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Brandon
I don’t think there is much of a learning moment on this post other than poor patient management and that he is practicing poor PT overall. It’s sad that individuals such as these can capitalize on social medial to promote their garbage. Can you (and other residents) give an example of a biopsychosocial learning moment (post from a reputable clinician or research article) that has added to your arsenal of knowledge in treating this underlying component when dealing with good patient care?Thanks for posting Erik. I’ve had more patients inquiring about outcomes w/PRP injections lately and have one pt who is undergoing a series of 1-3 injections for lateral elbow pain (she’s currently on injection #2). I do not know the type of injection or application method but plan to inquire. After injection 1 (in adjunct to PT post injection), she has improved w/her pain and function by ~ 80%. She just had the 2nd one hoping to gain the last 20% for return to painfree (and NSAID free) sleeping and golf playing.
It appears PRP, like many other new options out there for tendinopathy pain control, truly has not had enough RCT’s and/or does not have enough set standards to recommend its effectiveness to the masses….or does the pt truly have tendinopathy??So has anyone encountered the “difficult patient?” The one who will do NOTHING, has a negative attitude, has no motivation, and is an energy sucker?
Countertransference outcome bias anyone?2 Weeks ago I evaluated her. This pt is a self proclaimed agoraphobic 70 y.o incredibly deconditioned pt with chronic pain and a laminectomy gone bad. She literally yelled at me during the eval telling me I could not help her, I would only cause her pain and the only reason she attended the eval was because her surgeon told her it was PT or another surgery. Fun times. I took the time over the next 4 visits to provide her reassurance, a positive environment but still pushed her a little out of her comfort zone to slowly advance her mobility and strengthening and finally broke through w/her today as she told me all about how proud she is of her kids and the grandson she has raised from birth who has significant special needs. This “difficult patient” softened today and turned into someone who is actually progressing (slowly) in her functional progress and may meet a goal or two in pain control and using better functional strategies to care for herself.
Please remember to provide health CARE to those who may seem unreachable. You may be the first person to actually have taken the time to break through the tough exterior to the hurting person (physically and/or emotionally)Scott
I think you’ve hit the nail on the head in your statement that the pt “perceives therex flares his condition” because his perception is his reality. This is a really tough sell whether it is the pt who is glued to modalities, manual therapy….etc when it comes to passive vs active treatment. The education on pain science is one discussion which it sounds like you’ve at least approached w/him. The discussion about active vs passive treatment and participation in it is best had as early as possible when you are building relationships and overall expectations with a patient. You can focus on different things based on the patient and how you feel he will respond. First, you should educate him on the need to ultimately be an active participant in his healing and overall health maintenance. You should be used as a TOOL to direct the progression of healing but he has to learn to find ways for management of his body and symptoms because those symptoms may (and probably will) be present to some degree when he is not in the clinic and after d/c. D/c typically happens when the pt becomes independent in managing his care…the goal is never consistent treatment w/o the ability to reach goals of self management. I describe pt’s bodies like vehicles….if you do not personally maintain them through oil changes, tire rotation, etc, they will eventually break down. Most of us don’t live with a mechanic who will perform work for/on us every day. The pt will need to be the person maintaining the vehicle eventually. The final thing you could point out is that either the referral source or insurance company (and you) may/will eventually see a plateau of progress and d/c to an independent HEP will become necessary (or d/c to goals being met and he will still need to know how to manage bouts of returning symptoms). the PT’s job is to ensure the pt is ready for this time of taking on his own care.Erik
I like your statement referring to the MRI as a “picture” producing a static image of the pt vs looking at them from a function and movement perspective. Another analogy I provide is to inform patients that many people have “positive” findings on MRI that may or may not be linked to their symptoms as well as even if they have a positive finding, their course of care will still most likely be the least invasive/aggressive/expensive approach…which is PT anyway. So many pts perceive MRI results will finally provide a hard answer of what the underlying problem is. what they do not understand is that those test results will many times make things less clear when the findings do not correlate with signs/symptoms and overall intervention.Erik
I think you’re on the right track but how do you (or others) deal with the next level of questions or comments from patients:
-I think I need an MRI (from those pts experiencing pain but have had no trauma involved or indications that diagnostics are warranted)
-I think I need to see x specialist (ortho, neuro…etc when you “know” he or she has a basic degenerative or musculoskeletal issue that is straight forward)
-I need a chiropractor (because that helped a friend/family member)
-I need surgery (on heaven knows what structure…)
-I need more pain medication…no one understands how bad this hurts
-YOU don’t understand what I’m going through..!There will be a lot more but how have you or will you deal with these statements from your patients? Please realize we all have a little “crazy” in us, especially when we’re in pain or are dealing w/psychosocial issues. How you deal with the patient in front of you at the first time these questions/comments come up will shape your relationship w/your patient, the amount of respect you gain from them and the overall outcome of the case. Good to be prepared.
pls share your thoughts.It is so easy to forget that patients do not have the understanding of the hard anatomy/physiology of their injury and their healing process to the degree that a skilled clinician does because it’s something we understand so well and take that understanding for granted. As a first step to effective intervention we need to make it a point to do our best to educate them on this at the level of their understanding and desire to understand (some are of the mindset of “just tell me what i need to do to get better….I don’t care what the reason is—I got this from a pt recently and it was hard to hear but I’d rather hear the truth from a pt than have him waste both his and my time!) It is also VERY much our job to educate patients on the PERCEPTION of his or her pain and how that will directly affect their recovery. It is very valuable to utilize the pain video…great visual for pts but also important to understand that pt understanding and perception of pain and healing translates to improved outcomes and less dollars incurred to the pt and overall healthcare system as stated in the JSS article. Great resources and reminders!
KKHey Oksana
you mention a “negative” slump but “SLR of 60 degrees” in your original exam notes. What do you mean by this and do you think you can totally rule out neurodynamic involvement in this case? The neural tissue in this area is SO closely related to the soft tissue that I’m wondering how much it was potentially affected during the MOI and/or how much it could actually be involved as the healing process occurs (especially if you’re considering using treatments inducing lengthening therex)? Can anyone weigh in on this component of his case and how they would factor it in so you’re not missing a valuable part of his rehab and return to sport?Hey Nick
I use mirrors a LOT and encourage pts to also use them at home. Today I was working with a pt with LB and radiating LE pain when he was in his usual hyperlordodic posture. When we were able to do retraining with him with visual (mirror) and verbal feedback, he was able to get into a more successful posture and significantly reduce his pain during WB core contraction in functional retraining positions. He was having great difficulty initially achieving these results until I put him in front of the mirror and having him see the “before/after” positioning of his spine when he was performing exercises and activities. This patient has a really tough time with carryover between visits in performance of his HEP and thus with symptom reduction so I find with many patients this is a great tool for success. Many times I’ll take a video of a pt performing an exercise or activity correctly on their smart phone, but have found even if they have exact directions on performance of these things, without them seeing correct form will inhibit successful carryover. Many patients will tell me they don’t have a full length mirror so I then suggest they use other reflective surfaces (dark appliances, sliding glass door after dark…etc) to get feedback on general form vs having significant detail a clear mirror provides.
If you don’t think mirrors are an effective tool for these types of things in clinic or at home for the reasons you provided, what strategies are you using instead? Are you seeing success with them or are you still facing barriers with some pts?I think it’s so valuable that our profession has moved into the realm of treating the “whole” patient so much over the past few years as there is so much more focus on pain science and patient perception of their condition/pain and how much it impacts or maybe even can create a physical manifestation of their symptoms. I think it is important for each of us to consider these factors when treating our patients and altering programs to best meet these needs. I think it is JUST as valuable (if not more valuable) to realize when there is a component of the patient case…or maybe even the entire case…that needs an appropriate referral to a different practitioner for assistance. Eric gave a great example of this at the Rusty Smith course of referring a patient back to her PCP for discussion of some of these types of barriers as she new her level of comfort and the relationship w/her PCP would warrant a better interaction/resolution of non-PT related portions of improving her overall ability to become well. We all have “difficult patient” cases who need more than we can offer. Does anyone see any parallels or examples they can integrate from Rusty’s course and/or a current patient case that they could apply to the information in this article?
KKHey Oksana
What do you mean by + anterior drawer?
Have you been able to reproduce his symptoms with any functional eval or treatment techniques in the clinic?
How quickly do his symptoms occur with the aggs you listed?Residents
This residency is SO geared toward Manual therapy and how putting your hands on pts to assess, perform manual therapy techniques, reassess…and use the current evidence to guide your choices of treatment and WHO to perform these treatments with most effectively. You will encounter the battle every day of making good choices and being able to appropriately discuss them with your patients, referral sources and other healthcare practitioners.Responses to Aaron’s questions and the attachments, ESPECIALLY the blog? How do you respond to the Sports Physio?? We all need to critically analyze this and how it affects our daily practices and overall beliefs in what we feel so passionately about.
Comments please??