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On guard
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On guard - January 18, 2005 4:27:00 PM
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Jon Newman
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From: Amherst, WI
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A simple question to all. How do you, in general, help someone to decrease muscle guarding (secondary to pain) about a joint? Feel free to pick your joint if you feel more comfortable that way, I'm more interested in methodology than technique. Feel free to use a post-op shoulder or knee if you wish. They are less controversial.
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: On guard - January 18, 2005 4:47:00 PM
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gary s
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From: wantagh, ny, usa
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Jon,
Simple Contact.
Gary
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Re: On guard - January 18, 2005 5:16:00 PM
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Diane
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Yes, kinesthetic chatting with the tissue. Combined with positional release sometimes. Muscle energy other times. It depends on what it seems to require to let go. I like the patient's brain to come to its own decision about the matter, but it seems to need some sort of sensory input usually before it will melt down the defence.
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Re: On guard - January 18, 2005 6:03:00 PM
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nari
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From: Australia
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Agree in principle with the above, and add neural work, which melts away muscle hyperactivity (the visible. palpable sort) in moments.
Nari
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Re: On guard - January 19, 2005 12:59:00 AM
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SJBird55
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From: Michigan
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I don't use my hands to that high of a degree to actually get the relaxation or reduction in guarding. I talk... get them laughing... talk some more... explain/educate... tell stupid things about myself and more laughing... I don't muscle them or fight the guarding - I just slowly increase the range available basically with humor and indirectly get their body to trust me. In really tough cases... yeah, I'll use grade I/II mobilizations and muscle energy... but usually, I just use humor.
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Re: On guard - January 19, 2005 1:32:00 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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Until you get this patient: Had medial flexor tendinosis - cortisone injection "fixed" that; developed CRPS mostly in wrist and hand, had ganglion blocks and "nerveblocks" (at what seems the lateral triangle of the neck), which helped the pain and swelling "a bit", then had a flare-up of medial tendinosis, which was helped by cortisone again... When I saw her first after all of this, she had a normal looking wrist and hand (colour, hairgrowth, bloodvessels etc), severe pain at the whole wrist when I was gently taking her pulse (normal); 15 degrees of flex/ext of the wrist with MASSIVE pain reactions and tears, but no colour changes in the hand. I have managed with a lot of coaxing and slow progression in one session, to actually do a flexion/extension glide of the carpus with very little pain and a surprising ROM, but still no more than 15 degrees of AROM and PROM - palpation during PROM (gentle of course!) made clear that there was a very quick and strong guarding of the carpal flexor muscles - esp. the palmaris. This was all just to establish what the actual parameters of the local problem were. Needless to say, the problem is not local anymore....:-)
I have seen her two times now for some therapy, which involved lots of gentle emphasis on having her MOVE it within her present parameters, confirming that the actual joints have enough ROM in them to allow for more motion, that the muscles are being "held", likely secondary to sensitisation of the whole darn system, and finally, just some light hands-on on the brachial plexus area. ANY handling of the wrist results in a pool of tears; when asked about her goals, she was till stuck in the "I just want it to be better"-mode. I have lots to do, especially since her MD and her specialists (rheumatologist, physiatrist) as well as the patient herself see this as a strictly peripheral condition. Pain management in a multidisciplinary approach is NOT going to happen. Too bad, because this is I think the most reasonable approach for her.
Sorry for the ramble, but this thread one day after her last visit brought htis out. Talk about "guarding"!!!
I am very weary of too much hands-on - please fire away!
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Re: On guard - January 19, 2005 2:19:00 AM
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Jon Newman
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Hi Sebastian,
I don't think anyone is going to "fire away". At least I hope not. This thread was simply to invite people to describe some of their experiences with muscle guarding.
By the way, what are some of the major factors at play in muscle guarding? Another way of asking this is, who muscle guards and under what conditions do they do this?
jon
I should have stated above; what are our current conceptualizations of guarding. If I'm not mistaken the pain-spasm-pain construct has largely been discredited.
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: On guard - January 19, 2005 4:35:00 PM
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Jon Newman
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From: Amherst, WI
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Today I saw a patient with a total knee replacement approximately 10 days ago. She is struggling with bending her knee. When she left the hospital she was about 65 degrees flex. Upon PT exam she is 60 degrees (only 65 after some work that same day). When I ask her why she cannot bend her knee more she states, "It won't let me". On the other hand she doesn't find using an assistive device necessary and was proud to state that she cleaned her home and vacuumed. She has good extension. On Monday this week she was at 60 again. We talked, I did my best to explain pain, we discussed her goals, I gave her a poem. Today she was at 65 degrees and proud to have worked on it so hard. At the end of PT today she was at 72 degrees, prouder yet. I have only followed HER own movement into flexion and given verbal cues. We'll see what outcomes are but I'm sensing a rising sense of self efficacy and thus remain hopeful.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: On guard - January 19, 2005 5:34:00 PM
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FLOrthoPT
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From: wellington, fl, usa
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I have found for my TKA who are very guarded and low pain threshold, a strict regimend of self propelled active assisted recumant bije and self moving seat up for 20-30 mins, followed by total gym slant board at like level 6 of 10 with slow bilateral closed chain squats with slow pushing into flexion for about 15-20 minutes followed by some gait and ice seems to do very well. Add id some heel raises on the total gym as pt progresses. I have had about 1 person a week on this type program because they could not handle anything else and remarkably they do very well and regain full (120+)flexion rather quick (3 weeks) and normal gait even quicker. I know this is not really the question or topic, but try this out on some of your more guarded tka who are not immediate post ops, more like the ones who had home health or rehab first.
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Re: On guard - January 19, 2005 11:23:00 PM
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pablo w
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From: Canberra
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If I feel muscle guarding is an issue, and it doesn't appear to be voluntary, and the methods suggested so far fail, I have used surface EMG biofeedback with good results.
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Re: On guard - January 20, 2005 1:24:00 AM
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Sebastian Asselbergs
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Jon, I think there is a wide variety of muscle guarding "causes". But most likely will be due to fear of pain. She admitted during a few "reactions" that "No, it wasn't more painful than before you moved it". When I pointed out that her physical reaction suggested otherwise, she stated that that was because she was so afraid and tired of it hurting. I hope that the cerebral involvement with her condition is limited to sensitisation, and not too strongly to other, psycho-emotional ones - but my hope is futile I think. The multi-disciplonary approach is even more necessary in that case.
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Re: On guard - January 20, 2005 1:26:00 AM
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Sebastian Asselbergs
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Pablo, surface EMG is a valid suggestion - I still have one somewhere - I'll let you know what develops.
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Re: On guard - January 20, 2005 1:57:00 AM
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Jon Newman
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Hi Pablo,
Tell us more about your surface EMG experiences. What muscles groups do you find commonly problematic that respond well to EMG feedback?
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: On guard - January 20, 2005 10:47:00 AM
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childsjd
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Just can't resist asking the question here. Does anyone have any evidence that anything that has been said in these posts is actually effective? Again, there is now growing evidence in the literature for the treatment of back pain, none of which is mentioned here. It certainly does not involve things like simple contact (can't bear to give it the capital letters), "kinesthetic chatting", positional release, letting the patient's brain come to its own decision about the matter, humor, etc. Again, I am just amazed at the level of confidence indivuduals place in treatment approaches that have absolutely zero basis in evidence. Many that post in these forums would benefit from going back through first professional training in a contemporary evidence-based physical therapy program. I assure you they won't be teaching these types of approaches.
John
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Re: On guard - January 20, 2005 11:03:00 AM
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pablo w
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From: Canberra
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I have used a sEMG biofeedback unit (ProComp from Though Technologies) and sEMG+ software for quads and lumbar spine extensors. It's fairly straight forward: the computer screen shows a graph that corresponds to EMG activity, which gives patients direct feedback about what amount of muscle activity is present.
John,
For the evidence question you posed, the evidence for the use of biofeedback goes like this: it's about FEEDBACK to the patient! It gives the patient knowledge of performance as well as knowledge of results, no different to someone instructing the patient on an exercise and whether they have been succesful or not. Feedback as a means to change performance.
John, I am familiar with the evidence for the treatment of back pain. Exercise and CBT approaches are the interventions best supported by the literature. Manipulation doesn't have the same level of evidence from systematic reviews. If EMG biofeedback or Simple Contact or craniosacral therapy (just stirring the pot) can be used to facilitate exercise, then I think we can still use these treatments under the umbrella of evidence based care, don't you think?
Pablo
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Re: On guard - January 20, 2005 11:47:00 AM
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childsjd
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Pablo:
Simple answer -- no
John
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Re: On guard - January 20, 2005 12:13:00 PM
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nari
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From: Australia
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John
Simple response -why not?
Why deny evidence when it does exist?
Why not follow up on the suggestions made countless times on this bb re the evidence for treatments other than mechanical in origin (and even that is dubious)?
Your silence on this aspect is disappointing.
Nari
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Re: On guard - January 20, 2005 12:42:00 PM
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Jon Newman
Posts: 1706
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From: Amherst, WI
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Hi John,
My original question in this thread was "How do you, in general, help someone to decrease muscle guarding (secondary to pain) about a joint?"
I think if people can produce evidence of what they do, all the better. But you make it seem as though you don't make a single clinical decision unless there is an outcome study to support it. Is that your practice reality? Either that, or you would rather have everyone refrain from sharing their clinical experience here on rehabedge.
What should I have done with my lady who was struggling to gain some ROM? Did you note that I had done something wrong or contraindicated?
I'm also guessing that you either disagree with the article I've linked to in the thread "Evidence based medicine" or you've yet to read it.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: On guard - January 20, 2005 2:05:00 PM
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nari
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From: Australia
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jon
My example is similar to Sebastian's but less dramatic. Female, 60+, fell off a plantar box and fractured (L)neck humerus - straightforward, fracture, has united well(incident happened ten weeks ago).
Muscle guarding is phenomenal, as though there is a veritable cavalry on alert from her (L) occiput to the (L) knee. Abduction is poor; hitching starts at 30 degrees; flexion around 70 degrees.
Function is limited to simple things at waist level.
It took a while to elicit verbal emotions from this lady, but she has yellow flags galore; depression, fear of 'hurting' the fracture. She 'hates'her (L) arm, even talks of amputation as a better option. She hates her wrist, fingers, anything visible. Eye contact poor;reassurance falls mostly on deaf ears. GP has ignored my suggestion her depression needs to be addressed.
If I can get her attention for 20 seconds, assisted active neural stuff drops the guard, and establishes eye contact.
She then moves the arm quite well, without any cue from me, and just when it looks rosy, she thinks of something miserable and back rolls the cavalry...
In this case of muscle guarding - Rx of her emotive state is definitely required and nothing else would probably work much. Hands-on, I sense, might confirm her fears in a way- that there is something to be afraid of. I'm happy to be challenged on that!
At this stage she refuses to see someone, although she readily agrees that her fear/s make it worse.
Nari
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Re: On guard - January 21, 2005 3:05:00 AM
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childsjd
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Jon:
Your points on about the need for decision-making in the absence of perfect evidence is right on target. And of course, I am regularly confronted with having to make decisions about patients for which the evidence does not perfectly inform my practice. Decision-making in the absence of evidence is not what I am being critical of here.
What I am being critical of is well captured by Nari's comment saying, "Why deny evidence when it does exist?". No one has yet to produce this "evidence" that everyone is talking about. I don't know how many times now I have asked for this information, and not one single study indexed in Pubmed has been brought forth. Not even a single "bad" study or even a case report!
It's the level of certainty attributed to the previously mentioned therapies that should bother all of us. It demonstrates an incredible lack of familiarity with the evidence and frankly, implicates us as being gullible for anyone's fanciful ideas. The second issue that is concerning is the apparent unwillingness amonst some to incorporate even treatments for which there is substantial evidence, preferring instead to take their chances on treatments lacking any evidence whatsoever.
Decision-making in the absence of perfect evidence will always be important, but it should not come at the ignorance of well established treatments known to be effective for many of the conditions being talked about in these posts. Spending valuable time working on "simple contact" or "humor" at the expense of more efficacious strategies is just non-sensical altogether. Scarce resources and limited physical therapy visits demands that we do better than just providing whatever treatment fits our own personal philosophy about rehabilitation.
John
John
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