Mesodermal movement VI - Here's the plan

[Barrett Dorko]

Last Friday my friend told me that he felt better than any patient one week post-op had a right to. He ought to know, having operated on thousands of others himself.

“What you’ve done to my nervous tissue has made all the difference,” he said.

This man’s surgeon has reduced his post-op protocol to such a degree that it no longer includes a therapist of any sort. “Just start walking,” he says. “Here’s the schedule.” That’s it. That’s the “therapy.”

He has worked for years to reduce the amount of invasion and disruption he has to do in order to accomplish the movement of the mesoderm deemed necessary.

Isn’t it time for someone to tell this man that there’s a therapist who thinks the same way?

[caro]

High time.

[Barrett Dorko]

I saw the patient after posting and after a few days without any work on my part my friend continues to improve dramatically.

He's been in severe pain for 6 months, aside from when he saw me or positioned himself with great care. Despite that, surgery and corrective movement have resulted in a pain-free experience at this point and that has endured for four consecutive days. "I find myself smiling again," he says.

What now?

[John W]

Can he, will he write something about his experience that our colleagues in leadership positions would read?

[Barrett Dorko]

I'll ask.

[tom Reeves]

for what its worth, it seems more likely that he is an outlier and his response to his surgery is better than can be expected by most people. I think that basing his post op rehab protocols, if you will, on an n of 1 is putting the cart before the horse.

We have all had people who required only a nudge. There are many, many more in my experience that need more guidance.

Do you all not see that in your practices?

[John W]

...it seems more likely that he is an outlier and his response to his surgery is better than can be expected by most people...

What makes you think so?

I gathered from Barrett's case description that perhaps taking advantage of a similar mode of thinking to the surgeon's, i.e. minimal care, might provide a tipping point that could help many more patients.

If you're saying that Barrett was probably just lucky, then wouldn't it be worthwhile to find out if he can get "lucky" with more patients by using a reasoned and science-based approach that doesn't bilk the system of dwindling health care dollars?

I think it's worth a shot, myself.

[Barrett Dorko]

The point is that there isn't a rehab protocol in the usual sense and that since the orthopedist has abandoned any contact with the therapy community before or after he does surgery there is perhaps something for him to begin to realize here.

What gets me is the wall built by the surgeon and the medical community in general. I know that there are those who don't see it - but it stands before me and many others. In a way, it's like getting a PT program chair to consider the neuromatrix and what that would mean for their cirriculum. It has yet to happen.

Quite possibly the patient is an outlier, but he doesn't think so, and neither do I.

[Diane]

John, maybe you mean "flipping point".

[John W]

This is a really good point Barrett's making. There are some really perceptive surgeons out there who have become frustrated with the therapy community because they understand what it's become- and it's not pretty, particularly for spine care.

You know eventually and ever so gradually, the consequences we will pay as a profession for our willful ingorance of pain science will come to roost.

Well, maybe not so gradually...

[Barrett Dorko]

I don't blame the spinal surgeon for not telling his patients to go see a therapist after he works so hard to repair what he can. The reasons for that are all through this site.

[advantage1]

It definetely wouldn't hurt to speak with the surgeon. My impression of surgeons is that many are still using a pathoanatomical approach. I would be suprised if he knew about the pain neuromatrix. However, if he is and sees that you are as well then you would be off to a good start.

[Barrett Dorko]

In most cases I would agree, but this guy certainly doesn't want to talk to me, a mere PT.

That's a situation I've faced many times in the past.

[zendogg]

It may also be that surgeons feel that they have done their part and received their remuneration. What's the point of tracking down PTs and checking on their patients? That takes time and energy. Instead they give their patients the ole pat on the back and a fine pamphlet on recovery from a surgery and the importance of seeing a PT for rehab. Then they wash their hands of it. Could be...
Nathan

[PatrickL]

Barrett said:

He has worked for years to reduce the amount of invasion and disruption he has to do in order to accomplish the movement of the mesoderm deemed necessary.

Isn’t it time for someone to tell this man that there’s a therapist who thinks the same way?

this guy certainly doesn't want to talk to me, a mere PT.

Does this mean you wont speak to the surgeon? Who else will speak for you if you choose not to?

[tom Reeves]

Originally Posted by John W

What makes you think so?

I gathered from Barrett's case description that perhaps taking advantage of a similar mode of thinking to the surgeon's, i.e. minimal care, might provide a tipping point that could help many more patients.

If you're saying that Barrett was probably just lucky, then wouldn't it be worthwhile to find out if he can get "lucky" with more patients by using a reasoned and science-based approach that doesn't bilk the system of dwindling health care dollars?

I think it's worth a shot, myself.

I'm not saying that he was lucky really, I just think that there are many people who glom onto the notion that they need help to get better. Probably, they just need nudging in the right directions. Some people don't need the nudge, some need a structured program (at first) until they learn that all movement doesn't hurt. Then they learn that some movements make them feel better, then they learn that moving on with their lives is liberating.

If we use the ortho patient after a knee replacement there is a huge range of patients from the needy patient who has dealt with pain for years before having their surgery and need lots of hand holding, to the "self starter" who is happy to know that the surgery is done and they can get back to their life.

Just in the last two days I have had two patients from the same surgeon, one will be a nightmare because of her dependent nature, and one who happens to be self-employed and was walking with minimal limp using only a cane on day three after surgery.

If the standard procedure for the surgeon is to not have rehab and just walk (I realize that was directed to the post-op spinal patient but analogies can be made with other procedures for a minimalist approach to post-op care) then I suspect that there will be more failures than successes.

[nari]

Post-op recovery varies so much from one patient to the next that it may be impossible to determine reasons for the variability, too many factors to consider.

I have seen 75 yo patients trotting happily around the ward with TKAs or THAs, and others barely able to move by the 3rd day. Post-spinal surgery patients are just as variable, although I found the younger pts tended to have less anxiety and pain than the older ones.

Pre-op education can scare some people and reassure others. What Barrett did with his friend, however, might be the most valuable of the lot.

I don't blame the spinal surgeon for not telling his patients to go see a therapist after he works so hard to repair what he can. The reasons for that are all through this site

I have to agree with this; pre-op education sounds even more important if this statement is considered true.

I watched a friend of mine go through post-op TKA with the PT for four days, and was tacitly concerned with the attitude of the PT. She told him to push as hard as he could through pain in accordance with the protocol. His post-op meds were inadequate (he had a PCA which he forgot to use and the nurses did not check that he was using it for nearly 10 hours). He had moderate to severe pain for nearly 2 months afterwards despite being put onto opioids).

Nari

[Diane]

Not-well-managed post-op surgical pain is a huge source of chronic pain in the general population.
A PT, however well-meaning, who does not have as a focus pain ed. (along with the usual support for the patient e.g., helping them increase their functional tolerance), or doesn't understand the importance of leaving locus of control in the patient, can contribute to longterm unfurling of personal QofL disaster for patients.

[Barrett Dorko]

Patrick asks:

Who else will speak for you if you choose not to?

The patient. I carefully coach them.

BTW, this has never worked either, but I'm pretty sure it hasn't made things worse.

[advantage1]

Perhaps this study will add to the discussion:

http://journals.lww.com/spinejournal...ion.98273.aspx

[advantage1]

Interesting findings:

Conclusion: Early start of rehabilitation (6 weeks versus 12 weeks) after lumbar spinal fusion resulted in inferior outcomes. The improvements in the 12w-group was four times better than that of the 6w-groups indicating that the star-up time of rehabilitation is an important contributing factor for the overall outcome.

[Bas Asselbergs]

Thanks for that article.
My big beef with it is that the "rehab" is group-based. And that it does not describe what education the patients received. And that it does not provide us with info on pre-surgical education.
In my eyes, this study does not provide me with anything useful, sorry.

[advantage1]

There are certainly some flaws in the study design. However, this is what surgeons read and may explain the Rx choice of the surgeon Barrett is referring to.

[advantage1]

Bas,

You don't have to be sorry.

[Barrett Dorko]

If the surgeon reads at all this will not help, and he can easily use it to justify his choice.

To me, it always returns to this: Traditional approaches are senseless and they are usually provided by therapists without the faintest idea of the materials they're dealing with. Doing more of that will make patients worse and will at the same time generate greater revenue.

Am I wrong?

[Bas Asselbergs]

However, this is what surgeons read

Yes, a very good point.

[advantage1]

Traditional approaches are senseless and they are usually provided by therapists without the faintest idea of the materials they're dealing with. Doing more of that will make patients worse and will at the same time generate greater revenue.

Sadly you are right. I wish it weren't this way. It doesn't help that patients are being fed the wrong information as well and expecting treatments that are senseless.