Search for tag: "physical therapy"

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: 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: 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: What is spinal stenosis? Could you have that as a problem? We're going to talk about that next on Scope Radio.

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Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Ryan Spiker. He's an Orthopedic Surgeon and a Professor of Orthopedics here at the University of Utah. Ryan, what is spinal stenosis and who gets that?

Dr. Spiker: It's a great question. Spinal stenosis is very common, especially as we age. So in the elderly population, what happens is you get some reason for compression of the nerves in the low back. This is often from arthritis, degenerative changes, and slowly that compression can lead to pinching of the nerves in the low back, which leads to weakness and pain in the legs.

Dr. Miller: So the anatomy is . . . tell me about that. The spinal cord goes down through the vertebrae, which are the bones of the spine and they travel through a tunnel. And what happens? That tunnel becomes narrow, is that what happens?

Ryan. Absolutely. So at the bottom of the spinal cord, there are still nerve roots and all those nerve roots end up innervating our legs, providing sensation and strength to our legs. And in that bottom part of the spine, just above the pelvis, it's common for arthritis to lead to hypertrophy or thickening of the ligaments, thickening of the disk and then compression of those nerve roots. And that compression leads to the pain that often shoots down into the legs.

Dr. Miller: So is spinal stenosis then a condition that someone who is a farmer or a laborer would get more commonly than somebody who was maybe working at a desk, or does it matter?

Dr. Spiker: So it does matter. There's some effect of environment so what we do. Sitting is actually very bad for our backs and so that can be a risk factor in and of itself.

Dr. Miller: So a clerk or a professional who's sitting a lot might be at greater risk than even somebody who is out working all day?

Dr. Spiker: Absolutely. Depending on the type of the work and there are also some genetic risk factors that we've studied here at the U that have been shown to impact how often family members will get spinal stenosis.

Dr. Miller: Well, tell me a little bit about what the symptoms are.

Dr. Spiker: The most common symptoms are pain or weakness or heaviness of the legs and it's usually worse when people are standing up and walking and improved when they bend forward. So if they're using a shopping cart or if they're using a walker, it feels much better. But again, it's worse when they attempt to stand up straight or extend their back.

Dr. Miller: What kind of pain is it? Is it a burning pain in both legs generally, if they're walking more than a block, I mean if it's severe?

Dr. Spiker: Often, people will describe some burning sensation. Commonly, it's a heaviness. It's a feeling that their legs are disconnected from their body. It can be a sharp pain that shoots down the spine. There's some variation with nerve pain, but invariably, it's worse with walking and usually goes down the back of the legs and can go all the way down into the feet.

Dr. Miller: What age groups are most susceptible to spinal stenosis?

Dr. Spiker: So, for most patients, it's as they get older so usually in patients that are 50 or 60 or above. Certainly, there are causes of spinal stenosis such as fractures or really large disc herniations that can occur in a younger population, but the vast majority of patients are a little older.

Dr. Miller: In a previous talk, we talked about sciatica and how that's caused by disc herniations mostly. Would spinal stenosis be more common or less common than disc herniation-related sciatica?

Dr. Spiker: So similar in different groups. So at a national level, certainly more common to have spinal stenosis than disc herniations that would cause somebody to see a spine surgeon like me. Most spinal stenosis patients will have some progression over time or continue to have symptoms, whereas most patients with disc herniations will get better on their own and this won't require to come in to see a spine surgeon.

Dr. Miller: So tell me about the therapies, treatments, for spinal stenosis. Obviously, it depends on the severity of the problem.

Dr. Spiker: Absolutely. So our first line treatments are anti-inflammatory medications, non-steroidal anti-inflammatories.

Dr. Miller: Ibuprofen, naproxen, aspirin, things like that.

Dr. Spiker: Exactly. They help calm down some of the inflammation from the area of compression. And then getting people into physical therapy to help strengthen their core, take some of the stress off the bones and the nerves of the back.

Dr. Miller: Would you say that physical therapy is kind of an underused and underappreciated modality?

Dr. Spiker: Absolutely, absolutely. And often, I would say 60, 70, 80% of patients that I see in my clinic have not yet undergone physical therapy and anti-inflammatories. And sometimes, these simple interventions can really change the quality of their life.

Dr. Miller: How long would it take before someone would know if physical therapy was actually working?

Dr. Spiker: It's a great point that it does take time so often the first few weeks can be frustrating because it's difficult and it can cause some pain, but usually, within six to eight weeks, people start to see the fruits of their labor.

Dr. Miller: In your experience, when then do you start talking about a surgical solution to the problem?

Dr. Spiker: So surgery is always the last option, it's never the first option. And fortunately, we can usually get people better with the anti-inflammatories, the physical therapy, some nerve medications, neuromodulatory medications like gabapentin, sometimes even injections. If all of these fail and the symptoms are progressive and really causing a change in their quality of life, that's when we talk about surgery.

Dr. Miller: And surgical outcomes, how well does it work?

Dr. Spiker: So surgical outcomes are excellent in well-selected patients. So in patients that have gone through the right preoperative therapies and interventions, it ends up about 80-85% of people are much better after surgery than they were before.

Dr. Miller: That's a great outcome.

Dr. Spiker: Yes.

Dr. Miller: And over time, does that hold?

Dr. Spiker: It does. So we have great data up to about eight years now showing that people have continued benefit with surgical intervention for at least eight years and we certainly think longer.

Dr. Miller: Well, thanks, Ryan. So for our audience, basically surgery is the last option, but it has an excellent outcome. But prior to surgery you want to think about a good trial of physical therapy and the use of over-the-counter non-steroidals like ibuprofen and naproxen just to try to control the pain while you're testing physical therapy and working with your therapist.

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Dr. Miller: Medicine may not be the only nor the best treatment for low back pain. We're going to talk about that next on Scope Radio.

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Dr. Miller: Hi, I'm Tom Miller and I'm here with Dr. Rich Kendall. Rich is the Chair of the Physical and Rehabilitative Medicine Department at the University of Utah and we're going to talk about treatment of low back pain with non-medical modalities. Rich, tell us a little bit about physical therapy and how that relates to back pain and how exercise helps people improve their lower back pain. I think it's an area that's underutilized.

Dr. Kendall: Many people with back pain, just exercising on a daily basis will really reduce the intensity of their back pain quite a bit. Many studies have shown that back pain and exercise go well together. It can help with sleep, it can decrease back pain, lessen medication use, and even avoid surgery.

Dr. Miller: Rich, tell me a little about certain exercise modalities or maybe they're called stretching modalities, something like Pilates. I know that a lot of people say that Pilates is good, it improves core strength, but that may also translate into improved back strength and health.

Dr. Kendall: Well, Pilates is a very good exercise, but really there is no evidence that one form of exercise is any better than another form. Core-specific exercises, Pilates, Yoga

Dr. Miller: Yoga.

Dr. Kendall: A gym program where you lift weights. Really all of them can work in decreasing back pain. Now sometimes if an athlete is already doing a very rigorous program, they may need physical therapy with targeted exercises. But, in general, most people just sticking with a generalized exercise program and whatever they like. The key is doing something they like so you'll do it all the time.

Dr. Miller: One of the things that I struggled with is I didn't always have enough training in what physical therapists do. Do you find referring to a physical therapist to be helpful in cases where you're going to prescribe exercise therapy for people with back pain?

Dr. Kendall: I think for most people, starting with a physical therapist is a great idea. They're going to demonstrate the exercises. The therapist will watch that they can do the exercises correctly, that they have good form while doing the exercises, and also be able to look at other associated joints whether there's hip tightness or leg tightness, arm or neck tightness to try to work on some of those adjacent areas as well. But a lot of times, we'll start with a therapy and even then sometimes transfer over to a personal trainer.

Dr. Miller: Do you find that some patients are skeptical of exercises therapy? That they might seek medication instead? And how do you deal with that?

Dr. Kendall: A lot of people certainly are skeptical that exercise will do that. Nobody likes to exercise. Years ago, it was probably one of the hardest things to convince patients of. Now that everybody has to pay $35 or $50 a copay to go see a physical therapist, with two visits to a physical therapist you've paid two months of a gym membership. I can really convince people to exercise a little bit more. But many of the studies actually are showing people with degenerate discs, arthritis of the back, exercise is probably the best thing, even as well or better than surgery.

Dr. Miller: Rich, why is exercise beneficial in treating back pain compared to taking analgesics like Aspirin or Ibuprofen? How does exercise help in the long run?

Dr. Kendall: Well, there are a couple of reasons. First, you're strengthening your muscles. You really support the spine a lot better and with any arthritic joint, you strengthen the muscles around it, you load the joint a lot less and that triggers less pain from the joint. The second is you will get some change in the neuro firing patterns and how your brain perceives that pain. So overall your pain will be noticed less by your brain.

Dr. Miller: Could you explain why patients might be skeptical about utilizing exercise therapy or physical therapy to improve their condition?

Dr. Kendall: Well, one of the biggest things is that people already hurt doing very little activity and they think that doing more activity is going to hurt even more. So that is one thing that we have to overcome. The other is that they've probably been to therapy before or they've tried an exercise program and it may have helped them briefly, but then as soon as they stopped their pain came back. So they think it might be something more serious. Dr. Miller: So the key thing then is, number one, making sure they receive the proper instruction on the types of exercises that'll help strengthen the back and reduce the pain, but also encouraging them to keep up the exercise routine over time.

Dr. Kendall: That's true. Keeping it up is key and I always tell patients you can take a day here or a day there essentially Christmas and New Year's Day off, but every other day you should be doing some kind of activity. Whether it's five minutes or 10 minutes, that's great, but some kind of activity.

Dr. Miller: So, Rich, for patients that have mild to moderate back pain and who may not feel like they need to go in and see a physician, is there a website or a place they could go to find out what types of exercise might benefit them? Or do you even advise that?

Dr. Kendall: I think searching the web is a very difficult thing. If you type in low back exercises you get about 5 million websites to look at on Google. Knowing which one is correct, knowing which one is somebody just in their living room with no certification thinking that they're an exercise fitness guru is difficult. Really, I think that most people, unless you have an exercise background, seeing a therapist just one or two times, or even going and seeing a personal trainer at the gym it'd be a great place to start.

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