Sunday 22 July 2018

What I'm Doing Differently In My Third Year Out Of Physiotherapy School - Part 1

On a rainy summer day by Elborn College - the building where I spent the bulk of my two years in physiotherapy school.

August 28, 2018 marks the 3rd anniversary of my last day of physiotherapy school. This time last year I wrote a series where I discussed several changes I’ve made in my own practice. In this article I will share some of the things I’ve been doing differently since that time period.

1) Doing more neck strengthening instead of stretching

The traditional, stereotypical PT approach to neck pain rehab consists of a lot of stretching, soft tissue work, and needling of the upper traps, levator scapulae, scalenes and/or SCM muscles. For whatever reason, and maybe it’s just me, this approach never worked well for me or my clients with neck pain and just left a lot of people feeling sore.

By contrast – I’ve gotten much more out of isometric neck exercises (sets of 7-10 second holds within a tolerable level of force) and dynamic shoulder strengthening exercises such as front/side/rear raises, rows, shrugs and shoulder presses (based on the patient’s activity tolerance and physical capabilities). This approach is (in my opinion) better tolerated by my clients.

Side note: this isn’t to say I don’t do any stretching or soft tissue work in people with neck pain as I do see an anecdotal benefit in certain populations (ie radiculopathies) but many people I work with tend to  not enjoy being stretched and are limited more by pain before their neck movements even encounter resistance.

 Image courtesy Focus Fitness

2) Doing less more often in people with persistent pain

Working with persistent pain can be a challenge in terms of exercise prescription as it may be entirely possible that every movement/activity hurts and they can be easy to flare up. It leaves us in a bit of a conundrum as we want to be able to improve/maintain our clients mobility & fitness but we also don’t want to flare them up.

A solution I found came from a podcast I listened to with Greg Lehman last year where he suggested “doing less more often” with people with fibromyalgia and other chronic pain conditions. For example – I would prescribe a set of 3-10 of 1-2 exercises (depending on the client’s goals, limitations, level of irritability, and whether they are having a “good” or “bad” day) to be done repeatedly through the day.

I found this approach helped my clients immensely with maintaining (or even improving) mobility & fitness while minimizing the chances of flaring up.

3) Referring out (or at least backing off) if I’m not the right person to treat someone’s pain

This may seem like common sense physio. If someone has
-          Red Flags: ie tumor, infection, cauda equina syndrome and/or
-          Major orthopedic issues requiring surgery: ie fracture; dislocation; progressive neurological deficit; ligament/meniscus tear creating locking, instability, and/or giving out;
…. Then you need to refer out

I’m not talking about those in particular. I’m talking about cases where, quite frankly, physio just may not be the most valuable use of a client’s time and resources even in the absence of the above issues.

I’ve seen a fair amount of clients this past year with significant levels of pain and disability that were linked to significant psychosocial factors such as job stresses or even deaths/family illnesses. These clients would even tell me that as their stressors went up, so did their pain. After a couple of these cases I realized that, while physio can still have a benefit for maintaining/improving mobility & physical function, that the drivers of their pain were likely beyond my skillset and required counselling or psychotherapy to deal with these issues.

Over the past year I’ve also had patients referred to me for conditions that were clearly medical in nature – such as polymyalgia rheumatica. Again, while we can help with mobility in function, most of the treatment for conditions like PMR is medical in nature.

I’ve ranted before about how I don’t like personal trainers & strength coaches trying to be half-assed PTs but at the same time I don’t believe a rehab professional should try to be a half-ass psychiatrist or doctor. That’s where we need to realize our limitations and refer out to other professionals.

Side note: this isn’t to say that I completely stopped treating them – but we both came to a consensus that other resources were needed.

4) Bubble diagrams for pain science

Quite often I find patients want to know “what causes this?” That’s a great gateway to get into some pain science education. But instead of bombarding people with a bunch of neuroscience – I take the time to do a bubble diagram (similar to Peter O’Sullivan) to show all the different factors that can be involved with a patient’s pain including (where applicable)…
-          Tissue changes
-          Too much (or too little) activity
-          General health factors (i.e. body weight, smoking, poor sleep)
-          Psychosocial factors and maladaptive behaviours

This is a great way to get some practical, applicable information about pain out to the patient without bombarding them with info.

5) Giving patients exercise set/rep ranges

This follows in from Point #3 – I like the idea of giving patients set/rep ranges for exercises so they can adjust if they’re having a good day or bad day. I find this useful for people with persistent pain (or any fluctuating pain) and/or for “borderline” cases where you’re not 100% confident about how far you can push them.

That’s the end of Part 1 of this article. Tune back in a few weeks where I discuss four more changes I’ve made.

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