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This is a great video. I like the step back it takes towards the end to really show the viewer all of the factors that contribute to someone’s pain experience.
I have tried using the analogy that most of us have heard where someone would not feel an ankle sprain if a bus was coming toward them or a lion was near etc. I think most people understand this conceptually, but do not correlate it to their situation(due to it not being individualized). I think using a similar analogy with athletes in the context of their sport has worked better for me. The best example I can think of is a patient that I am seeing who is a Tae Kwon Do athlete. Asking her if her symptoms change when practicing or competing in TKD versus when she is at home or work and then explaining to her how the environment and her perspective change her symptoms. I think this has helped to change some of her views on her pain, however adding a video like this may help to change her pain experience further. I need to begin collecting videos like this. I really would like to get my hands on a copy of the Why Do I Hurt book as well that seems like a good resource.
I was going to post a recent article from the Journal of Spine Surgery as its own post, but this actually seems like an appropriate place to drop it. It shows the importance of pain education in patients that are undergoing spinal surgery over a 3 YEAR follow up. Take a peek below.
There are things that we see that key us in to how to progress our patients based on the subjective and objective findings we collect. What I articulated poorly was the difficulty I have found in communicating with physicians that refer patients to us and expect us to follow their protocol. I have found that some doctors do not want to hear this, especially from a new clinician. I thought that others may have had experience with this as well and had some thoughts on how they have handled micromanaging from their referral sources.
How does everyone work with patients that are referred from a surgeon that requires a specific protocol? The article talks about exercise protocols that the PTs were giving him and I can empathize with how this must make patients feel, but I also feel limited by certain referral sources based on the protocol they give me. This is a major frustration of mine for the very reason the author of the study brings up. It limits me from personalizing a PoC for my patients and it makes it difficult to progress and regress interventions for patients that may benefit from this.
One of the limitations the study discusses is the oversimplification of classification systems in the treatment of neck disorders. We have talked about this before with the lumbar spine and I thought is was good of the authors to bring this up. I’m sure we all see a great deal of patient’s that would fall into more than one category or not quite fit into any. Another portion of this system that I thought was oversimplified was the input vs. processing vs. output conditions. I think there is an argument to be made as to whether the Central and Sensorimotor dysfunctions could be both processing and output rather than one or the other.
As for whether central dysfunction covers a chronic neck pain patient well enough, I think the study did a good job of covering the variable presentation you would expect. One thing that was covered, but I think could have been expanded upon was the fear-avoidance and catastrophizing behaviors. This was discussed, but I think the patient’s history and catastrophizing behaviors are the most useful in determining chronic pain conditions and I think the article could have expanded on these topics some more.
I agree with August, the traction recommendation was definitely one that I was surprised about. Especially with the rather absolute language that the authors used that August already alluded to. I certainly do not use lumbar traction frequently, but I could see a patient seeing these guidelines and being against a part of treatment that could benefit them.
One thing that stood out to me was in the context of the guidelines at the end of the article. They stated that the guidelines initially moved away from grouping LBP by duration (acute, sub-acute, chronic) and focused more on LBP as a whole with considerations for risks of poor outcomes. We have talked during the weekend courses about the different classification systems and the pro/cons of each, including the idea that the CPRs we use may be more prognostic rather than diagnostic. I think with that in find providing guidelines with outcome risk in mind makes a whole lot of sense.
Being from LC I should probably have a better answer for this, but sadly I do not. I cannot say that I have specifically thought about muscular slings during interventions, but I have noticed pain and dysfunction with rotational motions in a number of my patients with LBP. I have found interventions that simulate they functional rotational activity with cueing for motor control have help tremendously. I chose they activities for the reason of selecting interventions based on function, but in reflection I can see how they would be activating these systems.
Some examples would be similar to these exercises:
Once again, Go Steelers and Happy Thanksgiving y’all.
I would have also completed a neuro screen for this patient, everything else looks pretty good screening-wise. With her history of motorcycle riding I initially thought that Guyon’s canal syndrome may be involved, so I might have added Phalen’s, Tinel’s and palpation of guyon’s canal. I also may have added ULTT to your objective measures. I have not taped this region of the body, but I have for the AC joint, medial arch, and PFPS. I have found some success with these techniques, but I try to make sure to explain to the patient that the taping should be a short term solution while we find ways to improve symptom free performance of their activities.
1)I think it would be reasonable to associate the left IO activity with the subjects being right handed and that the ipsilateral association of EO and SA may be related to contralateral activation of IO. It is surprising that the authors did not explain this as part of the discussion, especially since the IO was shown to be the most active muscle throughout their testing.
2)Good question. Based on this study and anatomy I think it’s hard to say with any confidence that you are only on one muscle when palpating the abdomen. Most of the time when I teach patients to isolate core muscle I’m more worried that they are not using their RA for everything and going into a mini-crunch. I think research is showing that isolating core muscles isn’t a largely effective intervention technique and many patients struggle with this intervention, so with some patients I think it’s better to skip this step all together and work on general core activation instead of breaking it down.
3)I use wall-slides all too much probably. I am going to start adding the isometric SA exercises. I gave those out to a couple patients yesterday and they seemed to respond well to them.
4)No, but this sounds like an interesting read.
5)It obviously depends on the patient and how much SA plays into their dysfunction. If they are someone with SA weakness and that is driving their presentation, then starting with the isometric exercises seems like a great place to start. However, if they have poor motor control then breaking down their functional activity into smaller tasks and focusing on scapular kinematics with some core activation might be the best intervention for them.My response for question 1 explains my thought process for the pictures Myra posted, but also Go Steelers.
I personally would love to see Physical Therapists become providers and begin to offer more wellness services. Right now we are mostly a reactionary service, treating injuries that could have been prevented with earlier intervention an education. I think there is a lot of benefit from having a regular visit with a musculoskeletal expert, especially with the current obesity epidemic and sedentary lifestyles seen with most people. We are in a great position to cause major change in that arena.
Myra brings up a good point asking whether this would still support person-centered decision making. I think the provider model has the capacity to support or detract from a person-centered decision making process. Ideally, we would be able to see the patient from year-to-year and better understand them as a whole person and help collaborate in the decision making process this way. However, I can see how this model could lend itself to a more paternalistic care approach. I think it would become even more necessary to make sure we explain to patients/persons that we (the PTs) are not fixing their problem, we are empowering them to make change without the continued reliance on our service or any other service.
Going back to the original point I made about the information (good and bad) that people have access to now and the fact that this can cause people to change their minds between visits, think about how much someone’s goals would change over a year. I agree with August, PTs in general do a much better job at seeing the whole person rather than a diagnosis, but there is still potential for Therapists to miss important pieces of the decision-making puzzle.
I think I was just feeling especially cynical after reading this blog post by Roger Kerry about remaining critical of the models we use for care. He recently had a mild backlash to a tweet/twit/whatever about use of the biopsychosocial model and responded with this post.
Thanks AJ for bringing my attention to the title of the article and making me give extra thought to the words. When reading through the section of the paper with the same subtitle A patient in the clinic; a person in the world a powerful quote was made:
“When different clinical groups or different individual clinicians can genuinely disagree on topics in their professional capacities, then how can SDM [shared decision making] fail to integrate an individual patient’s exposure to the wide range of information at her fingertips.”
This was certainly eye opening for me. Expecting a person to come to a goal-setting decision within the initial evaluation and then never change the “shared decision” we made throughout care is not very feasible once you give it some thought. Even with the wealth of educational intervention we typically utilize we are asking the person to make a decision based on limited information and without conversations that are undoubtedly going to occur once they leave the clinic. What I gathered from this except was making sure to not only reassess the person’s objective findings related to our functional goals each visit, but also touch base on their goal themselves and assess their thoughts and feeling on care/progress as time moves forward.
I do not have any additional podcasts or blogs that I use frequently, but here are a couple of tools I like for finding and pushing articles:
Scholar button is an extension for google and add-on for firefox (maybe other browsers if you like safari or EI for whatever reason) that will automatically search for links and pdfs of any article you highlight. You can also add libraries you have access too so it can pull from these sources. It has been a huge time saver for me when I have been trying to find full text for something I come across on the interweb.
Read by QxMD is another aggregator of journals and articles that has a nice look app associated with it. Now that Eric showed us the PubMed and RSS tricks I’m not sure how much I’ll use it, but it has been helpful in the past with letting me know when new articles are published in journals I follow and with topics I have subscribed to.
I really liked the topic that highlighted S4BE. That site has a wealth of resource all over it. I have quite a few tabs open from them right now (not a many as Justin though).
The most recent post about evidence of absence and the invisible unicorn was great at explaining a common conclusion that authors draw and it is usually not truly the case. This is a great tidbit to be aware of when assessing articles. I look forward to more posts from this blog and hope that is doesn’t remain just a week long special.
Also I really want this watch.
I look forward to seeing everyone tomorrow.
Thanks for posting this case.
As August already pointed out I think adding a step to your screen and unweighting the UEs to see if motion changes is helpful, especially with a patient s/p MVA as some level of muscle guarding/stiffness may be present. I think the Patient’s SINSS warranted the approach you took. Had his irritability been higher I may have decreased the amount of manual intervention performed. I think it is challenging when you have a patient with moderate-severe irritability and you want to include multiple manual techniques. Sticking to one or two techniques that will maximally benefit the patient and have minimal chance of flaring patient’s symptoms up is more important with those patients so that the provider-patient trust is not affected.
I think use of asterisk signs is very beneficial for both the PT and the patient. It is a way to assess if you (the provider) are treating what you are attempting to treat and it can create patient but-in immediately if you bring the patients attention to a change made within one or two visits. I like having at least one asterisk sign that is purely objective and not related to pain, which I find hard with some patients, especially one like this where his severity and irritability are lower. I have typically seen with these patients they are able to go through most screening and objective tools with little to no limitation and only have their symptoms in extreme positions or with endurance tasks making it harder to test-retest quickly and effectively.
I use DNF with most patients with neck and thoracic pain, however I do not always use thoracic intervention with patients with neck pain. My decision making for use of thoracic mob/manip intervention includes assessment of the patient’s thoracic mobility actively and with PAs in supine. I feel much more specific with mobilizations so I will target a specific segment and motion if I feel I can make a change in the patient’s mobility this way. I will use manipulation if the patient seems grossly hypomobile or if I am not making the change I would like with mobilization. I feel most comfortable with the supine/hooklying thoracic spine manipulation and I will modify it with a bridge for the upper thoracic spine. I utilize the prone manipulations similarly to when I am mobilizing. I feel more specific when utilizing the prone technique, but not as effective. I have much more experience with the supine technique.
I progress my DNF training similarly to August as well. Usually I start in supine and progress to seated and then to standing. Sometime this depends on where the patient’s functional limitation is (sitting v. standing). I have also found it to be beneficial for some patient to add a step from supine to against a wall so that they have gravity against them, but also have a surface for feedback similar to when they were supine. Once getting in a functional position I then add in challenges with the UEs.
This outcome measure shows a great deal of promise for use with patient’s that show signs of FA and chronic pain behavior. August brings up a good point that the cutoff score will help in determining how to progress with patients. I look forward to seeing if and how these cutoffs vary with further studies using more diverse patient populations. Another aspect of this study that I really liked was the fact that it takes into account what the patient is fearful of. Understanding whether the patient is afraid of pain itself, increased pain, or (re)injury is extremely valuable when determining how to progress our treatments.
To answer August’s questions, the only FA measure I have any experience with is the FABQ. I think it works well for patients with LBP that want to return to work or are limited at work due to their pain, but that makes it a very narrowly useful measure. However, the FABQ is useful in this specific population due to the large body of research behind it.
I honestly have not used these measures recently with patients, but I have been using graded exposure for a couple patients that want to return to tennis. They both display signs of fear avoidance with exercises during Physical Therapy and have given themselves return to play times that far exceed what you would usually expect with their injuries. As they became more comfortable with the interventions used I started to work in jogging, agility drill, and rotational challenges that simulate swinging a racket. One has begun to hit balls with a machine while the other has still been avoiding beginning tennis drills. I have noticed with the graded exposure approach both patients have hit a plateau at different levels of recovery and I have begun to incorporate more educational for these patients. It has been helpful for these patients to make them aware of the kinds of movements they are capable of during Physical Therapy Intervention and relating that to tennis or whatever activity is causing their pain. One of the patients has begun to realize that what we do in therapy is practically as challenging or more challenging than what they are doing on their own. This has increased his confidence for returning to full play, however we still have not gone there quite yet. I have not yet had a patient that I thought may need a referral to another provider, but I look forward to hearing what others have to say about this.