Why do I have a pain in my butt??!!

What do we treat the most at Missing Link Physical Therapy??!!!The pain in the butt!!! No, I don’t mean the client, but literally a pain in the butt sometimes referred to as sciatica or piriformis syndrome. Often individuals have difficulty standing, sitting, walking, running or going up stairs. This pain can be very debilitating and decrease function and quality of life. This blog is aimed to address ways to decrease pain and the necessary treatment required in order to regain your mobility and function.

Frequently when a sudden ache in the butt or leg occurs people always wonder, why? Individuals often don’t experience back pain and have not done anything differently to cause this pain. Well, the body is a great machine and was built to be resilient. Very often by the time you experience a particular pain the movement dysfunction has been present for years. It is like eating the wrong foods and years later you have hypertension and heart disease. In the majority of cases we can contribute the cause of the pain to a nerve irritation in the low back or peripheral muscles. For instance, with mild to moderate degrees of nerve irritation to the low back you can get this abnormal tightness and guarding of the hamstring, gluteal (butt) muscles, calf muscles and even heel pain or cramping of the bottom of the foot.

In order to start recovering from this state you need to remove the irritation to the spine. If the condition is acute this can be done by pharmacological means (please refer to your physician for the appropriate drug of choice). From a Physical Therapy disposition this can be done by avoiding certain postures; such as slouched positions, any activity that may place stretch on the hamstring (want to avoid stretching of the hamstring as it will cause stress on the nerve if there is nerve tension), reading in the bed with legs extended…Basically you want to avoid any position that will place stress on the nerve. Imagine a long string that is attached to your spine and extends all the way to your foot, every time you slouch or stretch the hamstring you irritate the nerve. The stretch may feel good initially but you will find that you may suffer a rebound effect of pain later in the day, with even more tightness in the particular muscle. Figure A shows an individual reaching into a box with a rounded back posture; this will increase tension in the back and also the nerve. Figure B shows an individual stretching the hamstring with a rounded back posture, at this time the nerve may be on maximal tension and irritation may be at its greatest. In Figure C the individual to the left is placing increased stress to the back and nerve, the individual to the right is exhibiting good technique with lifting by hinging from the waist and bending the knees.

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FigureA

hamstring stretch

Figure B

lifting

Figure C

After decreasing the nerve irritation it is now time to improve the muscle tension. This can be done by getting a deep tissue massage, foam rolling or trigger point dry needling (my recommended treatment of choice). You want to improve the muscle length of the gluteal muscles and back muscles. Figure D, E, F, H represent foam roll massages; these massages should be performed as tolerated, slowly kneading out the trigger points in the respective muscles. Figures G and I represent stretches that can be performed for approximately 45-60 seconds. Please refrain from doing exercises if pain is elicited.

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Figure D. Foam roll gluteals

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Figure E. Foam roll TFL

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Figure F. Foam roll low back. Be sure to keep back neutral or slightly flexed in order to avoid excessive stress on the low back.

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Figure G. Piriformis stertch

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Figure H. Foam roll quadrates lumborum (side of back).

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Figure I. Quadratus lumborum stretch (stretch to side of back)

Last step is to stabilize the spine by avoiding an anterior or posterior pelvic tilt. I recommend stabilization of the lumbar spine with the back in neutral.

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Figure J. The picture to the left represents an anterior pelvic tilt. The picture in the middle represents a neutral spine. The picture to the right represents a posterior pelvic tilt.

In this blog I have purposely avoided educating on abdominal stabilization as I believe that the exercise for stabilization should be monitored. The reason individuals have pain in the first place is because of a movement dysfunction, so I highly suggest getting assistance from a trained movement specialist (physical therapist, personal trainer, athletic trainer, pilates instructor, yoga instructor etc.). Pain does not just appear but is comes about due to increased stress being placed on a structure in the body over time. REPAIR THE MOVEMENT AND YOU IMPROVE THE PAIN.

Please take note that in order to have somewhat of a full recovery from this injury you must make sure that you are able to contract the deep abdominals appropriately and work on maintaining the contraction over time with your respective exercise/activity. With practice over time these muscles should contract involuntarily.

Over time if symptoms appear to be unrelenting and worsening we suggest getting further diagnostic testing to determine if there is structural damage such as a disc bulge/ herniation, degenerative changes in the spine, etc. Further medical treatment may be required in order to decrease symptoms prior to initiating an exercise program.

In our clinic we see many of these cases and have been very successful with treatment. We shall be delighted if you call us and schedule an appointment today. I am sure that you want to resolve the nagging pain in your ‘butt’.

You can Contact us at: Phone:703-858-5070, Email: office@missinglinkpt.com, website:www.missinglinkpt.com.

We are located at: 44933 George Washington Blvd Suite 165, Ashburn VA 20147

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Clinical Assumptions versus Clinical Hypothesis

In today’s healthcare system it has become quite difficult to find an answer to your medical problems. This is partially due to the dwindling dollars provided to healthcare providers by third party payers. This decline in reimbursement is evident especially with regards to the provision of Physical Therapy services. Healthcare providers now create a Clinical Assumption versus a Clinical Hypothesis to solve your health care issues. I will be discussing scenarios based on Physical Therapy because that is my field of interest; however, the same thought process can be extended to other healthcare professions.

In an insurance based system, regular Physical Therapy treatment sessions are usually in thirty minute increments. In this thirty minute session the patient needs to update the therapist on his/her progress, the therapist needs to perform a set of tests and measures in order to guide the treatment and there maybe the need to perform a manual intervention followed by exercise.          Is twenty-five to thirty minutes enough time to perform all of these functions?  Just imagine you as the patient or even you as the therapist, it is an anxiety driven process. Before the therapist can complete the patient’s examination/treatment, the next patient is waiting and the therapist has to leave the first patient unattended to perform exercises with verbal instructions. What I have found to be the problem with this system is that it is all rushed and doesn’t leave enough time to understand your patient’s pain and movement dysfunction. The patient has been left alone to do their exercise??!! But the patient has a movement dysfunction!! I believe that the patient’s exercise must be monitored. I also believe that if the patient has dysfunction with his/her daily movement it will be carried over into the exercise resulting in a rebound effect with regard to any pain being experienced. Consequently, the patient’s goal has not been met.  The therapist doesn’t have enough time to figure out if the exercise is appropriate or not, assuming that if the exercise worked for patient A, with the same diagnosis that it will work for patient B. This is an assumption we cannot make as the exercise prescribed to patient B may actually exacerbate the injury. Patients should always feel as though their functional goals have been met every session. This can happen if the correct hypothesis was created. With improvement in the patient’s condition the hypothesis should continue to change.

Another example of a Clinical Assumption (true story): Patient goes to the doctor because of dizziness. The doctor asked a few questions and assessed her lungs, heart and ears. The patient was prescribed high dosed steroids diagnosing her with a vestibular neuritis. This was all of a 10 minute visit. What was the clinical hypothesis? Where is the differential diagnosis? Low and behold the diagnosis was wrong and steroids were not required. This is one of many errors made based on quick Clinical Assumptions. How much did the patients healthcare dollars pay for this?

My past and current experience reveals that in the Physical Therapy practice with an hour one-on-one session you are able to solidify a clinical hypothesis and treatment and patients, at the end of the session, feel as though their functional goals have been met. This is especially important for the more complicated treatments. For example, I have treated an ankle sprain in both the insurance based and fee for service settings; in the first setting it can take 2-4 sessions to reach meaningful outcomes and in the latter setting only 1-2 sessions. The difference is that I had more time to form an extensive clinical hypothesis to drive a meaningful treatment.

This blog is not to push everyone to go into a fee for service system but rather to push the healthcare system to increase reimbursements. With improved reimbursements we as Physical Therapist become more efficient and will reach functional outcomes sooner, in turn spending less resources and medical dollars.

We need a healthcare system that spends enough time to format the appropriate Clinical Hypothesis versus a Clinical Assumption.  We can spend less time with the Clinical Assumption but our outcomes suffer. On the other hand, we can spend more time with the patient and form the appropriate Clinical Hypothesis and improve the overall function and quality of life of the patient.

It is unfortunate that the healthcare system has become a business and has lost the personable nature of medical care. Your insurance card (some people think it is for free services) does not buy you better healthcare but rather places the patient in a system of inefficiency where executives of insurance companies and healthcare systems get paid 6 million dollars a year, and where the patients who have been paying their premiums for years cannot pay for their cancer treatments.

Just some food for thought. Your health is important and the best treatment should be available to all.

Overcoming the Challenge of Today’s Healthcare System

As a young Physical Therapist growing in experience and knowledge I question our effectiveness in the healthcare setting. I don’t mean to generalize everyone, but I think we have lost the love for people. We have lost the sympathy and empathy on which healthcare was built on. Because of financial restraints we have cut the time spent with patients. Along with the time lost we have lost the ability to perform personalized care. I am not an exception and have been guilty of this; and with the loss of personalized treatment I believe that outcomes are not optimized. Being a healthcare professional does not only mean giving the right drug or correct treatment. By building an intimate relationship with your patient, a relationship of trust can actually enhance the affect of the drug or treatment provided. Yes, there is no research to show this, but through my clinical experience I have seen first hand that a combination of the right treatment and good relationship have positive outcomes. Conversely, the right treatment with flawed patient interaction showed poor clinical outcomes.

I don’t believe that we are going to heal everyone, but I do believe that we can optimize the quality of life and function of individuals with more TIME. I believe that with more individual time we can change peoples lives and we can ‘LOVE’ them more. We can be better at achieving the functional goals of the patient instead of priortitizing our own clinical goals with the time we have. I believe that with more time there will be less money spent overall and better utilization of our patients’ healthcare dollars.

In my young Physical Therapy practice there is a common trend of people coming to therapy only once a week. This is because with a one hour treatment focused on individualized care we are able to achieve the goals of the patient in a timely manner. People are, over time, paying less and also spending less time away from their overall ‘dysfuntion’. Individuals are optimizing their function and becoming an active part of society.

Our chronic population needs more individualized time as we are not only dealing with the physical affects of pain, but also the psychosocial aspects. We need to continue to challenge insurance companies on reimbursement for our respective skill sets. We are worth more!! We need to get back to patient centered healthcare where outcomes, quality of life and function are our primary goal. This is my utopia because I see it is possible with what I do on a daily basis. Patients and clients will testify to my ‘crazy talk!!’ The missing link to healthcare is not necessarily the next super drug, surgical technique or diet but rather the intangibles that cost us nothing. It is the eye contact, smile, attention, hug, holding of a hand… the list goes on! I challenge all those who are in healthcare to try this and see what your outcomes are. See the reaction that is driven from it.

Let’s love each other and the healing will follow.