A Missed Step in Physical Medicine

A Missing Step in Physical Medicine

Pain is a reality we are all familiar with.  We sometimes experience pain with specific movements or sometimes it’s a deep ache at night.  We have pain with long drives in the car or we have pain bending over to pick something off the ground.  There’s pain with standing for too long or sitting for too long.  We feel pain after twelve reps of a lift or pain after that first two miles of a run.  There’s the elbow that aches or that hand that goes numb in the morning.   How do we find the answers to the why, the how and the what to do about this pain?

It’s difficult to decide what to do when something hurts and where to find the answers to our questions.  There is a multibillion-dollar industry of tapes, creams, massage machines, wraps, foam rollers and medications that offer the promise of relief.   We can find countless self-treatment remedies on the internet.   Navigation through this information overload is not easy.  We are often left with more questions than answers. What’s the best choice? Do we self-treat and wait? When do we go to a doctor?  Do we need physical therapy? Do we get a massage?  Do we still work out?  Which answer do we choose?

I would like to present the best answer that I have found after over 22 years in this profession.  That answer is “It Depends”.   I realize that this isn’t that answer that you were looking for.   I think what we are a truly looking for are answers to the question of pain.  The questions are, what is wrong?, what can be one about it? and, what can I do to prevent this from happening again?

Let me paint my utopian view of a world of physical medicine where everything works for the benefit of the patient.  This view seems simple but is not often the case.  It respects the time and money of the patient and seeks the most pertinent and efficient treatment.    In this view, the patient chooses a provider bases on the best information they have on the intervention they may need.  That provider diagnoses or assess the patient to determine if they have the treatment that is most appropriate for your condition.  That provider either treats the patient with benchmarks and timelines in mind or refers to the provider that is best suited to treat the condition.  The provider then communicates to the provider being referred for care.

Here is a list of medical and licensed providers and a very brief overview of their expertise in the care of muscloskeletal conditions This list by no means fully reflects these providers education and expertise. Each provider has valuable interventions that are appropriate depending on a case of muscloskeletal pain.

The Medical Doctor (MD):
Most are not experts in musculoskeletal pain.  They have the expertise in determining if musculoskeletal pain is associated with an internal pathology.   Some common tools for medical intervention for musculoskeletal pain include muscle relaxers, pain killers, and anti-inflammatories such as injections and oral steroids.

These providers have the ability order diagnostic imaging studies such as x-rays or MRI scans.

The Osteopath (DO):
This is a medical doctor that is trained in the physical manipulation of the joints and soft tissues.   Some common tools for medical intervention of musculoskeletal problems include muscle relaxers, pain killers, and anti-inflammatories such as injections and oral steroids and varies musculoskeletal manual adjustments and hands-on manual therapy.

These providers have the ability order diagnostic imaging studies such as x-rays or MRI scans.

The Physical Therapist (DPT):
These providers have a wide scope to cover in physical medicine.  Physical therapists have a seemingly daunting scope of patient cases and a vast knowledge base to go with it.   Physical therapists work with patients that range from aches and pains to, neurological rehabilitation such as stroke victims and orthopedic rehabilitation such as total knee replacements.

The tool box of the physical therapist can vary from provider to provider.  Some common tools for intervention from a physical therapist include stretching and strengthening protocols, exercise prescription, dry needling, taping techniques, aquatic therapy, neurological therapies, electronic stimulation, ultrasound and traction, and varies models of manual therapy.

The Chiropractor (DC):
These providers have a wide scope of practice.  The primary focus of  hands-on treatment is spinal manipulation to address what they diagnose as spinal segment subluxation.  Today, chiropractors can be found working in scopes that address a variety of conditions throughout the musculoskeletal system.

The tool box of the chiropractor varies from provider to provider.  Some common tools include high velocity spinal adjustments, low velocity spinal adjustments, activator adjustments, taping techniques, ultrasound, heat therapy, stretching or strengthening protocols, exercise prescription and various models of manual therapy.

These providers have the ability order diagnostic imaging studies such as x-rays or MRI scans.

The Massage Therapist (LMT):
These providers have a scope where they manipulate and treat the soft tissues of the body.  Massage therapists have an entry level education requirement that can start at 500 hours of education.  These providers do not have the scope to diagnose a condition.  They assess your condition to determine whether your presented condition is contraindicated to their massage or manual therapy technique.

Some common tools and techniques include relaxation massage, deep tissue massage, myofascial techniques, lymphatic drainage, cranial sacral techniques, taping techniques, and various manual therapy techniques.

The Provider with the Missing Step:
These are providers that are often and hard to find.  They are hidden in four of the five provider descriptions.  These providers are the skilled manual therapists.  They could be a DO, DPT, DC or LMT.  Their skills often include a view that is a missing link in physical medicine.  This missing link is a step in the process that can drasticly save time and money.  This step can detect problems that cannot be detected with imaging studies, orthopedic tests and nerve conduction studies.   This step is frequently missed and often undervalued.

A skilled manual therapist has an assessment or diagnostic model that considers the complexities of the nervous system and the biomechanics of the musculoskeletal system.  They can detect with their hands tissue movement that is blocked by adhesion or fibrosis (scarring).  They can complete the step by restoring tissue motion that is central to a cycle of pain or dysfunction.  The clearing of this step can either solve the problem or clear a hurdle that is preventing another provider from advancing the progress of a case.  This restoration of tissue mobility can often happen very quickly, within minutes.

The expertise of the manual therapist is to detect and treat soft tissue problems that do not change with conventional stretching, strengthening or medicinal protocols.  The assessment is straightforward.  The therapist is determining with assessment and diagnostics whether the tissue has restriction or not. This question is often ignored and is often the missing step in providing the patient with the answers they seek.  Quality manual therapy can reduce this “stuck” tissue often within minutes or within a few visits.  I believe that a patient should always be provided with the best tools that are appropriate at the right time.

The question needs to be asked when presented with a painful condition.  Is this problem associated with mechanical restrictions in the moving parts?  Is there adhesion or scarring that you’re unaware of?  I’m not saying adhesion is the answer but a question that needs to be on the list.   It’s my experience that approximately seventy five percent of musculoskeletal pain can be reduced or eliminated with thoughtful and targeted treatment of “stuck” tissue.

It’s difficult to decide what to do when something hurts.  I have a vision that eventually,  as the science of soft tissue continues to evolve, manual therapists will become valued as a step in the diagnostic evaluation of those painful conditions that often evade conventional medicine.

The question for now is , what’s the best choice in addressing pain that won’t go away?  I feel that the best choice is to find a provider that seems to be asking good questions and answers your most important questions.  What is wrong? What can be done about it?  What can I do to prevent this from happening again?  Don’t forget the question that is missed the most.  Is this “stuck” tissue?



The Music of Movement

I have been a musician since I was introduced to a musical instrument way back in 6th grade.  Of course, I’m drawn to the analogy of music to movement.  All musicians know that learning an instrument takes persistence, repetition, strength and the ability to listen.  Take guitar for example. The more disciplined the practice and the cleaner technique results in a clean tone.

I see movement as a symphony.  This is well illustrated by the beauty of professional dancers or the powerful grace of gymnasts.  These athletes exemplify powerful stability and elegant mobility.  A swimmers flip-turn, an overhead squat, a turkish getup, and a dismount from the gymnast’s beam are movements are magnificent when symphony is masterfully conducted and the instruments in tune.

We all know that we can’t just pickup a guitar for the first time and shred a blues solo or pick up an Olympic bar and expect to squat our own body weight.  We earn those triumphs.  To play the music means we must first learn the instrument.  We must first learn how to move and learn what movements are available to our body.  Learning the instrument means listening to the notes as their being played.

I see movement patterns such as upper and lower body rolling, dead bugs, toe touches, bird dogs and half kneel chops and lifts as the “Mary Had A Little Lamb” fundamentals of movement.  If we cannot play a three-note song than why are we trying to play “Free Bird”.   If you want to overhead squat maybe you should be able to hip hinge and deadlift a kettlebell correctly first.  Or better yet hip hinge in a quadraped position.  Rushing to hurry up and play the instrument doesn’t usually make for good music.

And yes, sometimes the notes go out of tune.  In that case get the shoulder, knee or hip checked out if it doesn’t sound right.  It’s hard to play decent music on a broken instrument.  All instruments eventually require the time with the instrument tech or Luther.

You have fitness goals.  Take your time.  It’s worth the effort to own fundamental movement.  Learn to play the three-note song before the Beethoven’s 5th symphony. You want a long life of fitness.  Don’t just learn how to lift.   Don’t just learn how to run.  Learn how to move.  Make the music of movement.

A Golfer’s Elbow Diagnosis

There are many reasons for wrist pain.  These cases are common to most health care providers and often fall through cracks.   Ulnar nerve entrapment is effectively detected with a manual soft tissue specialization like Active Release Techniques.  X-Rays, or MRI’s and nerve conduction studies don’t reveal the nature of the problem.  Finding the site where the ulnar nerve does not move freely relative to it’s surrounding tissue requires a therapist to feel the movement.   You cannot treat want you can’t feel and you cannot feel what you don’t understand.  You cannot understand without a logical sequence of assessment.

A 42-year-old heavy equipment operator reports chronic elbow and wrist pain.  The onset of pain began after long hours working on a new machine that had a new layout of the hand controls.  He has been dealing with this issue for approximately three months.  He sought an orthopedic and medical evaluation for the condition.  A golfer’s elbow diagnosis was made and several weeks of physical therapy and an elbow strap was recommended to alleviate symptoms.

Where does it hurt?
He draws his finger along the ulnar side of his proximal elbow and wrist.

Do any motions make it worse or better?
He identifies that it is uncomfortable for him to straighten his arm.

Do you every have any type of numbness, if so where?
He indicates that his 3rd and 4th fingers is currently numb which is worsened with leaning on a chair armrest

Benchmarks Identified for Treatment
Immediate reduction in symptoms of numbness.
Decrease in symptom onset with leaning on armrest of a chair.

The Checklist

  • Palpation of passive qualities of elbow extension, flexion pronation and supination.
  • Palpation f passive qualities of wrist, extension, flexion, pronation and supination.
  • Observation of active qualities such as grip in elbow flexion and extension, pronation and supination.

Palpation of relative motion of tissue.  Noted restricted relative motion of multiple structures including medial septum, brachialis, tricep, fcu, pronator teres, pronator quadratus.  Multiple sites of ulnar nerve entrapment most distinctive at the pronator quadratus and distal FCU.

The Treatment
Protocols to decrease tissue texture and tension consistent with adhesion to restore tissue relative motion.

Ulnar long tract protocols at the site of restricted relative motion of soft tissues.

Treatment Results

Immediate reduction in symptoms of numbness.
10 minutes after treatment fingers were no longer numb.

Next Visit

  • Expect report in follow-up visit on the benchmark of leaning on a chair armrest.
  • Reassess