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Painless physical therapy vs. pain during treatment
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Painless physical therapy vs. pain during treatment - August 28, 2006 9:52:00 PM
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rv36116
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Here's the off-shoot of the other topic "Bilateral Leg Pain"
[QUOTE]nari wrote:
John,
How can one isolate one structure (capsule) and say it is tight and then stretch and strain it?
You're also stretching everything else in the vicinity - what has the capsule got to do with it?
I am sure you will back up with x studies done to show forced internal rotation produces some results - but give me Sarah's methods any day.
Coercive, forced PT was never in my books, though I got great results with much 'kinder' methods.
Nari[/QUOTE] [QUOTE]Rob PT wrote:
Coercive, forced PT isn't in my book either, nari, but I'd do the exact same thing for a frozen shoulder once a joint derangement is ruled out.
Otherwise, you're just going to see the patient for 3-6 months and have them creep along at a snails pace, which they could probably just go along with regular life and have the same effect 3-6 months down the road with out therapy.
Mechanically, if you have a "frozen shoulder" where every direction is limited, you will get the most bang for the buck with IR vs. multiple directions.
[/QUOTE] [QUOTE]Sarah C. wrote:
Jboy,
I'm not sure if we're comparing apples and oranges here, but I'll give it a shot. For this particular patient with bilateral leg pain due to stenosis (if that's the diagnosis), I'd look at the length of the hip flexors (especially rectus femoris and iliopspoas) and hamstings, and possibly the external rotators of the hips. If the patient lacks full hip and knee extension in gait (which is likely), I'd work toward achieving more ROM in those directions, per the above methods.
My concern was taking a painfree patient through an aggressive spinal evaluation. I tend to be a little more conservative and work on movement impairments vs. trying to find a needle in a haystack.
Sarah
[/QUOTE] [QUOTE]jboy wrote:
Sarah,
Sounds good (regarding your stretches). However, I'm not sure what constitutes an aggressive or non-aggressive spinal exam. This patient has had symptoms for 2 months (chronic). As long as this patient does not have any red flags you're safe. In fact, Eric has not even been able to reproduce the symptoms. You have 2 choices with a spinal exam, provactive or reductive. Since this patiente has no symptoms you have to go provactive or you'll never learn anything. If a clinician is not comfortable treating spines and does not have training beyond PT school, then I agree with a "non-aggressive"exam. I'd hate to induce a lateral shift you could not reduce.
John
John wrote:
Nari,
You're right. YOU can't isolate a capsule and I'm glad you're kind.
[/QUOTE] [QUOTE]Michelle wrote:
Nari,
I don't mean to get in the middle of something not really related to Eric's original question, but if you are only using "kinder" methods to deal with all physical therapy issues then you are missing the boat. Many physical therapy problems require the patient to cause him or herself pain, not only a frozen shoulder as John has suggested. I do not think it is forced or "coercive" therapy if the patient understands why it needs to hurt. Are you trying to say that when a patient is regaining ROM following a total knee that you expect it to be relatively pain-free?
Michelle
[/QUOTE] [QUOTE]nari wrote:
Michelle
It does depend on what you are treating. A stiff post-replacement will require some pain to achieve function, but it should not require ongoing pain. A "frozen" shoulder should not be forced; there are studies done to demonstrate that there is little difference to be gained anyway whether the patient goes to PT or not. In Australia we tend not to treat these people as the outcomes are the same with or without PT; and why cause more pain to little purpose. We review them periodically and I always used neurodynamics anyway, which is much 'kinder'.
If I have missed the boat, then I wonder about the successes with patients who have been given kinder treatments with minimal Rx pain. I know many PTs believe in the "no pain, no gain" principle but that is not how I work.
With chronic pain, it is even more important not to deliberately cause increased pain. Nociceptive physical therapy is the last thing they need.
Nari
[/QUOTE]OK CONTINUE...
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Re: Painless physical therapy vs. pain during treatment - August 28, 2006 10:02:00 PM
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rv36116
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[QUOTE]nari wrote:
With chronic pain, it is even more important not to deliberately cause increased pain. Nociceptive physical therapy is the last thing they need.[/QUOTE]Nari, I have a problem with the "natural healing" and the importance of "not to deliberately cause increased pain" for those with chronic pain.
This is 100% false.
When it comes to problems such as -tendonosis- (or some may call it "chronic tendonitis") where you must prescribe progressive eccentric loading to remodel the tissue... With out that force, you will never remodel the problem and the tissue will continue to degrade and the "chronic" patient will continue to be chronically in pain.
That is not just a "theory", it histologically shown under microscope to see the effects of the eccentric force to the tissue in a short time frame. You absolutely will not get any results with out that specific force, and it MUST hurt every time, or else the tissue won't remodel completely.
I would put a few hours of research into this because it will really make sense on why these patients never heal with the 'no pain/natural healing' method.
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Re: Painless physical therapy vs. pain during treatment - August 28, 2006 10:41:00 PM
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avalon
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Rob,
Did all your "tendinopathic" patients had a biopsy? NO!
Did all these patients exerciced too much their tendons? NO!
[QUOTE]You absolutely will not get any results with out that specific force, and it MUST hurt every time[/QUOTE]100% false!!!!!!! and there is no study that relies that.
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Re: Painless physical therapy vs. pain during treatment - August 28, 2006 10:55:00 PM
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nari
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Rob
Who ever mentioned "natural healing"?
I didn't. Are you suggesting that I just say nice things and let the time pass by so that 'natural healing ' takes place?
Come on....
If the conditions of the tissues are improved around the injury, such as improving ischaemic tissues (neurodynamics is one way) then the process of healing is speeded up. According to the theory of "injury healing", most healing takes place in the first 4-6 weeks unless the injury is constantly aggravated.
But I think this thread is going to degenerate into the ongoing debacle between those who think that pain must accompany PT interventions and those who don't, or at least minimise it.
Some pain is inevitable; but it doesn't mean we continually push into pain.
I am also talking from a chronic pain perspective and not necessarily from a defined injury which does require time to heal before attempting to remodel.
Nari
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 2:38:00 AM
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Jon Newman
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Is there such a thing as unnatural healing?
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 3:30:00 AM
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jboypt
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It's called suspended healing. Those are the patients you will see in the clinic with contractile dysfunctions. Disorganized collagen with weak tensile strength. You have to work them in the target zone (which, sorry Nari, elicits pain)you're a looking at 4-6 weeks and you may have to re-start the inflammatory phase to remodel this tissue.
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 3:33:00 AM
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jboypt
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Nari,
My hyphothetical listed a tight joint capsule (articular dysfunction). You called it a frozen shoulder. So please read carefully before quoting.
John
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 3:36:00 AM
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Jon Newman
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jboy, when you state "it's called suspended healing" what is the "it" you are referring to?
Will you define "contractile dysfunction"? I've got an idea but I want to be sure.
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 3:43:00 AM
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jboypt
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Avalon,
What is false. That Rob's patient's don't have biopsy's? He didn't say that and why so angry? I think Rob is trying to present evidence based medicine in it's researched from and it's clinical relation. The lipservice in PT school is evidence based practice. My expercience in truth is that many clinician's do not really offer precscribed exercise based on evidence. I only write this because, you seem so upset about Rob's post. If you happen to be one of the clinician's that don't practice evidence based PT, I suggest you re-think your ideology before you are forced by third party payers. I have two colleagues that review cases for insurance companies and advise reimbursement or not. The days of 30 plus visits with minimal change (objectively or functionally) are going fast. This is ABSOLUTELY TRUE!
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 4:32:00 AM
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Tom Reeves DPT ATC
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jboy,
Your final comment of your last post is absolutely true. Besides, even if they WOULD pay forever, isn't that dishonest? Fraudulent? Just the thing that we harp on the caricature of the chiropractor about? I can think of only two or three people who I have treated 30 times and they were TBI patients and one guy who worked for Orkin or something and fell 30 feet off of a roof, wrecking his thumb, elbow and both shoulders. I am embarrassed by PTs that treat people that long routinely with no change. It is wasteful and brands me by association.
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 4:55:00 AM
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Sebastian Asselbergs
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Whoa. I haven't seen anyone suggest to treat a patient for many sessions and "milk" the system. That seems a bit overboard to discredit another person in a debate. They disagree with an approach or with a point - no-one has suggested treating for 30 times! Check the thread.
And John (jboy), "Disorganized collagen with weak tensile strength" - an interesting statement. There are so any assumptions in that particular post that I am surprised by it. I have been practising for only 23 years, and the last 6-8 under the focus of "best available evidence", but I have yet to find "contractile dysfunctions" due to "disorganized collagen" etc etc - I have seen restricted motion, that's all. I also have not yet seen the necessity to re-start an inflammatory stage to "remodel tissue".
I think we need to look further than "pathological tissues" - we are talking about pain in this thread, and pain is a unique, individual experience.
Nothing more, nothing less.
It's intensity has absolutely no direct linear correlation with pathology.
So, why assume that particuar diagnoses "must hurt" while in therapy? Where is the evidence that it "has to hurt " to get better? Where is the proof?
I guess I will be a smudge on your version of PT's escutcheon - I can't help your perception of others.
But if anyone would ever call me unprofessional or "milking" insurance - I get pissed off.
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 5:08:00 AM
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avalon
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jboy,
I'm practicing scientific based practice. It is evident. I'm not angry and I just replied perhaps too directly to another evidence: There is no study that claims what Rob told us! Just saying a 100% is already a nonsense! That's all!
And I'm in private practice since 1980 and often stop treament when I estimate that I can't bring anymore benefit for the patient.
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 5:19:00 AM
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rv36116
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Now avalon, there's no claim because why? Have you searched for anything of the sort?
If you read the post, the "100%" is a reply to nari's comment that you should never give a chronic pain patient something that hurts them.
[QUOTE]nari wrote:
With chronic pain, it is even more important not to deliberately cause increased pain[/QUOTE]...to which I replied that the statement was 100% false.
Lets discuss the treatment of tendenopathy or "chronic tendonitis" from your perspective, avalon. I'm interested in how your > 25 years of experience has led you to treat this type of pathology. Thanks for the reply in advance.
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 6:40:00 AM
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avalon
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No problem Rob,
I'm using the same tools as Nari and I searched evidences on PubMed. Actually there is no real causation of tendinopathy or tendinitis. Scientists can not rely overuse to tendinopathy since "underuse" patients present the same pathology. And there is many cases where you have just a syndrome (pain located at) without any local problem.
How do you explain this?
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 6:47:00 AM
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avalon
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Patellar tendinopathy in athletes: current diagnostic and therapeutic recommendations.
* Peers KH,
* Lysens RJ.
Department of Physical Medicine and Rehabilitation, Gasthuisberg and Pellenberg University Hospitals, Leuven, Belgium. Koen.Peers@uz.kuleuven.ac.be
Formerly known as 'jumper's knee', patellar tendinopathy gives rise to considerable functional deficit and disability in recreational as well as professional athletes. It can interfere with their performance, often perseveres throughout the sporting career and may be the primary cause to end it. The diagnosis of patellar tendinopathy is primarily a clinical one but new imaging techniques, such as Doppler ultrasonography, may provide additional diagnostic value. Current therapeutic protocols are characterised by wide variability ensuing from anecdotal experience rather than evidence. Moreover, numerous reports in recent years have shattered previous doctrines and dogmatic belief on tendon overuse. Histopathological and biochemical evidence has indicated that the underlying pathology of tendinopathy is not an inflammatory tendinitis but a degenerative tendinosis. Consequently, pain in chronic patellar tendinopathy is not inflammatory in nature, but its exact origin remains unexplained. In pursuit of pathology- and evidence-based management, conservative therapy should be shifted from anti-inflammatory strategies towards a complete rehabilitation with eccentric tendon strengthening as a key element. If conservative management fails, surgery is opted for. However, considering the heterogeneity of surgical procedures and the absence of randomised studies, no conclusive evidence can be drawn from the literature regarding the effectiveness of surgical treatment for patellar tendinopathy. Parallel with the improved knowledge on the pathophysiology and pain mechanisms in patellar tendinopathy, new treatment strategies are expected to emerge in the near future.
PMID: 15651914 [PubMed - indexed for MEDLINE]
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 6:48:00 AM
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srcase
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jboy,
To answer your question to me directly:
[QUOTE] However, I'm not sure what constitutes an aggressive or non-aggressive spinal exam. [/QUOTE]I was referring to Shill's suggestion to take the patient through a mechanical spinal evaluation complete with repeated movements, looking for centralization. This patient was painfree before, after and during the examination. Centralization of what? And then, what exactly will that tell you?
When Eric treated with exercise and stretching, patient reported no night pain (primary complaint) for 2 days. Then you suggested end range extension in lying with overpressure, to produce back pain. You stated that in your diagnostic schema, dysfuntion and entrapment were already ruled out because dysfunction doesn't refer pain to the legs, and entrapment symptoms are constant. The results of the overpressure test would then lead you to diagnose the patient as ANR (?), derangement, or mechanically inconclusive. Let's say hypothetically that the overpressure test was negative. Now the patient no longer fits neatly into one of your boxes, what do you do next? I'm not baiting you, I'm sincerely interested.
Also, you stated that Nari misquoted you about frozen shoulder, but in your post dated August 27, 2006 you state:
[QUOTE] An example I was looking for would be something like this:Diagnosis is frozen shoulder (or whatever) [/QUOTE]The final point I have regarding this "discussion" is that there appears to be quite a bit of argument using the words, always, must be true, 100%, etc. I don't know about you, but whenever someone argues that something is ALWAYS true, I immediately get skeptical. Isn't this just a tactic used to make your case more believable? And when it's questioned, the comments turn to personal attacks on the therapists themselves, their methods, and billing practices?? Not called for. I'm asking for a professional debate here and not a school boy bully session complete with name calling and personal attacks. Thanks.
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 6:49:00 AM
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Jon Newman
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Knowing Nari to the extent that I do I can assure you Rob that Nari does not mean that patients never do anything that hurts at the time. I took her comment to mean that therapy that results in lasting pain is typically unnecessary.
Are all instances of collagen disorganization painful? If not, how does one determine the quality of collagen tissue by the presence or absence of pain?
It seems to me that the treatments directed at changing mesodermal tissues might very well do what they are intended to do. The hope is that the pain will just go away, naturally. And sometimes it does.
If there is a mesodermal structure that needs to me modified for some reason then I can't see why it wouldn't be done. How it gets accomplished is the topic of many conversations.
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 7:27:00 AM
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proud
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avalon,
Excellent post. I am also familiar with the work of Khan et al as well.
But I think I see some common ground there between yourself and RobPT. If I read correctly, RobPT is suggesting you must load these tendons. The debate centers around whether or not that loading should ellicit pain or not.
Am I correct? I cannot be sure, however I think the McKenzie part E( extremities), tends to suggest that the loading may cause pain and that in fact, this may be required.
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 8:08:00 AM
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Shill
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Sarah.
Refer to the post on provocation versus centralization. Im not sure who noted it, but it was likely Rob or proud. If the patient was painfree before, during, and after the evaluation, then one will gather that the person does not have a problem. If a therapist is good at what she or he does, she or he should be able to figure out how to provoke the irritable tissue, so as to direct treatment. If this isnt done, or symptoms do not surface during said eval, then that therapist is guessing. My patients deserve more than a guess.
You noted "Now the patient no longer fits neatly into one of your boxes, what do you do next? I'm not baiting you, I'm sincerely interested."
I dont want to answer for Rob, but you might be surprised that when the evaluation is done correctly, it is quite easy to place the vast majority of patients into the neat boxes, rather than piling them into a very large, often vague bag.
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 8:22:00 AM
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proud
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Shill,
Well said.
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