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This piece of literature helps me with decision making by highlighting the MULTIDISCIPLINARY approach to biopsychosocial rehab for low back pain. While I certainly want to grow in my own abilities to perform pain science education and cognitive behavior therapy, the reality is (at least at present) that there are other healthcare individuals who are more specifically trained to administer these services with specific patients than I am. It is outside of my comfort zone and routine and will require more work and effort, however I think that providing the best care for my patients in a biospychosocial framework means that at times I will seek to get them connected to other healthcare providers (e.g., pain psychologist) who will be able to better address certain aspects of the patients care.
The one aspect of the video that made me a little uneasy was when the question was posed, “What do we do with chronic pain,” and the answer was given, “forget about it.”
I completely resonate with the need to not perseverate on the pain experience, however I wonder how a patient with chronic pain would respond to being told quite directly, “forget about your pain.” Thoughts?
Thanks for posting Eric. Always helpful to have more resources available. I worked saw two pediatric patients earlier this year several months status-post MVA and think that this would have been helpful to share (in addition to my own personal feeble efforts to explain central sensitization). I have also specifically remember a mom I was treating whose son was complaining of persistent stomach pain the year after his dad died; several GI and blood tests were being performed (all negative), medication administered which was semi-successful, but again this video would have been very helpful to share.
Laura,
Thanks so much for posting this! Eric referenced it in his running medicine talk and in the talk last weekend – its truly a great article and definitely one to keep easily accessible.
I sure would go down the route you are – proximal extension strengthening to reduce need for distal propulsive force generation.
As Eric tried to point out, looking for things that jump out and correcting those will probably make a bigger difference than getting nit picky. In that line of thinking, if she is in 20 degrees of plantar flexion at initial contact, I probably WOULD look to change foot strike pattern. If forefoot contacts first but ankle is relatively neutral, then I wouldn’t change it. Same idea with step rate. Below 165 and I would definitely make it an issue, above 170 and I probably wouldn’t mess with it.
Would love to see the video if you can share it!
I hope not to blindly beat the drum I have been thinking about in recent days, but it is simply so hard to appreciate the unique personality of the patient and the quality and nature of patient-therapist interaction via a discussion board/powerpoint presentation, which undoubtedly is a huge aspect of treatment. Reproduction of lateral hip pain with knee extension + DF overpressure in one patient could signal significant fear, kinesiophobia, and catastrophizing in one patient, marked central and/or peripheralization in another, or something merely mechanical/neural in another. Determining which of the three is happening seems to be heavily based on patient personality as a whole as well specific interaction and response during testing. This is simply so hard to convey on a discussion board.
Thanks so much to Aaron and others for posting regarding the experience and rationale behind the posterior talar glide in the presence of ankle sprain/ATFL injury. Results > biomechanical rationale.
Alex – to me, that final point is what is most significant. I completely agree with your hypothesis about T spine mobilization; and that is why I feel this article has limited applicability to the more acutely injured patient.
For those with chronic symptoms, however, maybe this article does indeed make us not stress so hard to get to a segment specific dysfunction (though I would still argue we should try and make SOME effort).
Alex,
You apologized, and I forgive you for the lengthy post.
In all seriousness, it certainly seems like you were fairly thorough in your exam. The only thing I might have thrown in would be a brief functional movement or two – probably something as simple as a double/single leg squat. Just to get a sense for her willingness to move and also to add greater load to knee structures, if you were suspecting local knee pathology.
I certainly would not use the term “double crush,” to a patient. In fact, I would probably never use the word, “crush,” with a patient. If I felt that the idea of double crush was present, and it was necessary for the patient to understand their condition/buy in to my treatment approach, then I would try and explain it as simply and understandably as possible, “I think we can get the best results if we work both on A and on B.” If it wasn’t necessary for patient buy in or critical for them to understand, I might not even explain it.
I feel I have come to appreciate more readily case series/reports since starting this residency. They are often more practical, with greater attention given to clinical reasoning. The RCT’s usually contain methodological flaws that limit specific applicability anyway, and therefore while I wouldn’t make the case series the gold standard of treatment, it certainly has great value.
What was the patients affect/fear level during the exam? What is your interpretation of the reproduction of hip pain with ankle DF, TCJ PA, and knee extension? Did she complete a FABQ and what was your take in this regard to the patient?
Aaron – thanks so much for offering up the thoughts on differentiation between ATFL vs. other structures, and also for the taping technique. However, I think I am a little confused. Mechanically, it makes sense to me that a posterior fibular glide would IRRITATE an ATFL sprain. However, many authors (e.g., E. Magrum) recommend a such a posterior glide in the presence of an ATFL injury. Also, it has been shown that the position of the fibula is anterior in patients with CAI. With ATFL disruption, it seems that the talus would be anterior (which it has been shown to be) and that the fibula would be posterior (in opposition to what is placed). Perhaps I am not understanding the frame of reference for anterior/posterior.
I hope to have made my lack of understanding clear. Would posterior glide of the fibula assist in treating an ATFL injury (as is recommended by many) or incriminate an ATFL injury (as makes sense mechanically)?
Okana – the article you raised certainly seems to raise more questions than propose answers (as it manifestly attempted to do). “Return to play is complex and influenced by a range of factors.” That is certainly accurate and what makes life as a PT challenging in this regard.
As the article pointed out, waiting for full tissue healing might be a little excessive, but his fears certainly are a concern and indicate that he MIGHT not yet be ready for full return to activity.
Judicious use of the evidence means that the evidence is indeed considered, but is not the sole determining factor in making decisions. Judicious use of evidence means not discounting all of the other components of decision making shown in the Venn diagram (Figure 2). As the diagram shows, there is A LOT of components that go into that decision, which again, why the issue is complex.
I have yet to read the article, however if you are hungering for more pessimism and how we can’t use a simple special test or two to make the decision simple and easy, see the attached article.
Oksana – group 1 received CPAs at a set dosage, grade and location. Group 2 received largely either CPAs and/or UPAs with varying dosage, grade, location.
I certainly hope that I apply the findings of all studies to my practice, the question is simply how. I do NOT believe that the appropriate way to apply the results of this study is to forego clinical reasoning in applying manual therapy and instead just press and guess. I simply think there are too many methodological limitations to this study itself that make that conclusion erroneous.
To me the largest “limitation” in the study is the patient’s duration of symptoms, which averaged 5 and 9 years for group 1 and 2 respectively. While I would contend that specificity in our manual treatment is ALWAYS preferable, it is certainly in my judgment less crucial when dealing with chronic vs. acute conditions. That is, it is almost certain that in someone with a 9 year history of back pain central sensitization is a significant driver of their pain, compared to a more acute injury where nociceptive mechanisms are more responsible. In the first instance, manual therapy is likely to exert its effects more generally and globally compared to the latter instance where improved specificity would be more appreciated.
Another large limitation for me is the rather difference in techniques, as you rightly pointed out Alex. A CPA at a given level is different than a UPA at the same or another level; but certainly the difference is less than that between a CPA and a rotational or side bending mobilization in sidelying, joint mobilization vs. soft tissue mobilization, or even manual therapy applied to another region (e.g., hip or thoracic spine) while not directing any specific manual therapy to the lumbar spine. I imagine that a greater difference in pain and disability would be observed if prescribed CPAs were compared to a much broader spectrum of manual therapy vs. targeted CPA’s and UPA’s alone.
Your second question is a hard one to answer Alex. Obviously we work towards an improvement in BOTH categories, but when they begin to diverge what is given greater importance? What is the greater victory – a patient who is really satisfied with the treatment they have received and yet their disability is largely unchanged, or a patient who has significantly reduced disability and yet remains unsatisfied? I am honestly not sure. All I can say is that in clinical practice I feel I work towards the former.
This reads to me as a straightforward, practical application of some recent, encouraging evidence regarding therapeutic exercise for hip OA.
I truly appreciate the journals efforts to highlight the relatively recent evidence and give it some flesh via the imagined case report.
What was interesting to me was how the case report in fact went against the Cochrane review as far dosage and duration of therapy. That is, the interventions in the studies included in the review included 6 to 36 physical therapy sessions spread out over 6 to 12 weeks. Although longer term follow up data was collected at upwards of 6 months, it was interesting to see how the case report utilized only 4 therapy sessions spread out over 9 months. I sincerely appreciate the emphasis that the results of exercise may require more protracted periods of time, however I am not sure that an appropriate application of the study is to think that less therapy is required than what was in fact shown to be beneficial.
Otherwise, I appreciate the comprehensive nature of care in the imagined case report – education, referral for weight loss, hydrotherapy, strategies to encourage exercise compliance. We do well to integrate the published evidence (e.g., the Cochrane review) into our practice without losing sight of the comprehensive way we can specifically manage the patient in front of us, even evidence for such components is lacking.
“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
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?
Thanks so much for posting Laura!
A few things I would have added: slump testing (just to supplement SLR), thoracolumbar rotation (rotation towards decreases the size of the foramen, at least on dead people, and I have consistently seen this reproduce radicular symptoms), possibly quadrant depending on how irritable she seemed, recognizing you already reproduced her left sided LE symptoms – at least I may have checked right posterior quadrant as nothing else was reproducing her R LE symptoms.
Given the Hoffmans I would have done a quick cervical screen – rotation with OP/quadrant/spurlings, UE reflexes, would have asked about if she had any complaints of neck pain following her recent fall or if she has had any other cervical symptoms.
If above was all negative, seeing that she only has 2/5 for cervical myelopathy, lack of UE symptoms, no hyperreflexia, R LE symptoms seem more infrequent than L LE which seem to have a clear reproducible mechanism and pattern, I don’t think I would have been concerned about the Hoffmans. I may have picked up the phone and called the MD just to inform, but I think in this case you can move forward with relative confidence in treating.
I wouldn’t let the presence of the spondylolisthesis deter you from your examination otherwise, especially because the image hasn’t changed over the past several years. Research has shown very little to no correlation between spondylolisthesis and LBP, and has found it to be as high as 20% in an asymptomatic population (see attached).
I like the hand use Halley – I am going to try that! Thanks for sharing.
I like the use of mirror feedback, but I guess I have been struggling over whether or not that is truly external feedback. I tend to think putting someone in front a mirror and having them watch their knee position to avoid valgus is still somehow internal cuing, though perhaps less so than merely verbal cuing “don’t let your knee go in.”
Again, I like the hand idea – thanks!