Nick,
Nice article selection – should make for some good discussion. I would love to hear some of the other residents thoughts on your patient presentation and your leading questions. I have some insight to offer after taking a look but want to hear others first. With regards to your expectations question can you give us an idea of her personality and what her understanding/expectations were?

Aaron

Nick – great articles and thanks for posting the second one as well!

Just a few questions about your findings to clarify
– It sounds like you were able to reproduce mainly neck and shoulder/scap symptoms. Were you able to reproduce her hand numbness/tingling?
– Are the numbness/tingling of the fingers a primary complaint with the shoulder pain?
– One of the Aggs was “hand use”, which symptom does that aggravate?
– Did you do any sustained compression/distraction/spurling/quadrants or compression/distraction in quadrant position?
– What do you make of the ULTT causing symptoms around the scap and not in the neck or UE?
– Were you able to differentiate between ulnar n and C8 with any muscle testing?
– What position does she sleep in? How does she reposition to fall back asleep? Are the shoulder symptoms what’s causing her to wake up?
– What made you change your hypothesis from TOS to C8?
– (How) did your asterisks change after your treatment?

Lots of questions, I know… Just curious what patterns you saw and what your thought process was. I still find these types of pts very challenging and it looks like she’s not an easy case.

I try to assess expectations with every pt, but the degree may vary. I start by asking if they’ve been to PT before (eval) and sometimes just directly what they expect. I’ve had a lot of highly irritable patients recently and I spent a lot of additional time earlier to educate them on what normal responses to treatment/exercise can and should be, even/especially if it can lead to an increase in soreness or pain. I had a patient today, who has pretty severe LBP with B radicular symptoms and he went to see the spine surgeon this week to go over his MRI. He told me about the appointment 2-3 weeks ago, so I spent a good amount every visit educating him on MRI findings, function etc etc. I was still nervous how he would react, but he came back today and despite having “massive” HNPs, he was still fully on board with treatment.
I have another pt who’s wife is now trying to convince him to get back sx, (min hard neuro signs, main complaint is decreased mobility). He came in convinced he’d have sx within the month and after educating him on what’s going on, he completely changed his outlook.
One question that has seemed to work well for me during my subjective if a pt comes in reporting increased pain/soreness after last visit or with HEP, is asking the pt whether what they experienced was outside of what was expected based on our discussions.

Nick,
Great case. I was reading through your subjective and I would have agreed completely on what you had as your primary hypothesis and differential list afterwards.

From my understanding, it seemed to me that during her subjective, she complained of posterior and anterior shoulder pain along with scapular pain that all occurred together. During her objective (and correct me if I’m wrong), you reproduced her anterior symptoms with shoulder testing and her posterior shoulder/scapular pain with cervical testing. I’m not convinced yet that the shoulder needs to be ruled out for at least a contributing factor. I want to look at her scapular movement patterns and endurance. Was there anything out of the ordinary in terms of scapular dyskinesis or hypomobility with scapulothoracic accessory movements? With a history of hypermobility within her glenohumeral joint and I’m guessing some postural abnormalities since posture was one of your treatments?

When you tested her PAVIMs, you reported that she had normal to hypermobile lower cervical downglides but reported pain. Where during this range did she experience pain? Early or at end range?

During your treatment on the initial evaluation, you were somewhat satisfied that you reproduced then alleviated the complaint. Can you expand on what alleviated her scapular complaint since you didn’t reassess any asterisks at the end of the eval?

In terms of patient expectation, this isn’t a strong suite of mine at the initial evaluation. Sure, I give a ton of patient education and explain prognosis and plan of care during the eval and inquire about any questions or concerns, but I’m not so sure if I attempt to assess or influence expectations as much. Maybe it’s the time crunch at the end. For me, it’s more something that I look at over time. If someone is raising serious doubts of effectiveness of our treatment or showing signs of non-compliance, I will absolutely address it but really not until it comes to my attention or causing a problem, which could potentially go against my favor. I’ll be excited to discuss this with everyone!

Thanks for sharing Nick!

What was your patient’s irritability level? You mentioned that you did a right posterior quadrant test and you were able to reproduce her symptoms. Have you found that reproducing a patients symptoms early on skews following test results? If so how do you go forward in choosing the best objective exams? As well, any particular reason you used the supine thoracic manipulation as a treatment?

Something that I’m finding is how patient expectations influence motivation. As well, finding a comparable sign is crucial. I had a similar case and educated my patient how his neck was causing his shoulder burning pain. I told the patient to work through his exercises and he will see a change, surgery was not necessary.
He agreed to work through his HEP and by session 3 he had improved cervical AROM and decreased shoulder symptoms. If I’m able to reassess the comparable and make a change in function/ symptoms, then I try to use that information as an educational tool.

Nick –
As I mentioned before, I love this topic on multiple levels and I think valuable discussion could come from this to help us all, or just me, problem solve to find where and how to incorporate manipulation treatment into practice to achieve the most benefit. The faculty has brought up the topic of when and if consent should be implemented prior to treatment as well and I think this could fall into that topic with a different perspective.

For instance, I would say that I implement manipulation therapy in my practice a fair amount when I feel it’s appropriate. I feel fairly confident in my skills; however, I feel very apprehensive to “pull the trigger” on performing a “thrust” at times, particularly to the cervical spine. My biggest fear is that I surprise the patient to a degree that causes fear in them and I lose their trust. On one hand, I feel like asking for consent could cause fear and apprehension and may come across as a lack of confidence on my part. On the other hand, I want them to have an expectation of what I am about to do. So far I’ve used phrases such as, “this joint feels really stiff, it feels like it needs to pop, I think that would really help you”, etc, and then I just wait for a reaction or response. I’m exploring different approaches to this issue. Maybe I’m just over-thinking it. I realize some clinicians may just go right into performing the technique without warning. But I just feel a need to have an understanding of their expectations of therapy.

I noticed in this article they just told the patient’s they were going to “push” on their back. It doesn’t look like they informed them of the high velocity thrust. I kinda like the idea of showing a video as they did in this study. Maybe a video in addition to providing patients with the “JOSPT patient perspectives”, that were included in Aaron’s (or AJ’s, can’t remember which) presentation, is the way to go. This may be stating the obvious, but I think if we are planning to manipulate, we should definitely be asking the patient if they have seen a chiropractor and what their experience was like if they have.

Does anyone else share similar thoughts? What approach has been successful or unsuccessful for you (residents and faculty)?

Regardless of the technique being performed, providing more positive feedback and exuding a positive outlook to the patient regarding their therapy outcome is extremely valuable more than anything else we do. Maybe in my practice this has been more pronounced as my confidence grows, but this is one of the biggest changes that I have learned from Eric and Mike and have made a priority in my practice. If we could just influence other healthcare professionals to do the same thing, we would really be in business and on track to changing healthcare and dollars spent on healthcare.

Hey Nick
Did I miss it or do you know if there were specific aggs producing her distal (forearm/hand) symptoms?
Are her symptoms different on her work vs non-work days and could/did you affect any of her symptoms in real time with sitting postural education?
Did you also educate her on specific work station changes? (chair, desk, monitor, phone…etc?). We have SO many pts who present with postural problems driving so many of their symptoms are hugely contributory with underlying chronic problems that might not be the prime problem but a big enough issue that if you don’t address that, the pt will spend 40+ hours/week in a poor position which inhibits improvements in clinic or w/HEP.

Nice discussion you guys. Continue to work through some of the questions about the case today and tomorrow so that the discussion on Tuesday can be centered on the article itself. Sean, I think you bring up some very valid points about how we go about informing patients about particular techniques and how maybe the way in which we go about this (our attitude, tone, style, etc) may actually be more important than the actual information they receive verbally. At Kaiser the faculty would often say phrases like “is it ok with you if I give this joint a quick stretch?” and they would tell them they might hear a little sound like when you move your knuckle in a certain way but would downplay any audible effects and let them know that the quick stretch is really the important piece and seemed linked to change in the system. Sometimes patients are still surprised by the velocity of the technique and some sounds, which are certainly amplified in the cervical spine given their ear is so close. However, at least you have told them something and not completely withheld the intent of the technique. With regards to expectations about therapy in general I think some would urge to not wait until the end of the first session to ask this. Why not ask this as part of our subjective history intake as this changes our objective exam and treatment no different than asking about a particular aggravating factor or a red flag. There are plenty of textbooks that discuss rapport building and how important this is during the subjective and having this talk (their expectations) is an avenue to start that dialogue. I attempt to do this and then again at the end to make sure that their expectations were met. This seems to open lines of communication and I think also impacts their buy-in, compliance and cancellation/no show rate as well.

Nick,

Thanks for all of that clarification. This is such an interesting case! It’s tough because it doesn’t quite fit cervical radiculopathy CPR, the radicular pain into the UE isn’t there, she’s in this subacute stage where it’s not acute and not necessarily in the chronic stage, but I agree with you that it seems like the most fitting with the pattern recognition. I think you did a great job in choosing the initial treatments.

I also agree that the more I read about patient expectations with treatment outcomes of musculoskeletal treatments, the more I regret not addressing this more frequently. Unlike other measures, this is something we could easily ask about and assess on an individual basis because it’s so specific to each patient. I hope we can also touch on what you all have successfully done in the case of someone who does not expect any positive outcome of physical therapy in general, say someone who is only going through a “round of PT first to be able to get my MRI”. They might show up to every session, but it’s probably going to make a huge difference in outcomes if they don’t believe it will help.

Interesting research I came across in this review article listed in the references of Nick’s article: Individual Expectation: An Overlooked, but Pertinent, Factor in the Treatment of Individuals Experiencing Musculoskeletal Pain. Phys Ther. 2010 Sep; 90(9): 1345–1355.

Physiological Response

Studies of physiological responses that accompany expectation have been reported primarily in the placebo literature. Specifically, studies of expectation-related analgesia have demonstrated associated responses, including activation of the opioid system, changes in spinal reflexes, and specific activation of the brain and spinal cord. Price et al observed a significant decrease in brain activity, as measured by functional magnetic resonance imaging, associated with expectation-related analgesia in brain regions related to pain (thalamus, somatosensory cortices, insula, and anterior cingulate cortex).

Additionally, Craggs et al studied brain activity associated with expectation-related analgesia using functional magnetic resonance imaging and observed sustained activation of regions involved in pain modulation, such as the medial prefrontal cortex, posterior cingulate cortex, bilateral aspects of the temporal lobes, amygdala, and parahippocampal cortices. Furthermore, transient activation was observed in areas of the brain associated with emotion and information processing, such as the posterior cingulated cortex, precuneus, rostral anterior cingulated cortex, parahippocampal gyrus, and the temporal lobes. Finally, Goffaux et al observed a significantly diminished withdrawal reflex, as measured by the R-III reflex, corresponding to expectation-related analgesia. Together, these studies suggest very specific neurophysiological mechanisms related to expectation at the level of both the spinal cord and the supraspinal structures.

Hey Nick
not a bad form…definitely focuses on function and specificity of patient centered goals and provides some great objectivity to track for both PT and patient. BUT, I feel patients are so overwhelmed with the amount of paperwork we already require of them upon intake that this may be overkill. if we’re collecting a good subjective and focusing on patient goals and objectivity of those goals upon history taking, we will already have this in our documentation and have reviewed it with patients and can track his/her progress with our focus on short and long term goals. Others may find this form very helpful but in my practice I think it might be overkill for most patients. would you use it?

We utilize the PSFS, especially with our Medicare folks as it can be used to help determine functional status and reporting. We find that it is helpful when the outcome of some of the other scales, such as the OPTIMAL (which we use), does not seem to capture the patient’s level of impairment and need for care. The PSFS is not given to the patient on a sheet of paper but it is on our medical screening questionnaire but indicated that the PT will fill out instead of the patient. It is a reminder to ask their goals and limitations with regards to function, which we already do. The only difference is the numerical rating that the patient gives describing their current ability with that task.