Healing the Whole Body: The Key to Long Lasting Pain Relief

When I first graduated PT school, it seemed as though few patients ever got better. We were often left feeling frustrated by the lack of progress, and while they did see some improvement, they never quite returned to 100% before hitting a plateau and being discharged.

It’s not uncommon for medical providers to blame their patients for not adhering to their prescriptions (physical therapists can be the same way when it comes to home exercise programs!). Because I generally felt as though my patients were always putting in good effort, I kept asking myself, “What am I missing? Could there be something else driving their pain that I don’t know enough about?”

The purpose of this article is to shed some light on why you should seek a provider that appreciates the influence that one area of the body has on another, when you should see a physical therapist that specializes in movement analysis, and how using a physical therapist as your “orthopedic primary care doctor” can ultimately save you time, money, and tremendously improve your overall quality of life.

Everything’s Connected

Sometimes pain comes after an injury or a fall. Sometimes pain or change in function seem to start out of the blue. When you sustain a clear mechanism of injury, such as an ankle sprain while hiking, it makes a lot of sense to immediately address the pain and swelling with local treatments for the injured tissues. However, in the case where aches and pains seemingly come out of nowhere without any obvious reason, we must further investigate the underlying root cause to truly resolve the issue.

Physical therapists are taught in school to not only evaluate the primary area of pain, but also the joints above and below. During my residency and fellowship training, we were even taught to look much further, from head to toe.

This examination model is called regional interdependence, defined as “a clinical model in physical therapy that describes how different parts of the body are connected and affect each other.” (1)

Here are some common examples of regional interdependence in action:

• ITB syndrome due to gluteal muscle weakness or ankle stiffness
• Tennis elbow due to compression in the lower neck (2)
• Hip bursitis due to poor spine control
• Rotator cuff pain due to poor rib mobility
• Neck pain due to stiffness in the upper back
• Plantar fasciitis due to lower spine problems (3)

The trickiest part is that the area that is likely contributing to your symptoms is not usually painful at all!

So how do we know what to look for? We look through movement!

Using Movement as a Guide

If you saw your primary care physician with the main concern of not being able to run as long as you’d like, had difficulty with squatting or getting out of a chair, or couldn’t keep up on the Pickleball court, what would they examine? What would they offer you if you weren’t having pain?

The problem with the traditional medical model is that it emphasizes treating your immediate symptoms and not the true underlying cause, regardless of how long you’ve had them, which is often associated with a movement or position. This increases the likelihood of the symptoms returning in the future.

Being pain-free is a great symptom-based goal, and probably the main reason that you’re seeking care. Focusing on the quality of your movements doesn’t take away from that goal, it just provides a different measure to focus on.

Here are the expected outcomes when emphasizing a movement-based approach:

1. Pain relief that is long-lasting and less likely to return.
2. Return to participating in normal daily activities
3. Enhanced performance during fitness and sport activities
4. Reduced healthcare costs associated with repeated medical office visits and testing

Analyzing movement is key to understanding how to best guide the rest of my exam and even promotes the lifestyle and behavioral change necessary for long-term success.

Let’s explore this concept even further with a couple of case studies.

Case Study #1: Volleyball

15 year-old volleyball player with right knee pain for six months.

She denied any particular trauma or changes in activity levels. Since her primary concern was knee pain with jumping, the obvious thing to do was to watch her jump.

She demonstrated collapsing in the arch of her foot and her hips shifted unevenly when coming out of a single leg squat. My exam further concluded that she had weakness in the foot muscles and poor dynamic control of the arch during more powerful movements, resulting in patellar tendinosis.

After 6 weeks of localized strengthening of the foot and re-training her jumping pattern, she returned to volleyball pain-free. Her mother even told me that she was starting to get more blocks because she could get her hands over the net, which she was unable to do before the injury.  Talk about performance enhancement!

Case Study #2: Golf

64 year-old male golfer with right-sided lower back pain for two years.

This gentleman had previously injured his rib cage after falling on the ice years ago, but that it “had healed up just fine”. He also had two cortisone injections without significant relief. Since his primary concern was pain in the lower back during his golf swing, I naturally watched him swing a golf club.

He demonstrated limited rotation through his trunk and excessive side bending during his follow through, which also caused his primary pain. A thorough examination concluded that his lower spine actually moved quite well, yet he had stiffness in his ribcage and poor rotation through his lead leg.

In just 3 weeks, he played a full round of golf without significant lower back pain by performing just five minutes of a few simple mobility drills daily for his hip and trunk, as well as coordination exercise using his lower spine and pelvis. He was able to stay active and continue participating in his bi-weekly social outings.

The Healthcare Challenge

Current healthcare trends are focused on providing immediate relief via passive treatments (e.g., medication, injections, massage, dry needling, laser therapy, cryotherapy, joint manipulation, etc).

While these treatments are effective in providing short-term relief (especially for acute or sudden injury), there is no strong evidence that the benefits last very long, especially in cases of chronic or episodic pain.

Despite this information being around for years, there are several reasons why providers tend to focus on resolving pain immediately through use of passive treatments as opposed to taking an active approach that involves movement, nutritional education, and behavioral or lifestyle modifications.

1. Institutional barriers

Providers are under increasingly greater pressure from their organizations to boost productivity. This leads to seeing more patients in a shorter amount of time and billing for services that are often unnecessary. In traditional physical therapy clinics, “throwing the kitchen sink” at a problem is not an uncommon approach.

2. Insurance-directed care

When insurance companies have a say in which providers you can see, which services can be performed, and the rates at which those services are reimbursed at, clinical practices must adapt to these revenue changes.

3. Education doesn’t pay well 

While education on nutrition, movement, or lifestyle modifications would greatly impact a patients’ long-term health and reduce overall health spending, the truth is that holistic services are not reimbursed well by insurance companies nor do most providers have the time required to administer it.

4. Patient values

The #1 reason people seek a healthcare provider is for pain associated with a musculoskeletal condition. Higher satisfaction scores are directly correlated with meeting the patient’s expectations and resolving their pain as fast as possible through whatever means necessary.

Combined with the previous barriers, providers are more likely to provide a Band-Aid than to educate on other potential solutions with longer-lasting benefit.

When to See a Movement Specialist

With all this in mind, one question that can arise is “Okay, so when do I see a Movement Specialist?”

Remember, a Movement Specialist (such as a specialized Physical Therapist) will focus more on treating the root cause of your issue. We don’t disregard the symptoms, but rather look beyond them to see what imbalances and other patterns are underneath the immediate pain and dysfunction.

Here are some signs that indicate it’s time to book with a Movement Specialist:

• Insidious or slow onset of pain (“came out of nowhere” or didn’t have a specific injury)
• Chronic in nature (ongoing for weeks, months, or years)
• Failed prior conservative treatments (e.g., other PT, chiropractic, medications, injections)
• Not recovering well after surgery (e.g., total joint replacement, rotator cuff repair, spinal fusion, nerve release)

Once you’ve found a Movement Specialist, such as a physical therapy provider, an even bigger question arises:

How do you know that you’ve found the right physical therapist?

Here are some traits to look for:

• They take the time to better understand you and your injury
• They use movement as a guide in their decision-making
• They are thorough and explain why they’re doing what they’re doing
• They address both your immediate concerns and the underlying cause
• They set timeline and treatment expectations on recovery
• They see you as a collaborative partner in the plan of care
• They are willing to think outside the box and work with other providers or sources to help you achieve your goals

Take-Home Message

If you have failed physical therapy, other conservative treatments, or surgery in the past, there are still options out there to get you back to what you love doing most!

This involves finding the right therapist that utilizes a movement-based approach within a setting that eliminates the numerous barriers to high-quality care.

Chronic issues can be complicated and require someone who will look globally for contributing factors so that you can move and live your best!

When you focus on movement as your primary measure of success, you also get the benefits of pain relief!

References

1. Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. Journal of Orthopaedic & Sports Physical Therapy. 2007;37(11):658-660. doi: https://doi.org/10.2519/jospt.2007.0110
2. Coombes BK, Bisset L, Vicenzino B. Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. Journal of Orthopaedic & Sports Physical Therapy. 2015;45(11):938-949. doi:https://doi.org/10.2519/jospt.2015.5841
3. Bateman EA, Fortin CD, Guo M. Musculoskeletal mimics of lumbosacral radiculopathy. Muscle & nerve. Published online May 10, 2024. doi:https://doi.org/10.1002/mus.28106