George Tate

PTQ 030: Your patients journey to a winning record! How Dr. Paul Lonnemann knocks low back pain out of the park.

Dr. Paul Lonnemann explains how he approaches patients with chronic low back pain based on his experiences. He gives us several things we must recognize with our patient interactions and goes on to describe how he addresses particular patient situations.

Dr. Paul lonnemann has been practicing for 25 years with a background in orthopedic manual therapy. I asked Paul to share his experience when it comes to treating low back pain and in particular, chronic low back pain.

I was curious how he learned his style when is comes to approaching these patients and what all has changed as he gained experience in this area.

Paul said back when he started, the process of evaluating and treating back pain was based more on who the experts where that you learned from.

Shortly after he graduated he realized he needed to have a better handle on these patients and Paul then chose to go with the University of St. Augustine.

Paul continued to say how interesting it was that what Stanley Paris was saying in 1992 about patients pain, chronic pain, and patients understanding of pain was really ahead of his time. A lot of pain specialist are now confirming what he said.

Paul recognizes that manual therapy is an integrative approach that allows you to get your hands on the patient and for the patient to recognize that you’re a concerned care giver. He said that can not be overemphasized because it seems like the pendulum is swinging to the biopsychosocial side of things. Paul feels like in some instances it’s getting to the point where hands on experience is really not necessary and all you need to do is talk to the patient. He believes that the utilization of manual therapy is an important, integral part of connecting with these patients.

“Don’t just address the patients needs, you also need to address the patient perspective. Get a perspective on where they stand with the understanding their pain.”

When patients come to Paul, who resides in Indiana, most of the time they may have already seen a primary care doctor, a massage therapist or other discipline. Paul will integrate his understandings of chronic pain, manual therapy, and exercise into his patient interactions while figuring out how to connect with the patient for them to better understand their problem.

“In most cases of low back pain, there is something that we can identify that is making their symptoms worse and if we can get a better handle on that then we can empower the patient to control it.”

“Don’t let the pain tell you when to change your behavior, change the behavior before your have the symptoms.” Paul says if you can predict to the patient what things make them worse, they’ll try it because they want to prove you wrong! Paul will challenge them by saying, “I bet if you got up four times each hour your back pain would be decreased, I bet if you slept in a better position your back pain would be decreased so on and so forth.” Paul tells his patients, “if you come in and tell me that none of those work we will stop therapy.”

“We have to recognize that some of our outcomes are related to the patients decision on whether or not they change their behavior more than anything else”.

Tread lightly on the first evaluation if your patient has a high Oswestry score, in the danger zone on the FABQ or Start Back Screening Tool. You don’t want to overwhelm them with a new set of responsibilities but if you can get them to recognize their own behaviors and inform them about changing behavior in general, it’s a great start.

I asked Paul what suggestions he had for younger therapists, students, or someone who isn’t confident in their abilities to effectively treat chronic low back pain.

Paul says that it’s really important as a new graduate to have good mentors that you can bounce ideas off of. Being able to run your thoughts by someone more experienced and getting their thoughts and perspectives is critical. You’re biggest mistake is not making a connection with the patient. You need to set up a contract with realistic goals and let them know what you expect. “Get confident and comfortable in your skill set with the help of mentors and those you respect.”

”We need to be confident with what we know, we need to be honest with what we don't know, and we need to be honest with our outcomes. Patient appreciate that.”

PTQ 029: Getting back on the mat with Eugene Tsozik

Eugene Tsozik, The Jiu-Jitsu Therapist, discusses how he addresses rehab and injury prevention in the world of Jiu-Jitsu, grappling, strength training, and MMA. Physical therapy is an art form because we are all different.

Dr. Eugene Tsozik discusses how his particular background in Brazilian Jiu-Jitsu helps him address a particular patient population that participates in area of jiu-jitsu, grappling, and MMA. If you’re an avid runner, don’t you think your care would be better if your physical therapist was someone who ran?

When it comes to jiu-jitsu, the lingo and terminology is huge. If you have a background in a specific activity it can only help you relate to those who are seeking prevention measures or rehab for that particular activity. When it comes to jiu-jitsu, knowing particular positions, what is physically and mentally required to hold that position, what muscle groups are being worked, and what joints are being affected, could make or break your rehab or injury prevention program.

Knowing what these athletes go through is also important. Eugene says that his ability to be on the mat along with having experienced similar injuries gives him a great knowledge base for jiu-jitsu, grappling and other related sports. Your everyday physical therapist that has a great orthopedic base, they can treat you, but they will only get you so far. When it comes to getting back to jiu jitsu, things need to be addressed in a particular manner.

Eugene continues to fill the gap for  jitsu fighters, martial artists, and wrestlers. His vision continues to bridge the gap between getting back to everyday functional and getting back to jiu jitsu. The transition from physical therapy and rehab to getting you back on the mat is something that he loves.

How do you bridge the gap? Take out extraneous variables. When you’ve been forced to sit out from jiu jitsu and are finally ready to come back you need to be aware of how this process should work. A lot of people go full bore when they first return to jiu jitsu.  Getting people to back off is very important because if they don’t it can lead to injury.

 

When you first get back on the mat just move independently and play around with controlled movements using bands, then start adding some of those variables back in to their movements. Work your way back to working with a partner and continue to expose them to more positions.

Eugene actually admits to fracturing his radius during ju jitsu and his need to go back was so great that he would tuck his arm in and train one handed! Obviously not recommended… He said that ju jitsu is just one of those things, you don’t know it until you try it, it’s something that is pretty special.

Some people find something that drives and motivates them to the point that they would do anything in their power to get back from having sat out due to injury. This is where we come in as physical therapists, we can bridge that gap and give someone the opportunity to get back to doing something that they love.

We asked Eugene if he had any advice or tips when it comes working with those who are involved in ju jitsu, grappling, MMA, wrestling or other related sports. He says, “do your normal PT things and then bring it back around to gradually exposing that person to extraneous variables that you took out in the first place. Exercises that are more related to ju jitsu type movements are essential.

One thing that may be challenging when it comes to rehab for someone who injured themselves in jiu jitsu, martial arts or grappling is getting them to buy into doing other things besides ju jitsu.

“Getting them to recover and do things like stretching, mobility work, yoga, strength training, and other things on the side are so beneficial.” It will only help to keep someone on the mats along with their longevity when it comes to their physical abilities.

“Get them to buy into doing other things that will complement their ju jitsu. People don’t seek me out until they have the problem but you want to address me before you have a problem. Keep your body functionally optimal, don’t have your body break down and then try to fix it.”

“Getting people to realize and experience the difference in how they feel is half the battle when it comes to prevention. Getting them to consider participation in yoga, stretching, better nutrition can start to expose the potential to optimize their functional movements!”

“A lot of people don’t know how to get back to something, a lot of people think they have to go back 100 percent and that’s where progression comes in and gradually increasing your tolerance.”

“Some people come to therapy just because they have to get “this” taken care of so they can get back to what they were doing before hand. They don’t realize that starting therapy is the first step to getting back to the activities that you were doing before. Physical therapy and their getting back to their activities are both blended in.”

“Get them to believe in you and know what you’re capable of and know that you want what’s best. Physical therapy is an art form because we are all different.”

PTQ 028: Complete Concussion Management for the PT

Physical therapy can play an important role in concussion care. With appropriate training, licensed physical therapists can utilize their skill set to effectively manage concussion injuries. Dr. Cameron Marshall, Complete Concussion Management, joins PTQ.

Cam Marshall Headshot 2

Dr. Cameron Marshall is a Doctor of Chiropractic and sports injury specialist who holds a Fellowship through the Royal College of Chiropractic Sports Sciences in Canada. His primary research and clinic practice focuses on evidence-based treatment and management of concussion and post-concussion syndrome. Dr. Marshall is the founder and current president of Complete Concussion Management, a global network of sports medicine and rehabilitation clinics who provide evidence-based concussion care programs within their communities, and serves as an executive board member for Brain Injury Canada.

“When you look at all the therapies and treatments that are available for concussion patients, most of them are rehab.”

“Rehab professionals should be at the forefront of this particular injury, but a lot of therapists still aren’t really aware of the tremendous role that they can actually play.”

“It is such a huge area for therapists to get involved in and there are so many different ways in which we can help”

“The driving factor behind our programs is to empower therapists to help as many people as well possibly can.”

I asked Dr. Cameron Marshall about communication throughout the plan of care for someone with a concussion. Communication is always important, but conveying information effectively can be a challenge when the care team for someone with a concussion can be quite large. When it comes to keeping everyone up to speed, Complete Concussion Management has developed an application that provides a seamless way to keep everyone involved and up to date on the plan of care.

Education and training on the signs and symptoms of concussion are critical so that both healthcare professionals and lay people in the community are able to pick up on these injuries and know what their role is. Whether that be getting the patient to the right healthcare professional, or participating in the process of returning someone back to play or back to their prior level of function.

A coach, parent, or teacher doesn’t need to be an expert in the clinical management of someone with a concussion, but there are key signs and symptoms that everyone should know. Complete Concussion Management gives you appropriate resources, even if you’re not a healthcare professional.

A lot of courses in the past have presented good messages like “when in doubt, sit them out,” but Dr. Cameron Marshall and his team want you to know why you’re sitting someone out and what the potential implications are for that course of action down the road. It is critical to know the importance behind pulling someone out of play and also of following proper return to play strategy.

Research is constantly changing and Dr. Cameron Marshall has a system built to not only keep up with current research, but to also implement current changes into his teachings regularly. To do this, he updates his courses and modules monthly making sure he’s teaching the latest findings.

How does this work?

The process begins with a research team that analyzes the newest literature on a weekly basis. Subscribers that are part of the network get monthly research updates. Additionally, the entire course gets updated yearly. The idea behind this rigorous schedule is to provide people the most up to date information possible. By making current research easy for practitioners to apply, and essentially, easy to find, the quality of care provided can improve globally.

“Everything is so contradictory and I think that goes for all research. I think it’s important to go through it all because what you see published today will be completely refuted tomorrow, then the next day these concepts will often shift back the other way. If you were to read a couple studies here and there you could potentially believe something completely different than what is actually real.”

“What I think we need to consider is the fact that there’s always different sides of the story. We have to make sure we are reading everything and putting it all together so that we can develop the best clinical picture. Our goal isn’t to provide our ideas or what we think is appropriate, our goal is to provide a summary of the evidence. This gives people a good appreciation for what the current status of the literature is and also helps them to think critically about it and become a better clinician.”

Where is concussion treatment heading compared to what it looks like now?

“This idea of earlier return to activity is now going to be the way in which we start treating patients. How many physicians are sitting in their office with treadmills? Not very many. They’re going to outsource that to a trained physical therapist, so let’s get PTs informed because they are the ones who are going to be treating these patients.”

What if you are not around a patient population where concussions occur frequently? What are some things to look out for?

“The diagnostic criteria for concussion is minimal. There are up to 22 main symptoms, but the general diagnostic criteria for concussion is, was there a mechanism of injury?”

“Mechanism is acceleration of the head. This doesn’t necessarily mean they have to be hit directly in the head. Did they have a fall? Were they in a car accident? If someone was in a motor vehicle accident and their head didn’t hit the steering wheel, it is the head whipping back and forth causing the brain to move inside the skull.”

The bottom line is this:

“Was there an acceleration or deceleration force that occurred? Does your patient have any of the concussion signs and symptoms?  The Berlin Concussion Consensus statement is the most recent international document developed by leading experts in the field.”

“Another great tool is the SCAT 5 – Post Concussion Assessment Tool 5th edition. If you have a MOI and any one of the signs and symptoms than this is grounds for diagnosis. The problem is none of symptoms of concussion are very specific. Err on the side of caution and treat it as such.”

“If you’re a professional and you don’t necessarily feel 100% comfortable with concussion, you should probably be referring that patient on. If you’re giving the wrong advice that could create a lot of issues.”

How do you tease out comorbidities and polypharmacy in the geriatric population when it comes to concussions?

Here is a list of some good things to keep in mind when you suspect a concussion in the geriatric population. However, when you suspect a concussion is not the only time you should be considering the following. We just thought a list would be helpful.

Considerations for the Geriatric Population:

  • Higher prevalence of fractures
  • Brain bleeds
  • Brain swelling
  • Medications
  • Blood thinners
  • Are they on a new medication?
  • Medication side effects
  • Multidisciplinary communication is huge
  • Lifestyle habits
  • Do they have a spouse?
  • Do they have a Caregiver?
  • Do they have family in the area?
  • What’s their social network like?
  • One of the best indicators for recovery is a strong social network
  • Where do they live?
  • What are your resources?
  • Make sure you are understanding everything that’s going on.
  • Exercise can be beneficial, but what is their exercise capacity?
  • Do they have a heart condition?
  • Is there an increased risk for falls if they were to walk on a treadmill? (certain criteria via Buffalo Treadmill Test).
  • Higher probability to have a persistence of symptoms, some things that you would normally do with an athlete are a little bit more challenging with this population.

“There is a fear among people. I think that parents are afraid of pulling their kids out. I think that athletes, regardless of whether they are current or former, have a fear too. A lot of this stems from misinformation. As health care professionals, we have a duty to step in and provide therapy. We must also provide appropriate information to patients because we can stop a lot of this fear and make patients feel a lot better about their current health status.”

Are you interested in full clinical training regarding concussion management? How about becoming part of the Complete Concussion Management network? Visit Complete Concussion 

PTQ 027: Discussions on how to get the most out of your clinical setting.

Richard and I talk about how to have positive clinical interactions with instructors and other health care professionals. Let us know if our advice helps you get the most out of your clinical experience.

PTQ 026: The Challenge of A Lifetime – PTQ talks Neurologic Clinical Specialty with Dr. Elizabeth Ulanowski and Dr. Shelby Shroeder.

Learn about the first steps towards attaining a NCS and what that process looks like. Dr. Elizabeth Ulanowski and Dr. Shelby Schroeder share great information about programs, mentorship and experiences that gave them the skills they needed to approach their complex patient population.

Dr. Elizabeth Ulanowski,
PT, DPT, NCS

Learn about the first steps towards attaining a NCS and what that process looks like. Dr. Elizabeth Ulanowski and Shelby Schroeder share great information about programs, mentorship and experiences that gave them the skills they needed to approach their complex patient population. Hear why you should and shouldn’t go through residency and what their NCS means to them.

It’s never too early to start thinking about an NCS residency. However, it is important to keep an open mind and not to develop tunnel vision because interests can always change!

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Shelby points out that the most beneficial part for her was the mentorship she received. Knowing that every week she was going to have 3 hours of mentorship allowed her to progress her skills more quickly. Because neurologic patients can be very complex, it is beneficial to have a mentor to bounce ideas off of.

Dr. Shelby Schroeder,
PT, DPT

Why should you get a residency? This is a decision that carries a lot of weight and is not just credentials that go behind your name. You should want to invest yourself in this area of physical therapy. Getting an NCS is a commitment, but it is one that will help you to move evidence based practice forward.

When shouldn’t you do a residency? If you “kinda” like an area of practice, but you’re not really sure. If you just want to see what an NCS residency is like, then this type of training is not the way to go. Residency is a blood, sweat, and tears type of deal.

 

PTQ 025: Finding Balance in Yoga Therapy with Dr. Dava Nichol

From collegiate athlete to physical therapist to yoga educator, Dr. Dava Nichol (aka @thebalancedpt) talks with us about how she became involved with yoga and how she is now using it to transform her patients.

You may know Dava already from her Instagram, The Balanced PT. She started practicing yoga as a means to recover better from the sports she was involved with in high school and college.

At first, her yoga practice only consisted of one session per week. She discovered quickly that this one session a week helped to reduce the little nagging injuries that are often common with a sports career.

Now Dava practices yoga 5-7 times a week. Sometimes with a brief 15 minute flow in the morning, and other times with a 60 minutes session at a studio in the evening. She believes that you don’t need to be practicing yoga for 60 to 90 minutes to reap the benefits that it can offer.

With only 5 minutes a day, you can do something that draws your attention to the body while helping to increase mobility. Consistency is key.

Dava discusses how she draws from yoga principles during her therapy sessions with almost every patient. Mindfulness along with mobility can be a powerful therapeutic tool. Her background in yoga has really helped her to treat the total patient.

Have you been curious about how to become a Registered Yoga Teacher? Dava has had her RYT for 2 years now. Listen in to hear the steps that she took to become certified and what the process entails. She speaks highly of Yoga Alliance so I would check it out!

Dava has developed a large following through dissemination of high quality, useful content. Be sure to connect with her on social media and check out the current challenges she has running. There could be prizes involved!

Sincerely,

PTQ HQ    

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