I had an interesting conversation with a new patient today. The patient comes in and says to me “you know, I’ve had Sciatica before and went to physical therapy at my Doctor’s office”. I stop her right there, interrupting her “you mean to say you had a massage and electrical stimulation performed by an aide at your doctor’s office”. “Well, I don’t know but they did everything... the massage, ultrasound, and the electrodes”, she responds. I try not to laugh out loud but continue to ask her questions regarding her symptoms, past medical history, and such and so forth.
I start my evaluation questioning her about her pain, mechanism of injury, and chronicity of the problem. I then continue to test her reflexes, muscle strength, flexibility, all while monitoring for neurological symptomatology and analyzing her facial and central nervous system responses. As I am doing this there is a level of astonishment on her face, as if I am doing something completely new and out of this world. “Nobody has ever done that”, she says. “My Doctor just sent me for an MRI and sent me downstairs to do Physical Therapy in her office.” I look at her prescription and it vaguely says “Sciatica”. “you mean to say massage and electrical stimulation”, I responded. She laughed and there was a mutual understanding between the two of us.
As I finish up my evaluation, I quickly examine the scribble that I had made on my tablet. Making sure that I had ruled out as many possibilities as possible, I use my objective findings, clinical judgment, and yes common sense to make a Diagnosis. “L5 Radiculopathy affecting the Left Lower Extremity”. “Wow, that is exactly with the MRI said”, she noted in astonishment. “But I thought I had Sciatica”. “Your Sciatica is caused by a nerve that is being pinched by your L5 nerve root. “It is irritated and inflamed, and that is why you are having the shooting pain down into your thigh and leg”, I explained to her. “You see, Sciatica can be caused by a few things…. It is not a diagnosis in and of itself”. She looked at me, perplexed, as if I was the first person who ever told her the truth.
MORAL OF THE STORY: Is all “Physical Therapy” the same? Does your physical therapist use evidence and clinical judgment to make a clinical diagnosis and formulate a plan of care? If your “physical therapy” is in the basement of your doctor’s office, then 99% of the time the answer is NO.
Let's get a word in regarding the fact that there is currently an MRI EPIDEMIC in this country. Was an MRI really necessary to diagnose such a clinically observable Diagnosis? Would an MRI change a thing in the treatment of this patient? I think not.
Is getting an MRI Bad? Of course not! It definitely doesn’t hurt. HOWEVER, it is not absolutely necessary to diagnose MANY orthopedic conditions. Further, an MRI does not guide the treatment approach, a well thought out treatment plan does. It simply will confirm what a good Physical Therapist can establish on his or her Initial Evaluation. We need to move away from “the MRI” as being the gold standard in establishing a treatment regime. Not only is it redundant, but it is costly, time consuming, and ultimately can be a self fulfilling prophecy which the patient becomes attached to and identifies with. It limits participation, progression, and instills fear in true physical therapy. It can also promote patient addiction in Narcotic pain relief because of the idea that only surgery will “fix them”.
I write this essay not to glorify physical therapy as the panacea for all medical conditions. I write this essay to educate the public on what real Physical Therapy is about. I am a bit tired of hearing patients say that when they had physical therapy, the guy “massaged me and put on the electrodes. Sometimes they would use the vibration machine”. Enough of that nonsense! That is NOT Physical Therapy! If you have any doubts call your insurance company and ask.
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