Improving Physical Therapy Practice: One Patient’s View

After 6 years of treatment that included 4 failed courses of physical therapy for chronic neck pain, and 2 failed courses for frozen shoulder and rotator cuff tears in both shoulders, I discovered that my neck and shoulder pain had one root cause — the many years of poor posture, especially the slouched upper body posture that led to weak back muscles and shoulder blade instability.  Correction of lower body posture was also needed, since it is the lordotic/inward curve of the lower back that positions the upper body squarely over the hips and allows for stable, erect, well-aligned posture.  (Other primates like chimpanzees don’t have a lumbar lordotic curve, but have a long kyphotic curve of the entire spine; mostly they knuckle-walk with hunched-over upper body.)

The degree of lumbar lordosis is determined by the tilt of the pelvis.  The tilt of the pelvis depends on the action and balance of 4 groups of muscles: hip extensors, hip flexors, anterior abdominals and low back extensors. Ultimately neck alignment depends on the state/balance of muscles in the lower torso and legs.

Physical therapy for musculo-skeletal neck and shoulder pain should include correction of both upper and lower body posture. Initially that may take more time but treating musculo-skeletal problems piecemeal and having to repeat physical therapy later for the same problem or a different problem that stems from the same root cause is absolutely a waste of time, money (the patient’s, the insurance company’s and/or the taxpayer’s) and the waste of one of the few opportunities a patient has to receive intensive, personalized, one-on-one help from a qualified professional.

[The following applies to chronic musculo-skeletal problems but acute injuries can lead to chronic problems if not resolved effectively or perhaps poor posture alignment might have predisposed to the injury in the first place. Addressing some of the same issues may help.]

Physical Therapy should be more than a spa experience and more than a patient robotically doing a long list of exercises without knowing the specific purpose for each and how to monitor his or her own progress.  Patients need to know what the problem is, how it developed and what exactly needs to be done to fix it.

Such a conversation/instruction might include:
— an explanation of the problem’s root causes, whether postural such as forward head, or muscle imbalance such as tight outer thigh muscles and weak inner thigh muscles, and how it is (or probably is) causing the symptoms and/or pain;
— which muscles are too long or too weak and need to be strengthened, and which ones are too short or too strong and need to be stretched;
— the best exercises to correct that imbalance.  And these should not be a long list of exercises because more than likely there won’t be enough time for the patient to perform them as slowly or with as much concentration as is required to really make a difference.

In order to assign fewer but more precisely targeted exercises, the testing and initial evaluation are of utmost importance. (A classic reference such as Muscles, Testing and Function with Posture and Pain,  5th edition, by Kendall et al is invaluable for determining muscle strength, weakness, and length, and any joint misalignment. )  After progress has been made and pain is less, perhaps more exercises may be assigned to provide a routine that takes into account the patient’s occupation and life style (e.g. an office-worker at a desk 8 hours a day needs a different plan than a gardener) so that the patient’s particular misalignment/muscle imbalance doesn’t return.

— And if relevant, a discussion with the patient about changes to the ergonomics of his or her work situation. Sometimes people don’t realize there’s a better way to sit, bend, lift, work at the computer or text message.  Practicing a better way helps to instill that change.

When introducing an exercise, the therapist should instruct the patient what to notice/look for when doing that exercise, and how it feels to activate or stretch those specific muscles and how slow and how far to go; To this end, the use of pictures or diagrams of the body and the specific joints and muscles involved, along with a mirror set-up for the patient to see their own body in action is very important.  In this way the patient can visualize the muscles, joints and bones as his body is doing the exercise.  Studies using functional MRIs of the brain have shown that when a person visualizes a body action, the same area of the brain is activated as when the movement is actually performed. Combining visualization and actual performance might speed improvement, and in my experience the two together make all the difference.

The exercise that helped me overcome my chronic neck pain, the “fix the shoulder blades” exercise, I’d  learned and done in physical therapy for rotator cuff tears along with a bunch of other exercises. At that time, over 6 months prior, it hadn’t helped my shoulders much or my neck pain  (though it was for the shoulders not the neck, but the root causes of both problems — weak upper back muscles and hunched posture — were the same). But later when I did the exercise using a mirror set-up so I could see my back and the muscles around the shoulder blades during the exercise, and could concentrate on the muscles to make them contract harder, that made all the difference. Nothing in my experience of 6 courses of physical therapy for neck and shoulder came close to the way I worked those shoulder blades.

But getting back to the “should’s” of patient exercises (sorry to sound so authoritarian but I want to be more direct.)

After introducing the exercise, the therapist must follow through by carefully monitoring the patient for correct form, effort and time taken during the assigned exercises. (Assistants are not always helpful on this.) Ways for the patient to monitor their own progress should be devised; an example is the mirror set-up for the Fix the Shoulder Blade exercise; another is self-observation of the alignment of a body part that can be seen easily, such as the knee cap. When I had physical therapy for knee pain (PT course # 7), the physical therapist showed me that my knee caps had drifted off center. He didn’t use technical terms but explained to me why I needed to strengthen my inner thigh muscles and stretch the outer thigh muscles to recenter my knee caps. I could visualize this fix, and knew best where to focus my effort. I also knew what my knee caps would look like when I’d succeeded.  Another example is for tight quadriceps. Patients can self-test how effective their quad stretches are, by lying supine,  and pressing their lower backs to the mat/floor while tightening  their abdominals. Then they observe how much their knees have to bend to accomplish that.  The less their knees need to bend, the looser their quads.

The therapist should make sure that the root causes of the problem are being addressed. If chronic musculo-skeletal pain is involved, it may be complicated by poor posture alignment  stemming  from long-standing habit,  a secondary consequence of an acute injury, or the weakening effects of chronic illness.  Many acute injuries resolve in a timely manner; but if the patient has poor posture, acute injuries may take much longer to resolve, if ever, and become a chronic pain problem, unless poor posture is addressed and improved.  

One other roadblock to recovery from an acute injury such as a whiplash injury is the patient’s coping style. A person who tends to be anxious /emotionally over-reactive/ruminates or agonizes over what they may lose due to the injury if they don’t recover or other stuff may delay their own recovery.  Any time a threat is called into mind by rehashing memories related to the injury  or perceiving a return of pain, or the belief that pain will be worsened by a certain physical activities that will activate the “fight or flight” sympathetic nervous system and cause tightening of the muscles that will lead to worsening the spasm and pain.

Treat the whole patient, not just the symptoms, and teach patients what they need to know so the problem is less likely to return.  Patient empowerment through knowledge will improve their treatment and your practice.

And before I forget, a therapist should not assume that the information in a patient’s radiology report or an image in an MRI or CT scan dooms  therapy to failure; or use that information as an excuse when therapy does fail. And just because most of a therapist’s neck patients don’t get better doesn’t mean it’s because of arthritic changes or something else beyond the therapist’s control. (plenty of people with significant degenerative spine changes don’t have chronic pain. I’m one of those.) Maybe it’s what the therapist is NOT doing.

My first PT in particular, the spine specialist at a large PT practice, and the only one (of four) that I brought my MRIs too, was dismissive when I told her that I still had neck pain doing the exercises. She said it was to be expected with my degree of spinal arthritis, and gave me the phone number of the “best” spine surgeon in the city. Sometimes I imagine running into her at the grocery store and saying “Look at me now, 8 (or so) years later and I can do whatever I want, with no neck pain and no surgery. What use are your fancy spine mobilization techniques and all the weekend continuing education classes, when in the end they weren’t effective at all?

 

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