Evaluation and Reality

[Barrett Dorko]

Over on Rehab Edge in April of 2005 a thread was begun titled “What’s your lumbar evaluation?” and has since that time generated a total of 8 replies. Obviously, this is a larger subject than that and I was thinking we could start discussing it generally here and see where it might lead. I should say that I mean evaluation in general, not just of the lumbar region.

My contention is that we should evaluate our patients less rather than more and have written of that in “The End of Evaluation?” on my site.

Go to http://www.barrettdorko.com/articles/end_of_evaluation.htm

Anybody?

[Jon Newman]

Barrett,

I've found your evaluative approach not lacking in effectiveness and consistent with other areas of research regarding the "medicalization of misery". In a certain way, the increasingly popular move toward "patient classification" (versus specific diagnosis) mirrors your 'less makes sense' approach.

[nari]

Sounds a good idea, but after 20 minutes of searching on RE - could not find the article; the search function found nothing. However...it doesn't matter.

Evaluation (or as we write it, subjective and objective) seems to be a critical feature of clinical practice. I guess if we are trying to find a working diagnosis, it needs to be thorough. The problems with evaluating, initially and during treatment, then next visit, etc etc are:

Tenderness, stiffness can vary from day to day.

Palpation is notoriously unreliable, inter and intra-therapist.

ROM tells us something is stiff, but not what is stiff.

Strength will vary from day to day unless there is pathology present, or post-op immobilisation etc.

Neural tests are useful provided there is inter-therapist consistency on interpretation of a positive test and then, what to do next.

Pain scores.....arrgghh don't mention them.

History: I think this is important and often needs to be filtered for usefulness.

Evaluation sheets: More of these than one can shake a stick at. Quebec scale is good, also Tampa....the others..??????

Function: Much more important than ROM.

Language: most important. What does the patient actually say about him/herself? what symptom /function seems most important to them? Is it emotive, highly descriptive words, repetitive...

In brief, evaluations can run to three pages. Who reads them? The more is revealed, the greater the chance of being challenged, in court or out of it.

Most PTs do not agree with me (what's new ;))and I would look forward to others' opinions.

Nari

[Diane]

History, look at standing, how the feet look, where the knees point, which hip is easiest for them to stand on, general range of motion.. then treatment. I've pretty much quit treating the central part of the body and have moved to treating the lats, sides of trunk, outsides of hips in sidely, ITBs in prone over the last few years. I usually check the legs; fronts of hips, backs of knees, and heels/ bottoms of feet. When the legs work well the back is happier. I do muscle energy to mop up very obvious and painful lumbar movement restrictions. I never use direct, joint directed mobilipulation. Lots of education.

I record initial ranges and usually after the first treatment can report "range is better." I never measure anything, just use rough estimates like "hands to knees" or "midshin" or "top of socks" .. something visual.

[Luke Rickards]

the increasingly popular move toward "patient classification" (versus specific diagnosis)Jon, can you direct me to more on this?

Luke

[emad]

Hi ;

I have read the article with the above link ,give more attention to the summary of the article ,my imperssion may be bacuse English is my second Language ,so i got the imperssion that the language was too complex than the idea of the article,even sorry to say that the language make the idea too complex ! Just ,My view!!

Regadring the Evaluation process of the patient ,with time we do not need much effort to manage the patient ,we do every thing as habit ,i can not deny this fact !!

personally , i begin with history collect data/markers as possible ,collect prevouis health care professionals viewsand diagnoses as possible .

Important for me , all markers of history ,examination ,investigations correlate to each other .

I creat more than hypothesis listing them according to correlation and significance .

Recording is very important to measure progress or the vice !

Regards
Emad

[Jon Newman]

Hi Luke,

If I did this correctly there will be a PDF of a CE course description regarding this approach for LBP. Additionally, there is currently a push to classify patients patients as those benefitting from "stabilization" versus "manipulation". More on this can be read at the EIM site. These, to my mind, are examples of the trend toward classifying patients that will benefit from a technique versus coming up with a specific diagnosis to treat.

Barrett's 'less makes sense approach' and these other approaches have different underpinnings in my opinion. As I stated, I find Barrett's approach quite useful. I also advocate that red flags are ruled out even if the patient is a referral from an MD.

[bernard]

Jon,
The pdf file has another linked one, of interest:

[Jon Newman]

Thanks for that Bernard.

I personally find that Barrett's framing of the problem actually makes sense (to me anyway) while the other approaches seek to justify existing approaches to care whether they make sense or not.

[Barrett Dorko]

After writing this essay about not evaluating patients I sent it to David Butler for his opinion. He said he liked it but that I “should put a “?” at the end of the title so as to soften the blow.” I guess David knows heresy when he sees it.

Red flags are important and I point this out any time I lecture on evaluation, but I also point out that we are “born normally and then trained to become poker players.” We know that the vast majority of the ways we are inclined to move are hidden by a conscious mind that has learned well and often how to “get along” in a culture that wants control, symmetrical movement, responses to provocation within defined borders and as little unique, individualized expression as possible. We deny this to the extent that while we suppose others might be so constrained we can’t imagine it has happened to us. But it has.

Why should this change just because we are now standing in the presence of a therapist? Therapists who don’t recognize the cultural corsetry surrounding them will actually think that the patient’s history will be truthful and that their measured motion will represent what they can actually do. Neither of these things is true – not in my opinion. This changes everything.

Could it be that we’d be more effective and efficient evaluators if we simply looked for those things that the patient can’t hide yet remain essential for our understanding of their problem?

In poker it’s called a “tell,” and I focus on these.

[Diane]

These, to my mind, are examples of the trend toward classifying patients that will benefit from a technique versus coming up with a specific diagnosis to treat.

Barrett's 'less makes sense approach' and these other approaches have different underpinnings in my opinion. You are so right Jon. I'm sure the trend toward classifying rather than diagnosing has been shaped by insurance considerations, perhaps even pandering, rather than by real thinking.

[emad]

Hi ;

I do not object at all classifying ,on the other hand this makes the issue more applicable or more practical .

Good point Diane , that classification was created for insurance intentions not for scientific bases do you mean thus ?!
Anyway , good article .
Regards
Enad

[Jon Newman]

Luke,

Here's a recent and interesting classification study.

Characterizing the Course of Low Back Pain: A Latent Class Analysis. (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16495468&query_hl=1&itool=pubmed_docsum)

[Barrett Dorko]

In the first article Jon linked us to it is stated in the introduction that 85% or more of the patients we see with low back pain have discomfort “that cannot be attributed to any disease.” I agree. But they also say that “low back pain often cannot be attributed to conditions known to cause pain,” as if disease and pain were mutually inclusive.

This is simply untrue – and anyone who has read the work put forth by Wall, Elvey, Breig, Butler and many others the past 30 years would have to take issue with the basic premise of the study. If that’s so, why should we pay any attention to it?

My absolute inability to get past this issue is perhaps the major reason I can’t take these guys seriously. It’s probably the reason they feel the same way about me.

[nari]

I cannot see the point of classifying into groups of pain behaviour..what does that tell us? How does it change the clinical approach? Is someone with initial strong pain that diminishes over a period of time radically different from someone whose pain is constant? (Pathology excluded).

I agree that their premise for classification defies current knowledge. No wonder PTs get confused over LBP; if Joe Blow comes in with variable pain that is severe one day and almost disappears the next - what "category" is that? Surely the time spent trying to slot patients into neat boxes would be better spent educating on pain physiology???

Just a quirky thought. I dislike anything that attempts to categorise on the basis of pain experience; because it tends to 'make the features fit' according to the evaluation sheet. I suppose it is like the psychs who categorise according to behaviour; but that is different, I think. Different ball park.

Nari

[Luke Rickards]

Thanks Jon.

[bernard]

Hi All,

Human beings are certainly "complex systems" but I do not adhere to the idea that human beings are "chaotic systems", anyway.

Chaotic systems are often used when we are unable to describe them accurately. The variable number is so high that changing one is changing the whole body/mind and we have some difficulty/impossibility to fit cases in "pretty" boxes/ranks. This excuse is the consequence of our constant will to rule/classify things.

A "good" rule that I apply every day, in practice, is "taking some distance" from the "label" and trying to "see" the simple person that facing me.

[Jon Newman]

Hi Bernard, the following is beyond my ability to truly appreciate what they are saying but you might be interested in it.

Nonlinear Dynamics, Psychology, and Life Sciences, Vol. 10, Iss. 1, January, 2006, pp. 1-20
@2006 Society for Chaos Theory in Psychology & Life Sciences



Chaotic Dynamics in Simple Neuronal Systems: Theory and Applications

L. Andrey, Academy of Sciences, Prague


Abstract: The ubiquitous feature of the nervous system of wide spread occurrence of complex dynamics behaviour is treated. The cardinal question concerning the nature of generators of such complex behaviour, namely if it is ad hoc random or deterministic but strongly nonlinear, is analyzed. It is proved analytically that the discrete dynamics of single neurons with the sigmoidal transfer function is potentially chaotic. As the by-product the functional gain-threshold mechanism in neurons is derived. This allows for the new interpretations of famous experiments by Miyashita on squirell monkeys. Then it is shown that the continuous dynamics of the neural circuits of two-three neurons are endowed with the potentiality of chaotic firing, too. Finally, it will be argued that the classical dogma of stochastic or the ad hoc random neural coding can be taken as the limiting case of presenting new approach of deterministic or chaotic paradigm.

[Barrett Dorko]

I think we can agree that as much as we would like the person before us to be "simple" all the wishing in the world will never make it so.

My thinking on the subject of evaluation feels a little disorganized presently but will perhaps straighten out as I write this. Buchanan's point in Ubiquity where I got most of my ideas for the essay is that any complex system when in a critical state is best understood and controlled by making accurate appraisals of certain key aspects of the system. I address this in what I call "The Vitals of Pain" when I teach and that would probably be best addressed in a future thread.

What I want to discuss here is the tendency of literally every human being to hide their authentic way of being, especially while in pain and even more so when being scrutinized. This instinct to remain inconspicuous is bound to color any finding dependent upon some sort of active motion. If we don't take that into account not only will our tests be rendered invalid they will be inaccurate and ultimately meaningless. I hope this makes sense.

My question: What active movement can we trust to teach us about internal processes when dealing with an abnormal neurodynamic?

[bernard]

Jon,

Thanks for the paper. The paper doesn't bring something new. It says that the normal behaviour of a neuron is non linear and this property creates a kind of chaotic behaviour for the observer. The problem is well know with such sigmoidic functions (http://www.somasimple.com/forums/showpost.php?p=2116&postcount=12).

http://www.somasimple.com/flash_anims/shoulder07.swf

Two examples of complexity;
In 1993, I was working for a TENS manufacturer. We tried to find the best voltage amplitude and frequency for a quadriceps electrical stimulation (sorry Diane ;)). The goal of the preliminary study was to see if it was possible to find a common rule which may be applicable to all patients.
bad news: All muscles were effectively stimulated and we found a frequency for male and and one different for female gender and an average amplitude. But if you try to apply the average values, it doesn't work.
Conclusion: all muscles moved but all were different. The physical parameters that are created by the unit are too precise to be applied directly.

take two pain free people:
Let them walk:
They are effectively walking, all two.
If you track some parameters => step, speed.. You'll find some huge difference. If you try to follow their muscle activation, you may conclude that it is impossible to find a common rule between the two. That's wrong! They are walking.

Barrett,

What active movement can we trust to teach us about internal processes when dealing with an abnormal neurodynamic? A movement that goes out their useless loop. Many abnormal neurodynamic movement are already a consequence of an internal/central process.

[nari]

What active movement can we trust....when dealing with an abnormal neurodynamic?
A movement that the patient chooses to do when given the invitation to move in a way that feels better for them. No matter how restricting the pain may be in terms of dysfunction and ROM, etc. Most will move (if given the OK) in some odd ways, but that is preferable to external directions to move according to Gray's Anatomy. I have seen many classic examples where patients suddenly gain "ROM" and increased function because they have a better understanding of who's the boss around here...their own brain's inclination. I'm not necessarily talking ideomotion here, although that may be preferable.
Of course that doesn't work so well with those who sit and wait for expert instructions on how they can dry their feet after a shower.


Nari

[Barrett Dorko]

Nari,

I think you're close,but by implying that the trustworthy movement is the one that the patient chooses "to feel better" you haven't moved far at all from the typical type II stimulation or forceful stretching most employ before attending therapy. It simply isn't corrective or revealing in any sense.

It probably won't surprise anyone here that I think it is the nonconsciously generated motion that I trust not only to correct the problem but to simultaneously display the dysfunction in a way that, while fleeting, explains why it hadn't emerged earlier. The strangeness of it is part but not all of the reason.

Consider this: Would you know more about a person if you read the letter of introduction they had written themselves or if you read a few pages of their diary?

[nari]

Barrett

That was a trick question you asked.
To me it was too bleedin' obvious to state that it was the nonconsciously generated movement is the one best to trust. I was looking at second best, for those who may not be familiar yet with the nuances of ideomotion.

I don't know what type II stimulation is, and am not sure why a patient might choose to do forceful stretching when they are in pain, unless they have been to gyms and risky places like that....

I'd be more interested in the diary, but the 'themselves' that has been lost can be elicited to some extent by asking a couple of questions at the start.

Nari

[Barrett Dorko]

Nari,

By type II I mean the rocking and shaking and jiggling you see so many do when they hurt chronically. It stimulates large fiber (type II) firing according to Barry Wyke and thus "closes the gate" before the nociceptors can dominate the central response. I think that "stretching" accomplishes this as well. The way most go about it, it certainly doesn't lengthen anything permanently. I had dinner with Wyke one night and he was certain that telling people to do that should be pretty much the only job a therapist should do. We didn't discuss therapy that night.

I like the diary analogy and I think most would agree that this "unconscious" and normally hidden authentic expression would be far more relevant to the problem as well as the solution. At least, that would true psychologically - why not physically?

In terms of its relation to evaluation, well, wouldn't its expression be the beginning of the end of that?

[nari]

Thanks Barrett

Forced stretching, the sort employed by PTs, personal trainers, gymsters, etc doesn't get anyone anywhere, I agree. And this is where most of the few PTs who use neurodynamic techniques go seriously wrong; as Shacklock will attest.

Allowing authentic expression would indeed be the end of evaluation.

I think this is what scares PTs so much; that 'risk' of eliminating their clinical control over the patient. We are, by and large, control freaks, as much as we like to think we are not. I'm speaking in general terms here. If we can get away from the meme that the patient is here to see me and to do what I say it would be a step forward.


Nari

[Barrett Dorko]

A relevant quote:

"To control your cow, give it a bigger pasture."

-Suzuki Roshi,
Zen Master