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RE: A problem arises... - August 2, 2012 7:32:52 AM   
Tom Reeves DPT ATC

 

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quote:

When I get one of the "I have a high pain threshold" (and we all get those indeed), I simply acknowledge it. It usually means that the patient is trying NOT to be labeled as a wimp, because no-one has found anything on a MRI to explain their pain.
As soon as they understand the idea of phantom pain, they tend to feel better about their own suffering: someone loses a limb yet the limb is still hugely painful - I use an example of a military amputee; this usually puts the patient at the same level as a hero.
It validates their suffering without insulting their sense of self-worth.


That's often where I start too. I also talk about the caveman and how in times of stress, he had to be more alert to visual, olfactory, auditory, and tactile stimuli to remain alive. If the patient is under stress, they too might be more sensitive to those things.

They usually seem to get that.

(in reply to Sebastian Asselbergs)
Post #: 181
RE: A problem arises... - August 2, 2012 8:55:21 AM   
Chocco

 

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http://www.youtube.com/watch?v=gwd-wLdIHjs

I have actually had my patients that have had difficulty understanding pain watch this video. I think Moseley does a god job of explaining it without it going over most peoples heads and in an entertaining fashion. His Book painful Yarns can also be helpful for the therapists or the patients

(in reply to Tom Reeves DPT ATC)
Post #: 182
RE: A problem arises... - August 2, 2012 9:32:05 AM   
Chocco

 

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quote:

ORIGINAL: Niko



thanks for being positive. You also run into a problem if you try too hard to explain to patients the neurophysiology of pain. A lot of them will think that you are telling them that everything is in their brain and they are making up the pain. Some times is good to let patients hold onto their believes. Going against them will only make things worse. After all we are running a business, and client satisfaction is something that we need to consider whether we like it or not. I don't think that the weakness and stiffness cause pain is a a problem that starts from the PTs. Patients come from the physicians office already being told that weakness and stiffness cause the pain. oh and the biggest one: it's arthritis, that seems to be the most common answer to everything. And guess who patients trust more?  So now our job is to disregard the physicians and furthermore make them look uneducated. I have no trouble doing that but it is something very very challenging and draining my friend. The medical team needs to be on the same page in order to provide effective and efficient care.

Niko

quote:

trust more? So now our job is to disregard the physicians and furthermore make them look uneducated. I have no trouble doing that but it is something


Niko, I read a great article on how different countries are using mass media to educate patients on the psychosocial aspects of chronic pain. If I can find it again I will post it. I think it is important to explain to patients that they are not "making it up" and there is an actual physical process that is going on before you educate patients on the psychosocial/neurophysiological aspects of pain, especially chronic pain. Once they hear that there is something physical going on that they most likely have not heard from before they are usually excited at a new explanation.

(in reply to Niko)
Post #: 183
RE: A problem arises... - August 2, 2012 3:27:44 PM   
Sebastian Asselbergs

 

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Excellent point Chocco.

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Post #: 184
RE: A problem arises... - August 3, 2012 1:52:14 AM   
Niko

 

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Sebastian, Tom, Chocco, thanks for sharing your thoughts and ways of explaining pain to patients.

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Post #: 185
RE: A problem arises... - August 7, 2012 3:16:11 PM   
bgalindpt

 

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"Pain...it's all in your head...literallly..."

should we start wearing these shirts for pain awareness month?

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Post #: 186
RE: A problem arises... - August 8, 2012 4:53:32 PM   
Chocco

 

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quote:

ORIGINAL: bgalindpt

"Pain...it's all in your head...literallly..."

should we start wearing these shirts for pain awareness month?


i like it.

One thing that always makes me smile is every once in a while a vestibular patient will come in and say something like "everyone thinks it's all in my head" and I say "well it is" the look that I get for the 5 seconds before I explain to them where their vestibular system is located is priceless.

(in reply to bgalindpt)
Post #: 187
RE: A problem arises... - August 8, 2012 6:24:23 PM   
Sheld505

 

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Guys,

I'm wondering what your thoughts are for the patient who presents with lack of movement, say for example in the cervical spine, but denies pain. What is the explanation for this?

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Post #: 188
RE: A problem arises... - August 8, 2012 11:23:47 PM   
Tom Reeves DPT ATC

 

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great question Sheld505, but there CAN'T be any mechanical influence on things. There is no way that any other thing other than the central nervous system can influence function. NO WAY. The meat doesn't matter.

(tongue firmly in cheek. ALL the systems influence function.)

< Message edited by Tom Reeves DPT ATC -- August 8, 2012 11:26:14 PM >

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Post #: 189
RE: A problem arises... - August 9, 2012 1:40:58 AM   
ginger

 

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Sheld505
a few key words  and phrases to simplify

nociception does not equal pain.
nocieption varies , pain varies , seperately.
Individuals vary in the manner to which similar levels of apparent stiffness induces nociception.
apparent stiffness may not be real in the sense of variability.
periodicity of pain.
age related change is often not painful.
Some patients are poor historians .

< Message edited by ginger -- August 9, 2012 1:43:14 AM >


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Post #: 190
RE: A problem arises... - August 9, 2012 7:34:23 AM   
Sebastian Asselbergs

 

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quote:

Guys,

I'm wondering what your thoughts are for the patient who presents with lack of movement, say for example in the cervical spine, but denies pain. What is the explanation for this?

I know a guy with NO motion of the spine - and NO pain at all. Has a fully ankylosed spine from cranial base to pelvis.
There are gymnasts and skaters I treat with enormous ROM of the spine, and NO pain - rugby players with half the gymnasts ROM and NO pain.

It is all about context. Does the lack of ROM create a problem for the patient? Then that is a problem that needs attention - possibly a left-over residual restriction from previous irritation or insult; neurological "habit".

Does the lack of ROM not bother the patient in their lives? No problem.

(in reply to ginger)
Post #: 191
RE: A problem arises... - August 9, 2012 12:25:59 PM   
rwillcott

 

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Yes Ginger I am a physio. And yes I perfrom manual therapy on a daily basis. And no I do not claim to feel the specific motion of the L5/S1 facet joint moving under my thumbs. There is also a large body of literature that supports this as well. Do I apply manual contact and pressure over L5/S1 in some cases of back pain, you bethca.

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Post #: 192
RE: A problem arises... - August 9, 2012 10:17:31 PM   
ginger

 

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Just to be clear Rwillcott, the large body of literature actually shows there is VARIABILITY in the ability of different physios to assess and recognise states of mobility in spinal joints. Hands on assessment and treatment movements and such are skills based. Skills will always vary. The point is, should those with these skills feel obliged on the basis of this variability, to abandon their hands on assessment and treatment skills?, I think you know what my answer would be.
Every skills bases connection we make will have variabilty. We watch our patients walk in, immediately we can observe details of gait,posture antalgic movements. We ask questions, if done with skill the experienced physio can cut through the story to the facts, avoid time consuming detail and zero in on what matters. The student will however spend time on what does not, will write copious notes which provide no benefit, detailing matters while not appreciating what goes towards a solution.
Every advance we make as physios involves some level of increased skillfullness, should we look instead for a flat playing field, where all are the same?, where students are taught to assess using only scales or avoiding using their most precious tools entirely ?, of course not. We are human, we have a pair of wonderful sensitive devices at the end of our arms wired with amazing amounts of talent and ability to detect the minutiae of touch and movement.
The fact that variability exists in these skills can  not be refuted. The wise course then is to encourage best use of hands by undergrad education linked to talented manual therapists, rather than the wholly foolish alternative which would be to have our undergrads led only by those with mathematics as their holy grail, with lists of academic qulaifications but little in the way of real talent.
Use your hands, practice, refine those hands on skills, encourage others to do the same and we might, just might, avoid going down the academic sink hole of the skillshort literatii.

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Post #: 193
RE: A problem arises... - August 10, 2012 1:09:21 AM   
Niko

 

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quote:

ORIGINAL: ginger

Just to be clear Rwillcott, the large body of literature actually shows there is VARIABILITY in the ability of different physios to assess and recognise states of mobility in spinal joints. Hands on assessment and treatment movements and such are skills based. Skills will always vary. The point is, should those with these skills feel obliged on the basis of this variability, to abandon their hands on assessment and treatment skills?, I think you know what my answer would be.
Every skills bases connection we make will have variabilty. We watch our patients walk in, immediately we can observe details of gait,posture antalgic movements. We ask questions, if done with skill the experienced physio can cut through the story to the facts, avoid time consuming detail and zero in on what matters. The student will however spend time on what does not, will write copious notes which provide no benefit, detailing matters while not appreciating what goes towards a solution.
Every advance we make as physios involves some level of increased skillfullness, should we look instead for a flat playing field, where all are the same?, where students are taught to assess using only scales or avoiding using their most precious tools entirely ?, of course not. We are human, we have a pair of wonderful sensitive devices at the end of our arms wired with amazing amounts of talent and ability to detect the minutiae of touch and movement.
The fact that variability exists in these skills can  not be refuted. The wise course then is to encourage best use of hands by undergrad education linked to talented manual therapists, rather than the wholly foolish alternative which would be to have our undergrads led only by those with mathematics as their holy grail, with lists of academic qulaifications but little in the way of real talent.
Use your hands, practice, refine those hands on skills, encourage others to do the same and we might, just might, avoid going down the academic sink hole of the skillshort literatii.


Geoff, thanks for this post. I think what you are discussing here is very important. Manual skill development in assessing and delivering treatments is absolutely valuable. I think there is a major difference in receiving skilled vs unskilled manual therapy, I 'm sure that every physio here has experienced that at some point being a subject for manual techniques.otherwise lets just have our patients rub each others back and leave the room to go post on rehab edge (i'm starting to think that some people here are actually doing that). What I find interesting is that having good manual skills is not necessarily about experience. You can be reinforcing the same poor techniques for many years, especially if you have already abandoned any effort for skill development.

< Message edited by Niko -- August 10, 2012 1:12:46 AM >

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Post #: 194
RE: A problem arises... - August 11, 2012 12:19:38 AM   
ginger

 

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Thanks Niko, agree that some will tend to reinforce bad habits if not guided well at some point. Also that to have any real expectation of being able to solve problems ( I speak here of the range of spinal related MSK problems we see in an outpatient setting ), we must begin with a method that has the probability , done well, of addressing the source of the problem in the first place.
This is where I think many go wrong. By doing so over and over they tend to reinforce notions that compound their alienation from the commonest source of MSK pain , the vertebral spine. Only to go on then to give credit ( where little is due) to methods whose best effects can be said to be temporary, by adressing the locus of pain , rather than the source of the problem.
For every hundred patients I see, there might be one or two, whose problems can not be best considered at the spine. Referred pain(along with altered sensation, altered patterns of recruitment and autonomic disturbance ) is by far the commonest event in our daily treatment lives. Only by understanding this and directing appropriate skillful means can these problems be quickly and effectively undone.

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Post #: 195
RE: A problem arises... - August 11, 2012 10:31:11 AM   
proud

 

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quote:

ORIGINAL: ginger
Use your hands, practice, refine those hands on skills, encourage others to do the same and we might, just might, avoid going down the academic sink hole of the skillshort literatii.



Nice snippet. You forgot to add "ignore what science is telling us". So really this is what you are saying Geoff....just so we are clear:

quote:

Use your hands, practice, refine those hands on skills, ignore what science informs us, encourage others to do the same


And sink hole is a good choice of words....follow your line of reasoning and indeed we will head straight down a path of ridicule where reality is an after thought and tooth fairy science rules....it's called chiropractic.

We are getting closer and closer to that unfortunately.

(in reply to ginger)
Post #: 196
RE: A problem arises... - August 11, 2012 12:50:18 PM   
Chocco

 

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Proud, since you keep bringing it up

http://arxiv.org/abs/1204.0492
full text is available on the page

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Post #: 197
RE: A problem arises... - August 12, 2012 6:05:00 PM   
Niko

 

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quote:

ORIGINAL: TransientImage

Some food for thought for the readers who do not post: 

I personally don't use any manual methods or any modalities other than the occasional hotpack to bring the tissue to higher temperature to improve extensibility.  I don't use spinal mobilizations or MFR or CSR or mechanical link (a misnomer) or any of that other stuff.  I use basic stretch methods, exercise and some other physical methods added in.  I do check ROM and other measures. 

I often take into account pain that the client reports but I place it low on the list of importance, because once proper motion is demonstrated and function returns, the pain goes away -- usually by the third visit.  It always interests me how people see therapists for 16 to 20 visits with limited effect where the focus is all on pain, and I see the same clients afterwards because the 'pain is still there' and they are done by the 6th to 8th visit, painfree, back to work.



Transient,

You also bring up a very good point. I support the approach of focusing on function vs pain, as restoring function can also help restore neuronal circuits to pre pain state. You are also smart and efficient because you have found a method that brings positive outcomes while it requires less work on your part. I'm also doing the hotpack or icepack thing often, usually combined with e-stim prior exercise. If nothing else, the sensory input downregulates sensorimotor processes, and pt can go through movements easier with less tissue resistance. However, I do use my hands as well even if it's only for a few minutes per session. I feel that it helps me connect in a different way with the patient, creates a therapeutic environment, and reassures the pt that Im here to help. Also, when I use my hands I do use them in a skilled way. Most patients seem to greatly appreciate the hands on stuff, but the problem that may be difficult to control is that It can cause more patient dependence than independence. that might be the reason why some of the pts see therapists for so many visits, they just like the attention and they are not spending enough time to develop self management skills. I try to do less hands on with people that appear to be very needy. Regardless, I think the appraoch that you are using also depends on you as a therapist, your confidence in delivering and explaining the aproach (exercise or manual), the time of the day and day of the week, your mood, whether you like variability in your treatments or whether you gravitate towards a specific recipe, whether you have read something new and want to try it etc. As long as you are helping people get better with justifiable procedures then you are doing the right thing.

< Message edited by Niko -- August 12, 2012 6:29:12 PM >

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