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Jen, I think this article is great and contains some good information that we can use with patients that we see frequently.
Even though this article utilized C1-C2 manipulations, I still think any upper cervical manipulation could be beneficial for your patient. Over the past couple of years, I have seen conflicting information about the importance of manipulating a specific segment to achieve symptom reduction versus manipulation in general. Since we are seeking to achieve a more global pain modulating effect with our manipulations, do you think that you’d have to manipulate the OA joint specifically to achieve the desired result, or would any cervical manipulation suffice?
As for your second question about performing manipulations bilaterally, my thought would be that they are just trying to enhance the neurophysiological effects of manipulation and they can circumvent the refractory period of the side they already manipulated.
As for your third question, my biggest complaint with the article is that I cannot specifically incorporate it into my practice because I would always pair the manipulation with exercise. When looking at the nature of your patient’s cervical pain, it is likely that there is an underlying dysfunction (motor control, etc) contributing to the issue. By manipulating her, you may reduce her pain temporarily, but you aren’t really addressing the issue that is causing it in the first place. I think the article would have greatly benefitted from having a long term follow up to see what percentage of each group had another episode of cervical pain and HA.
As someone who is definitely guilty of giving unsolicited advice and summarizing research to patients who probably could not care less, this article provided me with some good tools to improve my rapport with patients. I particularly liked the idea of asking patients to describe what the best possible outcome would be if they made a change and then to ask them what they think would happen if they made no change at all. This gives us an opportunity to encourage our patients rather than to merely give advice. One component to the difficulty with the traditional model of motivating others is that we are often unsure of how much of what we are teaching resonates with our patients. I often find myself explaining concepts to patients in convoluted ways that probably do not make sense. By shutting my mouth and giving them the opportunity to express their concerns, I can serve them better. I will definitely try to incorporate more of this verbal judo in my future interactions with patients.
I agree with everything that you all have stated and I think that Katie’s article is a good supplement to the discussion. I do not see any barriers to extrapolating the results of this study to a population in the United States. I think the onus is on us as physical therapists to educate primary care physicians in our area about the research regarding conservative management of LBP vs surgery. In medical school, students usually get no more than two weeks of education on orthopedics. I think it is natural for MDs to refer their LBP patients to spine surgeons, because that is more of a known quantity for them. If more physical therapists made an effort to get to know the PCPs in their area, I feel that we could begin to sway a lot of these referrals in our direction. I would imagine that you have a better chance to convince a patient that spinal surgery should not be the first option if a spinal surgeon has not already told them that it is their only option.
Katie and Sarah, I agree with all of your points regarding the importance of mentorship and patient-centered care. This article reminded me of a concept that we discussed in physical therapy school regarding the “art” and the “science” of physical therapy. Someone who understands the “science” of physical therapy knows how to find the tissue or biomechanical cause of a patient’s pain and knows how to properly address it. Someone who understands the “art” of physical therapy knows how to properly educate the patient, treat them as an individual, and can empower the patient to take care of their own condition. In the article, the novice clinicians seemed to have a good grasp of the science, but did not understand the art of patient care. In order to be achieve the expert status that we are all striving for, we must learn to incorporate the art and the science of physical therapy into our practice.
Katie, I would agree that my most beneficial clinical rotations provided opportunities during evaluations to step out to reflect and organize my thoughts. During more complex evals or evals where you are pressed for time, it would be beneficial to use a portion of this reflection time to discuss what components of the exam must be conducted that visit and which ones would be appropriate to test at the first follow-up visit.
As someone who wouldn’t normally be classified as “well-organized”, I believe the clinical reasoning form will be beneficial in helping me organize my thoughts when evaluating more complex patients. Additionally, it provides a great framework for metacognitive thought, which will be imperative in helping us develop our clinical reasoning throughout the next year. I believe this will also provide us with excellent opportunities to reflect on the information that we gather during the subjective portion of an examination to ensure that we are screening everything that needs to be screened and also being appropriate with the intensity of our physical exam. After all, it is imperative that we do not flare up patients so badly that they do not return to our clinics.
While reading the article, I was fascinated by the thought of taking multiple 5-10 minute breaks away from the patient to fill out the form. Most settings do not allow 90 minutes for evaluations like the clinic from the article. I personally tend to use the full allotted time for an evaluation in order to begin a treatment program with my patients and to build rapport. I was curious if you all thought of any other potential barriers to implementation of the clinical reasoning form.