ABengtsson

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  • in reply to: Running Medicine #3641
    ABengtsson
    Participant

    Fully agree with Laura on Karim Khan and how he was able to simplify the subject. I’ve already used a lot of his analogies/explanations with patients and it has made a huge difference for me.

    The lecture on reactive vs. degenerative tendons was great too. I had an achilles tendinopathy eval the Monday after and got to use all of it right away. Started her out with isometrics and it’s been going well so far (2 visits, so far so good).

    Kyle – I’ve used dartfish (phone) and Hudl (tablet) and they’ve both worked pretty well. I’ve used it more after the VOMPTI gait/running lecture and haven’t had a chance since last weekend, but it has certainly made a difference in how I try to cue patients. The cues that have worked best for me so far are leaning forward and landing/running softly/quietly. I have not yet tried metronomes or music but will as soon as I get a chance.

    Laura – I have not used that test and I’m not sure it would be something I’d go to quickly. I’ve used the swing test a lot, because – like you said – it’s more functional, shows a whole lot more and I feel like if done vigorously enough, will give you similar information about ROM and willingness to move into straight leg hip flexion.

    I loved the lectures on CECS! I learned a lot there and I currently have a pt who would’ve been a perfect case for these lectures. The FAT lecture was great too, as that was something that was poorly covered in my PT program.

    The article is great and I’ve definitively noticed a difference with int vs ext cues. It might be my pt load, but the most cueing I do is with low back pts and lumbopelvic motor control, especially since I’ve started with the MET exercises.
    A few cues that have worked pretty well:
    – supine pelvic tilts -> think of pelvis as bowl filled with water and try to spill different directions
    – standing/sitting lumbar AROM EXT/SB -> reach up and over, create C shape with back; with those I use a lot of visual, tactile and verbal cueing and I’ve gotten great feedback especially with quadrant testing
    – prone hip EXT or any UE/LE exercise with extension -> reach towards wall in front/back as far as you can (instead of lifting up), elongate through entire body
    A lot of times these are successful, but I’ve also failed terribly with some patients using the same exact cues. I think a big part of it is just having a bunch of different ways (visual, auditory, tactile etc) to cue the same movement to different pts. Interestingly, I’ve had several pts who don’t respond to external cueing at all, but really like the internal focus type cueing.

    in reply to: March Journal Club Case #3559
    ABengtsson
    Participant

    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.

    in reply to: Exercise as Medicine #3550
    ABengtsson
    Participant

    I’ve only discussed this with one physician (Culbert) so far, but on several occasions regarding a handful of pts. He sees a lot of workers comp pts and all the pts I spoke to him about were WC. He’s very open to psychosocial factors because he deals with that population, but I’ve chatted with him for about 15 mins during lunch one day and he really appreciated getting the PT perspective.
    I can’t say that I’ve spoken to any other physicians regarding that and I doubt that most would be as open to the topic as he was.
    I’ve gotten positive feedback from a PA on one of my PNs regarding fear avoidance behaviors etc., but I heard the physician she works for doesn’t really care for psychosocial factors too much.

    I hope the “crazy people” comment was just poor phrasing. It’d be scary to think that a neurosurgeon says something like that, without being aware of the possible impacts.

    Considering how poorly educated some pts are, even after sx consultation, I think it’s extremely important to assess and address. I’d say the best way to educate other providers is through sharing research and making it relevant to a specific patient. Especially for surgeons, pointing out improved outcomes when considering and addressing these factors should be of high interest, so I guess the presentation shoulder be tailored to show benefits to both the pt and the surgeon him/herself.

    in reply to: Exercise as Medicine #3540
    ABengtsson
    Participant

    Eric – thanks for the update on your patient!

    What do you think brought about the change in her behavior/perception? It sounds like she did a 180… did you see this difference just between two visits, or was it over a couple of visits? It would be awesome to hear more about how she progresses!

    I had an eval on Friday with Xs, Os, /s all over the mid-low back and B LEs ant and post. The eval went pretty well and we talked a lot about the neuro science/pain ed, but I’m very anxious to see how much that carried over until his next visit. Especially, because he wants to get surgery in 2 weeks. It would be great to hear how you dealt with f-u visits after seeing such improvement.

    in reply to: Exercise as Medicine #3538
    ABengtsson
    Participant

    Laura – great points. It was really helpful to hear about Eric’s pt.

    I should’ve specified more… I think it’s being confident about what you say, but also assertive in the sense that maybe their beliefs are not the healthiest (or just factually incorrect). The question is, how we go about communicating that to the pt and that’s where it gets difficult. In pts who have very strong, unhealthy beliefs I try not to disregard their perspective, but gradually present them with information/a different perspective and help/guide them with coming to their own conclusions and possibly change their perspective. That way they maintain their autonomy and I think it helps if they go through that thought process and feel like they put the pieces together, vs just somebody telling them.

    in reply to: Exercise as Medicine #3536
    ABengtsson
    Participant

    Nick – I agree that sometimes an authoritative approach can be harmful, but I think there are certainly quite a few pts who feel more comfortable with having somebody be an authoritative figure and tell them/decide for them what needs to be done. I think a lot of this is just very dependent on pts’ personalities.
    One thing I still struggle with is guiding the conversation/subjective questioning to get the information I’m looking for with pts who’ll talk about everything and anything without answering the question. In those cases, I’ve learned assuming a little more authority definitely helps.

    I wouldn’t use the videos as a way to start discussion, but rather a supplement/review tool between visits and initiated discussions. A lot of pts know that exercise is good for them, but have no idea why it is good for them. Or some think that exercise is only for loosing weight and get offended when regular exercise is being recommended.

    I think the more PT as a profession gets the public recognition/understanding of our fields of expertise, the easier these interactions will be in regards to not having to fight for buy in/ acceptance of authority or whatever it can be labeled. As of now, it seems that the simple fact that an outside source (video), especially a physician, confirms what’s being discussed during the visit helps quite a bit with buy in.

    in reply to: Exercise as Medicine #3525
    ABengtsson
    Participant

    AJ thanks for posting that article!
    I’d make sure to educate the pt on the basics and how it relates to them specifically and then tell them about the videos as a way to either learn more about the subject or supplement what we spoke about in the clinic, as well as for future review.

    I’d definitely ask what they thought about the video and what they took away from it. The article suggests asking open ended questions and I feel like that’s helped a lot in changing my practice. Especially if they didn’t do their HEP, or in this case watched the video, how they react to those questions is quite telling and helps guide how to approach them about those subjects. What’s worked best for me when it comes to these conversations, is asking them about their daily routine and what they think is feasible. Especially if they already talk about enjoying going for walks, or biking etc. I just ask them what they would have to do to make that part of their routine and try to problem solve with them.

    The best compliment I’ve gotten from a pt so far was from a lady I had this exact conversation with and she told me that I helped her completely change her mind set. She displayed a lot of fearful and catastrophizing behaviors and thought that because she had arthritis on imaging she was doomed. Like Eric was talking about, some of her visits were very draining (several crying sessions), but it was very rewarding to see how much it helped her and how much she had improved. The article is great, because it is so specific and I can’t wait to incorporate more of that. I’m sure if I would’ve read that article before, a lot of these sessions would’ve gone a whole lot smoother.

    I often talk to pts about the progression from unconscious incompetence to unconscious competence and how that process occurs, both in regards to life style habits, movement patterns, posture etc. and I’ve had some good responses with that too.

    in reply to: Exercise as Medicine #3520
    ABengtsson
    Participant

    I’ve used the pain video a handful of times and it really helped with changing the pts’ perspective on their pain. Those videos also help me quite a bit with my pt ed in regards to condensing information and structuring the presentation better.

    in reply to: Timing of PT for non surgical MSK disorders #3506
    ABengtsson
    Participant

    I think the PT with back pain example is great, because it shows how much of a difference education makes.

    There’s already research on how good of an outcome predictor education is, even compared to imaging findings etc. An interesting study would be having individuals with a first episode of likely self-limiting LBP with an experimental group receiving all the pain science education vs. a control group.
    Maybe adding another group receiving pain science ed + postural re-ed/TE.

    The question is how well equipped the majority of people are to cope/confront without knowing everything that we know. I think a big part of vision 2020 is becoming the first provider people will turn to with these issues, even if it’s just for education, as they don’t really get a whole lot from most physicians.
    I had an eval today with a guy with LBP/radic signs. He had min decreased sensation and strength in his S1 dermatome/myotome and very low irritability of his low back. His surgeon told him that it will probably go away but that he “can surgery if he wants to”. Half the eval was spent on education, because he now thinks he needs to get surgery. Even in those cases that will get better without hands on treatment, I think there would be value in having people come in even if it’s for assessment (including functional and psychosocial outcome measures, yellow flags etc.) and education only.

    in reply to: Timing of PT for non surgical MSK disorders #3499
    ABengtsson
    Participant

    Laura & Nick – I think you both made great points about early intervention, regarding waiting vs. treating and I think there are definitely cases where somebody may not need any intervention.
    Even though someone who may not need a whole lot of treatment for a first episode of LBP, just a couple of visits could be very beneficial to modify behavior and movement patterns and likely prevent future problems.
    The issue there is that our literature isn’t great at supporting very specific treatments (as Laura pointed out) and early outcomes. Even if this would result in utilizing PT and health are dollars more than current common practice, 1-2 visits would still be cheaper than imaging, MD visits and meds etc. Additionally, I think if this were more common, people in general would become more aware of PT as a direct access option and hopefully, would come in earlier for more severe issues.

    Last week, I evaluated a guy for neck/upper quarter pain that started 4 days before (specific mechanism). Aaron had treated him for a few months for LBP last year and this pt told me that his first impulse last week was to come in and have a PT check it out instead of going to the MD, or ER. It was easy to tell that having had successful PT and good education completely changed his perspective on care. I saw him twice and he called in saying that he felt better and was good with his HEP. I’m guessing if he would’ve waited a couple of months or longer to come in, there’s no way he would’ve improved as quickly.

    Another new pt I had last week had been seen at our clinic for LBP a couple of years ago and it recently came back after having been asymptomatic since. He told me when he was first sent for PT back then he thought PT was BS (he didn’t hold back in regards to language). He then added that looking back he feels stupid (his words) and he’d never consider any other treatment option before doing PT.

    I think a huge part is education and promotion. Mark Jones talked a little about how they have ads and public education for PT in Australia and that’s definitively something we could use here.

    Laura – I think that case is 100% our place. That being said, appropriate and honest self promotion is vital there. I wouldn’t say that all PTs I know have the appropriate background to fully assess power lifting movements, which raises the question whether or not they should and whether that would be considered entry level PT knowledge. I’d say yes. Thoughts?
    Granted, there are lots of personal trainers who know a great deal about those movements and how to correct poor form, but in my opinion that is one of the areas that we as a profession should claim more for ourselves and send them to the personal trainer after, or get them to a point where they can perform those kinds of movements safely.

    in reply to: February Journal Club Case #3496
    ABengtsson
    Participant

    Oksana – thanks for posting. Great article!

    I think his age shouldn’t necessarily be a problem, especially if the intensity of activity matches what was assessed in the study.

    Nick made a great point in regards to injury risk with quality of movement. Especially considering his lack of DF, it would be interesting to see how he compensates – DKV, pronation, tib IR, hip IR etc. and why (depending on where hypomobility is coming from)

    Laura – good point about the importance of the “louder” results. It’s good to know the results, but I agree that the other results are more clinically relevant.

    I’ve used the “land softly” with only 2 pts so far, but had pretty good results. It was a lot easier than trying to break down the mechanics and cue them on everything separately. I’ve also used the hips back/trunk forward cueing in combination with the soft landing and that’s helped me quite a bit with cleaning up running form.

    in reply to: Medial Plica Syndrome in Pregnant Female #3458
    ABengtsson
    Participant

    Eric – sorry for the late response.

    I use that as a functional test to guide the rest of my exam and possible treatment options. Generally yes to quad tendinopathy, but I’ve had some pts who presented similar to Laura’s (not pregnant though) in regards to testing and med plica appearing to be source of pain, who got relief from CFM to the pat tendon. Just using those tests to get a better idea of where I’m going with the rest.

    in reply to: Medial Plica Syndrome in Pregnant Female #3425
    ABengtsson
    Participant

    Laura – thanks for posting!

    You mentioned one of her S* was achiness after increased acitivity – walking/stairs; were you able to reproduce her syx with any fxn tests? What really helps me with ant knee pain pts is differentiating b/w contractile and non-contractile. For me it’s been usually enough to do a step up/down and either add manual patellar glides or manual pressure on the patellar tendon and then either mobilize or CFM. It sounds like she may have to do more repetitive testing if you can’t reproduce the syx with just one rep. Aaron showed me how to use pre-wrap to finagle a patellar tendon brace (really simple – just never thought of it) and I’ve used that quite a bit to figure out whether pressure on the tendon decreases syx with repetitive movement.

    ABengtsson
    Participant

    Thanks for posting this Eric!

    Nick – I think you’re making a great point in your first paragraph and I’m right there with you. I’ve already had a few pts who had all kinds of procedures, but didn’t know anything about what was going on in their back, besides their disc being bulged/blown out/blown up/torn/out of place/ripped and whatever else they say.
    Just last week I evaluated 2 pts who had back sx.
    One of them had her sx a month ago and hasn’t moved since, except for going to the bathroom. She was so afraid that she just stayed in bed for 4 weeks, trying not to move a muscle. DTRs and dermatomes were all normal, but she could barely walk without her walker (or with for that matter) and her myotome testing was a disaster. Her original injury (HNP) was 2 years ago and she said she hasn’t moved much since, because she was afraid moving would make it worse. Obviously, there’s no telling how bad her syx were, but according to her she had no loss/decrease of sensation and no weakness in her legs after the injury; just pain.
    The other had his sx last summer after having received 6 epidurals within 2-3 months, of which only the first one helped somewhat. He said he didn’t have any changes in sensation, or apparent strength deficits, just pain in his low back and down his leg. After his sx he felt better for a 1-2 months (perhaps bc he didn’t perform any of the activities that aggravated his syx before the sx during that time frame), but has been back to square one since then.
    Neither pt had been to PT for these issues before their sx, or epidurals. I’ve had a handful of pts like this since September and I’ve been wondering how many of them actually needed that sx. What they all had in common was a focus on the horrible things that the images showed and some very fear inducing language regarding their condition.
    All in all incredibly frustrating, not only regarding the individual pts, but also overall effect on healthcare costs etc.
    Just sent this article to all my MD/med school friends.

    in reply to: January Journal Club Case #3373
    ABengtsson
    Participant

    Already a lot of great points made.
    How has he reacted to some of the assess/re-assessments regarding his syx? Was he able to make the connections b/w your initial findings, education and outcome of treatments so far?
    Also, this might be a completely wrong approach, depending on his personality, but have you tried printing out and article or two reg all this stuff and just given it to him to read?
    It seems like he might be interested and if he’s open to changing his opinion, just sharing that as a side note may help too. Just a thought.
    I’ve been surprised quite a few times by how much some pts are open to different ideas. Often times when I least expected it.

Viewing 15 posts - 16 through 30 (of 37 total)