Igor: Welcome everybody!
We are here today with Adam Brown from Cornerstone Physiotherapy, in Toronto.
Adam, thank you so much for being here. Very excited to do this interview. Tell us a bit about your background
Adam: Sure, thanks for having me, by the way. I’m happy to be here.
So I’m a physiotherapist and have been since 2002, so 20 years now, and I am the co-founder of Cornerstone Physiotherapy along with my partner, Joon. We also founded a company called
“Therapeut”, which is an in-home physiotherapy company, or rather a platform for physiotherapists to join and build a mobile practice.
My area of expertise is mostly in musculoskeletal physiotherapy, although I’ve branched out a little bit over the years. I spent some time as an advanced practice spine physiotherapist, working
with this spine surgery group in Toronto.
I’m a fellow of CAMPS, which will only mean anything if you’re a physiotherapist, but it’s a postgraduate education stream for manual therapy in physiotherapy, and we built Cornerstone into five clinics. We have 33 physiotherapists that work with us now across the GTA, and my role there is mostly in mentorship and teaching as a as a clinical lead in that organization rather than managing an active caseload of my own, which I’ve ramped down over the last few years
Igor: right, so very experienced
Adam: been doing this for a while I’ve been here for a while I’m an old grizzled guy.
Igor: not that old.
When we were chatting by email, one of the things that I asked you is where do you think therapists whether it’s physiotherapists, chiropractors, osteopaths, massage therapists, could be doing better, one of the areas you mentioned is that people are actually doing pretty good work on the acute stage of care, like relieving symptoms, but not so much in terms of permanent
changes in the way that a person’s body functions. Can you talk about that a little bit?
Adam: yeah, and you know, I should preface it with there are lots of people out there doing
lots of great work and anytime you make a statement like this of course they’re going to be people who it does not apply to. But on average if we’re looking at the profession of physiotherapy and all the other similar professions like chiropractors, osteopaths, RMTs, all
that sort of thing the focus has been on relieving pain – making people feel better, and of course that’s important and those tools are necessary in practice, but what rehabilitation really is is
changing an individual’s risk factors and their trajectory going forward and beginning to make some changes that that led to the problem that they’ve come to see for, and ultimately you know at Cornerstone, what we try to do is to mentor and teach therapists to be utilizing acute care in the in the beginning, in order to do the more important work of changing that individual’s risk
factors, whether that you know as an example might be to try and make somebody stronger, try and make somebody more mobile, try and improve their general overall health or habits that are leading to injury those sorts of things are not focused on in the same way in postgraduate education as maybe they should be because I think that’s where the really great work is done – to prevent them from ending up in rehab again in the first place.
I mean, reducing somebody’s pain in a lot of cases in whether whichever profession is doing it
isn’t that difficult and it’s fairly temporary and doesn’t really change that individual’s health. It just changes their experience of their current condition for a short period of time if we can use that window of time in order to provide an exercise stimulus or mobility stance or what have you that is going to have a lasting impact then I think we’ve really done our job.
So ideally you want to prevent the patients from ending up in rehabilitation again, although if they do they’ll take care of them right which is why in our organization we pull in information from strength and conditioning, from sport and exercise science pathophysiology medicine and
rehab and trying to use it all in order to vary, because what I like to say what we do is like apply the fundamentals of rehab but with an uncommon level of focus.
Igor: So yeah, I mean I just met you a few minutes ago, but based on what you’re telling me it
sounds like what do you wish you’re doing is actually very uncommon in the physiotherapy world because I am a personal trainer and I run a personal training company and when you do get referrals from physiotherapists, they’re largely focused on acute care, which don’t get me wrong – very, very important but you’re absolutely right it doesn’t change risk factors like strength, endurance, flexibility and so on, so it sounds like you guys are taking things a step beyond. You’re actually preventing them from needing further physiotherapy and making them more or less resilient.
Adam: And I think to blame the physiotherapists, chiropractors, osteopaths, and all that sort of things for this may not be quite correct. I think that most of us have those ideas in mind when
we’re working with a client we know what we want to change and what we want to do, but we don’t often set those expectations and give people the full spectrum of their care plan. And so we
don’t know when the average patient arrives in a physiotherapy clinic and says “I just really want this back pain gone” – yeah, understandable, but it’s also our job to say “okay, well here’s why you’re somebody that struggles with back pain. Here are the things that we can influence and so when we’re finished with this rehab journey, we need to have accomplished X, Y and Z to ensure that we’ve reduced your risk factors going forward, and then that changes the person’s goals and their perception and what they believe their finish line is, and so unless we communicate what we’re thinking in that regard really really clearly, and we continue to revisit those goals, so that it’s clear that what we’re doing with them is providing value to bring them to that point, then it’s hard for patients to stay engaged and involved in the process, because when pain is an outstanding motivator, but unless you have brought and focused that person’s attention on some of the changeable aspects that have led to their condition, they won’t see them and they ultimately haven’t felt pain in a while, and I think that was great I’ve had a good experience and now I’ll just go on my way and really what we’ve done is let them out of the clinic with the same
issues that they came in with.
So I guess part of it is just communicating the physiotherapist plan to the patient, so that they kind of buy into that they’re on the same page, that we don’t just want to get out of pain, but we also want to prevent it from coming back by modifying the risks with the risk factors, and of course, patient’s motivation and compliance, and everything comes into this.
Not everybody wants to invest the time and energy to fundamentally make a change and to
become healthier and stronger, more mobile, whatever it is that they need, but it’s our job to present that as an option and then people are going to make their own choices from there.
Igor: yeah, absolutely. What kinds of conditions do they see most frequently?
Adam: Well, at Cornerstone we have a few different programs: our musculoskeletal program is probably the largest and in that you know it’s a general orthopedics program, so we see a lot of
back pain, neck pain, shoulder pain, knees, ankles, sports injuries – all that sort of stuff that you would kind of typically associate with an outpatient physiotherapy practice.
Then, we have a large vestibular rehabilitation program, which deals with dizziness and balance disorders of all types and so that is delivered across all five of our clinics by a group of clinicians.
We have a pelvic health program, which really is musculoskeletal physiotherapy but with some
specialized training in disorders of pelvic health.
And then our most recent program is the long COVID program, where I’ve been working as a researcher and clinician alongside University Health Network to investigate the best possible ways to help people with that problem and to rehabilitate themselves from long COVID, and
we’re symptom monitoring technology to be able to do that remotely, which is really exciting work.
And very different changes every six months so. That’s been that’s been an interesting project,
but yeah, the bread and butter of Cornerstone is musculoskeletal care.
Igor: One of the things you mentioned was that vestibular rehabilitation. Now, I’m guessing a lot of the lay public hasn’t heard of that, and so who might be a candidate for that?
Adam: people who have issues, problems with balance, so dizziness is really a symptom not a diagnosis, and lots of things can cause dizziness. So often, it starts with a visit to the doc to get some idea in terms of what’s going on, although that’s not necessary. People can come straight into the clinic.
We take them through a process where we differentially diagnose all the different types of dizziness and what’s happening.
We treat mainly disorders of the inner ear that are causing that imbalance and that persistent dizziness, and so that can be everything from conditions like BPPV, which is probably one that people have heard of. Very often where crystals in the inner ear become dislodged and cause
dizziness all the way to Meniere’s disease, and a variety of others.
I am not a vestibular rehab specialist, Joon, who is a therapist and founder at Cornerstone is our sort of vestibular therapist, who has just loads of experience and has trained all over North America and it brings that uh knowledge up to Cornerstone, and trains leads that program.
It’s amazing now within the realm of orthopedics, with lower back pain, there are a million reasons for dizziness, there’s probably also a million reasons for back pain.
Now, one of the most common reasons that you see are they athletic reasons are they slip discs, arthritis, something else.
Yeah, so lower back pain – you’re right – there’s lots of causes and that’s why advanced imaging isn’t particularly useful, unless you’re using it to decide whether somebody’s a surgical candidate or not, but what it does in low back pain, rather than coming down to a discrete tissue diagnosis,
what we do is we sub-categorize types of low back pain, and by doing that we’re able to apply the right type of treatment to the right type of patient, so there are sort of sub-categories of low back pain.
So for instance, there’s inflammatory low back, pain which is really more of a systemic issue
around rheumatoid arthritis or ankylosing spondylitis. These inflammatory conditions, which can cause joint pain.
That’s really quite a different subtype of back pain than what you or I might have because we
went to the gym and did deadlifts that were too heavy.
Disc disorders are certainly very very common. That said, just because you have a disc bulge on an MRI doesn’t mean that’s the cause of your pain. Most of us have them, but when they’re acute, they’re pretty bad, and so you know you have that inflammatory low back pain and then you have mechanical low back pain, which then further subdivides into flexion-dominant back pain, extension, etc.
Igor: you mentioned something interesting that just because you have a bulging disc doesn’t necessarily mean you have pain.
Adam: no, most of us have bulging discs, but I believe that not every instance of mechanical
imperfection on radiographic imaging is associated with things. So in fact, there’s almost no correlation and that’s why MRIs and X-rays in particular with spine pain are of very little value
unless you’re trying to make a surgical decision, which is a little bit different, but no MRI ever came back that said normal. Yeah, it’s not a thing you know. Ultimately what’s happening is a
radiologist is describing what they’re seeing and of course we’ve all been walking around and
playing various sports and creating some changes in our backs over time and being able to predict which of those from the image is producing pain it’s just not possible.
So where a clinic a really focused and excellent clinical exam meets up with a finding that is on imaging, it that improves the probability that it’s an important finding.
What imaging really is for is after a focused clinical exam, determines that somebody who has a low back disorder might be in that subcategory of people who would benefit from a surgical
Outcome. Then they would use the imaging to ensure they have something that matches that presentation to go after.
The last thing you want to do is jump on an OR table and have them go in and find out well that’s not what we thought it was so.
Of course it’s used for that, but outside of that it’s a fairly blunt instrument because it tends to provide people with a great big paragraph of you know scary sounding changes that have occurred in their low back, most of which are totally irrelevant
Igor: that’s very interesting that some changes sound scary but are poorly related to pain, but other changes at other times you see nothing particularly remarkable, yet there’s pain.
Why would that be?
Adam: So there’s lots of different reasons. I don’t know if we have time to go into all of them, but different people have different nervous systems, so the sensitivity of their nervous system to stress on tissue, and that sort of thing.
There’s also the speed of that change. So if you have a disc in your low back that over years, because maybe you’re not as strong as you could be or your activity is at a certain level, it
begins to slowly degenerate, but it doesn’t kick off at any given time a particularly large inflammatory response, because there’s no large change happening all at once. Then you may not even really be aware of that change.
But once again, you know if you go and lift a sofa poorly and you bulge a disc all at once and it creates a big inflammatory response, you’ll know it. That’s more likely to be painful, and then all sorts of other things that feed into why people different people experience pain differently, and
in different degrees, and some of those are have to do with the nervous system some are
very purely psychological, some are neurophysiological, and some are whenever our brain is involved, it gets complicated.
Igor: I guess the only thing we can say is that pain is not purely mechanical.
Adam: No, I mean in fact only the signal is really even happening in the periphery. The pain or the experience of pain is happening in the brain and it’s a really interesting subject in neuroscience that we’re probably just seeing the tip of the iceberg despite the fact that there’s
been a lot of advancement in the last 10 years
Igor: yeah, absolutely. Well, this was fantastic. It was very helpful.
Any last words you want to tell our audience or people watching this video?
Adam: I think that if the people watching the video are interested in physiotherapy and in
trying to evaluate what they might need, I think that becoming an informed consumer is really important, and so on that first meeting, you should have a plan that not just focuses on that very short-term goal of you know we’re going to stick needles in this and we’re going to do some manual therapy and we’re going to try and make you feel better.
That’s interesting, but we intuitively know and likely you as a patient intuitively know that that’s not fundamentally changing your body and your risk factors, so you should hear something in that treatment plan that is a more stable and permanent change, that is going to serve you going forward out into the world when long after you’ve had experience with this physiotherapist or other clinician that will pay dividends later.
Igor: That’s a great message: leave the patient better off then before the injury.
Adam: Absolutely
Igor: Fantastic! Thank you so much.
Adam: Thank you.
