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1. Has he had neck symptoms or shoulder symptoms similar to these in the past. If so what did he do to resolve the issues or improve his symptoms. When he does get HA how long do they last and what does he do to resolve. Does he have any difficulty sleeping? Does time of day affect his symptoms?
2. I agree with your treatment for initial evaluation. Through mentoring I have learned to not try and fix everything and do too much day one. Keep it simple and improve presenting symptoms and give them a few things to work on and expand during follow up visits. I would consider doing a supine Tspine manipulation day one if they were open to HVLA techniques. Additionally for exercise I could consider Cervical SNAG’s to improve his Cspine ROM based on his objective exam.
3. When it comes to posture I usually borrow Kristin’s explanation she presented at weekend two demonstrating the normal curves in our spine in standing vs standing. From there I would ask him about his work place set up and explain to him the importance of keeping everything within arms reach so he is not leaning or reaching excessively for tools he needs. Educate him on chair height as well as computer and microscope height to hopefully relieve some stresses through his neck.
4. Yes I would consider a supine Tspine manipulation in this case. He has hypomobilities in his lower Cspine and tspine with resultant cspine rom restrictions as well as min pain levels at rest. Although the article you posted did not find significant differences between non thrust manipulation and thrust manipulation I have seen immediate benefits from supine Tspine manipulation for patients with neck and shoulder pain. Additionally after this past weekends course we see that it can have an effect on someone with low back pain as well. Thus we might be able to make a positive change on his secondary complaint of low back pain as well.You all make great points about the challenges of communicating with the younger patient. That population struggles to describe their symptoms and express their goals. Cam I agree that it becomes more challenging when you have the parent in the room who wants to tell you their story at well. It becomes important for us to balance the communication between patient, parent, and PT. I too try and keep our sessions as interactive as possible, geared towards their interest, to keep their attention and not let them get bored. I have also found that less is more with patients in this younger population. I try not to over explain or complicate tasks as that only results in the blank stare back in confusion.
One the same topic of communication, I am currently treating a patient who only speaks Italian. Fortunately for the evaluation the patient came with their significant other who was able to translate for us, but each subsequent visit has been just the patient and I. It has been a little struggle attempting to teach and educate this patient about her symptoms and our interventions. I have found that our best line of communication is through demonstration to this point. I recently started using the google translate app to assist our communication, but I was wondering if anyone had any suggestions or more experiences treating patients who’s primary language is not English?
1) Based on the examination, is there any missing data or information that you feel is required to proceed with decision making/treatment?
• I would also like to know when her last bone density scan was considering her history of OP. How long has she been dealing with this condition?
• Was there any other acute incident she can recall that could have led to her increase in symptoms and increase in fear avoidant behavior? Depending on the severity of her OP rolling out of bed could be a cause to a more serious condition.
• I would also question her further on her past PT experience and determine her expectations for treatment. I would like to understand her compliance and what led her to continue treatment for a similar issue for over 4 years
• I would like to know what she does for work, how long is she sitting for what hours is she working to get a better idea of how that could affect her symptoms, Additionally, I would like to know what her resting sitting and standing static posture look like.
2) Would you consider this person to fit the Whiplash Associated Disorder diagnosis? If so, why? If not, what would be a better diagnosis classification?
• Yes, I would consider this person to fit the WAD based on the MOI, positive DNF endurance test, and reports of loss of consciousness at initial injury. She also meets criteria for neck pain with mobility deficits based on her current presentation. She does not check off all the boxes for either presentation due to the lack of referral pain into the shoulder or headaches, but her initial accident occurred 4 years ago and we do not know if she was having any of those symptoms in the past that have been resolved or improved.
3) Do you see any red or yellow flags associated with this condition?
• Yellow flags: pt demonstrates worsening symptoms without MOI, fear avoidance behaviors with driving, long duration of PT for similar issue with some pain relief, but never returning to PLOF, always has pain
4) What concerns do you have about the patient’s current presentation and previous treatment?
• Age, PMH of OP and insidious onset of worsening symptoms
• Always liked PT and sees some benefit over the past 4 years, but reports that she has never completely resolved her symptoms, what are her expectations with this stint of PT – continued passive modalities?
• Moderate perceived disability on self reported NDI
• Fear avoidance behaviors with worsening symptoms
5) What would you prioritize for the first treatment option? Second? How would you progress or regress the interventions?
• First treatment option would be education – she has had PT in the past with many passive modalities but continues to lack the ability to active her DCF for prolonged periods of time. I would address her static sitting posture at work and attempt to create a change in pain presentation where she appears to be a large aggravating factor. I would educate her on a posture to encourage dec upper cervical extension and increased DCF activation.
• Second treatment option would be to improve her pain free Cspine AROM so that she can feel more comfortable with driving and being more independent in that aspect of her life. Through a combination of manual therapy and exercise, address her myofascial trigger points and joint hypomobility. Cspine distraction and STM to her active TrPs.
• Progress to joint mobs Gr-II to dec pain levels and teach her gentle chin tucks for improved DCF activation.
• Regress – mobilize Tspine if she cannot tolerate treatment to Cspine currently due to pain Supine on ½ foam roller with UE movements to mobilize neural system
6) Are there any interventions that you would consider to be inappropriate for this patient at this time? Why?
• Cervical manipulations due to age and history of OPAdditional discussion:
Based on her current worsening presentation (fear avoidance behavior) and her lack of success with PT despite her duration in care, and self-perceived disability would this patient benefit form a top down bottom up pain talk?In response to the article that Dhinu had posted, I agree with Jeff in that fact that I have much room for improvement when it comes to delivering a clear diagnosis, prognosis, and explanation to the patient. As I mentioned before I often find myself over-explaining and neglecting to use patient friendly words at times, which leads to increased confusion on the patients behalf. Additionally, I find myself using negative information such as the on mentioned in this article, “this procedure could lead to a slight increase in pain” as a means to prepare the patient for the movement. After reading this article I will be more cautious of the phrases I use as it can significantly influence the outcome of the procedure. Another factor that this article mentioned was taking into account patients expectations and previous experiences. I have been making a conservative effort during my initial evaluations to explain to the patient what to expect on day 1 and subsequent visits. I typically say something along the lines of, “you might leave a little more sore today than you came in because we are going to be attempting to reproduce your pain.” I realized that I needed to address this after a few of my patients came in during first follow ups telling me they left in more pain after the initial evaluation. Lastly, one point that I believe Jon mentioned in a previous post and was brought up again in this article was that professional dress, whether it be a laboratory coat, or tailored clothing had a positive placebo effect. At my clinic we are required to wear shirt and tie, which is new to me compared to my clinical affiliations where I typically just wore a polo shirt. There have been a few instances where patients have commented on the professional dress of the clinical staff and believed that it was a positive addition to their rehab experience.
“.. in a world of online information.. we are only ever one click away from either confirming our darkest fears or igniting a previously unconsidered concern.” This quote is more applicable than ever with the internet at our fingertips. I agree that patients that come in with imaging results or pre conceptualized beliefs about their pain based on what they found on the internet are the toughest cases. This reminded me of a patient that I had during my second clinical – he was in his late 30’s coming in with chronic radicular symptoms. My CI had been working with him prior, with minimal symptom improvement. This gentleman was convinced he had sciatica and was taking all sorts of medications to help ease his pain. Every session he would come in and we would spend the first 15 mins discussing his findings on the internet regarding his pain. He wanted to know the exact mechanism of what could be potentially causing his pain, instead of allowing us to assess and treat his own unique presentation. In the end we attempted to have the pain science talk with him and discuss new findings in research as Erik mentioned, but he seemed to not take kindly to the thought that pain could be in fact an output from his brain and not input from his tissues and did not return for follow up visits.
I believe that everyone has made great point about being vague and framing diagnostic tests findings with words that are not threatening as the paper mentioned. Cam I too have find myself over explaining findings and talking myself into circles until patients are looking at me with a blank confused look. I believe that it is important for us to keep in mind that everyone has their own thoughts and beliefs and we need to be sure that we tailor our words to each unique case.
I really enjoyed how this article highlighted the impact of the words we choose when we interact with and educate our patients. During my clinical rotations I remember one of my patients coming in and telling me that her doctor informed her that “her rotator cuff was hanging on by a thread.” Now this is an extreme example, but we can only imagine the effect of her doctor’s words had on her mental makeup and her outlook on rehab. Not only that now she was scared that her arm was going to fall off if she tried to use it promoting fear avoidant behavior.
Jon – The point you made “there wasn’t a large difference in the outcomes objectively, however there was a difference in the subject’s perception of their objective improvement” should not be overlooked. Patients are often times coming to us in a time of need and we need to appropriately address their physical concerns as well as creating a positive environment where they expect to feel better. If patients feel that they are improving and feeling better they will be more inclined to reach their goals.
As Casey and Jeff stated, this article reinforced why I decided to pursue continuing mentorship thorough a residency program. As a recent grad and novice clinician there were many point made in this article that I could really relate too.
One patient case in particular came to mind – during my first week I failed to recognize the SINNS my patients presenting symptoms (specifically the severity and irritability), more concerned with making sure I was collecting enough objective information for my initial evaluation. Like Jeff mentioned I was over-eager and aggressive and asked them to do too much. Unfortunately this person left in more pain then they came in with and neglected to return to follow up visits. As I reflect on this encounter I recognize that this particular patient would have benefited more from educational interventions as compared to movement based ones simply due to the irritability of the presenting symptoms.
As this year of residency begins I look forward to utilizing the VOMPTI clinical reasoning form much like the SCRPIT tool described in the article to improve my history taking and to formulate sound prioritized hypotheses. This will allow me to best determine most appropriate interventions for my patients.