The Beyond Pain Podcast

Episode 24: Prognosis or Diagnosis: What is More Important in Rehab?

• Par Four Performance • Episode 24

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Summary
In this episode of the Beyond Pain podcast, hosts Joe Gambino and Joe LaVacca discuss the nuances of pain management, focusing on the distinctions between joint pain and muscle pain, the significance of diagnosis and prognosis in treatment, and how these elements interplay to enhance patient care. They emphasize the importance of providing clear answers to patients to foster comfort and trust in the treatment process.

Takeaways
Pain is subjective and varies from person to person.

Joint pain is often more localized compared to muscle pain.

Understanding the mechanism of pain can aid in diagnosis.

Diagnosis provides comfort and clarity for patients.

Prognosis helps set realistic expectations for recovery.

The interplay between diagnosis and prognosis is crucial in treatment.

Clear communication enhances patient buy-in and compliance.

Conservative estimates in prognosis can alleviate patient anxiety.

Behavior of pain can indicate the underlying issue.

Building a rapport with patients is essential for effective treatment.

Joe Gambino (00:01.896)
Welcome back into the Beyond Pain podcast. I am one of your hosts, Joe Gambino, and I am here with the ever so philosophical Joe LaVacca Although I think the last few episodes, I'm taking the cake on that one.

Joe LaVacca (00:15.876)
I know if I'm good.

Joe LaVacca (00:20.132)
I know you wanted a little bit more rant. So I'm trying to be a little bit more rational in a lot of our conversations. you know, it's switching sides, you know, it's like good cop, bad cop.

Joe Gambino (00:20.138)
Yeah.

Joe Gambino (00:27.946)
Now we need, we need, we need Joe's strong emotional, emotional side, back out here. You can follow us on Instagram, at joe game, Vito DPT for myself and at strength in motion underscore PT for Joe, LaVacca. Now you can find this podcast on YouTube cups of Joe underscore PT. And we also have an Instagram page as well. The beyond pain, beyond pain podcast on Instagram.

And as always, there is an application form for you to fill out if you are interested in working with either one of us. in the show notes, easily accessible. You can always DM either Joe or myself via Instagram. We are more than happy to have a conversation. back.

Joe LaVacca (01:13.124)
Welcome. It's good to be back. I've had a nice week. I've enjoyed the comical theater that is the United States government in its full glory. So that's been exciting to watch. I guess burn or unfold, whatever adjective you like, depending on what your viewpoints are. So looking forward to another week of football, even though...

I see my season or my interest fading probably by the end of halftime this week, week two, which if you're a Giants fan like I am over the last 10 or 12 years, I mean, that's probably a little bit longer than some of the previous seasons have lasted. So to think like six quarters and then I'm out, I feel like really excited about my even upcoming weekends. And Joe, I go on vacation next week. You have a very impending important date happening.

Joe Gambino (02:07.403)
Mm -hmm.

Joe LaVacca (02:11.416)
Lots of things to look forward to. How are you, my friend?

Joe Gambino (02:15.948)
I'm good. mean, baby will be here in 13 days unless decides to show up early. So it's going to be here very, very soon. So excited for that. I think Joe, I'm going to make a prediction here for you. I think you're going to be somewhat pulled back into the Giants after this week. I think the Giants are going to play decently well because the commanders have a terrible defense, but you're going to be excited with Malik neighbors after.

Joe LaVacca (02:30.547)
Mmm.

Joe LaVacca (02:35.642)
Nah, I don't know.

Joe Gambino (02:45.897)
and that's what's gonna put you back into watch.

Joe LaVacca (02:48.112)
Well, you I really appreciate that kindness, Joe. And I would have to say, you know, here's the thing though, even if we did beat the commanders, even in our misery of the last 10 or 12 years, we've always beat the commanders. So if you look at actually like Daniel Jones's record, I think this even dates back to like when we were, know, quote, we had that winning season in the playoffs. I think Daniel Jones record against like the Redskins is like six and one or like eight and one over the course of his career.

against every other opponent, it's like three and 37. So yeah, mean, it's really great that we can beat the commanders, but that's not who we need to beat to move up. So I don't want them to actually, this is the other thing, I don't want them to win, right? We always do this, we win like six games, and then we have like the ninth pick. That doesn't help reset your franchise. So.

I don't know what to tell you, man. I'm hoping that I don't regain interest because I know it will just be false.

Joe Gambino (03:48.64)
No, man, you're be back in they're pull you in Joe

Joe LaVacca (03:53.498)
I don't think so.

Joe Gambino (03:53.672)
I believe, I believe, I think so, I think so, I think so. But anyway, question of the day. This comes from a client of mine, Morton, he gave me like five of them in one shot, so we're just burning through them.

Joe LaVacca (03:58.34)
you

Joe LaVacca (04:05.358)
Yeah, I got a couple too. I got a couple too. So you want to we'll take care of what you said. His name is Morton. Morton.

Joe Gambino (04:10.346)
Morning, yeah, so we'll do it on this one because the other question of the day that we have that makes sense I think mostly with next episodes topic. So I think this goes today, you we're gonna be talking about diagnosis and doesn't matter and how much do we weigh in and what's more important between diagnosis and prognosis. We'll define all those terms I guess as well in case you're not too sure about them. But the question today is,

Joe LaVacca (04:17.424)
Okay, all right, Morton, here we go.

Joe Gambino (04:37.874)
Is there any clear distinguishing factors between joint pain and muscle pain?

Joe LaVacca (04:43.578)
Hmm, I think quality of pain is an interesting thing. Because pain is so subjective, I would honestly say I don't know how to answer that. I may go out on a limb and start to put together qualities that I think people have reported on and that I think might make sense, but it also comes down to how irritable

all these structures are. So let's go with muscle pain. We'll start there. If it's muscle pain, I would probably expect it to be a little bit more broad, maybe a little bit more diffuse. Whereas a joint pain, a little bit more specific or localized. Depending on the actual sensitivity of those tissues, you might expect a muscle pain to improve as you warm up or as you keep moving.

whereas a joint pain might stay a little bit more static or constant. But I think that really varies. I was gonna go with how people typically describe pain, but I don't know if that's fair due to how subjective it is. Because muscle pain could be sharp. I guess it could feel a little bit localized. So I think when trying to distinguish broadly, I'd probably go in like.

how it behaves and maybe even what was the original mechanism that would help us. And maybe that ties into our chat today. But do you have an adjective or a way to describe like, you know, really specifically, especially virtually, because this might be even a better question for you, how to distinguish that, because I can always touch things and, you know, maybe rule certain things in and out on the table.

Joe Gambino (06:29.228)
Mm

Yeah, there, I think for, for where I'm thinking about it is, you know, joint pain is, is likely to be on the, closing side of the joint. So if you're pushing your wrist into extension and it's like pinchy or sharp or something like that, like inside the joint, likely that it's going to be, you know, then I start to think joint, not that it's likely going to be there, but my brain starts to go there. If you like look to the right with, and you have a pinch in your neck.

Joe LaVacca (06:43.652)
Mm

Joe Gambino (07:00.936)
right. Then I start to like, okay, is there a joint related issue? And then I'm looking at, you know, the other things that I'd want to see on top of that is from a movement perspective, you know, does active and passive range of motion, they vastly different? Are they the same? and you know, what kind of things are going on there? Is it actually like a joint limitation that's preventing movement from happening where we would expect active and passive range of motion to be like actually quite close together? Or is it like,

They have full, know, they can barely move their neck. But when I move them, then all of a sudden there's so much more degrees of motion where I'm probably not going to be thinking joint just as much. I always I've been finding that like the FRC functional range conditioning terminology of closing angle joint pain has been pretty solid. There are times though where you can have pinching and it's not joint issues, which I've also found as well. And usually I'll rule that out with some isometrics and stuff like that. If you can just do like a quick isometric or a quick movement.

and the pinch goes away, then my brain goes less to it being a joint issue or potentially some other tissue.

Joe LaVacca (08:05.306)
Yeah, I think you bring up, because I was going with, I actually hesitated because I was so commonly used to telling people about the closing side pain and how maybe for closing side pain and for those people listening or watching, like Joe was saying, if you're pushing your wrist in one direction, where your back of your hand, let's say if you're extending it, where the back of your hand gets close to your forearm, that's the closing side. Where the palm is moving away from the other side of your forearm or the inside of your forearm, that's the opening side. And yeah, traditionally,

we were sort of taught with FRC that if it's on the closing side, it's a joint related issue potentially. And then we can try to clear it or see maybe how sensitive it is with doing an isometric loading test and things like that. But then to your point, tendons, in my opinion, have closing angle pain. Bursitis has closing angle pain. Acute injuries have pain in every direction, right?

And maybe we can make an argument that there is a combination of soft tissue, like muscle related injury and joint related injuries with an acute issue. But I think even from the isometric loading test, the way that I kind of think about it now is not necessarily does it clear pain because I think 50 % of the time, if I can get someone to push into me hard enough or push hard enough into an isometric for 10, 20, 30 seconds, they're going to have an inhibitory effect of pain.

at least temporarily. So I think maybe to feed off a little bit of what you said, if it is a joint pain, maybe we go back to this idea of structure. Because even if I do load you and you temporarily feel better, then yeah, to your point, my range of motion would improve. But if it was a joint block or something like with my anatomy or my structure or a bone spur or whatever, even if that isometric takes away some pain,

I should still probably have the same amount of range of motion. And maybe that's a good way to sort of try to distinguish where we would target things or open up treatment with people. So is that maybe another way to think about it? Is it more structure? Can we make quick changes or not make quick changes? Is that even a way to think about joint?

Joe Gambino (10:23.274)
I know. think, you know, when we're just talking about symptoms in themselves, they're not the best measures for what is going on. So I agree with you on that. You need some other sort of.

Joe LaVacca (10:30.16)
Right. Right.

Joe Gambino (10:37.156)
Diagnostic something to start to push you in a direction to further believe that is the case So, you know some of these things like pain local to the joint on the closing side Leaning towards more joint issues can make your brain start to think that way more diffuse open angle discomfort Things like that can make you think more muscle something that's dull or achy, you know might fit the bill as well but then you need something else to kind of

confirm or deny, you can't just use the symptoms by themselves because they're not enough to make those decisions in my opinion.

Joe LaVacca (11:11.556)
Yeah, yeah, I agree. think, you know, for me lately, as I know, I always kind of keep shuffling my mindset and then reading something new or reading something contradictory. And I think I've bought up the the blue duck Adam Sandler enigma or problem, you know, when, you know, everything there's no such thing as a blue duck until you see a blue duck once. And then you don't need to see a blue duck again because you know they exist even if they are rare. So there's always going to be these little outliers to the rule that we have to sort of like, you know,

work our way through or problem solve through. So I would then typically probably fall back on when we load it, when we move you, what is the behavior of that tissue? How is it responding? And again, like what you were saying, if I have something a little bit dull, a little bit achy and we get it warmed up and it's on the opening side, is it muscle? Is it nerve? Right? Yeah, probably. But muscle and nerve and tendon and bursa are all going to kind of bleed into deep aspects of the joint too.

So I think the other rule, if we brought up FRC, was maybe some of these sort of like hierarchical range of motion or hierarchical patterns that also feed off of what we've been referred to as capsule patterns or joint patterns for each specific joint. So I do kind of occasionally fall back on those as well. And again, for those listening, the sort of idea in orthopedics, and I say idea because I don't know again if this has been really, you

proven to the nth degree or if it was just like a nice way of kind of thinking about joints. But I think it's held up for me enough where each joint will show you a quote unquote joint pattern in terms of its range of motion limitations. So in the shoulder, like how much external rotation or internal rotation do you have? How much flexion do you have? How much motion out to the side? And if we're seeing limitations in specific ratios between rotation and flexion and moving out to the side, then we might

infer that it's a little bit more of a joint related issue. But I still think it has to go back to behavior because we've seen people who are so acute and everything hurts and everything's limited. And I had a guy with acute back pain this week. I mean, it was an emergency text message. I got your number from a previous client. I need to see you. I'm going away on Monday on a work trip. I don't know what to do. And he came in and he was shifted and bent over.

Joe LaVacca (13:38.902)
and everything we did hurt. I mean, it didn't matter if I was moving his hand, moving his shoulder, moving his toes, everything. There was no closing, no opening, no patterns, no nothing. And that's what we would expect from an acute sort of injury. So maybe acutely, for me, a little bit harder to rule things in or out. But then once things calm down and then can we see behavior, I think that's where we can really be maybe really certain.

Joe Gambino (14:05.696)
Yeah, I like that. And let's let's shift here because I think this kind of really bleeds into the conversation today of prognosis versus diagnosis. Do you want to start that off by defining them and then kind of just going from there?

Joe LaVacca (14:19.172)
Sure, think probably more people are familiar with diagnosis, right? And I should have been a good podcast host and I should have, you Googled, you know, diagnosis and the root word. Maybe I'll just do it right now because we have the function of the internet in front of us. So if I Google diagnosis meaning, let's try to see if we can get the actual definition and maybe some root names here. Diagnosis according to Google, the identification

of the nature of an illness or other problem by examination of the symptoms. So let's see if we can find a little bit more of a route here. I think this is what people are more used to sort of thinking about when they go to the doctor or they come see us. What is happening to me and why? And then once we know why, well, what do we do to fix it? So I think diagnosis brings us to the here and now.

And that's obviously important for people in pain because I know they're always worried about the past, who they were, and maybe they're a little bit anxious about the future. So I do think diagnosis on our part is important to at least kind of maybe not nail it 100 % of the time because I don't know if that's possible for us, but I do think it's worthwhile at least suggesting to someone, you know, what we think is going on. And let's stop there with diagnosis.

what do you feel is important to relay to a client in terms of diagnosis? And has there been a big difference in that conversation for you when you were, you know, perfect stride, you know, one -on -one in person and now, you know, doing more virtual work one -on

Joe Gambino (16:04.672)
And I have the the root words here, dia and gnosis. They're both Greek words and they mean between in between and knowing. So there you have it. There are the roots there. As far as diagnosis goes, I do think that trying to get as specific as we possibly can, knowing the limitations of orthopedic testing and all that is helpful because I think there are certain things that when they pop up.

Joe LaVacca (16:11.376)
Hmm, here we go.

Joe Gambino (16:31.422)
Need to be addressed somewhat differently. you know, if it's nerve tissue versus bursitis, right? Like if you're distinguishing between bursitis and just like a tendon issue or something like that, right? Like they would behave somewhat differently and you know, over -stretching something like that for a bursitis perspective may not make sense, but for a tendon issue it might. so little things like that, I think would make, you know, a difference for us. just think giving more importantly for the person who you're working with them having some sort of.

answers usually is comforting for them. A lot of people that I see that the biggest struggle, especially with chronic pain when x -rays MRIs and all the imaging and every time they've see a provider and they say, we don't know what's wrong with you. It's difficult from a mental perspective for that person to comprehend, well, why do I have all this pain? What is going on? You know, everything is okay. Why am I in all this pain?

Joe LaVacca (17:21.808)
100%.

Joe Gambino (17:29.416)
So giving them as clear of a rationale between what we think is going on from a diagnosis perspective, but more importantly, and this is what I try to really educate people, and this is from when I was in person until now, is not so much about, sure, can like, you know, I'll let them know like, our tests are not that great, especially in a virtual environment, like, you know, I'm not going to be able to do all the special tests the same way that I would be able to do in person, but it's not, you know, the diagnosis,

you know, someone had a rotator cuff tear versus a labral tear versus anything else like impingement is really not going to change the way having more imaging or having a special test that came up positive isn't going to change the way that I'm going to treat that person. Mainly what I care about is what kind of movements are irritating that person? What kind of things have been stripped from their life because they can't do it because of pain? And then how can we start to work around that stuff and build up those qualities?

Joe LaVacca (18:11.653)
Mm

Joe Gambino (18:25.992)
And when we look at like that from a, know, and I think that's where PT like a PT diagnosis is not a medical diagnosis. It's more of the, this is what we're seeing from a moving perspective. This is the irritated tissue. This is the irritated patterns and this is the plan forward to build that back. And I think when we, when you can start to explain things in that realm, as opposed to saying like, I have to give you this sort of like tissue is the real issue. know, a rhyme there.

I think it goes, you know, it's easier from an education standpoint. It's easier for someone to buy in and then it's easier for your plan of care and when you're laying things out and creating buy -in with that person. So I don't know what you think about that.

Joe LaVacca (19:09.324)
No, think obviously we share a of similar approaches and I think maybe a little caveat or a little bit difference is I do think that emphasizing all the things we were able to rule out during assessments is really important to get closer to an approximate diagnosis even if we can't nail it. So I'm never comfortable, like you just said,

picking a specific tissue and saying, is the reason why you're having pain. Because again, I can't say that with certainty. But what I can normally say with certainty is listening to your story, listening to your pattern, if there was a mechanism, all the tests and things that we did today, here is what would have concerned me as a healthcare provider, as a clinician in your care, that would have made me told you.

Hey, you know what? think you need imaging. I think you need this. think you need this. Now, luckily, we didn't see any of these big red flags today or things that are ultimately concerning. So based on your behavior and based on this and based on that, I would say, let's approach this like it is a joint issue, like it is a tendon issue, like it is a muscle issue. And then that also then allows me to sort of then set up the prognosis, which is

where are we heading now that we have a label and how long will this label take to maybe fully resolve? So as much as I try to dance around that sort of impairment model, well, hey, we know you can't play golf or go work out because you're sensitive to flexion and you have had a lot of stress at work.

and we know that we have opportunities in building your quad function, so let's start there, that still maybe leaves a little bit of a uncertainty for clients. And I think for them to be able to tell their story is really important. And I think that's where the diagnosis is valued. So they can go to their spouse or to their colleagues or to their teammates or whoever and say, hey, you know what? I got my shoulder looked at. Good news.

Joe LaVacca (21:29.168)
It doesn't seem to be like a really big tear. I responded well to some movements. I think, you know, from what Joe said, we're just going to treat this like a tendon. We're going to treat this like a muscle. And then I have a few exercises to sort of guide this now. And we're looking at maybe six weeks, eight weeks, 12 weeks or more until I really have the results I'm looking for. And when it comes to prognosis and I've

you know, like to ask you about this, I always kind of put a couple of weeks or put, you know, a little bit longer of a timestamp on prognosis for people. And I do that for a few reasons. Number one, if they get better faster, hey, you know what, they feel better, like, hey, they did a great job. Hey, their bodies are really recovering. And it leaves a little wiggle room for life. Right?

Like I know so many people who come see me for the first visit. Kids get sick, they get sick, a business thing pops up. they couldn't do this, they couldn't do that, right? And now all of a sudden they lose a week on their timeline or maybe even two weeks on their recovery timeline. And now if I told them they were gonna get better in four or six weeks, four or six weeks later, no, I'm not better. That maybe creates a little bit more fear. But no wait, Joe told me this might take six to 12 weeks, right?

I'm still okay, this is exactly what was happening. So I do hedge my bets a little bit in the prognosis or where are we going rehab conversation and how long might it take me to get better. And I'm wondering if you think that that is fair to do.

Joe Gambino (23:12.798)
I do think it's, I don't think there's anything wrong with that. you know, when I'm, you know, trying to lay out a plan of care for someone and tell them how long I think it's going to happen. Cause it's always a question that someone has. I mean, this, you know, I, kind of use my, my experience and my judgment to kind of come to that, knowing what kind of, again, if I can kind of identify as a tendon versus something else, right. Where something that I think may be lingering around for longer. but I do think being somewhat conservative with it.

You know, helps because, you know, we talked about it before where once someone starts to feel better and they get, feel like that, they're at that point of like, you know, I'm almost done with PT is when flare ups tend to happen. So, you know, there's no surprises there when, when that stuff comes up and it gives you some time. And, you know, I usually, you know, just kind of like you, you know, I want to, you know, hedge my bets. I want to make sure that, you know, I plenty of time and that this way when they're, when I get them, but, know, if I tell them to take six months and they're done in three, I look like a genius Joe.

Joe LaVacca (24:11.904)
You do, you do. Yeah.

Joe Gambino (24:12.236)
That's way I work it now, but all joking aside, I think just, you can be a little bit conservative. I try to give people the best estimation that I can. Obviously none of us are perfect, right? So I usually will say, hey, I think it's gonna take us six visits. After we do three of them, we're gonna move to like a monthly or whatever. We're gonna start by monthly or whatever it is. And my assumption is that at this point we're gonna be...

just about fully recovered. And then from there, know, it might happen sooner, it might happen a little bit later, but you know, this is kind of where I'm thinking we'll just constantly reevaluate this across the time as we're working together because there are people, know, you'll get a better idea of how someone responds. Like this guy who I saw this morning, his neck issues when I first started speaking with him, I thought this would take longer than what it actually taking for him to start to get better.

you know, again, right? Like, I don't really know. I wasn't trying to be overly conservative with the timeframes that I gave him. But, you know, he responded way better than I expected from the history of what I was hearing with him, seeing multiple practitioners and having pain for so long and it seeming very joint related. I was like, OK, this might take us, you know, a few months to really kind of like get get through. And then, you know, we're a month in and he's like, the symptoms are barely even here anymore. Right. Like, I'm like, OK, well.

That's good. know, we're responding way better. You know, we're still got some little things to work on. Now we can expand to other areas and there are other things that he wants to focus on. So now we can start doing that stuff. but you know, that's kind of where I think having this like running prognosis where things kind of change with your education over time is I think valuable as well.

Joe LaVacca (25:54.448)
All right. No, totally. So I think diagnosis important for the here and now and validation. Prognosis is very important for the future and course of care, getting buy -in. And then like you said, mean, hedging our bets as clinicians, giving people space to sort of allow life to happen or maybe even, you know, their own healing processes happen. But I do think more and more

They go hand in hand. do think more and more they're equally as important. Whereas I think throughout my career, I've flip -flopped a little bit on which one was most important. Like, don't worry about the diagnosis. I tell people it's all about the prognosis. And then I flipped and now I'm like, well, it's really two sides of the same coin. And I think it's more important that we give people clear understanding at that first visit, build alliance, and then hopefully they fall into those timeframes, even if we are.

hedging our bets a little bit. anything else?

Joe Gambino (26:54.996)
Yeah, I love that. And I think it's really, when it comes down to this stuff, it's just more of giving people the comfort of having an answer that makes sense to them. And if you could do that, they'll feel better about the process. The likelihood of outcomes to move in a positive direction will increase just from that. And I think that will keep them, you know, consistent enough with your approach to give it time to actually make the changes. Because one downfall for a lot of people is a bounce from

Joe LaVacca (27:02.522)
Totally.

Joe Gambino (27:23.914)
this person to that person or this program to another program. And there's nothing that's going to be there to drive enough change or to see if it actually works. So I really like that. Take us home, Joey Boy. I'll give you the honors for two episodes in a row.

Joe LaVacca (27:25.541)
Yeah.

Joe LaVacca (27:34.81)
Yep. Amen. All right. You know, I did it yesterday or the last episode and I was like, man, maybe I do it. All right. Well, Joe, I love you. Listeners, we love you. And if you've made it this far into the episode, extra love to you. Thank you for listening and join us next week for another exciting episode of the Beyond Pain podcast.

Joe Gambino (27:41.791)
Mm -hmm.