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Matt,
Your questions about her sport history and training schedule — are you thinking like an Over Training Syndrome making her more susceptible to legitimate injury?
A case that’s always stuck with me was this 9yo girl with an ACL sprain and no other history of more legitimate injury.
The 9yo remarked “Well, my teacher told me she had the same thing happen to her and the rehab was a lonnnng process and even then the knee was never the same.” She said it so casually.
Pain is a concept built on perspective and experience, so I like to get an idea of any patient’s (esp younger ages) past injury history just to get an idea of how serious this event FEELS to them. I’ve broken bones, and I know there are injuries that just deeply feel like something is very wrong but how it’s expressed is all relative.
It can sometimes be fun to get an idea of the parents’ past injury history to get an idea of the perspective being passed down to the kiddo. Information like that can help guide my recommendation for further imaging and tell me how much I need to educate the parents about this potentially formative moment – especially if this patient (case example) is hesitant to participate in giving me clear, objective information.
A few thoughts here..
It’s really cool to see evidence of chemical changes after a spinal manip – it makes total sense for this case. Non-specific mechanical neck pain can express itself as a deeper, more vague burning sensation so we’d expect to see a modulation of C-pain fibers, which is demonstrated as we see increases in Oxytocin.
Cortisol didn’t change, which tells me how important it is to genuinely pay attention to indications of psychosocial factors – either on the paperwork or in subjective interview – to manage their stress levels. The intangible, qualitative aspects of care play a physical role in a patient’s pain experience.
Finally, here’s kind of a left field idea I had while reading: some professions seem to rely on providing a spinal manip to give value to their service. Patients seems to keep returning for the service, sometimes for years, because they feel better afterwards. In this study, we see evidence of a boost in feel good chemicals after a spinal manip… which makes me feel like if that’s the only service the professional is providing, that professional kind of acts like a pharmacist where the patient returns to “re-up.” So, if we know our patient tried this service for some time and is now seeing us, would the patient go through some withdrawal if we don’t provide a spinal manip in the beginning phase of our plan of care? Would my outcomes be worse off if I don’t take this into account, just because their body is primed differently at that time?
What do you guys think of additionally calling the NP-C with an open mind to ask what they’re seeing on their end that motivates the recommendation for an MRI? Do you guys have experience doing this?
Yeah, Jeff, I guess I was just thinking that if XRAYS come back negative and I’m still sniffing stress fracture (Failure of my treatment to provide relief, etc), then the article suggests US as a good method to more definitively rule out a diagnosis after a negative finding. Probably cheaper and more accessible (can PT offices do this?)..
I agree with you Jon, stress fracture is on my list in addition to a number of other orthopedic conditions. More details to the history of injury could help push the needle a bit (his training volume, how many other races has he participated in, etc).. I like the treat and refer option here with XRAYs indicated as a first line of imaging, but what do you think about a f/u with ultrasonogrophy if XRAYs come back negative and PT isn’t demonstrating gain?
My goal with concurrent PT would be to modify training volume as needed and modify contributing factors, if I’m really suspecting something that needs additional referral.
Yeah, good point Matt. The NZ article points out that Direct Access is expanding, and that’s in large part a reflection of the expanding education we’re required to receive to achieve a DPT degree (Which includes education of pharmaceuticals). That makes it extra interesting that of the ~300 participants, only 2 were DPTs.
I don’t see a problem with providing education on OTC meds, and I really think the biggest issue is the reality that the drug class is so readily available combined with not knowing when/ how much to take them. I appreciate Aspirin’s universal (Cox 1 and 2) and predictable effects for true inflammation beyond beneficial timelines, and I appreciate Tylenol’s acute pain-relieving benefits.
I’m not biased against other members of the drug classes… does anyone else have different preferences?
I’ve read it, Cam, but I haven’t purchased it for myself bc I have a hard time picturing how I’d use it as a tool with a patient.
Do you mind hitting me with an example?
Man, this is making me way more concerned about a potential glute tear. Check out this case report… there’s more than a few similarities.
Jeff, are you ever frank with your patients about a psychological dependency?
Yeah, good question Cam.
My thought is that we use the switch to Tylenol as an intentional step in using medication for their actual purpose. If he’s not experiencing inflammation, why are we using an anti-inflammatory drug? It’s my segway to being logical about the situation, but I see your point.
Hey Case, I dig the change-up in presentation style.
1. Hip OA > lumbar disc > myogenic referral pattern (iliopsoas, QL, glute med)
2. I’d be really interested in attempting to determine a relationship (or lack thereof) between his original back pain, current hip/ proximal leg pain, and his occasional sharp pain. For all I know, the distal sharp pain has always been there (knee OA, etc), and he’s just including it in his subjective report because he’s not really sure what’s going on anymore. If I can’t find a relationship, is it even mechanically driven?
I’d also be mindful in how I examine him. He’s fearful of making it worse, and his pain can be 7/10 with an apparent big referral down to leg to a worse quality pain so I’d be modest with my approach initially.
(Side note: I’d continue to attack his MOI. Change in meds, anything new going on that week, etc)
3. Things that make me feel better about potential red flags: He lists Best pain as 0/10, he has aggravating/ easing mechanical-seeming factors…
Hey Case — his BMI being 31.3 — is he obese or really muscular? I’d like to get a good mental picture of the gent. And what body part did they look at? (radiograph, I’m assuming)
Jon, I’m in total agreement with your initial effort to educate on what is occurring during an acute onset and what is likely not occurring currently (inflammation, etc). What I’m not hearing is his concern for deleterious effects to his GI system, etc. It makes sense to me that he’s more afraid of avoiding a potentially immediate, definite pain experience than a vague warning of GI dysfunction that he doesn’t understand.
What if we poke holes in his logic just by asking him questions? Tell me what you guys think of this logical progression..
– We ask him why he chose Ibuprofen initially. We admit that Ibuprofen is intended to be a pain reliever, antipyretic, etc, so it might make sense to use it in an acute phase when inflammation, etc are occurring. But the good news is that it’s unlikely that these additional processes are occurring 6mos later, as tissue healing has already occurred.
– So, if anything, Tylenol should be our drug of choice since it’s primary job is to relieve pain.
– We ask him if he’s currently experiencing pain or when the last time period was when he was experiencing pain?
– We suggest that he 1) switch to Tylenol, then after the switch 2) begin to taper the dose with either less frequent or half doses to begin to measure his unmasked pain levels.We could justify our motivation so that we can accurately get a view of his physical progress as we complete our plan or care… ?
I like the pretty immediate recognition for the value of collaboration when treating folks with TMD. It goes right along with Cam’s suggestion to call the dentist. I wonder if her initiation of TMD pain coincides with any particular part of her schooling 2 years ago? Could warrant a need for greater psych focus.
After reading this, I’d definitely ask more about parafunctions and a few more questions to help categorize the headaches. There’s a few points in what we know that makes me lean toward classifying this case as a Mastication Muscle Disorder. What do you guys think?
Cam, to add to your point, that portion of their discussion also makes the point that maybe making pain reduction the primary goal for long-standing pathology isn’t even the best idea — the chronic nature isn’t going to be healed within-treatment just from doing isometrics so it’s probably not even worthwhile to measure success this way.
My moral of the story is to be an active consumer of information — one of their counterpoints very simply looked at the research that the isometric-is-the-gospel claim came from, and they found that the results couldn’t be replicated upon attempt. As newer information comes out, need to be thinking about it. (Like the all-in-one value of thoracic thrusts).