Do I have to go the the physical therapist that my doctor told me to go to?

No.  Though the answer is simple, the pros and cons of this answer can’t be underestimated.  Legally you are allowed to go to any physical therapy clinic and see any physical therapist you want.  The prescription you get from the doctor for physical therapy may be written on one of their own prescription pads, or it may be written on a pad with a certain physical therapy clinic’s logo and contact information on it.  Most likely if this occurs the doctor recommends that you go to that clinic.  If you have never been to physical therapy before and don’t have any existing relationships with a physical therapist, you will probably go where the doctor tells you to go.  So is this a good or bad thing?

Usually this is a good thing.  I must admit, every therapist relies on relationships they have with referring practitioners to refer patients to them.  Almost always this is the primary way we get patients, through existing relationships with doctors, chiropractors, etc.  We are always looking for ways to build new relationships with other practitioners, whether it is a new doctor moving to town or connecting with them through a mutual friend.  However it may happen we are always on the lookout for new connection.

I would say that slowly however, there has been a shift in how people decide which clinic or therapist they prefer to go to.  With the internet and social media (like this blog for example), there are a variety of ways for physical therapists to get the word out to the public.  You can research a therapist, read reviews on them, find the 5 clinics closest to home, see pictures of the clinic and staff, find out who specializes in what and what the heck all those letters mean behind their names.  (Check out my old blog post for info on that)  You really have no limit on how you can research and delve into a clinic’s or therapist’s background.  As these opportunities become more available to the public the doctor’s recommendation holds a little less sway in the overall decision.

So do your homework.  If you have a certain condition your doctor will probably refer you to a therapist that specializes in that condition.  Whether or not that happens, read up on the clinics and therapists available in your area.  WIth new clinics popping up all the time there are no doubt good therapists out there that your doctor has no idea about.  Perhaps you can be the conduit to a new relationship between a therapist and your doctor, helping develop a relationship that is mutually beneficial for everyone!

Vertigo and physical therapy. An unlikely relationship.

It probably goes without saying that all of us have had an episode of dizziness at some time or another.  Maybe it was when you were sick, or when you got up from sitting too quickly.  Or perhaps it just hit you out of the blue without any reasonable explanation.  Regardless of how it happened, dizzy episodes are not fun, especially if they become a common occurrence.  Many of the causes of dizziness are treated with medication or another type of remedy recommended by your doctor.  Or perhaps you saw a specialist and they provided you with the cure for your dizzy spells.  But did you know that there are certain types of dizziness that are treatable with physical therapy?  Yep, if you are given a diagnosis of benign paroxysmal positional vertigo or BPPV, chances are a trip to a physical therapist can rid you of your dizzy spells.

A diagnosis of BPPV means that you have an issue with the fluid filled, semi-circular canals in your inner ear.  These canals are responsible for balance and our perception of acceleration and deceleration, among other things.  We have three canals in each ear.  Each canal is positioned at a different angle, enabling us to be able to perceive balance changes no matter what position we find ourselves in.  The canals are all connected at the base.  At the base there are otoliths, which I usually call (rightly or wrongly) little stones.  What BPPV means is that somehow the otoliths became dislodged from the base and are now free-floating throughout the canals.  This is what is causing your dizziness.  As long as you stay still you are fine.  But as soon as you move or turn your head the dizziness comes on because the otoliths are floating around.  Once you stop moving and the otoliths have a chance to settle your dizziness goes away.

So how can PT help with this.  After an initial evaluation the therapist will help you move your head through a series of specific movements.  These movements are designed to slowly move the otoliths through the canals and come to rest at the base.  Once this is done you need to stay as upright as possible for 2 nights.  That means no laying down flat.  Bummer huh?  But the good news is that after a few uncomfortable nights of sleeping semi-reclined your dizzy spells should be minimal to none.  Of course there are certain variables that may speed up or slow down your recovery and your therapist should be able to fill you in on the details.

So don’t despair if you have BPPV.  We can help!  So ask your doctor if he or she thinks PT would be helpful.  You never know, getting rid of your dizziness could be quicker than you think.

The alignment issue. Are your back and hips really out of alignment?

I know I’m heading into deep water over this one, but I feel it needs to be talked about.  Have you ever been told by your physical therapist that your back and/or hips are out of alignment?  And I’m not discussing this to bash on chiropractors at all.  I would say a vast majority of physical therapists deal with this issue as well, so this is squarely directed at our profession.  There are many times when your back or hips (or more specifically your pelvis) are a little off and need some TLC.  But have you ever been told this when the area isn’t bothering you?  Or have you been told this after the therapist palpates your back and determines that it’s out?  These are sticky areas that deserve some discussion.

First of all, there are some good clinical tests out there that can determine if your pelvis or vertebrae are stuck, not moving correctly, etc.  These tests involve you getting put into some funky positions and trying to provoke pain and determine mobility.  Testing such as these are pretty accurate.  What I am concerned with is when I see a therapist poke around your back or pelvis a bit, compare how a bony landmark looks on one side compared to the other and state your back is a mess without doing any other type of tests.  So why does that bother me?  Let me tell you.

The only part of your back that we can accurately palpate is the little bony tip of the vertebrae called the spinous process.  You can usually see these easily when you ask someone to bend over and touch their toes.  I’ve seen therapists palpate the spinous processes, comparing how one lines up compared to the one below it and so on.  If a spinous process doesn’t line up they declare that vertebrae to be rotated to the right or left.  The problem is that our spinous processes do not always grow straight out from the rest of the vertebrae.  Some with slightly lean right or left or even up or down.  This can be do to a variety of factors including how various muscles may pull on the vertebrae.  So sometimes the spinous process can make it look like the vertebrae is not aligned when in reality it’s in the perfect position.

Another common issue I see is palpation of the Sacroiliac joint, or SIJ.  This is where the tailbone articulates with your pelvis.  We have two SI joints and they are located near the small of your back.  Most of us have two dimples in our low back.  The SI joint is pretty close to the dimple.  There is a pretty big bony prominence that can be palpated at the SI joint.  For many years the therapist would palpate each SI joint and compare right to left to see if the bony prominences were equal.  If they weren’t it meant one or both of you SI joints was out.  Now a lot of PTs still do this and I’m not saying they aren’t doing a good job.  However, if this is the only diagnosing tool they are using then they could be missing the mark big time.  Here is what I’ve learned about the SI joint.  There are over 80 clinical tests used to diagnose a SI joint issue.  What does that mean?  It means none of them are very good.  If there was a good one out there, there wouldn’t be so many tests.  In the knee there are only a couple of tests used to diagnose an ACL tear.  There are only a couple because they are good ones, so there is no need to try to come up with another.   There is a study in which 10-13 experts in orthopedic palpation (doctors, PTs, surgeons, etc) palpated the SI joints on several patients.  They each did it independently of each other and came up with their own diagnosis.  They were all different.  There are MRI’s of people’s SI joints that show huge differences between the two, yet the subject had no SI joint or low back pain whatsoever.  What all this goes to show is that the SI joint is a tough one to get right.  Palpation alone is not very accurate.  Provocation tests (where you try to reproduce the pain) have been shown to be more reliable.  I only use provocation tests for the SI joint.  I don’t palpate the SI joints for mobility at all.  It’s not to say that they can be palpated, but if that is the only test being done I don’t know how accurate the diagnosis will be.

Be that as it may, if therapists palpate your back in the ways I’ve mentioned above it doesn’t mean they aren’t doing a good job.  However the information gathered from the tests needs to be formulated with information gathered from other tests to come to an accurate diagnosis.  But as stand alone tests I would say that they can’t be trusted.

I hurt like crazy today. Should I cancel my physical therapy appointment?

Sometimes through the course of treatment a you, the patient , can have a really bad day.  You wake up and they just hurt.  It could be related to your injury or it could be something totally unrelated.  Regardless, you hurt and don’t feel like moving around much.  If you have a PT appointment that day most patients call and want to cancel it.  This is totally understandable.  If you hurt you don’t want to hurt more.  And if your area of pain is the area getting treated you really don’t want to hurt it more.  If it’s a different area the thought of PT isn’t much fun.  So when you call wanting to cancel a thought goes through my head….

Come anyway!  I know that may sound a bit callous but PT can really help your pain, even on your really bad days.  The thought that goes through most patients minds is that they will have to do the same routine they usually do at therapy, that the therapist will push them,  pay little attention to their pain and in the end they will hurt even more.  Rest assured, I can tell you we will pay attention to your pain.  We have a variety of pain relieving techniques that we can use to help decrease your pain.  Things come up in life that cause pain.  It could be the therapy, it could be something else.  As therapists we understand this and should be able to adapt accordingly.  Every appointment doesn’t have to be about making amazing gains in your motion, strength, or whatever your issue may be.  Of course the general trend needs to go that way but there are days that decreasing your pain is as healing as increasing the weight on an exercise.

So if your pain exacerbation is coming from your injured area know that we ( the therapists) will modify your treatment plan for the day to incorporate more pain relieving techniques.  If your pain is in a different area but you are afraid coming to therapy might flare it up, we can modify your treatment plan as well.  Perhaps there are different positions we can put you in when you exercise so we don’t flare up the painful area.  Or maybe there are some pain relieving techniques we can use that will help both your injured area (the area you are coming to therapy for) and your flared-up area.  So give your therapist a call and explain the situation.  It’s my belief that something is better than nothing in regards to therapy.  We have a lot of tricks up our sleeves and I think you might be pleasantly surprised how you feel at the end of your appointment.

I get headaches. Can physical therapy help?

If you’ve looked at any list of maladies that physical therapists say they can treat you will undoubtably see headaches on there.  I remember when I first started PT school and I saw headaches listed as something that is treatable with physical therapy I was a little sceptical.  I figured it was probably some fringe aspect of PT, a little bit of hocus pocus.  How could you treat a pain inside your skull with physical therapy?  Come to find out headaches are very treatable with physical therapy, and the results can happen rather quickly.

It’s important to first point out that there are different types of headaches and only a certain type of these are treatable with PT.  Headaches that have a musculoskeletal origin are the ones where we can help the most.  That means your headaches is caused by some issue(s) involving the muscles, joints, ligaments, bones, nerves, or other tissue in your neck, jaw, or head.  Irritation or restriction of movement in any of these structures could irritate a nerve or blood vessel that goes to your head, potentially causing headaches.  Poor posture can be a contributor to headaches and is something we can help correct.  A big key in finding out if physical therapy will help comes during the initial evaluation.  If the therapist can provoke your headache during the evaluation, or causes a headache to come on soon after, there is a great chance we can help.  If you have no change in your headache during or after the initial evaluation and several treatment sessions, there is a high probability that your headache is not caused by a musculoskeletal problem.

Headaches due to chemical/hormone issues or more internal issues such as pathology within the brain itself will most likely not benefit from physical therapy.  Be wary of a clinician who claims he can treat all types of headaches.  Within a certain subset physical therapy is very helpful.  But if it doesn’t fall within the musculoskeletal realm talk to your doctor about your headaches.  He or she will direct you down the path you need to go to find answers.

My manual therapy training from the International Academy of Orthopedic Medicine (IAOM) has enabled me to accurately diagnose the specific issues in your neck that might be causing your headaches.  I am certified in manual therapy techniques for the spine and have had good success in helping people with their headaches that are musculoskeletal in origin.  If you live in Spokane feel free to give my a call at Thunder Physical Therapy at (509) 465-5400.  I would be happy to talk to you and answer any questions you may have.  You never know, getting rid of your headaches may be easier than you think!

Should I stretch before or after exercise? Or should I even stretch at all?

I think it can be safely assumed (for us men mainly) that stretching is something we all agree we should do but don’t do it enough.  Ask the average guy if he can bend down and touch his toes while keeping his legs straight and I bet you he can’t.  Ask the average female the same question and I bet she can.  Is this good or bad?  Should you even stretch at all?  Sure we all did the obligatory warm up stretches before our high school events but other than that it really wasn’t talked about much in school.  It was one of those things we all knew in the back of our minds was important but really didn’t know how to put into practice.  So, what’s the deal with stretching?

Is stretching good?  Yes.  Having overall flexibility in all of our joints is a good thing.  This is allows our joints to move throughout their entire range of motion.  If you are unable to move a joint through its entire range of motion you are most likely too tight and need to stretch.  Also, keeping our muscles, tendons, and ligaments flexible aids in the overall health of the tissue.  One common injury in people who are too tight is a severe strain or perhaps even a tear in the muscle.  A slip on ice or another type of quick, sudden movement can cause a forceful overstretching of one or more of the above mentioned tissue.  If this tissue is too tight to begin with a severe injury could result.  Perform a quick evaluation of your joint mobility.  Can you move your arms and legs throughout their ranges of motion without restrictions?  If you can’t you may need to start stretching.

Can you be too flexible?  Yes.  Generally this is not a problem most of us have.  However there is a subgroup of people who can become too flexible.  Sometimes it’s due to genetics and you don’t have much control of it.  But some people really like to stretch, and in the process can put themselves in quite a conundrum (that is my big word for the day).  Joints that are too loose can cause undue stress to the ligaments in a joint.  Ligaments are a type of connective tissue that attach from one bone to another.  If your muscles are too loose your ligaments will be under more stress when you push your joint to its end range of motion.  This in turn could stretch out your ligaments.  People that are very flexible tend to have more bony issues as well, as there is a higher propensity (another big word!  I’m on a roll!) for the bones in the joints to collide against each other.

Can you stretch too hard?  Yes.  I had a patient who I gave several stretches for her to do at home.  After a week or two of faithfully doing her stretches she wasn’t getting better, in fact she was getting worse.  After talking a bit I realized she was stretching way too hard.  She had the “no pain, no gain” mentality that if it didn’t hurt it wasn’t getting better.  Once we talked about how much pressure to correctly apply she began to do much better.  As a general rule you should feel the stretching sensation as you stretch, but it should go away rather quickly after you are done, and the stretched muscle should feel better.  If you develop pain right after a stretch that continues to worsen you stretched too hard.  Talked to your physical therapist about it and they can help you modify the stretch.

So how often and when should you stretch?  If you find you are unable to perform any of your daily activities because you are too tight then you need to stretch often, every day would be good.  The biggest changes that have occurred with stretching are in regards to stretching before exercising or participating in any type of athletic event.  Like I stated earlier, a lot of us have memories of gathering around and stretching before a high school football or basketball game.  I remember we had a synchronized routine that involved a lot of yelling.  I guess we were trying to psych ourselves up and intimidate our opponent.  There has been some research that has come out stating that it is more beneficial to stretch after an activity rather than before.  Aggressive stretching temporarily desensitizes the muscle, slowing down its ability to quickly contract in response to stimuli.  This could actually lead to injury if you are running and slip or get pushed.  If your muscles are unable to quickly respond to an unexpected stimulus you could strain, sprain, or perhaps tear something far worse than if your muscles were able to respond quickly.  Instead of stretching before an activity it is suggested that you warm up, that is you jog, jump, or do some gentle movements that will help get the blood flowing and your cardiovascular system ready.  This will prepare you much better for your activity.  The time to stretch is after activity.  At this point your muscles are nice and warmed up.  This will allow them to respond better to stretching.  Since you are done with your activity it doesn’t matter that your muscles will be slightly desensitized after stretching, the hard part is over, now it’s time to relax.  One of the most important things when stretching is to NOT bounce while performing the stretch.  Just have a steady hold and count to 30 and relax, doing this 3-5 times per muscle group.

There are a vast array of stretches out there for you to choose from.  Whether they are good or bad depends on what you are desiring to stretch and if you have any physical issues that might become a problem if you stretch a certain way.  This is something that can only be addressed in person.  I would be happy to help you with that if you have any questions.  Feel free to call me at Thunder Physical Therapy at 509-465-5400 if you have any questions.  So go out there, warm up, play hard, and then stretch!  Even though you won’t be able to intimidate your opponent before with some awesome coordinated routine you will be more prepared to beat them when it counts.

The highs and lows dealing with patient expectations.

The first minute or two of a patient’s first appointment with me is always the most telling.  In these first few minutes I begin to get a sense of what the patient expects out of their time with me.  Some don’t know what to expect, as they have never been to a physical therapist before.  Some have seen a physical therapist before and had either a good or bad experience.  That expectation is at times brought with them when they see me.  The hardest type of expectations for me to deal with are those of a patient who has a preconceived notion of what physical therapy is and expects to be treated in that way, whether it is a notion that I agree with or not.  Some my patients have no expectations at all, as this is their first time in physical therapy.  Their doctor told them to go but that is all they know.

Patients I see who have had a previous experience with physical therapy present an interesting dilemma.  If they saw me at an earlier time this of course makes things much easier, as we all ready have a relationship that we can build on.  Patients who I haven’t seen previously but had a good experience are usually very cooperative in their care and understand the benefits of physical therapy, as it has helped them sometime in the past.  It is my hope to build on their previous good experience, showing them how physical therapy, and more specifically, my approach to physical therapy, will help in returning them to a pain-free and fully functional life.  If they have had a bad experience in physical therapy they usually look at me with scepticism, thinking that since physical therapy didn’t work for them the first time around that it won’t be any different this time.  This makes my job a little harder.  I hope that by providing a thorough evaluation and explanation of their condition as well as being professional yet approachable that I will knock down some of the barriers the patient my have from their previous experiences.

Those types of patient expectations are pretty standard and if there are any issues are resolved without much fanfare.  The expectation that I find the hardest to come to terms with is when a patient has had a previous physical therapy experience  at a different clinic (usually a good one) and expects me to provide the same type of treatment as before.  Sometimes they come to me and say “I want the heat and the electrical things.”  And that’s it.  Or they come in and ask “Do you do massage?”  Well technically yes but probably not like they are expecting.  Or “my last therapist didn’t make me exercise, why should I now?”  Nine times out of ten they are asking sincerely and without malice.  They were treated a certain way and benefited from it and now expect the same from me.  This is where it can get a little sticky for me.  If what they are expecting is in line with what I think they need to get better I will do it.  However, if what they are asking for is just a band-aid or does not mesh with my treatment plan and overall physical therapy philosophy I will be more hesitant to do what they are asking for.  At this point it is up to me to convey my thought process to the patient in a concise, understandable, and professional way.  If I do this the vast majority of patients have no problem with my decision and are thank me for being up front with them.  Every once in a while I have a patient who isn’t satisfied with my explanation and half heartedly continues therapy or quits all together.  And this is the tough lesson I have had to learn over the years.  You can’t please everybody.

When I first became a therapist I would take it very personally when a patient didn’t like my treatment plan or decided that we weren’t a good fit.  To some extent I still do take it personally, but now I see it through a different lens.  I want to tell you this.  If you come to Thunder Physical Therapy in north Spokane and see me I will give all my effort in getting you better the best way I know how.  I am open to discuss other treatment ideas that I am not familiar with and perhaps incorporate them into your treatment plan.  But if you are asking me to do something that I am uncomfortable with I would ask that you allow me to treat you the best way I know how.  When I treat you I want to treat you well and with expertise.  If you ask me to treat you in a way I am not educated  in you won’t be getting my 100% effort.

I hope that doesn’t sound too harsh.  Situations like I mentioned above are rare.  I can can count on one had the times that a patient and I have not been able to come to an understanding on a treatment plan.  Please ask me questions.  Ask me what my thought process is on how I treat you.  The more you know the more likely you are to try harder and be consistent in your treatment and home exercises.  That makes you and me happy.  And that is something we can both agree on.