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It certainly reads like Understanding Evidence will be an ongoing series, which is great because I found the posts easy to read and engaging, which is a must for most EBP articles.
I’d love to hear everyone’s thoughts on teaching EBM to 11-13 year old students like the one author reports having done. I think that this is such an interesting topic because one third of EBM is understanding and critically appraising information and I think this is one of the biggest failings of junior high, high school, undergraduate, and at times even graduate education. Overall I think the focus of EBM on multiple value sources that go into decision making is also a worthwhile topic to be incorporated frequently into education. On the other hand, EBM as a topic itself can be abstract and dry, so I’d be curious how exactly the author framed her talk to this population.
Most importantly though, that watch is seriously sweet.
Brett, thanks for posting this case, as I am sure this mirrors a lot of the patients we see post-MVA.
About the objective details of the case, did palpation of the anterior and posterior neck muscles recreate any of his pain? What was the tissue quality like? Was resisted cervical motion more or less painful than AROM? One screen that I saw recently to consider more of a muscular component of hypomobility and pain in the neck was unweighting both arms and rechecking SB and rotation AROM to see how much the motion might improve. You also said this patient is hypomobile throughout his upper and mid T spine, but what is his upper and mid back muscular strength like and what are his biggest deficits for thoracic AROM with overpressure?
To answer some of your discussion questions:
I think for nearly every neck pain patient I have I prescribe some level of DNF training. The first reason for this is that every patient demonstrates decreased endurance in these muscles whether it be due to pain, atrophy, fatty infiltrate/histological changes, or postural/habitual. And similar to performing painfree mid AROM in the cervical spine, I’ve found that just finding a neck movement exercise that is not pain provoking and creating some movement overall can be a big first step for the chronic neck pain patient. As for progression, I typically start patients in sitting versus supine as I’ve found that even patients with moderate pain and irritability tend to not tolerate performing the traditional 10 second 10 rep cycle in supine. I then progress to performing upper and mid back exercises while also performing a chin tuck in standing. For thoracic manual therapy in the past I’ve primarily used mobilization of the T spine as a way to decrease pain in the severely irritable neck and manipulation of the T spine in the few patients I have seen with cervical radiculopathy. I think I’d like to start using T spine manipulations in the way you have done here and we talked about during the first course weekend as a quick primer for other treatments.As for the article, a couple things stand out. They spent 10 minutes on thoracic manipulation in group A, which certainly could have been spent performing lower grade mobilizations instead of HVLATs. I would love to see a comparison of the two if you spent the same time on each, as one of the biggest draws for me when performing a manipulation is how quick the treatment is. I was also surprised at how large of an improvement these chronic neck pain patients demonstrated, although part of this might be attributed to receiving 30 sessions of PT over the course of the trial.
Aaron, I actually hadn’t seen that VOMIT poster before and it brings up several body areas such as the ankle and T spine that I didn’t already have good examples for. I know that APTA has been pushing a graphic that demonstrates the number of disc bulges in asymptomatic individuals that if anyone hasn’t seen yet should definitely check out. My typical strategy for arthritic conditions is to discuss the disparity between when their pain started and their beliefs about when the arthritis actually began developing. Most patients readily admit that they think the arthritis has been developing over a long period of time, and by pointing out that they may have had findings on imaging well before pain started, they can start to see that they are not always equivalent. I would love to hear other strategies people use though, because this is something that I have a hard time with when working with patients who don’t respond well to a short and simple education like above. A quick search of youtube videos that provide similar education to the VOMIT poster turned up nothing.
Although it is a completely different population for a lot of reasons, I think you bring up a good point Justin because there are some strong parallels between individuals with chronic pain conditions and those post CVA. First I think the goals themselves are often not too dissimilar, with both a patient with chronic LBP and one post CVA wanting to do something as simple as walk for 10 minutes without needing to stop. I also think the need for more individual goals to foster motivation and teamwork are paramount for both groups.
For goal setting I have used the PSFS in the past but have found that patients find it a bit clumsy to use. One thing I found helped the patient come up with several relevant personal goals was to discuss during the evaluation and then have the patient take the PSFS home as homework so they could think within their own environment what sort of things were most important. As for this article, I really like the idea of asking patients what they want to focus on, and then providing them the best evidence based options (sounds like EBP to me!). I think going forward I will work on trying to always explicitly ask questions about preferred interventions as they relate to their goals.
Besides being an overall unique article and interesting read, I think this article just continues to highlight what Louw and Puentedura talked about in their viewpoint for JOSPT in March. Patient expectation of improvement or expectation of reinjury/tissue damage, in addition to the other psychosocial factors possibly present, can be large mediators of pain, disability, and fear avoidance. We know these things in terms of research and pain science but we do not necessarily communicate them in an effective way to our patients. All of us are familiar with data on the presence of common conditions (OA, disc bulge) in asymptomatic individuals that are listed at the start of the article, but merely just listing them off to our patients might not change perception at all. I know I have been guilty of not always providing clear and thorough pain education to some of my patients, and I have been around plenty of students and clinicians alike who have done the same. As much as we would like better collaboration with other healthcare professionals about pain science patient education, I think the onus rests firmly on us to become better at educating on pain science and measuring the possible effects of that education.