Archive for August, 2012

A good history will give you 90% of your diagnosis

We have all heard it, along with some others:

Ask the right questions and the patient will tell you what is wrong with them

This is what is taught in every school. Whether you are practicing medicine, chiropractic, or just practicing being cool, it is ingrained in us that the history is key to our diagnosis and treatment.

**Understand what I am about to say is considered a perfect world scenario where my fellow practitioners who practice manual medicine can rule out serious pathology that should not be in our office (cancer, heart ailment, etc.) This is obviously the reason why we need to always take a good history and Review of Systems.**

My opinion: I think history taking actually makes us worse. It clouds our view of what is truly going on. In fact, it’s a bad habit that you just can’t kick. As much as you really want to just forget about it, it simply won’t go away. And I am confident that I’m not the only one guilty of this.

When we begin to work up a patient, it is very hard to ignore the site of pain and actually go for dysfunction. As health practitioners, it is a huge leap of faith to focus only on dysfunction because we all know that the person standing in front of you has come with pain in a specific region and expects that specific region to get treatment.

Typically, I know the mind game goes a bit like this,

Good Justin:The left ankle has no dorsiflexion. Go after that dysfunction!

Bad Justin: The person came in with back pain. Just massage and adjust the low back. You know it will work!

Just like this

So what does this all mean?

I think in the end, we must find a balance. While assessing the patient for movement dysfunction, you truly may need to play dumb. By dumb, I mean you must forget why the patient is standing in front of you. For that time, literally forget the person had pain and take a clear picture of the dysfunction. Do not be tempted at all to go back to that painful site simply because that person has an ‘ouchie.’

Once that is all figured out, you certainly have every right to go back and treat the painful site with whatever magic trick is in your bag. First though, do yourself a favor. After exercising the dysfunction and before treating the site of pain, re-test everything. You may be pleasantly surprised to find  the painful site is not as painful without ever directly working on it.

Any of this sound familiar?

If you answered yes, then you are probably familiar with the SFMA (Selective Functional Movement Assessment). And, while I have not been formally trained in this yet (I will be taking it this October), it is a system my boss has taught me and one that we use everyday, with every single patient that walks into our clinic.

Using this classification system (DN: Dysfunctional Non-Painful, DP: Dysfunctional Painful, FP: Functional Painful, FN: Functional Non-Painful) I believe this puts a method to the madness. If nothing else, it helps organize thoughts and document findings.

Obviously, there is much more to it than that, and clinicians who are much more advanced with the system than I, who could do a much better job explaining the intricacies of the system.

Above all else, recognize what the patient tells you (history), rule out anything that should be sent out, and then forget everything they said. Find dysfunction. Treat pain if needed.


The Home Exercise Conundrum

Posted: August 24, 2012 in Uncategorized

Right now, I am fortunate enough to work with people who actually WANT to get better. I think being in school, people try to scare you, always talking about those patients who are trying to pull a fast one on an insurance company or possibly to get a few more weeks out of work. I can honestly say I have yet to encounter that. Not saying it won’t happen, just saying I haven’t experienced it yet.

Anyway, one of the absolutely fantastic things about working with people who want to get better so they can either get on with their lives, function better, or perform better is that they are always asking,

What can I do on my own to get better?

This is like music to my ears. Patients taking an active role in their own care I think, is the ultimate.

Music to (in) her ears

However, I have encountered a problem with this.

Let me explain:

In the office, my goal is always to find that perfect exercise which will really make an immediate change within the patient. However, in those instances where I do find that perfect exercise, I’m often finding that the patient simply does not have the equipment or capability to do it on their own. This all brings me back to my first point: What can they do at home?

Fortunately, the office I am in is equipped with a full array of gym equipment. Really, anything you want. And just as an example, one of my favorite exercises to engage the hip hinge and glute firing pattern has been the pull through, which I talked about in detail here. Often times, people with low back pain can get a 50-60% reduction just by utilizing a loaded hip hinge. These same people first look at you like you have 3 heads because they don’t get how back pain goes away without touching the back. Then, they ask what can I do at home?

And here is where the problem is. Most patients do not have access to either super heavy bands, heavy kettlebells, or any other implement that will allow for the same “training effect” as they get in the office. In a perfect world, loaded hip hinging would be their home exercise. However, this isn’t a perfect world and something I’m still trying to figure out.

Unfortunately for you, I don’t have the answer to this conundrum just yet. This was simply me thinking out loud and presenting an issue I have run into so far.

Again, there are far worse problems to have than patients who actually want to do home care.

Now it’s just a matter of optimizing what they can do in the office AND at home.

Most of you are probably familiar with the Joint by Joint approach coined by Mike Boyle.

In a nutshell, our bodies are essentially a stack of joints that alternate in the type of motion they crave. The foot wants stability, ankle wants mobility, knee wants stability, and on up the chain.

Using this approach, we arrive at the scapulo-thoracic joint. According to Coach Boyle’s theory, the scapulo-thoracic joint craves stability, and most rehab and training professionals write programs accordingly.

Here are a few common exercises used to create this stability:

Ok, maybe not the second one. But seriously, if I ever hired a trainer, she would be it! Honestly, how can you not smile when watching this?

I digress…

I had the pleasure of sitting in on a FMS Combo course this weekend and was fortunate to be grouped with a bunch of brilliant personal trainers and strength coaches. During one of the breaks I asked what they do while training a client who needs scapular stability (basically every person on earth) yet has no idea that their scapula actually has the ability to protract and retract. I guess similar to glut amnesia, we can call this scapular amnesia.

My thought was (is) basically that I’m not sure these people have earned the right to have scapular stability training. I tend to think they should first learn how to move their scapulae into protraction and retraction properly and then proceed to lock it in with stability.

Gray Cook always says mobility before stability yet I’m not sure he had this in mind. I’m also not sure it doesn’t apply here.

Any type of manual therapist will make a good chunk of their living treating neck pain. And, I think the people reading this blog generally understand that simply rubbing the neck won’t always make it better. The company line is,

A neck problem is never just a neck problem. A tight hamstring is never just a tight hamstring

My point is, we have established that treating only the site of pain certainly is not the answer. But, I believe the next step in the process is now figuring out what needs to be stabilized and what needs to be mobilized. A better way I’ve heard it described: does it need duct tape or WD-40?

So really, it’s just a question I guess: Does a joint that craves stability, in fact need to first learn proper mobility?

In case anyone missed it, here is the post I recently wrote  for my buddy Todd Bumgardner’s site.

With the Olympics just finishing, my post talks about how world-class athletes sometimes can be more dysfunctional than one might think.

Check it out!

World Class Athletes: What Have They Mastered?

They say a picture is worth 1,000 words.

What about a video?

In this case, I would venture to guess much more than just 1,000.

Last week, I was vacationing at the Jersey shore with my family. It just so happened that this was the weekend of the Triathlon/Duathlon for Autism which was literally going on across the street from our condo.

To be honest, not much more than that needs to be said.

Below is a video I shot while sitting on the boardwalk watching the athletes compete. Specifically, this is the final 100 yards to the finish line.