Forum Replies Created
-
Posts
-
Falls suck. Sorry Auggie. This article is a great review. I certainly don’t administer enough standardized balance measures! Either through subjective or functional testing, I can usually determine the PQRS question about fall risks, and implement appropriate balance interventions. I like the guideline stated in the conclusion, which is basically to adminster the TUG test, and then if they score over the cutoff score (13.5 seconds per shummway cook 2000), then administer a test more sensitive to change like the berg or tinetti.
We had a great lecture in PT school about how every 0.1 m/s increase in gait speed is $10,000 less care that a person will need to receive. I like using gait speed when possible!
I think you all make great points. This makes me think about some of the MET techniques that I see with some of the clinicians I work with. I get frustrated because they will see an “Flexed Rotated Sidebent (FRS) Left L5” or a “Left on Right sacral torsion” or “the FRS left corrects when moving from anterior pelvic tilt to posterior pelvic tilt, see?”
Many times, I don’t see. And it is frustrating. These patients feel better when treated with MET techniques, but I wonder if a regular UPA would have had the same effect.
I loved reading the responses, they were very informative. I really wonder about the whole “specific technique vs general technique” debate. I went to AAOMPT 2015 in Louisville, KY. There was a round table discussion with many big names in our field, and they all agreed we should stop doing studies about whether technique A or technique B is better for treating X. I found this really crazy as a student, but knowing more about the neurophysiological effects of manual therapy, it makes more sense now and fits with the theme of the article.
I think specificity of technique leads to improved outcomes. I don’t know if this is what is backed up by research anymore. I also don’t know what evidence I would need to be able to change my mind.
If you agree, what evidence/study would you need to see in order to change your mind that specific techniques are no better than general techniques?
Good Job Nic! Yeah I remember like week 1 of an ortho clinical, I get a patient who was post op knee or hip… honestly can’t remember.
The protocol said at this point to start hip adductor and IR strengthening (along with a lot of other recommendations), so I did that.
My CI talked to me afterwards and said
CI – “Why did you give that patient IR strengthening and adductor strengthing?”
ME – “because it was on the protocol.”
CI – “Did you test IR strength and adductor strength?”
ME – “Not IR, but I did test adductors”
CI – “were they weak?”
ME – “Not really.”
CI – “You have a functioning brain, and should not follow a protocol blindly.”Lesson learned!
I am still learning, so I follow protocols loosely right now, but I do varying as the patient presents differently
Justin, I agree with your assessment. A lot of times just doing one thing that the patient likes/suggests can build that therapeutic alliance and allow you to try other treatments that they aren’t so sure of ( we’ll do traction but only if we try xyz first).
This can be a double edged sword though, like you don’t want to keep doing traction if its obviously not helping, or having the patient rely on passive techniques like hot packs or massage. But this should be easily communicated and demonstrated to the patient with test-retest and allow that buy in/therapeutic alliance
I love these recommendations “Do not offer spinal injections. Do not offer spinal fusion, Do not offer disc replacement”. Strong words that I wish more PCP’s, OrthoSurg, and NeuroSurg would read!
Gus, I haven’t used FMS or SFMA specifically, but I’m somewhat familiar with them.
In our wellness type visits they usually start with an in depth discussion of the person’s responsibilities and activity level, previous injury history, and any current complaints of pain ( 10- 15 minutes )
Quick walking gait assessment, followed by quick running gait assessment if that person is a runner. ( 2 minutes)
Balance screen (30 second- 1 minute)
Functional squat assessment ( 20-30 seconds)
AROM and OP for cervical, shoulder, elbow, hand. AROM and OP for lumbar, hip, knee, ankle. (10-15 minutes)
Selected muscle testing/ further testing based on clinical reasoning (5 minutes focusing on problem area)
Home program prescription – 10 minutes
And that’s a 60 minute wellness eval!
One of the reasons I got into PT was the fact that we get more time than any other health profession talking to and getting to know our patients.
The article has a section called “a single medical encounter as the center of decision making”. They talk about all the other factors that go into a decision other than what happens during one doctor’s visit. People are constantly googling, youtubing, talking to friends and family, trying to decide between treatment options. I think the fact that we get so many encounters with the patient makes us the prime candidates to implement the model proposed in the article.
Encounter prep –> Encounter –> encounter processing –> feedback, continuation, resolution.
This takes into account that what people perceive or take away from our encounter may be radically different from what we were intending to communicate!
Also, I like the fact that they discuss that this may lead to fewer numbers of visits, because, similar to Myra, I have seen patients benefit from this type of wellness model. A patient with a nagging ankle pain that is not serious enough for them to seek treatment may benefit from a one-off consultation for them to work on the issue at home.
If you see that person back in 1 year/6 months and the issue is no better or even slightly worse, I think this is the appropriate time to initiate further interventions/education/PT which can lead to a resolution of symptoms prior to them becoming catastrophic.
Cool case, Nic.
1. Does she have any previous history of episodes of LE? People can often have recurrent cases. Is this her dominant arm?
2. Any change in activity level recently? Riding motorcycle more often vs previously, working more hours?
3. I can see that you made the decision not to do a neuro screen day 1, which is reasonable, given that I would also probably have tingling in my hands after riding a motorcycle with wrist extended for an hour, but I would like to see if ULNTTs, spurlings, compression, reproduce any of her pain or tingling in the hand.
4. Any pain with direct palpation of the triquetrum or lunate? Any “piano key” sign present? she may have TFCC dysfunction, but could also have damage to other carpal ligaments.
5. Love the idea of adding grip assessment next session and trying some lateral elbow glides.
6. I think the research out there for LE strongly supports thoracic and/or cervical manips! However due to her history of breast cancer, I would be hesitant, and would stick to mobilizations. On that note, cervical PPIVMs and PAIVMs should be assessed at next session.
7. Hard to deal with “blue flags” like inability to stop these repetitive actions at work. I like your idea of taping or bracing for her. She might benefit from a neutral wrist splint for a while to see if that allows any improvement in pain, at which time she can continue to slowly load the LE to improve tendinopathic changes.
8. On shoulder strengthening – articles presented during weekend 2 support shoulder and scapular strengthening for LE, so it would be interesting to see if she has any gross changes in shoulder strength.
9. In my short time treating I have had 1 or 2 LE cases, and both were independent with their home program after a few weeks and were discharged. I think that LE takes a long time to improve to 100% and patients can get impatient with therapy sometimes. Thoughts?
10. Never taped the elbow or wrist. A quick google yields this cool TFCC taping technique: https://www.alphasport.com.au/news/post/triangular-fibrocartilage-wrist-taping-technique/
Is this what you were going to try the following session?
It’s a great watch, but I’m not a watch guy, unfortunately. A brief google search for the watch show that you can’t buy one. I would wear a one of a kind watch.
The second blog has to do with an intervention being rapidly scaled up, and possibly causing harm. I think this is unlikely to really happen in PT because a topic is rarely ever “settled” or “closed”, at least not in my mind. It is an interesting question, though. If a topic has an overwhelming amount of evidence pointing in favor of an intervention, when does it become unethical to continue wasting research dollars on that topic? I think the scientific method requires that we continue to replicate and test certain assertions, so once something is “settled” you still need to have a big test of it once every decade or so. Newton’s law of gravity was “settled” for a long time. It doesn’t mean it was right.
The gem of the third blog is this link: http://www.students4bestevidence.net/library/ , which has a ton of great resources for us to use!
The fourth blog was a complete bust.
The fifth blog talks about the importance of explaining EBM to the masses. It doesn’t make a lot of sense for us to use this paradigm if patients don’t know about it, or if they aren’t aware they have a big role to play in their decisions.
The sixth one has to do with the philosophical question of “absence of evidence is not evidence of absence”, Which is something we should all keep in mind when we see a negative ( no difference) trial published.
The most recent one, published 10-21-16, is a nice historical overview of Archie Cochrane, and his work with EBM and the collaboration. I don’t know a lot about him and it makes me want to read his autobiography.
AJ – You succinctly laid out a really nice set of 5 questions we can ask to get the discussion rolling on pain, and whether we need to administer a specific fear avoidance scale. Did you get this from a specific framework/paper, or just through your experience? (1. Do you avoid movement 2. What their perception of pain is (ie all pain is bad), 3. Are they hypervigilant about it 4. how is that impacting their lives both physically and emotionally 5. whether they think this can improve or not.)
Justin – I love the wrist example. I’m stealing that immediately.
Katie – Great point about getting a good read on your patient before delving into biopsychosocial aspects of pain. Even when I feel like I have done a decent job of educating my patient, I have still gotten a response of “So, you’re saying it’s all in my head?”, which can be frustrating and decrease therapeutic alliance with the patient
Aaron – I like the idea of asking the patient “Why do you do that?”, as this makes them generate a hypothesis that you can work towards deconstructing. I think this is a better strategy than what most new grads do, which is that when we see something abnormal we immediately say “Oh, do you see that? you are shifted/asymmetrical with weight-bearing, etc” And then we put our own assumption as to why the person is actually doing that versus just asking them. Sometimes just saying something like “you are shifted” can make someone more fearful
For answers to your questions, Austin:
1) What measures of FA have you used most frequently in your clinic now or in the past? What do you like or not like about particular PROs? What are your thoughts on this metric for use in the clinic? Possible positives and negatives of its use?
Most often it’s the FABQ. I have used the Pain Catastrophizing Scale (PCS) and Tampa Scale of Kinesiophobia in the past. I actually hate using the PCS because of the name. I feel like sometimes a patient reads the name of the scale and thinks “Is he saying i’m being dramatic?”. I’d use it more if I could just black out the name. The FABQ is included in FOTO so the patient never sees the words “fear avoidance”.
2) When you do have a patient, potentially one who is trying to return to work, that responds with a high score on one of these outcome measures, to what extent do you address their fear avoidance? Has anyone utilized true graded exposure or graded activity training to address fear avoidance? Or has your approach been more informal and education based?.
I’m currently using graded activity with a chronic LBP and hip pain patient. It started with a lot of education (over at least 3-4 sessions) before she agreed to try it. She has been slowly decreasing her activity level and social activities for 15 years due to pain and avoidance. Allowing her to choose exercises where she can have initial success has been key in her buying into the treatment plan. In addition, when we perform treadmill training, giving her full control over when we stop the exercise really decreases her fear and is a useful strategy
3) Similarly, when you do have a patient with high FA, what sorts of resources have you used to refer patients to other providers?
During clinicals I had one or two patients where a psych referral was warranted and initiated. I have yet to initiate a psych referral while working at Progress. I currently have been co-treating a patient with body image issues that are starting to affect her function where one is warranted, but it hasn’t happened yet.
What other types of resources/referrals are you thinking about here, August?
Similar to other posts…
I agree I would have liked to look at muscular source of pain via unweighting of shoulder girdle or resisted cervical motions, as well as neurodynamic testing. I believe the patient’s min irritability would allow testing of these structures without too much provocation.
Other tools I might consider with this patient (depending on presentation) might be an FABQ. I did an in-service on a CPR from Ritchie et al in PAIN in 2013 that showed if they are over 40 years old AND score highly on the Post Traumatic Diagnostic Scale – hyperarousal subscale (PDS – http://www.ptsd.va.gov/professional/assessment/adult-sr/pds.asp ), then they are more likely to have chronic symptoms/not recover fully. I’m not advocating for CPR’s here, it just an interesting study to look at, and I have attached it. The PDS is not free, sadly, but maybe we could substitute the FABQ or a similar scale and repeat the study?
I am trying hard to incorporate a 2-3 quick subjective asterisks AND 2-3 quick objective asterisks to start each session, but I am far from consistent in doing this and need to improve.
Since the first VOMPTI weekend I have been using thoracic manips on every patient where they do not have contra-indications in order to practice my skills. I will use mobilizations on those who are not appropriate for manips. Would love to see a study in the C-spine similar to what we see in the L-spine i.e. manip and then see if changes in muscle activation in longus coli post (has this study been done?)
Techniques I have been practicing – seated CT junction manip, supine pistol/grenade manip, prone CT junction manip, prone rotatory manip
My progression of DNF training is similar to others, but once they can tolerate some seated activities w/ arm movements, I will progress to prone with head off edge of bed and have them do a few holds for endurance. I think this challenges the DNF while also working on posterior neck muscle endurance.
I participate in a local journal club with a few orthopedic surgeons in town. One of the older MD’s is in his mid 70’s and still practicing and performing surgery. He remarked at a recent meeting that they used to perform surgical lavage “Wash out” procedure for knee arthritis in the 1970’s and 1980’s, and they got reimbursed for the surgery. He said those patients usually did very well. It fits with what we see in this study.
Justin and August – great tips that I will use with my patient regarding pain education. If I start down the road of pain science with a patient, I will usually start with the “explain pain in 5 minutes” video, then move to the alarm system metaphor Justin mentioned.
I also like to use this analogy, not sure where I picked it up. I ask the patient what their favorite sport is, or what they used to play as a kid. Let’s say it’s tennis. If they have had knee/back/whatever pain for 5 years, I will say ” What do you think would happen if you practiced tennis for several hours every single day for 5 years. You would probably get pretty good, right? In fact, the part of your brain that controls the movements of your arm and racket, the part that deals with hand eye coordination, etc, these areas would get physically bigger. Your brain would be able to produce these movements with little to no thought. Well, your pain has been practicing too! You have been activating the area of your brain that produces pain for 8+ hours per day every day, and now your brain is really good at it.”
Great posts by everyone.
Justin and August – I agree with your assessment of goal setting with CVA patients vs chronic pain patients. There are many similarities between these populations. They both tend to do better when the understand more about their conditions, and when they come to accept them. Sometimes post CVA patients do a lot better when they just come to grips with who they are now. They are a new person, with new strengths and weaknesses that they must learn in order to cope and become functional again. This is also true with many chronic pain patients. I like to ask something like “If you continued to have your pain, but could do everything you want to do in your daily life, would that be acceptable to you?” If they answer yes, they have a path forward. If they answer no, then a deeper conversation regarding the psychology of pain is warranted, with possible referral to the appropriate mental health professional if they do not make progress.
Overall, I loved this study and will strive to use a similar framework with my patients and make them as involved in their goal setting as is feasible.