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Re: Ilioinguinal Neuralgia?
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Re: Ilioinguinal Neuralgia? - June 30, 2004 8:33:00 AM
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Dr.Wagner
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My strong personal belief (shared by most Docs) from being a PT and treating chronic pain for a year and now as a Doc, is that EVERY chronic pain patient should see a psychiatrist/psychologist/psychotherapist PRIOR to seeing a pain specialist. There is TOO much of an association between the brain and extremes of sensation (whether orgasmic or painful).
If there was a psychiatric eval prior to every "fibromyalgia" diagnosis or Fentanyl patch distribution then we would have FAR more success in treating pain or pain syndromes. And they would STOP seeing me at 2am because their "vicodin was lost" or "I can't sleep because the pain is worse"
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Dr. Wagner DO
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Re: Ilioinguinal Neuralgia? - June 30, 2004 12:14:00 PM
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Diane
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Hi Dr. Wagner,
[QUOTE] My strong personal belief (shared by most Docs) from being a PT and treating chronic pain for a year and now as a Doc, is that EVERY chronic pain patient should see a psychiatrist/psychologist/psychotherapist PRIOR to seeing a pain specialist.[/QUOTE]By "pain specialist" I presume you mean a physician who specializes in pharmaceutical treatment.
[QUOTE]There is TOO much of an association between the brain and extremes of sensation (whether orgasmic or painful).[/QUOTE]I suspect that's true, pathways for sensation of any kind can be given over to pain experience. The nerves actually physically change, with those carrying ordinary sensation becoming subverted to signaling "pain" instead of the usual warmth, cold, or skin touch. Allodynia is the term for that. Ordinary touch can feel like there are shards of glass under the skin ripping it from the inside. Or such a distressing sensation can stay long after the stimulus is gone, or can come on some time after the stimulus is removed. And there are some individuals out there that have decided to eroticize pain, turn pain sensation into a sexy feeling. I think they are probably just wired that way from the start. I have treated some patients of this persuasion, and it turns out they don't like uncontrollable chronic pain any better than anyone else does. Go figure. Pain comes in lots of different catagories, but is felt uniquely by each individual. Small wonder you find it so irritating; it won't stay in the box, marked "pain". And neither will the people with it who arrive in the middle of the night at your ER door.
[QUOTE]If there was a psychiatric eval prior to every "fibromyalgia" diagnosis or Fentanyl patch distribution then we would have FAR more success in treating pain or pain syndromes. And they would STOP seeing me at 2am because their "vicodin was lost" or "I can't sleep because the pain is worse"[/QUOTE]I quite sympathize with your crankiness from lack of sleep. It's not a life I would choose, yours, and I appreciate that you are out there choosing it instead of me. Thank you.
In my opinion (which you are going to read here whether you want to or not)..pain is more a neurological issue than it is a psych issue.
I think that a psych consult for each and every pain sufferer would drive up systems costs..not that I don't think there is overlap, or that people don't benefit from psych assessment and consultation. But again... there is usually some "issue in the tissue" that keeps a pain loop open,(referred to as "neurotags"); there often needs to be some approach, non-pharmaceutical, some intelligent hands-on (or off) theraputic accompaniment of such individuals, that includes movement, that can intervene in the loop and help the patient manage their "pain" (ideally turn it into non-pain) themselves.
That would be your local, friendly, direct access, non-quack, pain-savey PT, who has become fascinated by pain problems and the people who exhibit them, and who doesn't feel that "touching" actual bodies in a relaxed, boundaried, exploratory, non-pain-provoking manner is beneath their expertise level/professional dignity.
May neither you nor any of your close friends/family ever be plagued by this strange entity called chronic pain.
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Re: Ilioinguinal Neuralgia? - June 30, 2004 4:19:00 PM
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Dr.Wagner
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Lack of sleep...nah I work 40hrs a week. I am cranky when people with legitimate chronic pain have to endure the bad rep of those who abuse the system...which outnumber the valid cases ( I am assuming yours).
A psych evaluation would SAVE resources by 1. filtering the malingerers 2. by INCREASING access to pychological care for those that really need it (bypassing therapies that likely would have little benefit) 3. further accent care by adding pharmacological agents to those who would benefit from multidisciplinary care.
One must remember, I am in the business of NOT seeing patients more than once...while you are in the business of seeing patients frequently. I see the failures (usually they don't tell their therapist...sometimes not even their doctor).
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Dr. Wagner DO
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Re: Ilioinguinal Neuralgia? - June 30, 2004 4:25:00 PM
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nari
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I have just read through the posts, and agree with everything Diane, Pablo and others have said.
Pain is not black and white, it does not obey the rules in the anatomy books, it is not necessarily dermatomal, and has the annoying habit of labelling every chronic pain patient with the same tar brush from folk who do not update on pain physiology...
Dr Wagner, you are in a difficult job and full of challenges, certainly, but maybe if you do not like the heat of the kitchen....perhaps for your own wellbeing..move away?
Nari
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Re: Ilioinguinal Neuralgia? - June 30, 2004 4:57:00 PM
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pablo w
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Dr Wagner,
I don't know what the proportions of chronic pain patients who abuse the system may be. I'm not that naive to assume it never happens. It happens all the time, but I think we also need to take a look at the system itself and see if the way it is set up contributes to the problem.
There are many people with chronic pain who are not abusing the system, however. These are people who have very good chances of improving their situation, even though their pain may not disappear. Occasionally some of them will become so distressed by their pain that they will present to an emergency department, in the hope that soemething can be done about their pain and suffering. This doesn't make them malingerers, or mentally unbalanced, or system abusers. They are usually afraid, confused, and sometimes angry. The pain may lead them to depression. They will become anxious. These factors will enhance their pain experience. Being treated as pests to be gotten rid of, or told that their problems are all in their heads (this is how some of them feel, they tell me) I think only adds to their distress. I am confident you don't do this, and that you do whatever is in your power to help.
I understand your crankiness, though. Nobody likes being taken for a ride, and when we see things that don't add up to good management (like the guy I saw a couple of weeks ago who gets five pethidine injections a week for his back pain, from his doctor whom he has been seeing three times a week for two years). There are no easy answers to these cases, and in the emergency situation I'm sure they take up valuable time when these are not really medical emergencies. They also take up valuable time elsewhere, but there are many who benefit (including health care workers of many description). What is the optimal management plan for such cases, I'm not sure. I know that even with multidisciplinary (including psychology) aproaches, there are no clear-cut solutions.
We all do what we can. One thing we can all do is give people a fair chance, before we give up (and sometimes I think it is healthier to do just that). We (and by that I mean the therapeutic community, of all persuasions) have a role to play. We need to understand what our roles in contributing to the problem might be, and if we can, try to change it for the better. We have to know our enemy, in whatever form he takes. That way we can hopefully choose our tools better.
I know that if we could sit down and talk about this we would agree on many more points than those we would disagree on. We are, after all, palying for the same team.
Pablo
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Re: Ilioinguinal Neuralgia? - June 30, 2004 5:27:00 PM
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Dr.Wagner
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Nari...heat in the kitchen? Chronic pain aint heat...just abuse. Too many people feed into the machinery of abuse. Why don't you re-read the need for a multidisciplinary (including psych) with chronic pain. Why the resistance? Personally this discussion has degraded into "my experiences vs yours" which really leads to nowhere.
I think you guys have seen what I have, your ideas would change a bit also. I was VERY interested in chronic pain as a PT...but seeing the numbers of abuse as a physician has painted a different picture. The legitimate pain patient pays for the abuse in the system.
The chronic pain patient (abusing the system) can clog up an ED. It really is amazing...I invite you to come and spend a couple of evenings ;)
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Dr. Wagner DO
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Re: Ilioinguinal Neuralgia? - June 30, 2004 6:00:00 PM
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nari
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Dr Wagner
What proportion of these nuisance people are drug addicts, do you think? Do you reckon that addiction is the main reason they are there?
In that case, rehab is the only way out for them (apart from the obvious)and I can see your point about system/substance abuse, even though addiction is still a major problem for medicos.
I don't see how I am resisting the need for more MD interventions - they are more effective perhaps than individual intervention (proven) but as Pablo says, there are no clear-cut solutions and no guarantees.
Eventually it is up to the individual to take responsibility for him/herself, but in modern society we are getting so soft it becomes less and less likely that will happen as a rule.
Nari
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Re: Ilioinguinal Neuralgia? - June 30, 2004 6:26:00 PM
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Dr.Wagner
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I will let the psychiatrists define addiction, but everyone on long term narcotic use has tolerence.
Nari, are you a DC or from the UK? The term "medicos" is typically a chiros term.
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Re: Ilioinguinal Neuralgia? - June 30, 2004 7:03:00 PM
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Jon Newman
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This has been a great dialogue so far. We started with a diagnosis of iliopsoas strain with sx onset shortly after a routine surgery. Then a discussion about the source of pain with many hypotheses offered. Finally a debate about how to handle pain of unknown origin.
Options offered include:
Telling the person they are faking it and drug seeking.
Seeing a psychologist.
Working through the pain with the patient using unspecified techniques but biologically plausible and scientifically supported methods.
Without intent, I believe I arranged those options in rank order with the first being least effective. I do think a psychologist and a PT would make a good team. However, I would also argue that it would be disingenuous to state that PT’s do not use psychological methods. The extent to which those methods are used is guided by our code of ethics. We are duty bound to “accept responsibility for the exercise of sound judgment”. This includes recognizing when the individual’s needs are beyond the scope of the physical therapist’s expertise. As far as screening goes, perhaps a PT should screen for a psychiatrist rather than the other way around. If the person isn't responding to entry level behavioral principles combined with manual care, refer on.
As far as abusing the system: look no further than some of the practices in the profession itself (one of your points, I believe, Dr. Wagner). It takes two to tango. Diane is clearly emancipated from this as she is private pay and thus is not part of the “system”. Perhaps the trick, Dr. Wagner, is know which therapists in your area are ethical and up to the task of treating someone with pain of unknown or dubious origin. That person could become an extra box in your clinical decision algorithm.
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: Ilioinguinal Neuralgia? - June 30, 2004 7:35:00 PM
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nari
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Dr Wagner
As my profile states clearly, I am a physiotherapist and Australian. Medicos is quite standard useage, as is MOs, MDs, VMOs RMOs etc.
Jon, good point re PTs screening for psych - we are mostly skilled in this area of basic cognitive knowledge.
As physios vary so much from one to the other, it is difficult for anyone to work out who specialises in what; if most do not specialise in anything in particular, that means a lot of PR and education needs to be maintained by PTs so that doctors et all know where to refer.
It is hard enough here in Aust where we are autonomous and a very mixed bag of specialties!!
Nari
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Re: Ilioinguinal Neuralgia? - June 30, 2004 8:26:00 PM
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Alex Brenner PT MPT OCS
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[QUOTE]Welcome to the world of chronic pain, where people have symptoms that don't fit, pain that spreads outside the nice lines on dermatome charts, and are therefore considered cranks or crocks or crazy or attention seeking.
At least this patient still has pain that is in a pattern, even if the pattern is an odd one. There is probably still some hope for turning it around with some intelligent handling.
I will take the liberty of translating this into paintherapy-ese: "This pain pattern will not likely change using the rationale/application of joint manipulation."
Or exercise therapy. No amount of theraband/weight training/stretching is likely to produce reduction in this pain pattern, because no one is willing to consider the soft tissue or the way it is structured, or the nervous system innervating it, or how feedback from said nervous system may sound like microphone squeal to the brain. No one wants to know, I guess, that every nerve, incuding every cutaneous nerve to the abdomen, has its own nerve supply, the nervi nervorum, which, if its own blood flow is even a little bit impaired, can be raising a huge pain ruckus even if all seems perfectly normal in the world of outer appearances.
Or modalities probably. Electrotherapy might push it down for a bit. Ultra sound etc., but she'll more than likely be back before long.
No protocols will fit this patient, no insurer will pay for any creative approach to helping her. She is stuck sideways in the system, between the medical system on one hand who think she's crazy/young/female therefore bogus by definition, and a system that rewards the theraputic handling of bones and joints, so you better not use up any valuable cognitive space learning about any other systems of the body. Too many quacks out there, too scary. Don't want to be suspected of being one of THEM!
Treating pain in people/people in pain is like working in a hall of distorting mirrors. You have to be ready for anything, in good communication with your patient, and willing to be wrong in your assumptions, frequently. Pain is a wiley foe; it has no shape, it can't be imaged (well, that's starting to change but it's still a ways away).
Pain won't stay inside the lines, comes and goes as it likes, baffles the best intentions. That's life outside the ER and outside everyone's nice neat bone&joint mentality. Good luck Mickey.[/QUOTE]Diane,
I printed this out and posted it up on a board that I have above my computer. Anyone who has ever treated chronic pain needs to read this. Excellent. Thank you for writing it.
Army
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Alex Brenner, PT, MPT, OCS
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Re: Ilioinguinal Neuralgia? - June 30, 2004 9:15:00 PM
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Diane
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Hi, me again.
Dr. Wagner, I think Jon is right with his suggestion, that PTs who are pain 'specialists' could be the ones to make referrals to psych, which would cut down on medical costs, and by sifting out the patients they could actually help, cut down on numbers of those labelled with somatoform disorders etc.
I still think you are sounding fairly jaded. Maybe it's the people you hang with?
I wonder how you differentiate people with "legitimate" chronic pain from those who are faking it. I wonder if, say, a 'legitimate' chronic pain patient, perhaps one like Mickey's patient, seeks out help in an organized way, not the "crisis management" of ending up in the ER in the middle of the night with out of control pain and/or unfed addiction.
If that's one way to tell the real ones from the ones that are "abusing" the ER and your good training, then I would say again, that Mickey's patient doesn't fit your catagory of young female therefore automatically neurotic and attention seeking.
[QUOTE]One must remember, I am in the business of NOT seeing patients more than once...while you are in the business of seeing patients frequently.[/QUOTE]Actually my reputation has grown in inverse proportion to the few numbers of times, infrequently, that I need to see people.
[QUOTE]I see the failures (usually they don't tell their therapist...sometimes not even their doctor).[/QUOTE]You know, we all end up seeing each others failures. Until at last the day arrives when the patient is no longer somebody's "failure", but somebody's "success." And you can honestly tell them that although you've assisted them a bit they have overcome their pain problem themselves, with their own big brains.
(Thank you Army PT.)
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Re: Ilioinguinal Neuralgia? - June 30, 2004 10:40:00 PM
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nari
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The difficulty with the label of chronic pain is just that - its label. It has been around for years and became almost synonymous with whingers and layabouts and idlers (who could actually DO things on some days, but not on others); an undercurrent that suggests these people 'can't/don't help themselves'. Maybe, they just do not know how. Maybe that is our job as health professionals - teach them strategies, coping and motor strategies, hands-on by all means, or hands-off.
I have just seen a young woman, single mum, depressed, 11 yo son, has had (R) upper limb and neck pain for years on and off. When she walked in, she held the (R) arm akimbo and could barely let me touch it anywhere. Fear of damage was paramount, as was fear of the future. The GP called it 'tennis elbow'. i call it chronic, global pain that hits home when least expected, and yet allows flashes of normal life before it returns.
After 45 minutes she was painfree and could move her arm in any direction. Her demeanour, composure and gait totally changed.
What did I do? Listened. Educated on pain (NOT on the false diagnosis) and its physiology. While she talked about the yellow flags that slowly erupted, I was pinching her 'acute epicondyle' and it was painfree. I showed her what I was doing, and she was fascinated.
The pain will come back; but before I see her again she has a few strategies, and now understands she hasn't a serious condition, it cannot be 'harmed or damaged'...
No routine US, painful stretches, Tubigrip and whatever else is vogue at present.
We do not have to be 100% 'physical' to be successful in dealing with pain.
Dr Wagner I hope you realise that we pick up heaps of failures from the medical teams;wrong diagnoses, treatments. It works both ways.
Nari
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Re: Ilioinguinal Neuralgia? - July 1, 2004 9:03:00 AM
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Dr. Perkins
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[QUOTE]I wonder how you differentiate people with "legitimate" chronic pain from those who are faking it. I wonder if, say, a 'legitimate' chronic pain patient [/QUOTE]Everyone who is complaining of chronic pain has a legitimate problem.
We should be making an effort to determine the root cause of these patients pain so that a logical treatment plan can be established. Sometimes the problem is an overlooked musculoskeletal dysfunction, sometimes the problem is dysfunction of the central nervous system itself and sometimes the problem may be psychological. It certainly makes sense to me that many chronic pain patients should be evaluated from a psychological standpoint. A psychologists or psychiatrists input and assistance is very helpful.
[QUOTE] Treating pain in people/people in pain is like working in a hall of distorting mirrors. You have to be ready for anything, in good communication with your patient, and willing to be wrong in your assumptions, frequently. Pain is a wiley foe; it has no shape, it can't be imaged (well, that's starting to change but it's still a ways away).
Pain won't stay inside the lines, comes and goes as it likes, baffles the best intentions. That's life outside the ER and outside everyone's nice neat bone&joint mentality. Good luck Mickey.[/QUOTE] [QUOTE]Anyone who has ever treated chronic pain needs to read this [/QUOTE]This is an eloquent statement and a good example for why we shouldn't be trying to treat pain in and of itself. In a situation where a patient is in chronic pain and there is no evident neuromusculskeletal pain generator we should be improving posture, correcting movement patterns, educating the patient to remove there apprehension and leading them through a progressive active program of rehabilitation that can be monitored by disability indexes.
In my opinion, many times manual therapies are an adjunct to keeping the patient on track. On the other hand in some cases I have seen manipulation alone solve a “chronic pain” patient’s problems (due to an overlooked problem).
[QUOTE] Welcome to the world of chronic pain, where people have symptoms that don't fit, pain that spreads outside the nice lines on dermatome charts, and are therefore considered cranks or crocks [/QUOTE]Diane, thank you for your somewhat condescending welcome. You obviously have many of the answers that the rehabilitation community is struggling with in regards to how to rehabilitate patients in chronic pain. I have given my opinion as to how chronic pain in the absence of an evident neuromusculoskeletal dysfunction should be addressed.
[QUOTE] we should be improving posture, correcting movement patterns, educating the patient to remove there apprehension and leading them through a progressive active program of rehabilitation that can be monitored by disability indexes. [/QUOTE]Each pateint is obviously a unique case but I would like to here your opinion on how to rehabilitate these patients in general?
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Aaron W. Perkins D.C., P.T., M.S.
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Re: Ilioinguinal Neuralgia? - July 1, 2004 12:49:00 PM
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Diane
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Nari,
[QUOTE]Maybe, they just do not know how. Maybe that is our job as health professionals - teach them strategies, coping and motor strategies, hands-on by all means, or hands-off.[/QUOTE]Ditto that.
[QUOTE]We do not have to be 100% 'physical' to be successful in dealing with pain.[/QUOTE]Ditto that again. Often, 100% listening and attention to detail will be the first/best tool.
If we see chronic pain as a neurological problem, rather than a social problem, or an insurance problem (and I think pain research/brain research points in that direction), treating it fits straight into what PTs have done for decades, taking patients with neurological impairments and taking the time to persuade them that they can have a healthy safe life, and teaching them every way we can think of how to accomplish that.
People with pain most need to know that they aren't crazy, because many of them feel crazy, and it has already been implied to them by their well-meaning caregivers like Dr. Wagner perhaps, or you Aaron perhaps, that they must be crazy somehow.. The relief in being reassured that they are not, in and of itself propels them quite far into a successful outcome. Plus, much of the time, most of the time, the pain lessens or disappears with some good careful physical handling (pain wrangling.)
Aaron, [QUOTE]Diane, thank you for your somewhat condescending welcome.[/QUOTE]Apologies if my welcome seemed condescending.
[QUOTE] we should be improving posture, correcting movement patterns, educating the patient to remove there apprehension and leading them through a progressive active program of rehabilitation that can be monitored by disability indexes.
Each pateint is obviously a unique case but I would like to here your opinion on how to rehabilitate these patients in general?[/QUOTE]In general, I think you are correct in saying that each (chronic pain) patient is "obviously a unique case." Each is not only a 'unique case' but can only be treated as such, not in general; not til they get a set of tools they can use to deal with pain, at any rate.
Once they know it is possible to turn down the 'volume control' on their pain, have learned how, understand that it isn't magic, and have strategies in place to turn it down anytime they want, will they be able to benefit from "general" rehab type approaches.
Before that point, they are more likely to feel anxious, fearful, tense, and are more likely to hurt themselves or at least not help themselves very much.. 'telling' them to work through pain without educating them first is doing them a big disservice, I think. In a general patient population, there will be a certain number who will 'play along' with such a strategy, but won't really benefit and will wind up at Dr. Wagner's ER perhaps. In the chronic pain population that "failure" rate will rise dramatically. (My opinion only, based on who I treat and what they say. Others may have other opinions.)
Final word to Pablo: [QUOTE]One thing we can all do is give people a fair chance, before we give up (and sometimes I think it is healthier to do just that). We (and by that I mean the therapeutic community, of all persuasions) have a role to play.[/QUOTE]Ditto that Pablo.
Regards,
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Re: Ilioinguinal Neuralgia? - July 1, 2004 1:46:00 PM
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Dr. Perkins
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Diane,
[QUOTE]People with pain most need to know that they aren't crazy, because many of them feel crazy, and it has already been implied to them by their well-meaning caregivers like Dr. Wagner perhaps, or you Aaron perhaps, that they must be crazy somehow.. [/QUOTE]Perhaps, earlier in the post, when I said that I agreed with Dr. Wagner, I confused you. It may be dangerous to say that you agree with someone, especially in a discussion forum, because it seems as though you are agreeing with everything they said.
My point was that it is unlikely that the problem we were discussing earlier was an iliopsoas strain, or rectus strain, or some stitch wrapped around a peripheral nerve, etc. based on the reasoning that I listed.
I think that your comment is unfair, is an accusation and is inflammatory. I would like you to quote one of my posts where I say or even infer that patients in chronic pain are "crazy".
Here is a quote, from me, that directly counters your insinuation.
[QUOTE] Everyone who is complaining of chronic pain has a legitimate problem.
[/QUOTE]Also, I am not just "well-meaning". I actually objectively track my patients progress and can assure you that either improvement is being made or a consultation is occurring.
I don't mean to come across as petty, but, do you have a problem with Chiropractors?
_____________________________
Aaron W. Perkins D.C., P.T., M.S.
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Re: Ilioinguinal Neuralgia? - July 1, 2004 5:50:00 PM
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Diane
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From: Vancouver, B.C., Canada
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I have replied to Aaron's post by PM. Aaron, I hope you will share with the board how you handle such patients who each, as you say, have a legitimate concern.
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Re: Ilioinguinal Neuralgia? - July 1, 2004 7:41:00 PM
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Justin
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I hope this doesn't degenerate into another turf battle, as I'm sure this isn't why most of us find ourselves here.
I am one of the rank and file, stretch it if it's tight / strengthen it if it's weak / etc therapists and freely admit that I'm out of my league in discussions on this board, but I am desperate to learn new skills, as I often feel woefully inadequate, particularly in the face of chronic pain. I would LOVE if nari or diane would elaborate on their methods, particularly on the example of the "tennis elbow" patient who was painfree after 45 minutes. I have many more questions to ask, frustrations to vent, but most of all I would like some insight into your treatment (other than education and validation, as maybe it is just me but I have never been that successful with these as my only tools).
Thanks in advance...........
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Re: Ilioinguinal Neuralgia? - July 1, 2004 9:37:00 PM
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Diane
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Hello Justin,
I don't think there will be any turf battles, just the neverending struggle for clarification.
I think we've all experienced what you've described, feeling out of our league, etc. I seriously doubt you are inadequate, but maybe the paradigms you currently employ, are. If you'd like some discussion around technique, insight, frustrations etc. it might be time for a new thread, above on Barrett's pain forum. (I think we'd be up for that, right Nari?)
Apologies to you Mickey for the (in retrospect) hijacking of your thread. Again, good luck with your patient.
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Re: Ilioinguinal Neuralgia? - July 1, 2004 10:24:00 PM
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nari
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HI Justin and Diane
Justin, just to reassure you, I feel quite inadequate with orthopaedics - all the million tests for this muscle and that capsule; when the whole lot is intimately connected anyway.
I have also felt quite baffled by the complexities of persistent pain - to the extent i go off and think for a while: "what &*$## direction am I going to head here......."?
Diane, couldn't agree more re the move to Barrett's Pain forum for a PP thread (Persistent pain) and Justin, please visit. I am sure Barrett would not be displeased with this 'educative thread'? on the perils and pleasures of the brain.
Nari
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