Self-Efficacy, the Best Medicine

A recent blog post caught our attention and we shared it on our Facebook page (scroll to Thursday, May 19, 2016).  The post was written by Dr. Kory Zimney, PT, DPT for Evidence in Motion and was entitled, Is Your Treatment Needed To Get Patients Well?  The blog post is succinct and very well-written, so I encourage you to check it out even though it's written towards medical providers.

It's a funny thing about the medicine machine these days.  Aside from some very important advancements in communicable disease prevention and trauma/infection care, the machine has failed miserably.  Now you might think that really smart people with a lot of power are working on this issue right now and that they're going to come up with a fail-proof plan of action to guide us all to a brighter future.

Or you're not.

I was talking to a friend about this today as I spent a little time on the foam roller.  Have you ever used the hollow cylinder of hopelessness before?  Perhaps a more accurate description would be to say I was rolling in agony and having a conversation to distract myself from the fact that my quadriceps felt like they were melting from my femurs.  We spent our mobility sessions discussing everything from farming and local farmers markets to running around barefoot to healing from common injuries.  It occurred to me, as it has many times before, that we wouldn't have a healthcare crisis if people were healthy.

I'd always wondered being a child of the 90's and having observed this epidemic of diabetes, obesity, dementia, and other chronic illnesses develop, why aren't people healthy anymore?  I could look at my grandparents and see that their way of life brought more health than in the generations since, although I am not sure I can fully explain why.  They may not necessarily know more about medicine or the science but they were getting better results.

Can I tell you a story?

You might think it's sad, but it's really just a normal Texas childhood.  This is the story of the marriage between nature and nurture, the delicate dance of what you're given before and since birth.  I believe I was given the personality trait of stubbornness.  In a sense mother nature blessed me with a little self-efficacy.  I didn't always follow my own way but I always questioned the way things were and I always knew that my heart was worth fighting for.  My parents also exposed me to certain situations that may not be so acceptable today.  For example, after instruction on how to safely use a rifle, my parents might send my 8-yr old version to the woods alone and strongly suggest I not come back until dinner.  Now long before the days of cell phones (how is it that I thought the idea of a video-phone was so cool in the '90s and now that we have it I could care less?), before I ever imagined face timing another human being, I was clearly left to my own devises.  As children my siblings and I found ourselves in all sorts of conundrums and we were the ones who nearly always fixed it ourselves.  Nearly, my half-sister couldn't fix her own broken arm after we jumped off our backyard tree onto the trampoline and she continued the ride by catapulting 10ft in the air and landing on an outstretched hand.  Once my brother shot me in the leg with a pellet rifle when we were squirrel hunting.  The first thing he said to me was, please don't tell mom!  I never did and she'll never read this blog.  My brother later became a Military Policeman, go figure.

Before I could really earn the privilege to fish with my own rod, I had to show that I could cast it.  So I practiced casting a small fishing weight into a bucket in the backyard, hours at a time.  And when I started running raccoon traplines on the river, I had to show my step-dad that I could tie a proper knot to secure the boat.  When I crashed my bike on a homemade ramp, my father did not fix it for me because he told me not to jump my bike off a ramp.  I fixed my bike as best as I could and ended up with a bike that couldn't turn left (the front brake was bent and caught the wheel, so I could only ride straight or take a right...Zoolander anyone?).  My parents did not check my school work.  If I failed to make a satisfactory grade I was to ask my teacher for extra help.  I wrote all my own papers, I decided to take AP classes and exams, and I chose my own extra-curricular activities.  My parents always made it clear those were my decisions.  When it came time to go to college, I completed all of my own scholarship and school applications, studied for and took my entrance exams, and managed to pay for my own college.  I did the same with graduate school when I commissioned into the US Army.

Historically accurate representation of my childhood ramp skills.

What is important in the story is not how great I was or how hard I worked, it's about what I didn't have.  I didn't have protection from failure, instead, I had to deal with my emotions, learn the lessons, and move on.  Instead of fixing my problems, my parents said, hummm, that sounds like a problem.  You are capable of figuring it out though and you should go work on that.

As a licensed physical therapist having certain credentials, you know the sort of credentials that are supposed to represent knowledge, I try to know my stuff.  It not only seems like the right thing to do, it also seems like the legal thing to do.  I just wouldn't do well in prison, clearly not enough space in the yard for me to train for Leadville.  The problem with medicine and life is, if you aren't okay with being wrong, then you'll never be right.  Many great thinkers have agreed that roughly 50% of what we know is inaccurate and unfortunately we have no idea what 50% this is.  So to get what we say we really want, excellent patient outcomes, we must be emotionally mature enough to admit we were wrong.  Sometimes we have to struggle through problems to find the solution.  Certainly it can be a difficult and uncomfortable process.  I graduated from physical therapy school five years ago and already I have changed my opinions on many of the textbook answers, some have been complete 180's.  But in the end this is what is supposed to happen, we are not our ideas after all.

So what do we need more of in our current healthcare situation?  My short answer is self-efficacy.  Nature taught humans how to live healthy lives, when we were in touch with the earth, when we grew, hunted, gathered, and ate whole foods, when we were out working in the sun and went to bed after dark, and when we weren't hyper-connected to a digital world.  This is how my grandparents and many of your ancestors lived.  It makes perfect sense.  Mother nature vets everything with time.  We aren't all running around with medication deficiencies but if you go to a doctor's office or watch five-minutes of television you might think otherwise.  Instead of being in tune with our bodies, we ask everyone else's opinion about it.  Should I eat this or should I eat that?  Maybe you should eat real food and see how you feel.  Take out what doesn't work for you.  What's my ideal body weight?  What weight do you feel best?  How much sun exposure is healthy? When do you start to sizzle?  What should I do to heal this injury? Have you given it time and the opportunity to heal?  Have you any practice at listening to your body?  Should I take this supplement? Do you have a rare or fatal genetic disorder?  It's your call but a better question might be, what are you lacking that you should be addressing with something that's been around for ages, not something recently manufactured and you have no idea what's in it and the sketchy science supporting it is probably funded by industry (deep breath after that run-on sentence).  What did people do before the supplement?

As time goes on and I spend more of it in the modern industrial medicine complex, I have only one thing to say to the public.  Get closer to nature and minimize all the modern conveniences and mind-numbing time wasters.  Learn to listen to your body again.  I mean, really listen to it.  This is what my grandparents and great-grandparents had to do to survive, there were no other options.  In the end, they not only survived but they have lived long and robust lives.

Imagine a younger version of me in the early 90's riding in the bed of a pickup truck when it was still legal for children to do so.  The wind in my hair, two wide blue eyes scanning the open fields for anything that moved, a coyote or deer maybe.  That may seem like a dangerous practice but there were risk-mitigation strategies.  My parents drove slowly in low traffic areas, undistracted, and the kids knew the rules of how to ride.

The question I have is, how does that compare to parents driving distracted on their phones in traffic with their children buckled in the back seat?  Does the child booster seat and the airbags offer a sense of safety that gets abused?  Does this in some ways parallel how we have treated health as a society, just put it in someone else' hands?  We are such medical geniuses in 2016, of course there is a pill to cover every poor decision I have made.  Having been in both situations, I can attest that leisurely riding on backroads in the bed of a pickup truck is much safer, and not only that, it is a different sort of activity and experience altogether.  Which do you prefer, frantic and distracted driving to a head-on collision or exposing yourself to calculated risks like a slow ride in the open air so you can fully engage your life?  Perhaps my stubborn soul is to blame but I will always prefer the later.

Don't listen to me.  Engage your life, make mistakes, and find out what works for you.  Own it all.

What Is Evidence Based Practice??

You go online or your read an advertisement that says something like "...our _________ work in an evidence-based practice and use the latest evidence to guide our __________."  You read this and may think, "this sounds good" or "sounds like they know what they are talking about." Would you be surprised to hear that evidence-based practice is standard?  So why would a clinic advertise that this is different from everyone else?  Maybe it is their implementation of evidence based practice that is different or the fact that they even do it (an unfortunate statement I know).  So what exactly is evidence-based practice or EBP?

Evidence based practice is the implementation of a practice that involves the melding of best research evidence, clinical expertise, and the values of the patient.  Implementation of evidence-based practice happens in multiple ways but the ultimate outcome is highest quality of care for you in a reasonable amount of time. 

Integrating the best research evidence is not always easy or "perfect."  

It is difficult to conduct a study that is perfect by all standards.  In medicine and health the targets of our studies are people, and as we are all aware, people are not all the same.  We call this variability and variability makes it very difficult to fit one thing to everyone.  Therefore, in research, we try the next best thing.  We try to see if the treatment or outcome fit the majority.  This is where things become a little sloppy because to look at the majority we have to minimize as many confounders as possible.  Things such as researcher bias (wanting to make something true to be famous, financial reason, or personal reason), subject bias (the person being studied wants to be famous, a financial reason, or personal reason), and other influences (too many to list quickly) play a huge role in the outcomes of a study.

Research happens mostly at universities or institutions that have an invested interest in the area.  This can be a good thing but on the flip side it can lead to fudging the numbers.  Now technically we can say that numbers do not lie but you should know that the people who interpret the data do.   Actually integrating the best evidence into practice requires a deep understanding of the strengths and limitations of research.  Without this discernment we can become victim to many of the myths that have perpetuated the headlines (such as eggs will kill you or vaccines cause autism).  That said, we must understand that research is paradoxically both important for advancement of knowledge and sometimes blindly overstated.  The way in which studies are designed also affect their applicability (and data).  In general, all studies should be designed to disprove the hypothesis (i.e. what the research wants to prove or believes will be true).  The best a study can do is to say that the hypothesis (the theory) still stands to be challenged another day.

What we should strive to do is critically look at the research and apply it based on the quality and relevance to the individual. Research should continue to challenge our beliefs. That is why we conduct it, distribute it, read it, and talk about it.

Clinical experience is a very important thing but ask yourself "do they have 1 year of experience 10 times or 10 years of experience?"

I've worked as a clinical instructor and mentor for several years.  The one thing that I see happen repeatedly is that medical and health practitioners become very algorithmic or stuck in following a pattern.  Early on in my career I was told that the most powerful tools I could have were my hands.  I believed this for a long time but now I believe it is the mind. Being able to think and have flexibility allows you to develop, modify, and help each individual.  However, many of you have experienced being treated exactly like everyone else and not getting anywhere.  I would partially blame the current health insurance system for unthinking  medicine by making it all about numbers and profitability.  This does not entirely take the practitioner out of the mix.   The practitioner should be flexible and be able to learn from their failures as much as their successes.  They should be able to admit to making mistakes.  Thinking should not be something only the few do.  Every medical or health professional that you work with should be able to give you a clear thought process on why they are recommending something.  Additionally, they should be able to explain what will likely happen with their plan of care...whether you improve or worsen, what it means and what the next step should be.  This is truly thinking.

 

Have you ever been to a medical or health practitioner and you felt like they did not listen to you?

You may have said you did not want to take medicine or do certain things and they just ignored you and did not engage you in conversation or offer a compromise.   Maybe they just talked at and not with you.   This is a common thing today.  The current insurance system has led to dehumanizing of medicine by reducing the time someone can spend with you.  However, the practitioner can still maximize the interaction by using intake forms that ask about your life and goals.   This form can help generate a dialogue in this time-constrained environment.  Your other alternative is to choose someone who will spend the time with you.  This is your health and someone should be willing to ask you what you think and/or want.   They should be able to explain to you why your goals are realistic or need modification based on their expertise.  Medical and health practitioners should be there to help you get to outcomes but you are the one that will make it happen. Good practitioners are like coaches that work with you to improve.  They should understand you and be able to work with your individuality and not just your condition or label.   

 

No one is perfect and your medicine or health practitioner should embrace this.  They should be there to help you achieve whatever it is you want to happen. 

The interaction should be evidence-based practice.  If one of the three aspects is lacking, they should utilize the best of the other areas to help you in the best way.  The practitioner should not ignore one of the aspects and you should always feel like you have a part in your care.   Your belief in what you are doing and having interest is the key to success in health and medical care.  Evidence-based practice is the way a practitioner provides you with the best and most appropriate coaching.   If you are a passive participant, then you will probably get the outcome that is given to you rather than the one you make. It's your health, so choose what you feel is right and make sure you work with someone that can help you in a way that make sense to you and you can truly participate in your health.  

Shoulder Mobility and Beyond

Shoulder mobility is necessary for a large number of tasks.  It is crucial for performance of overhead activities such as the overhead squat, snatch, and jerk.  Many people find it difficult to perform these activities and may even experience pain or discomfort.  It usually feels tight or restricted and the many people's initial thought is there is a mobility restriction.  This generally leads people to foam roll, smash tight areas with a lacrosse ball, and hang from a pull up to get the shoulder moving.  There may be varying degrees of short term success but the problem may not go away completely (unless you are perhaps one of the lucky ones).  As we often ask ourselves...is a treatment really working if the problem keeps coming  back?  What else could be causing the shoulder to feel tight if it is not simply a mobility restriction?  The short answer, motor control.  This is where the idea of stability comes into play.  For our purposes, we will use motor control to describe the intricate dance and coordination of the muscles in our bodies.  When we demonstrate that we have control in our movements, we naturally move with less restriction, tightness, and stiffness.

So how does motor control work exactly?  You can consider our muscles the tools, our nerves the messengers, and our brain the orchestrator.  To create controlled movement, our body coordinates both our stabilizing muscles and our primary mover muscles.  The stabilizing muscles tend to be smaller and located deeper within the body, closer to our joints.  They help us "centrate" our joints and keep things moving smoothly and without unnatural restrictions.  Our primary mover muscles are larger, more superficial, and are responsible for creating the big movements we can observe with our eyes.  Understandably, there is a lot going on to perform any simple task (such as raising one's arm overhead).

A key deficit for many people is that their stabilizers do not contract quickly or adequately enough prior to the larger muscles initiating movement.

When this happens, we lose some of our natural joint stability and the end result may appear to be a stiff or tight area.  But often what is occurring is really a disorganized movement pattern, not a true mobility problem.  Most of us work our primary mover muscles frequently but do not necessarily provide adequate training for our stabilizers.

So how can you test whether or not you have a mobility problem or a motor control problem when it comes to tight shoulders?  It's actually quite simple.  Start by holding a band between both hands directly in front of you, elbows locked straight, and get some tension on it.  Next raise your arms over head and pay attention to how your shoulders feel.  If you can move overhead with the taut band and you feel less tightness than you usually do, you my friend have a motor control issue (Overhead Testing Video).  But how exactly does this voodoo magic work?  By loading the band prior to your big movement, you help to activate your stabilizer muscles first.  If activating your stabilizers first improves your movement, than you've proven that part of your shoulder tightness lies in your muscle coordination.

But what about the people whom the band does not have a big effect?  Now I want you do pay attention to where you feel your tightness.  If you feel mostly tight in the upper back, you might start looking at your thoracic spine or latissimus dorsi mobility.  If your posterior shoulder is screaming at you, you may have a posterior shoulder tightness, chest, or latissimus dorsi tightness.  If it is in the anterior shoulder, you may have chest or upper trap tightness.

The tightness in these areas could still be originating from an over reliance on stronger superficial muscles to stabilize the shoulder.

When this happens, you still end up with a similar problem of properly coordinating your stabilizers and your prime movers.  But in this case, you may require a more in depth movement analysis to find out exactly why you're cheating the movement.

We have a few examples of exercises for the shoulder that have been shown to improve motor control.  The key in their execution is quality repetitions and demonstration of control during the actual movements.  It makes sense right?  To improve shoulder control you want to practice controlling the shoulder.  Here are some exercises to help you.  Click on the exercise to see the video.

Bank Robbers

Scapular T

Scapular Y

Scapular I

Shoulder Flys Alternate

Seated Cross Legged Alternate Arm Raise

Upper Body Rolling

Changes in Motion After One Set of Exercises

 

After you gain the motion with the exercises, it is time to work exercises into that motion.  Work exercises that you are able to move the full range of motion without degrading form. 

If your form degrades, go back to the exercises and back off whatever made you degrade.  It is a good idea to perform these exercises at the end of a session as well to "recover" and fight off any stiffness.  

While proper shoulder motor control practice can often improve the problem, if you're not noticing a difference or still have persistent tightness, you may need a little extra help.  If you are in the Colorado Springs area you can get personalized attention with one of our movement assessments.  Our movement assessments are designed to look at your whole body movement and tackle the areas that may be causing or perpetuating compensations (and leading you to not succeed in your program).  You'll get personalized homework from these sessions to help you achieve actual, lasting results.  It's like going to the dentist...but for your whole body.  See our services page to learn more.

Knee Imaging is Not An Examination or Absolute by Itself

Many times we see patients that have had imaging done (sometimes costly) after having a minimal examination by their doctor.   Then they are told they have a...insert your diagnosis.... based on the imaging results, a very brief exam or a combination of both.   The knee is one of the most commonly imaged areas of the body. The infamous diagnosis of the knee is a meniscal tear.  However, there has been shown to be a high incidence of meniscal tears in non-symptomatic knees as well as symptomatic knees.  Additionally,  lateral or medial joint line tenderness and end range of motion joint pain seem to be the best indicators of meniscal issues.  There are other tests such a McMurray’s and Thessaly’s test that has some usefulness as well.  


One of the biggest problems we see is that people come to me with pain in the front part of the knee yet they are told they have a meniscal tear and that is why they have pain.   However, if you look at the anatomy of the knee the menisci do not go all the way to the front of the knee and there is actually joint capsule and a fat pad that take up much of the anterior knee.  So if the pain is felt toward the front of the knee it is almost impossible to palpate meniscus there.   

Meniscal tears actual occur for two main reasons: trauma or overuse.   The trauma kind is usually caused by a loading of the knee vertical with a twisting motion with the knee extended or flexed.  A pop is usually felt but swelling may not occur hours after the injury.  If the swelling occurs immediately, then more likely some ligament injury or anterior knee structure irritation has occurred.  The overuse kind is degenerative and occurs over time.  Overuse meniscal degeneration is usually seen after the third decade of life but can be seen early in individuals that perform high impact activities to the lower extremities (lots of jumping or constant twisting).  However, degeneration is common in people without any pain or issues.   Remember there are many soft tissue structures on the front of the knee and if they are compressed by the knee cap, they can cause debilitating pain and swelling.
 
The problems that should concern you with a meniscal tear is if the knee is locked in a position or unable to move through the full range of motion with help.   This would require a visit to an orthopedic surgeon.  Surgery is not always thebest course and complications do arise from surgery.   If you just have pain with certain activities and the motion is full, then an individualized thorough examination and rehabilitation is the best course.  If you are barely touched or someone tries to tell you what to do based on imaging alone, I would be wary of this.  It is your body and you have to live with it.