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The 2015-2016 VOMPTI residency theme (at least a significant one amongst a few) continues.
I am no expert on what I perceive and suppose to be a large scope of literature examining pelvic misalignment. The authors of this article postulate (albeit from 1998 research) that evidence is poor. My current view is that such misalignments are indeed possible – likely following significant trauma/impact or prolonged unilateral posturing or excessive repetitive motion in a unilateral direction. However, although I would imagine that such misalignments are possible, they are in no way common and are rarely THE source of a patients symptoms. Minor asymmetries have been, are, and will be present in all of us and do not need to be pathological. Again, not an expert on the literature or on this issue and would love to hear the thoughts of other residents/mentors.
In light of all that we have learned this year (and still learning) regarding the supremacy of central processing involved in the experience of pain, the results of this article are not surprising. To me it certainly helps explain the larger proportion of patients who feel as if there pelvis is in/out/up/down, etc… when in reality their positioning is little if at all different compared to what it has been previously when they were pain free.
Most of us tend to ask patients if they are having difficulty sleeping at night. I for one normally use their response to help me understand the nature/severity of their symptoms, however in light of the present study (and some of the other research they mention) we should perhaps be viewing their sleep difficulties not only as a consequence of their condition but as an impairment itself to be treated. Perhaps we should treat proper sleep habits as we would posture – something that will keep a patient from proper recovery. I recently found a very simple sleep hygiene handout (see attached) that I have given out; do any of you regularly educate regarding proper sleep habits?
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Tough topic. I have recently struggled with similar patients who have Ehlers Danlos and use muscle energy techniques to “put them back in place” every day. They’ve been taught these techniques in the past and either do them by themselves or by their spouses. It’s similar to patients to have been told they have a leg length discrepancy or have disc herniations/tears/etc., and I struggle with conversations with people who let these idiosyncrasies define who they are and how they view their bodies.
It’s easy to blame pain on an “out of place segment” because it’s tangible and one-dimensional. We are taught one way how our bodies supposed to look and if there’s something out of place, then that’s the source of the problem. The Moseley study where the patients with LBP drew what they thought their spine looked like is heart-breaking.
I try to use movement a lot when I explain either a manual technique or make sense of why a clinician in the past told them that they were out of place. Either I say there’s a little more stiffness on one side or I say I’m going to help get things moving a little better with this technique. And/or I incorporate how soft tissue tightness and tension affects the way our bodies move.
I think where once physical therapists might have been one of the sources of the misconception, we are now taking a whole new stance on chronic pain (thanks to multiple brilliant clinicians who have brought these concepts to light). Recognizing these patterns when that patient walks through the door is one thing, but being that clinician who can support the change of their view of themselves is another. I’m trying to use a lot of anecdotal stories and research as well as recognize earlier when I can start these discussions or refer out to another medical psychologist.
In regards to sleep, if the patients says they have no trouble sleeping, then I usually move on. Wow, what a big piece of the puzzle I could be tapping into if I dive a little deeper into sleep habits in general. Thank you so much for sharing that document Nick! That’s awesome.
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this topic so hard when other professionals such as MD’s and chiro’s are tell the patients this and we are going against everything they have been told in the past. The worst part is we have many in our own profession telling patients these things or even that they have cranio-sacral issues or other things with no evidence behind it. We have such an uphill battle to climb trying to get patients more aware of their body
I have not seen done many sleep tips besides breathing or positional changes with pillows. This is a great resource!
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Great points! I def agree that there are a lot of problems with that even within our profession. I just evaluated a pt (C/S radic) who kept saying that he blew out something in his neck. I asked him about it and he said that was the language that was used by his previous PT (who treated “lat epicondylitis” without looking at the neck for 6 weeks). The pt said he associated that terminology with his patellar dislocation years ago. Luckily he is very receptive and cerebral and the discussion went in our favor, but more often than not it’s not that easy.
I have another pt who’s been to the chiro weekly for 10 years and he certainly is not one who’d appreciate a confrontational discussion about his back excursions. I think with pts like that it’s just about chipping away slowly and educate every visit.
Nick – thanks for posting! I almost always talk about sleeping patterns with pts, because I feel like it often helps me guide further assessment, but I’ve never used anything like that. Definitely going to give this to a few of my pts!
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I think the problem with the dogma surrounding this concept is so multifaceted. One of the biggest issues is that we don’t have a much better, or at least well understood model of what really happens, to easily refute this belief. It is easy to educate someone who says something so obviously wrong that we can easily correct and support with good evidence why they are wrong. This simply is not the case with the mechanisms behind manual therapy. I think this is where the “rolling with resistance” idea comes into play with an attempt to gradually break down barriers that may limit your outcomes. The question may be – how much of this belief do we need to change, or is there a way we can utilize this belief to our benefit? Should this be how we are selecting who we complete more vigorous manual therapy techniques on or is this a red flag to avoid these techniques? How much a positive expectation and belief will impact our technique is likely more important than the possible biomechanical changes which may or may not occur. Check out this blog post below.
https://thesportsphysio.wordpress.com/2014/06/16/there-is-no-skill-in-manual-therapy-2/
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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.
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Hi all! Great discussion! After reading Adam’s rant, there are many points we can discuss about his blog, but here is just one:
1. He did not mention the value of assess/reassess. My question is, are you using this in your practice and are you noticing that certain techniques/vigor/direction of movement are resulting in different results with everything else the same (interaction with the patient, position of treatment, same session, etc)?
In regards to the bodyinmind.org post: These perceptions can be difficult to change and can have many influences that are deeply embedded in patient’s craniums. I may have mentioned this before, but I learned this the hard way after seeing a patient, spending a great amount of time explaining that the patient did NOT have one leg longer than the other, and was not ‘out’. She wrote this in a google review about 30 minutes after the treatment.
… The physical therapists are so thorough and look at your body as a whole not just the issue you are there for. … My son was also having an issue with his knee and one leg was longer than the other. The physician prescribes PT and after several visits, Myra found that his sacroiliac joint was out of alignment and he has not had a problem since.
I believe that manual therapy skills/specific techniques are often a BIG piece to the puzzle, but have always observed that the connections that PT’s make with patients are also important. Here is another statement in that same google review that is likely an important aspect to this family’s outcomes in PT:
… I am so thankful to know they are here when we need them. Thank you all for all the care and attention you have given myself and those I love and care about over the years, I cannot imagine where we would be without you!
I don’t think this aspect of care can be underrated, which is part of the reason I think social history is an important first line of questioning in a subjective exam. I get age, work, kids, and sometimes what their kids are doing in my subjective and often spend time talking with patients about their lives as I work with them.
As for all of the crazy perceptions about patient’s being ‘out’, ‘out of alignment’, etc, I think we need to be very very careful about the things we say to patients to try our best to make inroads to decreasing fear and misconceptions. In the past week, I have had a patient tell me a chiro told them their vertebrae ‘flips in and out’ and had two patients call with questions/worry about a PT telling them that they had one leg longer than the other. In any given week, I have a few who tell me their pelvis is out and that a PT has put it back in to resolve their pain.
Laura – I liked your comments about things you say to try to explain your findings to patients.
Anyone else? What kind of wording do you use to try to decrease fear and give the patient a more realistic perpective of what may be happening when they think they are ‘out’?
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I think Adam did a subpar job at getting his point across. It seemed that at times he was saying that the mechanical aspect of performing a technique does not require skill or special training (laymen being able to perform a technique without formal training etc.) and at times suggesting that clinical reasoning and appropriate application of techniques does not matter. I can see his point if he’s trying to say that all the manual techniques in the world don’t make a difference if you don’t know how to apply them, both on a clinical reasoning and psychosocial level. Recognizing a pt’s beliefs and educating/rolling with resistance and adjusting treatment accordingly has been one of the biggest learning experiences for me throughout the residency; also recognizing when a technique may be appropriate objectively, but may be something the pt isn’t too thrilled with. While there are some larger studies suggesting that specificity of treatment may not make a difference (vs. early intervention) and more recently Petersen et al. (JOSPT – see March review), there are plenty of studies showing the benefit of manual therapy (in combination with therex of course).
Another aspect that may be lost in the research framework is whether specific MT is ‘more better’ than non-specific intervention. If we’re looking at MCIDs and statistically significant changes, the other end of the spectrum may be lost – i.e. improving 80% vs improving 50% etc.
Adam’s points make more sense if one looks at MT as a purely mechanical intervention, however, I think we’d all agree that there is much more too it when considering psychosocial factors, neurophysiological and even systemic effects of treatment. Adriaan Louw talks about the endocrine system in combination with the nervous system and its role in regards to biochemistry in chronic pain. Moseley did the functional MRI studies of the brain and showed how education alone can change brain activity on a short term basis and who knows what else can be affected with education. Using manual intervention in this framework and using the physical experience of feeling the change that can be made after MT (assess/reassess) as an educational piece seems to bring much more value to MT and I’d venture to say that this does require skill. I think for most people it’s one thing to hear information, but another to experience what this information means. Just today, I told a pt about the MRI studies on pts with chronic LBP, watching somebody else bend over. He was right on board and told me how he can relate, because his back hurts just watching his kids jump around etc.
Sorry for the rant. But to answer question 1. Yes I do assess/reassess and yes, I’ve seen differences in regards to vigor of techniques making a difference without changing other factors.Myra – thanks for sharing that example. Aaron made a good point about rolling with resistance. I think some people get it right away, some need X different examples/metaphors, some need the experience, and some won’t change their beliefs regardless of what we say. Trying to figure out who’s in which category is certainly an art and probably somewhat of a gamble at times.
In one aspect I certainly agree with Adam… there are still plenty of PTs who think in strictly mechanical terms and focus on things like left-on-right rotations etc. without addressing the bigger picture and at the same time, feeding into or creating some of the beliefs we talked about.
A lot of times I’ll ask a pt what they mean when they use some of these terms (while not trying to sound facetious), both to figure out what it means to them and where they may have heard it. I think understanding what their specific belief or association with a word is and where it comes from makes the rest much easier. I like metaphors that don’t involve any structural terminology or words indicating damage – i.e. LBP if the T/S and hips don’t move well, I’ll talk about the teamwork between the structures and how parts of the team not doing their job, the others (L/S) will have to pick up the slack and will get upset/angry etc. Then exercise becomes a something that helps the L/S to pick up the slack, while mobilizations of hips and T/S becomes a way to make the rest of the team get off their behinds. This kind of metaphor, in combination with education on normal findings/changes etc. has worked pretty well for me. I also use analogies about the brain being a computer a lot, with chronic pain or movement patterns being programs that need to be updated.
Here’s another study that has set off a few light bulbs:
http://www.archives-pmr.org/article/S0003-9993(04)01323-1/abstract
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“There is NO skill in manual therapy, and it really doesn’t matter how you do it.” FALSE. Patient preference, expert opinion, published research trials, all refute this concept.
“Lastly but most importantly, all manual therapist needs skill in interaction! Being able to connect, relax, reassure and calm people is a ‘skill’ not to be taken for granted. It’s this skill combined with simple, confident, comfortable handling skills that I truly believe distinguishes a great manual therapist from a good one.” VERY TRUE
Not trying to be too blunt, but that’s how I feel about that post and what I think it’s worth. There is simply no mistaking it that there is indeed significant skill in selecting and performing manual techniques for the specific patient in front of me. I have made people worse and made people better, and have watched others do the same, on the basis of their manual therapy skill (again, selection and application of technique).
Nevertheless, the point is well received that INTERACTION with the patient is absolutely critical, and not to be taken for granted. I would guess that even upwards of 50% or more of the success of my manual therapy is owing to the “therapeutic alliance” or whatever you want to call it that is developed as I work with and interact with the patient.
But, to repeat myself, I think it is a case of both/and not either/or. Great therapist are skilled at BOTH selection/application techniques AND interacting with patients in a manner that makes them feel relaxed/cared for/reassured, etc…
– The Resident Physio
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I definitely have not had much success in attempting to change a patient’s belief on what they have learned from prior clinicians. I would say I’ve tried more along the lines of what Laura mentioned and attempt to uncover or provide an explanation to why the “out of alignment” is occurring and address the cause. I try to keep things as simple and as functional as possible and bring to light their impairments to provide an explanation. Just as Laura said, for example, maybe there’s a stiff joint, a tight muscle or a functional weakness that could be causing the issue. In an attempt to decrease fear, I’ll typically use the approach that I’ve gathered from O’Sullivan and educate them on the resilience and robustness of their spine and normal imaging findings. Sometimes all it takes is to just educate people that it’s OK for them to move. I love O’Sullivans flexed fist/wrist analogy to relate to the spine. I use this all the time now and you can just see the patient relax and a light bulb go off in their head after teaching them. The days of breaking out the spine model are over. I can’t believe how much I use to do that.
To follow up with Aarons comments, it’s definitely a red flag when individuals are seeking passive treatments. Again, I’m trying to educate them on us trying to get to the root of the problem. This is where I go back to the functional exam and relating those findings to their limitations and goals. If they think they have a short leg or a crooked spine or an out of aligned pelvis, I simply educate them that everyone is asymmetrical to some degree, especially at the pelvis.
On the subject of manual therapy, there is no question that our demeanor and placing our hands on a patient has an immediate effect whether we know what we’re doing or not. Our tone of voice, calmness, speed, vigor and even the temperature of our hands (mine are always cold, it doesn’t help) is felt by the individual and they either immediately feel comfortable or they can become even more fearful. I agree with a lot of what Adam said. If you don’t have an understanding of the biopsychosocial aspect to injury and pain and how to deal with people in pain, it doesn’t matter what technique you know. For me, the skill in manual therapy is when you know the anatomy of the body, have an understanding of what normal tissue and joints feel like and you’re able to determine if the abnormalities you are perceiving are relevant to the patient’s presentation. But, if you don’t have an understanding of the biopsychosocial aspect to injury and pain and your interaction with the patient elicits fear, it’s not going to matter what you know.
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It seems to me that most of our treatments are tailored to how the patient “feels”. If it’s body image with their pelvic alignment then I try to focus on an impairment and see if the patient’s reassessment changes. Adam’s article focuses on the power of listening to our patients. I find this extremely difficult especially if the patient is a talker. My question is how do we better facilitate conversations at least during the evaluation? I agree with Myra when it comes to reassessment because patients need to see a change not only for a buy in but also for relief either that me physical, mental or both. Then again what sets us different then chiropractors? They do manual work as well. I don’t know if they reassess but some patients do feel better after and sometimes it stays the same or they get better. I definitely say that having the knowledge behind why we choose a technique gives us a higher probability of creating a positive change.
I agree with Bialosky: stay away from contraindications and apply your skill based on your clinical reasoning. If manual therapy worked 100% of the time then we wouldn’t have people arguing against it. Obviously there’s skill through confidence and we see our patients for 30-60 min per session. What they do outside the clinic is not our responsibility. Life is life and people will continue to live it how they please.
Education is definitely a theme! I try to use words of “this is irritating causing a muscular response” or to support manual therapy I say “Have you ever touched something hot and then grabbed your finger and rubbed it?” I don’t explain the science behind hypersensitizing receptors but I explain how manual therapy is beneficial. Going back to reassessments, I use this as a HUGE learning tool. Those who say “my arm is the issue” I show them how I move their neck and that reproduces THEIR symptom. I try so hard to find some comparable sign (my hope it’s the primary) in each treatment. Those who are the pro athletes make it challenging but I have to stress that tissue somehow or else why are they here? I still have difficulty finding the ideal comparable sign. What do you do when you can’t find that one thing causing their pain? As well, we see patients after plenty of other treatments and I ask them to explain to me what their pelvic alignment means to them? If it doesn’t make sense to them then I take the route of Alex and explain the “teamwork” approach for the body to work as a whole.
Moral of the story: Listen, educate, find a comparable sign, reassess, move what is stiff, decreased hypertonic tissue, and listen/ educate again. Of course using clinical reasoning and getting creative is part of the fun.
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