It Will Never Get Better

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[00:01:06] I just speak to the patient and at the end hit Carpohen and a soap note generated. I love it and you will too. Welcome to Untold Physio Stories Podcast. Your perfect commute resource with physiophiliers, successes, interesting cases and more from the physio and rehab world with your host,

[00:01:35] doctors Andrew Rothschild and person, Reliezo. Welcome back to Untold Physio Stories and when you're host, Dr. E with my Domain Neotherapy Edge Mavility System and my Degree Head Master a 4 month online mastery program and with me is my co-host, Dr. Andrew Rothschild.

[00:01:53] Yes, I'm Andrew and I actually we hit the stop button a little bit too early talking about the last podcast and there's several other points we wanted to talk about for this what seemed like an abdominal or aortic aneurysm in the end of being severe conservation.

[00:02:13] It's severe conservation, yeah, I mean I would say as a patient, if I came to a doctor with complaints of abdominal pain and I was given to diagnosis of a abdominal strain especially as someone who's active, and then you prescribe PT I would think

[00:02:29] like I'm not even going to bother going. What do you say? I'm a little concerned with that the fact that you know, you know, the abdominal pain kind of wrapped around the side to the back

[00:02:43] but you would hope that talking with a physician there would be a clear like, you know, mechanism and the absence of a clear mechanism that that wouldn't be the first diagnostic from a primary care physician to come up with, you know. Yeah, for sure it also

[00:03:01] reminds me of a really old episode of the Simpsons or Homer Goes to the Carpacter. Do you ever see that one? Thanks. Oh, man, it's hilarious. Like he ends up like Homer ends up fixing everyone's back

[00:03:15] and becoming like this huge chiropractic competitor by like falling over backwards, falling over backwards over his garbage can. It's like a metal garbage can and every time and he starts just like

[00:03:25] everyone who comes to him he just pushes them over backward there with a garbage can. He likes the substance of their complaints for like five seconds because he figures out the like the ridges of

[00:03:31] the garbage can are like perfectly corresponded to like the spinous processes. Every time he pushes people over they get like huge cavitations. Yeah, then at the end like the chiropractors

[00:03:41] all the chiropractors and town they like beat his garbage can with their spine models. So he can't do it anymore. It's not funny. It's a really good episode. But anyway when he goes to see Dr Nick I don't even

[00:03:54] think Dr Nick is a character anymore. He says that, oh my no doctor, Hibbert actually the real doctor. Dr Nick. So modern medicine is really good with the fronts but we're not very good with the back

[00:04:07] and I'm thinking like that's really true actually though you know what I mean? Like you don't think of going to a PT for a domino pain. Right. Yeah. Absolutely. So what do we? Yeah, let's get to my story. Enough about your story. So I had the good opportunity

[00:04:29] of working with the professional athletes. His main PT follows me and I'm not going to say which athlete in which sport but his PT's concern was that he had some chronicle back pain. He kind of developed into like a bit of central sensitization and very high fear avoidance.

[00:04:50] So I looked at this guy's history before I saw him and I thought, well this is going to be too bad. I mean he's a professional athlete. He's like early 20s, very fit. So the

[00:05:02] history is just said he has intermittent pain. It started five years ago and he was able to return to sport and then he fell sometime maybe last March and then he's had pain on an off-since then.

[00:05:17] He only he's able to actually perform. He's able to practice. He's able to for the most part work out and the only thing that hurts with his intermittent pain is Lombard extension. So I just

[00:05:28] getting, you know, seeing that I just thought this is going to be like a super home run. Like why am I even being called in for this? Right. And then the last sentence was,

[00:05:37] and I don't think I'm ever getting better. Yeah, I know that's like that's one of those things so it's like oh this is why and it's exactly one of the things why I was being called in

[00:05:47] because even though the PT is heavily in a pain science and he's he's already talking about neurotags and dims and sims and all those things. I think the this young athletes biggest problem was that

[00:06:00] once he feels pain, he basically shuts down. He doesn't want to practice. He doesn't want to work out because he thinks he's damaged. His first MRI it turns out showed that he had one L4L5 disc

[00:06:15] herniation and he flew all over, you know, I think his dad is also a pro athlete. Now he's a coach and his mom also had spinal surgery and his mom I think was also an athlete.

[00:06:28] So his mom said surgery successful surgery. The the son or the athlete wanted to avoid surgery and I think as far they're also again just being who he is. He's this access to like all kinds of specialist giving him injections and everything. So after this most recent injury,

[00:06:45] he got another MRI and this MRI said he had a melt their whole level of either L5S1 or L3L4 like above or below the other one so he had now two disc lesions and mild annular tears with the diagnosis. And when he said this to me,

[00:07:04] he said something about his previous MRI said moderate to severe disc patrisions and both his PT and I said, oh well you're you're in more severe pain now but your MRI actually says mild. Your current MRI is better than your last MRI when your pain was

[00:07:28] was also better. Now your pain is worse and your MRI is actually better. So even quick get that that that would be like this big aha light bulb moment you know one of those things that David Butler

[00:07:36] mostly talks about like when that patient has the aha moment no aha moment there I'd off. So I mean I also was a lot of like two to three hours to spend with him so you know I told

[00:07:49] them all about the gray hairs on the inside and skin wrinkles on the inside and how common it for you know athletes who aren't even pro athletes to have things like disc herniations

[00:07:58] or even laboral tears and you know all of this guesses were like really low. Oh is it like 10 or 20 percent? No it's like 50 percent of for a lump our spine it's 87 percent on average for the

[00:08:08] cervical spine and for you know division one athletes for who are asymptomatic who have who they scanner hips like 70 percent of them had laboral tears and so that got him thinking quite

[00:08:21] a bit and he was more concerned about the most recent doctor six weeks prior had given him stem cell injections and said it's going to take six weeks for this to heal your spine. It's going

[00:08:33] to regrow the annualer tears and you're going to be fine. So we're going on six weeks now and he's pretty much no better he's not necessarily worse but he's just no better every time

[00:08:42] he tries like resty fine extension hurts and when he when he um when he works out either certain workouts are just not necessarily like I think harder slap oh my god I say slap shot it

[00:08:54] mean to say slap shot a harder swings of something was uh was painful and again very afraid very high fear avoidance and again mostly afraid of extension and I'm not sure what he thinks is

[00:09:07] going to happen in extension so my next big thing was specifically you know just basically five mechanics that extension is built in it's built it's built in by design you know there's nothing

[00:09:19] good or bad about flexion or extension just like there's no good positions no good or bad exercises it might be too much of one thing without without very ability but you know and I always

[00:09:29] use my example of if we flex our elbows as much as we flex their spines and maybe we do right or a knees we might if if the average person flexes their lumbar spine or their head or neck

[00:09:41] two to three thousand times a day the biggest difference is that we don't go into full extension so well I'm like how would your elbows feel if you flex them two to three thousand times a day

[00:09:49] but for the other you know anytime you weren't flex you weren't moving them actively you kept them flex instead of walking around with them extended and we pretty much do that with our spines

[00:09:59] we're always flexing but we don't go into full extension so how would like you know if your elbows would be stiff and painful by the end of the day what would your back feel like you're after

[00:10:09] day after day month after month you're after year when you finally go in extension and he you know he agreed and that it would be stiff and or painful so you know he's kind of like

[00:10:19] slowly sing the light and I thought he was asking more of a fearful question but he was asking more of like just out of curiosity to question he said so you're saying after six weeks the

[00:10:31] doctor said six weeks and then you know when he went back to the surgeon who had to fly to who gave him this injections the doctor said well now it's going to take longer than six weeks

[00:10:40] so he didn't really give him a time frame you know usually I say years he's saying so you're saying that it should have been better like if the injections were going to work they should have worked

[00:10:50] right now and I just said yeah and I wasn't sure if he was going to get upset with that or just think like something else needed to be done unfortunately that made him feel like well I don't need

[00:11:02] going to start to do something else other than just wait for this to happen because he was just kind of waiting you know he's playing a waiting game because the doctor told him that his

[00:11:12] discs then your lateres are going to regrow within a certain timeframe so how he ended the evaluation and you know I found other things too like he was weak and lumbar extension he was painful

[00:11:25] he was pretty severely limited and painful in lumbar extension he had full flexion of course he had like strong hip extents there are super strong AB doctors the things that are normally weak

[00:11:35] in most people he were very strong at him I mean his hip flexion was a little bit weak on on the same side and I think his diaphragm and he was a little stiff and trunk rotation to the

[00:11:46] right because it's mostly right side of low back pain so I found like certain things that his PT could absolutely work on again breathing strategies that he absolutely loved because this PT didn't quite address those things and he was weak and right lateral chain so again there were

[00:12:01] a lot of things that his PT could work on and a strength coach could work on but the thing that really made him change his language was I just did that so in like a strides stance I just told

[00:12:16] him to extend so his left leg was forward his right leg was back at home and put his hands on his back do some low bar extension so if you're really limited in painful then I just put my hands

[00:12:25] on his scapula you know done it showed us a couple of times in videos I've really been looking at like isometric and resisted extension for painful limited extension so I just said you know I'm going to

[00:12:37] first push you and just overcome my resistance so I let him kind of push me back into like we're both going back into like you know I don't know like a limbo contest I call it he he got within two

[00:12:52] reps and a lot of resistance full extension and my message was look you are I'm I'm can't a firing an extension pattern I'm firing your lumbar erectors and I know you're worried about

[00:13:04] extension and extension is painful but did that resisted extension hurt at all and he said no it was like a pain free and even at end range I just like started really cranking on him like look

[00:13:14] push me back as hard as you can and he's really pushing back like almost starting to sweat like starting to shake it's like you're really cranking on extension your lumbar extensors like if you're worried about what extension does to a disc if you're worried about this compression

[00:13:29] for Dr. Toldy that flexion is good and extensions bad but if compression was really bad if it was damaging discs when I did that like maximal isometric contraction in full extension you were pain free

[00:13:45] if we were smashing your discs or somehow like you know smashing all the jelly out or something or I don't know what exactly you think it's going to happen whatever it happened it did not

[00:13:54] happen because you did a maximal isometric contraction in full extension and that actually is what made it pain free so he was just like that's how I ended the first visit and you know I just gave

[00:14:05] him sidelines and extensions and he was just so happy that he could do extension and of course after his extension was full and nearly pain free then he just admitted to kind of doing sidelines and

[00:14:16] repeated extensions but I just spoke through his PT just last week and we're talking after like months and and potentially even years of you know no see a big language you just said it's entire language has changed about the way talks about his back that's wonderful yeah yeah

[00:14:31] now you made an understand if you didn't want to answer but do you you say what sport they played good hockey okay just surprising though that I was wondering about that is it surprising to have such fear of avoidance with pain because you know with hockey players

[00:14:50] as always you know as always the joke that you know they got punched in the nose but it was no as a joke and he's bleeding but going back in the gangster's a hockey player you know

[00:14:59] there is a contact sport that's associated with people who have kind of like football have like you know it's kind of like understand that this is there's would be a lot of pain on a regular basis

[00:15:11] that's very normal with based on their chosen sport yeah I know you think it's like you think it'd be like an NBA player something right because they're always like folding and trying to draw

[00:15:20] files and stuff and they're not necessarily considered a tough sport but I guess it goes to show honestly that anyone could develop your avoidance right and I think again having access to being

[00:15:31] able to like fly all over and just seeing all these specialists and everything who are basically giving you passive fixes and then you know like go back to the PT even though he trusts this

[00:15:42] PT it's hard I don't know I just told his PT it's also easier for me to come in you know as like an expert right he's more willing to listen to me like with either first expert who

[00:15:54] wasn't part of his current staff that actually gave a positive message yeah I guess too like you know you get used to certain types of pain obviously being playing hockey all his life

[00:16:08] you get used to certain pain and you know you can habituate to what is you know which is not associated with any kind of fear or injury and if this was a new very different pain

[00:16:20] that was not that he had no sort of a passive association with and then combined with all those no civic messages I guess you could see how it would be he would have that reaction what you

[00:16:31] mean otherwise expected from sort of a context for athlete yeah well I think the other thing too again you're just talking you're also talking about sure context for athlete they're used to having

[00:16:41] bruises or used to being beat up being punched in a face being slammed against the board hard checks and everything like that but I think the thing with I think one of the

[00:16:54] his major things was that you know I called them debombs you know as like man you just dropped so many debombs it's like the first 10 minutes or your history could sing just this camera right

[00:17:04] I think it just goes to show it just really relates to that pain science research shows that people who actually get MRIs end up with worse outcomes than higher fear of women see

[00:17:14] you know I think if you what if you didn't get the MRIs I think he wouldn't be so fear of boy it's and also I mean his second MRI was was better even though his pain was worse but I

[00:17:24] don't he didn't see it as better because somehow the any other tears really worried him yeah and the language the visual is really is really powerful but also too I think the experiential

[00:17:41] part is really important you know obviously what we say to patients is really important but we there's plenty of evidence that shows how much they actually hear from what we say how much they absorb

[00:17:51] and it's hard for people just to listen and believe and buy in but if you when you do something like the resisted extension and not that he experienced the fact that oh I can do this and it's no

[00:18:03] longer painful that's going to be really powerful yeah and you mentioned it on a podcast I think last year when I was talking about isometric extension and you said that there was like there was research

[00:18:16] on isometric extension strength I think it's like a for help period of time that it correlates with low back pain so I've actually been looking that up and I found that I mean I found in our

[00:18:25] sort yeah first the like the the articles I was finding from 2012 2013 when I think a lot of people were looking at that but I think I found a more recent one from 2021 okay yeah so yeah I'm like

[00:18:39] I'm really looking at that in a lot of not in like all low back pain patients but just like just chronic low back pain I think there's something to extension strength and I even really

[00:18:50] know if it's strength because it you know yeah is it endurance or is it just inhibition and then once you kind of like use a PNF like technique I'm not going to call it PNF because I want

[00:19:00] to get trolled by other IPA devotees but there's something about like restoring the ability to contract the directors with chronic low back pain I mean it could just be something simply simple as like building up the cup but you know I love the research it says

[00:19:18] people who do deadlifts actually have less low back they tend to have less low back pain than people who don't do deadlifts but his P2 was also even telling me like oh yeah we've been getting

[00:19:27] trying to get him to fire these extension patterns by programming and a lot of deadlifts but I'm also thinking like is in the right people or someone who's so fit someone it's like a

[00:19:37] sport that's like very leg dominant right if he only like firing lower mostly lower quarter posterior chain and this he really need like more upper quarter posterior chain you know and I used to work in a gym that actually had this life fitness machine like every single gym

[00:19:56] was life fitness this is like an older brand that I haven't really seen at newer gyms in this machine but guy who owned it said like all my clients have low back pain I

[00:20:06] was put them on this machine and it was like imagine like an abdominal curl machine but for extension so you sit in it you know you put the pin and how you choose

[00:20:15] however many want to place you want to do and there was like a little kind of back you push back yeah for like your buttocks yeah so it was like like isolated hips

[00:20:26] and then there's a pad that goes on your scapula and you kind of like hold onto something you just push back right now so like yeah first even like you know way back when 25 years

[00:20:35] ago when I was introduces a machine I was like oh yeah this is like garbage right I would never do this it's not like an erector strain and they don't need strength but I would put my patients on

[00:20:43] there afterward after restoring their extension and everything before pain science whatever and they really really liked it and I can try to replicate that especially in the past like year when I've been finding that a lumbar resistant lumbar extension helps people and then when

[00:20:58] I test them they're like really weak you know because I've been giving them like superman's or maybe like once they have like you know their flexion is clear and their extension is clear they're

[00:21:06] being given them like you know kind of currently reverse superman's like pro-notha table or just ice metrics superman's on on pro-notha ground but there was nothing like this machine that I could

[00:21:17] find you know people are like oh can you set up cables and have them you know cables and front of them and have them lean back it's just not the same there's like pushing backwards

[00:21:27] with resistance from the top is a lot different than an anchor point in front and then leaning backwards yeah yeah because there's like when you when the anchor points in front and you have nothing kind of pushing against your buttocks anteriorly it's like you co-contract your abdominals when

[00:21:47] you're using like a cable machine so I haven't found something that like kind of inhibit the abdominals while the erectors are firing. I remember reading a study a long time I would talk in like 15 16 years ago now that basically used that machine to quantify you know

[00:22:05] extensions, strength and endurance and it was it was the piano and it was that kind of stuff that really helped a lot people with back pain but they were looking at and I think this is some of

[00:22:15] the stuff you may have talked about on that earlier podcast that with the multifadist atrophy and the fatty infiltrate that's so common in people both with the Q-LO back pain and especially with chronic low back pain and then it was how greater cross-sectional area or improvement in cross-sectional

[00:22:32] area with multi correlated with reduced back pain and they were using that machine as the main exercise to do back extensions strengthening because they could you know you could control versus like a Roman chair, a little bit different, a little bit less you know I think for

[00:22:50] some people is not very comfortable to do they could control a lot of the more variables with this specific machine how they set it up. Yeah and I think this setup itself is pretty objective

[00:23:01] you know if you can do like a 10 pound plate people with low back pain could only do 10 pound like 10 wraps and people without low back pain with like similar builds could do like 30 pounds

[00:23:13] and 30 wraps that's really effective. You're on a sitting position it's less threatening maybe you know potentially the way the setup of the movement is because you're going you're extending but you're not going and you can't go into like hyper extension. Yeah and you're extending and it's kind

[00:23:29] of one of those things or it's like people are so used to the the supine straight leg raise that they immediately think oh my hamster is going to hurt or it's going to flare up my Z-addictor

[00:23:37] but then you test a straight leg raise inside lying and they have no idea what you're doing and it can go quite a bit further. You know so it's like changing the pattern doesn't fire

[00:23:45] the neuro tag so I think there's something too and that's one of the things that I actually problems solve too when someone has painful extension and they can't even lie supine or prone

[00:23:54] because they're just too much pain and they're kind of stuck in like a forward entouchic posture I have them first I tried to just you know do that, strides dance but if they can't do that

[00:24:04] I do in sitting and it turns out that like when you start inflection in sitting I push on them but they're ready maybe flexed forward like 50% then that haven't go up to neutral then from neutral

[00:24:15] I haven't kind of pushed backward into extension another couple times and then they can do an instanding. So yeah I think it's just like it's like a long bar extension without extending

[00:24:27] yeah and I'm gonna wait might be a little bit of hippy extension too but again I don't know it's just like a novel pattern I think it's everything I haven't found a machine that does

[00:24:37] that other than that one machine someone actually looked it up at the last course I taught last weekend is like is it said I'm like yeah that's exactly if they they found like a used one somewhere

[00:24:45] online for like $3,000 and like wow it's still too rich for my blood but there's got to be like something else that does it. I wonder if there's a bit of a taste they still might be in a lot of

[00:24:55] gems I wonder. Yeah I mean do you remember that brand life in this school I just haven't yet? Yeah yeah yeah yeah yeah yeah well hey you guys know any of any other similar machines

[00:25:06] he listened or he developed something like that or even come up with an exercise it's you know resist extension from the top but you have to be pushing backward not pulling something that's anchored in front of you that I'd be really happy to entertain that but

[00:25:21] you don't want to you are in sync if you have a if you have a long enough belt because we use a bunch of different belts be about attached to our cable cones if you're sitting on a bench

[00:25:30] and you can pull that you I find about to like belting belting this down yeah around the upper back and then they get a little touch that cable cone that might be the closest version you could

[00:25:41] you know yeah I've thought about that too I'm like a big thick resistance belt may work yeah yeah but then the thing about resistance bands is that it's it's not isotonic you know I like this machine because it was isotonic and we're talking about someone who's like weak

[00:26:00] extensors the more they go back into extension that's why I mean there is something I love many were assistants and that's what I consider the easiest manual technique because you can just grade the resistance if they have difficulty if they're shaking you know you can kind of like

[00:26:21] at the at the sticking point or at the shaking points it's somewhere in mid range you can just kind of like do a low threshold isometric and gradually increase the resistance to kind of

[00:26:29] facilitate their get them through that shaking point you just can't do that with like a machine or a band you know but the hard part is yeah how do they replicate it at home

[00:26:37] I guess one thing get to a point then the band might be a nice you know from a long-term maintenance sample potentially but or if they're using the cable if they're in a

[00:26:50] figure out a way you can write the cable column with a belt or the gym that has the machine you know yeah yeah closest thing what I said which doesn't work which we tried at the last

[00:27:01] course I was at was sitting like reverse straddle in an abdominal machine that does not work I could like barely get in and I could be like I was killed myself getting out of it so

[00:27:13] I wouldn't get in on all those gym fail videos oh man totally look like that if I had actually fallen I mean I I'm pretty much almost fell on it but yeah it was it it was a gym fail going in

[00:27:26] and out and also it was a cool machine because it was pneumatics it would resisted forward and backward so when I when I lean back into extension I was like oh it's working it's resisted extension

[00:27:35] and then I was in full extension and then I had to push forward and I couldn't push forward because my domals were like super stretched out and I couldn't control it so yeah it was it was a fail like

[00:27:47] all around yeah I showed if you actually shot it it would have been hilarious sorry hey it's well that's probably all the podcasts we're gonna record today we're gonna be fine to read your

[00:27:58] people can find me on instagram and twitter at a Rothschild pt all right hey if you like this podcast of any similar uh interesting cases or big physiophiliers make sure hit and interrupt or I up on social

[00:28:12] media please give us a rating on apple and Spotify or wherever wherever you listen podcast hit that's subscribe button and as always you guys have a great day