Yesterday I was playing with my 3-year-old and had an interesting thought. We were playing with a roll of decorative tape (one of her favorite things in the world) and her children’s scissors (another one of her favorite things). We were cutting the tape and wrapping on our arms and legs, then she said something interesting that got me thinking. “Daddy my knee hurts (she scraped it a couple days ago) but it’s getting BUTTER (how she says better).” With her bringing up her pains, us playing with tape and me being a PT nerd I automatically thought about Kinesiotape.

I remember when she got her scrape days before and she was freaking out, I kissed it and put a band-aid on it, which immediately made it “butter.” She went from complete lose of bodily control and crying, to instantly wanting to return to playing with a kiss and band-aid.

In my head (as we continue to wrap tape around my toes) I wondered, how similar are the two scenarios: a toddler getting kissed and a band-aid and an adult getting massaged and taped.

I rarely tape my patients unless they ask for it. (There is one scenario where I think it is helpful (link)). To me putting tape on something does nothing for the underlying cause of their symptoms, therefore I don’t offer it, and I am not alone in that (link).

But, and this is a big but. Sometimes it helps people…this gives me a headache. This is why my job is difficult. Sometimes tape is the only thing that makes someone feel better. It is the only thing that lets them lift their arm without pain or finish a workout unhindered. Why does a band-aid and a kiss make my daughter feel better? Placebo maybe, not sure. But it does.

This really gets at the heart of the messiness of clinical practice. It is my responsibility to offer my patients the most up-to-date and evidence-based care, which I try to do. This does not include tape, unless it does… We healthcare providers (that give a rip) have to wiggle sometimes. We have to listen to our clients, know the evidence and do things that don’t make sense sometimes (to a certain extent). If you find yourself disagreeing with me, first comment, I’d love to talk about it, then ask yourself this. Would you not give a 3 year old a kiss and a band-aid because “the evidence is not there…” or would you listen to her/him and do it lovingly. Just a thought. Let me hear yours.

I ALMOST never use kinesiotape in the clinic. I have a few reasons for that:

1. It is no better than sham taping (link, link)
2. It is passive (not exercise based)
3. It does not hold things together or change the position of structures (link)
4. I still have the arts and crafts skills of a 3rd grader…so I suck at it.

I think the evidence concluding that it is not better than sham indicates that it is not worth my time, but I do use it sometimes.

Over the last year I have probably used kinesiotape <5 times. I think 4 of those were because people out right asked for it without me mentioning a thing. In that scenario I’m going to ride the placebo train all the way to feel-betterville, while not over-promising anything. The one other time is what I want to talk about because I feel like it actually fits into my reasoning model, I just haven’t seen the type of patient enough.

Taping does have minor effects on pain (placebo?) and proprioception (https://www.ncbi.nlm.nih.gov/pubmed/8231783). Which make sense because you are putting something on your skin, so your nervous system is feeling that thing and giving you more awareness of the aforementioned thing. In my practice this is helpful for one specific condition or classification.

I try to be as evidence-based as possible, therefore I use the McKenzie system to classify patients. For my thoughts on that go here. One of the classifications is Posture, which essentially means that the patient’s symptoms are aggravated only when they stay in a particular position of a long time. When they get out of that position, their symptoms go away. Abnormal stress on normal tissues. This is a fairly rare presentation to see in the clinic, hence the reason I have only used tape a few times. In the posture classification the only thing that aggravates the patient is a certain sustained posture…so I get them in the posture that takes their pain away (ie. chin tuck/ double chin, when having their chin way forward hurts their neck) and I put tape on them in a way that when they move into their provoking position it tensions. The tension on the tape/skin is felt by the patient and acts as a reminding for them to move out of that position.

This is a very helpful educational tool for patients. It is essentially like having me with them all day to say “hey move your neck, so it doesn’t start hurting.” Nothing magically there.

How do you use tape?

“Haters gonna hate.”

I have found myself on a swinging pendulum of hate lately…that sounds really weird and terrible. Let me clarify. There is a spectrum between 2 things: hating on everything because it is not legitimate and accepting anything and everything because “it works for me.” In the rehab/ fitness world everyone falls somewhere on this spectrum. Some could care less whether something has been properly studied, it is sexy therefore they endorse it. The other side is a group of people who are air-tight clinical scientists that will not only shy away from treatments/philosophies/techniques that are not determined effective by research but will aggressively oppose them. One is a lazy and probably a bad clinician, the other needs to have a hobby and is probably tough to get along with..which is massively important in physical therapy (see all therapeutic alliance research). I have found myself closer to the grumpy guy who needs a hobby for the majority of my schooling and now into my career. I like science and I want to do the best job I can as a physical therapist, which has led me to read research and try to base what I do in the clinic on that research. However, I am starting to realize that being grumpy about what other people are doing in the clinic is silly…I am swinging on the pendulum of haterness. I have found myself embracing/being ok with some of the other philosophies that different from me lately, even if I don’t agree with what they are saying. For example, I don’t love when my current patients come to me telling me they had a mysterious essential oil massage over the weekend and they feel the best they have in weeks (I have been treating them for weeks…). I don’t like that. It’s confusing. It doesn’t make sense that someone with a raging disc herniation that is irritating a nerve root causing radicular leg pain would get better by rubbing lavender-mint oils on their back and “IT bands”. But it happens. People get better with weird stuff sometimes and I am starting to just come to peace with that truth. I am not going to try to tell the patient that there is no way lavender fixed their spinal nerve roots…I am going to go “Great! I’m so glad you are feeling better,” and move on with treating them.

I am ok with things that shouldn’t make sense working. I am going to chalk most of it up to placebo, for now. The real problem that I (and other PTs) face is this: how am I going to decide when a treatment is legit or not? That is the biggest challenge with all of this. Is lavender-mint oil a viable treatment selection for my patient? If so, how do I come to that conclusion?

While I have been moving slightly towards the other end of the spectrum as far as my attitudes towards other interventions, I still have a responsibility to treat my patients with the highest level of care I can, which means using treatments that are known to work. My gameplan is to learn the heck out of a very well researched and documented system (my choice is the McKenzie Method for a few reasons) and then layer in stuff that is less well understood as people don’t respond. There are people who will get better with lavender-mint but I’m going to try to bring them through a number of “tried and true ” interventions, get them strong and encourage the heck out of them before I move on to some more uncertain things.

This makes me look ultra un-sexy in the grand scheme of the rehab/fitness world, but I’m ok with that..haters going to hate.

Listen to your patient.

This is becoming a bit of a buzz-phrase if that is a thing. Listen to your patient, listen to your patient, listen to your patient.

To be honest it is a bit confusing to me. Maybe I just don’t understand the context of those saying this, but how are providers NOT listening to their patients?

Short rant begins now. I don’t understand how countless providers could not give patients the time of day and throw a solution at them. Any physical therapist worth their salt knows that about 75% of your “diagnosis” is made in the subjective portion of the exam. Not only that but in order to make a patient’s treatment work for them, we need to know what they do, what their hobbies are, who the heck they are. Even if we got all of that we still need to convince the patient that we give a rip about them. How are people doing that without listening…what the heck is going on in clinics all over the country.

Rant over.

I think the listening problem is actually a caring problem. Providers that aren’t listening to their people don’t care about their people. I don’t think I am over-exaggerating that point. It is simply our job to listen well and help our patients.

Please. I’m not going to plead with you to listen to your patients…that is like putting a band-aid on a gunshot. I’m pleading with you to care about your patients. I know you care for them but let’s starting caring about them. This will solve a large number of problems.

I have been newly intrigued by entrepreneurship through a series at Creative Live called 30 Days of Genius. This series is essentially 30 different interviews with the world’s brightest creative minds, business minds, entrepreneurs, coaches, etc. The interviews are fantastic and they email you one interview per day for 30 days.

It is tough to listen to these creative geniuses, brilliant entrepreneurs, and great business minds without being a tad bit inspired. Because physical therapy is my career and healthcare is my industry I view these thought-provoking interviews through a certain set of lenses. How can I apply these great principles of creativity and business to my field and make a difference? It’s a tough but intriguing question.

I think the solution starts with seeing the problem with as wide of a lens as possible. The soldiers in the trenches of warfare have a no ability to see the grand narrative of the whole war, but only the mud, muck, and danger that is right in front of them. It is the general who can zoom out and see the bigger movements of the opposing troops, underlying strategies and use data, as well as intuition, to predict his next move. We need more generals in healthcare. Seeing the big picture in healthcare is very difficult however because it is such a big system with so many parts and so many players. I don’t claim to see it very well or clearly, but I do think it is helpful to try to think on a large scale.

The second part of creatively solving the problem of healthcare is breaking down the problem into small and manageable pieces. Costs are high, quality is low, access is poor, waste is rampant, people are unhealthy. We have a lot of problems, that list is a very small one. Each piece can be broken down further. Why are costs high? Why is the quality low? Why is access poor? Why is waste rampant? Why are people unhealthy?

Then we go to the drawing board. What solutions can change the way healthcare is delivered to drive cost down? What solutions can make healthcare higher quality? What solutions can make access to healthcare better? What solutions can eliminate waste in the system? What solutions can improve peoples’ health?

I think we usually stop at this point. Most of the conversations on twitter derail here. We know there is a problem, even a solvable problem but there are at least 2 viewpoints and we end up smashing our heads against the wall and conversation stops. We don’t have time to deal with these questions, we have patients to treat and errands to run. I get that. But I truly believe that innovation happens when an individual takes a problem and tries to solve it. Healthcare is a big mess and there are plenty of problems, I don’t think the solution is for it to become “their problem” or an “us problem”. What is happening at the “you level?” What problems do you see in your community and how can your skill set change that? What about regionally? Nationally?

I believe that we need some major thinkers in healthcare, some generals that can see the whole battlefield and move skillfully toward solutions. Don’t let yourself think too small or too practically, true genius is born when boundaries are broken and limitations lifted.

It sucks to be wrong.

I was wrong about the McKenzie system (or MDT). In school, we were briefly taught a bastardized version of the McKenzie “system” and it only confused and irritated me. I hated it. It made no sense. It made no sense because it wasn’t pathoanatomical, which was all I knew. I wanted to know what specific tissue in the body was the “cause” of the pain. Was it the inner or outer portion of the annulus of the disc? Was it the facet joint synovial capsule? Or was it the articular surface of the facet joint? I NEEDED to know!!!

I needed to know because in school treating patients was just a puzzle to be solved and there was ALWAYS an answer. This test meant that this tissue was the culprit, the other test meant that this tissue was the culprit…I would explain it all eloquently on paper, write the correct answer and puff my chest out because of how awesome I was.

Well, things have changed and I was wrong about good ole’ Robin McKenzie and his system. The same reasons that I absolutely despised MDT have become the reasons I love the system, which are:

1. Pathoanatomy

I used to need and love the “pain generator” in school, now I love MDTs ability to avoid the tissue and get straight to what really matters the patient’s experience. I started to realize in the real world with real patients that it is very very difficult to determine the specific tissues that are “causing” someone’s pain, and we know better now…tissues don’t cause pain. MDT looks at how a movement affects the patient’s pain, objectively, no bias or assumptions as to what tissue is doing that.

2. Simplicity

I used to hate how simple MDT was. How could simply repeating osteokinematic movements reduce someone’s pain? Don’t you have to glide the facet joint caudally with an anterio-medial emphasis? The more I read and learned the more I realized that osteokinematic movements are effective because they do very similar things to what we aim to do with manual therapy. Get joints to end range.

3. Effectiveness

This has been the biggest reason for my new love of the MDT system. MDT helps me systematically finding “home runs” that I missed before I did repeated motion testing. I used to do central PAs or traction on patients who may have had a clear directional preference or even centralization.

4. Reliability

The system is reliable based on a lot of papers (source, one of many papers) and based on the fact that is made up of simple osteokinematic movements and patient response, not palpation which is not reliable (source, one of many here as well), especially for me as a new PT.

5. Active not passive

I have found in my work with clients so far that it is much easier to get the locus of control, or in non-nerd terms, the ownership of the care, onto themselves if my treatment approach is an active one. If the patient is the one doing the movement actively as opposed to me manually doing it for them or to them, they are more likely to understand that they are responsible for improving. I still use passive treatments and I think that passive treatments are still an important part of some patient’s care but it is usually harder to get those patients to “own” their care.

6. Easier to incorporate pain science

I have found that it is easier to explain how a treatment works using pain science when using MDT. The biggest help is that the assessment and classification have nothing to do with their “bulging disc”, “bone-on-bone”, or any other terrible verbiage that sticks in patient’s heads, making them feel brittle. MDT assessment and treatment makes it easy to tell patients that their bodies are strong, adaptable and feel better with movement.

While it sucks to be wrong, I’m glad that I wrestled with a topic that I was completely biased against and have grown so much from.

Disclaimer: I don’t claim to know everything about PT assessment and treatment or MDT. I am constantly reading and learning and this blog is part of that metamorphosis. I also think there are lots of other great systems for PT. My point is simply that I have found a lot of help from something that I previously biased and now find quite helpful.