FEATURE

Back in business

Jared Eliuk says physiotherapy played a major role in his recovery from a severe spinal injury

back in business
A year ago, Jared Eliuk broke his back while snowboarding.
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What can physiotherapy do for you?

Accessing physiotherapy services

BY JOEL SCHLESINGER
Winnipeg Health Region
Wave, September / October 2014

Lift your left leg and your right arm at the same time.

Ask Jared Eliuk to perform that simple task today and he will have no problem complying.

But it was a different story just over a year ago.

Back then, the 30-year-old Winnipegger was recovering from surgery to repair a broken back suffered in March, 2013, while snowboarding at Springhill Winter Sports Park.

"I ended up falling the wrong way while sliding down a rail at the hill trying doing a trick," Eliuk says, explaining how his accident occurred. "I slipped off a little early, falling on the ground in a sitting position and compressing all my lumbar vertebrae," he says.

"In my head, I heard a popping noise and then there was a lot of pain - I was basically winded to the point where it took me a couple of minutes to catch my breath. At the time, I didn't realize how bad it was."

After he was carried off the ski hill on a spinal board and taken to hospital by ambulance, an MRI revealed the extent of the damage - and it was indeed "bad."

Eliuk had not only compressed the lower vertebrae in his spine, he also fractured some of the vertebrae, too. He required emergency back surgery, twice, leaving him with two titanium rods and eight screws lining his spine to reinforce the broken bones. He was bed-ridden for two months before he could manage walking for short periods of time around his parents' home.

"At the time, I was told I'd probably never be able to touch my toes again - let alone go back to my job," he says.

Yet today, about a year and a half after his accident, Eliuk can do more than touch his toes. He was recently cleared by his doctor to return to work - a job requiring him to lift more than 40 kilograms.

For Eliuk, the first step on the road to post-operative recovery began with a visit to the Physiotherapy Outpatient Department at Health Sciences Centre Winnipeg. Located at 800 Sherbrook Street, the department serves as a hub for physiotherapy services provided by the Winnipeg Health Region.

The practice of using physical exercise to aid recovery from musculoskeletal injuries has been around in one form or another for centuries. Physiotherapy was used as a health aid in the late 1890s and started to emerge as a profession in the 1930s and 1940s. In the years since, it has evolved into an integral part of the health-care system, and physiotherapists are considered to be the primary experts when it comes to helping patients recover their functional mobility lost due to muscular strains or broken bones.

Eva Karpyza is the Regional Manager of Outpatient Physiotherapy Services for the Winnipeg Health Region and Manager of the Prevention, Assessment and Rehabilitation (PAR) Clinic at HSC. She says the demand for physiotherapy has never been greater. Physician referrals to Physiotherapy Outpatient Department, for example, jumped 30 per cent in 2013, compared to the previous year, and midway through 2014, referrals are up another 22 per cent.

In fact, the ever-increasing demand for services prompted the department to develop an innovative triage system for physiotherapy, one that shifts the focus from passive clinical visits to an emphasis on active home programs, education and establishing self-management strategies.

As Karpyza explains, the majority of patients referred by a physician for physiotherapy are priortized for care at the Health Sciences Centre or one of the hospitals or health centres. "We would like to see everyone as quickly as possible, but realize that some patients need to be seen on a more urgent basis to prevent problems and complications.

"At HSC, we have two physiotherapists who look at every referral, and they will determine if the patient is a priority or a non-priority," Karpyza says. "Priorities, for example, are fractures - if you broke your arm or if you had surgery, receiving physiotherapy sooner could be important. If you sprained your ankle, you may be a priority. People who are at risk for falls also need to be seen sooner."

The practice of physiotherapy is based on four pillars - education, exercise, modalities and manual therapy. And while modalities (like acupuncture and heat and cold therapies), and manual therapies (like joint mobilization) remain important parts of physiotherapy, education and exercise have become the workhorses of recovery plans.

"The change over time has more to do with the fact that we're now more focused on what the patients want to accomplish in physiotherapy - what are their functional treatment goals," says Karpyza, who has been a physiotherapist for 36 years.

That's why the first visit with a physiotherapist, the assessment, is so important, according to Shelley Capka, who works in HSC's Physiotherapy Outpatient Musculoskeletal Department.

As she explains, physiotherapists talk with patients about their lives, their work and daily activities to develop a recovery plan that will help them achieve functional goals - like being able to lift their young children, play soccer on week nights or return to their job full-time.

"We don't treat based on diagnosis or condition. We assess and, based on the assessment, we come up with an individualized program," she says. "It's not a set program for all patients. It's an individualized, realistic program that each patient can do to achieve their own goals."

The next step, even before starting any therapy, is education. Patients must learn about their injury, as well as what rehabilitation involves and what outcomes to expect.

"We also educate patients about what normal pain is, because we don't want people stopping what they're doing because they're experiencing a normal amount of discomfort after exercise as opposed to pain that isn't normal," Karpyza says.

Of course, the success of physiotherapy as a treatment depends as much on the patient as it does on the physiotherapist. A physiotherapist can develop a highly individualized recovery plan that targets a patient's specific illness, disability or injury. But the patient also has to be committed to carrying out the plan, says Capka. Without their active participation, achieving their functional goals - regaining mobility to carry out daily activities - makes an already challenging road all the more difficult, she says.

Eluik was motivated when he arrived at HSC Physiotherapy Services in July.

He was just about to move to a new job in Edmonton when his injury occurred and his life was put on hold. Because he was just starting his new job, he had no long-term disability. With no income, he had to move back in with his parents, and after weeks with little physical activity, the once physically fit former construction worker gained more than 15 kilograms.

"Taking a year out of my life where I wasn't able to do anything - it was like a negative transformation for me," he says.

His muscles in his legs, arms, back and abdomen had deteriorated to the point where any physical activity was difficult. He also knew he had to learn how to move differently because he had two large rods in his back that limited his mobility. He couldn't simply bend over to pick up a pencil from the floor like he might have prior to the injury. And he needed someone to teach him how to deal with his new physiology.

Like so many others, however, he was ready to endure a little additional discomfort if it would result in long-term gain to get back to some semblance of normal life.

After meeting with Karen Malenchak, a physiotherapist at HSC's physiotherapy department who also works at HSC's Pain Clinic, Eliuk was immediately moved to the top of the list for physiotherapy. "I was in the following week after meeting with her, and I ended up going four times a week for about eight weeks."

Starting out, Eliuk was very sore and weak. That simple exercise of lying on a mat and lifting one leg while raising the opposite arm caused a lot pain, and proved enormously difficult. "It doesn't sound like much, but when you have an injury like I had, something as simple as that seems like a major achievement."

Eliuk attended every class and seminar offered to him. He was part of Malenchak's lumbar stabilization class, held twice a week, geared for patients with lower back injuries.

Primarily involving stretching and core-strengthening exercises, the hour-long sessions allow Malenchak to work with each one in the group for a few minutes while others work on their personalized exercise regimes.

"It was like having a gym membership with someone there to coach you through what you were doing," Eliuk says.

Other days, Eliuk would attend the cardio core-strengthening program at the facility's pool. During the session, run by Capka, Eliuk and the others would start with stretching in the pool and then move onto 20 minutes of cardiovascular activity, followed by upper and lower extremity strengthening.

"It's a hydrotherapy class very similar to aqua-size," says Capka.

Eliuk says that, at first, the pounding sensation in his back from jumping up and down in the water was almost too much for him to bear. Then again, it was much easier in water than on land.

"I couldn't jog at all without pain," he says. "After doing the water class, I made leaps and bounds of progress in terms of what I was able to take in terms of strain on my back."

Eliuk had lots homework, too. Like all physiotherapy patients, his outcome was largely dependent on the work he was willing to put into his recovery program.

"We really work hard to impress upon them that it's not the work that they do with the physio, but it's the work that they do in between visits that will translate into better functional outcomes and help them achieve their goals," Capka says.

If commitment is central to a patient's success, then a lack thereof is a major obstacle.

While occasionally that simply boils down to a laissez-faire attitude on the part of individual patients, in many more instances, patients have difficulty following through on their physiotherapy plans because of the pain they experience when doing their exercises.

Improvement takes time, Capka says, and sometimes the pain is so acute, it can outweigh the incremental gains. Furthermore, some patients are particularly sensitive to their pain, and as a result, are even less likely to be successful.

That's why Malenchak and Capka started the Persistent Pain Class, a relatively new initiative aimed at helping patients who find pain is an obstacle to treatment.

"These are often people who have a lot of anxiety about their pain, which makes them hesitant to do anything that might increase the pain in order to get better," Malenchak says.

Taking place once a month at HSC, the purely educational class is geared toward patients who are identified as suffering from a condition called "central sensitization, which is characterized by pain catastrophization."

"These patients worry; they feel helpless; they feel like they don't have control over helping themselves," she says. "So it can make them very reluctant to participate in an active program, which can increase their pain while they're on the path to improvement."

After running the program for about two years, both physiotherapists have helped many patients, but they suspect more could benefit. "My sense is we're missing a lot of people who should be part of the program," Capka says.

Today, physiotherapists assessing patients at HSC work to identify these patients as early as possible and recommend they participate in the Persistent Pain Class. "We want these people to participate right away so that the active physiotherapy sessions following the class can be more helpful for them," Malenchak says.

In addition to teaching patients about the physiology of pain - what's happening in their body when they experience discomfort - they provide patients with non-medicinal solutions, like meditation and deep breathing, to help cope with it.

"It's the kind of education that can't really be done at the bedside because in a busy clinic, we can have a few patients exercising at the same time, so we're moving between them working with them individually," she says. "But this type of information about pain management needs to be presented properly with the right amount of time and attention or it can be misleading and discouraging, and people may get the impression that the pain is all in their heads."

By educating them about the physiology of pain - how the nervous system works and can become over-stimulated by injury - patients can understand how they feel, knowing that as they progress through a physiotherapy program, their pain will lessen. Yet while pain is a barrier to some making the most of physiotherapy, there are many others who downplay chronic, seemingly minor injuries and don't see a physiotherapist until their small problem becomes a big one. "For a lot of healthy people, it's human nature to wait things out because most other problems have gotten better in the past, but for that reason, we can see people who have had pain for months, so we're working on their injuries longer than we would if they had come to see us sooner," Malenchak says.

Eliuk does not have to be sold on the benefits of physiotherapy. Now working again, he says the help he received was truly priceless. "Simply putting my socks on was a struggle before physiotherapy, but now I have got a lot of the range of motion in my back that I had thought I would never have again," he says. "The staff was fantastic to work with - I would recommend it to anyone who thinks they need it, for sure."

Joel Schlesinger is a Winnipeg writer.

Wave

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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