Noisy Victims & Silent Culprits

I adore studying the sometimes subtle and intimate mechanics of our body through the window of orthopedic manual physical therapy. I just came back from a specialty course in Seattle. It crystallized for me the niche that makes orthopedic manual physical therapy so special and inspiring for me. That niche is clinical reasoning and tissue differential diagnosis through the detailed biomechanical exam. But what puts it over the top for me is identifying the” noisy victim and the silent culprit” for my clients on a day-to-day basis in myy work at Core Physical Therapy.

In the mainstream allopathic world of medicine, we are aware of the disease model. This model is based on healing by identifying/diagnosing and removing or suppressing the diseased tissue or pathology. The most common treatment tools used in this model are pharmaceuticals and surgery. Orthopedic Manual Physical therapy (OMPT) is based on a biomechanical model of examination and treatment. It uses clinical reasoning and tissue differential diagnosis to identify the “noisy victim and silent culprit”. The OMPT commonly utilizes therapeutic tools of therapeutic exercise, manual mobilization and manipulation of tissues and neuromuscular reeducation. Our goals therefore are to restore optimal functional mobility in the involved segment and the moving body as a whole.

The “noisy victim “ is the complaint that usually brings a person to PT, e.g. the painful shoulder or recurrent ankle sprains. In other words, a PT referral will be generated by the pain and inability to raise an arm for everyday things like lifting a coffee cup or a swollen bruised ankle after a disappointing 10K DNF (did not finish) race.

The “silent culprit” is identified by the OMPT as a biomechanical dysfunction that is the originator or contributor (sometimes remotely) to the noisy victim. For instance, the trauma that causes a sprained ankle (noisy victim) is not a silent culprit. However, the neurogenic weakness of L5 innervated ankle evertors may be a contributing silent culprit. Or a neuropathic fatiguable weakness (from a space occupying lesion in the spinal canal) of L5 innervated peroneals may be the silent culprit. A detailed biomechanical exam of a sprained ankle by an OMPT may reveal contributing silent culprits such as an unstable L5 segment or L5 disc herniation. Another example of silent culprits that may be found in the chronic ankle sprain (noisy victim) comes from sacral anterior torsion faults in the pelvis. Changing point of contact at heel strike and causing improper lower limb loading from sacral movement dysfunction may precipitate recurrent eversion sprains.

It is the OMPT’s goal to identify the possible silent culprits through a detailed biomechanical exam, thereby bringing a level of professional expertise to the clients recovery goals and treatment plan of care. The healthcare practitioner that does not assess for and identify the silent culprit, for example, the chronic recurrent ankle sprain, and only treats the local bruised tissue (noisy victim), may in some cases be inhibiting the clients recovery and fullest potential.
At Core Physical Therapy, I spend my day identifying or ruling out silent culprits and treating my clients with the confidence provided to me through my specialty training in orthopedic manual physical therapy.

I am inspired by the positive response and successful outcomes that my clients report. Even though I am diligent and thorough in my quest, I have never been accused of tilting at windmills.


Juliana Bohn, PT, CMPT
NAOIMT Certified Manual Physical Therapist
Core Physical Therapy
www.corePT.org

(References: http://www.naoimt.com/ and NAOIMT Faculty)

Osteoporosis: Everyone is at Risk for this Silent Disease

WHAT IS OSTEOPOROSIS?

Osteoporosis is the most prevalent of the bone diseases that affect Americans. One out of every two women and one in eight men will have an osteoporotic fracture in their lifetime. 28 million Americans have either osteoporosis or osteopenia, which increases risk of fracture, pain and significant loss of function and quality of life. A woman’s risk of hip fracture is greater than her risk of breast, uterine and ovarian cancer.

Osteporosis is the thinning of bone tissue resulting in loss of bone density. Bone is living tissue that is continually being broken down as well as replaced with new bone. Osteoporosis occurs when bone is lost faster than it can be replaced.

As bones become more fragile, they are more likely to break. Osteoporosis is a silent disease because it can progress without symptoms or pain until a bone breaks. Severe compromise of bone density is found in younger populations due to poor nutrition, increased carbonated beverage intake, amennorhea (absence of periods), eating disorders or execessive exercise. The simultaenous conditions of eating disorders, amenorrhea and excessive exercise are called The Female Triad and can result in profound risk in bone density in women throughout the lifespan.

The main factors which contribute to osteoporosis are:

• Faster rate of bone loss after menopause or amennorhea
• Poor bone growth during childhood and adolescence resulting in lower peak bone mass
• Bone loss due to eating disorders, medications or diseases.
  
  EXERCISE
  
  Research has shown that specific weight bearing or resistance exercises can:
• Improve bone density and lower risk of fracture
• Decrease pain
• Improve posture by decreasing or slowing the progression of thoracic kyphosis (rounding of upper spine giving a stooped appearance)
• Improve balance and coordination
• Decrease risk of falling
• Increase mobility
  
  OUR PROGRAM
  
  Core Therapeutics Physical Therapy’s Osteoporiss Program is designed to assess your individual needs and medical history and design a customized treatment program to optimize your bone health.
  
  HOW TO PARTICIPATE
  
  If you or a family member would like to participate in this program, please contact your physician for a referral to the Osteporosis Program at Core Therapeutics Physical Therapy. Visit us at www.corept.org or call us at 360.752.2673.

Mind over Bladder

Ever had a Peemergency?

Oh yes, we have all been there.  Getting out of the car, putting the key in the door and sprinting through the house to the bathroom.  Yikes.

This is the checklist you should go through if your bladder is either inconveniencing or downright ruling your life: 

1.  Please consult with your doc or nurse practitioner

• The number one cause of urinary urgency and frequency is bladder infection.  Get it screened and check it off the list.
• Urologic, gynecologic and colorectal cancers "whisper" to us with common symptoms like urgency, frequency, pressure, abdominal aching and bloating, and other symptoms.   Listen to your body when it is trying to tell you something.   It could save your life.
  

2.  Cut out bladder irritants in your diet

Seriously, do you really love caffeine more than you hate leaking?  Cut out caffeine, citrus, spicy food, carbonated beverages and acidic foods.  These all irritate the lining of the bladder and make it want to force the acidic urine out, resulting in urgency or leaking.

I know, you don't eat cigarettes.  But your body absorbs the nicotine just like it absorbs food, and the nicotine is fabulous at endangering your life as well as irritating your bladder.  Come on, just for fun,  track the your bladder symptoms.  Then reduce your back  the number of cigarettes by 50-100% and note any changes in leaking, number of trips to the bathroom and urgency at night as well.

3.  The thrill of your doctor's life:  bring in a bladder diary

A bladder diary is one of the most scientific measures of bladder behavior when it comes to leaking.  Choose 3 days (ANY 3 days, preferably one work day, one home day and another kind of day)  and write down the following information:

1. What you ate and drank, and at what times of the day or night.
2. When you emptied your bladder and whether it was small, medium or large?

• small = "I ran to the bathroom for this teeny amount?"
• large = the large amount most bladders usually empty first thing in the morning.
• medium = about a cup or so.

If you leaked:

• what time did you leak?
  
• what exactly were you doing when you leaked?
  
• how many pads did you use during that day?
  

4.  Pelvic floor exercises

The pelvic floor muscles are between your sitting bones and between your pubic bone and your tailbone.  They perform many important functions including:

• Faucet function:  Pelvic floor muscles act like a faucet and allow urine, feces and gas to escape or to stay put.
• Bra function:  They support your internal organs.  Yes, even for men.  But women have the greatest challenge regarding support as many are challenged by prolapse.  Prolapse is the "drooping" of the pelvic organs including the uterus, bladder, rectum or bowel into the vaginal tissue.  Sometimes it feels as if she is sitting on extra tissue or that there is a 'falling out' sensation.  Prolapse is a big topic and will be a topic discussed in later blogs.
• Sexual function:  The pelvic floor muscles contract involuntarily during orgasm.  There is a connection between pelvic floor muscle strength and sexual sensation.  Orgasms actually have a strengthening effect, so enjoy!
• "Sump Pump" function:  There is evidence that the contraction and relaxation of the pelvic floor muscles actually assists the fluid movement of the lymph, arterial and venous systems.
• Stabilization function:  Imagine the pelvic floor muscles are like an octopus in a hula hoop, with each arm attaching to the inside of the hula hoop.  When the muscles contract, they compress and gently stabilize the pelvic ring, just like the octopus would compress the hula hoop if it shortened its legs.  The pelvic floor muscles are a critical component in stabilizing the pubic bone, the sacroiliac joints, and enabling you to be an effective shock absorber as you walk, run and jump.  More about this important function in later blogs.
  

A researcher named Bump found that less than 50% of women perform pelvic floor muscle exercises correctly.  It is critical that you remember that:

• Pelvic floor muscle exercises should NEVER be painful during or after, in ANY place in your body.  
  
• Your buttock, groin or back muscles should not contract during the exercises.
  
• While wearing your clothes, there should be no observable movement of your abdomen, back, hips, knees, eyebrows during the movement.
  
• Your breathing should be normal and your abdomen should not pump in and out.
  
• NO ONE should be able to tell that you are doing them!
  

Sit on a rolled up towel as if it is a bicycle seat, so that the towel roll rests between your sitting bones and under your pubic bone.  Make sure that it is off your tailbone.  Sitting up tall with both feet on the floor and a chair with back support, ensure that you are supported in a comfortable seated position.

Inhale to prepare. As you exhale, lift your pelvic floor muscles up and in as if you are trying to stop the flow of urine.  Release the pelvic floor muscles so that they relax over the towel roll.  

Now ask yourself these questions:

1. Can I tell if the pelvic floor muscles are contracting?
   
2. Am I pain free when I contract my pelvic floor muscles?
3. Does it feel like the pelvic floor muscles relax after I ask them to relax?

You should be able to answer 'yes' to all these questions.  If the answer is 'no', then do not continue to perform pelvic floor muscle exercises because you could create or increase pain you have, or have other negative results.

Visit www.APTA.org and click on the link entitled 'Find a PT' in order to find a women's health physical therapist in your area.  Even if you are a man, they will be able to help you because they are specialists in pelvic floor rehabilitation.

5.  Be a scientist!

Oh yes, you are most definitely a scientist!  Your consistent follow through for one month is what will enable you to gather the information so that you can get the MOST from your co-pay to your health care provider.  When you present your body's response to these interventions, your health care provider can make the best recommendation for you.

Please remember the number one cause for temporary leaking is a urinary tract infection.  If you have chills or a fever, burning with urination, you should go to your health care provider immediately.

Urinary incontinence is common, yet the average woman waits 8 years before she tells anyone.  Men wait only an average of one year before they tell their health care provider, primarily because leaking in men is commonly due to post-prostatectomy incontinence.  A later blog will discuss this as well.

Absorbent pads are not a treatment, but may be used as a tool to prevent embarrassment. Many women do not consider leaking a medical problem and research has found that women are more likely to report their symptoms if their medical provider asks about them.

Yes, leaking is common in women but it does not have to be accepted.  If for no other reason than to save money on absorbent pads,  follow through with the steps above and take action in regaining control over your body!

Copyright Elizabeth Hampton PT, BCIA-PMDB, Core Performance LLC, All rights reserved.

This blog is not a substitute for medical advice.  You should consult your physician or nurse practitioner before acting on any of the information contained in this blog.