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Dhinu,
You bring up some good points when asking how to navigate the difficult conversation pertaining to a patient being skeptical as to whether or not conservative treatment will be successful, especially if their pain is limiting their everyday life to the point where they may not have the time and/or patience to see if their shoulder can experience a positive response to conservative means. I think this would be especially difficult if they are not willing to look into or buy into the evidence based research pertaining to the topic. In a case like this, I would try the approach of “In my clinical experience, many of the tears on imaging do respond well to conservative therapy and can live a near normal life. Sometimes surgery isn’t always the quick fix we like to think it is and can still have lingering pain and affects. And since you’re already here in PT, why not try this route and see how we feel?” This line of reasoning can sometimes work, but if the patient has loved ones or friends that endured similar problems with their shoulders, oftentimes patient’s will purely go off the past experience of others in weighing their decisions and managing their expectations and their mind’s made up more or less before they walk into the room. In a case like this, I will endorse their decision making and move forward in that manner. Now, if the patient was open to listening to what the evidence says, I would explain that yes, there is indeed a gap in ample research pertaining to long term follow ups with conservative treatment so I cannot say with confidence that the way you feel in one year will match the way you feel years down the road. I would also point them in the direction of Gotoh et al’s research of long term follow ups of arthroscopic surgical rotator cuff tears and how the retear rate post surgery is higher than previously thought, especially if there is a significant limitation in external rotation prior to surgery. I would hope this study would help them understand that although, conservative therapy can fail, so can surgical repair, and that if the patient is willing to undergo the time commitment for conservative treatment (I would also explain post-op rehab is also quite the time commitment), then we should at least give PT a go. Thanks for your thoughts and I hope I have sufficiently answered your questions.
Citations:
Shimokobe, H., Gotoh, M., Honda, H., Nakamura, H., Mitsui, Y., Kakuma, T., Okawa, T., & Shiba, N. (2017). Risk factors for retear of large/massive rotator cuff tears after arthroscopic surgery: an analysis of tearing patterns. Journal of orthopaedic surgery and research, 12(1), 140. https://doi.org/10.1186/s13018-017-0643-7
For this discussion I found it to be relevant to me and especially the profession to speak on RTC surgical repair versus conservative management as I encounter this situation frequently with shoulder patients. The questions in the topic that I think will help guide my discussion are the pros to shoulder surgery and the role diagnostic imaging can play in surgical management. I often find patients come to me with shoulder pain and a diagnosis from their PCP or orthopedic physician of a rotator cuff tear and the patient has MRI imaging to back it up. By the time the patient comes to me, they have heard or read the radiologist’s impression, oftentimes seen the word “tear”, and think the only option for them is surgical intervention. I find it to be challenging oftentimes to discuss what we see on imaging doesn’t always mean surgery, especially with mild or degenerative tears, and that oftentimes conservative management can be an effective means of treatment. I often times find myself discussing how most people, especially older adults, almost always will have some RTC partial tearing and it may or may not have anything to do with their pain despite having a radiologist and/or physician endorsing their pain by showing them imaging that shows that the pathology is in the same area as their pain. Moreover, when it comes to partial thickness tears, Mathiansen and Hogrefe in their 2018 review concluded that MRI is not the greatest diagnostic tool when it comes to properly identifying and diagnosing a patient with a partial-thickness RTC tear. This further solidifies my stance of shying away from scrutinizing imaging if no full-thickness tear was seen on the MRI and the patient retains painful AROM of the involved shoulder.
This being said, when a patient has had a violent traumatic fall or there is a full-thickness tear of a RTC muscle as seen on a MRI, coupled with painless PROM and/or lack of ability to move the shoulder actively because the muscle has been compromised, I begin to shift my thinking and conversations with the patient toward the possibility of surgical intervention if conservative management fails. A study by Piper, et al in 2018 supported the conservative treatment route as it did improve patient outcomes for some patients with full thickness rotator cuff tears, but those that did not improve or did not improve enough to meet the demand of ADLs, successfully underwent arthroscopic surgical intervention with positive outcomes. Overall in this study, patients that were operated on had better post surgical outcomes than those that were treated purely conservatively, but both did improve. My takeaway from this is that, conservative treatment is safer and cheaper so there is no reason not to try this management first, but explain to the patient that there are successful alternatives for people in their situation. With overhead athletes, I might be more likely to recommend surgery outright if they are trying to return to sport sooner.
Overall, I think diagnostic imaging plays a great role when guiding surgical intervention with patients with full-thickness tears, and I believe that going the surgical route can lead to positive results and I will encourage this route if conservative management fails or endorse it if the patient has made up their mind about it. The only time I would shy away from it is if there is partial thickness tearing as the likelihood of a misdiagnosis via imaging increases as well as the likelihood and positive conservative outcomes.Citations:
Mathiasen, R., & Hogrefe, C. (2018). Evaluation and management of Rotator Cuff Tears: A primary care perspective. Current Reviews in Musculoskeletal Medicine, 11(1), 72–76. https://doi.org/10.1007/s12178-018-9471-6
Piper, C. C., Hughes, A. J., Ma, Y., Wang, H., & Neviaser, A. S. (2018). Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: A systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery, 27(3), 572–576. https://doi.org/10.1016/j.jse.2017.09.032
Thanks so much! I think a great deal of the challenge of providing CBT adequately and appropriately lies in the difficulty in providing education/ conducting research on a topic that really isn’t tangible and varies so much from person to person. I think much of this comes through experience, cultural competence, and simply understanding the person in front of you. And I agree with you with the “plant the seed” concept! I feel like you can compare the idea to a strengthening progression; you start out with lighter weight and progress from there. I think this idea can be applied to educating a patient on how pain is driven in the body and mind. Simply explain the fundamental ideas initially without overwhelming the patient and then circling back in future sessions and expand on it and maintain a consistent focus on the idea of pain neuroscience. Thanks so much for your response!
Sarah,
I really enjoyed your response and I’m glad many of your patients responded well and recovered. I am with you completely with you in that we have to treat the whole patient and the physical impairments which involves discerning how much MSK pathology is driving the patient’s pain versus a heightened sympathetic response by the brain. I think the tricky part is knowing when to shift from using the majority of your time treating the physical impairments to treating more the emotional/hyperalgesia impairments that can begin to develop when the pain shifts from acute to persistent. In the absence of further trauma, the body will follow predictable tissue healing times yet sometimes the pain will continue to affect the patient well beyond that normal healing time frame. How would you handle this situation? If the patient after 5-6 months is still experiencing WAD type of symptoms, would you shift more towards a non-specific approach like we often do with the low back with CBT principles thrown in there? I’m curious for your thoughts because this is something that is hard for me to discern when faced with this situation.
During my clinical rotations, I saw a fair amount of whiplash injuries following car accidents. Much of these incidents were acute and they would seem to resolve within the matter of weeks. I did discover, which was surprising to me, that several of my patients did not recover at the rate I thought they would given the degree of tissue pathology. I figured this was mostly due to the severity of the injury or patient’s inability not to overwork the neck while it is still healing due requirements of their job or ADLs. I found it to be interesting to me as Julie Fritz in her editorial cited research showing that only 50% of patients following this kind of trauma recover in a time frame that is typical of soft tissue healing and that the severity of tissue pathology has little to no prognostic value. I think that this demonstrates the need to look further into what is driving the pain than simply the biological impact. I found that in my experience with these patients that when the pain becomes persistent for over 3-4 months and/or the incident in which the injury originally occurred was emotionally traumatic for the patient, I had to take on a more pain neuroscience and psychosocial approach much like I would with persistent low back pain patients. I found this approach, especially in patients that identified post-traumatic stress in conjunction with their mechanism (most often a car accident in these cases), to be impactful and helpful for the patient. I enjoyed reading how this approach was documented as successful to a certain extent in Trudy Redbeck’s clinical commentary where she discussed how Cognitive Behavioral Therapy can have a significant degree of beneficial impact for patients with persistent neck pain and associated PTSD. For me and my patients, CBT mainly looked like education towards knowing the warning signs of overworking the neck while driving or at work and the associated symptoms (some of my patients had headaches or vertigo spells) and focusing on function instead of pain and what they were able to do successfully that day instead of unsuccessfully. In addition, I would also perform active exercise with these patients with the hope that through strengthening and mobility, this will aid in the reduction of their symptoms. Reading further into Redbeck’s commentary however, I discovered that there is far more evidence from higher quality RCTs showing that exercise for persistent whiplash has little to no impact on outcomes. This shows me that in retrospect, I should have spent more time on the behavioral aspect instead of trying to improve their symptoms through exercise.
I think a very challenging factor to treating these types of patients is knowing when, and how much CBT should be implemented into my treatment so I use the patient’s time as wisely as possible. I think it is also difficult to discern the extent to which the psychosocial factors are driving pain as the interactions between the psychosocial and the biological aspects are difficult to measure and discern. Based on Michele Sterling’s editorial, I am not alone in the challenge I face in trying to ascertain the level of psychosocial implications in a patient’s neck pain. She exposes that there unfortunately is not enough literature discussing the interaction between the psychosocial and biological factors and the effect that they can all have on the patient presentation. I found this to be very eye opening because we have learned a great deal in school and clinically about pain neuroscience and the warning signs of fear avoidance beliefs/behaviors, and we also have a detailed, intimate understanding of the anatomy of the spine and tests to assess it to the point where we can rule out a fracture almost just as well as any imaging study, but we struggle to understand how one may impact the other and contribute to the overall wellbeing of the patient. My main takeaway from this literature is that, like the low back, there is a significant prevalence of emotional implications with neck pain, and if properly identified, quantified, and treated appropriately, can lead to far better outcomes for the patient.Sarah,
I really enjoyed reading your response to the articles because much of what you say I can directly relate to. I think it’s amazing how far pain goes beyond tissue damage, especially if it is pain ongoing for several months or years and it has an impact on ADLs. The idea of neurotags and brain smudging of the homunculus are concepts I can barely wrap my head around. If you have free time look at videos/articles showing functional MRIs of the brain and the parts of the brain that light up in response to pain in both acute and persistent pain patients. It’s incredible! And it shows how involved other parts of the brain are, including our emotional drivers with persistent pain. I think this underlines what you talk about next with demonstrating empathy, compassion, and active listening because these traits can have a huge impact on the emotional aspect that can often drive the sensations of pain. I’m with you in that it can be difficult to not think about what’s ahead on your schedule whether it’s a high complexity patient you are worried about or simply just catching up on charting. I’m glad these articles have heightened your awareness of the effects of how we carry ourselves and how we communicate with our patients can have meaningful impacts. Especially with some of the patients you mentioned with high irritability/severity where the more we try and do with them the greater likelihood we could just make them worse. The second article you spoke on I also read and it really stood out to me in how I am going to go about patient management in the future. Thanks for the great post!
I think this a great first topic to delve into as a resident as the subjective examination is something I so often overlook in terms of how I go about asking my questions and how I engage with the patient. I find myself going into the exam with the obvious intention of being kind and respectful, but mainly focused on getting the information I need to properly diagnose and treat the patient. I never really thought about how I form my questions and carry myself and the impact that can potentially have on the therapeutic relationship.
I thought the article, “On Opening the Clinical Encounter” to be very eye opening to me because I have never put a lot of thought into how I open my dialogue with patients. I make a point to initiate the conversation with an open ended question along the lines of “How are you? Let’s talk about what’s going on!?”. By doing this I feel that I am not closing down the conversation to whatever body part was circled on the body chart but instead allowing them to take the reins and tell their story. I found that in this article many of the opening lines did not resonate with me; I found many of them to be presumptuous or just plain awkward. I liked how the author spoke to this by mentioning that Dr. John Launer believes asking questions pertaining to the “patient’s problem” assumes that there is a problem when there may not be or maybe there are several problems. By allowing the patient to tell their story I think you are empowering them to decide the impact that it has on their life and if they deem it as a problem. Moreover, using words like “problem” and talking about pain in the opening words could be harmful to the patient. I read an article during PT school called “Words That Harm, Words That Heal” that went into how impactful word choices can be and how that can impact the patient’s outlook on their own situation (especially so with persistent pain patients) and how they perceive you as a therapist; first impressions are important! After reading this article, I intend to go into my evals with a greater intention of my word choices especially in my opening words.
The importance of choosing opening words carefully and being mindful of how you navigate the subjective exam is further reiterated by the article, “Evaluation is Treatment for Low Back Pain”. I have always appreciated the importance of building a strong therapeutic alliance and how that journey begins on day 1, but never in my life did I think that the initial evaluation, without any treatment, would have such a positive effect on patient outcomes. The fact that just the subjective exam alone had a positive effect on LBP and leg pain, FABQ, PCS, and lumbar flexion AROM is incredible. Although many of these measures lacked statistical significance or exceeded the MDIC, this still shows just talking with the patient can have a beneficial effect on their outcomes. The researchers spoke about how moving forward, if we can analyze and harness the elements that drive this progress, we can maximize outcomes for our patients. This especially had an impact for me because I have worked with many patients with persistent pain in conjunction with yellow flags such as fear avoidance behaviors, preservation, and anxiety. These types of situations challenge me because I know manual techniques and simple exercises will potentially only have limited effects.
Equipped with the knowledge of how to properly initiate and engage with my patients upon their entry to the subjective exam, coupled with the understanding that building a strong therapeutic relationship throughout the visit can have lasting effects on their outcomes influences how I go about these early interactions. This also helps to educate me on the clinical management of persistent pain patients and informs me that simply building good rapport with these patients can have immediate and lasting impacts on their outcomes.