There is a clash between knowing that biomechanics and structure are not 100% responsible (ie. a 1-to-1 relationship) for pain, and the fact that (from an Example I got from Mike Eisenhart) some one with a poorly moving C5-C6, (as best we can tell the difference and as valid as our hands may be) has a risk factor for future neck pains and problems.
No. Not causative, but a risk factor.
We run the risk of “throwing the baby out with the bathwater” as it were. Because we know that poor posture does not cause pain, does not mean that a lifestyle, in which poor posture exists and is showing up to you in the clinic, is not a risk factor. These risk factors should be, and need to be addressed.
I really dislike the concept of looking at someone’s asymmetries, or different structure and giving them a diagnosis of pathology. It doesn’t fit in my perception of reality, and therefore I am very at risk to overlook, ex: not care, about some slight “movement dysfunction.” This sets me up to not be as helpful as I could be.
Again, spurred from a convo with Mike E: Are we confusing creating patient independence (and giving them a positive outlook on their condition) with functional return. “Sometimes I think we say, hey, you’re functional, that’s good enough, insurance won’t pay for much more, see ya later.”-Mike Eisenhart (@mikeeisenhart). This attitude does not let us help people be “the best they can be, the best version of themselves.” Heck, you work on bettering yourself and you are functional!
Maybe insurance won’t pay, and yes, Payers are the Fourth Pillar of EBP, but that does not mean we have to stop. We explain that we can help. We have the skills to make life-long change in someone’s life… if we simply don’t stop at functional.
I struggle with this aspect: the part of DCing someone when they are “good enough.” I confuse good enough with functional and done with what physical therapy can offer.
That’s a tough concept. When to stop. Especially when the patient could use much more. As Dr. Mark Reid, MD (@medicalaxioms) stated “a correct diagnosis is often not what’s wrong with the patient.” We can help in many other ways.
Mike Riley, PT (@mikerjrpts) has a great example as well. He spoke of this on Jerry Durham’s podcast and at Graham Sessions this year. Here’s the gist of it: “if someone comes in with LBP and has CAD risk factors and we only treat the LBP, we are missing our some value. We could educate, teach, instruct, coach and can make a difference. Heck, due to these factors, he could have shoveled snow, had an MI and died vs seeing you for LBP from that same shoveling. We DO have the ability to modify these factors.” Exercise. Simple diet instruction. Lifestyle choices. Behavior behavior behavior… over time.
*Is this a perspective shift for you? Does this fit into what you think a PT does?*
Thought experiment: There is a difference between a PT clinic with a gym in it, and a gym with a PT in it. One is on one side of the injury, and one is on the other. I love the shift of adding Wellness/Fitness to PT… but a more proactive approach is certainly to add PT to Wellness/Fitness centers. Perhaps this is semantics, but I believe this subtle shift is paramount to impacting communities and perhaps reaching the vague yet ambitious Vision Statement of the APTA. You can’t change society from a reactive stance. Yes many come to PT, find joy in the process and develop healthy lifestyle habits to take with them in to the future. But that is only what… 5% of the population. Now maybe only 10% are in gyms/fitness centers… but combines that’s 15% and that’s a three fold impact YOU could make.
Yes this throws out old ideas. Yes new models of preventative care are babies and need nursing and cuddling to grow. And yes, your current PT practice that sees post-op and reactive care will still exist. There will always be the sick. But a trend towards improving the front end may make those we see a “different kind of sick.” Perhaps ones with less co-morbidities.
Let’s start with what we can do. Get out there in front of the problem. Put aside the understanding (the truth) that we cannot predict injury 100%, that we cannot prevent injury 100%. We can still modify risk factors. I can say exercise will help. I cannot say exercise will cure. So… I will say exercise will help then. Sorry, changing posture and moving “better” is important. It’s important to bend and move into all the corners of your ability and explore the body you live in.
Dr. Spencer Muro (@spencermuro) speaks about how we treat people in this way: he mentions that we, meaning we humans, do not treat anything. We only maximize or leverage the natural healing power of the human body. SSRIs? We are just using the receptors that we have. Hypoalgesia? Sure, we are just “pushing the buttons” to make those hormones drop.. like from a Tabata KB swing set. Since we know that all we do is use the body (like Wolverine) to heal itself… then why can’t we wrap our heads around building the body up to reduce the risk of injury/break down/disease? Come on! It’s the same process and we are the experts in maximizing what the body comes equipped with! Seriously.
This is our wheelhouse. We swing from here and we blast home-runs for dayyzz.
If a switch to hit this problem from the front end can be made, the back end will be even easier.
–Matt D
PTbraintrust 
Hi Matt
Thank you for your post.
I would have to say I disagree with this post currently but it may be because I don’t exactly get the point or think there is opposing evidence to what you are saying. Maybe you can clarify some of the things you write and maybe add some references.
Here is where my confusion starts.
“some one with a poorly moving C5-C6, (as best we can tell the difference and as valid as our hands may be) has a risk factor for future neck pains and problems.”
How do you know this? Current studies show we can’t palpate for shit so how did you even identify this risk factor and not invent it?
“Because we know that poor posture does not cause pain, does not mean that a lifestyle, in which poor posture exists and is showing up to you in the clinic, is not a risk factor. These risk factors should be, and need to be addressed.”
Are you talking about yellow flags here? Sleep? or posture? 99% of the people I know has a lifestyle that includes risk factors hell living is a risk factor. What exactly are you pointing your finger at here we could and should do?
“I am very at risk to overlook, ex: not care, about some slight “movement dysfunction.” ”
How do you even know what a movement dysfunction look like? What is a movement dysfunction? If you identify one how do you know you are not pathologizing something totally innocent and potentially creating a noceboeffect? Why is the focus on the flaw instead of the goal? If a person wants to do something specific why not help them get there instead of correcting something we have no means of knowing is right or wrong. Maybe it just is?
I am however pro we assist in helping patients change in the direction they wish to go as you end up with.
Kind regards,
Simon Roost Kirkegaard
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Simon,
I agree with you, and have the same thoughts go through my mind. How can I help the most (early intervention, pre-injury) while knowing that there are such limitations in assessment in finding risk factors of pain and future health problems. Mix that with the understanding that if we can address problems early, they impact the individual less. I am very pro-PT and movement and such, and also very on-board with current thought and topics/limitations of our abilities and claims.
Yes, our palpation skills in finding “dysfunction” have been shown invalid. I’m still putting my hands on people. In palpating a C6 … I suspect you and I would agree that there are clear beautifully moving joints, and clear jammed-up joints, and perhaps the major discussion lies in the gradient between obvious pathology and perfection. I don’t treat patients based off some magic palpation, or talk to them in a way that suggests poor joint mechanics, and I do not speak in a manner that links pain to anatomy in the pathoanatomical sense… but does that set me up to miss an opportunity to help them? (again, pre-injury) I don’t want to take this knowledge (of pain not being a 1:1 ratio to biomechanical damage) and ruin my position to help someone… if I can. In that I can. What do you do knowing that perhaps if you taught 1-2 simple movements, that person may avoid some future problem? Nociception may not be needed for pain, but it plays a role, a physical role, and we are physical therapists. Again, I struggle with what to do about this conflict.
As for the risk factors and posture? Yes. I mean all of that. We know that sleep, social skills, life, etc, are factors in current and future status. These are not stand-alone causes, but factors. The patient may not know this. I wish to share any modifiable behavior that I could that could positively impact their life. I think that makes sense, at least to me.
Movement dysfunctions? I have no idea what that means, hence the “.” marks. I do know that many PTs go after this sort of thing, in an attempt to improve the movement of people. As I say, that’s not my style. I know physics and biomechanics certainly affect performance and forces applied to joints, tissues, etc. So in that context, yes, one could be coached to move in an efficient manner based off their structure, motor control, strength, ROM, etc. I think you are completely correct in you comments about avoiding providing nocebo to normal. I worry that this knowledge, or this bias, will stop me from seeing an area to work on. Again, I think at this point we (all of us?) know there is no ideal movement, there is a wide variety of great movement choices for a person+task+environment. So how do we help here? (perhaps your answer is, “who says we should?”)
I actually agree with all of your statements. That is the problem. I also agree our professionals are the movement experts and are in a place to help people reach their functional goals (as broad as that is). That is the problem.
PT as a reactive position: “It hurts when I move my shoulder.” they say. Ok, I can help you with that.
As a pro-active position, knowing what we know (now), can we say “I know a thing or two about shoulders. Can I show you some motions to reduce risk factors in having an injury?” Can we say that and still be in line with science? I want to say yes, and I want to say no. You outline the “no,” and if it is “yes” then what do we look for? Well, we look for clear asymmetries and imbalances, but those may not be important and may be normal… so, can we help?
Cheers for the comments
Matt D
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