[Jennifer Boyle]

Hello everyone!

I just wanted to update you all on how the treatment session with the patient I presented on went yesterday. Upon arrival she expressed that after the last session she was having tingling down B upper extremities, neck pain, nausea, vomiting and spinning sensation. She stated that she went to sleep after this and woke up the next day feeling much better than she has in a long time. She proceeded to tell us that she believes after performing our treatments she was a bit stressed out about everything we were trying and this may have enhanced her symptoms that following night. Once she realized that next day she was feeling better her symptoms remained at a minimum for the rest of the week. After she told us all of this, I took it as the perfect window to start talking about her coping mechanisms as per suggestions during journal club. We opened this encounter with asking about how she typically takes time for herself and how she distresses and immediately she was very receptive to this question. She started to cry and admitted she did not have time for herself nor did she have any mechanisms to help her distress. We used this as a perfect opportunity to develop patient rapport as well as explain to her that this stress could be adding to her pain. We were able to help her connect the importance of physical and mental health and how this may be negatively impacting her recovery. We made sure that she understood what we are doing is just a small part of rehab and that to treat the whole person we need to also help her develop her stress outlets. As a result, we reached a conclusion of her joining yoga and coming into her therapy sessions early in order to work out for 20 minutes as her means of distressing. As for her manual treatment we let her pick the aspects she felt were most beneficial to her in order to let her take control of the situation. Gr V T-spine manipulation was picked from the last session with a decrease in tenderness to palpation to her upper trap post manipulation. I feel that yesterday’s journal club helped me an incredible amount in guiding my treatment session to look into her psychosocial presentation and not just her physical presentation to treat the whole patient and not just part.

[Jennifer Boyle]

I believe that this article is useful even in the US because the prevalence of low back pain is so predominant. Additionally, CPGs are great tools in helping to promote high quality care as well as reduce the amount of inappropriate variations of treatments among medical providers. This particular article stated that the use of CPGs could help reduce the number of unnecessary referrals to spine surgeons. If there is a reliable cluster of non-operative CPGs for LBP it will allow for patients to seek help without seeing an MD prior to treatment, which could expedite this process and allow for faster relief. During this study they were finding that patients were not as compliant with their non-operative exercise routines as needed to be in order to have an accurate measure of the efficacy in this CPG. I agree with the article and stress that as physical therapists it is our duty to promote therapeutic treatments such as exercise to help treat the cause of the pain earlier and avoid the wait times associated with a consult to a spine surgeon.

[Jennifer Boyle]

Everyone has made excellent points that I truly agree with. I think that this tool is essential in order to help myself as a new graduate eliminate my potential for bias thinking and look at the entire case being presented by the patient. As Justin stated, “showing our math” to our mentors is a critical aspect of the residency program that will allow us to further our clinical reasoning with a great tool to help structure our way of thinking. As the article stated, the ability to hone in on a clinicians clinical reasoning is a very challenging skill to develop, however, this tool is a way to expedite this process. Because it is best applied to working with patient encounters and getting feedback in the moment it is important to take the breaks during this process in order to get the most out of the experience and make sure my thought process is where it needs to be. With that being said, I do believe that the breaks taken during this process may disturb the flow of an evaluation but it is worth the clinical experience gained throughout the process.

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