This past month, I was performing a chart review on a patient who had recently undergone spinal surgery and saw the surgeon had written in his surgical consultation that “the patient has employed conservative care for over a year without resolution of symptoms”.
If you are not practicing medicine, you may not be familiar with the term “conservative care”.
We use conservative care to mean everything (cortisone injections, braces, physical therapy, occupational therapy, ultrasound, over the counter and prescription medications, synthetic cartilage injections on and on, I mean everything) except surgery.
Unfortunately, the patient was not progressing as hoped/ expected and a day long outpatient procedure had turned into a hospital admit. The orthopedic surgeon was hoping that physical therapy (me in this case) would get in, get the patient up and moving and get them cleared for discharge.
Unfortunately, when I went in, the patient could not move and I began to understand why the case had increased in complexity. To help me understand where to start, my first question to the patient, was what form of conservative care had they engaged in prior to surgery. The patient answered that they had been in chiropractic care and aquatic therapy for years prior to the surgery- and that was it. No breath biomechanics. No spinal biomechanics and stabilization training. No unloading techniques, anti-inflammatory methods. In fact, when I walked into the room, the patient had heat packs on their surgical site.
To further complicate the issue, the person had persistent, sensitized pain, and had developed kinesiophobia (fear of movement) and avoidance of movement during the years leading up to their surgery.
As I began to see the reality of the patient case more clearly, my heart felt so heavy with worry.
The patient had suffered for years without learning the basics of real conservative management of the spine or pain: neutral spinal alignment, using spinal stabilization to protect spinal structures, learning their functional losses (a brilliant classification to help us organize sensitizing and desensitizing physical forces on the spine developed by Eileen Vollowitz, PT), pain education to reduce kinesiophobia and reduce danger messaging.
And now, to literally add insult to injury, the person was dealing with the acute pain of a new surgery.
I feel overwhelmed at times that physicians, specifically orthopedic surgeons, are not checking on the quality of conservative care accessed by patients prior to surgeries- instead, using the quantity of conservative care as a guide post to decision making around when to apply surgery.
If the patient’s surgeon had asked one or two additional questions in a presurgical consult, they could have gleaned that the patient had zero education in pain or spinal relief techniques, and had not had meaningful physical therapy that could translate to symptom resolution or resolve spinal instability.
If it feels like a lot that orthopedic surgeons are not having this conversation, it is maybe even more intense that we physical therapists, as a profession, largely cannot agree on the body of education and intervention that should be applied prior to a patient moving beyond conservative methods to explore surgical options.
Part of this is because every patient, rehabilitation course, even anatomy, is unique. To be in practice in physical therapy is to be constantly in the present moment responding to conditions as they arise and fall away. It is very complex work. That complexity can be assisted by a helpful tool of priorities to address- I find the classification and organization of orthopedic care as proposed by Tim McGonigle and the crew at Folsom Physical Therapy to be of utmost relevance for our successful clinical endeavors.
(And as an aside, did you know that only Physical Therapists are licensed and trained to perform rehabilitation? It is violating several laws for other professions, ahem, chiropractors, to bill that they provide rehab).
There are attempts to synchronize care in physical therapy world these are known as Clinical Practice Guides. But they are vague and often fall short of specifics that would transform patient outcomes. We need simplified checklists that every therapist can have handy, and that orthopedic surgeons have become conversant in (such as in the case of the patient with persistent, sensitizing pain and a long term disc herniation). Off the top of my head, some concepts I would like to see a patient familiar with are:
1) Are you aware of techniques to unload intervertebral discs?
2) Are you aware of movement strategies to increase safety across your discs (what do you avoid? What do you enhance?)
3) Are you aware of how to create hip mobility and are your hips stable when you walk? (what are your walking biomechanics like?)
4) Are you aware of the biopsychosocial model of pain?
5) What tools are you using to reduce fear of movement? What is your pain strategy?
6) Are you aware of belly breathing using your diaphragm and pelvic floor while protecting your neutral spine?
7) Can you move through functional movements (sit to stand etc.) with your spine neutral?
What else would be relevant and important?
Obviously, the person that I met with was nowhere near being able to answer the above reflections, and on top of it, they were dealing with the acute byproducts of spinal surgery (inflammation, wound healing, loss of mobility).
Many of the acute factors will diminish over time, but the underlying lack of knowledge (and sensitized central and peripheral nerves) may continue to haunt this person.
As a medical community, we need to be thinking about the continuum of care- where does my care begin and when does it end? What will someone endure because of the care I have (or have not) provided? We need to be thinking beyond the scope of our own disciplines and looking further down the road to the wholeness of a patient’s life- if we do what we plan to, in the moment, how will that action impact the patient 20, 30, 40 years from now?
My hope is that I was able to make a small impact to reduce the mountain of unknowns this patient has to contend with, and that they will be able to continue their progress (once they leave the hospital and heal beyond their acute phase) with a wonderful outpatient therapist who is willing to spend the time and energy with them to help them become independent in protecting their spine, returning to functional movement and eventually independence in a full life from this point forward.
Happy healing,
Trina
