Just when I thought I was out, the clinic pulls me back in.
Though I’m glad to be back. There’s just a different vibe, different pace, and ever-constant variety of challenges that being in the clinic simply provides. This has been especially true working in a rural area. You see a much wider variety, which challenges you to broaden your skillset.
Previously, I was all about getting people in and out of the door as quickly as possible; and with very few visits. I would cut them down to once a week or every other week damn-near immediately, and try to hit that three to five visit sweet spot.
This strategy no doubt worked, and people got better, but I had noticed I’d get repeat customers. Maybe it wasn’t the area that was initially hurting them, but they still were having trouble creep up. Or maybe it was the same pain, just taking much more activity to elicit the sensation.
It became clear that I was skipping steps to try and get my visit number low, when in reality I was doing a disservice to my patients. This was the equivalent of fast food PT—give them the protein, carbohydrates, and fats, forget about the vitamins and minerals.
Was getting someone out the door in 3 visits for me or for them? The younger, big ass ego me, wanted to known as the guy who got people better faster than everyone else. Yet the pursuit became detrimental to the patient’s best interest. There were so many other ways I could impact a patient’s overall health that I simply sacrificed in place of speed.
I only got them to survive without pushing them to thrive.
I see a lot of individuals proudly proclaim how many visits it takes for them to get someone out of pain, but pain relief is only part of the equation. There are so many more qualities we can address before we consider a rehab program a success.
This stark realization has reconceptualized how I structure a weekly rehab program. I now emphasize all qualities necessary to return to whatever task the patient desires, and attempt to inspire them beyond those initial goals.
You want to know what my visit average is right now?
I stopped counting, and started treating.
Let’s look designing the rehab week to take your clients to the next level.
A late addition to the yearly course list, but a decision I will never regret.
Lorimer Moseley is one of my heroes in the pain science realm and I’ve always wanted to hear him speak. His teaching style—slow paced, humorous, filled with story, and unforgettable—really resonated with me and made his material so easy to understand.
My admiration for him tremendously grew because he was readily admitting if he didn’t know something, critical of his own body of work, and very open to what we we do clinically. I got the impression that he was okay with us practicing how we wish, as long as our treatments are science-informed and coupled with an accurate biological understanding.
I left the talk validated, reinvigorated, and better adept at educating patients. He put on one of the best courses I have been to. If you haven’t seen Moseley live or had the chance to interact with him, please do so.
We are hosting several courses at my clinic this year, and we would love to have you, the readers, attend.
The three courses that East Valley Spine and Sports will be hosting are all excellent courses. I have taken two of these classes prior, and the third I have taken a prior rendition of. And let me tell you, these courses are boss.
Aside from us bringing some excellent content, you will also have the opportunity to hang out with a good group of people, and imbibe in some good beverages with me.
Here is what we are bringing.
PRI Pelvis Restoration: March 28th-29th
I took this course a little over a year ago (read the review here) and I am very excited to be learning from Lori again. She presents this very complex material in a systematic and understandable fashion.
ISPI Neurodynamics: The Bodies Living Alarm: October 17th-18th
I took a version of this class when Adriaan spoke for the NOI group, and I am excited to see what tweaks have been made since. This time we are bring Louie Puentedura in to teach the class. I am excited to hear his perspective, as I have never seen him talk. Adriaan speaks highly of him, so he’s okay in my book!
It’s that time of the year that we get to look back and reflect and what posts killed it (and which bombed).
It seems as though my fine fans be on a pain science kick this year, and rightfully so. It’s some of the best stuff on the PT market right now. It’s definitely a topic I hope to write about more in the coming year, and one I will be speaking on at this year’s PRC conference.
But without further ado, here are the top 10 posts of 2014.
Going through the treatment process as a patient has really upped my game in terms of knowing when to integrate with my patients. It has also been a life-changing experience for my health and well-being. Learn how they did it for me.
So much fine tuning occured the second time around. I love how Jen acknowledged the primitive reflex origin of the patterns, as well as fine tuning both lift tests. She’s an excellent instructor (and fun to party with)!
One of the most powerful and humbling courses I have ever been to. Ron goes all out on this course, as it is his baby. What dental integration can do to a system under threat is a concept that I hope is further explored in medicine. We can’t do it alone folks.
This post marked a shift in my thought process and a realization of the possibilities that an integrated health system can accomplish. I have high hopes for our profession, and feel excited that an original post had so many views.
Couple the best manual therapy explanation I have come across and a gentle technique and you get a rock solid course. The only downside is that now Diane has tarnished any other manual therapy course for me, as I can’t rationalize any other explanatory model given.
Those patients that I am having trouble with are who I study the most. It’s that whole learning from your failures thing.
In studying these folks, I have noticed an interesting trend.
It doesn’t involve movement.
It doesn’t involve medical history
It doesn’t involve stress (though it always involve stress)
Instead it involves language. I have noticed a few commonalities in how those patients who are either not improving or have been in chronic pain for some time talk. There is one shift, however, that I notice more often than not.
Disembodiment from Your Sports Team
I don’t really watch a whole lot of sports; I’d rather play them. Sports fans however, interest me. It’s fascinating how much ownership a sports fan takes in his or her team.
This ownership is especially noticeable when things are going well. Think of the language one may use during the following instances:
Huge victory – “We finally beat the Packers.”
Draft Picks – “Our team got some huge prospects.”
Championship win – “We are the champions….my friends.”
Notice though, how oftentimes language may shift when a team is not doing so well.
Huge loss – “The Bears lost…Again.”
Draft flops – “I can’t believe they chose Steve Urkel first round!.”
Championship loss – “They blew our chance of winning.”
Robert Cialdini discusses this concept in his book “Influence: The Psychology of Persuasion.” When our team is winning, we manipulate our association to said team to improve our self-image. On the flip-side, when our team is losing, we will do things to distance ourselves (you can read an interesting study on this here). Perhaps it switches from “we win” to “they lost.” Or perhaps we wear team jerseys after a victory and regular clothes after a loss.
This same concept seems to apply to pain states. Think about those folks in acute pain/injuries:
“My neck hurts.”
“I tore my ACL.”
Compared to those who perhaps are in more chronic pain states, or at least those folks who I have noticed are not doing well.
“It hurts in the neck.”
“It must be that bulging disc.”
“I have the neuropathy.”
The former examples still have ownership with their problem, while the latter distances themselves. They become disembodied from the perceived affected area.
They lose the area’s image. They no longer love their team. That shoulder jersey they used to wear stays in the closet.
I’m going to quit using my arm.
I’m going the start calling my arm “the” arm.
I’m going to start saying the arm is killing me (to which I ask the patient if I should call the cops).
I’m going to persist in a chronic pain cycle.
What to Do What to Do
A patient’s descriptors and metaphors can play a critical role in how the pain experience is perceived. If thoughts and beliefs are what seem to impair one’s function, then it is those impairments that must be addressed.
Your goal is to get the patient to fall in love with the affected area again.
In order to play neurological cupid, shifting a patient’s language can have profound effects. It may be as simple as just making them aware of how they are describing the affected body region; relating these descriptors to brain smudging. You could also use the sports fan example above:
“Your perception of pain has led you to become a disgruntled fan of your shoulder. You need you [notice how I frame the needs to what they need to improve] to become a super fan of your shoulder again. It is your shoulder; take ownership in it. I’m going to show you some gentle exercises that will give you that winning streak you need to start cheering for your team again.”
Regardless of what direction you choose to go, you have to do all that is possible to change your patient’s perceptions, thoughts, beliefs, and fears regarding the pain experience.
It’s one of the hardest things we have to do.
What are some of your tips, tricks, phrases you notice?
This is a summary of section 2 of “Explain Pain” by David Butler and Lorimer Moseley.
Tissue Injury 101
When a body is damaged, pain is often the best guide to promote optimal healing. Sometimes it is good for us to rest, other times it is better to move.
A similar healing process occurs for all tissue injuries. First, inflammation floods the injured area with immune and rebuilding cells. This reason is why inflammation is a good thing in early injury stages.
A scar forms once the inflammatory process is over. The tissue then remodels to attempt to become as good as the original. Blood supply and tissue requirements determine how fast the healing process occurs. For example, ligaments heal much slower than skin because the former has a lower blood supply than the latter. This may also be a reason why aerobic exercise may speed up the healing process.
If present, pain usually diminishes as the tissues heal. However, pain may persist if the nervous system still feels under threat.
Acid and Inflammation
The alarm sensors described here constantly work and often get us to move. Movement keeps our system flushed. When we don’t move or a physical obstruction is present (e.g. sitting), acid and by-products build up in the body tissues. Oftentimes we will start to feel aches and pains when we stay in a prolonged position, which is our body’s way of saying “get up and move.”
Much like the alarm system, inflammation is a primitive way for our body to continue the healing process. Inflammation is designed to hurt so the injured area has time to heal. There is no need to fret when swelling, redness, and pain are present; our internal systems are merely repairing us.
We call swelling and its corresponding cells the “inflammatory soup.” This soup is a by-product of blood and chemical transportation, and sets off our body’s alarm system to increase sensitivity. All of these changes are essential to facilitating a healing environment.
Everybody be hatin’ on muscles nowadays as the source of our aches and pains. However, the authors put muscles in perspective for us with the following points.
Muscles are loaded with sensors, so can impact the pain experience.
Muscles can become unhealthy and weak.
Muscles are very difficult to injure, they are just very responsive structures.
Muscles are well vascularized which allows for quick healing.
The reason the authors wish to change the name of these structures is because anatomically they do not resemble a disk at all. The new name is “living adaptable force transducers,” or LAFTs.
LAFTs are made up of the same material as your ear, and contain some very strong ligaments. In the medical world, we have many different treatment modalities that target the LAFT. We have McKenzie, traction, surgery, and injection to name a few. Because there are so many different treatments for these structures, it is fair to say that LAFT injuries are still not fully understood.
LAFTs also come with very strong language: slipped, bulging, herniated. Using such strong language can stop someone from moving, which is far from the ideal regarding low back pain.
Here are some LAFT facts.
The LAFT outer layer has a nerve supply, so danger sensors can become activated easily. If the LAFT becomes injured, the surrounding structures will likely set off danger sensors as well. You want a lot of danger sensors if something is occurring near the spinal cord. It is kind of a big deal.
LAFT injuries usually do not cause instant pain. Pain usually occurs 8-12 hours later.
LAFTs naturally degenerate and do not have to contribute to a pain experience. At least 30% (and potentially up to 80%) of people without low back pain have LAFTs bulging.
LAFTs never slip.
LAFTs heal slowly, but they will always be a bit tatty around the edges. This attribute makes it hard to distinguish aging from injury.
LAFTs, spinal joints, and nerves are built to withstand high forces.
Skin and Soft Tissues
Our knowledge of pain is based predominantly on the skin. The skin mirrors the nervous system’s state. Rarely is the case that skin injury leads to chronic pain however. On the flipside, painful skin zones; changes in skin health; and altered sweating or hair growth can all be indicators of damaged nerves.
How often have you seen or had your skin become increasingly sensitive to touch after an injury? This is a common phenomenon that occurs because cutaneous nerves increase sensitivity in order to protect an injured area. Here are some other skin and soft tissue facts.
Damaged skin heals very quickly.
Skin has a high danger sensor density.
Skin is very mobile and loves movement.
Fascia is a strong tissue that lies under the skin and also contains many danger sensors.
Massage moves tissues and sends impulses to the brain. Therefore, movement and touch are great ways to refresh the virtual and actual body.
Bones and Joints
Most joints have lining known as synovium which keeps the joint contained and lubricated. This lining is loaded with danger sensors. Here are some other facts.
Joint pain seems to be dependent at which the speed damage occurs. Slow changes usually do not make the brain think there is danger. A dislocation however may lead to severe pain. Most people with worn joints never know about it.
Everyone has worn joints as we age. They are the wrinkles on the inside.
Joints love movement and compression.
Broken bones heal and are often stronger than before.
Joints in the back and neck can get injured, but may be too small to see on imaging. This may or may not set off the alarm bells.
Most of today’s neuroscientists agree that peripheral nerve problems are far more common than we think. Here are some fun facts regarding nerves.
Nerves have danger sensors.
Neurons can contribute to pain.
If a nerve becomes injured, it may become more sensitive to ensure you survive.
Nerves slide as we move. If a nerve cannot slide well, pain may occur while moving.
Nerves change as we age, just like everything else in our bodies.
Scans and nerve conduction tests cannot easily identify a damaged nerve.
Nerves can be injured but may not create a danger message for days to weeks.
The Dorsal Root Ganglion (DRG)
The DRG is like the brain of the peripheral nervous system. This is the first place that tissue messages are evaluated. Here are some facts for DRGs
Peripheral nerves have their nucleus in the DRG. It is here that sensors are made.
The DRG is extremely sensitive and changeable.
The DRG is very sensitive to blood chemicals, especially stress chemicals.
Sometimes the DRG fires just because. It is like your body’s car alarm. Sometimes the DRG can be hurt without having any pain too.
When a nerve is injured, oftentimes it will backfire. The reason for this is like a domino effect. If a nerve is stimulated at one end, it will send messages up the system to go to the other end.
Backfiring may not be an issue for the short term, but its persistence can lead to sustained inflammation. A less sensitive nervous system may lessen the amount of inflammation in the tissues.
Here are the common symptoms associated with peripheral nerve pain.
Movement or a sustained posture may ignite an injured nerve which keeps ringing.
May not hurt for a few days or weeks.
Skin zones may become itchy.
Might just feel weird.
Just because you feel these symptoms does not mean it is the end of the world. Understand that nerves are just responding to signals from the brain that tell them to increase sensitivity and improve warning capacity.
Our body’s alarm system alerts us to danger or potential danger. This alarm system is composed of sensors throughout the body, the eyes, nose, and ears. It is these sensors that are our first line of defense against harm. If one sensor fails the others take over.
Most of these sensors are located in the brain and respond to various stimuli. Some to mechanical movement, some to temperature change; the sensors in the brain particularly respond to chemical activity.
What is important to know with sensors is that they have a very short life expectancy of a few days. This cycling means our body’s sensitivity is constantly changing. It is with these life cycles that there is hope for those with chronic pain.
Moreover, the rate at which sensors are made is normally stable but can change very quickly in regards to a particular stimulus. So if we take for example one with persistent pain, the rate at which pain sensitivity occurs can be changed.
We lack pain receptors in our bodies. Instead, the various tissues have special neurons that respond to different stimuli. These receptors are called nociceptors, which translates into “danger receptors.” Nociception is occurring all the time, but only sometimes will it end in pain.
Nociception is neither necessary nor sufficient for pain.
The sensors correspond to particular neurons. In order for these neurons to become excited and send signals to the brain, an action potential must occur. An action potential is a spike in which nerves relay messages. These spikes require a certain amount of stimulation to go over a certain threshold. Think of it the same as if someone were doing many things to make you mad. Eventually, that person will cross the line and may cause you to get very angry. Action potentials act very much the same way.
These nociceptors can become very active very quickly depending on resting stimulation. If at rest these sensors are stimulated high enough, then small changes could cause the action potential threshold to more quickly be reached. This happens in acute injuries for example. Suppose you scrape your leg. The skin sensors along the scrape have increased sensitivity. This change may lead to even a slight touch to the injured area creating a nociceptive response.
Notice that above I have been neglecting to say pain. This is because the brain and spinal cord have to analyze the incoming nociceptive information prior to pain being felt. This processing is why not all nociceptive responses are painful.
When nociceptive fibers activate, a signal is sent to the spinal cord. Here at the cord, chemicals are released to activate surrounding neurons. The various neurons are built to respond to particular chemicals and not to others. This is called the Lock and Key Principle.
From the spinal cord, neuronal messages are relayed to the brain. In the brain, all relevant stimuli are processed and sorted out to determine the best course of action. There is not one part of the brain, but several, that deal with pain. These areas are called “ignition nodes.”
The response that can occur from the brain can affect multiple body systems in order to get us out of trouble. Here are the different effects that can occur with an injury.
Sympathetic nervous system – Increase heart rate and vigilance, mobilize energy stores, sweat.
Motor system – Run away, fight, protect damaged area.
Endocrine system – Mobilize energy stores, reduce gut and reproductive activity.
Pain production system – Motivate to escape and seek help, attract attention.
Immune system – Occurs later post-injury, but cleans up injured area, increases sensitivity, produces fever, makes one sleepy.
Parasympathetic system – Occurs later post-injury, but promotes healing.