Five Questions

[nari]

Barrett's question #2 is addressed to the patient, by the PT; which I thought rather odd at first, as patients sometimes know of their pathology (eg scleroderma) and often they don't. But their narrative and the concepts therein can be very helpful.

If I get a reply such as 'arthritis', 'slipped disc', 'torn RC', 'osteophytes', etc, then the labeling by the doctor needs some deconstruction, by the PT. The cause remains somewhat irrelevant and may be wrong or inaccurate, but that does not mean we then apply another label, whatever that may be. We might describe to the patient the process by which we will proceed with Rx; and leave it at that.

In this country we are used to making our own diagnoses, and have done that to some degree for decades. Ours may not be any more accurate than the doctors', however.

I am somewhat stuck with this question, so will leave further comments for a later date.

Nari

[EricM]

I assume that at least a part of the answer to question #2 lies in the length of time that has elapsed since any actual tissue injury. If there had once been an injury, detectable by the cardinal signs of inflammation, and sufficient time has passed to allow for tissue healing, then no significant pathology would be present.
This is what you mean right Barrett?

Additional disease process could include something like cancer, or any of the odd problems diagnosed on House. (which has been good this season, in my opinion).

eric

[Barrett Dorko]

I like what Eric has said here, and it's certainly something I consider when listening to the answer to question #2.

The following is a compilation of posts by Sean Collins, a PT who moderates the “Medical Complexity” forum on Rehab Edge. Early in its formation he questioned the appropriateness of questions posed by an osteopath who now co-hosts the forum. I thought his concerns were quite legitimate and have highlighted a few lines I liked. I was never convinced that his questions were answered.


"I always respond as in a direct access scenario, but direct access does not mean examination or treatment that may be outside the scope of practice. Given the scenario provided I think this child needs a medical examination first, so I would refer them either to the ER or to a MD. Just because you accept walk in appointments does not mean you should automatically jump to examine each and every person that walks in the door.

Also - this is my response based on "direct access" without the ability to order a radiograph.

when did direct access mean diagnosis of pathology as opposed to direct access post diagnosis for diagnosis of impairment, functional limitation and/or disability? Am I missing something?

…perhaps the diagnosis does not require an xray to diagnose - however - are PT's really supposed to be making such differential diagnoses without medical supervision - even with direct access?

If I am correct - should the new thought processes (this is what Dr. Wagner suggests the quizzes regarding diagnosis are about) be geared toward scope of practice of the physical therapist as opposed to physicians? Do such cases and examples for PT's confuse the scope of practice issue, and make it more difficult for therapists to contribute to an understanding of what direct access, autonomy, PT diagnose are within the scope of PT practice?

I agree that it is within our scope of practice to examine and evaluate to convey our impression if we have to refer. And that it is important to know when to treat and when to refer - this is the entire point of the direct access movement. I also agree that it is not our role to send all cases to the ER - but in cases you are unsure of based on the history, and can possibly be dangerous to perform examinations on until certain (worst case scenario) diagnoses are ruled out should be sent to the ER for medical evaluation."

Me again. When it comes to "PT diagnosis" my main feeling remains an uneasy confusion.

More on this soon.

[nari]

The apparent issues surrounding direct access are difficult to comprehend.

It doesn't mean there is a need for PTs to order XRs, it doesn't mean referral-only PTs become pseudodoctors if they gain direct access.
It does mean we should be able to interpret XRs with knowledge and consider what we find as part of a Rx plan - or not.
It does mean we use our knowledge to know what is beyond our ability to intervene safely and ethically.

The incidences of sending a patient off to ER are few. They happen, but anyone with an understanding of physiology and red flags would prefer to err on the side of caution and risk a possibly unnecessary referral to ER or the GP, faced with a possibly undiagnosed ominous sign.

How do Canadians feel on this issue?

Nari

[Diane]

I've sent a handful of people off to see the doctor since I've been direct access.
The most dramatic was a pregnant woman with leg pain. When I looked at her legs, one was swollen and the other was not. Uh-oh. I laid her down and phoned her doctor right away, who called back immediately and said, "Put her in a cab to VGH and tell her I'll meet her there in Emerge." Yup, she had a huge clot. She lived to thank me a few years later. The other stuff has been skin cancer mostly. One guy who seemed like his low back pain was more visceral in nature than somatic.. I was thinking prostate.
Most of the people who come in to see me have already gone and been checked out medically.

On one occasion prior to direct access I sent a woman whose heel pain wasn't resolving, and who had a rash across her nose, back to her doctor to ask him to check her out for lupus. Darned if I wasn't right about that.

On the other side of the coin are people who've been scared by their PTs jumping to conclusions that a knee pain and a bit of a loose drawer sign automatically indicates a torn cruciate, etc., who have sent them in to get CT scanned/MRI'd, whatever.

I feel that PTs should be taught to make good assessments/PT diagnoses and refer if necessary, rather than have to wait on the other end of the pipe for referrals; I think overall it would bring costs down. It's expensive for people with benign pain (which most pain is) to have to pay for or have a system pay for medical workup then be referred to PT. A PT diagnosis will always be about pain<->function, not defined pathology.

[nari]

Another aspect of the problem of PTs dependent on referrals is that they could miss out on those patients who may need us more than the sore finger/sprained something/weak quads referrals; we miss those who go to the doctor with back pain, are given drugs, told to rest up and see a PT if it isn't better in two weeks.

It is expensive for many to fork out money to see a doctor only to be told to go to physio; assuming there has not been direct trauma which needs investigation.

A patient can have unexpected indications of a serious nature at any time; even if seen by a doctor in the recent past. An elderly woman, in the outpatients' dept of the hospital, came for "physio" to her left arm, which had been annoying her off and on for a few weeks. She had headache, stiff neck, and a sleep deficit. What raised my suspicions at once was the complaint of a 'sore throat' - which she described as 'sort of deep' pain. Off to ER - where she was treated for unstable angina. Now she may have had some degree of physio-treatable arm pain; but that was irrelevant.

All PTs should be in the position of recognising red flags, access or not.

Nari

[Barrett Dorko]

I've given this issue a great deal of thought and today I feel it comes down to this: The "hole" in therapy through which many patients fall is created and maintained by the therapy community's lack of knowledge and understanding of the very basics of neuroscience as it is related to painful problems. I see this hole growing larger as the neuroscience advances while the work/interest in learning it decreases. It is extremely common for physical therapists directing that portion of the rehabilitation in a specialty pain clinic to be completely unaware of Wall, Ramachandran, Butler, Gifford, Breig and others as well as being distinctly oblivious to any information available on the Internet. I am not exaggerating and I am in a unique position to know this, getting around as I do.

I will always wonder why a profession so poorly prepared to understand, much less treat, painful problems such as an abnormal neurodynamic -and most would agree these are an enormous percentage of our patients - would want to add even more responsibility to their job.

[Jon Newman]

Hi Barrett,

I remember that thread at RE and if I'm not mistaken I had PM'd Sean about it.

I'd like to track back to the second of five questions

Are there any disease processes or pathological problems that are relevant to and might be responsible for your pain?

When I ask this question the patient typically cites something. This leads to the usual confusion of biomedical diagonsis being equivalent to pain. Pain is the same kind as tendonitis, it the same kind as a degenerated disk. I think it is what is called a category mistake.

I'll add that I think it is a mistake to become more and more skilled at learning about the alternate category (biomedical diagnosis) when there is already a profession devoted to do that. This seems to tie in with what Eric has commented on as well as your previous comments regarding PT's niche is 'for when things go wrong'.

[nari]

Barrett

Call it traditional thinking - it is much easier to follow what a charismatic teacher enthusiastically tells them to do and has a million RCTs and other studies to back it up. Takes effort out of the consolidation process in PTs' brains. The other side of the story could be that they simply do not have the confidence (or courage) to question the contents of a course that is basically about home ground; even if the outcomes are inconsistently positive.
Those who do question the premises behind numerous popular techniques are seen as renegades or outsiders.

I don't agree that diagnosis should be left entirely to the medicos and radiologists; but I come from an environment where diagnoses are usually questioned and altered, sometimes, by PTs - it's just part of our physio world. Of course I am referring to the simple stuff, the causes for aches and pains in joints, and so on. It's part of the learning process....

jon,

Does knowing that a "torn rotator cuff muscle" exists alter the way you would treat it? Especially when it responds well to methods that have nothing to do with "strengthening" ? Just curious.

Nari

[Jon Newman]

Hi Nari,

I think that's a reasonable question. I assume that the person before me is there primarily because they have pain that is likely coupled with one sort of limitation or another. History and a general observation of movement would likely reveal whether tissues need to be protected. Perhaps history alone would reveal that. I don't think it would alter MY care although strengthening and stretching connective tissue is not my primary approach when someone comes to me in pain. I imagine that if these were my primary strategic approaches, such knowledge would alter my care. Maybe that's the obsession with the (in honor of Diane) mesodermal diagnosis.

[nari]

That is worth a thread on its own...the validity of mesodermal diagnoses which seem to lead so many PTs astray, including many of those who attend Barrett's classes and find a lack of mesodermal thought.....

Nari

[Barrett Dorko]

Wonderful discussion.

Jon,

Your link regarding category mistakes is especially relevant. As some of you know, I'm currently in Las Vegas where my family has gathered to greet my son Alex. He's home from Iraq for two weeks and his stories of searching the road for explosives designed to deceive him fit here perfectly. He says, "When you travel the same road every day you just know when something has changed." Isn't examination of the human body similar in many ways?

I'l be writing more about this.

I think much of this issue revolves around discovering and defending an accurate and relevant essential diagnosis. This doesn't require great leaps in knowledge toward medical school minutia. I think it's wise to leave that to the physician, whether or not he or she does it well.

The third question:: What is your autonomic state and how is that related to your breathing pattern?

Thoughts?

[EricM]

I observe breathing patterns looking at apical vs diaphragmatic excursion and rate. I ask about the presence of cold hands or feet. However, recently at least for me, the clinical answers to this question have been split roughly 50/50 in similar chronically painful states. This makes me think either I may be missing something in my assessment, or that autonomic imbalance may only be relevant to the patient in question. What I might interpret as 'normal' may be abnormal to the patient and thus still have a significant influence on the pain state.

Eric

[nari]

I think that many patients consider cold hands and feet 'normal' because they have always had cold extremities. However, in someone who feels quite 'normal' ambient temperature in the extremities, an increased sensation of warmth after contact is informative.
Long before learning SC, I noticed that patients in an altered ANS state had high RRs, often around 25-30, and apical. After some diaphragmatic practising, they reported feeling calmer and their RR decreased; sometimes the pain decreased, and other times, not. They usually put it down to relaxing.
Then I worked out that they needed to practise deeper breathing while moving around; this worked sometimes; and if they practised during neurodynamic movements, they noticed the pain less, which I put down to distraction.
Several patients found a significant difference between breath-holding and breathing during neurodynamic movement. Some found it much better to hold their breath (on a neutral chest expansion, not on inhalation) during the movement. I personally find the same thing - but I know I am the only person to think this fact.

Eric, I agree that sometimes the autonomic state may only be relevant only to the patient in question. I have seen some dire chronic pain people who are quite warm despite their 24/7 pain state. Not sure about this.

Nari

[Barrett Dorko]

Nari,

I would say that my experience of this has been remarkably similar to yours.

Hidden within each of the "five vitals of pain" that lead to the questions is something most evaluative schemes do not have: opportunities to teach and learn along with an obvious relevance. Because of this, a great deal of care is provided during evaluation. This certainly shortens the time necessary to treat people. It'll probably cost the therapist money as well. Too bad.

Cooling in relation to those physiologic and behavioral processes that accompany sympathetic increase is the "physiologic signature" of the abnormal dynamic. I know that there are patients who aren't cold and should be but typically they're good diaphragmatic breathers for some reason, most commonly chior or yoga. In any case, this third question gives me the opportunity show them how these things relate to their discomfort and thus draw them further toward a realization that much of their pain is a consequence of their behavior - behavior they can control.

Abnormally warm people are also out there. Most of the time they have mid-thoracic issues and, I presume, are dysautonomic. I've seen this improve dramatically coutless times. I have no way of proving that of course, so I make no claims.