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?*
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 Dancigers, DPT
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
Keeping it Eclectic...
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