Diagnosing Wrist Pain for New Nurse Practitioners
Listen
Watch
Show notes:
Wrist pain is a SUPER common chief complaint in primary care. Most of the time, luckily, it’s chronic wrist pain that’s from overuse (versus the more acute, dangerous differential diagnoses with injuries), but it’s still a lot to work through as a new nurse practitioner.
Diagnosing Wrist Pain in Primary Care
In this week’s video, I’m covering the overview approach to diagnosing wrist pain in primary care for new nurse practitioners:
✅ What first triage questions to ask
✅ Red flags to watch out for
✅ History questions, physical exams and special tests to perform
✅ When to refer and when to consider getting imaging
NOTE ABOUT IMAGING - there's no specific link, I didn't have my notes in front of me so I didn't want to misspeak-- but what I said was correct in the video-- initial imaging for wrist pain includes posteroanterior (PA), lateral, and oblique views of the wrist!
Resources mentioned in this episode:
For further imaging guidance, this is a popular resource, but please note it's from a private company. You can verify further imaging on the American College of Radiology (ACR) website as well.
-
WEBVTT
1
00:00:08.580 --> 00:00:16.560
Hey there, welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator,
2
00:00:16.780 --> 00:00:22.740
and founder of Real World NP, an educational company for nurse practitioners in primary
3
00:00:22.740 --> 00:00:29.100
care. I'm on a mission to equip and guide new nurse practitioners so that they can
4
00:00:29.100 --> 00:00:34.800
feel confident, capable, and take the best care of their patients. If you're looking for clinical
5
00:00:34.800 --> 00:00:40.680
pearls and practice tips without the fluff, you're in the right place. Make sure you subscribe and
6
00:00:40.680 --> 00:00:46.040
leave a review so you won't miss an episode. Plus you'll find links to all the episodes with
7
00:00:46.040 --> 00:00:57.080
extra goodies over at realworldnp.com slash podcast. Oh my goodness, I am so excited to
8
00:00:57.080 --> 00:01:02.760
share this week's video with you. I just can't even describe how excited I am. In this week's
9
00:01:02.760 --> 00:01:07.720
video, I did an interview with a physical therapist. She's actually my personal physical
10
00:01:07.720 --> 00:01:14.680
therapist after I had an injury last year, and she's amazing. She is so full of pearls of
11
00:01:14.680 --> 00:01:20.420
practice, so full of wisdom, just so smart. I got to ask her all the questions. The theme
12
00:01:20.420 --> 00:01:25.480
of our interview is, what would you like a primary care provider to know? I took some
13
00:01:25.480 --> 00:01:29.200
questions from the audience. If you are on the email list, you will have the opportunity to submit
14
00:01:29.200 --> 00:01:32.980
your own questions for upcoming interviews if you're not already on the list. But we talked
15
00:01:32.980 --> 00:01:37.660
about a whole bunch of things. Red flags, not to miss, when to refer to physical therapy,
16
00:01:38.080 --> 00:01:42.120
who would benefit from physical therapy that we might not think about, what to expect,
17
00:01:42.200 --> 00:01:47.380
how to counsel patients. Oh my gosh, just so many good things. Addressing the topic of
18
00:01:47.380 --> 00:01:52.940
access to physical therapy related to funds and all of that stuff. I really hope you enjoy
19
00:01:52.940 --> 00:01:58.100
it. It is so much fun to record. Please let us know what questions you have. I would love to have
20
00:01:58.100 --> 00:02:02.980
Stephanie back on. Again, she's just the best, but I hope you enjoy this interview. If you have
21
00:02:02.980 --> 00:02:06.820
not grabbed the ultimate resource guide for the new NP, before you check out the rest of this
22
00:02:06.820 --> 00:02:10.500
video, head over to realworldnp.com slash guide. You'll get these videos sent straight to your
23
00:02:10.500 --> 00:02:14.400
inbox every week with notes from me, patient stories, and bonuses that I really just don't
24
00:02:14.400 --> 00:02:19.520
share anywhere else, including the opportunity to submit questions to upcoming specialists on
25
00:02:19.520 --> 00:02:24.220
channel. Without further ado, here is our interview. Thank you for being here. Would
26
00:02:24.220 --> 00:02:29.620
you like to introduce yourself? Thank you so much for having me. Hi, everyone. My name is
27
00:02:29.620 --> 00:02:34.600
Stephanie Burns. I'm a doctor of physical therapy, and I've been practicing about 10 years.
28
00:02:35.820 --> 00:02:41.560
I mainly work in the orthopedic outpatient setting. Awesome. Awesome. I love working
29
00:02:41.560 --> 00:02:49.500
with you so much, and you know so much information. I have so many questions. We'll
30
00:02:49.500 --> 00:02:55.340
get to the framing question. How would you describe physical therapy? I think the context
31
00:02:55.340 --> 00:03:00.180
of the situation is that I feel very well-versed in physical therapy, especially since working
32
00:03:00.180 --> 00:03:04.480
with you personally, learning more and more about what physical therapy is and what it does
33
00:03:04.480 --> 00:03:08.540
and all of that. I think that sometimes the nurse practitioners who are new are not as
34
00:03:08.540 --> 00:03:14.500
familiar with physical therapy and what you do. There are a lot of things to clarify. Maybe
35
00:03:14.500 --> 00:03:18.400
to start from there so that they feel more comfortable sending referrals to you and knowing
36
00:03:18.400 --> 00:03:24.100
when to refer to you. Yeah, that's a great question. Honestly, the profession of physical
37
00:03:24.100 --> 00:03:30.120
therapy has changed over the years. It started as a bachelor's, it morphed into a master's,
38
00:03:30.120 --> 00:03:33.920
and now there's no schools out there that even have a master's program. You have to
39
00:03:33.920 --> 00:03:41.100
have a doctoral degree. Really, what the idea is is that we're all movement scientists.
40
00:03:44.460 --> 00:03:51.280
We really did have a bad reputation. We had a reputation of being people who were helping
41
00:03:51.280 --> 00:03:57.040
patients after surgery. That was our main job. Because of that, we pushed a lot of people.
42
00:03:57.180 --> 00:04:03.600
We pushed them and it was painful. I think a lot of that was just the best evidence-based
43
00:04:03.600 --> 00:04:07.660
practice back then was if you didn't have the range of motion, to push the range of motion,
44
00:04:07.660 --> 00:04:14.710
to make the range of motion. There are some cases where you do have to do that, but they are so
45
00:04:15.660 --> 00:04:20.060
minimal. There are very, very few cases where you really have to push through that pain.
46
00:04:20.339 --> 00:04:24.640
The evidence behind that has just changed drastically and the profession has changed
47
00:04:24.640 --> 00:04:30.120
drastically. We don't work under a physician or a nurse practitioner. We work autonomously.
48
00:04:30.780 --> 00:04:36.100
We really have learned how to work best with the patient as an individual.
49
00:04:37.080 --> 00:04:44.700
That means basically that one size doesn't fit all. We can't just push everyone and get the
50
00:04:44.700 --> 00:04:48.940
same range of motion for everyone and get the same strength for everyone. It's just really
51
00:04:48.940 --> 00:04:55.520
important to really hone in on what that individual's goal is and what the practitioner
52
00:04:55.520 --> 00:05:03.000
wants us to, as a team, what we're all trying to achieve from it. Do it in a way that's actually
53
00:05:03.000 --> 00:05:09.120
pretty comfortable for the patient. It's not painful. It's about optimizing movement.
54
00:05:10.420 --> 00:05:14.240
That's a really great question because I think that comes up for me a bit.
55
00:05:15.200 --> 00:05:20.020
Is physical therapy supposed to hurt? I think that I've had some patients come back
56
00:05:20.020 --> 00:05:25.420
with various experiences being like, it was too painful. Then some people saying,
57
00:05:26.160 --> 00:05:29.780
their physical therapist said to them, I never want you to leave in more pain than when you
58
00:05:29.780 --> 00:05:34.860
started. What is the general consensus on that from your perspective or does it really patient
59
00:05:34.860 --> 00:05:42.820
to patient vary? Well, it's difficult because pain is difficult to define. Pain comes from
60
00:05:42.820 --> 00:05:49.380
each individual's experience with pain. If you ever notice pediatrics, a child's pain is going
61
00:05:49.380 --> 00:05:54.640
to seem like the end of the world. It's because they've never experienced anything before.
62
00:05:54.860 --> 00:05:59.420
Everything is just really dramatized. For instance, if you work with some of the elderly
63
00:05:59.880 --> 00:06:04.400
population, they can have a fracture and be like, fine, no big deal. Now, of course,
64
00:06:04.640 --> 00:06:09.580
that's categorizing. Not everyone is like that, but the more experience we have with pain,
65
00:06:10.100 --> 00:06:15.720
the less we are afraid of it. So much of physical therapy, at least in the outpatient
66
00:06:15.720 --> 00:06:24.000
world, is learning how to get over the fear of movement. Sometimes there's a psychological
67
00:06:24.000 --> 00:06:28.400
pain involved. Sometimes there's a trauma involved. Sometimes there's something like
68
00:06:28.400 --> 00:06:32.860
abuse, but sometimes it could just be a car accident too. All of these things create a
69
00:06:32.860 --> 00:06:42.720
psychological trauma that really can affect our ability to move and to feel okay. If we don't
70
00:06:43.420 --> 00:06:50.960
feel safe, then our pain is going to be worse. It's really the physical therapist's job to make
71
00:06:50.960 --> 00:06:54.960
you feel like you're in a safe environment and make you really be able to feel like you can
72
00:06:54.960 --> 00:07:00.780
communicate. If you can't communicate to your PT that you don't feel comfortable, that this
73
00:07:00.780 --> 00:07:06.920
is too much, it shouldn't be the PT saying back to you, well, this is what we have to
74
00:07:06.920 --> 00:07:13.540
do. They should really be able to hear that and be able to say, okay, I understand that I'm
75
00:07:13.540 --> 00:07:18.400
not physically asking you to do too much, but that doesn't matter because it feels like it's
76
00:07:18.400 --> 00:07:23.980
too much for you as the patient. Because of that, we have to back down and we have to
77
00:07:23.980 --> 00:07:29.060
say, okay, let's break it down. Let's just do this in steps. It's not a big deal if it's
78
00:07:29.060 --> 00:07:33.920
too much for you, but the PT has to work with you with that. That's the whole idea of
79
00:07:35.000 --> 00:07:39.740
individualized treatment for each person out there. I'm just laughing, Stephanie thinking
80
00:07:39.740 --> 00:07:44.900
about us working together and I did this really tiny baby move. I had a back injury last year
81
00:07:44.900 --> 00:07:50.200
and I did this tiny little baby move and I was like, does this supposed to hurt this much?
82
00:07:50.280 --> 00:07:57.180
And you were like, you were so nice about it. It was just super weak. You're customizing
83
00:07:57.180 --> 00:08:00.220
things and we're like, we're just not going to do that exercise because you're too scared,
84
00:08:00.220 --> 00:08:06.860
basically. I still appreciate that about you and I think that sometimes patients will have
85
00:08:06.860 --> 00:08:10.220
a frustrating experience where they'll come back and feel like they didn't have that
86
00:08:10.220 --> 00:08:16.360
relationship with their physical therapist. That can be really hard. I think that brings
87
00:08:16.360 --> 00:08:24.520
up one thing that you and I have talked about a lot is about using physical therapy
88
00:08:25.460 --> 00:08:30.800
handouts and what is the difference between physical therapy diagnosis and management
89
00:08:30.800 --> 00:08:35.280
versus medicine diagnosis and management, if you want to speak to that.
90
00:08:37.600 --> 00:08:41.539
So I can share from my perspective, nurse practitioners will say things like,
91
00:08:41.820 --> 00:08:44.940
oh, you have a back pain and you have back pain and it's going down your legs.
92
00:08:45.160 --> 00:08:48.500
And then so we're like, okay, here's a sheet of exercises and you can go do that.
93
00:08:57.000 --> 00:09:02.240
So back pain is a good one. Another good one is like shoulder, like a rotator cuff injury.
94
00:09:04.660 --> 00:09:11.300
So I think the biggest issue I've seen with it is that there are phases of physical therapy.
95
00:09:15.240 --> 00:09:19.340
So there's that fear phase, right? You have to kind of like relax the patient.
96
00:09:19.700 --> 00:09:22.860
And one thing I just want to touch on is that can be, some of the physical
97
00:09:22.860 --> 00:09:28.080
therapy environments that are out there, like people that are treating more than one patient
98
00:09:28.080 --> 00:09:32.280
at a time, like an open gym environment, or just kind of like, you don't really feel
99
00:09:32.280 --> 00:09:36.500
like you're getting that attention that you need. Make sure that it's a good fit for you.
100
00:09:36.580 --> 00:09:41.160
I just want to say that because really one-to-one physical therapy, one-to-one
101
00:09:41.160 --> 00:09:46.320
treatment with any practitioner is really, for me, I think that's the most helpful aspect.
102
00:09:46.320 --> 00:09:46.860
Yeah.
103
00:09:48.560 --> 00:09:54.760
But sorry, back to your other question. With the handouts, like there are phases of healing.
104
00:09:55.340 --> 00:09:58.840
And so the first thing is, you know, kind of calming that patient down,
105
00:09:58.860 --> 00:10:05.020
reducing some of that pain, get them to really not like tense, protect and avoid,
106
00:10:05.200 --> 00:10:10.940
because that's what they want to do. But in some of the language that we use,
107
00:10:10.940 --> 00:10:16.940
make sure you don't sleep on your stomach, or you don't lift anything over 10 pounds,
108
00:10:17.020 --> 00:10:23.480
or you really don't want to lift your child from the ground. That type of language can really
109
00:10:24.680 --> 00:10:32.220
encourage fear in our movements. And instead, it's a little bit just as much as sometimes we
110
00:10:32.220 --> 00:10:38.800
have to sit and breathe with things that are emotionally uncomfortable. We have to kind of
111
00:10:38.800 --> 00:10:44.800
sit and breathe and relax and try to move as normal as possible, even when physical things
112
00:10:44.800 --> 00:10:52.480
are uncomfortable. So instead of that like tense, protect and avoid, you kind of want to think
113
00:10:52.480 --> 00:10:56.620
of it more of like relax, breathe, and move as normal as possible.
114
00:10:57.040 --> 00:11:01.000
Yeah. Yeah. And then one of the things that you and I talked about how like with nurse
115
00:11:01.000 --> 00:11:08.100
practitioners, the more of the challenge for us, it lies in the diagnosis.
116
00:11:08.100 --> 00:11:13.040
And then once we get to the diagnosis, our treatments are very algorithmic. So step one,
117
00:11:13.040 --> 00:11:16.740
two, three, and four, or is it like it sounds like with physical therapy,
118
00:11:16.760 --> 00:11:21.620
it's actually quite the opposite? It's more like psychotherapy.
119
00:11:24.720 --> 00:11:28.400
There is a big emotional component I can attest to it.
120
00:11:28.560 --> 00:11:33.240
There is, but there's also like a problem solving component to it.
121
00:11:34.090 --> 00:11:38.280
So kind of like we're talking about those phases. So like that first phase is that relaxation,
122
00:11:38.500 --> 00:11:44.600
the next phase for one individual might be to strengthen, and then the third phase maybe
123
00:11:44.600 --> 00:11:49.180
to stretch. And the problem with some of those handouts is they cover all the phases
124
00:11:49.180 --> 00:11:57.380
immediately. And that's where people get a little confused or maybe not the best,
125
00:11:57.380 --> 00:12:04.720
most efficient results from it, because some work and some don't. And because of that,
126
00:12:04.720 --> 00:12:09.600
they get frustrated. Definitely. Yeah. And I've found, at least I know in our work,
127
00:12:09.760 --> 00:12:12.740
and it sounds like it's been like that for other patients too, is kind of like,
128
00:12:12.880 --> 00:12:17.900
if I'm having this pain, my body is very different than somebody else's. And so my
129
00:12:17.900 --> 00:12:23.240
greatest laborum is not doing anything on the left side, compared to like the other
130
00:12:23.240 --> 00:12:27.520
muscles. Right. And so it sounds like it's also very much like the game is kind of in
131
00:12:27.520 --> 00:12:30.960
figuring out the right treatment for that person. Does that sound right to you?
132
00:12:31.440 --> 00:12:39.960
Yeah. Like from a diagnosis standpoint, the words of like rotator cuff care or shoulder
133
00:12:39.960 --> 00:12:52.140
impingement or tendonitis, tendinosis, tendinopathy, they all kind of mean the
134
00:12:52.140 --> 00:12:58.540
same thing. Like, okay, so before you all hate me for that, what that means is that yes,
135
00:12:58.540 --> 00:13:03.380
of course, from a medical standpoint, something is different happening onto the tissue,
136
00:13:03.380 --> 00:13:06.380
right? We understand that we understand the structure that involved is different.
137
00:13:06.960 --> 00:13:13.640
But from a treatment standpoint, it may not change it at all. So one of the biggest take
138
00:13:13.640 --> 00:13:19.800
homes that I learned in physical therapy school is we treat the person and we treat the
139
00:13:19.800 --> 00:13:26.400
impairment, but we don't treat the diagnosis. So again, like diagnosing something, sure,
140
00:13:26.420 --> 00:13:30.040
you know, we know that like, if they kind of move like this, they're going to have a
141
00:13:30.040 --> 00:13:35.680
rotator cuff issue or if they have issues with their back that are very directional
142
00:13:35.680 --> 00:13:42.080
preference based, okay, maybe it's more of a disc herniation. But for a treatment,
143
00:13:42.380 --> 00:13:48.940
there is no diagnosis equals ABC treatment. And I think a lot of patients want that,
144
00:13:48.940 --> 00:13:52.920
of course, who wouldn't want that, right? A little filing cabinet would go in, here you go,
145
00:13:53.020 --> 00:14:00.960
perfect. That would be great. And that's where it comes into similar more like psychotherapy
146
00:14:00.960 --> 00:14:05.940
than it does with, with medicine, because there is no like pill that fixed it, right?
147
00:14:05.960 --> 00:14:10.460
It's about listening to the patient, about hearing the patient about understanding their
148
00:14:10.460 --> 00:14:14.580
fears of movement, and then really trying to, you know, get to the bottom of it,
149
00:14:14.580 --> 00:14:20.380
because you can, I mean, there are so many more minutes in the day than just the 30 minutes or
150
00:14:20.380 --> 00:14:26.160
60 minutes you have with the PT. There's not even so much about doing your exercises.
151
00:14:26.560 --> 00:14:31.980
I know I'm going to get a lot of things for that, too. But we want you to do your
152
00:14:31.980 --> 00:14:38.520
exercises. However, even more importantly than that, we want you to change how you move.
153
00:14:39.220 --> 00:14:45.420
Right. So if let's let's go back to that emotional metaphor. If I was struggling with
154
00:14:45.420 --> 00:14:50.920
something emotionally, and I take five minutes or 30 minutes out of my day to meditate,
155
00:14:50.920 --> 00:14:55.800
right, it's better than nothing. But what if I just try to like have a mindful attitude
156
00:14:55.800 --> 00:15:00.740
throughout my entire day, right, that's going to make a bigger change than just that 30
157
00:15:00.740 --> 00:15:08.500
minutes when I have all these other minutes in the day, not being mindful. So that's that's
158
00:15:08.500 --> 00:15:14.620
stronger. It's absolutely better than nothing, of course, but throughout the day, and really
159
00:15:14.620 --> 00:15:19.260
being mindful of like, every time you lift your arm to get dressed or to reach, you know,
160
00:15:19.500 --> 00:15:24.240
are you hiking that shoulder every time you move your back? Are you doing something kind of,
161
00:15:24.360 --> 00:15:28.820
and what you're working on and what they're working on it are two different things because
162
00:15:28.820 --> 00:15:33.560
they come from two different places and two different compensatory patterns that have been
163
00:15:34.240 --> 00:15:41.100
Right, right. So I have questions here from our audience. Is there something that often you get
164
00:15:41.100 --> 00:15:46.020
like referred to you, that's quote unquote referred too late, like something that would
165
00:15:46.020 --> 00:15:50.600
be you would prefer that they get referred sooner they could advise patients of when
166
00:15:50.600 --> 00:15:54.460
they're making their decision whether or not to go to PT like is there any are there any
167
00:15:54.460 --> 00:15:58.700
situations where you see you'd wish they went sooner or that you see that are too late?
168
00:16:00.200 --> 00:16:10.760
Yeah, um, anything that's chronic, I would say is too late. No. Sorry. Yeah. What I mean by that
169
00:16:10.760 --> 00:16:17.200
is a lot of times, patients can go to a practitioner and they can say, Yeah, I've
170
00:16:17.200 --> 00:16:28.680
had this knee pain, but I've had it for 10 years. And in my experience, that's not the
171
00:16:28.680 --> 00:16:32.540
person that's going to be like, Oh, let's do a knee replacement and spend 10 years.
172
00:16:32.820 --> 00:16:38.460
But no one's ever asked, did you ever have PT because sometimes they hadn't. So when people
173
00:16:38.460 --> 00:16:45.620
have surgery before PT, it could be a personal preference where someone just didn't didn't want
174
00:16:45.620 --> 00:16:50.680
to go through that they just wanted to get the surgery first. But there's so much benefit
175
00:16:50.680 --> 00:17:00.380
at least trying it. I recently just had a patient who had a C6, C7 neck herniation,
176
00:17:01.040 --> 00:17:06.160
and he was in he couldn't even lay on the table. This guy was in a very, very acute,
177
00:17:06.339 --> 00:17:13.060
severe situation. And the referring provider was very much like, you can try PT, but
178
00:17:13.660 --> 00:17:18.200
good luck, you're going to need surgery, right? So he really wanted to do a cervical
179
00:17:19.160 --> 00:17:24.119
fusion for it. And as we know, you kind of need all of that mobility. When you take a
180
00:17:24.119 --> 00:17:28.720
piece of the spine, it doesn't just affect that piece affects above and below and kind of all
181
00:17:28.720 --> 00:17:33.320
the way down the chain. So we want to avoid that as much as we can, because there really
182
00:17:33.320 --> 00:17:39.300
are some some downsides to it, especially if you're on the younger side. And this guy came
183
00:17:39.300 --> 00:17:45.340
in and definitely was not my easiest patient that we figured it out and we problem solved.
184
00:17:45.340 --> 00:17:47.910
He's absolutely fine. He has no symptoms.
185
00:17:51.960 --> 00:17:54.800
Didn't even take that long. It's probably like three months.
186
00:17:56.120 --> 00:18:01.260
You know, so it's, it's just always worth that shot. In my opinion, obviously, I'm
187
00:18:01.260 --> 00:18:06.760
a PP, I'm going to advocate for it. I mean, what do you have to lose?
188
00:18:07.260 --> 00:18:10.700
Right. Well, I guess I think that's like, that's one of my kind of like pet peeves is
189
00:18:10.700 --> 00:18:16.080
this misunderstanding interdisciplinary misunderstanding, because all algorithmically,
190
00:18:16.100 --> 00:18:20.480
like I said, like if we have a diagnosis, I talked about orthopedic hacks in primary care,
191
00:18:20.520 --> 00:18:25.300
which is basically like NSAIDs physical therapy injections and surgery. That's the pathway for
192
00:18:25.300 --> 00:18:32.560
most orthopedic injuries. I agree with that. Very oversimplified. But like, yeah, I think
193
00:18:32.560 --> 00:18:38.240
that because our physical therapy is not in our diagnostic in our in our toolkit, it's
194
00:18:38.720 --> 00:18:42.620
doing it. And so it's like, Oh, well, what I can do is refer you for an injection or
195
00:18:42.620 --> 00:18:47.260
do the medicine. Right. And I think that because people in the medical on the medical side,
196
00:18:47.280 --> 00:18:52.260
like don't fully understand what physical therapy can do, then it's overpassed. Right.
197
00:18:52.640 --> 00:18:56.080
And like, I think one of this, like, I just have so many things that I just like want to
198
00:18:56.080 --> 00:18:59.920
share. It's like the things that I've learned from you. I feel like, I don't know. It's
199
00:18:59.920 --> 00:19:05.720
like, I just want to like download my brain onto people who are like, you know, like,
200
00:19:05.720 --> 00:19:10.180
because I guess like from that example, like what so I guess if you can like, kind of walk us
201
00:19:10.180 --> 00:19:15.080
through, if there's a kind of like, if you can give like a zoomed out perspective of what
202
00:19:15.080 --> 00:19:19.580
what you would do for a person like that, like, what are it like, do you know what I mean,
203
00:19:19.700 --> 00:19:25.760
how do you boil down what you did for that person? So that like, demonstrate how physical
204
00:19:25.760 --> 00:19:31.560
therapy helps, right? Like, was it strengthening? Was it mobility? Was it like, I can, I can
205
00:19:31.560 --> 00:19:35.420
talk about my situation and what I've learned, but I don't want to, I want you to explain.
206
00:19:36.780 --> 00:19:40.800
Yeah. It's a great question. Great question. And this is just a case, right? So it's just
207
00:19:40.800 --> 00:19:47.460
one person. Exactly. So he responded, I don't know if you're familiar with like Mackenzie
208
00:19:47.460 --> 00:19:55.060
based physical therapy. So Mackenzie is a man who was in Australia, who came up, it was
209
00:19:55.060 --> 00:19:59.880
kind of a funny story. So there was a table, a physical therapy table that was like
210
00:19:59.880 --> 00:20:04.760
an angle versus flat. And he told the patient, oh, you know, go lay down, I'll be with you in
211
00:20:04.760 --> 00:20:11.000
a minute. And they were there for back pain, low back pain. And they laid down on their stomach.
212
00:20:12.080 --> 00:20:15.520
And they weren't supposed to, they're supposed to lay on their back. But what
213
00:20:15.520 --> 00:20:21.100
happened was this patient was better when they got up. And it gave him, I think it was
214
00:20:21.100 --> 00:20:27.060
Robin Mackenzie, but it gave him an entire new perception of like, wait a minute. So
215
00:20:27.060 --> 00:20:34.900
the disc is protruded posteriorly. What if we move posteriorly to make it glide anteriorly?
216
00:20:35.040 --> 00:20:38.660
And that's what we call a directional preference. So in this particular case,
217
00:20:38.840 --> 00:20:44.480
you know, that particular man on the table, you know, he responded well to like extension
218
00:20:44.480 --> 00:20:51.100
because we were gliding the disc more anteriorly by moving posteriorly. And you can also,
219
00:20:51.100 --> 00:20:56.260
you get some people, it's a little bit less common to have someone with an anteriorly
220
00:20:56.260 --> 00:21:01.160
translated disc, but sometimes like gymnasts or skaters or dancers, people who go into extension
221
00:21:01.160 --> 00:21:07.220
a lot will have that. And then they're going to respond to flexion or another group that tends
222
00:21:07.220 --> 00:21:11.960
to respond to flexion would be more your people with like spinal stenosis because they
223
00:21:11.960 --> 00:21:16.520
need the canal to be open. And so we're going to get more of that opening with flexion.
224
00:21:16.960 --> 00:21:21.080
One of the things that can be deceiving, which is kind of tied back to that handout
225
00:21:21.080 --> 00:21:24.900
question you had is that when you see back pain, a lot of times on that handout is
226
00:21:25.540 --> 00:21:30.180
go into a ball, bring your knees to your chest, right? So why does that help? It does help.
227
00:21:30.760 --> 00:21:36.300
But only temporarily and actually can not all the time, but can do more damage.
228
00:21:36.600 --> 00:21:43.320
So if you're going anteriorly, right, you're going to open up that vertebral space
229
00:21:43.320 --> 00:21:48.240
and you're going to allow that disc and that nerve to breathe. However,
230
00:21:48.960 --> 00:21:55.140
it's also going to, because it has more space now, it's going to slide out in that direction.
231
00:21:55.260 --> 00:22:01.300
So when you close it back down, now the disc is living more so out here and pinching on that
232
00:22:01.300 --> 00:22:08.720
nerve even more, right? So if we close it down, that hurts, right? It's uncomfortable.
233
00:22:08.760 --> 00:22:14.980
It's painful. So immediately we think, Oh, don't do it. Kind of, right? Maybe don't do it
234
00:22:14.980 --> 00:22:19.640
so much load or so much gravity. What if we did it in like a gravity minimized position,
235
00:22:19.700 --> 00:22:25.960
like that guy on the table. And then so ending up, you know, kind of bringing your yourself
236
00:22:25.960 --> 00:22:30.860
backwards. And then, so now your vertebral space is going this way and you're kind of pushing
237
00:22:30.860 --> 00:22:35.700
that disc back into place. And now it's more centered. And what you have to do now is you
238
00:22:35.700 --> 00:22:40.840
have to stabilize it to stay there. So the ligaments around here, they've been kind of
239
00:22:40.840 --> 00:22:43.860
stretched out because things aren't in the position. The muscles are probably a little
240
00:22:43.860 --> 00:22:47.380
atrophied. That's probably how you got there in the first place. And then you have to,
241
00:22:47.380 --> 00:22:52.660
you have to get it to stay there. But if you try to stabilize it there the whole time
242
00:22:52.660 --> 00:22:58.340
without putting the disc back into place, that's like not really going to be effective.
243
00:22:58.700 --> 00:23:02.820
Totally. So it's like a combination of assessing what the issue is, whether it's
244
00:23:02.820 --> 00:23:10.260
spine or shoulder and like identifying what is too loose and what is not strong enough
245
00:23:10.260 --> 00:23:15.620
and what is light. And I think like one pearl, I just like, I feel like I have to gush it out.
246
00:23:15.660 --> 00:23:20.100
It's one of the things you talked about with me was like, people talk about, I think I see
247
00:23:20.100 --> 00:23:24.280
these things on like health, pop health things everywhere too, of like stretch this muscle
248
00:23:24.280 --> 00:23:28.960
every day. Right. And it's like, this muscle is always tightening people. But do you want
249
00:23:28.960 --> 00:23:31.780
to talk about like what muscle tightness is? I know we have some other like referral
250
00:23:31.780 --> 00:23:36.060
related questions, but what would you say to somebody who's like, oh, my back is always
251
00:23:36.060 --> 00:23:41.720
so tight, I just need to stretch it? Yeah. Well, let me just wrap up that previous question.
252
00:23:42.140 --> 00:23:46.540
So the, because the guy was a neck patient, I didn't answer any questions about that,
253
00:23:46.540 --> 00:23:52.800
but there are also directional preferences for the neck. And a big one is kind of posture,
254
00:23:52.860 --> 00:23:56.800
because when we tend to sit, we kind of do this, right? So our neck is really forward.
255
00:23:56.820 --> 00:24:00.620
And then that's how we screw, you're laughing because I'm telling you about this.
256
00:24:02.720 --> 00:24:04.520
You're like, I'm going to sit up close later.
257
00:24:07.020 --> 00:24:08.960
I promised I'd do my exercises.
258
00:24:11.980 --> 00:24:16.260
But if you kind of tuck that chin in, you pull it back, you know, it's not about squishing,
259
00:24:16.280 --> 00:24:19.620
right? Cause you can hear that in my voice, it kind of, is that awkward?
260
00:24:21.600 --> 00:24:26.320
But if you elongate, like you have like a string in the back of your head and you're
261
00:24:26.320 --> 00:24:31.680
kind of being pulled up and back, that opens up some space, also pushes that disc back in.
262
00:24:31.700 --> 00:24:35.840
So we did a lot of different variations of that for him. We kind of tuck the chin,
263
00:24:36.060 --> 00:24:40.240
the first one didn't work. We did a little bit of like a lateral component because he had a
264
00:24:40.240 --> 00:24:44.660
lateral component with the disc. We kind of tech the chin and did the chin tuck because that
265
00:24:44.660 --> 00:24:50.640
created a little bit of different force that was very helpful for him. And then we just
266
00:24:50.640 --> 00:24:55.400
progressed it. So you kind of find the biggest thing is find the thing that works.
267
00:24:55.400 --> 00:25:00.560
And if you can't ask someone else, because there is something that does work.
268
00:25:00.900 --> 00:25:05.440
Yeah. And like how beautiful of an example to share with people, because like to see behind
269
00:25:05.440 --> 00:25:10.420
the scenes of what actually happens in physical therapy, to know that like you can help somebody
270
00:25:10.420 --> 00:25:15.300
with that severe problem through movement alone. I mean, the person has to come to
271
00:25:15.300 --> 00:25:18.840
appointments they have to do, they have to participate, right? They have to sustain the
272
00:25:18.840 --> 00:25:24.740
things that you practice together, but that is so impactful. And he was, he was a great
273
00:25:24.740 --> 00:25:28.800
patient. You know, he was super on top of everything we talked about. So that's, it
274
00:25:28.800 --> 00:25:34.460
really does make a big difference when you kind of implement everything that we ask you to.
275
00:25:34.460 --> 00:25:41.900
Yeah, totally. But yeah, do you want to share, I guess like about muscle tightness?
276
00:25:42.220 --> 00:25:47.580
Oh, yeah. So I think one of the biggest misconceptions that can be out there is,
277
00:25:48.240 --> 00:25:54.680
is what is tightness? So let's take a runner. That's a pretty standard example. So an
278
00:25:54.680 --> 00:25:59.640
IT band, right? Everyone gets like a tight IT band. So IT band, kind of that lateral
279
00:25:59.640 --> 00:26:04.120
aspect of your leg from your hip down to your knee, right? So if you're running,
280
00:26:06.080 --> 00:26:12.120
and this tightens up, people are like, oh, I just, I foam roll it. Sure, great. That
281
00:26:12.120 --> 00:26:17.560
makes sense. It's going to release it. But my question is, well, why does it get tight?
282
00:26:18.060 --> 00:26:22.260
You know, what, what are we missing? Because if you keep running and it gets tight,
283
00:26:22.260 --> 00:26:24.660
and then you keep foam rolling, and then it gets loose, and then you keep running,
284
00:26:24.740 --> 00:26:27.560
gets tight, and you keep foam rolling, gets loose. What are you, what are you really solving?
285
00:26:27.560 --> 00:26:32.180
I mean, people kind of do that. They're like, oh, well, this is just what I have to do.
286
00:26:32.180 --> 00:26:36.640
They think it's like their body is like, oh, my body is just this way.
287
00:26:36.880 --> 00:26:41.980
Yep. Yep. They absolutely do. And if you got to go beyond that, you really have to
288
00:26:41.980 --> 00:26:46.560
go beyond that. And again, if you don't have a PT that doesn't go beyond that, find a new one,
289
00:26:46.560 --> 00:26:50.760
because that's, that's not great practice. You don't want to just be chasing symptoms.
290
00:26:51.060 --> 00:26:56.520
You always really want to be getting to the root of the cause. So this is a little bit of
291
00:26:56.520 --> 00:27:01.720
statement. It's not true for everyone, but sometimes with runners, what actually is the
292
00:27:01.720 --> 00:27:07.340
issue is a weak glute med. So our glute med is also on the lateral aspect of our hip,
293
00:27:07.800 --> 00:27:12.560
and glute med tends to get pretty atrophied. And not, not even so much that it doesn't exist
294
00:27:12.560 --> 00:27:17.420
in a strength way, but we don't tend to have that neural connection to it anymore. We lose
295
00:27:17.420 --> 00:27:22.780
that neural plasticity. So it takes a little bit of time to turn back on. It kind of went
296
00:27:22.780 --> 00:27:29.080
muscle that went to sleep. It's dormant. So we can, we can make it back up. And that's great.
297
00:27:29.160 --> 00:27:33.200
But that's what people don't realize is, Oh, well, if I just do this exercise, it'll wake
298
00:27:33.200 --> 00:27:40.000
back up. Maybe, but if you're not taught how to do that exercise, you're not taught
299
00:27:40.000 --> 00:27:44.400
where you should feel it. You're not asking yourself what is the intention of this exercise
300
00:27:44.400 --> 00:27:49.240
and where should I feel it? You're probably not getting that result. In fact, you may still
301
00:27:49.240 --> 00:27:56.160
be using your IT band. Because that glute med has shut off, right? That, that has a responsibility
302
00:27:56.160 --> 00:28:04.560
in the body. So if it's not working, something else has to absorb its job. Right? So we have
303
00:28:04.560 --> 00:28:10.720
this force that the glute med is supposed to absorb and supposed to distribute and it's not
304
00:28:10.720 --> 00:28:14.260
doing it. So who is going to do it? And this is why I said it's a little bit of a blanket
305
00:28:14.260 --> 00:28:19.800
term because that may not be IT band for some people that may be low back, that may be
306
00:28:20.260 --> 00:28:25.080
piriformis, that may be, so it, you know, it, it, it's different for different people
307
00:28:25.080 --> 00:28:30.340
and it can be different based off of your activity. But people tend to just kind of like
308
00:28:31.300 --> 00:28:36.200
lengthen the glute med. So let's say we did that, right? We have no, I'm sorry, lengthen
309
00:28:36.200 --> 00:28:40.180
the IT band. I misspoke there. Let's say we did that. So say we have no glute med
310
00:28:40.820 --> 00:28:47.500
and we stretch out the IT band. Well, what support do we have for our body while we're
311
00:28:47.500 --> 00:28:55.900
running? We don't have anything now. It's causing, it's giving stability where something
312
00:28:55.900 --> 00:29:00.940
else is weak, basically. Right. Well, it's, it's overworking, right? It's doing its job
313
00:29:00.940 --> 00:29:06.480
plus the glutes med job. And so what happens is it gets tight, it gets tired. It's like,
314
00:29:06.480 --> 00:29:13.060
look, I'm done. Like get someone else to do the job. So if you don't, so that's why,
315
00:29:13.120 --> 00:29:16.020
you know, people say, oh, you know, stretch, stretch, stretch, stretching is great,
316
00:29:16.480 --> 00:29:21.880
but strengthen first. And I don't mean like, you know, in your day, I mean, in your phases
317
00:29:21.880 --> 00:29:28.500
of therapy, strengthen first, because if you really focus on that glute med strength and the
318
00:29:29.300 --> 00:29:32.820
neuroplasticity and the connection with the brain and then translate that to running and
319
00:29:32.820 --> 00:29:37.300
you can really feel that glute med activate while you're running, which is kind of hard,
320
00:29:37.320 --> 00:29:43.560
but super important. Then the IT band barely even have to stretch it because it's not tight.
321
00:29:44.100 --> 00:29:46.740
Right. And I feel like that's one of the things you and I talked about in terms of
322
00:29:46.740 --> 00:29:51.120
the chronic knee pain too. Cause it's like, I think that nurse practitioners get frustrated
323
00:29:51.120 --> 00:29:56.300
for on patient, for patients behalf because there's so much pain chronically for so long.
324
00:29:56.400 --> 00:30:00.080
And it's kind of hard to tell that to a person with chronic knee pain,
325
00:30:00.640 --> 00:30:04.620
go to physical therapy, it's going to help you without being really comfortable talking about
326
00:30:04.620 --> 00:30:07.500
why. So I think that's like one of the reasons I'm so grateful you're talking about all this.
327
00:30:07.520 --> 00:30:12.060
Cause I think that even if our job as nurse practitioners is not to identify glute medius,
328
00:30:12.060 --> 00:30:16.960
right? Like you, we can still understand how this whole thing works. So that when we work
329
00:30:16.960 --> 00:30:19.980
for a patient, Hey, you have chronic knee pain, physical therapy is actually really going
330
00:30:19.980 --> 00:30:26.140
to help you because it's building up the muscles that are supporting the joint so that
331
00:30:26.140 --> 00:30:29.320
the joint isn't doing all the work in a similar way. Right. If I'm saying that right,
332
00:30:29.320 --> 00:30:35.060
similarly to the IT band is overworking your knee, physical joint is overworking. So when
333
00:30:35.060 --> 00:30:38.580
you do physical therapy, maybe it's uncomfortable because you're, you're strengthening muscles,
334
00:30:38.580 --> 00:30:42.960
but eventually all of your muscles in your thigh and your hip and all of that
335
00:30:43.300 --> 00:30:46.720
are going to alleviate that pressure, which ultimately in the long run is going
336
00:30:46.720 --> 00:30:50.180
to be helpful. Like you said, like it's not like you have to go to physical therapy forever.
337
00:30:50.520 --> 00:30:54.900
You learn and you understand what you need to do. And then if you get new pains and
338
00:30:54.900 --> 00:31:00.220
place, you can see PT again. Right. So from, from a PT perspective, that would be amazing
339
00:31:00.220 --> 00:31:05.300
if that was explained that way to a patient, because sometimes what happens is they let's say,
340
00:31:05.300 --> 00:31:09.240
let's take me away, for example. Right. So they have this chronic knee pain and then they
341
00:31:09.240 --> 00:31:13.140
come in for an X ray. That's kind of the standard protocol and in the orthopedic world.
342
00:31:13.460 --> 00:31:17.740
So they get their X ray and it has osteoarthritis and they say, well,
343
00:31:17.740 --> 00:31:21.540
what is arthritis? Right. And then the practitioner explains, well, it's
344
00:31:21.540 --> 00:31:29.440
of the joint. They hear the word degeneration, which is breaking down, which is damage,
345
00:31:29.740 --> 00:31:33.940
which is irreversible. And all of those words kind of where we're talking about before,
346
00:31:34.100 --> 00:31:38.660
they create fear and they create loss of hope because they're like, well,
347
00:31:38.840 --> 00:31:45.020
what can I do about that? I have to get the surgery. Right. So what we, but we know
348
00:31:45.020 --> 00:31:50.420
that people who have arthritis, there are people that don't have pain, right? So we
349
00:31:50.420 --> 00:31:56.960
X rayed a bunch of asymptomatic people. There are many things that are still positive,
350
00:31:57.060 --> 00:32:03.540
quote unquote, in their X ray. So whether it's a degenerative disc disease or it's,
351
00:32:03.540 --> 00:32:07.620
you know, more like that degenerative osteoarthritis, that doesn't necessarily
352
00:32:07.620 --> 00:32:13.000
mean that person has pain. Yeah. So where the pain really comes in,
353
00:32:13.000 --> 00:32:20.480
it's, it's physics. It's, it's the forces that are being put on the joints because the muscles
354
00:32:20.480 --> 00:32:26.640
around it are not supporting it. Yeah. So if, if pain was explained like that from day one,
355
00:32:26.680 --> 00:32:30.360
from the, from the first person that that patient had interaction with, it's like, look,
356
00:32:30.360 --> 00:32:35.960
pain just means that there's one area of your body absorbing more force than another,
357
00:32:35.960 --> 00:32:42.440
very simply put. And, and PT is that person who will teach you how to distribute those
358
00:32:42.440 --> 00:32:50.180
differently. Yeah. Yeah. And I think like, too, like it's so holistic and it's so like for just
359
00:32:50.180 --> 00:32:55.700
as another example, like I love giving examples for NPs, but like I, I've had neck pain and,
360
00:32:56.820 --> 00:33:01.600
and what we've been doing together, you and me is rotator cuff. It's like,
361
00:33:01.660 --> 00:33:06.720
yeah, we're doing my shoulder and my back because what's happening is that my trapezius,
362
00:33:06.860 --> 00:33:11.960
my like upper traps are doing all the work because of my baby little back muscles
363
00:33:11.960 --> 00:33:16.160
that aren't doing what they're supposed to do. Right. But for me, I'm like, oh, I just have
364
00:33:16.160 --> 00:33:20.040
neck pain. Maybe I'll just stretch where it's really tight. Like, no, actually you're going
365
00:33:20.040 --> 00:33:24.820
to build up the other muscles so that that muscle will relax by itself. And then my neck
366
00:33:24.820 --> 00:33:32.820
feels better. So that goes along with that. Like that's your chronic tightness there.
367
00:33:32.860 --> 00:33:36.540
Right. So what did you want to naturally do? You want to stretch it out now? Is that bad?
368
00:33:36.580 --> 00:33:40.640
No, it's not. It feels good. It's great, but that's not the solution, right? That
369
00:33:40.640 --> 00:33:45.520
was really providing more support so that the upper trap didn't have to do everything.
370
00:33:45.620 --> 00:33:50.020
Right. Work so hard. Absolutely. Yeah. Give it a break.
371
00:33:54.760 --> 00:33:59.620
With imaging though, one of the questions that we got was about what imaging,
372
00:33:59.800 --> 00:34:02.980
like, so if somebody is going to refer, so say somebody has a patient in front of them,
373
00:34:03.160 --> 00:34:07.020
chronic knee pain do, and it's the first time they're seeing a provider say like,
374
00:34:07.020 --> 00:34:11.380
I was diagnosed a long time ago. My first thought is like, you only need to do physical
375
00:34:11.380 --> 00:34:16.320
therapy first. And like, by the way, for people who are watching, I hope this is getting a
376
00:34:16.320 --> 00:34:21.100
bigger, clearer picture for you because I have to sell people on physical therapy, not for
377
00:34:21.100 --> 00:34:26.860
my benefit, not for financial gain selling, but for them to buy into why physical therapy is
378
00:34:26.860 --> 00:34:30.860
so important. So hopefully that is meeting here, but having that conversation with a
379
00:34:30.860 --> 00:34:34.560
patient, I feel very confident saying to them, physical therapy will be helpful for you.
380
00:34:34.560 --> 00:34:38.199
They're going to go, you're going to go in for a physical therapy evaluation and you're going to
381
00:34:38.199 --> 00:34:43.100
set up a plan going forward of weekly or twice a week for a set amount of time, weeks or months,
382
00:34:43.100 --> 00:34:47.280
making even an estimate of how long it's going to be. And that is going to ultimately help you.
383
00:34:47.500 --> 00:34:51.719
So that's, that's my feel if you have any addendums for that. The other part of it is
384
00:34:51.719 --> 00:34:56.480
the question that people have is do they need imaging first? Like, so is that like how you
385
00:34:56.480 --> 00:35:02.100
would, before a patient gets to you, what do you wish they kind of knew and did in the
386
00:35:02.100 --> 00:35:07.680
text of how to explain it? And then also in imaging? Yeah. So, I mean, of course everyone's
387
00:35:07.680 --> 00:35:14.780
a little bit different, but if there are red flags, imaging is important, right? So diagnosis
388
00:35:14.780 --> 00:35:20.560
dependent, right? Like, so it is Asia or yeah. Or, or how did they, why are they there? Were
389
00:35:20.560 --> 00:35:24.720
they, was there trauma? You know, was there a fall? Was it a car accident? Things like
390
00:35:24.720 --> 00:35:31.880
that. They need to be imaged, right? Cause we don't want to be doing anything with a
391
00:35:31.880 --> 00:35:37.260
outside of a fracture. It could be, you're not really going to see it in x-ray anyways,
392
00:35:38.560 --> 00:35:44.520
right? So, so we don't even generally have any of that information and knowing that we
393
00:35:44.520 --> 00:35:49.600
don't treat based off of diagnosis, we treat based off of impairment. And just to clarify,
394
00:35:49.820 --> 00:35:54.620
what is an impairment? It's the thing that the patient can't do. So did they lose range
395
00:35:54.620 --> 00:36:00.360
of motion? Did they lose joint mobility? Did they lose strength? Pain? Is this an
396
00:36:00.360 --> 00:36:06.780
impairment? Fear of movement is an impairment. That's, that's what we treat. So really
397
00:36:06.780 --> 00:36:13.700
imaging isn't, isn't necessary. Now there are times where we want images because we're,
398
00:36:13.700 --> 00:36:17.900
we're stumped, right? We're kind of just like, you know, maybe, maybe if we could,
399
00:36:17.980 --> 00:36:23.320
like a glut meat tear, I would say that's a very, very underdiagnosed overlooked
400
00:36:24.540 --> 00:36:28.760
diagnosis. You know, you hear hip bursitis a lot, you hear a little back pain a lot,
401
00:36:28.760 --> 00:36:32.960
but we talked about, you know, how important that glute meat is to support the back, support
402
00:36:32.960 --> 00:36:37.100
the hip, support the knee even. And a lot of times, especially in folks who are a little
403
00:36:37.100 --> 00:36:42.140
bit older, it's porn. Oh, I think I had a family member like that actually. Yeah,
404
00:36:42.440 --> 00:36:47.660
that sounds familiar. Yeah. Yeah. And that, that's one thing I would, I always want like
405
00:36:47.660 --> 00:36:53.240
an image for because it's such a frustrating diagnosis because you go back and forth a lot.
406
00:36:53.420 --> 00:36:57.400
You're like, is this coming from the back? Is this coming from the hip? Because without
407
00:36:57.400 --> 00:37:01.440
the glute meat, it's kind of coming from both, right? Cause it really needs that support.
408
00:37:02.780 --> 00:37:09.480
But that's not something we expect a patient to have coming in. We don't, we don't mind that
409
00:37:09.480 --> 00:37:13.140
they don't have that. It doesn't really affect anything. The only time we really
410
00:37:13.140 --> 00:37:17.920
want imaging is if we're stumped. And the best way to do that is just to have,
411
00:37:17.960 --> 00:37:23.220
if we can have open communication with the nurse practitioner or the doctor or the orthopedic,
412
00:37:23.220 --> 00:37:29.560
whoever was the referring provider for the patient, if we could just have open communication and send
413
00:37:29.560 --> 00:37:34.340
you guys an email, I mean, sometimes emails are really hard to find or really hard to obtain.
414
00:37:34.640 --> 00:37:40.380
And so if we could send you an email, A, giving you a patient update status, right? And B,
415
00:37:40.540 --> 00:37:44.460
maybe like opening that door for communication, saying like, Hey, you know, this isn't,
416
00:37:45.080 --> 00:37:50.320
what we're doing isn't working. You know, what, maybe they do need an injection because
417
00:37:50.320 --> 00:37:55.400
pain is such a barrier. Maybe they really, you know, maybe they do need an image. These
418
00:37:55.400 --> 00:38:00.560
things aren't unnecessary, but sometimes they're over prescribed. Yeah. And I was
419
00:38:00.560 --> 00:38:04.420
going to say in my own personal practice, like I usually tell patients aside from those like
420
00:38:04.420 --> 00:38:09.060
red flags, like diagnosis dependent red flags and like trauma and acute injuries,
421
00:38:09.500 --> 00:38:12.580
just to clarify for new nurse practitioners, those are what we're talking about.
422
00:38:12.760 --> 00:38:18.540
But also like if I've cleared those, I say it's always worth it to see a physical
423
00:38:18.540 --> 00:38:23.940
therapist because in my experience, they always tell me I can't work with this patient. They need
424
00:38:23.940 --> 00:38:28.480
an MRI or they should see orthopedics next. Like they will let me know, or they'll be like,
425
00:38:28.480 --> 00:38:31.060
you know what, they're in too much pain to participate. Can you give them some pain
426
00:38:31.060 --> 00:38:35.880
medication or something like that? Like usually, is that typically your experience as well? Like
427
00:38:35.880 --> 00:38:40.000
I love, I feel like I can trust a physical therapist with that. I mean, I have, I've
428
00:38:40.000 --> 00:38:45.700
worked with better and not as stellar ones, but the ones that I really trust, like I'm like,
429
00:38:45.700 --> 00:38:50.200
I set it up for the patient of what to expect and then they let me know how it's going.
430
00:38:50.860 --> 00:38:55.400
Yeah. I mean, the better communication you can have with your physical therapist, the more,
431
00:38:56.820 --> 00:39:00.820
the more comfortable you're going to feel sending your patient to one.
432
00:39:01.060 --> 00:39:05.280
If you have that relationship with a PT, doesn't have to be just one, can be a whole
433
00:39:05.280 --> 00:39:10.280
network of them, you know, to choose from. And then, you know, you also get kind of
434
00:39:10.280 --> 00:39:14.640
a feel for people's styles of how they do things. And you may be able to say, oh yeah,
435
00:39:14.640 --> 00:39:18.920
this patient, I kind of recommend them to that person because they're more, they kind of pushed
436
00:39:18.920 --> 00:39:21.980
you a little bit more. They're going to get you back to, you know, playing soccer and this
437
00:39:21.980 --> 00:39:26.500
patient, oh, they're really good when people are scared and things like that. So yeah,
438
00:39:26.500 --> 00:39:30.700
I think the biggest thing is, you know, try to create that relationship with the PT
439
00:39:30.700 --> 00:39:35.620
because to tell you right now, like we want it. Yeah. You know, I so appreciate you saying
440
00:39:35.620 --> 00:39:40.220
that. I feel like I stay all the time, cold calling for specialists of any kind for
441
00:39:40.220 --> 00:39:43.200
nurse practitioners to develop relationships with the people that they refer to because
442
00:39:43.200 --> 00:39:47.600
they want it. And I appreciate saying that because it's like, you're trying to do your job.
443
00:39:48.020 --> 00:39:51.640
And like we sometimes they feel like they're bothering and it's like, no, they're at,
444
00:39:51.700 --> 00:39:54.480
you're actually helping make sure that the appropriate patients are going to the right
445
00:39:54.480 --> 00:39:58.400
place, right? Like we, you don't want to send you things that you don't have the ability
446
00:39:58.400 --> 00:40:04.140
to see or because they are not appropriate, right? Yeah. So there are definitely things that
447
00:40:04.140 --> 00:40:08.900
like are outside of people's skillsets. You know, not every patient sees pelvic floor,
448
00:40:08.900 --> 00:40:14.280
not, sorry, not patient, not every physical therapist. She's patients, but pelvic floor
449
00:40:14.280 --> 00:40:20.320
dysfunction or TMJ or a hand issue. So absolutely, you know, knowing what their
450
00:40:20.320 --> 00:40:25.900
specialties are and, and if you don't ask, like we would love to talk to you.
451
00:40:25.900 --> 00:40:34.360
Yeah, they're not scary. They get so scared. I'm looking at the questions that were
452
00:40:34.360 --> 00:40:39.560
submitted. So are there any red flags that you see that get missed by a provider that referred
453
00:40:39.560 --> 00:40:50.420
them or is it not, not too bad? So I worked, I think, which probably like when I worked in
454
00:40:50.420 --> 00:40:56.420
like Somerville and Cambridge and things like that, and I can't tell you why this location
455
00:40:56.420 --> 00:41:01.640
was like this more so than others, I'm not really sure. But there's a high percentage
456
00:41:01.640 --> 00:41:07.980
of patients that are hypermobile and that is a diagnosis. I feel like that's
457
00:41:09.320 --> 00:41:12.840
really underdiagnosed unless someone's coming from Children's Hospital, you know,
458
00:41:12.840 --> 00:41:16.780
where they're kind of getting it as a kid and they, and there's times where I've
459
00:41:16.780 --> 00:41:23.780
diagnosed people with EDS and I'm like, yeah, Ehlers-Danlos syndrome. Exactly. And I'm
460
00:41:23.780 --> 00:41:27.460
like, you know, you really got to talk to your doctor about this or, you know, there's a
461
00:41:27.460 --> 00:41:35.820
Boston that I'll send them to or it's, it's a, I see, I don't have a percentage per se,
462
00:41:35.880 --> 00:41:39.200
but I would honestly probably guess maybe more than 50% of my patients
463
00:41:39.980 --> 00:41:48.100
have this. And, and so what is hypermobility, right? So the way we diagnose it or kind of
464
00:41:48.100 --> 00:41:53.650
can say that someone has it or not is just based off of the Byton scale. And if you're
465
00:41:53.650 --> 00:42:00.970
familiar with that, it, it's just nine tests. So the first thing is, is your hands. So can
466
00:42:00.970 --> 00:42:09.010
you reach like your, your thumb down to your wrist? No. Okay. But you'll see like something,
467
00:42:09.270 --> 00:42:12.890
you know, this is like an, the old word would have been like double jointed, right?
468
00:42:13.070 --> 00:42:17.270
And so you'll see people like, they can do that. I can do some of them. So like
469
00:42:17.270 --> 00:42:22.030
the pinky is next. So if you can bend your pinky back beyond 90 degrees.
470
00:42:24.290 --> 00:42:31.290
So you're, you're at like 88 degrees over there. Just about there, but you can see how that's
471
00:42:31.290 --> 00:42:37.430
obviously more than 90, right? Or this one doesn't go as far, but still more than 90.
472
00:42:37.910 --> 00:42:42.670
So that's, so it's one, two, three, four. Okay. So each side of the body counts as a
473
00:42:42.670 --> 00:42:47.610
different number. The next thing is elbow hyperextension. I don't really have that,
474
00:42:47.610 --> 00:42:52.010
but you're looking for more than 10 degrees of, of hyperextension. And you really want
475
00:42:52.010 --> 00:42:56.110
to measure that passively because actively they'll just kind of stop here. And so you
476
00:42:56.110 --> 00:43:02.510
really want to get that full hyperextension. So that's five, six. And then the knees. So
477
00:43:02.510 --> 00:43:07.710
you're looking at either standing or supine hyperextension of the knees. Same thing
478
00:43:07.710 --> 00:43:14.870
that 10 degrees. And then if they can or could as a child, like palm the ground
479
00:43:15.370 --> 00:43:19.390
with their knees straight. So like bending forward, reaching their palms on the ground,
480
00:43:19.390 --> 00:43:23.050
other fingertips has to be like a flat palm and their knees have to stay straight.
481
00:43:24.210 --> 00:43:30.310
So if you have more than four of those be positive tests, it's considered classified
482
00:43:30.310 --> 00:43:36.590
as hypermobile. And that can really change diagnosis. So, you know, people who are
483
00:43:36.590 --> 00:43:40.610
hypermobile, there's been strong links with anxiety even, right? So these people are
484
00:43:40.610 --> 00:43:46.730
going to have possibly a more, a higher fear of movement. There's been strong links with
485
00:43:46.730 --> 00:43:53.570
lack of proprioception. So one of the things that's like another criteria that fits into this
486
00:43:53.570 --> 00:43:58.790
is do you trip a lot? Are you clumsy? Do you drop things? And so from your standpoint,
487
00:43:58.790 --> 00:44:02.490
you may think of those questions as like a neurological concern, right? Like they're,
488
00:44:02.690 --> 00:44:05.990
they're developing some sort of neurological disease and you're like, oh, that's not good.
489
00:44:06.350 --> 00:44:09.830
But what if they've just been like that their whole life? Like the person and
490
00:44:09.830 --> 00:44:14.950
kind of like, like, you know, I clipped my shoulder like on doorways a lot.
491
00:44:16.270 --> 00:44:19.930
Like, oh, and the thing is that you don't know where you are in space.
492
00:44:19.970 --> 00:44:23.770
So interesting. I feel like I sort of meet criteria for this.
493
00:44:24.910 --> 00:44:28.650
I think you do absolutely. I think we tested that. Yeah.
494
00:44:29.170 --> 00:44:32.330
My neck is a little hypermobile. I'm definitely clumsy. Definitely clumsy.
495
00:44:34.990 --> 00:44:39.350
That's so interesting. So you probably are just treating them a little differently,
496
00:44:39.350 --> 00:44:47.210
just being more mindful. Yeah. 100% for them, it's posture. It's posture because
497
00:44:47.210 --> 00:44:52.790
so let's say they stand with that genuine recurvatum in their knees, that hyper extension,
498
00:44:53.090 --> 00:44:58.590
right? What's going to happen to their low back? It's going to increase the lumbar lord
499
00:44:58.590 --> 00:45:04.770
doses, right? So I've had people come in, you know, 10 plus years of back pain,
500
00:45:04.770 --> 00:45:08.890
watch them stand, they hyper extend their knees, they have that increased lord
501
00:45:08.890 --> 00:45:14.070
doses. I say soften your knees, I tape them in a softened knee position so they can't move.
502
00:45:14.730 --> 00:45:21.330
And they come in, their vaccines gone. So great. So it's such an easy fix. And I just
503
00:45:21.330 --> 00:45:24.810
feel like, like that's, that's gotta be in people's radars a little bit more to have
504
00:45:24.810 --> 00:45:29.590
that like hypermobility scan, because it does lead to a lot of different things. And it
505
00:45:29.590 --> 00:45:33.910
means someone has like Ehlers-Danlos syndrome, or they could have pot syndrome, or even like
506
00:45:33.910 --> 00:45:39.590
our fans, you know, they have cardiac issues, there's other systemic things that could be
507
00:45:39.590 --> 00:45:45.090
going on as well that need to get ruled in and out. Totally. That's so, that's so
508
00:45:45.090 --> 00:45:48.810
interesting. One of the questions was about being able to read physical therapy notes.
509
00:45:48.810 --> 00:45:54.850
And for me, I glaze over and I'm just like, it's going well. I signed it and it's in
510
00:45:54.850 --> 00:45:58.990
their chart. Like I don't really know how to read physical therapy notes. I don't know why.
511
00:45:59.010 --> 00:46:02.030
Like I can't even think of the examples. I just remember reading and it looks very
512
00:46:02.030 --> 00:46:06.210
different from the way that we write our notes. And so I just was like, therapy's going well,
513
00:46:06.410 --> 00:46:15.410
I think. Just like maybe bad. Yeah, no, it's, we know what happens. You know, generally we
514
00:46:15.410 --> 00:46:19.150
only sign notes for Medicare. We send notes out to be signed for Medicare patients
515
00:46:19.150 --> 00:46:25.650
anyways, just because that's an insurance requirement. But there is, there's a
516
00:46:25.650 --> 00:46:30.430
Massachusetts requirement that every 30 days, a physical therapist has to do a progress
517
00:46:31.630 --> 00:46:37.010
and most EMRs will just send that to the referring provider, like in a fax or an email
518
00:46:37.010 --> 00:46:40.650
or whatever. So that's, that's why you get our notes a lot of the time. Oh, I was wondering,
519
00:46:40.850 --> 00:46:46.270
I was like, I wrote a prescription. I don't know why. Like, why are you talking to me?
520
00:46:46.470 --> 00:46:50.390
Go away. But I just was like, I didn't understand the signature part. I thought
521
00:46:50.390 --> 00:46:57.650
always being an inconvenience that I wasn't sending stuff in the first place, but I
522
00:46:57.650 --> 00:47:03.870
signed the initial evaluation, every progress note, which is every 30 days in the discharge
523
00:47:03.870 --> 00:47:11.530
note has to be signed or the insurance company doesn't reimburse us. Which that's a whole
524
00:47:11.530 --> 00:47:16.790
different soapbox, but there's no other insurance company that does require that.
525
00:47:17.190 --> 00:47:20.930
But Massachusetts law does require that we send the progress note. Now that progress note
526
00:47:20.930 --> 00:47:25.110
does not have to be signed if it's not Medicare, but we, we do have to send it
527
00:47:25.110 --> 00:47:29.570
I see. I like hearing, I like hearing it. I just don't know how to interpret it.
528
00:47:30.210 --> 00:47:34.430
Yeah. So, so basically it's, it's subjective is the first part, right? So it's like, what,
529
00:47:34.650 --> 00:47:39.550
how does the patient feel things are going? So that's, that's good or bad, you know,
530
00:47:40.850 --> 00:47:44.590
the object of stuff, I think would be the hardest because it's all just numbers
531
00:47:44.590 --> 00:47:48.850
and you're like, what, what, you don't know what the normal, the normative value is.
532
00:47:49.170 --> 00:47:53.450
So it's like, oh, they have, you know, 55 degrees of flexion. Like, well, what are
533
00:47:53.450 --> 00:47:58.170
you supposed to have? You know, that doesn't tell me anything. So I can, I can definitely
534
00:47:58.170 --> 00:48:02.750
understand that. I think if you read any part of it, read the assessment because that's,
535
00:48:02.750 --> 00:48:06.230
that should be written in like plain English. That's just kind of like, you know,
536
00:48:06.310 --> 00:48:10.630
patient presents with this. They could do this. They now can do this. They're still
537
00:48:10.630 --> 00:48:16.290
working on this. They would still benefit from PT is generally like the formula for that
538
00:48:16.290 --> 00:48:20.630
aspect. Yeah. And I usually, I feel like too, when I've seen them and I do appreciate
539
00:48:20.630 --> 00:48:24.510
seeing them, like the part that I understand, but it's usually like, what are the goals? And
540
00:48:24.510 --> 00:48:28.610
it's like, to be pain free by the, like, there's usually some sort of like metric goal of like,
541
00:48:28.690 --> 00:48:32.650
they want to be without pain during certain activities, like that kind of thing. Yeah.
542
00:48:33.190 --> 00:48:36.190
Yeah. I usually just say like, do you need more physical therapy? I'll write more.
543
00:48:37.890 --> 00:48:43.810
Yeah, you do. I think one of the other questions that really came up a lot was about,
544
00:48:44.450 --> 00:48:47.770
I think the main challenge that I see in primary care, aside from like kind of like
545
00:48:47.770 --> 00:48:51.290
convincing patients. And again, I say that in quotes because I'm not, I'm not coming from
546
00:48:51.290 --> 00:48:55.450
a nefarious place. I'm coming from like a connecting them to understanding what exactly
547
00:48:55.450 --> 00:49:00.190
the benefit is. Right? Like it's, it's not, I have no agenda as I can to help them. Right.
548
00:49:00.310 --> 00:49:04.070
But sometimes you have to get people's buy-in and you have to explain, like,
549
00:49:04.370 --> 00:49:09.050
what are their objections? And usually the main objections are, is this going to help me?
550
00:49:09.090 --> 00:49:12.450
How does this help me? Right. And so that's what the purpose of our talking is so that we
551
00:49:12.450 --> 00:49:16.510
can fully understand, I mean, we can't fully understand it in like a half an hour, but you
552
00:49:16.510 --> 00:49:21.370
better understand what the process is and how it actually believe with gusto that is going to
553
00:49:21.370 --> 00:49:27.470
help. Right. And then number two and three are about cost and about time. And it's either cost
554
00:49:27.470 --> 00:49:30.950
because they don't have insurance or their insurance in Massachusetts. There's a plan
555
00:49:30.950 --> 00:49:36.110
that only covers 60 visits per year for any condition. I don't know if that's been
556
00:49:36.110 --> 00:49:39.830
updated, but there's some other ones that will cover, like for me personally, I had a back
557
00:49:39.830 --> 00:49:47.090
injury being covered for I think 60 days only. And then the other part of it is copays, right?
558
00:49:47.150 --> 00:49:50.370
So like, is there copay too high? Those are the main like objections. And so when it comes to
559
00:49:50.370 --> 00:49:53.890
like selling a patient on it, it's kind of like addressing those things. But what's the,
560
00:49:53.990 --> 00:49:57.390
do you have any thoughts about that? Cause I know that we were both frustrated with the
561
00:49:57.390 --> 00:50:01.770
state of insurance access and physical therapy access. So what are your thoughts about that?
562
00:50:02.570 --> 00:50:12.930
Yeah, it's hard. I disagree with how insurances deal with that because I mean, every insurance
563
00:50:12.930 --> 00:50:20.370
is different. Of course. I know there, it has since changed, but there was an insurance that
564
00:50:20.370 --> 00:50:28.530
said 30 days actually. It's like, you get 30 days to fix the condition and it's per condition
565
00:50:28.530 --> 00:50:37.670
per lifetime. Really? So if you had an ICD-10 code of NIOA, right? You got 30 days in your
566
00:50:37.670 --> 00:50:46.170
entire life to fix it. It's wild. So then they changed it to 60 days. And I think they've
567
00:50:46.170 --> 00:50:51.230
since changed it to 60 visits in a year, which is much better. 60 visits is a lot.
568
00:50:52.230 --> 00:50:56.430
Generally you should be seen for under 20. You know, it should be, if it's really
569
00:50:56.430 --> 00:51:01.330
straightforward, like an ankle sprain or things like that, you know, 12 visits or so is like
570
00:51:01.330 --> 00:51:06.970
two to three months is really enough. Or if someone has, especially anything with like
571
00:51:06.970 --> 00:51:12.690
healing from a fracture, those are pretty straightforward. Post-op is generally going
572
00:51:12.690 --> 00:51:17.670
to be about four months. Unless it's ACL, it's going to be about six months.
573
00:51:18.350 --> 00:51:22.490
Oh my gosh. I love hearing this because like, from my perspective, like that is so
574
00:51:22.490 --> 00:51:28.070
disparate from insurance. And also it's nice to hear that like, I think it's also important
575
00:51:28.070 --> 00:51:32.370
for us to know as nurse practitioners, how to set patients up for success. Yeah. So
576
00:51:32.370 --> 00:51:35.550
then step aside, but like even in that communication piece, like this is going,
577
00:51:35.670 --> 00:51:39.870
like when you and I first met with my back, you were like, Ooh, 60 days is not that long.
578
00:51:40.270 --> 00:51:44.150
And I, in my perspective, I was like, Oh, really? It's going to take a long time,
579
00:51:44.150 --> 00:51:47.950
but that's nice to know. I know about an ACL tear, but like, I didn't know about
580
00:51:47.950 --> 00:51:53.910
four months and that's helpful to know. Yeah. Usually like that 16 week. And this is again,
581
00:51:54.050 --> 00:52:00.110
kind of categorizing, but if you look at pretty much any post-op rehabilitation protocol
582
00:52:00.110 --> 00:52:05.350
around that four months, Mark, they're starting to do like sport activity, right? And a lot
583
00:52:05.350 --> 00:52:09.870
of, not all, some insurances don't even cover it. If you're only working on sport activity.
584
00:52:11.330 --> 00:52:16.690
Sometimes that can be a little bit tricky to, you kind of have to be
585
00:52:16.690 --> 00:52:21.010
creative with how you write things. So it's just a conversation that you want to have with
586
00:52:21.010 --> 00:52:26.590
your patient too. Like sometimes I'll see people have like a $75 copay and I'll be like, you know,
587
00:52:26.730 --> 00:52:30.730
can you be here twice a week or do you want to just do once a week or do you want to
588
00:52:30.730 --> 00:52:37.030
do once every other week? It's our job to work with you to figure it out. So if you
589
00:52:37.030 --> 00:52:42.310
only get six visits, but it's your job to know your benefit though, right? So to know
590
00:52:42.310 --> 00:52:48.890
come in and kind of discuss the concerns that you have. Most people are going to try to see you
591
00:52:48.890 --> 00:52:53.950
twice a week, right? Because it takes that repetition to really build it. There's, I think
592
00:52:53.950 --> 00:52:57.590
there's a study out there. It says it's a little vague. It says between like 300 and
593
00:52:57.590 --> 00:53:04.150
600 repetitions are really needed to not learn a new skill, but just actually build that
594
00:53:04.650 --> 00:53:08.990
neuroplasticity of a muscle firing rate. So that's, that's a lot. And then if you're
595
00:53:08.990 --> 00:53:14.550
doing, if it's in the beginning and you're not really getting that feedback often enough to
596
00:53:14.550 --> 00:53:19.210
know that you're firing it correctly, then you're firing it incorrectly and then you're
597
00:53:19.210 --> 00:53:22.830
kind of wasting your time. And so that's why we try to say twice a week, at least in the
598
00:53:22.830 --> 00:53:27.050
beginning. And then maybe once a week after you feel more comfortable and you're working
599
00:53:27.050 --> 00:53:32.470
on more of the strengthening aspect, but we can move, we're very flexible in that. And if
600
00:53:32.470 --> 00:53:36.170
they're not, then you have to think about, you know, do they want your
601
00:53:38.030 --> 00:53:42.090
fee or do they want to help you? So you gotta be careful with that.
602
00:53:49.630 --> 00:53:54.870
That's our episode for today. Thank you so much for listening. Make sure you subscribe,
603
00:53:55.210 --> 00:54:00.670
leave a review and tell all your NP friends. So together we can help as many nurse practitioners
604
00:54:00.670 --> 00:54:05.550
as possible, give the best care to their patients. If you haven't gotten your copy of
605
00:54:05.550 --> 00:54:11.490
Ultimate Resource Guide for the new NP, head over to realworldnp.com slash guide.
606
00:54:11.910 --> 00:54:16.550
You'll get these episodes sent straight to your inbox every week with notes from me,
607
00:54:16.870 --> 00:54:20.750
patient stories and extra bonuses. I really just don't share anywhere else.
608
00:54:21.110 --> 00:54:24.090
Thank you so much again for listening. Take care and talk soon.
© 2025 Real World NP. For educational and informational purposes only, see realworldnp.com/disclaimer for full details.
