Hands on vs. Hands off: How do we find the balance?

[iwhitney]

For this patient reflection, I wanted to bring up a patient that I found to be particularly challenging, but also someone whose situation brings up the importance of balancing our clinical decisions based on the varying levels of presentations we see. The patient presented with a chief complaint of neck pain that had been getting progressively worse since he had an ACDF performed to C3-7 in April 2021. He was also recently involved in a rear-end collision about one month ago that further increased his pain and left him feeling like everything he did was limited and painful. The patient was cleared with no fracture at the ER following his MVA and I cleared him during my exam for any CN involvement, VBI, CAD, or ligamentous instability. Despite the ACDF procedure, the patient still has significant foraminal stenosis in his lower cervical spine as observed in imaging. During the exam, I felt like just about anything I had the patient do increased his pain or caused him to flare-up, ultimately limiting my ability to differentiate the source of his pain. What I did know is his pain did not radiate past his upper trap area, but did extend to the periscapular region as well as to his posterior skull and was described as burning, sharp. From all stand points, it seemed clear to me that this significant increase in pain he was experiencing was radicular in nature and likely, the MVA he recently was in caused his nerve roots to become inflamed secondary to the inherent foraminal stenosis. Also, I felt the likely whiplash moment from the accident caused him to develop signs/symptoms of a cervicogenic HA stemming from the upper cervical spine.
Leaving this patient’s initial evaluation, I felt uncertain about how his pain would change into the next visit since he was so highly irritable. When I saw him for his follow-up, he felt like his pain had continued to get worse and mentioned to me that he almost didn’t show up because he wasn’t sure what I could do for him. On the way into the treatment room, he stopped by the model skeleton to “look at the neck and figure out what was causing his pain.” Reflecting back on this encounter, I feel like I should’ve used this as an opportunity to educate the patient thoroughly on what I had gathered from that initial evaluation and what I think was contributing to his pain. However, I think I just wasn’t fully confident at that point as to what was truly contributing to his symptoms. The patient was still presenting with cervical limitations in all planes and most movements increased his pain. I decided to place him supine and see how he would respond to gentle cervical distraction. Initially guarded, after a couple minutes he mentioned he began to feel better than before and that it seemed to be working. For the remainder of the session, I worked on gentle OA mobs, neutral lower cervical mobs, very gentle STM, and cervical isometric exercise. Leaving the session, he felt a lot better about his situation but still seemed unsure as to how he would feel into the next few days.
I feel that I definitely could’ve done a better job with this patient of utilizing education and motivational interviewing in order to better help him understand what I think is contributing to his pain and the overall expectation for his prognosis and outcome. I feel that finding that balance between hands on and hands off therapeutic interventions is incredibly important and part of the overall clinical reasoning process that we are hoping to improve. Going forward, I plan to incorporate more visual education techniques including models and specific examples to help him understand his own presentation better and improve his own expectations for PT. I’m curious what the group thinks about the controversial discussion of hands on vs. hands off since this is something we can apply to so many different levels and types of patient presentations. Where do you all find yourself using more of a hands off approach? And what kind of patient presentations do you often emphasize more of a hands on approach? Or even better, how do you find that balance?

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