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I’ve recently had an influx of student athletes on my caseload, and I’ve found a common trend line that younger folks have a really hard time expressing their symptoms. A big part of what we’ve been talking about is how perception influences a patient’s interpretation of their pain experience. The more I think about it the more I connect the dots to what we’ve been discussing here that perception is largely based on experience. So it’s no wonder these younger kids have a hard time describing the true spectrum of their experience – it’s all still very binary for them (e.g pain or no pain). They have no developed concept of what pain is or what’s even possible for their human body. It’s likely that they parallel their body unit not as an active organism capable of healing itself, rather more likely to something that’s obvious like a car engine. In their world, medical diagnoses are given to you; you have a cold, or you get the flu.
It’s been interesting trying to mold their conceptual understanding of their bodies, rehabilitation, and what they’re really capable of. We have a huge opportunity to guide human beings to a better experience of life and potentially start nipping future MRI and surgery seekers in the bud.
All great points made prior.
1) I’d be interested in her proprioception. If available, it could be helpful to place a laser pointer on her head and see how well she recognizes how far she’s actually moving. There’s decent evidence to suggest that pain is a protective response based on perception – at this point, we’d assume any “damage” from the initial injury would have been healed long ago. (Check out this research study: Bogus Visual Feedback Alters Onset of Movement-Evoked Pain in People With Neck Pain by Harvie, et al in 2015).
2) I love the idea of WAD as an umbrella term for the spectrum of rehabilitation she’s sitting in. This patient has an apparent disconnect between her magnitude of injury and magnitude of disability, exhibited by the difference in AROM vs PROM restrictions noted. Thinking about that more, I’d be interested to know the test position for AROM. If seated, I wonder how she’d perform if her head was supported, such as rotation with the starting position supine head supported by pillow?
3/4) Her description of why she’s in your office screams yellow flags to me. She wanted it to be known that she was hit by a “drunk” driver going really fast (40mph). It’s likely, and reasonable, that she feels wronged and feels that she deserves care and comfort. Being placed in a cervical collar for a full month seems long considering fracture was ruled out, and it’s reasonable to assume this contributed to her perception of being disabled adding to her idea that it’s dangerous to move. Her longstanding history with the prior PT is interesting, and I’d worry that a majority of his approach was from a passive care perspective rather than one that is empowering.
5) I’d start with a Pain Neuroscience Education talk. After 4 years, it’s reasonable to feel comfortable with the fact that all prior tissue damage, if any, is now healed – and yet the patient is still fearful of moving. It’s important to reframe her thinking of what might be harmful and what the pain signals are really telling her; she has more control of her situation than she thinks. Next, I’d begin by working with her to really map out what she’s capable of. Supine, supported upper quarter isometrics; can you turn use the muscles without pain or limitation? Supine supported head A/AROM; can you move without pain or limitation? Proprioceptive work can be really powerful here. Even without a laser pointer, the PT can have the patient close their eyes to take away the visual input and demonstrate A) the patient can move farther than they think, or B) the patient isn’t moving as far as they actually can, indicating they’re holding themselves back. She’s used to years of passive treatment, and objective examination shows indication for benefit from manual treatment so this should be included too but not as a primary treatment emphasis. Progress the treatment by taking away support, or regress it by adding cuing and assistance by PT.
6) I’d stray away from anything stimulating, vigorous, or fast-paced. Slow, static<>minimally dynamic movements will probably be a best approach to bridge the gap between her perception of injury and disability magnitude. Modalities might be a good entry way into her buy-in to feel familiar, but this should be phased out quickly or emphasized for home pain management strategies.
I really appreciate how Dhinu and AJ’s articles compliment each other. I found it so interesting that major determinants of satisfaction for male patients are the therapist and overall outcome, whereas female patients were more satisfied with organization and communication. It really goes to show that clinicians can begin to predict successful forms of framing their approach to the patient, within reason.
When Dhinu’s article discusses phrases that may generate nocebo effects, such as “this test could lead to a slight increase in pain,” it makes me reflect on some ways I’ve grown to prefer to phrase the situation with my patients, like “this will help us map what you can do.” I’ve found that generally framing it as a positive experience – the why of it – is more helpful than talking about the negative aspects. As I read these articles, I’m realizing that patients are gathering as much information as the Therapist in the evaluation. They are almost comparable to an audience member of a play; constantly drawing information from the characters’ garb, their demeanor, and intentions.
At the end of it all, everything boils down to knowing the person in front of you. Dhinu’s article explains that placebo is the meeting point between active biologic change and psychosocial context. The question then is, how do we access that biologic change within the context of this individual? Jeff, I think your difficulty committing to a diagnosis can be mediated through AJ’s article. Where confidence and expertise may be a growing portion on the overall scale of things, maybe you can create balance by increasing other components proven to help, such as empathy and active listening.
About 6 months ago, a young mother walked into my office reporting “debilitating” low back pain. She moved with purpose, cautiously, and with poor isolation of muscle and joint movements. What was most astonishing was that she reported her back pain became much worse 2 weeks ago that she attributed to sleeping later than usual that day; off-hand, she mentions that was also the day her doctor interpreted her MRI, explaining that a spondylolisthesis is an unstable segment that her entire spine is resting on.
I quickly jumped into the rehabilitative framework of cognitive behavior therapy, attempting to change the way she’s thinking about her low back pain. This proved unsuccessful, however, since I failed to parallel with the patient. Her catastrophic idea of what is happening in her body was so far opposite what I was explaining to her that it simply didn’t resonate, and she likely didn’t believe I was taking her pain as seriously as I needed to.
In a way, I often feel like a safari guide as patients embark on the path to rehabilitation. Patients are usually aware of what they might encounter or how to prepare, but most have never done this before. Newer pain research is supporting that pain is an output from the brain rather than an input from the tissue, so if a patient perceives the presence of potential harm or danger they might walk the path of rehab with greater hesitancy or fear.
The young mother taught me a lot about successful management strategies for catastrophized pain. Jeff, I love your approach to use the teach-back method, really seeing what resonates with your patient. I began giving my patient a word bank to choose from, such as “pain-pain,” “bothersome,” or “annoying,” hoping to develop within her a deeper sense of what she’s experiencing. I framed her reality with context, citing research that shows we can’t hang our hat on form dictating function. These strategies took my map of the “safari” and overlaid it with hers, leading us on a smoother course to a positive outcome.
I love this article for the way it parallels a common thread in the book I’m reading, “How Emotions are Made” by Lisa Feldman Barrett. Dr. Barrett describes how we as humans are the architects of our own realities; we interpret what’s happening around us and create meaning for them. Dr. Benz and Dr. Flynn’s article here does a great job describing a clinician’s role in helping guide how a patient is interpreting their experience in our ability to give it meaning, shaping a patient’s response. This may mean that we limit the use of catastrophizing phrases, or maybe we don’t create an “event” precipitating a manipulation technique, in Aaron’s example.
Our bodies respond to the predictions our brain uses to help us function – and survive – in this world, and that includes the regulation of our sympathetic and parasympathetic nervous outputs. If our brain predicts failure or potential harm, it’s no wonder that our bodies will respond with resistance to change. This really emphasizes the importance of clinicians’ first impressions and handling skills, and is exemplified on a grander scale when patients’ outlooks are observed to influence the success of their surgeries.
Connecting the dots between a Physical Therapist’s desire to do good and a patient’s desire to be helped tells us how to implement this back-door approach to generate the most positive outcome for the patient. The verbiage “to be helped” is interesting, because what a person defines as being helpful is innately original to that person. To be most effective in our treatment, communication, and care, our approach has to be patient-centered to that person in front of us at that moment.
I loved the common themes used across everyone’s responses to the SCRIPT article, and how we organically use synonyms to some descriptive terms that stood out to me in the article.
In being here, I think we all recognized the importance of embodying not only our role as a clinician but also one in “patient management.” As Direct Access and the scope of our practice grows, Doctors of Physical Therapy need to respect the duty to ensure comprehensive care that often reaches outside the window of the patient’s visit. A thoughtful practitioner knows when it’s appropriate to call a doctor’s office, alter a treatment frequency, or rule-in a pathology that may be outside the scope of the practice.
We aim to improve our clinical reasoning, which a novice practitioner may not respect as an ongoing process; a notion that doesn’t end in the initial evaluation. The SCRIPT provides an opportunity to gain an effective, efficient system that isn’t utilized as a blanket examination to the patient rather it becomes “applied” to the individual in front of you. A great example from the text is the mention of patient history transitioning from essentially a checklist of questions to an “interactive” process.
I know I initially became interested in engaging in a residence program when it became apparent that I was proving my initial hypotheses, rather than “testing” them. My logic may have been adequate, but my approach was not. I hope to genuinely use evidence to guide my practice rather than dart throwing. I hope to respect the value of a pause, so that every action is intentional and fruitful. I hope to develop my skills with you all and deserve the title of Doctor of Physical Therapy.
Hey Tyler,
Erik Kreil here, I graduated from LCDPT 2017 and am excited to begin the program at the Progress PT location in Glenn Allen.
I have to say, that was such an interesting presentation of a convoluted case yesterday that lead to some really interesting discussion of the importance of specifically describing a patient’s irritability when determining stage of classification in a protocol for treatment.
I think the group discussion hit on some important points — will you keep me posted how she progressed through rehabilitation?