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Your most difficult cases to treat
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Your most difficult cases to treat - June 8, 2004 7:29:00 PM
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chiroortho
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I have noticed that certain conditions seem to be much more difficult to address than others over the years, despite my best efforts. As you know, in terms of my chiropractic practice I have often needed a lot of help from my PT colleagues with shoulder problems. From a chiropractic standpoint my offerings are generally limited to evaluating the shoulder and obtaining imaging studies, but beyond that all I really have to offer these patients are modalities to address their symptoms and advice to help them avoid exacerbating their pain.
I have found that PTs are outstanding in providing rehabilitative care for shoulder injuries, and as you know advice and symptomatic treatment is often simply not enough to effectively manage these patients.
PFPS is another condition that frequently requires a referral to a PT.
What are some of the more common conditions that you encounter that seem to defy your best efforts?
I look forward to hearing from you.
Greg
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Greg Priest, DC, DABCO
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Re: Your most difficult cases to treat - June 8, 2004 11:05:00 PM
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Alex Brenner PT MPT OCS
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Hi Greg. I would say my most challenging patients have been TMJ disorders. Probably because my training is lacking and I have a hard time with oral palpation/treatment. I also have not had a great success treating patients that have snapping scapula, non-organic low back pain, and fibromyalgia.
Patients with chronic pain are also difficult for me to treat because the military system that I currently work in is just not set up to manage these type of patients. I think I have a lot to offer these patients but I just am not set up with the resources to deal with it.
With regards to difficult non specific shoulder pain (impingment, etc) I have found some success with shoulder moblizations and a lot of scapular and thoracic spine work. I think a lot of times when we fail in shoulder treatments is because we focus so much on just the glenohumeral joint or the rotator cuff and do not address any other problems that may be contributing the problem such as thoracic spine stiffness, AC/SC joint pathology. The same is also true for PFPS, I think too many times we get so focused on the knee joint that we forget or ignore hip or foot/ankle problems that may be contributing.
I would like to say I was good at treating everything, but that is simply not true. I would be interested to see what others say.
Army
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Alex Brenner, PT, MPT, OCS
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Re: Your most difficult cases to treat - June 8, 2004 11:47:00 PM
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nari
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Army, I cannot add much to your post - I have to agree that many PTs just look at the site of pain and treat that, without going outside the square.
"Frozen shoulder" and PFS are classic examples.
I would venture to say that acute spinal pain is challenging, though not as much as chronic pain.
I agree with you that a lot can be done with these often global pain patients, but it is not easy to do without support of a MD team; all I can say is to forget any diagnoses and look at the process that is presenting and do whatever is possible to reduce fear of movement, erronous beliefs and negative thinking. You can be effective just doing that.....
Another real challenge are the 'failed' joint replacements -where post-operatively, their much reduced ROM is fixed, pain is considerable and their function terrible. Optimal rehab is very difficult!
Nari
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Re: Your most difficult cases to treat - June 9, 2004 4:05:00 AM
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chiroortho
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Army, Nari,
Exactly right about the shoulders and knees. I learned some manip techniques for the shoulder in school, but I don't think I've ever used one. And TMJ...I can get an MRI if trauma but then I only send them for bite splints. I wasn't aware that PTs had some techniques for TMJ treatment. That is good to hear.
PFS is something that I've taken more interest in lately because it seems that I've had a run of patients complaining of knee pain that is clearly PFS.
One of the things I appreciate most about your profession is that you seem to deal with the cognitive aspects of pain very well. I don't think I spend nearly enough time with that.
Lastly, acute backs are probably the thing I do best. It's interesting to hear the different challenges.
What about tennis elbow? Our treatment is very effective for some, and seems to be essentially useless for others.
Lastly, nari brings up frozen shoulder. In my ortho training we dealt with this at length, going through all sorts of assessment/treatment protocols, etc. but in the end I remember one prof saying essentially, 'they're going to get well in 6 months with or without you.' I remember even being taught that adhesions could form in the axillary redundancy, and if we could just get some ultrasound up into the axilla we might be able to theoretically 'break up' the adhesions. It's been probably 15 years since I heard this. Is there any truth to it?
Greg
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Greg Priest, DC, DABCO
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Re: Your most difficult cases to treat - June 9, 2004 5:22:00 AM
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PTPLUS
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Quote:
"I think a lot of times when we fail in shoulder treatments is because we focus so much on just the glenohumeral joint or the rotator cuff and do not address any other problems that may be contributing the problem."
Good point, I always look at foot and pelvic biomechanics when evaluating a patient with possible mechanical knee pain, but I probably need to look at the core more when looking at mechanical shoulder pain.
The other point I'll add that in addition to health care providers overlooking cognitive issues is overlooking the obvious. An example would be getting so caught up in mobs and very specific exercises that we forget to put the hard sell on body mechanics and posture modification for a patient that really needs it like a young mother.
My toughest patient? I always cringe when a male 18-30 comes in with LBP. Have a hard time getting good compliance.
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Re: Your most difficult cases to treat - June 9, 2004 5:42:00 AM
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SJBird55
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For patellofemoral cases, I really liked the Nov 2003 Journal of Orthopaedic & Sports Physical Therapy. It was a special issue on patellofemoral joint dysfunction. In particular, the theoretical perspective by Christopher Powers and then the article on the 2 case reports have realy made an impact on how I now address patellofemoral complaints. In particular, I have never been sold on quad isometrics and straight leg raises for home exercise programs, so in situations where the hip does seem to be involved (which seems to be a lot of the time) I believe the photos in Fig 3 make an excellent home exercise program. In the clinic, I don't have the luxury of a lot of PT visits, so I've actually canned the boring, lay on the table quad stuff and changed my whole way of treatment - and there seems to be a better amount of good results versus toss a coin and see what comes up. To be honest, clinically I always saw the biomechanical hip stuff, but never really put everything together, those articles created a light bulb to go off in my little brain. Yes, I know that case reports aren't the best to base clinical practice, but rationally what was presented does seem to make sense.
The spine is still difficult for me. There is too much that we don't know about the spine. Why are there some folks easily tolerate herniated discs and there are others that you'd think were dying?
It isn't just the "condition" that needs to be mentioned for difficulty, but there are some patients that are quite difficult to me. Depression makes it difficult for me. Pre-teens and some teens are difficult for me - either they can't focus, don't necessarily want to communicate about their condition, or they over-exaggerate. The folks I term "motor-morons" are difficult and frustrating - they have no clue what their body is doing or how to concentrate to make it do something specific. And those negative, negative, negative patients... it's like pulling hair out to substantiate the positive objective findings or positive changes in function.
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Re: Your most difficult cases to treat - June 9, 2004 11:27:00 AM
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chiroortho
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[QUOTE]My toughest patient? I always cringe when a male 18-30 comes in with LBP. Have a hard time getting good compliance.[/QUOTE]You think those guys are tough, try getting an 18 year old surfer with a rotator cuff tear to stop surfing for more than 2 days! I live on the east coast of Florida, and man, those surfers would probably rather have their fingernails pulled out than to give up surfing for a month. Surfing must really be fun!
Cocoabeachpt, do you ever run into this?
Greg
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Greg Priest, DC, DABCO
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Re: Your most difficult cases to treat - June 9, 2004 2:28:00 PM
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nari
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"Tennis elbow" (aka epicondylopathy) is relatively easy to fix; think neural.
If we can get patients in the early stages of the so-called 'frozen shoulder' we may well be able to prevent it. But we don't, so we can advise and wait for it to resolve spontaneously, or use neurodynamics and cervico-thoracic movements to ease things, and monitor progress, for psychosocial reasons if nothing else. These patients are liable to launch into persistent pain if we do not keep an eye on them.
I do not get many adolescents at all - but the noncompliant person who is keen to just get on and do things they enjoy, often treat themselves anyway. It is the oldies who fold up and rest, rest some more and fear activity that are tricky, too.
Aren't we lucky to have such a diverse canvas of challenges for us to deal with??!!
Nari
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Re: Your most difficult cases to treat - June 9, 2004 2:59:00 PM
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chiroortho
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ArmyPT, how do you deal with persistent back pain in your soldiers that probably tend to have recurrences due to jumping out of planes, etc. I treat some military folks for LBP from time to time (an air force base is close by), and they are highly motivated to get back on the job, period. Especially the 'PJs' (pararescue jumpers). They're probably second to surfers in their 'fix me today or I'm not wasting my time' gung ho attitude. I'm so glad that we have folks like this defending our country.
I have treated a number of SEALs, and they told me that at the breakfast table there was a big bowl of ibuprofen which they essentially ate like candy to get through their day. I assume that he was speaking somewhat facetiously, but because of the constant dings they get, I'm not sure! :)
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Greg Priest, DC, DABCO
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Re: Your most difficult cases to treat - June 9, 2004 4:53:00 PM
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Shill
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Chiroortho,
What you learned in school doesnt have a great deal of truth to it. Average recovery time for frozen shoulder is 3 to 36 months, and is indeed a frustrating thing to treat. There are no adhesions, so both of the common names for this are misnomers. No ice inside the shoulder ;) , no adhesions. The loss of the capsular redundancy is a continued theory, but why it becomes so is still the million dollar question. I think we need to standardize our treatment for this, so that EVERYONE with a capsular pattern of restriction at the shoulder gets: Anesthesiology consult for an interscalene nerve block, then is immediately sent to PT (that day) for short lever arm grade 4 mobilizations/ grade 5 manipulations. Inferior glides and posterior glides were the mobes/manips studied. This has been published in JOSPT, twice, and had great results, yet we still muddle through the long period of joint mobes, stretching, and other treatments that probably help, but are really not much fun for patient or therapist, unless both are sadistic.
Once pain is taken out of the picture, the mobilizations have so much greater of an effect.
OK, Im done.
Steve
Greg - I do have some good recent references,if you'd like, I can dig them up, and email them to you.
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Steve Hill PT
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Re: Your most difficult cases to treat - June 9, 2004 5:09:00 PM
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Dr.Wagner
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What do you mean no adhesions? I have seen the adhesions post mortem, actually very cool. It is very much like a fascial web, dry. Granted this was a very advanced stage.
The other question is why do a scalene block in the OR then transport them, when you can have an orthopod manipulate the shoulder in the OR? Saves transport time...I suppose you could have a PT do it in the OR, but that would require procedure privileges. I think for the sake of convenience, doing everything in the OR is easier.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Your most difficult cases to treat - June 9, 2004 7:43:00 PM
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chiroortho
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Shill,
Wow! 36 months...I had no idea.
As to the references, thank you for the offer but it sounds to me like you guys have a better protocol than me, so best to just send the adhesive capsulitis folks to the local PT.
Appreciate the info.
And Dr. Wagner, I've heard of this OR procedure, and frankly it makes sense to me for advanced cases when all else has failed. Some of these folks are so miserable that I think they'd practically eat broken glass if it meant that they could get some help.
Greg
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Greg Priest, DC, DABCO
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Re: Your most difficult cases to treat - June 9, 2004 8:44:00 PM
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nari
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There is strong evidence that the fascial net (the 'freeze part)in the shoulder on op is identical to the one inhibiting function in Duyputren's and the two go together very frequently, I have observed. One resolves, the other does not.
Manips, I believe do not succeed much, and are not done often here because of dismal results.
The whole sad aspect of this condition is its strong potential to be reversible within the first few months, saving months/years of dysfunction.
I have had folk in early (painful, abd <60 degrees, ER<50%) totally resolve to normal within 4 or 5 months or less, and improve steadily from the third or fourth session on. Some have remained unchanged - but that was well down the track.
It must be recognised EARLY!
nari
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Re: Your most difficult cases to treat - June 9, 2004 9:58:00 PM
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Alex Brenner PT MPT OCS
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Hi all. There has been some great work in the Army on frozen shoulder. At the Army-orthopaedic residency program last year the fellows who have recently graduated performed these techniques that Shill described on patients with adhesive capsulitis. They presented their research at a conference that I attended last year. It was very impressive. They had an anesthesiologist perform an interscalene block in the OR and then they brought the patient down to the PT clinic so that they could put them on the up/down plinth. They used this plinth so that they could get proper leverage on the patient. The patient then underwent high grade mobilizations 4-5's to the shoulder in arthrokinematic positions (not just random thrusts or manipulations). At the conference they showed a video performing these on a patient. It was impressive, loud audible pops when they would move through the adhesions. The mobilizations did not appear easy, three therapists would have to tag team the patient while they mobilized the shoulder for almost an hour. After they felt comfortable that they had moved through all the adhesions the patient’s shoulder was packed in ice. For the next three days the patient would be brought to physical therapy for continued AROM and PROM movements. The success rate was incredible and they had reports of patients going from large deficits in ROM to near normal pain free movements in just days.
One thing that I learned from this presentation was how futile my attempts have been at trying to mob a frozen shoulder with grades I-III mobilizations. After watching the effort that these ortho fellows had to put into the mobilizations to break the adhesions it is no wonder I can not get very far with most of my frozen shoulders. What they gained in one week would have taken me months.
At the time that they presented the research they had performed these techniques on 5 patients, all of whom made complete recoveries in a matter of days. They have since done dozens of shoulders and continue to do them down at Brook Army Medical Center in San Antonio.
At my last PT clinic we were lined up to perform our first but then the Iraq ground war kicked off and all of our military anesthesiologists were deployed to war.
Army
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Alex Brenner, PT, MPT, OCS
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Re: Your most difficult cases to treat - June 10, 2004 1:05:00 AM
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Alex Brenner PT MPT OCS
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Chiroortho,
The military population that I currently work with is an elite airborne unit. They are mostly very young. I would say the average age of the patients I see is around 25. Most are very athletic and were either high school or college level athletes. It is an exciting population to work with and we do see a lot of back pain but they respond very well to manual therapy and exercise programs. Some of the senior leadership (platoon sergeants, first sergeants, commanders) are older and they seem to have more problems but for the most part they are very motivated and seem to be compliant with advice and exercise programs.
[IMG]http://img28.photobucket.com/albums/v85/brennerak/airbrone2.jpg[/IMG]
Here is a recent picture of some of my soldiers jumping into Normandy, France last weekend. Last weekend was the 60th anniversary for this military maneuver and was watched by thousands. A friend of mine had door position on the jump and said he could hear the crowd cheering over the noise of the aircraft engines before he jumped. I am the jumper on the far left (just joking, I am airborne qualified but did not get to do this jump).
[IMG]http://img28.photobucket.com/albums/v85/brennerak/in_aircraft.jpg[/IMG]
Here is a picture of my brigade while in the aircraft on their way to Iraq. About 4 hours after this picture was taken these soldiers made a pitch black night (about 3 a.m.)combat jump into Northern Iraq under some enemy fire. Their ruck sacks are laying on their laps, Machine guns are in a case that is attached to their left leg, the reserve chute is above the ruck sack and the main parachute is on their back. They had to sit like this for several hours while on the aircraft waiting to jump. Gives me chills when I look at it and think about it.
[IMG]http://img28.photobucket.com/albums/v85/brennerak/fullbattlerattle.jpg[/IMG]
Lastly, here is a picture of one of our light infantry soldiers on patrol in Iraq. This particular soldier is wearing what we call "full battle rattle". Flack vest (15 pounds), Load bearing vest with ammo and full canteens (15-25 pounds, weapon with loaded ammo (15 pounds), Ruck sack with gear and extra ammo (no less than 80 pounds), Kevlar helmet with radio (5-8 pounds).
Got Back pain?
God bless our soldiers.
Army
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Alex Brenner, PT, MPT, OCS
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Re: Your most difficult cases to treat - June 10, 2004 3:40:00 AM
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chiroortho
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ArmyPT,
That treatment for AC by the ortho residents in the Army ortho residency program is VERY impressive. Much has changed since my ortho training.
Great pics!
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Greg Priest, DC, DABCO
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Re: Your most difficult cases to treat - June 10, 2004 5:38:00 AM
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Shill
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From: Madison WI USA
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Dr Wags,
From A. M. Wiley. In The Journal of Arthroscopic and Related Surgery 7(2); 138-143 "The arthroscopic appearance of frozen shoulder", 1991.
37 patients
"In no patient was the infraglenoid recess obliterated by adhesions, although it was inflamed and appeared contracted. There were also no intraarticular adhesions."
Now, they do go on to admit that due to the contracted joit space, it was difficult to examine the recesses.... but nevertheless.
They described the lack of adhesions as a "surprising finding"
I'll see if I can find more of these.
Steve
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Steve Hill PT
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Re: Your most difficult cases to treat - June 10, 2004 7:54:00 AM
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tr6454
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Who is going to carry a full ruck in the next generation? We can't even have our kids carry a back pack with school books!
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Terry
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Re: Your most difficult cases to treat - June 10, 2004 8:53:00 AM
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Shill
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From: Madison WI USA
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Dr Wags,
The orthopod manips are through long lever arms, and subject the patient to higher risk of fracture. Read the study from JOSPT, 1996 regarding the block and the short lever skilled mobilizations. THEN come back with questions. :cool:
I hope you know I say this last sentence lightheartedly.
Steve
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Steve Hill PT
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Re: Your most difficult cases to treat - June 10, 2004 10:42:00 AM
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Dr.Wagner
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My point was this...you said no adhesions...I have seen adhesions, not by arthroscopy but by open dissection.
My point about OR Adhesive Capsulitis stands as a point of 1. convenience 2. practicality 3. success 4. low rate of adverse outcomes NOT to disprove your thoughts. Your ideas are just fine, things are done differently at different hospitals or outpatient surgery centers. I really don't need to read the article because I am sure the article is just fine...but I would hesitate to make the statement that AC contains no adhesions...I would imagine a infraglenoid capsule "although it was inflamed and appeared contracted" might appear to have adhesions if stretched...furthermore, sound more like "splitting hairs" or simple verbal differences in definitions of adhesions. Like saying it should be renamed "contracted capsulitis" :rolleyes:
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Dr. Wagner DO
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