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For the patient that tells me “You don’t understand what I am going through” I will say, “you’re right I can not experience what you are feeling, but I want to help you feel better and this is how I think we can accomplish that…”. With patients that I recognize with irritable symptoms or with fear avoidance behaviors I try to gain trust by letting them know that they are the experts on their own body, they’ve lived with it their whole life. I want them to communicate with me their pain or the reservations so that I can cease an ineffective treatment or let them know that what they are feeling is the goal of the selected treatment. With the latter of those 2 goals it is always helpful to let the patient know what to expect with a selected treatment prior to initiating it.
Those first 2 visits are tricky things with patients. If I don’t nail those down trust is hard to gain. I have seen quite a few patients recently that come in on day one stating they need imaging or a specialist or their chiro. I have found a lot of success with explaining that MRI/x-ray is a picture and doesn’t show movement which is when most patient’s hurt. I also explain the false positives shown with imaging and I feel like this helps with most patients. The expense of an MRI is also sometimes enough to gain some buy-in for PT over imaging/surgery. It is not my first option, but it is definitely something that works well with certain folks. I have noticed some that still have that look about them that says exactly what you already brought up, “but that study or image is not me”. This is something I have struggled in finding an effective response for and I would love to hear what others have done in similar situations.
1. That must have hurt. I’m sure she had some type of dysplasia, I really hope she didn’t have to live with a constantly subluxing and/or dislocated hip that long. It would be interesting to know more details about the procedure, since it seems to have lasted a fairly long time without symptoms returning.
2. I wouldn’t change much. Thorough lumbar screen, I liked the added R hip flexion with use of a step for AROM. I’m not sur I would have gone through all of the provoking positions with OP, but if she was having mild symptoms and you wanted more info why not right.
3. I was helping treat one of Kristin’s patients with LBP yesterday that had significant hip mobility deficits. He has been responding well to lumbopelvic dissociation intervention in supine, quadruped, and functional positions. He really wanted to get back to golf, so it made sense to focus on golfing type activities and gaining rotational control through the low back and hip. I’m not sure your patient would have needed all of those interventions, but maybe something to try with a similar presentation in the future.1. 3×10 lol – more in answer 2
2. I feel like this only works with a small highly motivated and high level patient population. Most folks are doing to either not perform their exercises or perform them in a way that is not optimal. At a minimal checking the patient’s HEP performance once every 1-2 weeks to tweak it seems necessary to me. However, for most patients the more we interact with them the better off they’re going to be.
3. This is a tough call due to how the treatment selection was structured. The way I read this was that the treating therapists were able to select 2 additional techniques after long axis distraction with thrust, Distraction in hip flexion, IR in prone, and STM. So then you have to decide what would be most effective for the subject after that. It just isn’t clinically applicable. In the clinic we would chose whatever is best for the patient and if they are lacking extension for example and have OA I would want to perform some distraction techniques, possibly some manual stretching if indicated, PA mobs, and lumbar spine intervention if the patient has limitations there. This article shows the difficulty in creating a well-designed study and retaining clinical applicability.
4. I hardly ever use US and I do not know what it could offer a patient with hip OA. The provoking area would be so deep I could not see US providing any effect at all. I would love to hear what others think about US for this patient and patients in general. It is just something I rarely break out in clinic.I have been seeing a lot of patients following MVAs and have been practicing pain science education with graded exposure. The #1, #2, #4, and #8 concepts Butler posted are things I regularly address with patients. I explain that what the patient is experiencing is a normal response following a car accident and that it is the body’s way of trying to protect itself, however sometimes it can be a little overprotective (like a helicopter parent, or crazy girlfriend, etc.). What we are going to do is retrain your body that not all movement is bad or warrants a protective response. We will do this by slowing adding non-painful motion back to this system starting with small non-weightbearing motion all the way back to walking and/or sport. That way we let it knows things are going to be okay without sounding the alarm.
What works for others? How would you change my spiel?
For reference:
1: Pain is always normal, personal, and real.
2: There are danger sensors, not pain sensors.
4: Pain depends on the balance of danger and safety.
8: Bioplastic… pain can changeGreat read. The honesty of some of the doctors in this write up is refreshing. The article mentions a doctor that reversed his stance on hormone therapy for postmenopausal women with heart disease and how hard it was to hear his patients’ response. Admitting your error, especially in front of a patient is difficult. Maintaining trust with the patient would be not only challenging, but also significant for their care. This is a great lesson in the importance of staying current, utilizing truly effective treatments, and checking your pride every now and again.
Another point that was brought up in the same area of the paper was our cultural bias toward novel over proven treatments.
“We have a culture where we reward discovery; we don’t reward replication,” Prasad says
I think this is so true, especially when I look at all of the information that is pumped our way from varying sources. It is so easy to get caught up on one wildly new idea before properly vetting it. As a clinician I think we have a huge challenge with the current research and clinical landscape to stay current, but also stay grounded.
1. I agree with you, I find it hard to believe that this group of patients would not have a significant change. This is definitely a large a part of my current practice too and anecdotally, I have found benefit in addressing activity level and encouraging increased activity in older adults with CLBP.
2. FABQ or STaRT. I should probably look to diversify.
3. I think graded exposure is the way to go. I talk up any aerobic activity early and often with most patient’s, but probably more so with patients with CLBP.
-My little soapbox speech goes something like this, “The best CV/general exercise for you is something that you will do regularly, so if you like walking, biking, swimming, group exercise, badminton, etc. do it. Getting your heart rate up will increase blood flow and healing throughout your body, decrease your pain, and increase your feel-good hormones. That’s 3 good things for you right now and in the future, so finding something you will make a habit of is important” I change it up based on the person, but that’s the just of it and I have found that it works with most folks.
4. I always ask “what would you be doing if X body part/region wasn’t hurt” or “what did you like to do before your injury? if they are having a hard time answering “what do you do for fun/exercise”. I have found pretty good success with that, but I still get the occasional patient that states they do nothing or just watch TV.
5. I like asking questions based on the patient’s perspectives to help get the patient to start thinking about what they want out of PT and to motivate them.
1. I don’t think I would start with manipulation with this patient. He doesn’t really meet the typically patient characteristics that would seem to benefit from manipulation intervention with his chronic and distal(ish) symptoms. However, I would not completely give up on it at a later visit if I thought it might help, especially since the patient has already indicated they think their chiropractic intervention helps. Perceptions are powerful things and if this patient truly believes they will help then they might even if he isn’t the typical candidate for that intervention.
2. I might had assessed some hip special testing just to be sure it is not involved, but you screened for it and this may be something that would not have added much to IE and could be reassessed later if the patient is not progressing as expected.
3. This is something I would have my eye on. I would refer out if his foot drop was severe enough he was unsafe at home/work/whatever or if other neural signs popped up in eval. It looks like his neural screen shows some differences side to side, but the myotome testing shows no weakness with repeated testing. Since he was referred and didn’t report any other red flags or neural signs I think it becomes something to keep an eye on, but not refer out for immediately.
4. That’s a toughy. It would be interesting to see if his running form changed as his lateral shift did and if that affected things at all.
5. I liked that you looked at his bike posture. I feel like this is missed with a lot of folks. I would do the same with all of his exercises, modify his form if needed and make talk to his about avoiding loaded lumbar extension exercise. Try to give him alternatives to exercises that would not be safe or comfortable for his anatomy.
6. I can’t say that I have. Looking forward to hearing about this.
I agree with you August, I think the article is really interesting and was a good read. I’m not sure how much of it I would attempt to explain to patients due to inducing fear. The first paragraph of the results section is eye opening. I knew that imaging was variable, but I would not have guessed the results would be this varied.
“There was marked variability in the reported findings across
the 10 study examinations. Across all 10 examinations, there
were 49 distinct findings reported (in either the Body or the
Impression section of the MRI reports) related to the presence
of a distinct pathology at a specific motion segment. The
findings included vertebral alignment, disc bulge, disc degeneration
and desiccation or spondylosis, disc height, disc
herniation, stenosis of the central canal, lateral recess and
neural foramina, nerve root involvement, end plate degeneration,
and facet degeneration. Among the noteworthy aspects
of this aggregated set of findings is that none of the 49 reported
findings were unanimously reported in all 10 study
examinations, and only one of the findings, the anterior spondylolisthesis
present at L5–S1, was reported in 9 out of 10
examinations. Of the interpretive findings, 32.7% only appeared
once across all 10 reports.”It would be interesting to see this study expanded upon with different patient presentations and areas of the country. It would be interesting to see if imaging results shares a pattern with the prevalence and cost of surgeries in different locales across the states.
This post got lost in limbo somehow, sorry for hijacking your post Kyle/Nic.
I have seen 2 patient’s with similar symptoms and demographics and one patient I am currently seeing that is an adolescent. None of these patients have been mildly irritable like your patient.
My thoughts on additional testing for this patient would be a gait/running analysis and tests of abdominal strength and endurance to see if these are contributing to diagnosis. It seems like this will be a tough patient to categorize due to his minimal irritability. I always have more difficulty with these patient’s due to the difficulty in reproducing their symptoms in clinic. Reassessing some of the LE and lumbar ROM with combined motions and axial load may add some value, but he seems like someone you may have to fatigue before his symptoms show up.
Here is a good resource from Medbridge, I haven’t looked in depth for research regarding this condition. I would be curious as to an update with your patient as I have felt like the patients I have seen with similar symptoms were difficult to manage.
Phase 2 based on OBJ
Don’t stretch the AchillesFlexibility training 3x30s 2-3x/day
-Hamstring stretching
-Thomas stretch
-ITB stretch with pro stretchStrength
-SLR 4-way or hip machine 4-way if available to allow weight bearingMotor Control
-Squats
-Focus on maintaining medial foot loading in hopes to prevent knee varus and improve force distribution through Achilles
-Side steps with resistance to improve strength/activation of hip ERs
-Trying to prevent varus to valgus seen at step
-SLS – with rotational challenge if possible to involve hip ERs/IRs
-Progression to step down as intervention as bio mechanics improve with previously listed interventionsPhase 1 of Rehab
Modification of current program
-Cross-training (biking, swimming, anything not running/jogging/walking/etc.)
-Assess gym program and modify any Achilles exercises to mid-range and avoid ECC
-No stretching of Achilles tendon/gastric-soleus complexInitiate isometric program for Achilles tendon
-In neutral or into slight plantar flexion
-With total gym or seated with powerband or theraband
-5 reps at 45 second holdsSchedule
-Day 1 – isometric exercises
-Day 2 – cross train
-Day 3 – Gym exercise without exercise involving Achilles
-Day 4 – rest
-RepeatPhase 2 of Rehab
Assessment
-Ankle position
-In prone
-In standing (ankle and globally)
-Squat (ankle and globally)
-SLS (ankle and globally)
-Swing test (ankle and globally)-Based on findings assess
-Core strength/endurance
-Hip mobility
-Hip strength
-Knee strength
-Ankle mobility
-Ankle strength
-Rear- and midfoot mobility
-Intrinsic muscle activationIntervention based on assessment
-Could include flexibility and/or strength training throughout core and LE
-Most likely will include motor control intervention for functional activities and impairments foundI would hope that if the NDT intervention flairs the pnt up that their sxs would decrease with cessation of the technique. What concerns me most with prescribing it before fully understanding the pnt’s response is that they will continue to perform the technique as part of the HEP and continually irritate that tissue before their follow up visit.
I think body mechanics with her daily activities can definitely be beneficial, but I would also take with her about her stress levels. This is obviously an issue for her based on subjective with her nausea sxs, stolen credit card, work, and other life happenings. Recommending exercise as a means to reduce this or determining if referral to another provider is necessary could be beneficial for her.
1 I think you did a good job of covering your bases with TOS and obj testing. To me you covered screening out cervical, thoracic, and shoulder involvement well.
2 I avoid prescribing NDT intervention on day 1 due to the chance of latent response when performing these techniques. I like being able to see the patient for a follow up to assess their sxs following IE before prescribing NDT intervention as part of the HEP. To describe neural mobilization in general and the theory behind a glider technique I like using bike brake cable as an analogy, since it has a sheath and the actual cable running through it. I will explain that you want the cable running smoothly through it, but sometimes the cable can snag or get compressed and then it will not slide as well. I heard it from somebody in my clinic and it made so much since to me since I have loads of it lying around. Unfortunately, not everyone knows what brake cable looks like, so it doesn’t always work.
3 ???
4 I think you did a great job of finding specific objective test-retest findings at each visit with this pnt and I think that is hugely important with pnts that have several sxs. You were able to assess a baseline, provide intervention, and reassess to determine the pnts response. This way you know for sure that the intervention is affecting their sxs in some way.
5 This is a tough one, especially for pnts that work in skilled labor. I have found that a lot of pnts in these careers do not feel like they can change jobs do to not having the required skills to perform a different task. I think it is always important to try to modify their environment first. When this doesn’t work, I think it is better to ask something like, “Have you ever considered a different job”? I think is a fairly open-ended way to at least see where they are at in thinking about how their job affects their daily life.