How to love your job after 43 years and why surgery often isn’t the answer to your joint, back and neck pain.
Throughout my 43 year career as a physical therapist, I have been lucky enough to be able to be involved with students at Georgia College. My relationship with Georgia College began when I first graduated in 1976 and began working at Baldwin County Hospital. Back in the day, there was only myself and Marvin in Baldwin County and two or three other therapists in Macon for the entire middle Georgia area.
At that time we were allowed to supervise non licensed personnel to deliver PT, so I hired GC students to fill part time positions at the hospital. I tried to hire students that thought they wanted to go into PT because 1) competition for acceptance into a program was stiff and 2) I thought it helped to work in a field before majoring to assure it was something the student really wanted to do. Selecting students was very easy. I simply called Dr. Harriett Whipple and Dr. Doris Moody for recommendations. They knew all the students that wanted to go into PT and knew which students would work out well.
More recently I have been involved in the internship program through the Exercise Science Department. These kids are assigned to various PT clinics to observe. Here again, the purpose as I see it, is to assure that they know what they’re getting into. Education is very expensive nowadays and errors can prove to be very costly. Watching these kids, who have varying real interest in the profession, has made me reflect back on my own decision to become a physical therapist. And more recently reflect on why, after so many years, am I able to stay energetic, positive, and enthusiastic about “going to work”.
Initially my interest was one of learning. In PT school I was taught a little about a lot of things. The thought was that you get the basics in school and then decide what “direction” you wanted to go after graduation and then learn on the job and through continuing education, based on your interest. I think it’s the same now.
“Directions” included pediatrics, geriatrics, acute care (hospital), school systems, nursing homes, orthopedics, neurology, amputees, home health, burns, developmental disorders, and on and on. I gravitated to the orthopedic direction, mainly because they all eventually got better in spite of what I did to them. I was fortunate enough to work closely with Dr. Tamayo and Dr. Hattaway and learned different things from both. And a lot about “skinning cats”.
I was then fortunate enough to be offered a position as Director of rehab for a big outpatient “sports medicine” clinic in Macon, working with Drs. Kelly, Richardson and Hattaway. Learning curve was steep as I struggled to learn about ACL reconstructions and ankle sprains and various other orthopedic injuries. Most of this came relatively easy. Except for treatment of spine pain: low back pain with and without leg pain and neck pain with and without arm pain. In school we learned that if we heated the painful area, it got warm and felt a little better for a little while. But it never stayed feeling better. Bed rest was advised over exercise. I saw many a patient be admitted to a hospital for traction for several to many days and then go home without any improvement. All of the exercises were based on “William’s Flexion Exercises”; basically bringing knees to chest. Any and all other directions of exercises was frowned upon. Almost all treatment was based on the patient’s diagnosis by the physician which was in most part determined by their x-ray or MRI and not on how the patient felt or how their symptoms changed throughout the day. We would treat this patient with degenerative joint disease. Or degenerative disc disease. Or a “muscle spasm”. Or facet arthritis, etc..
In the mid to late 90s, the assistant director of rehab, Kathy Nelson (in my opinion the best physical therapist who has ever worked in the southeastern US) suggested that we send one of our therapist to a “McKenzie” class. This form of treatment (MDT; Mechanical Diagnosis and Therapy) had been developed by Robin McKenzie in New Zealand in the 1970s and was just being introduced to the States. The cornerstone of this program was that different people with the same symptoms often need to do different exercises to abolish their symptoms. A unique concept! Matching the correct treatment to each patient based on their response to movement!
When Gina came back from the course, she was very excited. She began to improve patient’s pain in the exam room at the very first visit. And they remained better! Even after getting to their car! (the joke back then was “I felt better after therapy, until I walked back to my car”). We were all excited about this new treatment and then Gina’s husband took a job out of state and we lost her. So Kathy suggested that I take the courses. Over period of several years I took the required courses and then took (and passed!) the credentialing exam during a McKenzie International Conference in Ottawa in 2001.
Understanding, finally, how to successfully treat spine pain reenergized my interest in going to work. It made PT fresh again, and I was excited to see new patients because it was a challenge to figure out what each needed based on their response to movement and not just on their x-rays. Kind of like solving a puzzle. And when we got it right, which was very frequent, the joy on the patient’s face was awesome. For my remaining years in Macon, I sent every therapist that I could to the McKenzie institute for training. This incredibly simple system was getting great results. We were able to teach people how to treat themselves and empowering them to take more control over their healthcare. So here I was in 2001 with renewed interest and excitement in my job after 25 years in the field!
For the next several years I was able to work with therapists in my clinic and with Georgia College interns. Some of the interns seemed to grasp the concepts of MDT quicker than new graduate therapists. I found this odd, but had to remember my skepticism when first exposed to MDT and how much i had to “unlearn” to finally grasp it.
Three of four years ago, I began exploring the non spinal, component of MDT. Robin McKenzie had put one line in his book that said that the same principles that work for the spine also work for the extremities. The McKenzie Institute had begun incorporating extremity treatment in their classes. And I had taken an extremity class but just couldn’t make it work in the clinic. About the same time that I was starting to make sense of it, I found that my usefulness at my job had run it’s course. And I was offered a severance package of three months with pay.
I began 2018 without a job and wondering if I should end my career. But I was just getting excited about the possibility of making MDT work in the extremities. So I decided to open a small “no insurance” practice. And keep the fee reasonable, $50.00, which is what most co-pays were at the time.
For several years, I had known of a company from Tallahassee Florida called Integrated Mechanical Care or IMC (imcpt.com). They had implemented MDT principles and over a 20 year period had proven to reduce the number of MRIs, epidural steroid injections, and surgeries and by doing this had reduced the cost of musculoskeletal care by 40-45 % in their population in Tallahassee with Capitol Health, an HMO in Tallahassee. They had taken this treatment to several large self insured companies such as Michelin, Kia and Hyundai, to name a few, and had put MDT therapists on site at some of these locations and were saving them tons of money. I decided I wanted to be a part of that.
I contacted Chad at IMC and was told that they only used MDT trained therapists but that those therapists also had to pass their additional certification. IMC was guaranteeing a savings and had to insure that their therapists could get great results. I spent my 3 month severance studying for IMC’s exam and in February 2018 took and passed the IMC exam and became an IMC affiliate clinician. And WOW did I ever learn a lot!
Part of IMC’s success is, believe it or not, keeping patients away from imaging studies until they are absolutely neccesary. Advances in imaging have come a long way and are now very accurate and they have saved many people’s lives. Especially in brain images to find tumors or determine causes of strokes and in abdominal studies for masses, etc. In musculoskeletal care they are very accurate about what is actually happening in the spine or in joints. Extremely accurate.
But more recently they have been doing imaging studies on asymptomatic people; people with zero pain and no loss of motion or function. And they’ve found that 60% of asymptomatic people show a medial meniscal tear by MRI. 40% show a literal meniscal tear. 45% of us asymptomatic people have a rotator cuff tear by MRI, and this goes up to 78% if you’ve ever been an overhead athlete. 60% of us have a hip labral tear. And, depending on what study your read, between 50-60 % of us, still asymptomatic, will show a disc bulge in an MRI of our spine.
So you take a 40 year old landscaper who has an onset of back pain at work. He has an MRI that shows a disc bulge at his lumbar spine. Is this a new bulge or one that’s been around for a while? Is it really the cause of all his pain? If 50-60% of us have a bulge and it’s no big deal, does he really need surgery? If he can go to a MDT therapist and learn how to abolish his symptoms, is the MRI really necessary?
One low back pain Worker’s Comp study shows that if the patient is NOT referred to a specialist and does not have an MRI, then the average length of disability is 11 days. If he IS referred to a specialist or has an MRI, then the average length of disability is 151 days. So I think a better way is to send him to MDT and if he doesn’t improve, THEN do the MRI.
So this is what keeps me excited these days: empowering people to help themselves and keep that landscaper away from surgery and away from the fears that are associated with an imaging study. That, and teaching Georgia College Exercise Science students that a weak core is not the cause of all back pain! I’m grateful that after 43 years I still find inspiration and drive. Here’s to 43 more! Well, maybe not the whole 43 more, but at least a handful more.
How I try to help people avoid surgery and get back to living their lives.