"Real Physical Therapy"

[christophb]

I need some advice from all you smart people out there.


I had a gentleman come through my doors with neck and shoulder pain for about 1 month duration. He acquired it one morning upon waking and it never resolved. The pain radiates from the neck to left shoulder, notes a tightness and fullness in the arm and hand without numbness and there is no motor loss. Shoulder was negative for any impingement signs, ROM was painful at its upper limits, neck ROM decreased about 50% all directions. He came in desperate and frustrated. He is out of work (just retired from the military) and is having trouble finding a job. He was + for general neurodynamic tests neck/LS/left UE. He has also received massage therapy, pain meds that didn't help (although he kept going back to the massage therapist)

The problem is this... I did the education thing, SC thing, skin mob thing, abdominal breathing and the guy looks at me like I’m smoking crack. He canceled all his appointments after 2 sessions (1 eval/1 treatment) failed to improve his pain. Hence the quote "I need real PT” As far as I am aware my treatment made sense. Usually I can let these people slide on by without caring much (really that's a lie... I am waaay to passionate about what I do), but I have a huge number of cases like this on my schedule. I'm wondering if is it me or just a phase in the clinic. Is there anything that youse guys have found to ease these types of people into treatments? By these types I am referring to a desperation and frustration in wanting pain relief yesterday.

Thank you, Chris

[emad]

Hi Chris;

Do not you think you and your patient just need time ?

Assure him ,try to reach relaxing of the muscles sround cervical ,i do not know if i could elaborate the role of that massage in pain elongation /evoking .

I can remember one comment of my teachers during undergraduate study said we are not making miracles!

Regards
Emad

[bernard]

Chris,

You'll ever find those guys who are thinking that real PT is painful with hard massage and lot of strengthening exercices.

He is thinking that your approach is not the one he is seeking for even if may work. It will work only if they are convinced! He is not!

Nari will certainly conclude with her famous quote: "win some, lose many". :confused:

[christophb]

I certainly am aware that it needs time. I usually try to leave my magic wand at home ;). Yes, I can agree with the win some, lose many quote. Problem is, I hate to lose! I certainly have my fair share of success in the clinic, yet, if I dwell on those folks (although it is much much much better for my mental health), I find it does little to progress my understanding and growth as a PT.

So, what if the patient can't or refuses to understand it needs time (despite frequent reminders)? Also, I was pondering understanding. Most people that come to me want resolution, some in that category don't mind if a little understanding comes along with it. The ones I have trouble with are those that want resolution with no interest in understanding. Or am I just making some connection that really isn't there.

Chris

[Barrett Dorko]

Chris,

Before I forget - You're a dead man.

Now that I've gotten that out of the way let me say this: I've been there and will be again, and I'm an old guy with all kinds of grey hair (in my beard anyway) and a well-practiced manner that normally allows me to navigate through the land mines of clinical life. I learned long ago that what I needed to attend to and consider more often than anything else was the way I felt after such a thing, but even more importantly, the way I recovered from it.

I'm reminded of a scene in Star Trek - The Next Generation. Captain Pickard is dealing with a junior officer who has failed at some important and dangerous assignment. People are dead and the officer feels that this is her fault despite her best efforts.

Pickard: Right now you're feeling utterly alone and solely responsible for this disaster.

Junior Officer: Yes, I am.

Pickard: Well, you'll get used to it.

Does that help?

[emad]

Hi :

In my own view ,from my practical work , i think the human being does not concern so much to those :

# Pain Severity
# Pain Addressing
# Pain overcoming

They want to know and only assure that there is no great risk/danger ,in another meaning ,this pain is ordinary and there are plenty of people experienced this pain and they overcame it .

Anyway,you just need to discuss with your patient his Belief/meaning of that pain ,may be he thought that he has very dangerous problem .

If he insist to resist understanding ,please bring your wand with you the next session :rolleyes:

Regards
Emad

[christophb]

Barrett,

That's oddly comforting. Captain Pickard is one of my fictional hero's (although I prefer oolong to earl grey).

In a clinic that is seeing patients back to back with occasional overlap, it's rare I get a chance to be introspective following patients like these. I can understand the value in doing such a thing however. It's funny, but a good friend of mine who is a psychologist recently told me the same thing you just did. Somehow it needs to penetrate my thick stubborn skull.

Emad,

That's good advice unfortunately it was unsuccessful. Maybe he will find some value in it down the road when receiving US and traction from another PT, who knows.

Chris

[Diane]

Maybe he will find some value in it down the road when receiving US and traction from another PT, who knows. Or manipulation from someone..

[Jason Silvernail]

...and not meeting them.

Don't despair, Chris, I see a lot of senior military Type A people, very sympathetic dominant, progressive decrease in fitness activities, expectations not in line with physiology, etc, etc.

Since I do practice manipulation, some of them do get a great deal better quickly, and word seems to spread about that. Of course, in my population, only about 50% of people are likely to benefit from this treatment (via the prediction rule) so many people come actually expecting this, and are quite disappointed and cranky when they don't get it. Especially the more chronic ones, with yellow flag type of overlays to their pain experience.

Remember, with a certain set of expectations and demands for immediate relief, it's not likely anyone else will give him what he wants or help him much, either. He could have seen you, Barrett, Emad, and me and probably none of us would have fared any better.

Like Barrett said, you're a dead man. Think of it not as your problem, but rather his. He simply wasn't ready for what you had to say, and he likely will not do well. It appears he has many psychologic factors for poor prognosis. I learned to let these folks go a while ago. I give them my best, but am rarely able to get through or change their function or outlook.
Like Picard said, get used to it.. :)

J

[nari]

Chris

Passion for passivity is endemic, amongst the public and some PTs.
A crude meme or mantra for patients might be:

PT = fix me up; patient = lie down and think of England (or the USA or anywhere).

Maybe these persons are seeking attention and solace; they are sick of making their own decisions about things, so having to think about something the PT asks of them is all a bit much. "That's not what doctors and PTs are for"..and oddly enough, these folk are usually quite accepting of 10 exercises they will never do.

However, think about the flow-on effect - if you meet the patients' expectations (quick fix, passive) the myth/meme is perpetrated...

There will always be losers and you won't be one of them. The three in ten who sees the light is worth the seven who get huffy and go away to look for another plinth and an obedient PT. :) :)

Nari

[christophb]

Thanks to all for your comments. I have no doubt I will still be affected in some way by the patients who "don't respond" to what makes sense. However, now I can pull up this thread and say, "oh yeah... let go stupid" :)

Chris

[Jon Newman]

One of the newer drug advertisements on television these days depicts a bunch of folks in white coats that are ostensibly MDs. These Robert Young stand-ins are virtually begging the viewer to ask them about a new drug for the relief of something. I'm sure MDs love this stuff. This thread kind of reminds of that. I guess there will always be a role for paternalism since the "patient centered care" model is necessarily at the mercy of those feeding memes into it.

[nari]

As a sort of aside, the Community Health scheme where I worked for a while, advocated that we never use the word 'patients'. The people who came for services were clients; I guess this is part of the bureaucratic model. The physiotherapy service is free for them (as it is throughout Australia in hospitals and health centres for everyone) so the word 'client' is an odd usage.

I wondered if the word 'client' has different connotations for expectations.
Hairdressers, lawyers, real estate agents and others use it.
Does it enhance the passivity meme or reduce it?
Does it weaken the illness belief or strengthen it?

One woman said to me that it was fantastic to have broad-spectrum free health care from physios, OTs, dieticians and podiatrists; and she was most responsive and responsible.
Maybe it also comes down to rights and privileges. Those who take it for granted may be less likely to listen and be educated. They are also more prone to shop around until they find an obedient PT.

Nari

[Diane]

I toyed with the idea of using the word "client" for a little while, long ago, wondering if adopting it might further de-pathologize therapeutic interaction. It occurred to me that all services provided by humans to one another, including our own, are placeboic.
Then I decided to keep "patient." I don't know what impact it would have had on the patients to be called "clientel".. but it had a negative impact on me.. in the mental role play involved in considering the term, I started to feel like a real estate agent or hairdresser... which didn't feel at all congruent with what I do. So I never adopted the word. It's one thing to "provide" placebo to "clients", and quite another to "elicit" it from "patients".

[stregapez]

Either word usually seems relatatively innocuos to me, when i'm in the role of either, probably partly because I seldom hear either a medical practitioner or massage therapist actually using either word in front of me.

I suppose I do prefer the word "client," though, even for medical practitioners with lots more training than me (a CMT) . I didn't much like it when i first started to use it but I've gotten to where I do like it. I see it in the sense of "serving people" in a broad sense where they are ultimately in charge, and which doesn't preclude facilitating ways to help them help themselves. A definiton like "The party for which professional services are rendered" (change party to person) works well for me. And I definitely don't feel like a realtor. I am "rendering my services" to help people to feel better in their bodies.

Though, like I said, I am usually ok with it (if i like the practitioner) "patient" does, to me, tend to imply more both that the person is "sick," and that the person is the practitioner's charge, maybe in a somehwat "paternalistic" way (It's use really started to bother me when I was on the JBMFR Talk list, where you were supposed to sign your emails with "patient" if you were enjoying jbmfr treatments)

I usually think of the word patient as defined this way:

http://www.medterms.com/script/main/art.asp?articlekey=39154

"A person under a physician's care for a particular disease or condition."

and i think that concept may have limitations.

This defintion sounds ok to me though :
"An individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward maintenance, improvement or protection of health or lessening of illness, disability or pain. (US Centers for Medicare & Medicaid Services),"

Though the "healing arts" part could have it's limitations too

I suppose it's partly a matter of what one is used to, and practitioners probably give the words their own personal meaning.

Dana

[Diane]

It's one thing to "provide" placebo to "clients", and quite another to "elicit" it from "patients". From my earlier post.
I had a further thought on this:
If this is in fact our work, based on Patrick Wall's definition of placebo, that it is not a stimulus applied but rather an effective response elicited, then for sure it takes two, an elicitor and an elicitee.
If pain relief is generated within a patient's brain, by the patient, as a result of the interaction, and this patient is screening out all interaction with Chris that he does not already "believe" will help, (then Barrett is right and) Chris is sunk. If Chris stands up for what he knows, rather than succumbing to the patient's erroneous belief system, and to his own workplace's inferior standards of conduct/reasoning, then Chris might be sunk with that particular patient, but he is not altogether a 'dead man'... he has behaved ethically unto himself, has stuck up for the truth/better reasoning for all, has done his best to try to convince the patient of it, also his workplace.

I think (based on the description) this individual wants someone to dish him out some pain, in the form of painful "treatment", that hurts more than what he is experiencing spontaneously, so that he can externalize something, i.e. counterirritation. If that's the case, my response would be, go find someone else to hurt you good then. I don't do that sort of "therapy."

You win some/lose a lot, and there are some mountains you just can't climb. In the end, one has to live with oneself.

[christophb]

Yeah, I like Diane's version better :thumbs_up

Seeing it in this light, I might be dead in the whole corporate/productive sense of things but so much more alive in the whole "zen" sense of things, which I rather prefer.

Chris

[Diane]

Plus, Chris, you can eventually go out and create your own one-man private practice, which will attract to you the type of patient best suited to your ability to help/your frame of reference for helping, plus all the work you could ever want as far as treating persistent pain is concerned. It's not like there is any shortage of it. The therapeutic relationship/crucible is what successful treatment all hinges on, and no doubt you can create that, and ethically, your way. The ex-militaries can continue with the corporate version of PT if that's what they want, or think is "real".

[EricM]

The direction this thread is taking has reminded me a passage from The Fountainhead, by Ayn Rand. (I think I've quoted this somewhere else before). The following dialogue occurs between a University Dean and the book's main character Roark, an idealistic young architect.

“The Client,” said the Dean. “The Client. Think of that above all. He’s the one to live in the house you build. Your only purpose is to serve him. You must aspire to give the proper artistic expression to his wishes. Isn’t that all one can say on the subject?”
“Well, (replied Roark) I could say that I must aspire to build for my client the most comfortable, the most logical, the most beautiful house that can be built. I could say that I must try to sell him the best I have and also teach him to know the best. I could say it, but I won’t. Because I don’t intend to build in order to serve or help anyone. I don’t intend to build in order to have clients. I intend to have clients in order to build.” (Emphasis mine)
“How do you propose to force your ideas on them?”
“I don’t propose to force or be forced. Those who want me will come to me.”

Chris's patient clearly needs help and in the face of this reality how idealistic should a therapist be? Should we really be trying to only attract patients to us who suit our particular ideals or can we be flexible enough to meet the needs of any patient who walks in the door regardless. Do we only have one product to sell to our customers, or is our product that which meets their needs?

I suspect my own answer to this might change depending on the sort of day I've had.

I don't mean to rock the boat wildly, just enough to stir up a little more discussion!

Eric

[nari]

Eric,

I think we should be able to see anyone who walks in the door, even if just for an assessment and sent away somewhere else. Our product should meet their needs, even if only haflway for some!

I'd love to ban many 'orthopaedic' people (eg THRs and TKRs) and see only spinal and chronic pain - but that is just me.

Ayn Rand's words are appropriate. And it does depend on the day/week thing; after all, we are as human as our patients but hopefully complain less.

Nari

[Diane]

we are as human as our patients but hopefully complain less. We more than likely don't complain any less at all. Just about different things. (Freshness of produce. How the steak was cooked. Price of gas. The state of the world. Young people today. Our neighbour having a loud party all night. The weather. A bad haircut. An appliance that breaks down. Not enough light. Too much light. Forgetting to buy vacuum bags. Computer that won't cooperate. Practitioners who think mesoderm causes pain. Who think they can fix mesoderm, that it will solve pain. Etc.)

[martin58]

I'm new to your group. Having got my first taste last week an Mr. Dorko's Charlotte semiar. A simple treatment of e-stim combo would have allowed him to leave with a smile and satifaction. I not saying I don't believe in what I learned in the class, but reading between the lines of the origian post. His guy's pain is stress related. Recently retired military and unable to find work. I also don't see this as a persistant pain problem considering it's recent onset. Persistant to me means months upon months. To sum it up touchy feely therapy is fine for some but not the best for all

[Jon Newman]

Hi Martine58 and welcome. Now that I've got that touchy feely stuff out of the way I'd like to ask about your assessment

His guy's pain is stress related.

If the above is true, and I'm not sure we can know that with any sort of certainty, how is e-stim combo going to relieve this guy's stress?

[christophb]

OK, But...

Are you saying stress caused his pain? I would agree that it may be involved in his ability to cope with it. And if the problem is stress related what is the physiology behind resolution with E-stim? And would it even resolve with e-stim. This guy had been seen for a month a few times weekly by a massage therapist with no improvement, yet he continued on with the massage therapy. Why would this be? He quit me after the initial eval and one treatment (I might add when he saw me a second time, he was flared-up from a MT session that offered a days worth of relief followed by more pain than he had to begin with). He also had multiple sessions of PT for back problems when he was in the military. When he didn't get the treatment he wanted he went up the chain of command to report her (don't worry Jason, the PT was Navy ;) )

[christophb]

Doh!, Jon was quicker.

[martin58]

Gut feeling, though I didn't actually meet the gentleman. I still feel two and two adds up to four. If you meet anyone whose stressed out they most commonly carry it in there shoulders. Being between jobs will cause stress. Though I described the TX as touchy feel it was not meant as a derogatory statement, I value what I learned in that class and have applied it on a couple of patients. The method to my madness with E-stim combo is the deep heat, endorphins and the increased blood supply to the area.

[christophb]

deep heat, endorphins and the increased blood supply to the area

Massage should the same, at least as far as increased blood supply is concerned. Why did it not work?

I have to add that each of the 2 times he finished a session with me, he felt much better than when he walked in and had more motion.

Chris

[nari]

I don't know what estim combo is anyway - presume it is a gadget which stimulates muscles. I think it is used for stroke pts with only some success.

It seems that stress is associated with ongoing pain, but its role in causing it is dubious...or so the literature says.

Chris's patient has persistent pain and finding a cause for it is like searching in haystacks for needles. He may (note: may) have responded to neurodynamic mobilisation due to the positive testing; but I have a feeling this fellow is more in need of some kindly counselling, perhaps to help deconstructing his meme that he needs painful exercise and strengthening.

Is that worth considering, Chris?

Nari

[Barrett Dorko]

If you meet anyone whose stressed out they most commonly carry it in there shoulders.

Can you explain what you mean by this?

[stregapez]

I don't feel infiormed enough to comment on the aformentioned patient's source of pain , but feel obliged to say : Stress can cause pain. There are many times (less and less frequently) when I have been a living testimonial to this.

"Stress" can, among other things, cause or contribute to depression and anxiety, and those can at least contribute to pain. I believe they can cause them. Is is really not an established fact depression can cause physical pain? I've certainly read this; though never researched it. I've seen it in myself, and some of my friends and family members. Can't anxiety, for example, cause sympathetic activation, which can, among other things, cause muscle tension/nerve irritation? Seems to happen to me quite a lot if if allow it to. Same things can cause me stomach pain. It can happen in a heartbeat for me, or grow over an extended few hours or days.

It does, however, bother me very much when practitioners *insist* anxiety or stress is the cause of a given ailment in cases where the patient/client feels it isn't

By the way, again, massage that could be productive can become counter-productive when it is too agressive

Dana

[Jon Newman]

I don't think we do justice to the study of pain when we say that it has one cause (e.g. stress causes pain or depression causes pain). Wouldn't it be nice if it were that simple? Certainly there are plenty of stressed people with no significant pain complaints. The same could be said of depression and anxiety. I think we'd be better off describing how these things may bring us closer to the "critical state". Strepgapez, you mentioned something about "allowing it to" happen to you. Can you expand on that?

[stregapez]

Mostly I mean allowing things which contribute to "stress" and/or significant emotional/mental pain or alienation into my life, or to dominate my life (certain situations, certain people or types of people (especially realtors and astrologers :) ), types of interactions, types of thought patterns, or dogs that bark alot..

And/or , to a certain extent (but only to a certain extent) I can consciously respond to potential "stressors" in less harmful ways, and/or try not to give them special attention. I suppose the two overlap in a sense.

Dana

[stregapez]

oh and certain inactions, sometimes, too.

Like Barrett said in another post (as I recall) ~ Stress is living someone else's life.

Some people have more of a choice about this than others, however, I believe, whether as a result of economic status or genetic makeup or who your parents are or whatever.

Dana

[Bas]

A very quick clear case of stress related pain (severe blinding headache) - totally gone while in Cuba for a week. Pt comes back to reception work where she will get the blame for a 2 hour hole in the dentist's schedule, a fight with her partner, trouble with teenage child, massage (very gentle) aggravates, neck muscles supersensitive triggering more pain. Too many "unhappy" matters accumulating to major pain. I don't do a thing with her - advise her on seeking other solutions, make a suggestion about "self-time" in a tub with the door locked - and the next day she called and said that was like "magic" - absolutely NO pain, until the next morning....she is now convinced she has to tackle her problems at work and home to make changes in her pain status - and THEN maybe we need to look at her physical aspects - IF there are any....

[Diane]

Bas, you were being a physioTHERAPIST instead of a PHYSICALtherapist.. sounds like you caught that one right in the glove. :)

[OaksPT]

Chris,
Take a look at this book if you have access to it, heretical thinkers do sometimes (frequently) win the Nobel prize. Unfortunately, you have to contend with the status quo in an effort to make your point, never an easy task.

I Wish I'd Made You Angry Earlier: Essays on Science, Scientists, and Humanity (Paperback)
by Max F. Perutz

Scott

[Diane]

I wonder if our conundrum will perpetually be a juggle among the three factors highlighted in this essay (http://www.edge.org/3rd_culture/hd06/hd06_index.html):
GÖDEL IN A NUTSHELL (VERENA HUBER-DYSON):

The essence of Gödel's incompleteness theorem is that you cannot have both completeness and consistency. A bold anthropomorphic conclusion is that there are three types of people; those that must have answers to everything; those that panic in the face of inconsistencies; and those that plod along taking the gaps of incompleteness as well as the clashes of inconsistencies in stride if they notice them at all, or else they succumb to the tragedy of the human condition.

The first kind are prone to refer to authorities; religion, bureaucracy, governments and their own prejudices. They postulate a Supreme Being that knows all the answers because everything must have an answer. With inconsistencies they deal by hopping over them, brushing them aside, sweeping them under a rug, ignoring them or making fun of them. These people are unpredictable and exasperating to deal with, though often disarmingly charming.

The second kind are the more heroic and independent thinkers. They are not afraid of vast expanses of the unknown; they forge ahead and rejoice over every new question opened up by questions answered. But when up against the walls of inconsistencies they go berserk. These claustrophobics are in fact the scientific minds.

And then, finally, there are the ordinary humans who make do with both inconsistencies and gaps in their experience of life and the world. Some of those, when driven to the brink of endurance by roadblocks of paradox and pitfalls of the unknown, go mad.

This reminds me of that guide to ethical reasoning that Jon presented here on a thread lately, especially page 7.. see below.

[stregapez]

Good call Bas.

On the massage thing, I wanted to add that many years ago, during a period of my life when my psyche was really a mess (post having a kid when i was a not ready/still a kid, with no emotional support, basically) I went for massages a few times and felt much worse after. There were also times of going for them and feelig much better (significantly those were from mts who were personal aquaintances) .

Some of that may have had to do with the gentleness or aggressivenes of the massage, but , significantly, one thing I remember was the feeling of having a bunch of mental stuff i needed to talk about, some of which was heightend by the massage, and instead feeling like I should be quiet, and was captive and silent on a table and getting therefore tenser by the moment. I didn't want see a counsleor, i just wanted someone to talk to, though ideally i guess i'd have found a counselor i could "just talk to." One time I remember sitting up after the massage and asking this woman who I'd never met before if i talk to her about my personal problems, and she listened and i felt much better (not that it was really her duty as bodyworker to go that far out of her way, guess she had extra time between appointments) . I think being touched can bring up emotional stuff , which is one reason it's good to let your massage clients ramble on if they need to.

Anyway, the point there was that someimes that feeling of being still under a stranger's hand when you have alot going on inside could be one reason for feeling worse.

Why do you think it made her feel worse?

Dana

[christophb]

Dana, I have no idea why he would be more painful. See Barrett's threaded "the Pallbearer" I think it may apply.

Also, "the shift" he mentions at the end of the first post is what I never felt during the sessions with this gentleman. Perhaps I could have brought the shift out with giving in to the expectations of what PT should look like and do some stim. Perhaps there would be a placebo effect or physiological effect from it and if I sensed a shift I could have moved in with SC. Perhaps not, No matter, he is elsewhere now.

Chris

[nari]

Bas

Before doing the SC course last year, this was my version of 'doing nothing'. and about 1 in 4 patients got 'nothing' in terms of physical hands-on stuff.
Invariably it worked well; and almost every time their pain reduced, sometimes vanished, and suffering decreased greatly. My half hour with each one was education, discussion on some goals, some breathing.

Unfortunately some other PTs thought it was odd that I had patients coming in 'for a chat', but, as Diane says, they are the physicalists...

We need to do a heck of a lot more of this, instead of trying to be personal trainers in body function to everyone. But I know I am out on a limb here, so I invite disagreement and philosophical bantering.;)

Nari

[Diane]

This is from a rock climber link that Ian sent me:
I coach people of all descriptions to use their body in the easiest natural way. You do not learn so much as become reacquainted with your dormant kinaesthetic system; a process I call "declumsification". If you think of yourself as unco-ordinated rest assured that you are much more able potentially than you would likely imagine. Super powerful people still reach a limit, a limit that crisper awareness can push back. I set specific movements to enable people to recover precise movement intuition. These are low power and so are easy to try repeatedly. As you succeed on one, others are introduced to open up the speed , precision and strength of intention and concentration of the pupil.

It occurred to me that this is what is missing most of the time, from most of our handling and teaching of patients (apart from Barrett perhaps..).. "declumsification", helping the brain recover "movement intuition" instead of always getting lost trying to beat up on some kind of mesoderm. I think there is "sensing intuition" that is just as important, likely..