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Interviewer: Before considering surgery for back pain, there could be other options you might want to consider first. Dr. Andrew Joyce is a physical medicine and rehabilitation specialist, focuses on non-surgical treatment of various muscle and spine issues. So here's a scenario. A patient has been told by another provider that their back pain might benefit from surgery. They come to you for a second opinion or just wanting to know if there's something that they can do before surgery. First question is there?

Dr. Joyce: Definitely. In the vast majority of cases, there's something that we can offer to at least try to ameliorate the pain before jumping to surgery. There's a variety of treatments that we look at, whether it be medications, therapies, modalities, or procedures to go and help manage people's pain.

Interviewer: And does that happen often that you end up talking to a patient that has been told surgery is what is going to help with their back pain and have not been told about some of these other options?

Dr. Joyce: Yes. I would say, you know, we're fortunate here at the university because most of the way our referrals are sent in, they get sent to us first to evaluate for non-operative treatments before we decide whether or not the patient would really benefit from surgery. But in the community, that's not always the case. And so it's not uncommon for patients to have back pain or pain originating from their back and sciatica, who see another provider who offers them surgery, and then come to us for a second opinion to see what else we can do.

Interviewer: Let's talk about some of the options that somebody might take. Where do you start that conversation?

Dr. Joyce: The first thing we do is we try to get a comprehensive physical and history from the patient. And what we're looking for is to try to identify what the exact source of the pain is. And so we'll review with you, you know, the history of your pain, where exactly is it located, we'll take a look at imaging, and we'll look at different other medical conditions which may factor into our decision. And then once we've looked at all of that, we'll discuss the different options that we can use for different procedures. And so it varies depending a little bit on which diagnosis we think you have.

Interviewer: And I think a lot of times patients think these non-surgical options tend to be like some sort of like a cortisone injection or something like that, which is definitely an option, but there are other options as well. So walk me through some of those options and how they might apply to a patient.

Dr. Joyce: So the most common injection and the ones that people call, you know, cortisone injections are basically steroid injections. And what matters is not necessarily that you're injecting steroid, it matters where you're injecting the steroids. So we use these steroid injections in various parts of the body depending on where we think your pain is coming from. So if you're having pain that's caused by a herniated disc pressing on a nerve, well then we would do an epidural steroid injection, where we place steroid in and around the epidural space to bathe that nerve and calm down any inflammation and irritation that's happening to the nerve. On the other hand, if you're having pain that we think is coming from your sacroiliac joint, which is a large joint at the base of the spine, then we would inject the steroid into the sacroiliac joint and use that to calm down inflammation and irritation to the area.

Interviewer: And then other than the injections, what are some of the other options that you can offer a patient and what situation with those apply?

Dr. Joyce: Some of the more common things when people have arthritis related pain in their back, we do a series of procedures where we do test blocks to help determine if the arthritis is truly the source of the pain. And those are called medial branch blocks. And if patients do feel substantially better after those test blocks, then there's another procedure called radiofrequency ablation, where we actually burn those little tiny branches of nerves that go to the joints and help relieve the pain. And those can actually be very durable. They can often last anywhere from six months to a year and a half, at which point we can repeat it and get similar pain relief.

Interviewer: And then I've also heard of electrical stimulation. Is that another option?

Dr. Joyce: Yeah, and this is kind of an emerging technology. Spinal cord stimulation itself has actually existed for over 50 years. But in the past 10 to 15 years, there's been huge advances in the technology that we can use for it. Now this is almost never a first line treatment that we use. But for people who are having severe pain in their back and aren't getting better, we can use electricity to kind of help modulate the pain signals. And so that involves putting electrical leads either in the epidural space behind the spinal cord or even more superficially, around nerves in the low back to help block the pain signals.

Interviewer: And then does the type of treatment that we've talked about, we've talked about injections, we've talked about the burning the nerves, we've talked about the electrical stimulation, does that really, really depend on the type of pain somebody has? Or are those options suitable for all types of pain and you just kind of cycle through one after another? I mean, is there some sort of a procedure you like to go through?

Dr. Joyce: No. Yeah, it definitely depends on the type of pain and where the source of the pain is. So, you know, if your pain is coming from purely the arthritis in your back and I do an epidural steroid injection, I'm not expecting you to get substantial relief of that pain. So it really depends on where the pain is. And where this becomes more complicated is when patients have more than one thing going on, right? It's not uncommon for patients to have arthritis in their back, that then causes some pressure on a nerve. And so they have more than one thing going on. And so then, in those cases, we will use more than one of these types of procedures to help with their pain. But really, it depends on what the source of their pain is.

Interviewer: And I'm kind of getting the feeling that back pain can be kind of a complicated thing. I mean, it sounds like you have to know what's causing it and then what treatments are the most effective for that type of pain, depending on what kind of pain, what's causing it, the location. How often just kind of after a couple of visits do patients find relief, versus you've kind of got to look a little bit further in the cases where patients might have multiple things going on?

Dr. Joyce: It depends on the patient. I would say, you know, for many of our more acute patients, so patients who have had pain for between 6 and 12 weeks, those patients tend to, on average, do a lot better, because they haven't had the pain for quite so long and oftentimes it's less complex. But certainly, when it gets more complicated, sometimes it does take a little bit of trial and error and some searching. And sometimes these injections can actually be helpful, both therapeutically to help people with their pain, but also diagnostically to help us determine the exact source of pain and help us get a better treatment program put together.

Interviewer: Kind of a mystery that you have to unravel in that case.

Dr. Joyce: Exactly.

Interviewer: Yeah. And then at what point would you even recommend somebody for surgery?

Dr. Joyce: Most common reasons that I will have someone be seen by surgery is back pain or neck pain going down their arms or their legs, with associated numbness, tingling, and in particular weakness. When people are having symptoms that are causing, you know, objective findings on our examination when they're objectively weak, that's when surgery is most indicated. And that's oftentimes when I will send them to surgeons earlier rather than later because we don't want patients to be left with any sort of neurological problems long term. And surgery is the only way to decompress nerves and help prevent that from happening.

Interviewer: Is weakness generally always a sign you're going to be sending somebody to surgery or not always?

Dr. Joyce: So it depends a little bit on having objective weakness, but also on the pattern of weakness. So we know certain nerves in the body go to certain muscles. And so we'd expect that if a nerve is being compressed and causing weakness, it would affect those muscles that it innervates. And so what we look for is to try to see if the pattern of weakness matches the nerve being pinched. And if that's the case, then surgery might be necessary.

Interviewer: And again, it just really sounds like coming to a specialist like you is really just a great step just to make sure.

Dr. Joyce: Yeah. I think at that point, if there's any concern that you might have weakness, or you're having neurological findings and you're not sure what to do, definitely seeing a specialist, like us, I think makes a lot of sense.

Interviewer: What you described, you know, choosing the right place for an injection, the type of injection you want to use sounds really, really complicated. What do you recommend a patient look for in a provider that's doing that type of work?

Dr. Joyce: You want to make sure that the person who is doing your injection has done hundreds of these types of injections and is well versed with it before you go in with them.

Interviewer: Whether that be through a fellowship that they did, that extra year after medical school specializing in this, or they've done numerous procedures over the length of their career.

Dr. Joyce: Agreed. Yeah.

Interviewer: For patients who have lost a limb, phantom limb pain is a very real and very painful condition. And what exactly is it, and how is it treated?

Today, we're joined by two specialists who really treat this kind of condition. Dr. Colby Hansen is Director of Amputee Program at the Craig H. Neilsen Rehabilitation Hospital, and Spencer Thompson, a doctor of physical therapy and a board-certified specialist in neurological physical therapy specializing in the treatment of amputees.

Now, when we're starting to first kind of understand what phantom limb pain is, why don't we go with that question to begin with? Dr. Hansen, what exactly is phantom pain?

Dr. Hansen: Phantom pain is the perception of pain in a limb that has been amputated. For someone who has lost their leg, they may still feel painful sensations as if they are coming from the missing leg, the missing foot, the missing ankle, etc.

Interviewer: What exactly causes that? And correct me if I'm wrong, there are no nerves there to be creating that pain, are there?

Dr. Hansen: Well, it's a good question. Pain signals obviously have to originate from the site of pain, and then travel through the nervous system up to the spinal cord, and then up to the brain.

And in our brain, we have essentially a map that represents signals that pertain to every part of our body. And so, even though we may have lost a limb, we haven't lost that map in our brain. And so it can still perceive signals going to that part of the brain, which may be then perceived as coming from the missing part of the body.

In addition to that, the residual nerve in the remaining part of the limb that would have gone to that part of the limb is still there, and it can also send signals originating from there up to the brain which can be perceived as pain.

Interviewer: And how severe is this pain?

Dr. Hansen: It's very different from person to person. There are some people who may not feel pain, but they may feel the sensation of their limb. We call that phantom limb sensation. And then there are people who may have very severe phantom limb pain, and then there are going to be those who have perhaps only very mild or very intermittent phantom pain experiences.

Interviewer: I want to shift over to Spencer Thompson. Spencer, when you work with these patients, as an outsider, it's a little confusing, right? If someone has a twisted ankle, a physical therapist works on that twisted ankle, right? In this situation, it seems more that there is a neurological almost perceptual type pain happening. How exactly as a physical therapist do you help patients with this condition?

Dr. Thompson: I think understanding first how frequent it's happening for them gives understanding to how to best treat it. But one of the ways that I've found that's an easy way, that's not medication so it doesn't really have any systemic effects on the patient, is something called mirror therapy.

Like Dr. Hansen talked about, that pathway, that map is already in their brain, and sometimes that system gets ramped up where it feels like . . . sometimes people feel like their foot is twisted or contorted in a certain position, or they get those zaps of pain. Because that part of their leg is missing, what we want to do is train the brain in the sense that that part of their limb actually can move without pain. And the way we do that is with the mirror.

Interviewer: Is it a special mirror?

Dr. Thompson: No. I tell people to just buy a door mirror at Walmart for $15 or whatever. What you do is you put that mirror in between your legs. And you can do this with an arm as well, right? But you want to in a sense block your amputated side. And the mirror is going to show the reflection of the intact limb, whether that's the arm or whether that's the leg.

When I teach this to patients, what I tell them to do is their whole focus needs to be on the reflection of that intact leg, so that reflection is covering the leg, their amputated side. It looks like when they're looking over there . . . Say the left leg is amputated, I have the mirror on that left side, but it's showing the reflection of my right leg in that mirror, so when I'm looking in the mirror, it looks like that's actually my left leg, if that makes sense.

Interviewer: Oh, wow. Okay.

Dr. Thompson: Then, what I do, or what we tell patients . . . I work a lot with more lower limb, so I'll just describe what you do for lower limb, but it could be the same for upper limb type of thing.

I tell them, "I want you to keep your whole focus on that mirror, of that reflection of the intact limb, because we want to train your brain that is there, that it can move without pain." And then I teach them to move that ankle up and down, move it in and out, move it through circles in all directions, spell the alphabet with that ankle, kick the leg in and out, move the hip up and down, in and out. Any type of movement like that that can be moved through a pain-free movement, you're sending signals to the brain that that leg can move without pain.

Interviewer: The leg that is not there?

Dr. Thompson: The leg that is not there, but by looking at that reflection, you're sending input into the brain telling the brain that that leg can move without pain.

You can try it yourself, even if you're not an amputee. It's a little trippy at first. When the patients try it, they're like, "That feels so weird." But it's cool.

The biggest kicker with it is it takes consistency. Any time you're training the brain for something, it takes a lot of repetition, it takes consistency, it takes effort.

There's research out there. There are more research studies that need to be done to continue to prove efficacy of this, but protocols that I recommend is doing it for 5 or 10 minutes every day for 4 to 6 weeks.

And people that I've seen that have committed to that, there's a variety of results. Some people, it doesn't work. Some people, it does.

Some people feel like the edge of their phantom pain is taken off. We call it telescoping. The phantom pain may be on the distal end of their leg, in their foot. But sometimes that pain travels up, so it's not necessarily in their foot. It kind of travels up a little bit, and it's not as intense.

And some people, it helps out quite a bit. Or if they have an intense phantom pain session, they do it, and it just kinds of melts that pain away.

But biggest thing I would say is . . . I talk to people, and I'm like, "Have you tried mirror therapy?" They're like, "Yeah. I tried it, but it didn't work." When I kind of explore a little bit more, I find out that they haven't really done it on a consistent basis. They've tried it four or five times and it didn't really maybe have the effect they wanted, and so they stopped doing it.

And so my biggest thing was if you really want to see if it works, give it a shot, but be consistent with it. Shoot for every day. Put a timer on your phone for five minutes and be consistent with it and see what happens.

Interviewer: Now, Dr. Hansen, I guess I'm just a bit of a layperson here, but a $15 mirror that you can get at a big box store can significantly help with your pain. What exactly is happening, I guess, in the brain, in the nerves, with this therapy to have it work?

Dr. Hansen: Yeah, it's a good question. I think the simplest way to maybe try to conceptualize what's going on here is we have obviously five senses, right? Touch, smell, taste. Vision is one of our strongest senses and drives some of that pathway to that part of the brain represented by that missing limb. I think we can start to replace some of those pain signals going there with healthy, normal-feeling normal movement type of signals going there.

When we can have this visual input that's looking as if we're looking at our missing limb and that it's there, and if we can harness that input, which is very strong, to then do some of those things that Spencer was mentioning, move the phantom limb through the mirror in these different ways and not reconnect but sort of drive some of that pathway to that part of the brain represented by that missing limb, I think we can start to replace some of those pain signals going there with healthy, normal-feeling, normal movement type of signals going there.

Interviewer: Dr. Hansen, say there is a listener who either they themselves have an amputated limb or there's a loved one with an amputated limb, and they are dealing with some of these phantom sensations, phantom pain. Where do they start? Is it a general practitioner, is it a specialist, is it a physical therapist? If they need some help, where do they go?

Dr. Hansen: Good question. I would say the place to go is a high-level rehabilitation center that sees a lot of these complex types of patients. There may be some sort of small community rehab centers that don't see this very often. Usually at bigger centers, not just academic medical centers, although most academic medical centers should have the expertise. I am a rehabilitation physician, but not all rehabilitation physicians do amputee care. Sometimes orthopedic surgeons may do amputee care and do a very good job.

But I would say you start by looking for a large medical center that sees and treats complex rehabilitation types of patients, and then likely you'd be plugged into hopefully an amputee clinic at our institution run by myself as a rehabilitation doctor, but also that incorporates other expertise, like physical therapy or rehabilitation psychology, etc.

Interviewer: Spencer, for a patient who might be dealing with this kind of pain, what is something that you tell either them or their loved ones about what they can expect with working with a physical therapist to treat this condition?

Dr. Thompson: PTs, I think sometimes people think we're just mean people, that we just like to . . . We have this tagline that's "PT stands for pain and torture." I mean, yes, it does take work and sometimes pain, just like working through anything to improve, but we're here as huge advocates for you. We're on your team. PTs, our goal is to help improve your daily function and mobility and to get you back to living life to its fullest.

I would say for patients, give yourself some grace, some compassion. You've been through a lot. Your body has been through some significant changes. Just take a minute and breathe and just acknowledge all that you've been through and all the . . .

I tell all patients that I think the media sometimes does the amputee population a disservice in some aspects, because we see all these Olympians that are doing these amazing things, which is awesome that they are, but people sometimes have this expectation of, "Once I get my prosthetic limb, I'm going to be out running, doing all these amazing things." But the media doesn't also show the phantom limb pain that people experience or just the different trials that they do experience.

And so don't compare yourself to what's shown in the media. Just take it a day at a time. You're going to have good days, you're going to have days that are harder, but just be patient with yourself and just know that day-by-day, it's going to get better.

There is hope. There's help out there. There are great resources. We run an amputee support group here through the University of Utah that I run. There's a company called the Amputee Coalition. There's support out there. You're not alone in this. Talk to other people that get it, talk to professionals that understand, and I think just build your team around you that can help support you, and be patient and give yourself grace in this healing process.

Interviewer: Learn more about the dance clinic and how it can help you if you're a young dancer, or a dancer that's been doing it for a while. We'll talk about that next on The Scope.

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Interviewer: Trina Bellendir is a physical therapist in the dance clinic at University of Utah Orthopedic Center, and today we're going to learn more about the clinic. It's a resource for you as a dancer that hopefully you'll use before to prevent injuries, and if you do have an injury, it's also a place you can go to have that taken care of. So first of all, who is the dance clinic for? Is it just for amateur, professionals, both?

Trina: It is actually for both. Anyone that has an injury or would like to prevent an injury, or they know that there's some dysfunction, or their dance instructor has told them, "You need to work on this," that's what I'm there for.

Interviewer: Okay. So that's a good trigger word, right? If your instructor says, "This is something you need to work on," and you're not able to do it, that would be something you can help them with. Tell me about a typical visit. Who is that person?

Trina: I've had a few that came in with, "You need to work on your arch supports and lifting up your arch," and them not knowing how to attain that arch. So my job is to teach them which muscles to use, how to show them their points on their feet to get those activated.

Interviewer: Got you. Can you give us some other examples?

Trina: Knees over the second toe. Dancers tend to let their knees fall in, so we'd like to have them knees always in line with their second toe to help prevent some of the chondromalacia patella and knee dysfunctions.

Interviewer: And a lot of those dysfunctions, is this true or false, are caused by some sort of a muscle strength imbalance or a flexibility imbalance that you can help with?

Trina: It is. Most of them are muscle imbalances and we just need to do some minor exercises to help them rearrange those.

Interviewer: Got you. So it's for professional dancers as well as amateurs, young and old?

Trina: Young and old. I've seen them up to 50 or 60 and as young as 8.

Interviewer: Got you. And your typical patient, I would imagine, is somebody that comes in that has hurt themselves at some point, and maybe has ignored it for a while because they're hoping it would get better. You would hope to have fewer of those and more people that are coming in more proactively. Talk me through how somebody might know that they should actually come and visit the clinic.

Trina: Any time you start getting just the basic strains, pains type of thing that doesn't go away after you've iced it and rested it for a day or two, those are the type of people I'd like to see in there, preferably before they are unable to dance and the show is tomorrow.

Interviewer: And then for those that come that actually have some sort of a chronic issue, how do you normally work them through that?

Trina: Well, I treat the chronic issue first mainly by treating, getting their symptoms under control. Then we'll look back and see what caused the issue. Not just the ankle, but does it even arrive at the hip or at the back. We need to make sure the entire body is working well together and those muscle balances are correct.

Interviewer: Do you have any sort of technology or tools that helps you analyze dancers? I've been to a runner's clinic before, and I loved the fact that they filmed me. I learned so much from that.

Trina: So I am in a fairly unique position working at the university, that we have a motion capture system that we have in the clinic. We have a force plate that is actually brand new that we can test their ground reaction forces with. We have isokinetic machines for strengthening and testing, as well as what's called a foot mat. It does the pressure sensitive areas of your foot so they know where they're putting the pressure.

Interviewer: So a lot of kind of cool tools.

Trina: We have lots of fun toys over there, yes.

Interviewer: Yeah, to really help somebody through whatever particular issue they might be facing. So if somebody comes in for a visit and they're in the situation, either I guess. Let's talk through both of these. They're looking to do something that they're not able to at this point, or they have hurt themselves and they're looking to rehabilitate. How often does somebody usually have to come back before they start noticing some results?

Trina: I like to see results after the first visit.

Interviewer: Really?

Trina: That doesn't mean that I've got them completely better, but I want to make some changes day one. So maybe not better, but at least a change, so that way we know we're heading in the right direction.

Interviewer: I see. And does insurance cover this?

Trina: Insurance covers most of it. If we take your insurance at the University Orthopedic Center, then your insurance will cover the dance clinic as well.

Interviewer: So really, I mean, it's just great insurance against hurting yourself or being able to enjoy this thing that you enjoy for a long time.

Trina: It is. It's basically your co-pay versus a new pair of dance shoes, which can run anywhere from $50 to $150, $200. So your co-pays $25, $50 even, and it's worth it. I just would prefer to have people come to me early and have me say, "Well, it's just a little strain." I'd rather have that, give you a couple of exercises, treat some of the mechanics that you're doing early, versus waiting until it's a chronic issue and then it's going to take months to get better.

Interviewer: It's a lot easier to untangle that early on, so.

Trina: It is, and I try not to take you out of dance, because telling a dancer they can't dance is awful. So we try to keep you in your sport as long as you can, unless it's too bad.

Interviewer: So really, pay attention to what your body is telling you, and it's a great resource you can take advantage of that is fairly reasonably priced if you have insurance through the U.

Trina: Absolutely.

Interviewer: What about somebody that doesn't have insurance through the U?

Trina: People that don't have insurance through the U, we do take cash pay. We try to be kind with that, and if you pay upfront, it's a 30% discount.

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Interviewer: It's time for Seven Questions for a Specialist. Today we have Rob Shingleton. He is a physical therapist. I'm just going to ask you seven questions, seven answers. You ready?

Rob: All right, shoot.

Interviewer: All right, here we go. What's the best thing I can do for optimal body function?

Rob: Our motto is exercise is medicine.

Interviewer: All right. What's the worst thing I can do other than not exercise?

Rob: Well, not exercise.

Interviewer: Sure. Is there something else?

Rob: Well, overeat.

Interviewer: Yeah, sure. That's a big one, right?

Rob: Under eat, overeat.

Interviewer: What's the most common problem that you encounter as a physical therapist?

Rob: Probably obesity.

Interviewer: All right. I know you specialize in a specific type of physical therapy.

Rob: I do.

Interviewer: Is that the case in your specialty as well?

Rob: I think as a whole obesity is a very overriding problem.

Interviewer: Why is physical therapy so awesome?

Rob: Wow, isn't that obvious? I think it's just because we get people moving. We try to get them healthy. We try to instill a positive attitude in the patients.

Interviewer: A lot of times you're kind of a cheerleader, aren't you?

Rob: Oh, definitely.

Interviewer: Yeah, in addition to giving knowledge and helping people get back to work quicker.

Rob: Cheerleader, social worker, case manager, trainer.

Interviewer: What can't physical therapy do?

Rob: Well, we can't cure your underlying disease.

Interviewer: Yeah. You just make it a little bit better maybe.

Rob: We can help you get through it.

Interviewer: I thought you were going to say it can't do itself, that it's really up to the patient to do a lot of the stuff.

Rob: Well, we can certainly give you good home programs, but ultimately it's up to the patient.

Interviewer: Got it. Is there an exercise that you think everybody should do?

Rob: Aerobic exercise, whether it's walking or upper body aerobics or water aerobics or . . .

Interviewer: Get that heart rate up.

Rob: Yeah, get your heart rate up.

Interviewer: Why did you specialize in physical therapy?

Rob: Originally I kind of looked into medical school, some other areas in healthcare. I was always involved in sports in high school myself, had a lot of injuries, went through a lot of physical therapy, so it was just kind of a natural transition for me. It was something I had experienced and thought, wow, I'd like to be like that guy.

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Announcer: Seven questions, seven answers, it's Seven Questions for a Specialist on The Scope.

Interviewer: All right, it's time for Seven Questions for a Specialist. Today it is physical therapist Randy Carson. Are you ready? I'm going to ask you seven questions. Just answer them as quickly as you can.

Randy: Yeah.

Interviewer: What's the best thing I can do for optimal body function?

Randy: Exercise.

Interviewer: All right. What's the worst thing I can do?

Randy: Eat poorly.

Interviewer: Why is physical therapy so awesome?

Randy: I think it's so awesome because we still have a lot of one-on-one time with patients, where that's pretty rare in the healthcare industry.

Interviewer: What can physical therapy do that most people are unaware of?

Randy: That's a good question. In my area there's probably not a lot. I will say a misconception is that we give a lot of massages.

Interviewer: It's not the case?

Randy: I'm going to turn your question around. That's not the case.

Interviewer: What exercise should everyone do? Is there some exercise that everybody should do?

Randy: Absolutely. Everyone should walk and walk a lot.

Interviewer: What's the most common question you get asked when somebody finds out what you do? You're at a party. What happens after that?

Randy: It usually has to do with shoulder or knee pain and a lot of knee pain when I run.

Interviewer: And they want to know what you can do about it.

Randy: Yes.

Interviewer: What can you do about it, by the way?

Randy: Well, you should definitely get in shape so that you can run instead of trying to run to get in shape.

Interviewer: All right. Why did you specialize in physical therapy?

Randy: It's kind of a funny story. Way back when I was in 7th grade, I decided I wanted to be a PT after watching a news special on someone with a spinal cord injury that learned how to walk again. I decided way back then to do it, and I never turned back. That's the area of the field that I work in 23 years later.

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Interviewer: What are the methods that physical therapists use to treat pain? It's more than just movement exercises. We'll talk about that next on The Scope.

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Interviewer: Tamara Dangerfield is a physical therapist at University of Utah Health Care, and she specializes . . . her branch of physical therapy is pain management. That's what she does. And it might surprise you to find out that there are different ways that physical therapists can help you manage pain. I want to find out more about those. So let's talk about that.

Tamara: There are many things that all physical therapists do. There are other things that some physical therapists do. The things that all physical therapists tend to do that can be very effective, they use electrical stimulation, a TENS unit. A lot of people have tried various forms of electrical stimulation on their own. In the physical therapy, that's often in conjunction with something we do. Yeah, it's just . . .

Interviewer: Those little pads that kind of send those pulses to you.

Tamara: Yeah. But it feels like a little tingly pulse that goes through your skin, and it interrupts the pain signals to your brain, so it's a useful way to treat pain. They use traditional modalities at times, heat based modalities, cold based modalities. There are lots of categories within that. There are laser treatments that are used. There's ultrasound that's used.

Interviewer: Really?

Tamara: There are different technologies to deliver heat or cold, and all of those things tend to have effect at the cellular level, and really, we believe most of what they do is improve blood flow or cellular regeneration to the region, and that's largely how they treat pain. About two years ago in the state of Utah, we now have the option to do dry needling, which is a form of treatment that treats myofascial trigger points. So literally sticking a needle in a trigger point in a muscle.

Interviewer: Is that like acupuncture?

Tamara: The needle is like what they use in acupuncture, but it is very different than acupuncture, primarily because physical therapists are not acupuncturists, and the training and the assessment tools and the treatment tools and techniques that an acupuncturist use are very different than what I would use.

Interviewer: Got you.

Tamara: When I use dry needling, I use that as a way to just get a trigger point and a muscle to release. You can use manual pressure to get trigger points and muscles to release, and different massage types of techniques can also be very helpful. Trigger points cause a lot of pain and a lot of movement restriction, so when you can get those to let go, you restore both of those things. It helps with pain and restores movement.

Interviewer: And if you have a muscle therapist that does manual trigger points and that's not quite working, is the needle like the next step up for those stubborn ones?

Tamara: Yeah. I think typically, that's how it's used. A lot of times, the movement therapies alone work well enough. Sometimes you need to add some manual therapy to that, and when all else fails, you can stick a needle in it. Sometimes it's good to start with that too. It just gets deeper. It allows you to get deeper into the tissues then in a shorter amount of time. But I would just like to add, that all of the modalities, all of the, you know, bells and whistles and things that we use to help treat pain, ultimately need to restore movement, because that is your body's way to treat pain.

Movement is how you keep things functioning in your body, and so if you're using those modalities, again, as some type of opioid or some way to avoid movement and restoring normal movement to a region. So range of motion, strength, flexibility, all of those things that you need to restore normal movement. And sometimes just being aware of the pattern. Those are the things ultimately, that you really need to have your body take care of its own pain.

Interviewer: That sounds a little counterintuitive, right? One would think that if I'm experiencing pain I should not move and let that rest and let it recover, but really movement in a lot of cases helps.

Tamara: Yes. And that's what science has learned more and more. Literature repeatedly points to movement as the way to address chronic pain problems. In the very acute stages of pain, after a surgery, right after an injury, pain is a signal to your body that something's wrong and you should be careful with it, but that doesn't mean that you shouldn't ever move it again. And when the initial injury has healed, it is critical that you start moving again, or else you're just going to end up aggravating something else.

Interviewer: So it sounds like you have a lot of different ways that you can help somebody with their pain if they come to a physical therapist, especially somebody that specializes in it, such as yourself.

Tamara: A lot of different ways.

Interviewer: The goal is to get rid of that pain so you can restore your normal movement which then ultimately helps the pain continue to be managed.

Tamara: Absolutely.

Interviewer: And you find a lot of your patients have success with these methods.

Tamara: Yes. They do. And the other thing that I just would like to add as a pain management physical therapist, and this is not something that you might always find within physical therapy, but I think you'll find more and more is mindfulness based techniques, mindfulness and the use of relaxation techniques, diaphragmatic breathing, even mindfulness meditation, to help keep the nervous system kind of quieted down as you work on restoring movement. Sometimes, movement just becomes so highly associated with pain that people are very afraid of it, and I think that's probably the biggest driver as to why people might stop moving or avoid moving, as they're just afraid of the pain and they haven't learned how to make the movement as comfortable as they can, and to actually figure out how to listen to their body, and how much is okay.

Interviewer: So lean into it a little bit.

Tamara: Lean into it a little bit. Don't be afraid to move, but don't be afraid to change it up a little bit if it's not working. You know, if one type of movement or one type of exercise or something isn't working for you, you can change it. There's different ways.

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Interviewer: Physical therapy. It helps in more ways than you might think. We'll examine that next on The Scope.

Announcer: Health tips, medical news, research, and more, for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: You know, many people only have kind of a tip-of-the-iceberg idea of what physical therapy is and what the benefits are, and, I guess, even for me, I primarily think about a physical therapist as somebody who helps me recover after, like, a knee injury, or surgery, or some sort of traumatic injury like a car crash, but Rob Singleton is a physical therapist at University of Utah Healthcare, and he says that there are actually other ways that physical therapists help, and you've been down many of the paths. You started out in the common one, which is, like, the orthopedics.

Rob: Yeah, about 22 years ago when I graduated, I started out in, you know, right out of school in sports medicine, orthopedic rehab. And I think that's kind of the common area that most people think about when they think about physical therapy, is like, you know, your typical ankle sprain, knee sprain . . .

Interviewer: I've got a wrist problem.

Rob: . . . football injury. Yeah, carpal tunnel, all that kind of stuff.

Interviewer: Sure. So you started out there, and then you got more and more specialized. Explain that path.

Rob: Well, I did that for about seven years, and then had an opportunity to come up to the university, and actually filled in for a therapist who was working in wound care.

Interviewer: Wound care?

Rob: Wound care. So physical therapy, we do a lot of wound care.

Interviewer: That just boggles my mind. I never imagined that. And what's the ultimate reason that you would seek out a physical therapist to do wound care?

Rob: Typically it's for ulcers, either like a diabetic ulcer, stasis ulcer, venous ulcer.

Interviewer: And then the goal of that physical therapy for that wound is to keep it from getting worse, to help it heal?

Rob: Yeah, keep it clean, help it heal.

Interviewer: Got you, all right. And then you've moved on from even that, now.

Rob: Yeah. So I did that for a while, and then got really interested in rehabilitation for neurological injuries, brain injury, spinal cord, stroke, and then was on the inpatient rehab unit for about eight years, mainly working on the spinal cord injury team.

Interviewer: Got you. So, boy, we've already learned a couple of things that I didn't know physical therapists did--wound care, and I guess, now that you've mentioned it, like, neurological things. That makes sense. What are some other areas a physical therapist might work in that I never would have guessed before?

Rob: Oh, wow! You know, there's therapists in pain clinics that works, you know, with pain management, and you have, of course, the orthopedic. There's acute physical therapists who work in the hospital, on the hospital floors with, you know, either in the intensive care units or the regular units. And really they're kind of the first line of defense as far as the hospital goes, you know, because your therapy starts right there. So they're the building block, really.

Interviewer: Gotcha. So there's a lot of different areas that physical therapists work. Is their kind of one overriding, though, goal or mission of what it is that you do, regardless of where you are?

Rob: Yeah. I guess if you could put physical therapy, define it by one word, it would be mobility. We're the profession that wants to get people moving, you know, either back on your feet, or moving in your wheelchair, or, you know, however you move. We want to get you back.

Interviewer: Regardless of the reason that is inhibiting your movement?

Rob: Yeah, back functioning, moving, being mobile, being as independent as possible.

Interviewer: So, like, even in the burn unit, it just occurred to me, like, when a young child burns their hands, that can cause mobility issues. A physical therapist would be there helping them with that.

Rob: There are physical and occupational therapists in the burn unit, you bet.

Interviewer: So when it comes to physical therapy and the overall kind of, what they call the continuum of care for patients, I'm trying to think . . . I was going to say, like, toot your own horn, you know. What is it you guys have, but . . . but let's maybe go the opposite direction. What would it be like without physical therapists?

Rob: Wow! That's an interesting question.

Interviewer: Like how it change . . .

Rob: People wouldn't get pushed as hard after their surgeries or injuries to get better, I don't think. You know, and that was, I think, probably historically how it was, that if you had a major surgery, or an injury, or an illness, you would be discharged from the hospital and go home, maybe have some nursing care, and then you'd kind of be just left to your own accord to get better.

Interviewer: To figure out on your own, yeah.

Rob: Yeah, to start getting up, to start moving.

Interviewer: So with physical therapists in the picture now, you push patients to get better, which helps them heal faster, get back to their life in a way that . . . like it was before, so it's not less than?

Rob: Yeah, and research is very clear that, you know, early mobility leads to faster recovery.

Interviewer: And the trend is getting, you know . . . get people up quicker and quicker. My mom had a knee surgery and she was up the next day.

Rob: Yeah, and I know they're doing a study now on in one of the inpatient acute units on really early mobilization in the intensive care units, and that's showing some really promising results because, you know, when I was up there, it was kind of, "Oh, you know, let him be for a little bit. Don't push him too hard. Get him moving." But towards the end of my stay in the inpatient intensive care units, it was really, you know, "We've got to get these people up as quick as we can, as safely as we can."

Interviewer: What are some common misperceptions about physical therapy or physical therapists that you run into?

Rob: I think probably the biggest misconception is that that we like to torture people.

Interviewer: You don't?

Rob: No, we're really . . . well, you know, I speak for myself, for the most part, very loving, giving, healing kind of people, tend to be very gentle, but we can push you. But we certainly don't want to inflict pain. Pain can certainly become part of the process, but it's not our goal to hurt you.

Interviewer: At kind of the end of the day, if, you know, somebody is just finally kind of having their mind broadened as to what physical therapists can do, and that they help in a lot of different areas, how would somebody know if maybe a physical therapist would be somebody they want to seek out for a condition or an issue they have, you know, beyond the obvious?

Rob: Well, I think you know, with the internet and Google, if you type in your condition and how it's treated, with most things, you're going to see therapy, in some sense, come up as a treatment option.

Interviewer: So maybe a good new paradigm for somebody to have is that physical therapists, instead of just being in one place, are probably everywhere.

Rob: Yeah, and I think people, you know, would be quite surprised when they come into clinics and there's a physical therapist there.

Interviewer: It's nice.

Rob: You know, we're in a lot more areas than people really realize.

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Interviewer: How has physical therapy progressed in order to help get patients back to the activities that matter most to them? We'll explore that next on The Scope.

Announcer: Health tips, medical views, research and more, for a happier and healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Rehabilitation physical therapy has changed a lot over the past few years and as a result, patients are able to get back to the things that matter to them more quickly and in better ways. Randy Carson is a physical therapist at University of Utah Health Care. Let's first start by taking a look at what it looks like, what it looks like today and maybe what it might look like in the future. So 20 to 30 years ago, physical therapy, what did that entail?

Randy: So in my area which is inpatient rehab a lot has actually changed. One of the main things is the amount of time that we get with patients. So in the past somebody might have a stroke or a spinal cord injury or a traumatic brain injury and we'd have them in inpatient rehab for two, three, four months, sometimes even six months with like a spinal cord injury. Now we have patients for three weeks maybe even four weeks. On the outset we might have someone for a month and a half.

Interviewer: So that doesn't sound good. I would want more time with my physical therapist. But I'm sure it is a good thing.

Randy: Well, it's been good and bad. And I understand why you would think that's not a good thing. And it's not in the sense that the body doesn't really heal any faster.

I think one big misconception that people in rehab are different than you and I. But in all actuality it's you, it's me, and we're one car accident away from being in there. So if you break your neck in a car accident, there has really not been a lot of change in our body's ability to heal a spinal cord injury. So we are under a lot of constraints that quite frankly are insurance driven to get people home quicker.

But like you said there's some good. The good that's come out of this is patients obviously spend less time in the hospital and it's also shaped our practice a little bit in the sense that we're a lot more aggressive with patients than we used to be. So if you had six months, you took six months to get someone better. And what we're finding is if you have six weeks, you're finding yourself doing things that you didn't dare do in the past. And it's really pushed the limits on intensity of exercise, and maybe less of a linear approach that's taken towards patients and making them better.

So a good example of that would be, you know, a stroke patient that can sitting, doesn't have sitting balance because the stroke has altered that. In the past we would work on sitting 'til no end until they could do it. Now we might even bypass sitting and go straight to standing, which is absurd to think about working on standing when someone can't even sit. But what we've learned is that you skip a step like that and sitting balance falls into place on its own. That's something we've learned because of being pushed to be more efficient and be faster.

Interviewer: Yeah, and as we look at the past and the present too, I think that research has even shown that that more aggressive approach is better.

Randy: Yeah exactly. And I think the research has actually almost found that. It's looked at, we used to spend this amount of time with patients, now we are spending this amount of time with patients. But our outcomes haven't actually suffered and in some cases are even better.

Interviewer: Yeah, expectations have increased and outcomes have increased as well. What are some of the other differences between say 20 to 30 years ago and today?

Randy: I'll actually talk about something that's not different. A physical therapist's main job is to working with a patient and be one-on-one with a patient and there has not been a replacement or you might call it an advancement. I would consider it maybe not even an advancement if we lost that opportunity to work on patients.

And then as far as equipment goes, it's been both the same and some differences. We still use bare bones equipment of our hands and our skills and mats and wheelchairs and crutches and walkers and canes. And that hasn't changed and I don't really see that changing. But what's been exciting is the introduction of things like robots, robotic treatments, treadmill training where we can actually put someone in a harness and suspend them over a treadmill and use training on that. You kind of name it as far as devices have been a big, big, change in the last 20 years or so.

Interviewer: Yeah, that one-on-one hasn't changed but some of the technology that allows you to do some of the things you haven't been able to do has changed.

Randy: Yeah.

Interviewer: What about the future? I would imagine that one-on-one is still going to be a big part of what physical therapists do because there is no one size fits all. Every individual is an individual. Just because two people had a car accident doesn't mean that they've responded to it in the same way. So what's in the future?

Randy: I think the general trend in the past and now is smarter and more efficient. And I think we'll probably move to that direction, keep moving in that direction. I think in the past we haven't really set up a facility to optimize care. And we're talking about building a new rehab center right now. And to build a facility that's a little bit smarter, patient focused. So I see that as a big opportunity for growth as far as smarter and more efficient. And we're probably going to be pushed to get home people even a little bit quicker, even though I feel like we are probably hitting the boundaries there. And then technology is definitely going to be a continued growth area in therapy.

Interviewer: What out there in technology? You mentioned a couple of things like the treadmills. Is there anything out there that is kind of out of your reach at this point that you are excited to see maybe come into fruition?

Randy: Yeah, right now robotics is in more of a tease phase. They're out there and they're not really that useful yet. But I think they are going to become second nature useful and really easy. For instance, right now to walk, you know a lot of our patients don't have tolerance to walk long distances, so it may take 30 minutes to set them up in a robotic gate training kind of device right now, to walk two minutes. So obviously that's very inefficient. So I think the set up time and the devices have a long way to go and I think they'll get there for sure.

Interviewer: Any final thoughts? Anything that I should have asked? Anything you feel compelled to say?

Randy: The one thing that I would stress is if you ever find yourself in a rehab center, when you look at it, it kind of looks like a war zone, you've got people in wheel chairs that are not able to stand. They might have two or three people helping them to stand, or devices helping them to stand. But I would just stress that they're the same people as you and I and you could find yourself there.

In fact, we've had a lot of people that work at the hospital be in rehab. We've had celebrities be in rehab, we've had a lot of people be in rehab. So if you ever find yourself and you take a look, it might be kinds of shocking when you look at it more like a portrait or picture. But if you come back day after day and you see the tremendous progress that people make, you really kind of get rehab then.

So if you come once you'll be shocked and afraid to ever step foot in there again, but if you keep coming back day after day, you really see that miracles that people . . . you know they wheel in or maybe even wheel in a wheelchair or wheel in a bed when they get there and they walk out of there. That's really the beauty of the job I do.

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Dr. Miller: Can you do everything you always wanted to do after your knee or hip replacement? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today, The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi. I'm here with Dr. Chris Pelt. He's an orthopedic surgeon in the Department of Orthopedics here at the University of Utah. Chris, what do you tell your patients after they've had a knee or hip revision or replacement? Can they do just about anything that they used to do or wanted to do but couldn't because of pain or limited range of motion?

Dr. Pelt: So, patients will undergo hip and knee replacements at younger ages than ever before today.

Dr. Miller: What is an average age, by the way?

Dr. Pelt: So, the average age is actually around the mid-50s, whereas, if you think about the 1960s, '70s, and '80s, when joint replacement was in its infancy, the average hip replacement or knee replacement would be done on patients in their upper 60s, 70s, and 80s, and that age has been pushed down further and further as our outcomes have improved with joint replacement surgery, and patients today are more active at a . . . later into life with higher intensity activities, and they really want to be able to do those things that they've always loved doing later into life, and so . . .

Dr. Miller: Well, I remember there used to be more restrictions, or at least thought to be restrictions, on what activities could be done following a joint replacement, but that's changed a little bit. That thinking has changed with the new, I guess, prosthetic devices. Is that right?

Dr. Pelt: Our implant technology has definitely improved over the years. Our bearings are wearing at a lower rate and lasting longer now, and, like I said, we're doing them in younger and younger patients who want to be more active. So, we used to tell patients that they should be more sedentary, that they should avoid doing certain activities, and as time has progressed, we've pretty much relaxed most of those restrictions on our patients. We have patients that snow ski 300 days out of the year if they can. They will . . .

Dr. Miller: What about playing tennis or racquet sports?

Dr. Pelt: They love to do it, and they will do it, and we tell them it's okay. There are some . . .

Dr. Miller: And they shouldn't worry that they're going to wear down that prosthetic joint?

Dr. Pelt: I don't think so, and if it did, there may a revision option available for them in the future, but we really haven't seen significant failures of our implants due to patients being more active. In fact, if anything, I think an overall patient's outcome is improved when they're more healthy and active into their later years as opposed to being sedentary. So, I would encourage most patients to be more active and do those fun things that they want to do, so, golfing, tennis, hiking, skiing.

Dr. Miller: Running is maybe one you're not so clear about?

Dr. Pelt: Running is the one activity I might tell a patient that if they did that as their activity of choice for exercise, that perhaps they could choose a lower impact activity.

Dr. Miller: Cycling?

Dr. Pelt: Cycling, swimming, elliptical, any of these would be lower impact and perhaps a little bit easier on the implant. But ultimately, we do have patients that still love to run. They run whether they're playing basketball or racquet sports, like you mentioned.

I've done a hip replacement on an 80-year-old woman who enjoyed running marathons, and she had come in to see us at our six-week appointment and had already run a half marathon, which is a little bit premature. We do have to let the implants grow into the bones, but people want to be active, and they will do things. When they feel better after having their arthritis pain relieved by the surgery, they will become active again, and we want to encourage them to do that.

Dr. Miller: So, if you're getting an implant, let's say at the age of 50, how long if you're still cycling or skiing might that implant last?

Dr. Pelt: We expect 15 years on the average for a knee replacement and maybe 30 years for a hip replacement, even when a patient's really active. The differences there have to do somewhat with the type of bearing, where a hip replacement is sort of a round against round, versus a round against flat bearing of a knee replacement. But many knee replacements we see back in follow-up at 20 plus years, still doing quite well, and many of these patients have been active for much of their lives.

Dr. Miller: Do you see the technology evolving in the future, where the implants will last even longer eventually?

Dr. Pelt: Yeah. I believe it's coming out soon. I mean, there's new improvements. May not be in the next 5 years, but perhaps in the next 10 years we'll see some improvements for longer-lasting bearings in implants as surface coatings and the types of materials that we're using start to improve. The bearings that we use may evolve slowly and continue to show improvements.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.