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Thanks for sharing this case Sean. This has prompted some great discussion with the therapists and students over at our clinic the past couple days.
This isn’t a black and white case and I don’t think that you can immediately answer the question “To operate or to not operate”. There’s a lot of factors at play and I would certainly be the person who helps him map out all the different pro and cons for each option so HE can help make the informed decision. Instead of telling him what he needs to do, list out what are the benefits and risks of each and have an open discussion on what each entail. I would think that most patients would appreciate this rather than having a PT and a surgeon pulling them in two different directions.
Richmond, the student at our clinic now, posed an excellent question. If you were to read through this case, but stop before you read the MRI findings of the labral tear, would you change your opinion about treatment? Would the patient?
Biopsychosocial vs. Biomedical. Do we treat the labral tear and probable ligament dysfunction, or do we treat the whole patient, his goals, his limitations, his preferences while keeping in mind the biomedical piece? His goals are to return to daily function and to swimming, he has mechanical impairments that we can address conservatively, and he already responded really well to the first session. I would definitely support a trial of conservative treatment but obviously monitoring progress, pain, any occurrences of further subluxations, and changing course if needed along the road.
I’m impressed with the successful implementation of multi-disciplinary communication that the GP, psychologist, and PT had. I mean wow, every two weeks a teleconference on patient progress and each member informed on the other’s treatment. Reminds me of in-patient grand rounds in the hospital setting.
Also, to take away from our last course, primary activity limitations:
– Unable to perform previous exercise routine >> immediate introduction of strength training program and gradual return to running program within patient tolerance– Unable to perform work activities >> ergonomic solutions with workplace visits and simulated work tasks
The patient might not have had huge changes in all the outcome measures, but the main concerns he came in with : days off work, not able to perform previous exercise, difficulty sleeping all had the biggest improvements.
I have said in the past that I struggle with decision making and when to implement greater amount of psychosocial aspects to patient care. You can easily see that the therapists saw the importance of implementing these aspects by assessing through subjective (feelings of anxiety and anger, interference with work, history of condition), outcome measures, and functional tests. They made the decision right away to include the GP and psychologist within the treatment and focused on a supportive, self-efficacious, and purposeful plan. Sure, they added in specific exercises for “trunk strengthening”, but clearly the focus was on a much bigger picture.
This is a great application of recent evidence into a comprehensive, patient-centered approach. I appreciate the detailed explanation on their decision making based on both the patient in front of them, their needs/expectations to achieve long term results and on the recent evidence from the systematic review.
Although their PICO question was based on land-based exercise vs. no treatment only, they also incorporated aquatic therapy, weight management strategies, patient education, and using an exercise diary as well to provide a comprehensive approach. They used the evidence to support part of their treatment, but did not let it limit the others.
The authors of this report did a nice job of stating the limitations of the systematic review results such as variability of type, frequency, and intensity of exercise, and they also used the limitations to their advantage. It gave them more room for decision making based on the patient and focused on patient adherence to the exercise routine. I enjoyed this article – transferring stats into reality.
Great job with your presentation Alex and thanks for sharing a particularly tough case.
From my understanding:
Double crush = proximal compression of a nerve that decreases ability of a nerve to withstand compression at a distal site. Central sensitization = impaired inhibition of nociception in the pathways that lead to/from and augmentation of pain perception within the brain (short version). ALSO, after sensitization has been set in place, further peripheral perceptions of harm can sustain or worsen the sensitivity. I can’t imagine that they cannot both happen in the same patient, but it comes down to what, how, and when to approach each. Do you initially start with 1) pain education, ensuring their maximal understanding of what is causing their pain, and making sure they have some management strategies set in place OR 2) mechanical/neurodynamic approach addressing impairments OR 3) both at the same time?I struggle at times when I have initiated treatment with a patient who I think could benefit from a mechanical focus, realizing they have components of central sensitization, then having to back track and sometimes contradict myself because I’ve already started treating him with a mechanical, peripheral focus. I realize that you have to “roll with resistance” and if they don’t buy in at first, sometimes you have to layer it in as you can when the patient develops trust. But’s not like adding in a certain exercise or manual technique, it’s the entire concept of what they are feeling and why. I understand the importance of addressing this FIRST, but lately I’ve been finding that it’s hard to do this smoothly.
With the case report you presented, I was surprised to only read one sentence at the end of the discussion on possible involvement of his biopsychosocial components with his case, despite chronicity, fear, widespread symptoms. I’d be curious to find how much of a long-term change he sustained after treatment.
The case is certainly interesting and tough to wrap my brain around, especially with the neurodynamic testing that you performed with a negative slump, however positive SLR and positive modified SLR. On top of all that, it seems like you weren’t able to reproduce or change the numbness (correct me if I’m wrong).
During the initial evaluation, did you reassess any of your asterisks after the treatments to see the changes of the lumbar spine or hip treatments? Sometimes I find that if I do too many different treatments and they are no better, worse, or better, I don’t know what I did that specifically made a difference. I probably would have picked only lumbar spine or hip, reassessed, then added more at the next follow up visit to avoid muddy-ing the waters.
Where do you think that the “double crush” is happening with her? If I truly think that there is a mechanical irritation or sensitivity at two different points, I talk to patients about their nervous system and how it connects to every point in our bodies. In our daily lives, we don’t just move at single joints we move as a system and if we have a weaker link proximally, it might affect the way our joints and muscles move at a distal point. To agree what Nick said, I would say that we have a good chance of helping you more if we focus on both areas. I tend to avoid using the term “double crush” with patients as well. The imagery that could come to mind of anything in our bodies that is “crushed” cannot be healthy.
No need to apologize – more details, the better. Of course, I have more questions…
To clarify the HPI, the insiduous onset of sciatica in her 20s’s – this was similar symptoms to her current complaint? Same with the hip pain in her 30’s? And with my understanding, she has been experiencing all these symptoms for the past 5-6 years since retail job, got better with physical therapy, but then has had a recent worsening of symptoms in November?
When was the horse kick?
Does she currently ride and did she ever mention any problems with riding on a horse?
What specific surgery did she have for bladder cancer?
I think you all make fantastic points about specificity of our manual techniques and I want to contribute to the question about the Global Rating of Change.
There was an interesting article published in 2009 in JMMT on the Global Rating of Change (GROC) scale, including the strengths and weaknesses of using such a scale. One of the points that the authors stress is the ambiguity and the variability in which you can use this scale, and the interpretation that patients can take in regards to answering the question, “Are you better, no change, or worse?”.
“Reliable and accurate function of the GROC places considerable cognitive demand of the patient, and a prominent criticism of the measure is founded in the contention that people are unable to accurately recall prior health states. An ability to recall and quantify status at a previous time-point is necessary for proper function of the measure. If the reliability of the recall is poor, the change score measured by the GROC scales is unduly influenced by the status of the patient at the time of the scale administration.”
The authors of this article don’t make the distinction whether the patients were referencing how they felt in regards to where they were at the beginning of the study, or where they were with the initial onset of their condition. Nick mentioned that the onset of symptoms were averaged between 5 and 9 years, so there is abundant possibilities for what memory constructs these patients are using among the time period of their condition to relate to their change. I think there’s an important distinction here and it would be important to determine this with our patients before we hang our hats on the significant change with GROC results, especially a small difference in treatment such as the specificity of non-thrust joint mobilizations in the same region over 4 visits.
Regardless, I agree that it is crucial and of arguably more importance for the patient to perceive improvement in their condition rather than objective improvement. But, we might have to take these study results with caution.
Tough topic. I have recently struggled with similar patients who have Ehlers Danlos and use muscle energy techniques to “put them back in place” every day. They’ve been taught these techniques in the past and either do them by themselves or by their spouses. It’s similar to patients to have been told they have a leg length discrepancy or have disc herniations/tears/etc., and I struggle with conversations with people who let these idiosyncrasies define who they are and how they view their bodies.
It’s easy to blame pain on an “out of place segment” because it’s tangible and one-dimensional. We are taught one way how our bodies supposed to look and if there’s something out of place, then that’s the source of the problem. The Moseley study where the patients with LBP drew what they thought their spine looked like is heart-breaking.
I try to use movement a lot when I explain either a manual technique or make sense of why a clinician in the past told them that they were out of place. Either I say there’s a little more stiffness on one side or I say I’m going to help get things moving a little better with this technique. And/or I incorporate how soft tissue tightness and tension affects the way our bodies move.
I think where once physical therapists might have been one of the sources of the misconception, we are now taking a whole new stance on chronic pain (thanks to multiple brilliant clinicians who have brought these concepts to light). Recognizing these patterns when that patient walks through the door is one thing, but being that clinician who can support the change of their view of themselves is another. I’m trying to use a lot of anecdotal stories and research as well as recognize earlier when I can start these discussions or refer out to another medical psychologist.
In regards to sleep, if the patients says they have no trouble sleeping, then I usually move on. Wow, what a big piece of the puzzle I could be tapping into if I dive a little deeper into sleep habits in general. Thank you so much for sharing that document Nick! That’s awesome.
The second article really puts things into perspective and the concepts are important to consider. Neuro patients are ortho patients, and ortho patients are neuro. Focusing on sequencing, orientation towards a goal, and quality vs. quantity of movement. I like the concept of less is more for our sessions as well as our HEP’s.
Both articles have me thinking about use of PNF concepts and how I don’t utilize them enough in the clinic compared to straight plane exercises. With those concepts, I also remember how much they stress tactile cueing and hand placement to optimize muscle activation patterns. With all the cues listed in the first article, I would think that tactile cueing and increasing the patient’s kinesthetic awareness of the task would be of great benefit. For example, using the cue “Gently bring the tip of your shoulder blade towards the spine”, placing your hand on the scapular inferior angle and guiding it towards the spine as the patient attempts to perform the exercise.
Nice! I love these ideas Kristen. Good call Sean! Is resting the neck against a stable surface any part of it as well? I’m thinking that supporting the thoracic spine and head will help posture and get patients out of increased thoracic kyphosis and forward head when performing scaption…
It’d be similar to using a stool in front of someone’s knees to prevent anterior tibial translation during a squat.