Dr. Nathan Kadlecek, PTIs a physical therapist committed to providing high quality health information, largely focused on lower back pain and the gross overuse of diagnostic imaging, medication, surgery, low quality treatment methods, and the over-diagnosis of pain conditions. He's also a powerlifter, pain nerd, macro-scale thinker, and wants to help you think differently about pain, healthcare, and life. |
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America needs help. It's suffering from a chronic pain epidemic.  Don’t confuse ‘how you feel’ with ‘why it works.’ Effectiveness does not explain the why.
POP. Sweet relief. I love getting my back cracked. It feels amazing and causes me to just want to lay there for a few moments and soak it in. When I was applying to physical therapy programs, my idea of helping and healing people from musculoskeletal issues was that I would be able to diagnose and then treat people based on their specific dysfunction. This could have been a slight positional change in the spine where one segment was rotated more than another, or a pelvis that was rotated too far forward (anterior tilt) or even one of the innominate (hip) bones being rotated more than the other on the sacrum. I thought I was going to be going to school to fix people and that I, and only I, with my hands could determine what the true dysfunction was. I was wrong. I had an existential crisis. **Disclaimer: I am not a manual therapy hater and I use it from time to time.** Tl;dr
Why is this important??
------------------------ I CAN FIX YOU WITH MY HANDS! Upon taking my first class in my physical therapy program at Columbia University, I was bright eyed, bushy tailed, and ready to learn exactly how to fix people. This started with in-depth anatomy classes with a lab section for cadaver dissection, physiology to further solidify our undergrad knowledge of each of the bodies internal processes, and various classes specific to neurological conditions, orthopedic conditions (muscle, bone, tendon, ligaments, etc.), pediatrics, geriatrics. Each of these classes were interesting, however none piqued my curiosity more than the orthopedics courses. These were the courses that would talk about exercise, manual or manipulative therapy, soft tissue mobilization (i.e. massage), and various modalities. In these courses, particularly the spine course, I was fully engaged and soaking all of the information up like a wet sponge. But, there was a problem. When it came time to start practicing and learning about spinal palpation (feeling spinal segments) and we were asked to perform special tests to determine the difference in rotation of various segments, or the height differences of one innominate bone (hip) from the other, I couldn’t do it. I sucked. I’ve sucked at things before, I mean, really terrible. I was so bad at field goals my freshman year of high school that I didn’t even get the kicker position (I went on to get a scholarship in college as a punter/kicker). I barely passed neuro in PT school. And wrapping presents… yea it looks like a child did it (although there have been improvements ;) ) This spinal palpation and diagnosis thing though, I couldn’t get it. No matter how much I worked at it or practiced it, I couldn’t feel what the highly experienced professors could feel. I remember one day I asked, “I really can’t feel the difference, and really, won’t everyone feel something differently, anyways? Isn’t this based on our own perception and confidence?” The response from the instructor was “you just need to practice more and eventually your hands will get more sensitive to the motions.” What’s funny is that I ran into this instructor a few years down the road and found that he doesn’t even believe that, go figure. The educational system is weird. With the help of some highly skeptical friends, who were older and a bit wiser than I, they helped me build up a healthy set of skepticism towards the palpation of “segmental dysfunction,” and the idea that something was either “out of alignment,” or “mispositioned,” and that it needed to be “corrected,” and that this was somehow the cause of pain. In addition to my skeptical bros, our final ortho class was extremely insightful. For the entirety of the past two years of PT school I had been under the impression that pain was largely caused by biomechanical faults that could be palpated and corrected by manual therapy. At the beginning of my third year, this paradigm was absolutely crushed and I was left wondering why the hell I even went to school and paid hundreds of thousands of dollars. I was left feeling disillusioned and angry that so much of what we had learned was based on old and outdated evidence. It was exhausting and defeating. Thankfully, as time went on, and we continued to learn and push through the final third year, things started to look up. I found that instead of feeling disillusioned from my bias being challenged and destroyed, that I now had more freedom and that many of the patients suffering with chronic pain that I had worked with in the past (who didn’t respond to manual therapy at all) might have some hope after all, to suffer less, that it wasn’t about me ‘fixing’ them. ----- LAW OF THE ARTERY AND LAW OF THE NERVE I love reading and studying about beliefs, behavior, bias, fallacies, and many other areas of behavioral economics. This has spurred me on to read numerous different books on the topic, one of my favorites being Thinking Fast and Slow by Daneil Kahneman. If you haven’t read this book, you need to, as you’ll realize you aren’t nearly as smart or bias free as you think. Due to this love of learning about biases, beliefs, and become more skeptical, a curiosity arose. Just like I had wanted to fix people with my hands, many people before me also wanted to do the same; not only Physical Therapists, but Osteopaths and Chiropractors, too. I became curious about how each of these professions started and where in the world did the term “out of alignment,” crop up from. I’d learned and read about the origins before but never as in depth as now. Before osteopaths, chiropractors, or physical therapists, there were “bone setters”. These bone setters were present in Indonesia, China, Japan, Russia, Hawaii, Nepal, Mexico, and other parts of the world. They performed various techniques of manual manipulation including “adjustments,” “high velocity low amplitude thrusts,” “osteopathic manipulations,” or whatever you’d like to call it. They also reduced actual dislocations of the hip, knee, and shoulders, although they had no formal medical training. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565620/#B8 The first Osteopathic Medicine college: 1892, in Kirksville Missouri, Andrew Taylor Still the father of Osteopathic Medicine opened the American Osteopathic College. Founding belief: Law of the Artery: “He based his theories of disease and dysfunction on the “disturbed artery” in which obstructed blood flow could lead to disease or deformity. This would become known in Osteopathy as the Law of the Artery.” The first Chiropractic College: 1897, in Davenport, Iowa, Palmer opened, The Palmer College of Cure, now known as the Palmer College of Chiropractic. Founding belief: “...Palmer began to reason that when a vertebra was out of alignment, it caused pressure on nerves. He further reasoned that decreasing nerve impulses would surely affect visceral function leading to disease (the Law of the Nerve).” The first physical therapy college: 1913, in Otago, New Zealand. The School of Physiotherapy at the University of Otago, NZ. Founding belief: No particular “founding belief,” as this profession developed organically out of close relationships with orthopedic surgeons. PT’s were originally known as “reconstruction aides,” for injured soldiers during and after World War I (WWI). Mary McMillan was the first and most prominent reconstruction aide, as she was taught by the pre-eminent Sir Robert Jones, a physician in England who co-authored the treatise “Orthopedic Surgery.” Use of massage, corrective exercise, and other modalities were originally utilized. Prior to the 20th century, much of medicine was still following the motto of “observe and use what helps, avoid what does harm,” which sounds good in theory, but doesn’t always work. This can be evidenced by a procedure to treat fevers back in 1796 and into 1800’s, “bleeding,” using a tool called a lancet (scalpel). It was assumed that if you get rid of the symptom, fever, you solve the problem. So… why not just make people bleed enough to where they become cold. Clearly this wasn’t a great approach and in my mind emphasizes why it’s important to also understand the mechanisms as to why things work so we don’t continue to do incredibly stupid and counterproductive things. We shouldn’t judge professions based on their beliefs 100 years ago, and we also shouldn’t judge individual people just because they are part of a certain profession. I think this is counterproductive and does not take into account individual beliefs of practitioners and the evolution of professions over time. However we should absolutely hold people accountable when the narratives given to people about pain are incorrect as these can cause serious chronic issues down the road. ------- FALSE BELIEFS DO CAUSE HARM “Why should I care about how it works or what they’re telling me, I just want to feel better.” Feeling better at the expense of possibly developing chronic pain down the road is not a healthy trade-off. Like I stated before manual therapy and adjustments/manipulations/mobilizations all have a positive effects for many people, however the ‘why’ behind it working is also important. Here is where I have some qualms. Over the past three years of practicing as a physical therapist, i’ve had multiple people, nearly every day, tell me either, “my back is out,” or “my hip popped out,” or “my PT said my hips were WAY off,” and I need to go get it adjusted to get it put back into place. I’ve had more people than I can count, get an adjustment to “put it back in place,” and then who are deathly afraid of exercise because it might “pop it out.” These conversations are frustrating for a few reasons. Disclaimer: *This applies to PTs, Chiros, and Osteopaths. I’m not singling one one profession, so don’t get all bent out of shape ;).*
Clearly, we have a problem. The # of individuals suffering with chronic pain continues to increase, and seemingly, the amount of people who still believe outdated information from the 1800’s is HUGE. I will state it again, just because something has been around for 100’s or thousands of years, and has some positive effects, does not explain the WHY. This “why” is important because it’s now understood that this is a huge contributing component of who will suffer from a chronic musculoskeletal pain condition, and who will not. ------ SO… IF MY BACK AND HIPS DON’T GO OUT, WHAT’S GOING ON? There is no doubt that often times our back or hip feels a bit or very ‘off.’ If you really dig deep into your first experience of this feeling and who was the first few people to give you advice on it, it’s likely you’ll remember somebody who said “oh, you need to be careful,” or “you should go get adjusted,” or “wow, your hips are WAY out,” or “your L5 vertebra is way out of place by 2mm.” Often times we feel and experience pain, and immediately we tap into our memory to see if this is something similar. If it’s not something familiar that we’ve experienced before we’ll go search it up and see if we can figure it out. This is typically when someone will get told that “oh, it’s because your back is out of place,” lemme just pop it back in… Back pain itself, especially the kind where we feel something is off, that nasty muscle spasm and grabbing feeling, or sciatica, are multifactorial. The irritated structure could be a nerve, muscle, tendon, ligament, disc, or something else, but, there may be a better way to think about this. Rather than trying to find an exact diagnosis (when there typically is not one), what if you thought about pain as what it’s NOT vs. what it is. If you can rule out that the pain is not due to a fracture, kidney stone, infection, cancer, gall stone, and some other rare conditions, then chances are, with a program to stay moving, and working on your self-efficacy and healthy body beliefs, that things are going to be okay. Perception is reality, however reality can be warped. If your perception is that your back hurts, therefore your back is out, then your reality that you’ve created is (likely) that everytime your back hurts, it’s because your back is out. When really, this is not happening, for reasons cited above. Our perception of situations and events is usually horribly flawed. We are incredibly irrational actors, and the sooner we can accept that and become a little more skeptical and use a few more sources, the sooner we will be able to make a dent in this massive problem that is chronic and persistent pain. What do YOU think? As always, please leave your wonderful comments below or respond directly to me via email with your love mail or hate mail :). Email me AND for a much more in depth review of this topic please visit https://www.painscience.com/articles/structuralism.php -- it's really an epic document! VERY detailed and rational. A few more references: 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565620/#B8 - A History of Manipulative Therapy 2. https://sciencebasedmedicine.org/chiropractic-vertebral-subluxations-science-vs-pseudoscience/
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If You Ask These Questions; You'll Find a Great PT It’s too difficult to find a physical therapist who’s actually good at what they do. I hear this all the time, “i’ve gone to a few physical therapists offices before and it was just the same old stuff over and over again,” or “I was really tired of getting passed off to aides and only being seen by the therapist for 10 to 15 minutes.” This is an unfortunate reality at a lot of PT clinics in the country. Good news for you is that I am going to be going into exactly how to find a great physical therapist near you, and, if you’re not happy with your current provider, how to find a better one. For those of you strapped for time... Here is your TL;DR version:
Groups of physical therapists who are great at what they do:
 A few qualifiers:
Trust Do you trust the person you are working with or potentially working with? Like with any relationship, the relationship you develop with your physical therapist or rehab professional is incredibly important. If you don’t trust this person, how can you expect the rehab process to be effective? Developing trust is faster for some than others. I’ve worked with clients who come in and we instantly hit it off, immediate trust. For others, it takes a few sessions before that person feels confident in the plan we’ve set forth. I’ve also worked with people who end up not having as much trust in me and we didn’t have a great outcome. I find that this is likely the single most important aspect of the rehab process, what we rehab professionals call the “therapeutic alliance.” Have we jointly created a therapeutic alliance, a team approach, that will help you reach your goals, and are we on the same page.  Positivity I’ve been in clinics where the only thing I hear therapists saying are negative. As a colleague of these individuals, I can tell you, it’s terrible. It’s even worse for the patient as they are then working with someone who is burnt out, apathetic, and not giving 100%. Thankfully i’ve worked at clinics and hospitals where the therapists are the most positive people i’ve ever met and you can see this manifest in the patients lives, too. When you have an injury or are dealing with severe pain, it’s important that the person you are working with be incredibly positive. While working through pain is not necessarily something we desire to be doing on a daily basis, it becomes a lot easier when you have a positive and uplifting coach working with you to guide you each step of the way.  Keeping up with the research Do they have a practice of keeping up with the research? This one is a little harder to gauge from a patient perspective because you’re likely not that familiar with physical therapy research. A few questions i’d ask the therapist would be “what are recent continuing education courses you’ve taken,” “what are your favorite research journals to read,” “any recent studies that you found interesting?” You could also ask who some of their favorite researchers are. These are a few questions I would ask your therapist to see if they truly keep up with the literature. To really be certain, ask a few different therapists the same questions. If you do this, you’ll be able to get a better idea of different practices and commonalities between each PT. Honest? Do they talk straight with you and say “I’m not sure, i’ll get back to you on that?” I’ve found that the absolute best physical therapists that i’ve worked with are comfortable with saying “i’m not sure,” to the patient. Many times, people want to know how long something is going to hurt for, how long it will take to get their shoulder range of motion back, how long before they can start running again, among many other questions. The reality is that we can’t predict a lot of things, especially timelines. In my experience, the best response to these questions is something along the lines of “i’m not sure and I can’t predict exactly when things will change, however we know based on ‘X’ that most people see a return to ‘Y’ within this date range.” Ranges are much more accurate as each individual will recover at a different rate. And… to some questions, we just don’t know. High Volume Clinic “PT Mills” These clinics are called “Therapy Mills.” I can’t tell you how many people come to me and say, “I really didn’t have a good experience at my last physical therapy clinic. I was one of four people that the therapist was seeing and I had no idea what I was supposed to be doing. They just put me in a corner and I stretched while they worked with someone else.” Personally, I don’t think this should be happening, UNLESS it’s a sports clinic with multiple athletes recouping at the same time who understand what they are supposed to be doing. The most important parts of rehab are the understanding of what you should be doing and then actually doing it. If there are 3 or 4 people being seen an hour by one therapist it’s almost impossible to completely understand why you’re doing what you’re doing, there just isn’t the time to explain to each person and then correct it. It’s possible you will still get better by going to a clinic like this, however, it really waters down what the rehab process could be in terms of you completely understanding your pain/injury, what the plan is, and how to properly execute it.  Minimal Time with Therapist Like I said above, if the therapist is seeing >3 patients per hour then it’s likely you’re only going to get 10-15 minutes with them. I usually spend 10 minutes just catching up with the patient to see how they’re doing! Lol. I’ve worked in clinics like this in the past and it’s too hard to gauge patient progress if you only get a short amount of time with them. If the PT has a physical therapy assistant (PTA) on staff, that’s great. The PTA is also a licensed professional that works in a similar capacity to what a physician assistant (PA) does for a physician. Each of these team members should be spending adequate time with you, at least 30 minutes so that you have ample time to ask questions and get the work in. Unanswered Questions Which brings me to my next point… if you’re only being seen for 10 minutes there is no way that anyone can sufficiently answer your questions. I don’t care what any healthcare provider says, that’s simply not enough time, especially during the initial evaluation and first follow up to help you understand exactly what’s going on. Largely Passive Treatment Sessions Ice, heat, massage, dry needling, cupping, scraping, and other modalities can be helpful to reduce some short term symptoms, but if you are getting some rendition of these every single treatment session, particularly at the end, the clinic is probably just doing this to bill for it. That’s a waste of your time and a waste of insurance dollars on something that’s not really needed (in most cases). Like I said, some of these modalities can be helpful in the short term, but what I see way too often is that people become dependent upon these and start to believe that these are the cure for their pain or injury. It’s not accurate and rehab sessions should be focused on helping you understand the rehab plan and ultimately building self-efficacy, or the ability to cope and learn long term solutions. Are They Familiar With Treating Your Specific Concern? This is not the end all be all, but ideally your therapist has at least some experience working with your specific concern. For general pain concerns in major joints such as the shoulder, hip, knee, neck, and mid/lower back, most PT’s have tons of experience with this. When it comes to specific foot injuries, hand injuries, jaw pain, women and men’s health issues, neurological conditions, among others, it is more important to find someone who is comfortable and confident with these. There is a bit more specialization and complexity with that list. Summary Find a therapist who you:
If you do most of these above you’re going to have a successful experience with your therapist! What has been your biggest frustration when working with a physical therapist?
Rotator cuff tear?
Arthritis? Meniscal tear? Herniated disc? What do you all of these things have in common? They can typically be treated non-operatively. In another blog post physical-therapy-its-much-more-than-exercise-and-massage-santa-cruz-ca.html, I wrote about what physical therapy is, and, I added a portion which talked about how rotator cuff tears can respond really well to non-operative management. Like, really well!! |
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