Bringing Back the Excitement to the Extremities
    Richard Rosedale, PT, Dip. MDT

Monday morning, another busy day ahead...you look at your case load with dread: two OA knees, one hip bursitis, a plantar fasciitis, a bilateral patella femoral syndrome, two chronic rotator cuff tears and an assortment of other patients with recalcitrant and difficult to classify conditions. What a depressing bunch- 5 pm can't come soon enough as you contemplate a day of administering treatments that aim for slow and unimpressive gains at best or "maintaining function" at worst. Occasionally you stumble across an intervention with a rapid response and you try to hide your astonishment at realizing that this time you actually beat natural history.

Then, as you think about the day ahead, you suddenly remember that today was meant to be different. You recall the patients from the weekend's MDT course you attended; they actually changed before your eyes. Most had been labeled not dissimilarly from your list of patients, prognosis universally poor, failed previous interventions, perhaps heading for months of persisting and debilitating pain or worse; for the dreaded surgical consult. Yet on the course, they responded, not in months or years, but in minutes: more range, less pain, restored function. What if you could reproduce this in your clinic? What if that plantar fasciitis patient walked out of here without limping, the patella femoral patient drove home with no pain, the rotator cuff tear patient grabbed his coat off the hook with no grimace?

As you are thinking about the possibilities, the feeling of dread passes, you're thinking in a different way about your patients, you're getting excited about seeing them and the more chronic and unresponsive they have been, the more excitement you feel about their potential response. All of a sudden your patients have possibilities, not for an agonizingly slow change impossible to distinguish from the natural ebb of an episodic condition, but for dramatic change, change that you will know is a result of a specific loading strategy.

In walks your first patient of the day: "Hi Tom, I'm going to reassess your knee today. I know I told you that you will just have to live with that pain from your degenerated knee for the rest of your life, but there is a chance we can aim higher than that and I want to explore the possibility of getting some quick changes. Are you ready?"

Ok, maybe they won't all change before your eyes, but what if even half of them do and what if among those are a few of the most chronic and disabled. Just the thought of this fires you up, you feel raring to go, to move those joints to places they have not gone for a long time, searching to expose those derangements that are hiding within.

There is a word which I am hearing from colleagues more now than I have heard over my 16 year career; the word is "fun", as in "that patient was fun to treat". Doesn't quite fit with an OA knee or plantar fasciitis does it? Hopefully, as more therapists wave goodbye to the pathoanatomical status quo and attempt to discover the extremity derangements, it is a word we will hear more and more.

As you read the Q and A with Mark and Scott in this issue, you can get a sense of their enthusiasm and their conviction that this could change the face of orthopedic conservative care. No doubt the change will be slow; therapist by therapist, as more attempt to fully explore the possibilities of rapid responses, more and more patients will experience solutions and strategies to address their persistent and recurrent symptoms. Mark has also given us a case study of a "cool knee" he recently saw.

No matter where we are on the learning curve, examples like this should spur us on to keep searching and discovering those derangements and applying as rigorously as we can the principles of MDT to the extremities. We can all work to change the face of orthopedic therapy and have fun while we do it, that's tough to beat!

"There is no mystery whatever - only inability to perceive the obvious."
Wei Wu Wei, 1964, All Else is Bondage; Non-volitional Living