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Re: Ilioinguinal Neuralgia?
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Re: Ilioinguinal Neuralgia? - July 2, 2004 3:44:00 AM
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Barrett
Posts: 967
Joined: July 28, 1999
From: Cuyahoga Falls, Ohio
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Hello,
I think the "Consummatory Act" thread in the Bullypit was one of the best examples of how actual methods of care can be discussed and made clear that I've ever seen. A new thread of a similar sort is certainly welcome.
I suspect Nari helped the "tennis elbow" patient not only by verbally accepting their story but by doing so manually as well. It seems evident that Diane does this regularly and a technique such as this forms the foundation of my own work. By combining what we know to be true about the effect of neural tension and the brain's instinctive response to that we can handle people in a fashion that reveals and encourages self correction and, along with the patient, watch nature take its course. This is how I would have dealt with the woman described at the beginning of this thread. I would have asked manually "What do you want to do?" And this patient would have shown me.
Justin,
Read "Do Nothing" on my web site. Maybe that will help.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Ilioinguinal Neuralgia? - July 2, 2004 3:56:00 AM
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Sebastian Asselbergs
Posts: 1205
Joined: September 29, 1999
From: Barrie, Canada
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Diane and Dr. Wagner: a friend of mine is an Emergency Medicine specialist and suggests that your respective perspectives (nice, eh?) are not mutually exclusive. He suggests that "genuine" chronic pain patients usually have an excellent grip on their management and will rarely "need" to go to EDs, are in regular contact with their MDs, while the "malingerers" rarely see PTs and use EDs a lot. I thought that was a reasonable idea. Having seen many chronic patients as a PT, I can say I am more with Diane with regards to my professional experience; however, knowing two cases intimately who are "milking" their (insurance) complaint to the point that they now ARE disabled (probably could pass a lie-detector test) and have physiological and neuro-muscular changes
gives me some idea as to what an ED MD could see. These two will see any PT, DO, MT for a little while, "because the insurance sent me" but then worsen... One was talking about being catastrophically injured and maybe getting $1,000,000.00 settlement.
Yes, there is much more going on than just $$. Enormous lack of self-esteem, combined with great acting skills, and perception of having no future (meaning "no big $$") are the main ingredients. Of course there's much more, but the long and short of it is, ANY mention of the research and theories on the management of chronic pain and importance of motion are ALWAYS countered with "I tried that, makes me worse, and then I have to go to the emerg...."
I think these are the ones who get into Wags care more often than Diane's or mine. Three physiatrists, one psychologist, one family doc, two neurologists, and thanks to his very high profile lawyer, no conclusive diagnosis but a firm "poor prognosis"! No kidding...
OK I had to vent a bit too...
_____________________________
Mundi vult decipi
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Re: Ilioinguinal Neuralgia? - July 2, 2004 6:36:00 AM
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Diane
Posts: 1507
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From: Vancouver, B.C., Canada
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Sebastian,
(Shudder..) I think you are right, that these manipulators are the ones ending up at Wagner's ER and other ER's, coloring the lenses through which he/ER docs see the world.
Are you in a position to "fire" these two from your practice? Reserving the right to do so, in cases where there is clearly no future for a theraputic relationship to develop, is important for one's own self-preservation. It can be done quite gently. "Sometimes there just isn't a theraputic fit. Perhaps someone else might be able to help you better than I can." (Translation: "We reserve the right to refuse service.")
Thank goodness most chronic pain/persistant pain people are for real. Thank goodness for options: direct access, cash practice, and professional autonomy. Conditions are then good for actually getting down to the business of helping those who are seeking help of their own accord. They are automatically committed to the process, at least with the conscious part of their awareness..the more of their brain you can bring into the process the better, but I agree, there are some (very few, but some) mountains you just can't climb.
I still doubt Mickey's patient is one of these. This thread got so long partly because of an assertion she was.
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Re: Ilioinguinal Neuralgia? - July 2, 2004 7:30:00 AM
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Dr.Wagner
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From: Indianapolis
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You know I think this discussion has gotten so far off topic that it likely doesn't represent the true case presentation at all.
It is far too difficult to enter into a discussion like this over the internet...most of this needs to be experienced, seen, and felt.
Nari, medicos is still a weird term. What am I...once a physio now a medico? Weird.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Ilioinguinal Neuralgia? - July 2, 2004 8:14:00 AM
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MickeyPT
Posts: 39
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From: USA
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Just a quick update on the patient. My PTA was working with her today and she discovered some information the patient had forgotten to tell me. Apparently the day before her appendectomy she had a MVA and hit a telephone pole. She received a small head injury and bruising around her lower abdomen and across her chest from the seatbelt. I'm thinking this may be something significant. Her surgery was early the next morning. This patient has a personality of someone who goes above and beyond what is expected of her. Today she had 7/10 pain because she over did it at work (as a pharmacy tech) and was forced to ascend and descend stairs repetively. Does anyone think this auto accident contributed to this pain? Wouldn't the surgeon have noticed any internal trauma at the time of the surgery? Thank you all for the input over the past weeks. Even though some of us disagree on the proper diagnosis all the information has been enlightening. Thanks again. Mickey
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Michael McIntosh PT, MBA
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Re: Ilioinguinal Neuralgia? - July 2, 2004 10:51:00 AM
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Barrett1
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From “Pain: The Science of Suffering” by Patrick Wall (page 90): “Emergency situations are a problem, but the real challenge occurs when pain persists beyond the “appropriate” time. Medical personnel can become grossly dismissive and switch their attitude to suspicion that this is no longer a “proper” patient. They may act as though pain is an option, especially when the initial pathology has gone but the pain continues. The doctor becomes uneasy when patients fail to respond to their treatment and this discomfort of the doctors may escalate into irritation, guilt anger and withdrawal.”
I think this quote is appropriate at this point, and perfectly germane to the nature of this thread. I also think you could substitute physical therapist here for “doctor.” I don’t see Wall suggesting that the patient changes too much as chronicity sets in. I think it’s the attitude of the caregiver when faced with this situation, and the one described isn’t going to help anybody.
The revelation about the previously unreported trauma reminded me of another quote: “…the foremost authorities on the subject of recall all agree that there is a thin veil between memory and imagination. If this is the case how can I be expected to believe everything I’m told? When I go back through what I’ve written I can’t help but wonder if it describes what actually happened or even what I think I remember the patient told me.” That’s from “History and Imagination” at http://www.barrettdorko.com/articles/history_and_imagination.htm
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Re: Ilioinguinal Neuralgia? - July 2, 2004 12:38:00 PM
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MickeyPT
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From: USA
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Thanks for the input Barrett1. I am not ruling out the possibility of symptom magnification just yet but let me attempt to give a description of this patient to support why I am having a hard time fitting her into a category 95% of my "typical" chronic pain population belong. I work in a multidisciplinary chronic pain facility where our team of anesthesiologists refer patients to us if they detect physical therapy may be beneficial. The referrals are screen by our team of psychologists who determine if there are psych issues in addition to physical issues. This patient was determined to have no psychological involvement and therefore referred for PT only. She had been living with this pain since fall of 2003 and was putting off seeking help because she figured it would eventually go away. Recollection of the MVA happened when she and her husband came upon the site of the accident while taking a drive earlier this week. She brought it up in small talk with the PTA.
During our course of treatment I have to constantly watch her face to make sure we aren't overdoing it because she feels this situation falls under the "no pain, no gain" category. I have told her over and over…that is not the case in this situation. I have to constantly remind her to let me know when it begins to hurt, otherwise, she will keep on going. This isn't only the situation in therapy. She also overdoes things at work and works shifts even when she is in pain because she doesn't want to burden coworkers with her complaints.
I really want to help this girl because she is a genuinely good natured person who has the unfortunate burden of chronic pain. I want to be sure I'm not treating the wrong condition in this young 21 year old girl. It is possible I shouldn't be questioning our physicians opinion but something just isn't right. If her pain doesn't begin to subside I'm not sure what route I should take. Maybe the psychologist and I have been fooled and she is flying under our radar but I want to be darn sure of it before I make that call. That is why I started this forum. I appreciate all of the input and if this case turns out to be psych related then I'll eat my words. Thank you. Mickey
_____________________________
Michael McIntosh PT, MBA
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Re: Ilioinguinal Neuralgia? - July 2, 2004 7:01:00 PM
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nari
Posts: 1568
Joined: November 14, 2003
From: Australia
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Barrett
True, I did place my hands on her arm, but only after I had explained the reason for her pain, as I saw it. Initially, I could not assess her because of her fear of being touched (worsening the pain) and moved (ditto). Her epicondylar area was lethal to her, she cringed even while talking about it.
So as we discussed whether she needed the pain or not, and she discovered there seemed to be no reason why she had this pain, other than she used to be a waitress; I moved her arm out from the side, fiddled with her elbow, etc etc (all of five minutes)and when I had my fingers curled quite firmly around the epicondyles, I asked her to look (she was staring at the ceiling and at me as she talked). She stared in amazement- she felt no pain. Zing - the lightbulb went on,
I could have asked her to do her own free movement, but at the time, I felt she would freeze up in fear anticipation. Might try that at a later date with someone similar...
This does not happen too often, I assure you, But it happens often enough to show how important it is (to me, anyway) to explain the pain, and then prove it. Physical assessments early on can increase pain experience - these people have had endless physical 'assaults'. Too strong a word?
Sometimes I wonder....
Nari
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Re: Ilioinguinal Neuralgia? - July 2, 2004 8:34:00 PM
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Diane
Posts: 1507
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From: Vancouver, B.C., Canada
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Hi Mickey,
[QUOTE]She received a small head injury and bruising around her lower abdomen and across her chest from the seatbelt. I'm thinking this may be something significant.[/QUOTE]Was she the driver? I think you're right, it could be significant. Did you check and clear her for right upslip, outflare/inflare, pubic shear etc? Any of these could irritate the ab wall/nerve array and produce a long lasting pain state, even after the bruise is long gone or the appy is long over.
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Re: Ilioinguinal Neuralgia? - July 3, 2004 5:41:00 AM
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Dr.Wagner
Posts: 1242
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From: Indianapolis
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Likely what this patient needs is a new set of eyes to view her...find a treatment plan (manual therapy) and stick with it. My suggestion is a fellowship trained Physiatrist that has the ability to perform pharmacologic therapy, invasive therapy, and has in house LMT's or PT's to provide manual therapy. This patient has run into a wall and if you are spinning your wheels and you really can't help her, it is unfair to charge her for experiementation or just "shots in the dark". She needs an approach and to stick with it...not hodge podge. This patient needs a team approach and people licensed and capable of giving psychotherapy if needed. 20 is far to young to THINK you have chronic pain...it will follow her the rest of her life.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Ilioinguinal Neuralgia? - July 7, 2004 8:40:00 AM
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MickeyPT
Posts: 39
Joined: May 1, 2004
From: USA
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Diane
I haven't yet examined her for the areas you mentioned. But it is a good thought and I'll screen her pelvis on the next visit. Pain level is still 6/10. I plan on discussing treatment options with the physician on our next team meeting if further testing doesn't reveal anything. I tried the myofacial release for the iliopsoas you had mentioned earlier but she couldn't tolerate much pressure on her abdomen. If her pain level goes down maybe that will be an option. Thanks again. Mickey
_____________________________
Michael McIntosh PT, MBA
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Re: Ilioinguinal Neuralgia? - July 7, 2004 11:47:00 AM
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Diane
Posts: 1507
Joined: March 9, 2001
From: Vancouver, B.C., Canada
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Mickey,
[QUOTE]I tried the myofacial release for the iliopsoas you had mentioned earlier but she couldn't tolerate much pressure on her abdomen.[/QUOTE]..Er...that was Bonnie's technique, not mine. I would probably not aim that deep, ever. (I like to change things at a superficial or barely subcutaneous level. Short focal length. Brain won't perceive threat, won't make pain, will take info and use it to mop up pain output.)
Cheers,
Diane
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