serious pathologies.  Let’s use cancer as an example.  Once you see something abnormal on the x-ray, such as a mini golf ball growing in patient's spine, that would be positive for cancer.  But if you don’t see anything, then that doesn’t mean you can rule out cancer.   Another common example is that x-ray will be normal for first 10-14 days with stress fractures.  

7) The way you communicate to your patient and their doctor is very important.   The doctors are very busy.  When I call them, use words that describe patient’s unusual findings to grab physician’s attention.  Back it up with all the findings that support my suspicion.  If I am having the patient call the doctor themselves, I need to educate them how to report their symptoms.  For example, instead of saying, “I have a neck pain”, the patient needs to say, “I have a throat pain, that radiates to my chest and to my face, and I have been having difficulty swallowing”.  

7) Lastly, we cannot force a patient to do anything!  We can recommend that it’s in the best interest to do x,y, and z (example: go to an ER) but ultimately, it’s their choice.  We cannot force their family members either, or their dog, Willy.  

Stay tune for an interview with Dr. B in a few weeks!  

-Kay Lin, DPT, CSCS   

Last week, I had an amazing opportunity to shadow a physical medicine and rehab doctor (PMNR).  The experience has shed a new light on my understanding of what patients may encounter when going through our health care system.   

Overall, the MD had a very good rapport and at times, therapeutic alliance with the patients.  They do have a long term relationship with the chronic population as they frequent them every 6 months or so.  Here are some philosophical differences between PT and MDs.  

1) Heavy use of pathoanatomical cause to explain patient’s pain: with all the patients, he educated their condition using the scans from imaging and the findings.  For example, the MD showed the normal hip x-rays and compared it to the degenerated spine x-rays.  Then reassured patient that the symptoms are not coming from the hip, but rather it’s coming from the back.  For other patients, he explained that the patient is having pain is because they have too much degeneration in their facet joints or there is significant decrease in disc space.   After shying away from pathoanatomical based approach to treating patients, it was an eye-opener to see that the MDs educate patients heavily on imaging findings correlating to their pain.  

As a PT, when I educate patients, I emphasize on reassurance and structural integrity of the human spine.  If the patients ask about their imaging findings, I tend to educate patient on how the imaging findings have low correlation to their condition.  I may have been toward the opposite spectrum of deemphasizing the imaging findings.  Also, patients have been ingrained with the pathoanatomical approach from a very credible referring MD.   I should reconsider learning about what patient already has learned about their condition and have a more gradual way of educating patients now.   As appropriate, I will need to gradually shy patient’s beliefs away from pathoanatomical model when they see us for PT.    Patient education in regards to imaging findings is still something I continue to work on. 

2) Lack of referral to the PTs if he suspects that it’s structural problem:  if the imaging demonstrates stenosis, severe degeneration, etc, he will elect to put patients on medication regimen or surgical referral.  

3) I did not see CRPS taking into account, when many patients demonstrate signs of that.  No referrals to PT is made if MD suspects that the problem is a result of structural changes (for example, lumbar stenosis).  This is troubling since this approach has failed our patients and contributed to opioids pandemic.    Articles like this shows that PTs should be integral part of managing chronic pain population.

Later I had a talk with one of the PMNR doctors, who agrees that correlation between low back symptoms and imaging is poor.  He explains that he has attempted to convince his patients countless number of times without  having much success.  If patients are not buying the MD's education, it's hard to imagine that a PT can convince the patient otherwise.  I think the main source of patients’ beliefs on pathoanatomical causes of low back pain is from media and google searches: pages like this is the first link that patient sees when they google “low back pain".  

Kay Lin, DPT, CSCS

Andrew has been my PT mentor for almost a year now and has been very generous with his time mentoring me online.   Andrew graduated from VCU’s Medical College of Virginia with DPT in 2006. Since then, he has been a physical therapist for ten years working in a variety of outpatient orthopedic clinics. He went on to complete Manual Therapy Residency and Fellowship training through the Ola Grimsby institute in 2011 and 2012, and became a Fellow of the American Academy of Orthopedic Manual Physical Therapists in 2013. He has served as adjunct faculty and a guest lecturer in the Department of Physical Therapy at Virginia Commonwealth University and has also provided lectures at the UT Medical Center in Memphis, TN. He is also currently an instructor with the Institute for Advanced Musculoskeletal Treatments (IAMT), as well as a mentor for a manual therapy fellowship program.  Now he is also co-hosting Healthcare DisruPTion podcast with Jerry Durham.

How did you end up in this awesome PT profession?

This is somewhat of a long backstory but I’ll try to keep it relatively short. My undergraduate degree at Mary Washington College (now the University of Mary Washington) in Fredericksburg, VA, was in Geography, I don’t recommend this as the ideal path to take to physical therapy but I did was necessary for me as I originally thought I would be a teacher. I played soccer for two years in college and then got into weight training. I’ve been active all my life, playing both competitive soccer and basketball, but never considered a career in the health/fitness industry. However, after I graduated college in 1999, and getting a desk job, I began having persistent low back pain. I recalled having intermittent low back pain and “catching” while in high school and college while playing soccer- I felt like I couldn’t bend forward, but it would last for a week and disappear. However, now that I was sitting 8-10 hours a day, the low back pain started increasing and becoming more persistent. I recall tweaking at the gym and then symptoms began spreading into my left leg. Then one morning after an indoor soccer game, I could barely get out of bed. The symptoms had progressed down my leg to below my knee. To make a long story short, a year later I ended up undergoing a laminectomy/fusion at L4/5 for spondylolisthesis. I had two experiences with PT, both pre and post-op, neither of which were remarkable, other than the fact that it exposed to something that I thought I could be good at and would enjoy. In fact, it was my mediocre experience with physical therapy that made me think, “I can do better.”

What are your top 3 areas of expertise?  (for example, chronic pain, being a mentor for the fellows, teaching, etc).    

As for "expertise," I would refrain from calling myself an "expert" in anything. In my opinion, once people refer to themselves as that, they stop learning and growing. I sometimes feel as clueless as I did right out of school! But the areas I probably have the most knowledge in would be manual therapy, mentoring/teaching, and pain science.

What are you up to these days professionally?  

I am treating patients in the clinic 40 hours/week. I am heavily involved in marketing for the clinic, some with physicians, but mostly through community involvement and on social media. Virginia has good direct access and since I returned to the clinic in July 2015, I have helped grow our direct access referral base from 5% to 14% in the past year. A colleague of mine and I are also considering whether or not to try to buy in to the practice we work in or start our own thing. There are positives and negatives to both so we’re in the process of doing our due diligence and figuring things out.

In the meantime, I’m also a contributor to blog on themanualtherapist.com and I co-host a new podcast called the “Healthcare DisruPTion podcast.” It is up on ITunes and as I’m writing this, the first three episodes have been released. The regular release day is Thursday,and I do a Periscope broadcast the Monday following the episode release discussing my takeaways. I also am working on building my first con-ed course, which I am hoping to start teaching, at least locally, by the end of the year.

What kind of course is it and what motivates you about doing it?  

The course I’m creating is an exercise/movement course. I’ve been teaching for the past couple of years with another con-ed company but it’s been their material, some of which I don’t enjoy teaching. I wanted to do something that was uniquely my own. I feel like a lot of exercise courses out there are predominantly on the performance spectrum, involving higher level functionality,  but that is not necessarily a true representation of what most of our patient populations are comprised of. I wanted to do something that would beneficial for patients at any level, and would incorporate pain science with basic concepts that could be applied right away into clinical practice. I am also a student of personal development and consumer behavior and I have incorporated some of these concepts into the course, because how we communicate with patients, build rapport, and establish the therapeutic alliance will have a significant determination on the outcome.

What excites you to get out of the bed every morning during work days?  

It sounds cliche, but being able to help people feel better and get back to their lives. I also work with a great group and for a good owner who allows us plenty of autonomy so there’s very little “workplace stress” that often comes with certain environments. I enjoy the people I work with as well as (most) of my patients, so going to work is something I actually look forward to.

If you’re dreading going to work the next day on Sunday night, you need to think long and hard about 1)  where you work and if it’s the right place for you, and 2), are you actually doing what you want to be doing?

Let’s talk a little about manual therapy.  Due to our limited time with patients, the residents are taught to use manual therapy only to increase patient buy-in, to decrease pain, and to improve range with impingement signs (posterior knee pain with knee flexion, anterior hip pain with hip flexion, etc).  Do you have your own indications for doing manual therapy?  

I think manual therapy is indicated in a variety of situations. As a fellow in the American Academy, I certainly have a bias or preference towards utilizing manual therapy, especially early within an episode of care. I would argue, however, that the effects of manual therapy are most often due to neurophysiological changes, not true alterations in biomechanics, especially in the short term. Any rapid improvements in range of motion, for example, are more likely due to a reduction in pain, altered proprioception, reduction in tone/guarding, reduced fear of movement, motor pattern disinhibition, among others. Manual therapy is not truly “releasing” tissue or breaking adhesions. A true capsular or intra-articular lesion is not quickly resolved and requires stress over time. The only exception may be a capsular entrapment in a facet joint, but I have found those to be very rare.

There are times, however, where using manual therapy may not be appropriate or beneficial. For example. patients with high levels of allodynia or hyperalgesia may be too sensitive for manual therapy and often are better treated with “safe” movement to help calm down the system and later they may tolerate and benefit from manual therapy.  

I do have beliefs similar to yours about manual therapy.  Is it possible or do we even want to “stretch” a joint capsule?    

To my understanding, the only tissue that responds to “stretch” is muscle. We do. however, want to stress collagen (the tissue comprising the capsule), in order to stimulate fibroblast synthesis and  repair, as well as increase lubrication to the tissue. Collagen has a relatively fixed length but it’s overall elastic range is due to a combination of the dry weight and the lubrication, which adds to the “crimp” zone of the tissue. An immobilized tissue will lose lubrication and the amount of “crimp” it has and therefore will lose relative length before trauma and ultimate failure . In a situation like an adhesive capsulitis or stiff posterior knee capsule, regular stress over time is the best way to induce the needed stimulus for tissue adaptation as well as improving lubrication. Initially, I think this is best achieved through manual therapy, partially due to the other benefits including reduction in pain, muscle tone/guarding, as well as helping reduce fear and demonstrating that the motion is safe. But ultimately, the patient performing regular movement/mobility over time will be what is needed.

Do you give stretches (muscle or joint) to the patients to do at home?   If so, what’s your reasoning behind how it helps the patient?  

I rarely give patients “stretching” in the classic sense. I have found that muscle LENGTH is very rarely the limiting factor in a person’s mobility. On top of that, when you put a sustained stretch through a muscle, we also have to consider the other tissues that are being affected that do not respond to stretch. However, I do often give MOVEMENT, repeated motions, and self-mobilization exercises to patients. Protective muscle guarding is often a limiting factor in motion, so trying to remove the painful stimulus, and then getting the “tight” area moving is often sufficient.

Tissues respond to stress over time, not force. So I have found dosing consistent, regular movement the way to go. But, if patients report liking stretching, I recommend only short-duration holds of 5-10 seconds at most, which let’s be honest, that’s what most patients are doing anyway even if you prescribe 30-60 seconds.

Will you agree that we are no longer using our hands to “fix” patients?  For example, sacral nutations, counter nutations, bones being out of place, amongst many others.   If so, are you using more of biopsychosocial (BPS) in your interventions?  

I would certainly agree that we should be moving past the belief that we are “fixing” pts and certainly beyond the notion that we can put things “back in place,” especially joints like the SIJ, in which the joint line cannot even be appreciated until after a surgeon works 30 minutes with a scalpel. One problem is, is that this mindset shift is not only slow going through physical therapy, but has become an accepted thought among patients as well. I often find that I have to help patients understand that they are much more robust than they think, and things don’t really slip, “out of place” so easily. And if they did, we’d be a whole lot worse off.

In my mind, the BPS model is THE model. People forget, the “B” is still “bio” which is the tissue and mechanics, but instead of that being the ONLY thing, it also takes into account the person, their beliefs, and the context in which the event(s) occurred. Nothing happens in isolation. If you’re a hand model and cut your finger, I am willing to bet that you will experience more pain than if a soccer player cuts their finger.

How do you incorporate pain science, when most everyone else in the health care team (MDs, surgeons, etc) are treating patients with pathoanatomical approach?  I find that incorporating pain science into my patient education makes me stand out as an outlier/weird compared to other health care practitioners that the patient has already encountered.  This results in losing the patient’s confidence at times...   

Losing the patient’s confidence is certainly a risk when talking about pain science, which is definitely a challenging concept not only for health care practitioners, but for patients to grasp as well. Kind of like exercise, we have to know how to dose out education effectively. I often use metaphors, which help take the abstract and complex aspects of pain science and put them into language and visuals that patients can more easily understand. When I first started incorporating pain science into pt discussions, I failed quite often. But over the past year or so, I have had very few outright rebukes. Some patients take longer than others to really embrace, but ultimately, I think people are happy to know that they aren’t really “broken” or “diseased”  and what they may be dealing with is not a life sentence.

The biggest change I’ve made is not talking about just the “brain” as people too often jump to the wrong conclusion that “it’s all in my head.” I now use “nervous system” or just simply “you” because it really is the whole person experiencing pain and multiple systems interacting with each other.

One of my philosophies is the good old “Golden Rule-” essentially do unto others. I would want the truth told to me, and I feel that in order to build a relationship, trust must be established. And you can’t have trust without the truth. Pathoanatomical diagnoses and a Cartesian idea of pain are simply no longer the truth. We have to evolve in our understanding and curation of knowledge. It’s what’s right for the person sitting in front of us, and it’s what’s right for our profession and healthcare overall.

Yet, despite our best intentions, the person on the other end may not be willing to receive it. And that’s ok. I’m all about meeting the customer where they’re at, but I’m also not going to let them lead me down a pathoanatomical rabbit hole. I’m happy to refer them to one of my colleagues or even another provider if they don’t want what I’m offering.

What’s a bad advice or two you hear frequently given in our profession?    

“If it hurts, don’t do it.”

“It’s because your core is weak”

What’s a bad advice or two you hear frequently given from more experienced PTs to less experience PTs?    

I might be fortunate that I haven’t found myself in this situation too often, unless it was me delivering the bad advice, and then of course I don’t remember :) But in all seriousness, most “bad advice” I’ve heard dispensed to less experienced PTs from more experienced ones is anything that has to do with “numbers,” “units,” etc. In my opinion, when decisions are made in the best interest of your patient (customer), the business will ultimately succeed. When decisions are made in the best interest of the business or the insurance company, it’s only a matter of time before failure will catch up with you. You don’t schedule a pt 3x/wk because it’s a company policy if they only need twice or if they can only do twice. The company policy is what is best for the customer! You do right by them, the business will do right as well.

Your top 2 favorite/ most commonly used manual techniques for spine?

Two areas I find that need addressing and that I get a lot of bang for the buck is the OA joint and upper/mid thoracic spine.  A simple OA joint distraction mobilization can be great for treating headaches, TMD, and general neck and/or shoulder pain/dysfunction. Thoracic spine techniques are also very valuable because thoracic mobility is lacking in so many patients and can have such an effect on neck/shoulder issues and well as lumbar spine/hip. The most common technique I use is either a simple prone thoracic gapping mobilization or the supine thrust manipulation to the upper or mid thoracic spine. I’m a big fan of manipulation and if I can manip it rather than mobilize, I’d rather do that, if appropriate. Frankly, it’s more fun to do, and saves time.

80/20 Pareto’s principle: 20% of what you do get 80% of your results. What is an 80/20 of being a great PT?

Two things-- the soft skills and the basics. By soft skills  I mean your ability to communicate and build relationships with your patients. Everyone wants to learn the newest sexy technique when the reality is we use those much more infrequently than we do our “people skills.”

Now, don’t get me wrong, I think having a toolbox of wide variety is very helpful, but ultimately you need to get very good at the basics first. In my mind, if you can’t do the basics well, you’re not ready to move on to something more challenging. For example, if you can’t do a mobilization well, you can’t do a thrust manipulation yet. If you can’t move well slow, you’re not going to move well fast. The basics include--confident handling of patients, a variety of general joint mobilizations in different positions, soft tissue mobilization and then some basic spine thrust manipulation.

Don’t worry feel the need to learn EVERY technique that’s out there. Ultimately, you’ll  the ones you’re most comfortable with and the ones you use the most often. Get really good at those, and then work on others that you’re less confident with.

I agree about working on the basics first rather than learning new fancy techniques.  If you can go back in time and give yourself advice after graduating from PT school, what advice would you give?

#1--Find a mentor early!

#2- Most of what you learn in school (other than anatomy) unfortunately is useless in the real world (at least it was for me), so start reading pain science, consumer psychology, customer service/experience, and business/marketing if you want to better serve your patients, become more valuable to your employer, and get ahead in your career.  

18. Name 2-3 PTs who had a huge influence on you and why?

Rick Kring, my Residency and Fellowship instructor at OGI and now CEO of OGI--motivated me through his knowledge and passion to become a better manual therapist

Martin Dominguez, private practice clinic owner and my boss--does things for the right reasons in the right way but also demonstrates that a leader doesn’t need an ego-- they can be humble and confident in what they know what they don’t know; and is willing to hire the people to build a great team.

Jerry Durham- introduced me to the concept of the customer experience and consumer psychology and now I co-host with him on the Healthcare DisruPTion podcast

Who comes to mind as the most successful PT?

Success is hard to quantify. There are many PTs who have made a lot of money and are therefore financially successful, and there are many PTs who are having and will continue to have, a significant impact on the profession. Having the biggest impact might be another way to ask the question, and even then, it’s way too hard to pick just one. Even if we consider just the big names, they are all going to have their acolytes and their detractors. But the main ones that come to mind are Robin McKenzie, Brian Mulligan, Stanley Paris, Robert Maitland, Louis Gifford, and David Butler. “Newer” PTs that I would consider successful include Mike Reinold, Gray Cook, Kelly Starrett, and Chad Cook.

$50-$500 PT related item  that you purchased recently that made your life easier.  

The item(s) I have most recently purchased are all books. Some are clinical and others are customer/experience and personal development focused. I don’t know if it made my life easier or not, but it’s certainly made me happier. Sometimes the more you learn, the more you realize you don’t know. But even still, you will know more than you did before. My main recommendations would be:

Aches and Pains by Louis Gifford

Mastery by Robert Greene

Mindset by Carol Dweck

The Obstacle Is The Way by Ryan Holiday

The Ten Principles Behind Great Customer Experiences by Matt Watkinson

A Guide To Better Movement by Todd Hargrove

Start With Why- Simon Sinek

To Sell Is Human-- Daniel PInk

Linchpin-- Seth Godin

A Complaint-Free World by Will Bowen

The Talent Code by Daniel Coyle

What is one of your weakest area that you are trying to improve professionally?  And how are you working on this area?  

One of the main areas I’m trying to work on professionally is the customer experience/sales side of the profession. Regardless of what we want to think, as Daniel Pink says in To Sell is Human, if you work with people, you are in sales. We are trying to get people to come to our clinic, we are trying to get referrals from many sources, we are trying to get our patients to trust us, and we are trying to get our patients to buy in to our plan of care. All of that requires “selling,” which is often perceived (as I did as well) as a dirty word.

How I’ve been working on it is reading several books, many of which are listed above, listening to both physical therapy and business-related podcasts, and with my interactions with people on social media and with a mastermind group that I started locally with some small business leaders.

I have learned so much from this interview. I really appreciate your time! How can people learn more about you?

@ARothschildPT on twitter and instagram

Feel free to Email me as well at asrothschildpt@gmail.com

Healthcare DisruPTion podcast on tTunes and http://updocmedia.com/podcast/healthcare-disruption-first-episode/

IAMT: http://www.iamt.org/about-us/our-experts/andrew-s-rothschild/

1)  Patient’s pain mechanisms are composed of 3 things:  a) centralized pain (from brain) b) nociceptive tissue (from tissue sources such as a bursa) and c) peripheral neurogenic (from nerves like sciatic).  So the sum of these 3 mechanisms will be 100%.

Examples: Patients with fibromyalgia may weigh heavily on the centralized mechanism.  An athlete may have mostly nociceptive pain. 

I need to work on drawing a pie chart in my head during subjective, which will guide a more tailored objective exam.  For example, if the patient’s subjective is nociceptive heavy, I will design my objective exam to find the tissue source.   However, if the patient shows more centralized mechanisms, I will focus more on learning about their lifestyle, personal and environmental factors, and to determine appropriate dosage for graded activity.  

2)  I can use narrative reasoning to understand the patient’s story.  Learning about the patient becomes especially important with chronic pain population.  This will help me understand about patient’s lived pain experience, perceptions, personal and environmental factors.  

As a result, I will 1) build a better rapport, 2) deliver tailored patient education 3) get a better idea about the underlying pain mechanism/pie chart, 4) design possible interventions, amongst many others.

If good narrative is achieved, the clinician should be able to answer the following questions. (Jones and Edwards 2006).  

• What are the patient’s perceptions about their pain/illness?
  
• How informed is the patient about their pain/ condition and the appropriate strategies for managing it?
  
• What is/has been the effect of the pain/disability on the patient?
  
• How is the patient perceived by others and how has this affected how feels about self?
  
• How does the patient compare self to others?
  
• Explore what can/cannot do, self-worth, perception of contributions/lack of contributions.
  
• Does the patient think others believe them, and how do they say or imply this makes them feel?
  
• Does the patient ever avoid activities or withdraw from others because of pain/disability
  

3) I used to deliver my patient education at the end of the evaluation, but I have learned that I can start “sprinkling" patient education as I perform the subjective and objective exams.  Doing so will improve time efficiency.   The patient will also be less likely to be overwhelmed with information overload.  Also, if I deliver patient education all at once, it is hard for me to recall everything, so some information might be left out unintentionally.  

Until next time!

Jones M, Edwards I. Learning to facilitate change in cognition and behavior.  Gifford L, ed. Topical Issues in Pain 5. Falmouth: CNS Press; 2006:273-310.

Kay Lin, DPT, CSCS

PT Inquest

You won’t find a better evidence-based PT podcast than this.  The hosts, Erik Meira and JW Matheson, analyzes 1 journal article per  episode.  It’s a great way to stay current with the literature.  This podcast will improve your skills in analyzing literature critically and properly applying that to your own practice.  Plus JW is hilariously nerdy. 

Several episodes to get you started: 

Episode 81: Effect of Abdominal Bracing on GRF

Episode 75: How a Tendon is Like a Doughnut

Episode 72: How To Tear An ACL

Episode 56: Exercise Interventions for the Treatment of CLBP

Episode 50: Mechanisms of Manual Therapy

Episode 42: Classification Systems for Chronic LBP

Episode 32: PT and Hip OA

Episode 31: Biomechanical Markers After Manipulations

Episode 30: Therapeutic Alliance

Tim Ferriss. (Non-PT Podcast)

Tim Ferriss is a well-known author of The 4-Hour Workweek, The 4-Hour Chef, and The 4-Hour Body.  Jamie Foxx equates him to “white Oprah” of the podcast world.  He interviews world-class professionals, businessmen, and thinkers including a physical therapist like Kelly Starrett and strength coaches like Pavel Tsatsouline.   This is a great podcast for self-improvement in professional and personal aspects of life.  It will redefine your concept of productivity and living a full life.  Fun fact: his mom is actually a physical therapist.

The Movement Fix

The host, Ryan DeBell is a chiropractor but don’t let the stereotype hinder you from listening to this podcast.   Most modern chiropractors and PTs should have similar clinical reasoning and tool boxes for an optimal outcome of each patient.

He has built up an impressive guest list with the greats such as

•    Shirley Sahrmann
•    Stuart McGill
•    Erson Religioso
•    Greg Lehman
•    Perry Nickelsten
•    Mike Reinold 
•    Charlie Weingroff 
•    Gray Cook 

Therapy Insiders

Hosted by Gene Shirokobrod, Joe Palmer, and Erson Religioso covers wide variety of topics such as the business side of PT, interviewing skills, cash PT, blood flow restriction, mentorship, etc.  Here are a couple of my favorites..

The Mechanics of a Treatment Approach w/ Dr. Stuart McGill

Everything You Need To Know About Mentorship w/ Dr. Jeff Moore

Physioedge  

Hosted by an Australian physiotherapist David Pope, this podcast is a great resource to listen for tendinopathies and pain science.
You can start off with their more recent episode: 

Physio Edge 047 Rotator cuff tendinopathy with Dr Chris Littlewood

Kay Lin, PT DPT CSCS

Traditionally in health care, patients have been told what to do when they come in for therapy.  If we want to build better therapeutic alliances and maximize our positive effects, we need to consider our patients’ expectations and preferences.

A lot of what we do makes patients feel better due to patient education, assurance, general effects of exercises and placebo effects. So we have to maximize the potential of our treatment's specific and non-specific effects by giving options to patients as often as possible.

Studies have shown that manipulation, McKenzie, stabilization, strengthening or graded activity all have small effect size improvements for low back pain.  And when compared to each other, there is not a significant difference between each of these treatments.   This reinforces that patient preference for a treatment approach should be highly considered.

Any type of treatment (be it a specific type of manual therapy, therapeutic exercise, or modalities such as cold/heat) has the potential to be effective for all patients, but in reality not every treatment will work for all your patients. This is where the patient’s expectations and collaborating with the patients come into play. Perhaps you have encountered a patient who prefers a non-thrust mobilization over a high velocity low amplitude (HVLA) mobilization. Even if you are the world’s expert on HVLA techniques, this particular patient would receive greater benefit from a non-thrust mobilization.

"It is the patient who ultimately must make informed choices about the care he or she will receive.”²

A few examples from my clinical experience:

1) After an evaluation, I used to assume that the patient would return for his or her return visit; however, I now explain my findings and present treatment options.  I then allow the patient to choose to make a return appointment.

2) When I am giving a home program, I will ask if the patient believes the exercises will be beneficial and feasible in terms of positioning and timing. Most of the time, he/she will agree with the program. Other times, modifications are made to accommodate the patient.

3) Before performing manual therapy, I will present the patient with options and ask if he/she has any preference between them or even an active exercise. If the patient has no preference, I pick the technique I am most comfortable with.

4) If patients are completing their HEP with improvement of symptoms, I would ask what the patient find to be most helpful and least helpful to their condition. Then I will reason why and discontinue that particular exercise if it makes sense and reinforce with more exercises similar to the ones that are benefiting the patient. 

“Collaboration with patients is part of the clinical reasoning process of an expert”³

During my residency, we are taught the importance of presenting our evaluation findings to the patients, providing options for treatment, and letting them make the decision.  They take ownership by selecting their own intervention, which results in better adherence to the home program. Recently, one of my patients came in with a shoulder pain after dislocation with subsequent relocation, and presented with very limited shoulder range of motion. I made the mistake of giving the patient supine home exercises. She returned 2 weeks later with minimal improvement due to lack of compliance with exercise. It was not the patient’s fault as her preference was doing exercises in sitting or standing, as she does have a full time day job and would like to do the exercises throughout the day. I could have avoided this pitfall by asking during the evaluation if she had any positional preferences and coming up with practical exercises to do.

"Collaborative reasoning is the nurturing of a consensual approach toward the interpretation of examination findings, the setting of goals and priorities, and the implementation and progression of intervention" ¹

In PT school, I did not realize the importance of patient collaboration. Continual self-reflecting and learning will be crucial to grow as a professional. Ask patients what they think and get them involved!

1. Edwards, et al., Clinical Reasoning in Physical Therapy. April 2004. Journal of Physical Therapy.  312-330. 

2. Putting patients first:Patient-Centered Collaborative Care. http://fhs.mcmaster.ca/surgery/documents/CollaborativeCareBackgrounderRevised.pdf

3. Wainwright, et al.  Novice and Experienced Physical Therapist Clinicians: A Comparison of How Reflection Is Used to Inform the Clinical Decision-Making Process  Journal of Physical Therapy.  January 2010.  75-88.

Introduction: Roland Lucas graduated from the University of Sydney, with a degree in Physiotherapy, in 1992.  He completed the Manual Therapy Residency Program at Kaiser Permanente in Hayward  and is a FAAOMPT.  He currently runs a private clinic in Sunnyvale, Ca called Lucas Physical Therapy and Fitness.  He is also the chair of COMPTSIG.   Enjoy!

1.     Can you tell me a bit about how you started your private practice?

a.    I transitioned from working at Kaiser Permanente in the Bay Area to private practice in the early 2000s. I did very little planning and was lucky things worked out. I started out in a shared space, but transitioned to my own office a year or so later.

2.     I am aware that you perform biomechanical analysis in your clinic. Can you tell me a little more about it?

a.    My area of expertise has always been about direct treatment to the source of the symptoms without too much focus on movement analysis. In 2013, I took a Six Month Certificate Series in Advanced Functional Biomechanics offered by Christopher Powers PT PhD FACSM FAPTA and it really opened my eyes.  However, I  don’t do a full biomechanical evaluation on everyone as I believe biomechanics is only a percentage of a patient’s problem. Also, if people have significant musculoskeletal impairments (such as weakness or pain limited movement) I tend to try and resolve them, with traditional manual therapy and exercise, prior to full video analysis as I want to get a more accurate assessment of the patient’s true mechanics.

3.     If I am gonna start my clinic now and incorporate this kind of technology, how much am I looking to spend?   

a.    The system I have is an entry level system, costing 3-5k, but the analysis is very labour intensive. If video analysis was the major focus of my practice then I would have to upgrade to a more automated system starting at around 15k. 

4.     What kind of impact is COMPTSIG making on our profession in California ? 

a.    COMPTSIG has worked with the CPTA to defend our right to practice manual therapy in California.

b.    Additionally, CAREC (a pre-cursor to comptsig) helped the PT schools in California unify their approach to teaching manual therapy.

c.     COMPTSIG also provides a forum for like-minded PTs to become involved in the mission of advancing manual therapy practice in California.

5.     What makes someone a “manual therapist”?

a.    I have a very broad definition of manual therapy.  I think a person is a manual therapist if they use their hands during patient treatment, even relatively simple procedures like passive range of motion and soft tissue mobilization. However, it is important to have professional specialization in manual therapy where PTs delve into mastering the theory and depth of manual therapy practice. In some ways all PTs are manual therapists, but with varying levels of expertize and experience.   

6.     What are some ways to maximize the non-specific effects of manual therapy?  

a.    The intention of my manual techniques is to improve tissue physiology and movement quality and explaining this intention probably maximizes the neurophysiological effects of manual therapy. Some of the things that matter include: trying to understand patient’s point of view, explaining their condition, explaining the plan before doing it, giving options, considering their expectations, giving a heads up if there should be any soreness, etc.  All of these things will together build confidence, rapport, understanding and maximize any non-specific effects. 

7.     What kind of physiological effects do you think is going on when you perform manual?  A lot of evidence is showing that mostly neurophysiological effects occur after hands-on treatment.  For example, it takes tons of force to deform a fascia in cadaver studies.

a.    I don’t think the absence of evidence for tissue changes is the same as evidence of the absence of tissue based-effects from manual therapy. At this stage, I am not willing to relegate the effects of my manual therapy to only neurophysiological effects.  I still approach my patients from a mechanical/histological point of view. I am aware of the role of manual therapy induced analgesia (MIA), but I am not willing to rule out the possibility of tissue based changes. It is a really big philosophical question that strikes at what it means to be a manual therapist. I feel that it is reasonable to believe that connective tissues have time-limited response to loads applied during manual therapy just like how they respond to mechanical loads from exercises.

8.     Can you zoom in and give me an example of what you theorize is happening at a microscopic level when you are applying PA’s on L4-L5 in prone? 

a.    If a section of the annulus fibrosis is symptomatic due to alterations in its loading tolerance and if loads applied during PA's to L5 stress the annulus beyond its comfort zone, then it is reasonable to assume that manual therapy may result in a fibroblast-initiated attempt at remodeling the symptomatic tissue (mechanotransduction), similar to what we hope for during exercise-induced changes in tendinopathy.  When looking for movement- related changes, and especially malalignment-related changes, due to manual therapy we have been disappointed, so we have started to explain the benefit of manual therapy by neurophysiological responses (MIA), but I feel this is premature. We may not need to have evidence of movement-related changes to conclude that there have been beneficial connective tissue changes. Currently, we do not have strong evidence of histological changes due to manual therapy, and if they exist they are probably small and time-limited,  but I am uncomfortable saying that the primary benefit of manual therapy is a short-term analgesic response, probably in the vicinity of 20% reduction in pain. 

b.    I think at this stage considering the limited evidence, it is better to consider that manual therapy works due to a number of proposed explanations: 1) short-term analgesia, 2) long-term brain related changes, 3) histological adaptation and remodeling, 4) structural lengthening.  At this stage I am uncomfortable ruling out #3 and #4.

9.     Are there effects that you have seen anecdotally where research has yet to support in regards to manual therapy?  

a.    Treating thoracic spine for thoracic spine pain certainly works but we don’t have much evidence.   Most of the research on thoracic manual therapy has focussed on the role of treating the thoracic spine in patients suffering from neck or shoulder pain.

10.  According to 80/20 Pareto’s principle, 20% of what you do get 80% of your results.  What is an 80/20 of mastering the manual techniques?  

a.    I agree with the 80/20 principle in manual therapy. Out of all the techniques I know, I use 20% of them for 80% of my patients. Also, I feel that using the appropriate amount of force,  and hitting the right structure, is more important than manual therapy technique complexity or mastery. The main problem a new grad may have in hitting the symptomatic area is due to potential clinical reasoning errors during the evaluation process, so they should make sure they have strong system of unbiased evaluation that focuses on identifying both contributing factors and the source of the symptoms. Additionally, PTs need to make sure they have a range of techniques of varying intensity to impact all of the possible symptomatic regions in the body. Physical Therapists should make sure they have articular techniques for as many degrees of freedom that each joint has, and they should also have a range of soft tissue techniques that they can apply throughout the body.

11.  What advice would you give yourself if you can go back in time 15 years ago?

a.    I would say 2 things:  Go to more conferences to broaden my horizons and challenge my biases.  I focussed primarily on continuing education courses that interested me, which is very valuable, but may lead to narrow-mindedness. Adding conferences into the mix of weekend and long-term courses helps expose therapists to ideas they may not have sought out directly.

b.  Become involved with the APTA or other professional organizations. An easy place to start is the local district meetings or special interest groups, but there are opportunities to volunteer at the state and national level as well.

12.  Name 2-3 PTs who had a huge influence on you.  

a.    All of the staff and students on the 1996 Kaiser Hayward residency program. The residency program gave me the necessary technical and theoretical foundation, but unfortunately I was not able put it together in a clinical package while I was there (I actually failed one of my final exams). Fortunately, after the residence I worked with Larry Brown and Dennis Dempsey and they really helped me iron out my clinical reasoning. After their mentoring, I went back to Hayward to retake the exam with much higher confidence and passed.

13.  Can you give me an example of specific feedback they gave you?

a.    It has been a while, but I think one thing that resonates with me is that after working with them I de-emphasized pattern recognition/diagnostic labeling and focused more on deductive reasoning.  Prior to working with Larry and Dennis I seemed to focus more finding the “clinical diagnosis” and how that impacts treatment selection, versus developing treatment selection through the patient’s specific clinical presentation.

14.  Give me a specific patient example you saw last week regarding this thought process. 

a.    I think the key thing here is that we often have hypotheses regarding the source of the symptoms but we must develop hypotheses regarding the potential impact of available manual techniques. Consider, a patient I had with radiating left arm pain last week. After I ruled out the presence of significant neurological changes, which would significantly alter the course of management, I direct my evaluation to locate the most relevant findings that could potentially be related to the complaint. I become less concerned if the source of the symptoms is muscular, discogenic or facet joint in nature. I am more interested in locating physical exam findings in the region that is most symptomatic and most different from normal. Then it becomes simple trial and error to test the impact of these possible techniques (in her case Unilateral Anteroposterior Pressures at C6 and C7) on her symptomatic movements.

15.         What do you recommend that PTs start doing or doing more to advance our profession?  

a.    Don’t be sheep. Think critically about patients and research. You are the person responsible for translating research into clinical effectiveness and you will have to decide how relevant the evidence is in comparison to your experience and the patient’s expectations.

b.    Make sure you develop a range of therapeutic skills.  And some of these skills will not be evidence based, such as a certain manual techniques or exercises that have not been examined yet.  For example, we keep having this debate about the relative benefit of thrust versus non-thrust manual therapy.  It’s irrelevant; you need to learn both.  Science is going to change and patient expectations vary. Having a greater clinical repertoire will give you more options to be clinically effective.

 Rapid-fire questions:

1.     If a kid walked up to asking for your advice about life and you only had a minute what advice would you give?

    Develop a skill and learn how to do it well.  Be great at it! 

2.     What 2 books would you recommend that are not written by PTs?  

Wrong: Why experts keep failing us.  by David Freedman: I very much like this book because it describes the limitations of knowledge transfer and how new information often contains significant bias. It discusses how people are mistakenly mislead by guru’s and how the scientific research we read has the potential to present a skewed  point of view of the truth.

 The Art of Thinking Clearly by Rolf Dobelli : In the vein of Thinking, Fast and Slow by Kahneman this book has 99 chapters each focussing on a known critical thinking error. Nearly every reasoning error presented is applicable to musculoskeletal rehabilitation, either in the therapist or the patient.

3.     Who comes to mind when you think about the most successful person?

Many people are successful in one avenue of their life, eg career, but sacrifice other aspects of their life to do so. A friend of mine from Physiotherapy School, John Riley, has attained professional success without sacrificing relationships and the pursuit of his non-monetary interests. His career was a means to living a fulfilling life, raising his family and giving back to the community. His career was not the purpose of his life. This kind of success is difficult because it is individually defined and often contradicts society’s expectations for success in life.

How can people learn more about you? 

My clinic website

 My education website

Stay tuned!  I will continue to post more of my learning experiences from the Kaiser Residency program.  It will contain more visual appeal (pictures and better formatting) once I figure out how to work this website!

Kay Lin DPT CSCS 

We have updated the website of the California Orthopedic Manual Physical Therapy Special Interest Group of the California Physical Therapy Association.  Check it out at www.comptsig.org

Use the Membership page to join or renew your membership. 

Use the Con Ed page to view upcoming comptsig sponsored courses and courses that are offering discounts to comptsig members

Our Resources page has links to our study groups, member only forum, research summaries, and member directory. Some of these resources are limited to member's only.

If you would like to help with comptsig's mission please contact Roland at chair@comptsig.org.

Roland Lucas PT MPhysio FAAOMPT

COMPTSIG Chair

Thanks to all the PTs who signed up for Andy Brenan and Clare Lewis' popular oneday grade V course May 22nd. COMPTSIG is bringing their course to Southern California in Sept 11th, 2016.  

Registration Details for the Los Angeles Course are here.