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Re: On guard
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Re: On guard - January 21, 2005 3:14:00 AM
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Shill
Posts: 1097
Joined: February 13, 2003
From: Madison WI USA
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Nari,
A selfish request for me:
Could you measure the difference in ROM next visit, goniometrically, so that we can see the amount of change before and after? Then show these numbers to the patient? Im sure you explain well to her how much of a difference there is, but I would like to see it in precise objective form, including positions in which motions were measured. I dont want this to sound as if I am questioning your techniques, it is just to help me understand how much of a difference there is in her motion.
Thanks,
Steve
_____________________________
Steve Hill PT
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Re: On guard - January 21, 2005 3:14:00 AM
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ericm
Posts: 171
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From: Nanaimo, BC
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John, with regards to the TKJR example Jon presented, what would you have done?
Eric
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Re: On guard - January 21, 2005 3:33:00 AM
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childsjd
Posts: 63
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Eric:
Probably something along the lines of moist heat (for which there is some data to relieve acute pain) and mobilization procedures. Thrust techniques would be my choice if the example were muscle guarding in the lumbar spine, and presumably would meet the rule because of this being more of an acute situation. Mobilization procedures would be my choice for the knee and shoulder example, more along the lines of repeated osscilations, 3 bouts of 30 type approach. Again, considerable evidence exists for a manual physical therapy approach in these patients (several high quality RCTs). The techniques mentioned by others (other than perhaps muscle energy) were not studied in these trials, hence I'm uncertain why you would do them.
John
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Re: On guard - January 21, 2005 4:23:00 AM
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SJBird55
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From: Michigan
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Oh, John... don't go slamming me for using humor. Geesh... I was speaking of post-op issues and most patients do have a ton of guarding post-op. And, I do collect outcome data and I know that when categorizing patients as The Guide defines combined with body part that my effect size ranges from 1.084 for patients with cervical problems to a 2.28 for patients with elbow problems. There isn't anything out there in literature that even comes close to indicating to me how well I do in treating patients. My effect size is pretty good in my opinion. Since what I do appears to be working from a very simple interpretation of my data, humor is fine to use. How's that for a rationalization?
I know from looking at my data and comparing it to what I learned from your clinical prediction rule that I can probably have a better effect size than my current 1.40 for patient with lumbar problems categorized as either inflammation or connective tissue dysfunction AND I can probably definitely reduce my average number of visits to be less than 11 visits.
I do believe that therapist personality, communication style, ability to connect are very important, definite variables when it comes to working with people. There haven't been any studies on that kind of thing either, from what I have read. I believe that good outcomes do take into consideration literature but also has that personality factor involved somehow.
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Re: On guard - January 21, 2005 6:45:00 AM
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childsjd
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SJBird55:
I continue to like your way of thinking. You make rational arguments based on sensible decision-making. Well said. Interested in being a full time doctoral student at some point in the future?
I agree about the importance of the interpersonal characteristics you mention. We have some thoughts about how to capture this and determine its influence on outcome.
Seriously though, if you're ever interested in getting a PhD, let me know. You would do well.
John
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Re: On guard - January 21, 2005 6:50:00 AM
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VagusX
Posts: 216
Joined: March 26, 2003
From: Savannah, GA, USA
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Number one way to decrease muscle guarding is distraction. Keep em deep breathing (smell the roses, blow them down!), keep them talking and tell them a interesting story with a calm voice. RELAX!! I've also put strong intermittant IF/TENS of the joint being worked. The muscles get contracted by the stim and when the contraction subsides from the stim current I press into the range. And of course valium works wonders.
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Re: On guard - January 21, 2005 8:27:00 AM
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SJBird55
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From: Michigan
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John, I haven't really thought about it. Is humor allowed? ;)
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Re: On guard - January 21, 2005 1:06:00 PM
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nari
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From: Australia
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Steve,
Some posters may not like my reply, but I do not take much notice of ROM. Increase in ROM, done in figures, does not tell anyone of the actual increase in function, if it occurs. With this woman, in particular, the ROM is going to vary a heck of a lot depending on her cognitive state.
But I do take your point - and in this case, a record of ROM along with change in function would be useful. I will let you know a little more down the track....
I also plan to give her a TAMPA questionnaire.
nari
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Re: On guard - January 21, 2005 2:14:00 PM
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ericm
Posts: 171
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From: Nanaimo, BC
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I realize this study doesn't look at muscle guarding in the sense I think Jon intended for this post, but it does add some validity to Nari's obsevation concerning increases in ROM vs function that result from our interventions. This study looked at the effects of dry needling for posterior thigh pain referred from the gluteal region:
http://bjsm.bmjjournals.com/cgi/content/abstract/39/2/84?etoc
From the conclusion: [QUOTE] Neither dry needling nor placebo needling of the gluteal muscles resulted in any change in straight leg raise or hip internal rotation. Both interventions resulted in subjective improvement in activity related muscle pain and tightness. Despite being commonly used clinical tests in this situation, straight leg raise and hip internal rotation are not likely to help the therapist assess response to treatment. Patient reports of response to such treatment are better indicators of its success. The mechanisms by which these responses occur and the reasons for the success of the placebo needling treatment are areas for further investigation[/QUOTE]eric
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Re: On guard - January 21, 2005 2:48:00 PM
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coloradojulie
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From: colorado usa
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SJ there was a study/survey done on therapist characteristics and their ranking of importance to users of PT. Evidence based practice and level of education were NOT amoung the top indicators of whether they judged a therapist as compentent. It had more to do with what you stated...they listened etc. Also the predictors of expert practice in physical therapy which was also recently reported had less to do with DPT or OCS and more to do with the way patients were managed...and not necessarily based on the interventions used.
That said...I agree with John regarding the need to evaluate what we do with evidence. It is refreshing to have someone on the forum who is consistent in all manner of evidence based practice rather than what most of us seem to do...pick and choose. There have been several discussions on this board where many now who are defending their non-defensible (based on evidence) treatment methodology, who were quick to slam manipulation with chiropractic due to lack of evidence.
That being said, very little evidence exists that most of what we do has significant effectiveness. The list of myths in another thread excluded virtually everything we do! I have found more positive effectiveness literature for massage therapy than physical therapy in my recent pubmed searches!
Keep the evidence coming John...and keep us honest.
_____________________________
PRC
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Re: On guard - January 21, 2005 5:48:00 PM
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Jon Newman
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From: Amherst, WI
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Hi all,
Please don't confuse my TKA post as a comprehensive case study of what I do with this person. I posted what I did in the context of trying to decrease muscle guarding during treatment. I address walking, self assisted ROM, etc, and you know, the stuff a knee and the person who owns it want to do when done with PT.
John, in actuality I did use heat and failed to mention that as a variable that may have influenced my outcome. My apologies; good catch.
I've spent most of my night searching the literature with numerous key words and combinations of key words for more info on muscle guarding (muscle tonus, hypertonicity, pain behavior, guarded movement, etc). There is almost nothing past correlations and theoretic constructs that I've found. Most articles had to do with motivated behavior or reflexive behavior or perception. Anyone else find any? I guess one has to generalize the results with what makes sense from a biological and/or psychosocial standpoint.
John, I failed to find those RCT's on manual therapy in TKA's (or muscle guarding). Could you help here? Maybe I misunderstood the context of that post.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: On guard - January 22, 2005 2:27:00 AM
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SJBird55
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From: Michigan
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Hey, Colorado... are congratulations to be said yet? boy? girl? Welcome back.
I've read Resnik and Jensen on expert. But, I haven't seen (or if I did I don't remember) anything on characteristics and what customers of our services prefer. Where'd you find that one? I'd be interested in reading it.
Jon, I understood what you were getting at.
Colorado, that last bit of what you wrote is so frustrating to me. It is sad, but true. And then, when research does come out with something that is shown to be effective, do all of us listen? I guess I just don't get it. And maybe I have these frustrations because I haven't worked with any therapists that I would consider high caliber for the last 7 years. Right now where I am at the therapist that owns the company does his standard hot pack, ultrasound and massage with every patient. How can I change his current practice patterns without losing my job? He firmly believes he does a great job and when he verbalizes this to me I just look at him and give no comment. (From me, no comment is a stronger action to take than even attempting to discuss the issue with him.) I don't know, but I have a feeling that things won't change in our field until our customers (physicians, patients and third party payers) start demanding our outcomes as clinicians. When that happens, then I can easily see ourselves competing within ourselves and trying to find ways to be better than our competitors (both within our same field of practice and with alternative health providers).
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Re: On guard - January 22, 2005 5:36:00 AM
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cneup
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John
With regards to the EBM comments . . . I am a firm believer in EBM, however, I also believe that the absence of evidence for certain techniques should not preclude their use in practice. Published evidence flows from anectdotal evidence - we don't know everything yet and current literature (especially PT literature) is far from perfect. That said . . Do you personally venture into "unsupported" territory when evidence based practice fails?? Especially when the issues are of a more emotional or psycho-social nature?
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Re: On guard - January 22, 2005 6:24:00 AM
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Diane
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From: Vancouver, B.C., Canada
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I want to highlight something John said earlier:
[QUOTE]..simple contact (can't bear to give it the capital letters), "kinesthetic chatting", positional release, letting the patient's brain come to its own decision about the matter, humor, etc. Again, I am just amazed at the level of confidence indivuduals place in treatment approaches that have absolutely zero basis in evidence.[/QUOTE]Correct me if I'm wrong, but it sounds like our fair John has come to some very premature conclusions about life in general and PT in particular.
1. No one is allowed to use the association areas of their minds. All PT application must flow from RCTs (top down.)
2. No creativity allowed. (See point 1.) PT minds must numbly and robotically follow protocol-esque regimens.
3. PTs must not read anything except in our own narrow field. We must avoid reading neuroscience in particular, as it might give us funny unprovable notions regarding treatment of pain.
4. Don't bother learning any anatomy or embryology or anything about evolution or cellular biology or physiology. These are just a waste of hard drive space that could better be spent designing and carrying out outcome studies to further tighten the limits of what we can do to people, how, and when.
5. Don't interact with your patients too much, especially don't (God forbid) touch their soft tissues! There's nothing in the literature to support PT being done with any eye to improving soft tissue function.
6. Soft tissue is scary and wooey, and anyone who wants to work with it or any of its associated functionality, is an unscientific screwball and doesn't belong in PT, which is all about joints, bone, muscles; the only turf worth gaining is to be gained from chiros, when we claim manipulation for ourselves.
5. Any science, or conclusions based thereon, issuing from PTs in any other parts of the planet except for the US, is at best suspect and at most worthless. Especially because Pubmed is God, and anything not on there doesn't exist, by definition.
6. Furthermore (by decree): No mother may touch her infant without a manual beside her to tell her how. All contact is forbidden between family members or members of similar or different species until officially OKed. (No children may be lifted, no cats or dogs may be handled, no horses ridden until John says it's been RCTed and OKed and given the go-ahead by the air force/PT command.)
7. Common sense is hereby outlawed until further notice.
That pretty much covers how I interpret John's attitude. Perhaps I exaggerate, perhaps not. John, you sound like a young'un. I want to say something for old PTs here, about using our own nervous systems in manual therapy.
It is this:
By the time we get to be in our 40s and 50s, and have had our hands on thousands and thousands and thousands of human beings, things have begun to sift through the brain on their own. Patterns of practice have established themselves based on interaction and observation of many people and conditions over decades of practice. The older one gets, the more one appreciates and respects all aspects of the nervous system, for example.
All interaction with this is no doubt testable somehow. However, by the time a PT's skill set has developed to the place where
1. they can feel pretty much anything going on in a patient's body just by touching that body, and futhermore
2. can, through touch, elicit changes in behavior in those tissues,
3. it dawns on them that light contact extracts more from a patient's nervous system than any coercive manouver ever will (and we "know" because we've tried coercion...)
...by then we are old and have generally grown beyond the place where it means anything much to us to prove anything to anyone, or try to tell others how to practice, or say much beyond "This is possible, that is possible.."
We haven't broken any rules of science, we've stayed in contact with the world view of PT, we didn't dabble in sorcery; we have simply eliminated all practice tools and concepts that were irrelevant from our daily professional lives. We have Occam razored ourselves.
To summarize I'll say this: there are lots of kinds of scientists out there just like there are lots of kinds of tissues in the body or trees in the forest. The kind I am would correspond to "naturalist." I'm out there every day, collecting specimens and cataloguing and comparing and labeling, for my own elucidation, and mostly in my procedural hard drive, and always to become better and lighter at handling patients.
And you know something else? In this country (Canada) we PTs who graduated long ago probably had it way too easy; we assumed from day one that we all had the right, duty, responsibility to use our minds, hearts, hands as professionals in the best way we saw fit. Nothing was "outside our scope" if it helped patients. Manipulation has been part of PT here for eons, since before PT became designated as a standalone profession out of the side of the nursing, remedial massage, and army gym trainers at the turn of the last century, and stood beside the medical profession as a supportive war time buttress to deal with the tsunamis of amputations, and polio epidemics that came later. It is too bad you have to bother "proving" it works, to new generations of PTs and insurers in order to recapture ground you lost to chiros. Manipulation is acceptable, I agree that it should be a PT tool (one of many..).
Just don't for a second think that's it's the only one anyone should use just because you are for the moment in love with manipulation and yourself and your study. Live for awhile and grow up some, and you'll see how the whole thing goes together, how it fits into the plethora of tools we have available, which grows without limit as we learn. Personal learning is unstoppable. Don't make the arrogant mistake of denigrating experience as worthless, or work already done in other countries as inconsequential, or the willingness of PTs to comply with our profession as nonexistant. PT is a multicountry system that exploded into existance in all westernized countries once the world grew to a certain size. And it has cultural differences and flavors.. it is definitely not a onesizefitsall profession.
Having said all that, I appreciate that your disciplined and wellhoned work will open up new territory for PT in your country, and probably in other countries as well.
Over and out,
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Re: On guard - January 22, 2005 6:38:00 AM
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Barrett
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Well Diane, once again I see we're intellectually on the same plane. As I've said before, I'm certain we handle patients in much the same way.
John's combination of hostility and ignorance is especially powerful when he chooses to so very carefully ignore the questions posed by those of us who wonder how he's drawn the conclusions he has.
I'm no psychic, but I doubt that this will change.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: On guard - January 22, 2005 8:50:00 AM
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Jon Newman
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I found this article today.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9564710
I found it interesting because it reinforced something I've told my inpatient hip and knee replacements (if one generalizes the findings). The MD was able to fully flex and extend their knee 24 hours ago while they (the patient) was not conscious of their knee. Thus their work was less to increase their ROM than to tolerate what they already have. Deciding what movement to do is easy. The hard part (sometimes) is figuring out how to get them to tolerate it.
Here's a rhetorical question: Could you consider a TKA or THA a chronic pain patient? The very reason for the surgery is that the patient can no longer cope with the pain and has begun or already changed their behavior to compensate.
The more I read, the more I'm beginning to feel that muscle guarding is simply an automated behavioral response (i.e. there is no muscle dysfunction) to aversive stimuli.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: On guard - January 22, 2005 9:00:00 AM
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ericm
Posts: 171
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From: Nanaimo, BC
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I've wondered that too Jon. Perhaps there is some degree of phantom joint pain present? A variety of somatosensory sensations can linger in the phantom limb, especially sensations that the patient experienced just prior to losing the appendage (Ramachandran and Blakeslee 1998). These sensations resurface as what Ramachandran refers to as repressed pre-amputation memories (Ramachandran 1998).
eric
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Re: On guard - January 22, 2005 11:37:00 AM
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gary s
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From: wantagh, ny, usa
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Jon,
A lot of altered biomechanics thrown into the mix. Ever notice that when you ask a THR pt to flex their hip when supine they'll also actively flex the knee, thereby creating a kind of tug of war? I've always believed that it's the gradual increase in pathomechanics that leads to the actual joint degeneration.
Gary
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Re: On guard - January 22, 2005 1:12:00 PM
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nari
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From: Australia
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I think phantom pain is far more common than recognised - probably a lot of invasive surgery results in this, after bits and pieces are removed.
There is the phenomenon of the so-called and possibly outdated 'adhesive capsulitis'- maybe it can be roughly compared with TKRs etc.
Orthopods are sometimes amazed when they think the joint is 'frozen' and it isn't - it moves easily under aneasthetic - then ''refreezes' later, quite often. This isn't hearsay; I have heard the surgeons comment on this. So the cause is not some mechanical mishap, but a neural one??...
Diane
Well said. There is a lot of bath water to throw out, but until we test its chemistry reliably, it would be plain silly to throw out the babies as well.
We would not have any work left worthwhile doing if we waited for validated studies to tell us how to fill the day's work...
Nari
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Re: On guard - January 22, 2005 2:18:00 PM
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cneup
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I've been thinking that guarding has much more to do with cognition than pure mechanics. In that case it may be necessary to "trick" the patient into moving the injured body part. Gary Gray uses this idea quite a bit with his rehab techniques -- driving the body subconsciously to get the correct movement pattern. I'm still trying to figure out how to do this .. Any thoughts??
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