Education and Exercises – The Cornerstone of Physical Therapy

“If your therapist only does a ‘treatment’ to you and misses out the ‘get it moving/ rehab/ graded recovery / functional recovery process – then its my opinion that your therapist is a complete waste of time”

Louis Gifford
Aches and Pains P.159

In his article Chiropractic and Osteopathy – How do they work?, respected physiotherapist from UK, Adam Meakins wrote:

The lines between physiotherapy, chiropractic and osteopathy have become blurred. As physiotherapists we should be giving only education and exercise-based advice. We believe in self-management, giving patients ownership to get themselves better and not looking for repeat business.

Indeed, the past few years we have seen the crossover of practices among many different rehabilitation specialists. While I don’t have anything against chiropractors or osteopaths, there has got to be distinguishing line somewhere. Good thing, there is… Physical therapists are well known in constantly educating their patients and keeping them actively part in the rehabilitation process instead of just keeping them passive, with the practitioner doing all the work.

Education.

A good physical rehabilitation practitioner must be able to educate their clients/patients properly. Education starts with discussing the underlying condition as accurately as possible. What and where is the problem? Why does the problem exist? Many times patients come to physical therapy to have assurance that there is nothing particularly a major problem with their [insert musculoskeletal problem here]… In the discussion, it is important that the clinician uses non-threatening words to make sure that what we tell our  patients won’t cause a nocebo effect. Nocebo is a detrimental effect on health or symptoms produced by psychological or pyschosomatic factors. In rehabilitation medicine, these factors involve mainly the words that we use when discussing with patients their conditions.

nocebo

“A massive fear inducing nocebo” – Ben Cormack, Physiotherapist

Nocebo effect is particularly common in pain management. Even well trained clinicians use inappropriate words that cause more harm than help to pain patients. Sometimes, these inappropriate words are used intentionally to encourage the patient to to sign up for long term treatments. This happens when the patient is made to believe that some things are wrong with their body and they need a regular or at least a long term, repeated fix. Examples of these are: spinal vertebrae being out of place that need some long term adjustments, some muscular imbalances that need repeated correcting, core muscles being weak causing recurring low back pain… the list could go on! [More about this in future blog, but there already numerous articles regarding these issues].

But what is so threatening with these words? In their article, The Nocebo Effect: How Your Power of Suggestion May Harm Your Clients, Matt Danzinger, a personal trainer and Jonathan Fass, an orthopedic physical therapist wrote:

Words like “fat, scrawny, or weak” are words that harm. Words like “damaged” or “broken,” phrases such as “you’re going to be injured,” or “you don’t move right” can destroy what you are trying to build.

Telling a patient they have degenerating discs, bad posture, displaced sacrum, etc. can be perceived as threat by the brain. And when the brain perceives a threat, real or imagined, pain is produced. Imagine if everyday our patients believe that their posture is bad, they have a bulging disc, their knees are degenerating. How would the brain react to these catastrophic thoughts? We know now that pain and tissue damage are not always correlated. Unfortunately, pathologizing posture and movements is very common and rampant in musculoskeletal medicine resulting in fear-avoidance behavior and catastrophic thinking. I’m not saying that discs or joint degenerations are not real, just not causative factors of many recurring or chronic pain conditions. [Again, this topic needs a totally separate article].

In other words, educating patients regarding their condition is essential part of physical therapy practice. But more important still is to say the right words that are more helpful than harmful.

Exercises.

Prescribing appropriate rehabilitative and therapeutic exercises is one of the most important parts of a real physical therapy program. It is prescribed both in the clinic and as part of patient’s daily home program. Very often, they are prescribed as graded movement exposure wherein the exercises prescribed depend on the patient’s capacity and tolerance at the time of treatment. These exercises are also specific to the patient’s underlying problem – acute injury, non-specific pain, or presence of pathological condition.

While other specialists may administer mainly passive treatment to “fix” the client’s problem/s, physical therapists make use of the therapeutic effects of exercises to relieve pain, increase range of motion, strengthen muscles and improve movement. That’s right, graded movement exposure can actually help relieve pain. So no need to avoid movement altogether. Furthermore, exercises can promote tissue repair after tissue injury, or surgical repair of damaged tissues in the musculoskeletal system through a mechanism termed as mechanotherapy.

I am not in anyway saying that these so called passive treatments like heat, ultrasound, massages, manipulations, joint and soft tissue mobilizations, even kinesio taping have no place in physical therapy. Although evidences of the therapeutic effects of these modalities are weak at best, they can be in some cases they can be helpful. [Ok, so more and more orthopedic physical therapists are discarding their ultrasound machine, and for good reason]. I do spend a great deal of time doing hands-on therapy on my clients or patients prior to giving exercises. They can produce neurophysiological changes in the tissues to make movement drills easier and tolerable. For example, soft tissue work and joint mobilizations can help decrease pain, decrease muscle guarding, and increase range of movements. Exercises are then carried out to help maintain these improvements though activating the nervous system. That is why a good home exercise program, and adherence to these exercises are essential in the over all success of a physical therapy program.

So the next time your physiotherapist gives you only passive treatment without giving you exercises to do in the clinic and to do at home, you are hereby advised that you find another therapist.

gangnam

 

 

References:

A meta-analytic review of the hypoalgesic effects of exercise. Kelly M. Naugle, Roger B. Fillingim and Joseph L. Riley. 2012

Exercise as medicine – evidence for prescribing exercises as therapy in 26 different chronic diseases. B.K. Pedersen and B. Saltin. 2015

Mechanotherapy: how physical therapists’ prescription of exercises promotes tissue healing. K.M. Khan, A. Scott. 2009

Further Readings:

Placebo and nocebo effects in the neurological practice.

 

 

Physical Therapy Approach to Pain and Injury Rehabilitation

When I write “Physical therapy approach to pain and injury rehabilitation,” I mean my personal approach in managing various musculoskeletal conditions. And my approach is mostly based on the works of Erson Religioso’s “Ecclectic Approach”, Greg Lehman’s  “Reconciling Biomechanics and Pain Science”, and some of Gray Cook’s “Functional Movement” principles. No, I don’t utilize nor promote Cook’s FMS screens. I only follow how he manages musculoskeletal problems where he starts with mobility and stability and concludes with strengthening. Following all these pattern and principles make it easier for me to treat injuries at a minimum amount of time, and with high success rate. I am not going to talk about specific techniques here but rather the flow of my treatment protocols. Specific techniques will be discussed separately some other time.

So here are the areas I work on when working on patients and clients with pain and/or injuries.

  • Pain Relief

Relief of pain would obviously be the most immediate immediate concern of most clients or patients with musculoskeletal conditions that come for physical therapy. They are in pain and as a result making them less functional and less productive. Treatment to relieve pain will depend on many factors including the stage of the underlying condition [whether acute, sub acute or chronic], the intensity and frequency of pain [constant or intermittent], accompanying symptoms, trigger factors, patient’s general lifestyle among many others. So generally I start my treatment with pain science education. Pain science education is winning half the battle in treating patients with musculoskeletal pain. It helps clients understand how pain works, how the treatments I do can help, and lessen their anxiety and fear avoidance.

no-pain

Next I do some manual techniques. Touch in itself has calming effects. It can decrease soft tissue tone and relieve spasm. It can stimulate mechanoreceptors in the skin and underlying tissues [nerve, fascia, muscles] that bring about neurophysiological changes in the brain that help desensitize the painful area. [Please note that I did not say release fascia, loosen scars, or break myofascial nodules and any therapist who tells you that has not evolved with the new evidences yet or tricking you with the skills they thought they have].

But pain can be tricky. Much of the pain we experience is an output from the brain and thus there are times the site of pain is not always the site in question. And so adjoining joints and tissues are also checked for any pathology, dysfunction or restrictions. Painful neck, check the shoulders. Painful back, check the thoracic or the hips, painful knee check the hips and ankles… The manual techniques I use depend on the problems I find in the assessments. And they are pretty simple. There are many manual therapy techniques out there that are unnecessary and only help the therapist look cool and seemingly more qualified.

  • Improving Mobility
ankle mobility exercise

Ankle Mobility Exercise

Pain and mobility are usually correlated. In the presence of pain, range of motion is decreased sometimes just owing to the fact that the person in pain will tend to guard the joint, to protect it from triggering more pain, or to avoid causing more harm. When pain is decreased, muscle guarding is decreased and joint range of motion is improved.

But mobility is not just about joint range of motion. In fact in many cases, textbook range of motion in some joints are not necessary for functional activities. The point of mobility drills is not how far you can go but how easily and smoothly you move. Movement patterns and joint proprioception are altered in the presence of pain or injury. Mobility drills have something to do with sending sensory information to the nervous system that can bring about change in movement and perception and improve joint proprioception.

  • Improving Stability

As mobility is improved, stability training comes next. Truth is, stability and movement co-exist in the human body kinetic chain. Mobility and stability are the cornerstone of movement. That is why they come first in many musculoskeletal rehabilitaion. Joint stability refers to the ability of the muscles to maintain or control joint movement or position. It’s training the  muscles and surrounding tissues of the joint to function in coordinated actions under the control of the nervous system. Just like mobility, satbility drills are neurophsyiological. Stability exercises aim to let the nervous system have the musculoskeletal units move in coordinated fashion producing efficient and smooth movements.

core - bird dog

Bird-dog Exercise for Trunk and Lower Back Stability

  • Improving Movement

Efficient movement is constant balance between mobility. After basic mobility and stability training, more dynamic, functional movements are introduced. Speed is increased as needed, and directions are varied. While I introduce mobility and stability initially in single planes, transverse planes and diagonal movement patterns are added.

Walking Lunge with Twist as Movement Retraining

Walking Lunge with Twist as Movement Retraining

Movement retraining follows functional movements, and are modified depending on the person’s daily, recreational and sporting activities. Movement retraining will help break the abnormal movement pattern the injured person has developed as a result of pain, muscle guarding and fear avoidance.

  • Strength and Conditioning

Injury and pain does not only affect mobility, motor control and movement but also strength and endurance and thus affect the body’s overall performance. Resistance exercises with the use of everything from body weight, to resistance bands, to free weights, to compound machines will not only strengthen and recondition the muscles, ligaments, tendons and bones but also help promote further healing.

Yes, we use weights in physical therapy!

Yes, we use weights in physical therapy!

Prof Karim Khan of the British Journal of Medicine explains in an interview podcast that exercise-based rehabilitation relies on the cells of the injured tissue sensing the exercises stimulus, converting the signal to protein synthesis, and repairing tissue. This is why rest doesn’t work.

In the event that my client would need a more vigorous strength, conditioning and functional training, I refer them to a more qualified strength and conditioning professional.

  • Return to Performance
voleyball pt meme

Do the things you love,,, pain free!

The highest goal of any kind of rehabilitation is for the injured person to get back to doing what they love – whether it’s running, or dancing, or sporting activities, or playing with the children. In some cases I go and supervise my clients start their sporting program again. I have had a client who’s been indoor rock climbing for five years. He’s had medial epicondylitis [yes, it’s acute] and pain around muscle guarding. After few sessions with him, I joined him at the indoor rock climbing site as he attempted to start climbing again. I’ve done the same thing with my client who is a professional contemporary dancer.

Don’t let pain and injury stop you… Physical therapy can help in more ways that you realize. A good physical therapist can help you in every step of the way – from your recovery to return to performance.

Keeping Up With The “Trends” in Physical Therapy Treatment

hot not


Trends can be a good thing or bad thing. It’s a good thing if we define trend as an update or upgrade. Old things are abandoned as new paradigm shift is welcomed. In science, it means that new studies present a more scientific fact nullifying those that have been previously believed and taught. Or trend can be a bad thing when it is described as fashion or fad. Here today, gone tomorrow because they don’t have scientific studies to back them up. In physical therapy, there had been numerous techniques once used and now being abandoned. That’s fine too. Which medical science does not evolve and advance, and still use same method of diagnosis or treatment for decades?

I am happy to be in the bandwagon in this journey of new trends in my profession. Some therapists just want to stick to what they are used to in their practice but I am not some therapists. I refuse to be left behind. Thanks to all of those practitioners who constantly push researches and studies so that physical therapy and physical rehabilitation practices will truly be evidence based and treatments based on psuedosciences be contained or minimized. Thanks to clinicians and researchers who are bold enough to call out and challenge the charlatans who provide training and products with unproven effectiveness as a way of monetizing the practice.

I am forever grateful to everyone who keep supplying oceans of new information to the community of PTs around the globe through facebook, twitter, and online forums. Not only from physical therapists but also from related professions like atheltic trainers, strength and conditioning coaches and massage therapists.  There’s always going to be arguments from different groups with different paradigms in the practice, Overtime, as I read discussions and sometimes join in these discussions, I have learned which side to choose. Yes, sad to say, there have been some inevitable divisions among physical therapists. But of course, we can all disagree with respect! Everybody is entitled to voice their opinions. At the end of the day, science wins by landslide.

So, over the years of following various clinicians and researchers, balancing the views of each one, I have come to embrace these trends in the practice, which form much of how I work on my clients and patients now – from assessment to explaining the what, why and how of my interventions.

1. Manual Therapy

Now, manual therapy is really not a new thing. It has been around for quite a while. Many manual therapy techniques are shared by a number of rehab professionals which includes osteopaths, chiropractors, physical therapists and massage therapists. Since manual therapy is simply the use of the therapist’s hands in treating various musculoskeletal conditions like soft tissue pain and injury, many have used these hand techniques in so many ways, some good and some plain ridiculous. I am not the one to point out which ones I think are unscientific but you can read some of them here!. Also, many manual therapists have given big claims on how can manual therapy works wonders, in which no substantial study to back them up. Stuffs like releases fascia, corrects malalignment, boost the immune system, among many others. How one can break up scar tissues and fascia when a surgeon needs to use an scalpel to do so?

I can say that if there’s anything new with manual therapy is it’s how we understand how it works. Manual therapy does not deform fascia, put back an out of place sacro-iliac, or release trigger points. Most of the effects of manual therapy are neural not mechanical or structural. We cannot mechanically deform fascia with hand forces but instead we stimulate skin mechanoreceptors which sends signal to the brain to allow a tensed muscle or soft tissue to “relax”. Most of the time it’s not the techniques that are flawed but how the mechanism of the techniques is explained [i.e., based on purely biomechanical models].

myofascial release

Also,  manual therapy has been made a panacea in MSK [musculoskeletal] physical therapy by many practitioners. But manual therapy is really just a means to an end. Manual therapy as a tretment is mostly passive and thus can make the patient dependent on the therapist all the time. That is why many manual therapists in other disciplines like chiropratic can keep their patients/clients for years or even a lifetime. I also know some physios who became osteopaths who tell me that they don’t prescribe exercises anymore. But the goal of pain and injury rehabilitation is to make the patient/client functionally independent and be able to mange their symptoms. That is why I don’t stop with manual therapy in treating my patients. I use manual techniques to address symptoms of pain, stiffness and limited joint motion, after which I proceed to what physical therapists are known for – movement!

Here’s an excellent article by Greg Lehman on fascial treatment fallacy.

2. Functional Movement Therapy

Physical therapy is the engineering of human body.

Physical therapy is the engineering of the human body.

Like I mentioned, manual therapy is not main intervention in many physical therapy treatment. Movement is. The goal in injury rehabilitation is not only to relieve pain but to improve movement. Injury, if not managed by movement therapy will impose risks of re-injury. Pain might be relieved but the abnormal movement patterns adapted thru the presence of pain or injury are not addressed. Thus, slight deviation in future tasks may trigger central sensitization causing pain to recur. Also injury not rehabbed properly has a higher change of re-injury. Proper rehabilitation cannot be done with manual therapy alone.

Movement, like manual therapy, is not a new thing. In fact it is as old as the physio profession itself. Physical therapy by definition, is all about movement. Just that movement had just got the attention it deserves in the recent past. Movement goes beyond prescription of therapeutic exercises to certain conditions [i.e., 3 best exercises for back pain, neck pain, etc]. They should be functional and diverse, addressing the specific goal of the patient/client – to continue with sporting activities, to be able to get back to dancing, to be able to carry out household chores pain free… the list goes on.

My movement therapy intervention starts with graded movement exposure. This process addresses patient’s fear avoidance of movement. Much of the rationale for graded movement has something to do wit pain neuroscience, which third but possibly most important in the list.

Once the patient/client has gained more confidence in movement, more complex movement patterns are taught and prescribed as next home exercise program. Movement matrices [movements in different planes and combination of planes], increased speed of movement, movement with resistances are developed and taught. For clients who have more active lifestyle or are involved in sporting activities plyometrics may be the final phase of movement therapy

3. Pain Neuroscience

no brain no pain

Understanding pain neuroscience makes pain and injury management becomes so much simpler and easier. Instead of coming up with ridiculous and unscientific biomechanical paradigm like postural pain, muscle imbalances, spinal units called vertebrae and disc going out of place, increased anterior pelvic tilts, unequal leg lengths, and many other fear mongering biomachanical phrases which can cause more anxiety to the already suffering pain patient, explaining pain in the context of neuroscience gives a better assurance to the clients that their condition is not that bad. It may take time to “heal” but with excellent prognosis. Pain science paradigm is also cost effective as it eliminates, in most cases, the need for expensive scans and imaging like X-rays and MRI.

In a nutshell [as condensed from words by Jason Silvernail], pain neuroscience is grounded in the notion that pain is a conscious feeling that motivates protective behaviour, not a discrete biological event that occurs when tissue is truly in danger. Thus, the relationship between true danger and perceived danger is modulated by the sensitivity of our protective system. Meaning that pain and injury are more not necessaruly correlated. Understanding these things decreases perceived danger and therefore pain, and positions a biopsychosocial approach to rehabilitation as the best approach to rehabilitation.

Read this primer on pain science here.

4. Preventative Healthcare

To some, physical therapy as preventative healthcare is something new. Many still see Physios as go to professionals if someone has serous injury, physically handicapped or has neurological problems. But physical therapists, sometimes in collaboration with personal trainers and nutritionists can help in prevention of many chronic conditions like stroke, diabetes, osteoporosis, falls and fractures in the elderly, and obesity, among many others. Proper physical therapy assessment and training can also help prevent or minimize injuries in young and professional athletes, weekend warriors, performing artists and other active lifestyles.

exercise is healthcare

Exercise is medicine…

Office workers and those whose jobs require them to either sit or stand for long hours can also benefit from the services of physical therapists. Moreover, children nowadays lack physical activity as they spend more time texting and playing computer games. Physical therapists can provide education and activity prescriptions to inactive populace, either children or adults.

So these are what comprise my approach in my physical therapy practice. In the past, I have been impressed with so many techniques my colleagues teach and use. I have tried to learn some of them. I felt sorry for the things that i couldn’t afford to learn. either through lack of money or lack of availability of the training. In some classes I attended, I was even taught a watered down version of what evidence-based practice is, just so they can justify the things they teach and do which lacks solid and strong scientific evidences.

As I stay within the scope of evidenced based practice, not only my interventions have become simpler but I have been seeing higher success rate, and happier, more satisfied clients and patients.