Pot-Pourri

[Johnny_Nada]

What makes you choose the interventions you choose then for those types of conditions? For example I have a young basketball player with acute low back pain. He came in in a lot of pain. I saw him a week later and it was almost completely gone. I didn't give him anything crazy in his HEP, just some stretches and simple easy ways to load the back muscles that were not painful. Now I'm basically giving him exercises that would simulate the basketball environment: suicides, box jumps, lunges with trunk rotations etc. He's playing multiple games per week without any pain at all. He probably doesn't need to see me. He probably never needed to see me.

I feel so unskilled.

If done in the context AJ1 talks about, you are very skilled and consistent with the evidence. You also avoid type II medical malpractice. To your colleagues you may not appear skilled and look like a glorified personal trainer (as do I). I won't say what they look like to me....

[FrustratedNewGrad]

Premise 1. The vast majority of musculoskeletal conditions encountered are normal predicaments and carry little in the way of serious health consequences.

Premise 2. They resolve with time and without treatment

Premise 3. If treatment is provided, the evidence for effectiveness is likely overstated.

Premise 4. The treatments are small in risk but do carry harms

Premise 5. It appears it doesn't really matter what you do so long as you are doing something

Premise 6. Efficacy and effectiveness are two different things

Premise 7. The outcome measures the outcome and is not justification for treatment

I was thinking, a lot of people come to PT for chronic problems which do not get better with or without treatment. I've been getting a handful of patients, always female, complaining of ongoing posterior hip pain. Worse when sitting long periods and when walking/running extended periods. It's always aggravated with what would be called the piriformis test. I've never really had much success with this type of issue.

No matter how much hip strengthening, foam roll/lacrosse ball massaging, stretching done, it hardly ever gets better. I can't tell if I just don't have the clinical skills or it doesn't matter what is done or not, nothing is going to change.

[Johnny_Nada]

My new continuing education course....

Benign neglect, regression to the mean and natural history: An evidence based approach to treating pain.

[Barrett Dorko]

Frustrated,

There's no way to speed up or handle another that diminishes the affect of motion that would naturally occur? Can "regression to the mean" be opposed by something so familiar that it has been rendered invisible?

Can such a handing (if it exists) be defended?

What is the origin of this complaint of pain?

[Jo Bowyer]

Benign neglect, regression to the mean and natural history: An evidence based approach to treating pain.

Which we have monetised for over a century by doing the equivalent of this....

[marcel]

While some promote plausibility, it appears there is limited effectiveness?

Ferreira, Giovanni, et al. "Neurodynamic treatment did not improve pain and disability at two weeks in patients with chronic nerve-related leg pain: a randomised trial." Journal of Physiotherapy 62.4 (2016): 197-202.

That makes one think about: which other treatment has been shown to improve pain and disability at two weeks in patients with chronic nerve-related leg pain

Pick any treatment you like,
Ps is it evidenced by rigorous (critical) research (like cochrane standards; or one step below)

Then ask how come there are this amount: ? of treatments that do exactly this:
"improve pain and disability at two weeks in patients with chronic nerve-related leg pain"

There just might be one treatment type that does the above, spinal cord stimulation (?)
(there's one withdrawn cochrane review (outdated) on the matter)
Major limitation is certainly not all "patients with chronic nerve-related leg pain" will get an indication for SCS

Health Quality Ontario. Spinal Cord Stimulation for Neuropathic Pain: An Evidence-Based Analysis. Ontario Health Technology Assessment Series. 2005;5(4):1-78.

Conclusions
Level 2 evidence from 2 studies of high quality supports the effectiveness of SCS to reduce pain in some neuropathic pain conditions.
There is supportive evidence from secondary outcomes from level 3a evidence that treatment with SCS improves functional status and QOL.

https://www.ncbi.nlm.nih.gov/pubmed/...rd+stimulation

[FrustratedNewGrad]

Frustrated,

There's no way to speed up or handle another that diminishes the affect of motion that would naturally occur? Can "regression to the mean" be opposed by something so familiar that it has been rendered invisible?

Can such a handing (if it exists) be defended?

What is the origin of this complaint of pain?

Considering the pain occurs with repeated movements and compression, it would seem to be mechanical deformation. The tissue cannot handle the load being placed upon it. Loading the tissue and those synergistic to it so that they can better handle the capacity would be my usual plan of action. It hasn't worked.

Issues like tendinopathy respond to load. Another strategy would be to find a new way to move to unload irritated structures. I've always had a hard time with that, unless the movement is obvious.

[marcel]

PS posted a Shah et al 2015 (BiM), question on the EIM site regarding DN (BS)

http://www.evidenceinmotion.com/blog...r-edo-zylstra/

[Johnny_Nada]

Marcel,

You've been busy!

[Johnny_Nada]

I feel like I've read or heard this countless times now. We hear about patients fearing pain or fearing activity, exposing them to it or violating their expectations to help them. I read and hear about showing patients how to move with less pain. I get it. I do it daily.

Here is a question: What about those individuals that just don't WANT to do it if pain is present? What if they don't fear it? What if the job, activity, hobby simply isn't enjoyable when it hurts or provokes pain? What if the job was tolerable when comfortable but sucks ass when painful? I see people daily that are willing and desire to perform activities despite pain. I see others (the more challenging type in my opinion) that are pain averse. The mere experience of pain renders activity undesirable and unwanted.

[Josh]

Johnny to add to what you said:

What about those that are defined by being "in pain"?

A fair amount of my patients seem to saddled with a personality that seeks the "care" that comes with being miserable. I know this is a pretty strong accusation and I am not applying it to all, I may be totally wrong, but it's something I have observed....i think....

[marcel]

Josh

Pain and Personality: Do Individuals with Different Forms of Chronic Pain Exhibit a Mutual Personality?
Pain Practice 16(4) · April 2015 

Abstract
The role of personality in the experience of chronic pain is a growing field, with endless debate regarding the existence of a "pain personality". This study aims to compare different chronic pain types and consolidate the existence of a common personality. Thirty-two females with chronic orofacial pain and 37 age-matched healthy females were assessed with the Temperament and Character Inventory-Revised. Chronic pain subjects had either trigeminal neuropathy (neuropathic pain) or temporomandibular disorders (nociceptive pain). This study revealed that individuals with different chronic pain types exhibit a mutual personality profile encompassing significantly higher scores in Harm Avoidance and significantly lower scores in Self-Directedness when compared to healthy subjects. In fact, this combination is associated with Cluster C personality disorders. In conclusion, our study reveals that irrespective of type, chronic pain may be associated with Cluster C personality disorders. Indeed, there has never been empirical evidence in the past to suggest that chronic pain as an overall concept is associated with any particular personality disorders. Therefore, a potential future avenue of chronic pain treatment may lie in targeting particular personality aspects and shift the target of pain-relieving treatments from sensory and psychologically state focused to psychologically trait focused.

A potential future avenue of chronic pain treatment may lie in targeting particular personality aspects of chronic pain patients. Although some pain treatment programs target nonsensory aspects of pain, these do not
target specific personality factors. For example, psychological therapies such as cognitive behavioral therapy (CBT) target psychological states, for example cognitive-evaluative and affective–motivational states, rather
than traits. Although it is well established that CBT is an effective chronic pain treatment,29 there is considerable scope for improvement.30 One possible way of improving treatment efficacy is to include trait-focused psychological therapy, in particular the temperament and character trait of Harm Avoidance and Self-Directedness. Individuals high in Harm Avoidance are described as being cautious, careful, fearful, tense, apprehensive,
nervous, timid, doubtful, discouraged, insecure, passive, negative, or pessimistic even in situations which would not worry other people.11 They are inclined to inhibit their behavior in relation to harmful stimuli and react to
stressful events such as ongoing pain with high levels in state depression and/or state anxiety.4,11,27 Indeed, we recently demonstrated that both groups (neuropathic and nociceptive) included in this study show significantly
higher values in state depression and state anxiety when compared to an age- and gender-matched healthy control group.19 As Harm Avoidance is strictly linked to an individual’s ability to cope with potentially harmful
life events,4 a high score in Harm Avoidance may reflect an individual’s tendency to anticipate pain with pessimistic, negative, and fearful thoughts. This may disseminate into longstanding rumination15 resulting in a
vicious circle of chronic disability and suffering (fearavoidance model) that exacerbates the pain experience itself.

Full text:
https://www.researchgate.net/publica...al_Personality

[Johnny_Nada]

https://twitter.com/erikMeira/status...7Ctwgr%5Etweet

courtesy of GB over at EIM....

[Johnny_Nada]

http://startingstrength.com/article/swoggers-revenge

[John W]

http://startingstrength.com/article/swoggers-revenge

Great story. So disappointing that this guy wasn't able to find a therapist to help him start moving better sooner. That probably would have helped reduce his pain sooner.


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