[AJ Lievre]

Wow, you guys are really doing a nice job. Let me add to the theme of the discussion. Check out this article and reflect on what you feel you do well and/or what you need to work on in regards to patient interaction. Are there things about the dynamic of your work environment that helps or hinders this interaction?

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[AJ Lievre]

August,
I agree with your statement that these beliefs and feelings can lead to avoidant behavior. However, some have not reached that level yet, but its important to identify those who may get there. My concern would be that a PRO like this could get pigeon holed based on the name. Yes, I guess I would have chose something different (Pain beliefs or pain perception??). Just don’t know what that would be. I’m not that smart!

[AJ Lievre]

Nice post August. I like the idea and what they are attempting to do with the questionnaire, but I don’t like the name because what they are doing is so much more than looking at fear avoidance.
All patients with chronic pain do not avoid movement. With regards to patients with chronic pain, what we do want to know as clinicians in addition to whether they avoid movement are; 1. what their perception of pain is (ie all pain is bad), 2. are they hypervigilent about it,3. how is that impacting their lives both physically and emotionally, 4. whether they think this can improve or not. This PRO is attempting to identify these variables, and that’s why I’m a bit perplexed in the name selection.
In response to some of your questions; if a patient of mine has fear of movement I always address it. How and when I address it changes from patient to patient. Some patients are receptive and some are not. Just like all techniques, the more I worked at it the better I got at it, and the more patients understand what I am getting at (analogies work the best).
I will utilize graded exposure for patients who avoid specific movements due to fear of that one movement. I will use graded exercise for patients who view all movement as painful. The design of these approaches rely on goal setting and sticking to these goals. This has worked well for my patients in the past.

[AJ Lievre]

Nice discussion everyone. Glad you found the article helpful.
Scott, one thing you brought up is asking the patient if they are doing everything they want to do in their daily life. This may be interpreted by the patient in a different way than you anticipate. Often times folks with chronic pain do enough in their life to get by, avoid activities that they feel drive their pain up and have come to accept that situation. This allows them to do “what they want” without a problem or pain. Rusty Smith put it perfectly when he related this to the patient “shrinking their world”. What you may want to consider is asking the patient, “if you did not have pain what would you like to do” or “before you had pain, what did you like to do”? This may open a new dialogue and potentially provide the patient with goals they thought not possible before.

[AJ Lievre]

Based on what Eric talked about last weekend, how would you introduce the video to the patient? In addition, would you just give them the link and hope they watched or would you ask them questions about the video when they come back? What kind of questions would you ask them?
Read this article and see if there are some points you can take from it that would help you have that conversation.

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[AJ Lievre]

To me it is similar to ACL rehab. You need to stress the graft in order to make it grow stronger (wolfs law), but recognize when there is too much stress. If we continue to avoid stressing the posterior aspect of the capsule altogether it will likely not develop the tensile strength it needs.
I do believe that it plays into a fear factor and possibly movement avoidance that Eric will talk about next weekend.

[AJ Lievre]

Laura,
I would go through your myelopathy cluster first, including UMN testing. If you get nothing, you may consider testing a Hoffmans or a reflex in the compromised position. Need to be cautious when provoking cord s/s to assist in diagnosis.
Did Myra’s case presentation this weekend give you any new ideas of what else may be going on with this person?
AJ

[AJ Lievre]

Hey guys,
Your posts continue to be though provoking. This weekend we will cover some strategies to assess t-spine mobility and treat in sitting as well as other ways to examine neurodynamic mobility.
Laura, you stated that your neuro exam was negative. Was that a segmental exam only or did you include UMN testing. With bilateral UE symptoms in sustained extension you certainly want to utilize the myelopathy cluster to rule out cord compression.
I agree with several other posts, putting him in extension quadrants to see if you can reproduce his unilateral symptoms. However, with the distribution it does not appear to be root level.
If you feel comfortable placing him in sustained extension and there are nor VBI s/s you may consider testing UMN (ie hoffmans) in this compromised position.
One of your strongest ** seems to be decreasing his pain with STM to entrapment points of the plexus as well as opening the anterior rib cage. Not completely familiar with a sternomoty, but sounds traumatic and may be dealing with tissue adhesions. This may be contributing to his breathing difficulty.

Easy with the T4 syndrome. There is a reason that there is limited evidence on it.
AJ

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