The never-ending continued propagating myth that perfect alignment is necessary is entirely wrong. Some of the more common types of hocus pocus that you’ll find on the internet and through google searches claim the ability to speculate that a majority of your joint pain and pathology is due to misalignment of the body. They state: for you to resolve your pain and pathology, you must be perfectly aligned. Otherwise, this will cause long term pain and issues as you get older. Some of the common myths that “cause your pain” include:
Your shoulders sit unevenly.
“Overpronation of the foot”, which causes knee collapse (valgus), which eventually leads to shoulder and neck pain
Leaning, slouching, favouring one side is the root of all your pain and dysfunction in your lower back and hips.
But one of my lungs is smaller than the other…
Unfortunately for the pundits, basic human anatomy already suggests that we are “out of alignment.” The anatomy of our body is already sufficient evidence to suggest that we can live and be alive without “perfect” and proper alignment. For example:
The left lung is smaller than the right due to the placement of the heart, which:
Is placed slightly to the left in an area named the cardiac notch
One interesting way that we can further elaborate on the complexity of the human body and the “asymmetries” that are present throughout is subdividing the ‘abdominopelvic cavity’ (basically the space from the abdomen/bottom of the sternum to the bottom of your pelvis). The subdivisions are named the right upper quadrant (RUQ), left upper quadrant (LUQ), right lower quadrant (RLQ) and left lower quadrant (LLQ) (Marieb & Hoehn, 2019).
RUQ: Right portion of the liver, gallbladder, right kidney, the smaller part of your stomach
LUQ: The left portion of your liver, larger portion of the stomach, the pancreas, spleen and left kidney
RLQ: Appendix, part of the small intestines, the cecum, right ureter
LLQ: Majority of the small intestine, some of the large intestine, left ureter
(LibreTexts, 2020)
As you can see, the contents of each quadrant of the body are different. There isn’t an identical distribution and allocation of organs that perfectly balances and aligns the body. Around us, there are even more common sense examples of imperfect alignment being completely healthy, including:
Being right-handed or left-handed
Driving a car (especially a manual car)
Which hand we hold our coffee in
Getting out of your bed or sleeping on one particular side of your bed
Unbelievable, “imperfect” and amazing athletes
Adam Meakins is currently (as of 24/08/20) making a fantastic series on Instagram (@adammeakins) called: Amazing Asymmetries. The concept of the Instagram posts outlines individuals who are asymmetrical due to:
Limb deficiencies
Genetic variations
Spinal scoliosis
This is a fantastic representation of how those with predefined “imbalances” and “asymmetries” can perform at the very highest levels of their sport. Even without these imbalances, there are various examples of one-sided or one-handed sports. One of the most notable and evident is tennis. Some of the most famous tennis athletes including Rafael Nadal, Novak Djokovic and Roger Federer don’t switch hands when they play tennis to “optimise” their symmetry and are still able to dominate at their sport.
Not much… Trying to “optimise” and create perfect alignment is an imperfect practise and shouldn’t be pursued. Unfortunately, there are still many clinicians that strive by this mantra and will ask you to see them over and over again because they feel the need to achieve this impossible standard.
Instead, clinicians should be focusing on the root of your problem/issue and identifying the direct and clear reasons to why you may be suffering pain and pathology. Often, we may be directed to look away from just the pain and pathology site, as various factors can affect pain, including:
Stress (e.g. looking after three young children, or approaching deadline for work)
Sleep (e.g. less than 8 – 10 hours of sleep)
Other health concerns (e.g. heart health, liver health, kidney health)
Negative beliefs (i.e. Doctor told you you needed surgery, injections or multiple scans)
Go live your life without worrying that your left foot drifts slightly more than your right. Lift your kids into the air without worrying about that left arm that rotates internally marginally more than the other. Go and squat down to reach for something in the bottom drawer and disregarding the 2 degrees of scoliosis you have in your lower back.
Worrying about unnecessary and over-detailed analysis of every fault in your body is exceptionally detrimental, unhealthy and completely unnecessary. If your health practitioner directs you to do this and suggests that you come in every few weeks or months for a tune-up… Then a consultation with a new practitioner might be recommended.
References:
Marieb, E. N., & Hoehn, K. (2019). Human anatomy & physiology (Eleventh edition.). Pearson Education, Inc.
LibreTexts, 2020. 1.4F: Abdominopelvic Regions. [online] Medicine LibreTexts. Available at: <https://med.libretexts.org/Bookshelves/Anatomy_and_Physiology/Book%3A_Anatomy_and_Physiology_(Boundless)/1%3A_Introduction_to_Anatomy_and_Physiology/1.4%3A_Mapping_the_Body/1.4F%3A_Abdominopelvic_Regions> [Accessed 16 August 2020].
Red flags should be the first point of assessment in any condition. Regardless if it is neck pain, shoulder pain, lower back pain or even foot pain. Red flags are important as they can indicate to the health professional of any serious underlying pathology or anything that would need to be sent to the emergency department for immediate investigations. Across each of the joints, there are some specific red flag signs and symptoms we need to be aware of.
These signs and symptoms should never be interpreted as a direct causation or diagnosis of the conditions that may be associated with them. Instead, a cluster of symptoms are what is commonly used in order to diagnose and correctly identify the condition (Sizer Jr et al., 2007). Therefore, when analysing these red flags, contact with your local doctor is usually the recommended course of action. As in these situations, if an allied health practitioner (e.g. physiotherapist, occupational therapist etc.) identifies any red flags, the usual procedure is to refer onto a doctor for immediate review or referral.
From a clinicians point of view, there are several factors that we need to be aware of (Sizer Jr et al., 2007):
Patient history
Physical changes (e.g. changes in bowel and bladder function, blood in sputum, bilateral or unilateral radiculopathy pain)
Unresponsive to conservative treatment
Report of present fluctuations in signs and symptoms. Presence of serious pathology is indicated by:
Pain that is worse during rest vs activity
Worsened at night or not relieved in any position
Poor response to conservative care including a lack of pain relief with prescribed bed rest
Poor success with comparable treatment
Physical examination and laboratory findings
E.g. Abnormal reflexes, gait (movement) changes, strength disturbances / differences, changes to sensation (i.e. numbness, tingling)
The Three Category System
A three categorical classification system has been developed and proposed by Sizer Jr et al. (2007). In this paper Medical Screening for Red Flags in the Diagnosis and Management of Musculoskeletal Spine Pain, he outlines this three step categorical system for each part of the spine. Namely, the cervical, thoracic and lumbar.
The classification system that he uses is as follows:
Category 1: Factors that require immediate medical attention
Category 2: Factors that require subjective questioning and precautionary examination and treatment procedures
Category 3: Factors that require further physical testing and differentiation analysis
Category 1
Category 2
Category 3
Blood in sputum Loss of consciousness or altered mental status Neurological deficit not explained by monoradiculopathy Numbness or paresthesia in the perianal region Pathological changes in bowel and bladder Patterns of symptoms not compatible with mechanical pain (on physical examination) Progressive neurological deficit Pulsatile abdominal mass
Age >50 Clonus Fever Elevated sedimentation rate Gait deficits History of a disorder with predilection for infection or hemorrhage History of a metabolic bone disorder History of cancer Impairment precipitated by recent trauma Long-term corticosteroid use Long-term worker’s compensation Nonhealing sores or wounds Recent history of unexplained weight loss Writhing pain
Abnormal reflexes Bilateral or unilateral radiculopathy or paresthesia Unexplained referral pain Unexplained significant upper or lower limb weakness
Sizer Jr et al. (2007)
Cervical Region
Category 1 Findings:
These examinations are usually performed as a result of a trip to the emergency department as a result of motor vehicle accident or fall. Major injuries to this area include fracture or dislocation.
National Emergency X-Radiography Utilisation Group (NEXUS)
These two decision-making criteria can be used as a screening device to rule out the need for radiography of the cervical spine.
Category 2 Findings:
Mechanical conditions of the cervical spine that require special attention in category 2 are upper cervical instability (atlantoaxial laxity) and vertebrobasilar insufficiency (VBI).
Atlantoaxial laxity
Suspicion of ligament laxity in the upper cervical spine may be tested through two specific physiotherapy ligament tests – The Sharp Purser test and TLA laxity test. Further radiographic evaluation must be undertaken to confirm any upper cervical instability.
Vertebrobasilar insufficiency (VBI)
VBI circulation is important as it can lead to transient ischemic attacks and cerebrovascular accidents. However, difficulties arise as the signs and symptoms of VBI overlap with more common diagnosis, especially vertigo. The red flags that are relevant to this diagnosis are:
Visual disturbances (diplopia) – Blurry or double vision
Auditory phenomena (sudden sensorineural hearing loss) – Hearing loss
Facial numbness or paresthesias – Numbness, tingling or pins and needles especially around the lips or tongue
Dysphagia – Difficulty swallowing
Dysarthria – Difficulty speaking
Syncope (drop attacks) – Sudden syncope episodes
Category 3 Findings:
Finally, the cervical spine should be screened for radiculopathies (pinched nerves) and myelopathies (compression of the spinal cord).
Radiculopathy can be screened through inspection for muscle atrophy (wastage / loss of muscle), sensory changes (numbness, tingling, pins and needles), tendon reflex testing and a positive Spurlings test.
Cervical spine myelopathies can include symptoms such as: loss of dexterity (e.g. difficulty writing or handling small objects), nonspecific weakness (e.g. unable to grip) and abnormal sensations. Lower cervical myelopathies can also include weakness and stiffness in the legs, as well as changes to their walking. The most common cause for myelopathies is a traumatic injury or incident, usually from a stabbing / gunshot wounds, motor vehicle accident or falls.
Thoracic Spine
Category 1 Findings:
There are numerous category 1 red flags that can be found within the thoracic region. Primarily because the same signals that arise from the organs often coincides with a selected region of the musculoskeletal system. Essentially what this means is that the pain felt in a muscle, bone or general upper back area can be caused by pathology involving the organs.
A common example of this relates to acute myocardial infarction (i.e. heart attack). Pain can often be felt in the left pectoral region (i.e. around the left nipple of the chest) and the upper arms or sternum. This is often associated with pallor (pale color of skin), sweating and nausea.
Tumours, metastatic disease, metabolic diseases and fractures can also create pain signals around the area. These conditions can often be marked by severe thoracic pain, decreased range of movement of the thoracic region and potential intercostal neuralgia (i.e. stabbing, burning pain between the ribs).
Category 2 Findings:
Of particular concerns are osteoporotic changes to the thoracic vertebrae, which can lead to severe changes of postural deviations, vertebral fractures or spinal cord injury. A red flags can be evaluated to identify the potential likelihood, including:
Age over 50
Long-term corticosteroid use
Presence of menopause
Category 3 Findings:
As discussed previously, category symptoms require further physical testing and differential analysis. Within the category 3 classification for thoracic level related pathology, many of these symptoms must be clustered together to provide any meaningful reasoning. These symptoms include:
Referral pain to the front and side of the rib cage
Parathesia or dysthesia (e.g. numbness, tingling, pins and needles, abnormal changes to touch and feeling)
Sensory loss (e.g. absence of feeling)
Bowel and bladder changes
Hyper-reflexia (associated with reflex testing)
Coordination loss
Lumbar Spine
Lower back pain is extremely common and these red flags are important, as they can indicate more serious diagnosis such as: malignancy, spinal fracture, infection or cauda equina syndrome (Downie et al., 2013).
Category 1 Findings:
The category 1 symptoms as mentioned in Table 1 outline many of the symptoms that are evaluated in lumbar spine pain for red flags, particularly of which include:
Numbness or paresthesia in the perianal region
Pathological changes in bowel and bladder
Patterns of symptoms not compatible with mechanical pain (on physical examination)
Progressive neurological deficit
Category 2 Findings:
Similar to the thoracic spine, lumbar vertebrae are also at risk of compression fractures. The risk factors relative to the lumbar spine remain the same as the thoracic region. Infections can also arise in the lumbosacral region, which produce symptoms such as:
Fever
Malaise
Potential bowel and bladder symptoms
Severe lower back pain
History of drug use
Prior spinal implementation or surgery
Severe lower back pain radiating into both buttock and thighs
Category 3 Findings:
Lower back pathology can sometimes be associated with altered or changes in sensory, motor and reflexes. These can be tested through physiotherapy sensation tests, muscle tests and reflex testing. Two common tests we also use to assess nerve involvement is the straight leg raise test or slump sitting test.
Other serious pathology
Signs and symptoms unrelated to the spine can also manifest in other serious conditions. These include infections, malignancy (cancer) or a more serious pathology called ankylosing spondylitis.
Chou et al. (2007) briefly outlines some of the symptoms that are associated with a more severe diagnosis:
Cancer:
History of cancer
Unexplained weight loss
Failure to improve after 1 month
Age >50 years old
Infection:
Fever
Previous drug use
Recent infection
Ankylosing Spondylitis
Younger age
Morning stiffness
Improvements with exercise
Alternating buttock pain
Awakening due to back pain during the second part of the night only
Conclusions
As you can probably tell, there is a lot of overlap between symptoms for each region as well as other pathologies. Many of the findings in category 3 also present in category 1. Which is why a cluster of testing is required in order to rule in or out any certain pathologies.
The world of diagnosis through the use of signs and symptoms is still evolving, and there is certainty more ongoing research require to create established clinical guidelines for clinicians (Chou et al., 2007; Downie et al., 2013; Verhagen et al., 2016).
So if you do have any of these red flags, the important thing to remember is to take a deep breath, relax and go seek a professional opinion from a healthcare professional. Ideally in these situations, a doctor would be first point of call, as they can directly refer or treat many underlying pathologies not related to the musculoskeletal system.
References
Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J. T., Jr, Shekelle, P., Owens, D. K., Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, & American Pain Society Low Back Pain Guidelines Panel (2007). Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of internal medicine, 147(7), 478–491.
Downie, A., Williams, C. M., Henschke, N., Hancock, M. J., Ostelo, R. W., de Vet, H. C., Macaskill, P., Irwig, L., van Tulder, M. W., Koes, B. W., & Maher, C. G. (2013). Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ (Clinical research ed.), 347, f7095. https://doi.org/10.1136/bmj.f7095
Sizer Jr, P. S., Brismée, J., & Cook, C. (2007). Medical screening for red flags in the diagnosis and management of musculoskeletal spine pain. Pain Practice, 7(1), 53 – 71.
Verhagen, A. P., Downie, A., Maher, C., & Koes, B. W. (2016). Red flags presented in current low back pain guidelines: a review. European Spine Journal, 25, 2788 – 2802
Have you ever wondered what the difference between doctors and physiotherapists are?
Are you confused as to who you should see when you do get that pain or injury? “What’s the difference?” is often a hard question to answer, but in this post, I will help you understand the:
Qualifications of each profession
Scope of practice
Who you should see first, and
Questions that you should be asking your health professional
I have had my fair share of injuries before my physiotherapy degree. And so, I also have had experiences with multiple trips to the physiotherapist or doctor. Unfortunately, among the good experiences, I’ve also had terrible consultations with physiotherapists and doctors.
My two worst experiences include:
Getting told by my doctor, I should quit my sport because it would lead to long term damage
Feeling like I was getting milked like a cash cow by my physiotherapist who kept me coming in every week for ‘maintenance’ check-ups
Although these two experiences don’t highlight the bulk of medical and physiotherapy professionals, it is helpful to know what you should and shouldn’t expect when getting reviewed by each profession. In this post, I will highlight who may be more appropriate to see, and some useful questions to ask about your pain or injury.
Breaking down the professions
There are many different types of physiotherapists and doctors. Each of these specialities requires various forms of training and experience. These include:
Cardiorespiratory (heart and lung)
Neurological (brain)
Geriatrics (older adults)
Paediatrics (children)
Musculoskeletal (the muscles, joints, bones)
And many, many, MANY others specialities.
For this blog post, the ones that we mainly want to focus on are:
Private physiotherapists
General practitioners
These two practitioners are the ones you will most likely see when you have any initial onset of pain or injury.
Qualifications
Physiotherapists
Physiotherapy degrees can vary from 2 – 4 years depending on where you go to for physiotherapy. Physiotherapists are required to complete placements in private practices, hospitals or other services during this time. In which they are required to shadow or follow a qualified physiotherapist.
Physiotherapists operate under AHPRA (Australian Health Professional and Regulation Agency) and PBA (Physiotherapy Board of Australia). An additional affiliation that a majority of Australian physiotherapists have is the APA (Australian Physiotherapy Association).
In Australia, physiotherapists are classified as first contact practitioners and can see patients without a referral from a doctor. The physiotherapy system is different from many other countries which do require a doctor’s before the first consultation.
Some patients will still choose to see their GP’s first to get healthcare subsidies for their physiotherapy appoints.
General Practitioners
University degrees for doctors can take 4 – 6 years, depending on where you go to for university. Upon graduation, doctors usually undertake a residency/internship, which is a rotation as a doctor in a hospital for a minimum of 1 year. After which, they must take further vocational training in the form of:
FRACGP (Fellowship of Royal Australian College of General Practitioners) takes three years, or
FARCRRM (Fellowship of Australian College of Rural and Remote Medicine) takes four years
Doctors operate under AHPRA (Australian Health Professional and Regulation Agency) and MBA (Medical Board of Australia). An additional affiliation that a majority of Australian physiotherapists have is the APA (Australian Medical Association).
Scope of Practice
Scope of practice essentially defines the actions and limitations of a healthcare provider, which can vary depending on any additional training that they may have undertaken.
In a general practice, a doctor can:
Refer for MRI, X-ray or any other scans
Prescribe medication (pain medication especially)
Refer to a specialist for further review
Refer to allied health professionals, such as physiotherapist, podiatrist or exercise physiologist.
The roles and duties of physiotherapists are:
To perform a comprehensive subjective (verbal) and objective (hands-on) assessment
Provide treatment and rehabilitation plan in the form of:
Manual therapy or other hands-on modalities
Exercise prescription and rehabilitation program
Education of pain and injury
Understanding when to refer on to a doctor or other healthcare practitioner
Discounted Referrals
If you receive a referral from a Dr, you may be eligible for a Chronic Disease Management (CDM) plan. Under this management plan, a doctor must diagnose you with a “Chronic Medical Condition”, that is a condition “…present for six months or longer” before you are eligible for Medicare rebates for Allied Health Professionals.
Details of the rebates as follows:
Five total visits in a calendar year (Note: unused visits in previous years do not roll over into the new year. A new referral must be made at the start of every new year).
Currently, Medicare will only cover $54.60. If the physiotherapy practice charges more for their CDM clients, you may have to pay an out-of-pocket gap fee to cover the costs.
Must be referred from the Doctor to the eligible physiotherapist using a referral form
If you have acute pain or injury, then the first point of contact should be any healthcare practitioner that is available to your earliest needs. It doesn’t make sense if you have to wait two weeks for a physiotherapy consultation if the closest physiotherapist is booked out. Similarly, if your doctor is in a hectic period and is unable to meet with you, then the option to see a physiotherapist is also present.
For acute injuries, the recommendation would be to go to a physiotherapist. These generally settle within a few weeks, but having a physiotherapist to guide you and educate you on the path makes the journey much smoother.
If your pain or injury has been chronic and ongoing for an extended period, then referrals and communication should be made between both a physiotherapist and a general practitioner. This way, the two professions can create a treatment plan together that will best address the patient’s needs and help them improve.
Useful Questions to Ask Your Physiotherapist or Doctor
Below is a short infographic on the types of questions you should be asking your healthcare practitioner on your first consultation.
Conclusions
The world of healthcare practitioners is a complicated and hazy area. There are many crossovers between the roles and responsibilities of each profession.
Physiotherapists are your main contact for:
Thorough assessment and identification of pain areas
Treatment techniques to reduce pain and improve function
Exercise rehabilitation for long term outcomes and recovery
General practitioners assume the responsibility of:
Eliminating any major red flags; which include sending for investigations or referrals to specialist
Prescribing pain medication
Referral to allied health practitioners (including physiotherapists, podiatrists, dietitians or exercise physiologists)
So in the incident where you may have suffered an injury or have experienced some pain, go to whichever healthcare specialist is available in your area. In a future post, I will elaborate on what to look for in your healthcare worker and how to know whether you should be moving on!
Schedule an appointment now to see how our physiotherapists can help you!
We are located between Flagstone Family Practice and Terry White Chemist. If you are unable to find us, please talk to the reception of Flagstone Family Practice and they can guide you through!
There is plenty of car parks availabe throughout the complex.
