Profitability in a Modern Private Practice

Profitability in a modern private practice. What’s all that about? By profitability, I don't mean rolling in cash... I just mean generating enough revenue to cover wages and running expenses in a typical private practice clinic.

I think Private Practice Physio is facing a new challenge as we see more clinicians treating in a "high value" manner… a manner geared toward promoting patient self efficacy and self management... and moving away from therapist dependency and pathoanatomical assessment/treatment systems. I support the intention behind efforts to provide high value care. And I don’t doubt that the value of what we do lies, at least in part, in how well we can promote self efficacy, reduce dependency, avoid unnecessary imaging, avoid pathomechanical focused models of assessment/treatment etc. I also like the fact that alongside these goals, Physios are keeping in mind “big picture” values... striving for improvements in "societal health"... reducing overall societal healthcare expenditure... and attempting to broadly raise the standard of Physiotherapy.

It seems for this new wave of Physios, it’s not just about the patient they're treating, but also the impact their treatment might have on the patient's friends, family, community, and our profession. These are admirable goals to have in mind. But this approach to providing Physiotherapy can be problematic. I think there are challenges on two fronts.

Front One (high value physio who isn't doing as well as he/she thinks)

The first, is what I think is a tendency for clinicians to unwittingly "miss the mark" in their attempts to deliver "high value" care. I think these Physios are acutely aware of the type of Physio they don't want to be (overservicing, fear mongering, dependency creating). I think the pressure to avoid being a low value care provider comes mostly from social media, and perhaps also from the university curricula. It's obviously a good thing to see Physios rejecting practices that we can collectively label "low value care". But it's one thing to know what kind of Physio you don't want to be... It's another thing to know how to be the Physio you want to be. And I think this is where Physios are struggling. I suspect they enter into clinical interactions with a mindset of "If I just do the opposite of what a stereotypical low value care provider does, I'll be delivering high value care"... As if the pathway to achieving the goals of reduced healthcare expenditure, improved societal health, improved patient self efficacy, reduced dependency on treatment, reduced medicalisation of msk problems, is as simple as minimising passive care, promoting self-management strategies and seeing Patients for fewer appointments. Of course, it's not that simple. And as a result, I think we are seeing a disconnect developing between what these Physios are delivering and what Patients value.

I think the difficulty with this thinking is that the outcomes Physios are striving toward are “off the radar” for most patients. They’re kind of intangible from a Patient's perspective... At worst, I think the Patient just feels like they haven't gotten what they came for. I'd guess that a typical Patient doesn't care about improving societal health. Nor are they likely to be worried about the financial pressure on our Medicare system… at least, not at the expense of their own immediate symptoms/problem. I'm also really sure they don’t care about the overall trajectory of care standards in Physiotherapy. They just want to get their own problem sorted out. They're far more likely to value us remembering their dog's name than us not using manual therapy or minimising the number of appointments for an episode of care. I don't think we will ever see a Patient leaving a 5 star review praising a Physio for avoiding manual therapy.

So I think our (profession wide) challenge on this first front is to understand that there is a difference between the "real" value we provide (what the patient, and more broadly our society needs), versus the patient's perceived value (what they want). If we aren't meeting the Patient's perceived needs, we are all screwed. The Patient will simply vote with their feet and move onto another clinic. Weirdly enough, in these scenarios, a Physio may be patting himself or herself on the back for a job well done... Patient is discharged with all the info they "need" after a couple sessions with a detailed plan to self manage their problem. Meanwhile, the Patient is ringing around for another Practice, still seeking out what they "want", and in the process, running the risk of landing in a Clinic that provides horribly low value care.

I think these Physios need some help to sort out how they go about pursuing their goals. How can they learn to bridge the gap between what a Patient wants and what the Physio determines they need? As long as they are "missing the mark", in terms of meeting their Patients perceived needs, I think they are going to struggle in Private Practice.  They will struggle to get word of mouth referrals in the community. They will burn through new Patients and will struggle to build a caseload. And they will inevitably fail in their desire to make the big picture changes they want to make... they simply won't be able to build enough of a footprint in their community to affect change on any scale. And if that is repeated across 1000s of Physios across the 1000s of clinics, I think the private practice profession itself will struggle. 

But it's not just the profession wide implications. There are personal and immediate consequences for these Physios too. The likely knock on effect is that the Physio starts receiving pressure from their employer to "increase their patient numbers". As an employer, I know I certainly can't afford to "carry" a Physio on a fulltime wage who isn't able to meet each Patient at their perceived needs. The Physio will likely resist because they are already certain they're practicing in a "high value" manner. They see themselves as clinicians doing things the "right way"... they're thinking that the boss should be happy to have such a dedicated, caring, well read and up to date employee. And they'll likely conclude that the boss is the outdated one. The boss is out of line... promoting a culture of overservicing and profiteering. The very thing the Physio is most keen to avoid.

But where does the truth lie? Is the employer likely to be pushing a Physio for the sake of huge profit margins? As a clinic owner I can say certainly not. The reality is that the pressure coming from the employer is likely nothing more than an effort to not go broke. If it costs a clinic $900 to get a new Patient through the front door, and a Physio is discharging Patients after only four sessions (~ $500 revenue), the clinic is losing $400 on every new patient that physio treats. That's like a cake shop selling cakes for $20 despite it costing $30 to make it. If, at a minimum, a Physio is not bringing in enough revenue to cover the expense of each new patient, they ultimately won't be able to deliver any value to the Patient. So it's not about an employer forcing an employee to "overservice" for the sake of excessive profit. It's about ensuring that the Physio is delivering value for all stakeholders. It doesn't matter how "high value" a physio thinks their treatment is, if there is a failure to break even point on each patient, it essentially becomes no-value care because there won't exist any business from which to provide treatment.

So there is this need to strike a balance between the true value we provide patients, and the patient’s perceived value. The trick is to learn how to bridge the gap so that the treatment becomes "high value" for all stakeholders (patient, physio and business). That’s where excellent clinical mentoring is needed.

Front Two (high value physio who is doing really well clinically, but not covering expenses)

The second front is where the "high value care" Physio is able to "hit the mark" with Patients. They're doing great. The Physio successfully "sells" the idea of self management, promoting self efficacy, deconstructing unhelpful narratives etc. It really is a win for the Patient when we consider where they might otherwise end up under the care of an archetypal "low value care" provider. So, the physio is happy and the patient is happy. But... is the employer happy? Probably not. Why? The employer will not be happy if the patient has been discharged from care without enough revenue being generated to cover the expense of bringing that Patient through the front door. And from what I can gather, this is happening a fair bit. How might this story play out?

Essentially, the outcome, if left unchecked, is the same as the Physio who is struggling to meet the patient where they're at. If a Physio can't break even, they can't really expect to be employed... even if they are ticking all the boxes regarding high value care and meeting patient perceived needs. The solution here is relatively simple. The high performing, “high value” Physio needs to increase his or her fees. If each new patient cost the business $900, and a Physio is discharging a happy, self managing Patient after 3 sessions, then the fee per session needs to be $300. This is where the rubber meets the road. This where a truly "high value" provider has to have the courage to charge what they're worth.

But would the market support that price? Would a patient actually choose to pay $300 per session? What if the Patient is "fixed" after one session? Would he/she pay $900?

How much should it cost to receive truly high value care? If a Physio providing 1-3 sessions of care dramatically changes a patient’s life, saving them from falling down a rabbit hole of expensive and arguably unnecessary assessments and interventions, how much is that worth?

You could make the argument that it's worth $1000s, maybe more. It's hard to prove though. It’s hard to put a value on cost prevention. It's harder to sell the idea that a service provided today will save $$ tomorrow. That's why there's the saying in politics "There's no votes in problem prevention". Fixing a problem here and now with a tangible solution is much more saleable. And therein lies the difficulty. Would a patient pre-emptively spend $1000s on 3 sessions of physio? Probably not. It's tricky because although  it is truly significant to prevent the expense of $1000s on useless assessments/treatments, the Patient will never know that. They just ride off into the sunset not worrying about their knee or back problem because it never became the expensive, life changing problem it otherwise might have become.

Compounding that problem is that, as a Physio, it feels good to know you helped someone avoid going down an unhelpful, expensive management and possibly harmful treatment journey. And because steering them in a better direction can be pretty simple when it all works well, it feels "wrong" to take a lot of money in exchange for our work. I know I feel that way sometimes. It can be as simple as saying "you're back's ok. You don't need to do x,y,z... have a go at a,b,c instead" and that starts the ball rolling for really big changes in their life. It seems like an overreach to ask a patient to pay $1000s for that. Further compounding things, is this idea that a good clinical outcome at lower cost to the Patient can be seen as a "win" in the broader battle to "reduce societal cost of healthcare".

So, on this second front, where we have high value care clinicians providing really valuable care, we have this weird situation where the basis for the pride in the work is inversely proportional to the consultation fee. How will that story end in the long run? I think what we are observing is an insidious self de-valuing of high value care providers.

While it’s easy to say the solution is simple- raise fees. It is also difficult because it involves Physios exploring some of their (probably) deeply held values around helping others. And there's also the broader goal of "reducing societal costs" to unpack too. But these are realities we have to face as providers of care in a competitive marketplace. Personally, I think the idea that we can reduce the societal cost of healthcare by, for example, seeing Patients for 2-3 sessions instead of 6-8 sessions is wishful thinking when we view the proposition relative to the massive spending on unnecessary surgeries, imaging, injections etc.

I think the best way we (in a private practice setting) can more effectively reduce useless spending in healthcare generally, is by replacing it with useful spending. I don’t think it’s the amount of spending that is problematic. It's the quality of the product being purchased that counts. If a Physio is able to deliver "high value care" and discharge a patient to effective self management within only a 2-3 sessions, and those 2-3 sessions truly allow a patient to get on with life and avoid other wasteful spending, that is a huge win for the Patient. They are getting a great outcome that they would not get in most other clinics. I think it's really important that the fee for that service should reflect the true value of that session. And we shouldn't be scared to charge our value for it. 

This is the challenge for Physios on this 2nd front. If they truly are able to deliver favourable clinical outcomes in fewer sessions than other clinicians, there is a need to increase the fees charged per session. Not because the goal is to charge more for the sake of it. But because at a minimum, the expense of providing a new Patient needs to be covered. There is absolutely no value for us as providers in getting a patient to the point of independent self management if doing so falls short of breaking even.  

Let's consider a hypothetical set of business numbers from a hypothetical clinic to demonstrate the point;

• total expenses per year (wages, super, running costs)= $500k

• profit = 0 (owners wage already included in wages above)

• number of new patient per year = 600 

• cost per new patient = $833

Let’s say this a well run clinic with no wasteful expenses. It’s running as lean as it can. Now let's say this clinic has 3 physios who each get an even split of these 600 new patients. How much does each generate in revenue from treatment sessions provided?

• Lenny see 200 new patients and generates $167k

• Carl sees 200 new patients and generates $167k

• Ned sees 200 new patients and generates $100k

So on a per new patient basis

• Lenny generates $835 per new patient, for a profit of $2 per new patient

• Carl generates $835 per new patient, for a profit of $2 per new patient

• Ned generates $500 per new patient, for a loss of $333 per new patient

In this hypothetical scenario, let's say that Ned is the archetypal (successful) high value provider. He is delivering on all fronts. Patients love him. They're getting back to doing what they love. And it's all happening with an average of 2-3 sessions of treatment. Lenny and Carl on the other hand, are seeing patients for 6-7 sessions on average. They're patients also love them. And they're happy with the care they receive and the outcomes they're getting. But they just don't get the same result as quickly as Ned does.

This also seems backwards, right? On one hand we have a great Physio like Ned working his butt off to stay up to date on research and update his practice accordingly. And it actually translates into a measurable performance difference compared to his colleagues. But on the other hand, those efforts are not being rewarded with appropriate remuneration. Why? Because the wages we earn are derived from the revenue we generate, and the revenue we generate decreases as Patients become more independent. Meanwhile, the dodgy physio/chiro down the street is capturing a good chunk of the market, drawing patients into a routine of weekly manips for years on end.

I have heard stories from so many clinic owners who are stressed to the max over their employees who have been burning through new patients without generating enough revenue. The Physios dig their heels in because they're sure they're practicing the "right" way. The owners dig their heels in because they simply can't afford to carry the burden of an "unproductive" Physio. So what gives? From the owner’s perspective, I know one thing for sure. It makes me terrified to hire a new Physio!

What Can Physios do?

I think Physios who identify as being “high value care” providers need to be able to step outside themselves and consider whether they are providing truly high value care for all stakeholders. It’s not enough to simply practice in a manner that gets you plaudits from your favourite social media silo. It’s worth reflecting on your work and asking yourself, “Am I effectively bridging the gap between myself and my Patient. Have I worked out what story the Patient wants to hear? Have I worked out what story I think the Patient needs to hear? And am I able to bridge the two with a meaningful narrative and treatment plan.

If you can answer yes to all those questions, but you’re still getting pressure from your employer to increase your patient numbers, I think you have to back yourself to raise your fees. Put your high value treatment where your mouth is, so to speak. If you’re as effective as you think you are, people will pay above market rates to see you. And if doing so works well, that is a win for everyone. You generate more revenue to support your wage. Your employer stops losing sleep over your “numbers”. And the business thrives as a place for more patients to come and get better.

But if increasing your fees, scares away your patients, then you need to ask yourself, “am I really as effective as I think I am? Is my service offering as valuable as I think it is? In this scenario, I think the onus is on the Physio to decide that something needs to change. The onus is on the Physio to accept that there is more to delivering truly high value care than he/she has been shown or has learned to put into practice. It might simply be that the market itself will simply not support a higher than average fee for service. In this scenario, I think it is time for the Physio who identifies as a high value care provider to be ok with the notion that he/she is also an under performing physios. These two things can co-exist. And when they do, it is time to bite the bullet and engage in mentoring from those who can help you to learn how to deliver value to all stakeholders involved in your employment.

STRESS FRACTURE WITH NO CHANGE IN RUNNING HABITS?

by jim zouch

A young female distance runner reminded me of the importance of discussing diet, sleep, stress and the menstrual cycle/or absence of, in a recent presentation for  acute pain in the shin. Often patients, particularly runners are quite aware of their running mileage and the changes in their running volume that might be linked to injury. Less frequently are patients aware of other factors that may contribute to an injury such as a stress fracture.

This was the case in a young runner who presented at the start of autumn following a few weeks of shin pain. She had reported her running volume had been really consistent and had not experienced an injury. Because of these factors, she had decided to continue to run through the pain believing she hadn’t sustained any major damage. When I mentioned that other factors may contribute to running injuries, she volunteered that she had been a little more tired than usual and had recently changed her diet to reduce calories. I mentioned that absence of a menstrual cycle may be a symptom of what we term RED-S or Relative Energy Deficiency in Sport – a name given to describe a potentially serious syndrome that essentially results from a lack of nutrition to support the body’s demands.

She volunteered that she hadn’t experienced a menstrual cycle in the last three months. We discussed the various ways that relative energy deficiency can affect many of the body’s functions and I directed her toward some further reading. In this situation we discussed the stress fracture may be a symptom in itself and that it was important to address any potential issues with her diet, sleep and overall health in the first instance.

We decided on a course of non-weight bearing because of her immediate pain with walking and referred her for a discussion with a Sports Medicine doctor to discuss some further investigations. I also recommended she discuss her eating habits with a registered dietician. For the purpose of the article and client confidentiality, I’ve kept the discussion brief but in reality, once we had identified there were some signs and symptoms of RED-S most of our appointment time was allowing this patient to discuss her issues in a safe environment.

As a clinician it reminded me how important it is to create an environment where a client feels comfortable to share all of their issues.  

WAKING UP WITH NECK PAIN

BY JIM ZOUCH

We received a phone call from a young professional, lets call him Tom, who had woken up with acute neck pain. He reported his neck was stiff and painful turning left and right. He was curious to know if this was something physiotherapy could help with. We booked Tom into the clinic that morning and went through his symptoms and recent history. Tom could not remember doing anything differently the days before, and didn’t recall a moment of injury. He did mention that he had been quite busy at work and hadn’t slept as well the last week. Tom reported his pain was all in the neck and did not experience any other symptoms.

We took Tom through a physical examination to determine the movements that irritated his neck as well as a neurological examination involving reflex, sensation and muscle power testing to screen for any potential neural injury. From Tom’s history and examination, I explained to Tom he had what is termed ‘acute wry neck’, a label given to acute neck pain that commonly occurs out of the blue, without a mechanism of injury. I explained to Tom, although the underlying pathology is not well understood, its quite common in younger people and has a favourable outcome with movement and time.

We also discussed how physiotherapy could help reduce the pain and get the neck moving again. Tom was quite relieved after our examination to understand he had not caused himself major harm and that he could expect to get better in a reasonably quick time frame. We spent some time performing some ‘hands on’ therapy to help with pain relief and sent Tom away with some basic exercises to continue to restore his function in the coming days. I explained to Tom, the condition was likely to get better with time but we could help with pain relief and provide some guidance along the way. Tom was quite happy with the pain response and booked in early the following week. I expect Tom will be significantly better by our next session and hope to see him back to normal movement really soon.

FOLLOWING UP ON A HEADACHE PATIENT

By Zac Mackenzie

SESSION 2

This week I followed up with this a patient I wrote about previously. I was interested to see how he fared headache wise. During our session, he advised me that his headaches had significantly improved and his neck was feeling less stiff. So, we planned in this session to do some more hands on treatment to hopefully completely resolve his symptoms then head over to the gym to have a look at his technique with overhead exercises.

When we reviewed his overhead technique, I noticed that he had significant recruitment of the neck and upper back muscles as he started to fatigue. I suggested that he utilized a simple cue such as keeping the point of his shoulder away from his ears during above head exercises which will reduce the activation of these muscles. I also suggested that over the next week or so until his headaches had completely settled that with above head and shoulder exercises he keeps a few reps in the tank during his sets, which will make sure that he doesn’t utilize the neck muscles as his shoulder fatigues.

We also went over a few neck and upper back strengthening exercises to work into his routine. The aim of these will be to progress them over time as part of his headache prevention program to perform 2x a wk. We planned to review again next week where we would look to complete his program. After this we will look at monthly reviews to progress these exercises.

I followed up with this patient again this week. We had a chat about how his symptoms had been going in the past week. He advised me that his headache symptoms had all but resolved. He also said that he’d been concentrating on those cues we spoke about when lifting overhead although he hadn’t been lifting too heavy. He also said that he’d had a couple of sessions of the upper back and neck strengthening exercises and they seemed to go okay.

SESSION 3

Our plan this week was just to review those existing exercises as part of the maintenance program and add in 2 more exercises. I showed him a good way of progressing the exercises as they became too easy, and how to regress them if he found that they aggravated his symptoms. We also spoke about how he could manage relapses, by going over the mobility exercises and dropping the overhead work until symptoms settle. We also spoke about how he can gradually increase his overhead lifting over the next couple of weeks back to his normal level.

We planned to review again in one month to go over the exercises and see if we can progress.

session 4

Following up with this patient again, I was pleased to hear that he had no headache symptoms since the previous visit. We used this session to again go over his technique when lifting over head in the gym. This time we increased load back to similar weight that he was lifting before the headache episode. Again we looked at keeping his shoulders away from his ears, and concentrated on this as he begun to fatigue. After the session he said he felt fine headache wise which was pleasing.

We went over 1 more exercise to complete his neck and headache strengthening program and agreed to review again in a month to update the exercises. 

AN EPISODE OF SEVERE LOWER BACK PAIN

by patrick lyons

Two weeks and five Physio sessions ago, a fit and healthy 45 year old woman came to see me for severe and disabling lower back pain. The pain was on her left side and spread to her left buttocks and down the back of her thigh to the knee. Her pain began insidiously. Although there was no event or trauma that triggered the onset of symptoms, she did report that she had been unwell for the week or so preceding the onset of symptoms. She had been more sedentary than normal and had been coughing frequently.

She previously came to see me for left sided lower back pain a few months ago. This earlier episode was her first experience of lower back pain. It also began insidiously but was not as severe or disabling as her current symptoms. It resolved with three sessions of treatment. For both the previous and current episode, the patient, lets call her Sophie, had a significant lateral shift to the right side in standing. In the current episode it was more severe. Sophie’s movements were severely hampered. She was unable to stand tall, unable to sit for more than a minute or two, and she could not lie down on her left side at all. She also reported a pins and needles sensation over her left buttock.

Clinical Impression

Sophie’s symptoms and movement limitations are best explained by an irritation of her left S1 nerve root, perhaps as a consequence of an acute injury to her L5/S1 intervertebral disc or facet joint. Her laterally shifted posture could be interpreted as a reflexive attempt by Sophie’s body to unload and protect her injured body tissues from further compression and irritation. She is feeling pain as a consequence of the injury itself but also as a consequence of her body’s own protective mechanisms which bring about a degree of nerve sensitivity and muscular guarding. Importantly, the initial injury itself can be quite minor, meaning that Sophie’s severe pain is likely mostly a result of her body’s protective response to the injury.

This a very common presentation of symptoms. Nearly always, this injury follows a predictable trajectory of recovery. Initially, there is a period of severe, disabling pain where basic movements such as getting out of bed, siting, rising from sitting, bending at the waist or standing tall are very difficult. This period of usually lasts a few days. As inflammatory processes begin to subside and muscular guarding begins to lessen, movements become a little freer and less painful. By about day 7-10 following the initial onset of symptoms, most report that they feel about “75% back to normal”. By this stage people can usually walk normally but will still have difficulty with prolonged sitting and will find it difficult to get up and moving if they have been static for more than 20-30min.

In Sophie’s case, there was no traumatic event or incident that triggered her symptoms. So the likelihood that she has a significant structural injury in her spine is low. I suspect that if we were to do an MRI of her lumbar spine, we may see evidence of some degenerative changes to her L5/S1 intervertebral disc. Perhaps with her recent bout of illness and frequent coughing, she managed to irritate the L5/S1 disc and set off a sequence of inflammatory processes that ultimately triggered her body to suddenly become “protective”.

Over the two weeks that Sophie has been attending Physio, my focus has been on helping Sophie understand that it is unlikely that her injury is as severe as her pain may be leading her to believe. I have been reiterating that the severity of her pain is partly (perhaps mostly) explained by her own body’s capacity to ramp up its sensitivity to movement and load. So long as her body is in a sensitive, protective state, her movement and function is likely to limited and painful. With this in mind, we have been implementing treatment that serves the purpose of reducing her body’s movement sensitivity with gentle manual therapy and appropriate exercises for her to do at home.

To date, Sophie’s back pain has resolved 100%. And she is now able to move through a full range of motion into forward bending, backwards bending and side-bending. She is however, still dealing with pain in the buttock region, with occasional spreading to the back of her thigh. She also is still experiencing some tingling in the buttock region. It appears that her body has let go of much of the muscular guarding that was initially limiting her movement, but she still has symptoms that suggest her S1 nerve root remains irritated.

I hope to see an ongoing reduction in these “nervey” symptoms over the coming weeks. It’not uncommon for such nerveroot symptoms to hang around for months after one of these lower back pain episodes. However, if these symptoms plateau and are preventing Sophie from participating in her normal daily activities, I will speak with her about a possible MRI to rule out the presence of structural pathology in the lower back that may require further investigation +/- review by a spinal or neurosurgeon. In my experience I would estimate that less than 1% of the cases of lower back pain end up requiring a surgical solution.

Update

It’s now a week since I wrote the post above. Sophie is now three weeks and 6 physio sessions post onset of symptoms. She reported that over the past week, particularly the past 3 days, her symptoms have significantly decreased. The tingling she was experiencing over her left buttock is “shrinking” in the sense that it is less intense and is distributed over a smaller surface area of her buttock. She is also finding her movements through the lumbar spine to be easier… previously she could reproduce her pain with movement quite easily, now she reports that she has to move nearer to the end range of her normal movement in order for her to feel the pain in her left leg.

These are all great signs that suggest to me that the irritation around her S1 nerve root is settling down. The rapid improvements help to reinforce the idea that even though she was in severe pain for a few days, her initial injury was more likely only mild (in terms of severity of damage to tissues). Severe symptoms are unlikely to resolve quickly if they have arisen from significant damage to a structure in the spine. In Sophie’s case, I suspect she has some degenerative changes at her L5/S1 disc, and that her initial symptoms were triggered by a rapid ramping up nerve ending sensitivity subsequent to a mechanical irritation of the disc.

I expect her symptoms to continue to diminish over the upcoming weeks. The challenge for Sophie for the next few weeks will be avoiding flare up of symptoms. It will be important for her to get back to her usual daily activities and exercise outline gradually.

5 Week Update

It’s been 5 weeks since Sophie’s last Physio session. I have reached out to her to see how she is doing and she reports that she is doing very well. It is very common for these really acute episodes of lower back pain to completely resolve over a 10-12 week period as has been the case with Sophie.

Now that Sophie is feeling relatively normal again, she has a great opportunity to integrate some new exercises into her day to day activities with a view to preventing a recurrence of her pain. I have suggested this to her… now I wait to see if she takes the offer up.

It is very common for patients to lose their motivation for the injury prevention component of a rehabilitation program. Hopefully Sophie can see the value in coming back to learn some skills to look after her back in the future.

12 Week Update

Sophie reports she is doing well. Back to normal function but too busy to return to the clinic to work on some injury prevention strategies

A CASE OF RECURRING HEADACHE

by zac mackenzie

This week I had the pleasure of treating a young man who suffered from recurrent headaches. These headaches would come on usually every 2-3 months and would generally settle within 1-2 weeks. He was extremely physically active and these headaches would often occur after a gym session that involved a lot of overhead exercises. He seemed frustrated with the recurrence as it stopped him from training and although he knew that the pain would subside with treatment he was more interested in getting an understanding of how to prevent this from happening again.

On assessment, I found that most of his symptoms were on the left side of his head and neck and he was restricted in movements of his neck towards that side. A quick look at his neck muscle function also demonstrated that he had some weakness in his neck muscles which is a common finding in neck related headache patients. We discussed a treatment plan looking at firstly reducing his symptoms with some hands-on treatment as well as some home exercises this week with the aim of getting in the gym to go over his technique with overhead exercises next week when his symptoms had improved.

We also spoke about long term treatment of his headache symptoms and that once his symptoms had resolved it would be worth investing time into a neck and upper back strengthening program which will prevent the headaches from occurring again. We discussed the research surrounding recurring neck related headaches and how often these are linked to neck and upper back weakness. We will aim to address these deficits through a targeted strengthening program.

I provided him with some manual therapy which seemed to reduce his neck pain and headache and prescribed some neck and back mobility exercises to do at home.

I look forward to seeing how he has progressed next week. 

THE START OF THE SPORTING SEASON

 By Jim Zouch

As a physiotherapist it’s a common story I hear at the start of every sporting season. Typically, it involves a client presenting with a ‘pull’ in one of their lower leg muscles upon returning to training or within the first few matches of the season. More often than not, it’s the second or third ‘pull’ the client has experienced in a matter of weeks as they have tried to navigate their way through the injury, often resting until the pain disappears then returning back to sport.

One such client presented last week having felt a ‘pull’ in her quadriceps while sprinting during a training session. She rested the leg for a week and upon feeling no pain with her day-to-day activities returned to training only to have a recurrence of the same sensation.  She was visibly frustrated having had a season off sport due to covid and was extremely enthusiastic to get back into the game she loved. 

She was aware that she had likely injured one of her quadriceps muscles but wasn’t sure of how to go from her current state, back to sport without the same thing occurring. At the time of presentation, the client was able to perform most functional activities I threw at her without pain or discomfort. As part of our assessment, we used a hand-held dynamometer to assess her ability to generate power in a kicking motion, testing both legs individually. We observed a 30% difference in strength between sides. The client found this extremely interesting and it helped us frame why returning to sport prior to regaining strength might leave her at an increased risk of another injury. It also serves as our ‘baseline’ measurement that we will use for upcoming sessions to test her improvement in strength that occurs as a result of both natural healing alongside an appropriate strength programme.

The testing opened a really nice line of questioning from the patient about ‘how strong should she be’ and ‘how long will it take to get these numbers higher’.  We discussed setting some goals over the coming weeks and establishing a minimum score (within 10% of her other side) that she should achieve, before we discussed higher intensity return to sport activities. The strength testing also gave us some information about what of training was likely to be safe during her upcoming training sessions without comprising her healing. 

I’m looking forward to seeing the improvements in strength over the next few weeks!

PATIENT CONTEMPLATES KNEE REPLACEMENT SURGERY

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by patrick lyons

This week I met a new patient with a long (four year) history of knee pain. He described his pain as mostly manageable… except for the past six months or so, over which time the pain had become worse for no obvious reason. He had had some x-rays of his knees done three years ago, and consulted with an orthopaedic surgeon at the time. The patient said that the surgeon thought his knee pain was a product of osteoarthritis in the medial compartment of his knee and the patellofemoral joint. The surgeon didn’t recommend surgery at the time, but he did predict that he would eventually need to have total knee replacement surgery.

Fast forward to today and this patient is reasonably certain that joint replacement surgery is the only way forward. But before making the final decision to have surgery, he was convinced by his wife to trial a period of physio first.

The patient seemed keen to better understand the need for surgery, relative to non-surgical options, as he was keen to avoid surgery if it was possible. We had what I thought was a really useful conversations about the pros and cons of proceeding with the knee replacement surgery.

I’ll provide a summary of that conversation as well as some details of the treatment I provided in the entries below.

***UPDATE***

For this patient, who for simplicity’s sake I’ll refer to as John, a major concern was that there were no viable non-surgical options to manage his knee problem. John’s view was that his knee was arthritic, and that the arthritis was causing his knee symptoms. So the only way to resolve his symptoms would be to remove the influence of arthritis by way of a joint replacement. He had assumed that the recent worsening of his pain was a result of accelerating progression of his arthritis.

John was relieved to hear that a plausible explanation for his recent increase in symptoms was his daily activity levels. John has been more sedentary over the few months. His usual golf routine had been disrupted by covid19 restrictions, and he had fallen out of the habit of walking around centennial park in an attempt to avoid crowds of people.

I explained that arthritic knees tend to be happier when we use them. And that they get cranky when we trend toward being sedentary. I felt really confident that at the very least, we could get John back to his “pre-flare up” level of symptoms… which was a level he was managing well. And I’d also be hopeful that there is room for further improvement.

The plan to get John there revolves around an initial focus on symptom reduction and setting up activity parameters so that we don’t keep stirring up the knee. And then progressing to a graded walking program to get him going on the golf course and coastal path again!

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