Week 8

Hello everybody.

            Now that I am entering the final week of my internship, I would like to evaluate the progress I’ve made in my research from beginning to end. My question going into the project was, “What physical therapy methods at Synergy make the treatment advantageous over others?”

After working there for several weeks, I have a few answers that make Synergy unique in its approach.

            The first method I learned occurs in the evaluation stage of a patient. When a patient comes in with an injury, the job of the therapist is not to just discover more about the injury, but what caused the injury. As seen in Allan, the actual root problem to a calf tear was poor ankle joint movement. We have to treat all weaknesses in the kinetic chains of movement throughout the body to ensure health. If one muscle is injured, its counterpart is probably either injured or weak.

            The second method involves releasing tensions with aggressive manual therapy. Often, injuries to a muscle will force the muscle’s tendon or neighboring muscles to pick up the slack. This causes scar tissue buildup and tightness, as tightness gives the muscle/tendon more leverage and simulated strength. The body relies on these compensations to avoid hurting the injury further. Everything around the injury protects it in these unhealthy manners. It takes a great deal of effort to work out the knots formed from long-term habits. But the re-injuring of the area allows for us to prevent the body’s inclination to protect it at all costs, and instead we can heal the body the optimal way. When the tissue is broken down, the blood vessels regenerate in the area, allowing for healthy muscle growth. Instead of building on tightness, we can actually make the muscles stronger from scratch.

            The third method is teaching what muscles to work during activity and in what situations. This is accomplished by giving the patients exercises that isolate muscles in a strategic manner. The most prominent example would be assigning step-ups to a patient with poor gluteus activation. It is inefficient to avoid a muscle as big as the gluteus when walking, yet most people put unnecessary strain on the rest of their leg by doing so. This phase of treatment is also largely neuromuscular regeneration, teaching the muscles to collaborate with the body and mind.

            There are of course many other details that go into Vincent’s methods, but these are the basic themes he works from. It is fascinating to learn that so many assumptions are completely wrong. A lot of the logic is counter-intuitive. Every patient is a different puzzle. I just enjoy trying to figure out what Vincent’s answer is going to be for every problem we encounter.

Week 7

Hello everyone,

This week I’d like to talk more about my experiences and my role at Synergy. I started out the project carrying around my notebook and watching the physical therapists. Now I have learned enough that Vincent sometimes lets me plan and handle a patient’s visit from beginning to end, with his supervision of course.

I have been there long enough to see the progress in many patients. I have gained a lot of their trust and respect by relaying what I learned from Vincent and using that information on them. A lot of patients need similar exercises for similar injuries. Now that I know the common compensation methods and minor flaws in technique that most patients need corrected, I can coach them through the exercises. I have learned how to adapt specific activities for a variety of physical abilities. The patients listen to my advice and Vincent always checks in to make sure I am coaching them correctly.

When Vincent’s hands are tied, he lets me call in patients to the studio and get them warmed up while evaluating them for the day. I have to record their self-assessed pain and fatigue levels. If a patient is fatigued in the muscles we wanted to work on, then we will just take that as good news and continue with the same therapy. If they report pain we may decide to slow it down. Also, we will first manually stretch them and remove tension in their tissues to loosen their muscles for activity. He will sometimes let me do both. Then we will supervise the rebuilding of that muscle, making sure that it strengthens in the right areas and doesn’t scar in the wrong ones.

Now that I know Vincent’s goals for the patients I see, he allows me to choose the exercises for them. I learned all the purposes different exercises have. For example, if we wished to treat a patient with poor glute activation, we would have them perform single leg stands while reminding them to squeeze the glutes. If a patient had tendinitis in their elbow from not using the flexor muscles in their forearm and instead using the tendons, then we would have to build strength in the forearm muscles with exercises involving the movement of the hand while inside a rice bucket (the rice adds resistance to the motions). After the patient’s visit is over, I have to record what exercises they performed for insurance purposes and for further reference. It requires deciphering whether what the patient did was done manually by the therapist, was a therapeutic activity, therapeutic exercise, or involved neuromuscular regeneration. Recently, I have begun learning how to document this information in the actual format insurance companies use.

Week 6

            This week I learned the process of evaluating a patient when they first start at Synergy. I will show the process by describing Vincent’s thinking process for a patient named Allan.

            Allan walked in with a slight limp. He said he hurt his left calf walking uphill about a week ago. He described it as a sharp pain. Then, last Friday, he was busy with a lot of activities. After that day he told us his pain level was at an 8 out of 10. A day or two before coming in, his right knee began to hurt too. Overall, he only starts to feel pain at the beginning of activities, but can still get through them.

            After hearing his story, we measured his range of joints to get some more clues. First, we tested his ankle joint. In a motion called dorsiflexion, which is moving the ankle to point the toes upwards, he only had 1 degree of motion, both active and passive, whereas most people should have around 10-15 degrees. This stiffness is usually due to low fluid levels. But the takeaway from this discovery is that his calves were probably trying to move his ankle join when the ankle joint couldn’t adjust to the uphill climb, given that the calves pull the ankles into dorsiflexion.

            When we were trying to move his legs in all different directions, he revealed all kinds of compensation methods, like rotating his legs, so long as he didn’t have to use his calves. He also couldn’t stand on his tiptoes. This proved the stiffness in his calves and Achilles was due to them being so weak. The right knee pain that began later was probably due to him compensating on the other leg and bearing too much weight on that side.

            The final conclusion based on that information was that he had a tear in his calf. It couldn’t have been a bone injury because he only feels the pain after activity. We also concluded that it was an interstitial tear, one that goes between strands of calf muscle, breaking them apart, but not actually breaking any strands themselves. If it was a tear that went across strands, then we would’ve noticed a bump in his skin from where the muscle would have snapped and coiled up. Also, he wouldn’t have been able to walk.

            In order to treat Allan, we can’t just break down the calves and build up the strength again. We have to solve the original, underlying problem that caused the calf to tear. And that was the stiffness in the ankle. It is always important to not just treat the injury, but the cause of the injury. And it’s usually not obvious. We taught him stretches for his lower leg to begin loosening up muscle. Later on we will tear the scar tissue. Then we will build up necessary strength. We will also move the ankle joint in all directions forcefully to allow more fluid to enter the joint. When he has range in his joints and strength in the supporting muscles, then we can discharge him.

Week 5

Before I get to the complex topics, I would like to continue covering the basics this week. One greatly overlooked aspect to physical therapy is the patient-therapist relationship. Since therapy requires a patient’s trust and dedication, it is vital that the therapist establishes the ideal image from the second they walk in the clinic.

The first impression is the make-or-break moment that will determine how effective the therapy will be in the future. When a patient comes in for an evaluation, the therapist needs to gain their trust by showing their expertise. They have to explain the problem and immediately create a treatment plan. Then the patient will believe the therapist has a clear idea on their condition, allowing them to follow directions more strictly and to keep them from questioning the therapist.  

In most clinics, there will be TVs around the room. When the news is on, patients will often voice their opinions to other patients and the therapists. They are looking for an excuse to distract themselves from the pain of the exercises. The opinions tend to be very strong and often disagreeable. It is the therapist’s job to nod their heads and let the patient feel like they are in agreement, as long as they never actually say that they agree. We all trust those that are like us. Patients will communicate and listen to therapists that they believe think alike, and the patient feels understood.

The therapist must also know how to treat the patients with different dedication levels. Eager patients need to have their backs patted. Patients will often love to hear that they are doing something right. Other patients may be negative and need the motivation to come from therapists.

Week 4

The more I learn about physical therapy, the more I realize how much people underestimate how complicated the practice is. So many things I took for granted are actually completely wrong. A lot of the concepts are counter-intuitive, but scientifically proven. I’d like to share a few examples.

            Everyone with two legs will tell you that they know how to walk. But 99% of them have a glitch in their movement. Most people assume it would be unhealthy to land on the front leg when it is completely straight. However, it is actually better to do so because the muscles perfectly protect the joints when they are all activated, which can only be accomplished in a straight leg. Also, most people don’t know how to fire their gluteus muscles when pushing off their back leg and fail to push their hips all the way over the planting leg.

            Another misconception is that people think the abdominal muscles should hunch the back forward when they are flexed. They see the Abercrombie models and push their chests forwards and down to try and match their appearance (do not pretend like you don’t do this in the mirror). The actual way the abdominals are supposed to be used is to elongate the spine. They should be sucked in, which you can feel when you suck in your stomach. Then they should be flexed against the spine, which you can feel lift your ribs up. Together with the gluteus muscles, abdominals most influence posture, and good posture prevents most back and neck injuries.

            The last example I would like to share is the idea that stiff muscles should be rested and painless muscles can handle increased work. Most patients assume these as truth during their treatment. They either end up overworking when they leave feeling good, and come back with pain, or they rest too much when they feel stiff and they build up scar tissue. At Synergy, patients are encouraged to stick to their prescribed exercises and stretches, as they are designed to either work out stiffness in tight muscles or build strength in loose muscles. Also, most doctors tell patients to avoid things that will cause pain. They want them to stop the daily activities that can potentially harm them. Vincent believes that instead we should prepare them to handle the activities they do so as not to change their lives too drastically. We train them by practicing what will cause pain, and when the pain comes, we treat them. After several repetitions of this routine, the patient is able to handle the tasks with ease and can return to their normal lives.

Week 3

Hello all,

            Here is a picture of knee flexion, as I talked about last week. Roger began treatment at the 90 degrees position, and is now around the 125 degrees position.

           

            I’d like to use this week to explain the evaluation process at Synergy. When new patients come in, we must first perform an evaluation that analyzes the state of their condition, from which Vincent can determine the best path of treatment.

            The evaluation starts with asking the patient about the injury, such as when it happened, the history of the patient, and any surgeries they underwent. This gives us a general idea. Then we ask about their pain levels. This determines how aggressive we should be in treatment. Additionally, if the patient has constant pain, the injury is most likely in the bones, whereas temporary periods of pain usually signify muscle or tendon injuries. Next, we measure the range by getting the patient to actively move the joint in all directions possible. If the injury is muscle or tendon related, the patient will have the normal passive range, but will be unable to actively move their joints to normal limits. If the injury is bone related, they most likely will have pain for both passive and active motions.

            The beginning of treatment involves learning the necessary stretches to start to loosen the muscles and joints. This makes the therapy more effective and ensures long-term health. So when the patient first comes in, we teach specific stretches designed for their injury, making sure they learn every detail of the stretch. The patients are expected to do the stretches at least 5 times a day, every day. Most patients that do follow this regiment have much quicker recoveries. Since the patients only come into the clinic for a couple hours a week, it is vital that they incorporate the therapy into their daily schedule. Synergy is unique in the emphasis of being proactive and giving the patients the tools to stay healthy on their own.

Week 2

Hello everybody.

This week I’d like to introduce a special case that might shed some more light on Vincent’s philosophy.

What Roger is going through is extremely rare. It all started with a routine knee surgery. Everything was going to be fine, until he got a staph infection after the surgery and was hospitalized for 3 weeks. The damage was so severe that he couldn’t bend or straighten his leg at all. They performed another surgery on his knee to wash out the infection, and he was lucky to live past it.

After that surgery, he spent weeks immobilized, resulting in an immense buildup of scar tissue. Surgery after surgery, they tried removing the scar tissue, but it kept on building up again. Eventually, his patellar tendon got so tight that it started to shrink. Since it is attached to the kneecap, it dragged the kneecap down the more it shrunk. When his kneecap moved down a couple of inches, it only made him even more immobile.

There were no experts in Arizona that knew how to deal with his problem, so he ended up travelling to the Steadman Clinic in Colorado to see an arthrofibrosis expert. After another surgery trying to remove the scar tissue, an orthopedic surgeon at the clinic decided to remove the patellar tendon and cut it out completely, which is what is so unique.

In recovery, his kneecap moved back to its normal position. However, without a patellar tendon, he has instability in his knee, and there is no longer a tendon protecting his ACL, which happens to be reconstructed from an incident he had 20 years ago. He came to Synergy with an active range of 90 degrees flexion, meaning he couldn’t bend his knee past that angle. His leg muscles, particularly his hamstrings and calves, were so weak from atrophy that he couldn’t carry any weight on that leg. Furthermore, he came at serious risk of injuring his ACL. Vincent was able to break down enough scar tissue to where he can now flex at 130 degrees and extend to around 5 degrees, almost completely flat.

Looking forward, he will need a procedure involving the injection of carbon dioxide and saline to inflate the joint and avoid traumatizing it. Then they will put in a graft that will perform as a patellar tendon, protecting the knee and allowing him to move freely. The surgeries will cause him to lose his active range, and he will get weak again. But at least he is now able to have that surgery, and he is prepared for the long journey ahead. The graft will affect not only his active range (how far his muscles can move the joint) but also his passive range (how far the joint can be moved by someone else). And even though he will never fully return to his state years ago, we can help him get his life back together.