[awilson12]

Great points all around.

I, too, enjoyed learning about the concept of grading and incorporating more than just the mechanical load and feel this has such value to making PNE a more all-encompassing treatment. Personally, I have not really found a great way to work in some of these concepts, but for sure need to start playing with adding these things in as I progress with patients.

Kind of going off what Eric said- I had an interesting discussion with Micheal the other day about various treatment routes to take with a difficult patient. It basically came back to the importance of clinical reasoning to help tailor your approach.
Some “highlights” of the conversation:
– reflective questioning is so important to get insight into the patients belief system
– differentiating between fear avoidance because of fear of damage, fear of increased pain, past experience, etc. & letting this guide your treatment and education

Adding in these concepts with the patient seemed to work well during the session, but I will be interested to see any carry over next visit. What are some of the ways from session to session y’all get the patient to reflect? Any suggestions on methods of the test-treat-reassess model in this context to gauge understanding, effectiveness, progress, etc.?

[awilson12]

There were so many incredible things to take away from this weekend that really got me thinking about my patient care on many different levels. I love that he was so open to, and even hoping for, that dissonance or unsettling feeling to happen for everyone because of something that was brought up. I feel like this had a big impact in multiple ways- 1) it helped me to realize that change is rarely (if ever) going to happen if we aren’t open to question things that we are both familiar with and unfamiliar with and 2) it kind of puts us in the shoes of our patients who are receiving this “pain” message and struggle with accepting it because it is not what they have been convinced of for so many years.

It was also a great, but challenging, experience to dive deeper into looking at some of our practice patterns and thinking about them in a more scientific method mindset. I feel like this really plays into test-treat-reassess in that every time we are doing something with the intention of achieving whatever outcome it may be, we need to take it a step further and say is what I did truly having the effect that I think it did. At first I really struggled with this and kind of had the mindset of “well I just graduated and am just trying to figure out how to be an efficient PT with what I have, I’m not ready to add this on top.” But once, thanks to the amazing Lorimer, I questioned why I was having this unsettling feeling and dissonance I was able to more fully understand this concept and the implications on my practice. It for sure has the potential to change your practice and dispel myths that you were bought into (which is 100% necessary for growth), but it also can just help you be more efficient with the tools that you do have by thinking about their effects with the background of a sound theoretical model.

I also loved getting to dive deeper into the intricacies of pain and the current framework for all of the contributing factors. In school we learned, on a basic level, that there are many modulating factors that either facilitate or inhibit pain but didn’t dive much deeper than that. With this information I felt like I still knew more than the patient, but not much more, especially if they grasped the concept as well. Now with learning about the “bottom of the iceberg” I personally have a greater understanding of how, for example, stress interacts with pain and don’t just know that it affects it because that is what someone told me. The idea of neurotags and all of the different interwoven connections through the brain, spinal cord, and body is amazing to me and I can’t wait to go back and review the notes to reinforce and continue to grow my understanding of this all. Personally, knowing the science and framework behind pain (and the iceberg analogy) helps me to have more confidence in talking about pain to others. It was super helpful to end the weekend with some take home points of how to approach this topic with patients in a simplistic way despite our understanding that this topic is anything but simple.

Another thing that I learned a lot about that I wasn’t expecting was public speaking and patient education. I loved that he went through and had us think about all of the influential and validating techniques that he uses while presenting to 1) get the audience thinking 2) keep people engaged and 3) make each person feel some sort of connection to what he was talking about. While he has many, many years of practice to make this look easy (and I will definitely never be as smooth doing any of it), using these techniques can be helpful in both presentation type scenarios but also just in everyday patient care. I now feel like I have a better way to judge my actual presentation of material to patients based on external criteria and can use this to help me become a better educator. One of the my favorite points he brought up was ensuring that the patient really understands what you are saying, rephrasing if necessary, but always sticking with repeating the message that hit home with them.

[awilson12]

Thanks for the share! Definitely gets me thinking about how I approach chronic low back pain compared to my knowledge on what the evidence says. I think a lot of times I let my lack of confidence in delivering this message be a reason that I tend to fall back on to a more general approach and explanation rather than dive into pain science education. This definitely is a tricky subject to approach as you don’t want to be just another health care provider in the medical system that is invalidating to the patients experiences, so I feel like it for sure takes some practice in delivering this message in a way that is more likely to be accepted and understood. I think it also points to the importance of the subjective exam to identify beliefs and fear avoidance patterns that need to be addressed.

I like the idea of framing ideas about pain, hypersensitivity, etc. in a more relatable way. I have had a few patients during my internships that fall under the chronic non-specific LBP category and have had varied success in trying to use analogies. One patient in particular that it didn’t work well with just seemed to be unaccepting of any explanation that din’t give her some sort of specific diagnosis of something that was wrong or damaged that she could cling to. Have y’all had any success in breaking through with these patients?

[awilson12]

I think the editorial Eric posted brings up some good points about the intention behind isometrics in this study. On a case by case basis there might be a time and place in the tendinopathy realm for isometrics- maybe based on irritability or dosed based on the RAMS (retrain, attain, maintain, or sustain) model and requirements for the patients goals versus for the intention of acute pain relief. I like that they point out that in situations of tendinopathy, the expectation of therapy shouldn’t be a “quick fix” and working into some pain may actually be necessary.

I have limited clinical experience with treating tendinopathies so I am always interested to hear what approach other therapists take based on the evidence out there and the patient they are dealing with. Personally I am not partial to one type of contraction over another. From an irritability standpoint I’m wondering if there is more utility in focusing on treating impairments away from the primary location of pain, along with education on activity modification, until more site specific treatment is tolerated. Thoughts?

[awilson12]

Hi! My name is Anna Wilson and I just graduated from Shenandoah University in August. I am a VOMPTI resident at the UVA clinic. I really enjoy getting to work with athletes and helping prepare them for return to sport. My pipe dream PT job would be to work for a few years for a premiere league team (especially Manchester City), a NWSL team, or the USWNT. I am excited for the course series and am looking forward to learning and reviewing concepts and techniques, learning from more experienced clinicians, and taking advantage of the insight everyone has to offer.

[awilson12]

Agreed- it is so much easier said than done to delicately balance validation and “damage control” based on already established views.

[awilson12]

Being a new clinician we aren’t always going to know the “best” thing to do and come to the same conclusions as a seasoned clinician, which can be unnerving and overwhelming at times. However, the evidence out there, including this article, that points to the power of a positive patient-therapist relationship and placebo is something we can use to our advantage in spite of our lack of experience. As Taylor mentioned, this article points out the importance of being fully engaged and positive throughout patient interactions. It might be easier said than done in some instances, but this is definitely a simple tool that I can use to help improve patient outcomes.

This also makes me think of the cliche quote of “fake it ’til you make it” and how this comes into play with the placebo effect. You can’t expect a patient to trust and believe in your abilities when you can’t confidently present what you know, your plan of care, etc. This highlights the importance of your verbal and non-verbal communication in the face of uncertainty. One of the studies the article referenced stated that “low or negative expectations before treatment affected outcomes 6 months after treatment.” 6 months. Our words, mannerisms, and presentation of information matters, and building up positive expectations for treatment is a big part patient care that can’t be overlooked.

[awilson12]

So often during evaluations I find myself starting off with a game plan that, on a smaller scale, mirrors these forms- a running list of differentials, a general idea of red flags I need to dive deeper into, what might be some objective findings I expect, etc. But then, all too often, the subjective gets into full swing and that game plan is quickly pushed to the back of my mind, and I revert back to “auto-pilot” of just checking off the steps of asking questions without truly processing and thinking about piecing everything together. This then leads to a lack of attention to detail during my objective examination because I lost sight of the “game plan” and don’t have a clear path to follow. In the end I get enough information to mediocrely come up with a diagnosis, prognosis, and treatment plan, but when reflecting afterwards I come back to that same place of I know I can do better but I am just not sure how to slow myself down in the moment to do so.

This article reinforced the benefits and importance of residency. It is so valuable to have a system in place to learn from more experienced clinicians so that I can become a better clinician myself. There are many things that as a new clinician I can be better at, but at the root of it all is my clinical reasoning and critical thinking. Like Barrett said, using forms like these that commit your thoughts to paper, will greatly help to start making reflection in action a natural process. These clinical reasoning forms are helpful to record and spur thought processes and keep you on track during your examination, but, for me, will also help to remind me to slow down and think about what I am asking and doing in the moment rather than afterwards.

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