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Clinical Reasoning Typical cases are discussed there. The cases are brought by practioners.

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Old 17-09-2016, 05:58 AM   #1
gollygosh
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Default pain vs passion

50 year old male was in MVA last year. Was sent to PT for neck of back pain. In the course of PT, had another MVA with additional referral for PT. This totally unlucky guy had a third MVA this time adding a diagnosis of medial epicondylitis. Eventually our OT talked to me about treatment that included pain management. I encouraged her to educate re pain: defense vs defect, hurt vs harm. She tried, but didn't feel up to the task and got him referred to me. He has 2 passions life-- he loves to cook professionally, and loves to play the piano-jazz
AROM is close to normal, strength testing is inconclusive due to pain. The man holds his arm in supination--as if holding an egg. He complains of burning throbbing aching intermittently. I suggested pronating his arm and supporting it on his lap, or a pillow. The position change relieves pain in thd short term. In the last six visits I have observed, and reminded him repeatedly that he seems more comfortable when he alters the position of his forearm, He stares at his arm, as says " I don't mean to do it. I reply that chronic pain is a little like a bad habit, and that he needs to teach himself to come up with a new response to pain that may include changing positions more frequently, deep breathing, self talk, less concern about tissue damage and more working on gradually regaining his passions.
in the course of accidents, diagnoses, doctors and lawyers, he had been told to stop cooking, stop playing the piano. So pain and medicine has taken a lot from him.
when goal setting he started with " I want to feel better." I countered with "if you feel better, what would you do?" He smiled and said "cook , and play the piano ". I have been having him meal plan, and do food prep--he says it so slow--I say it is a start. He currently is trying to regain the ability to flip food in his sauté pan. Several times per day. I had him sit at the piano sideways, and play one handed for 30 second, to progress to two hands and a normal position when he felt comfortable. He currently plays piano 10-15 minutees 2-3 times per day. Pain was 4-6 and now is typically 2-3 with occasional shooting 5-6 in ulnar nerve distribution. In general we spend alot of time talking, introducing novel approaches to movement, and problem solving and cheerleading. He perceives progress, but thinks it should be faster. He wonders if he should go to a pain doctor, or maybe a hand specialist.
I am not sure what will happen next, but I remain hopeful
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Old 17-09-2016, 07:30 AM   #2
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You are enabling him to re-member.
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Old 18-09-2016, 04:18 PM   #3
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As I inteact with this man I find myself hoping that he achieves his goals. I hope he will be the one patient in our department that convinces people that Physical Therapy is so much more than muscles and bones. I feel amazed at how far I have strayed from the "conventional " model of PT .

Some words that I find curious in this conversation is "why" and "still" I am a "why" person. My patient says "why do I still hurt. Why, why, why? And I encourage him to move beyond why to "what can I do right now?"
Then there is "still". "It still hurts" "I still can't do everything how I want "
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Old 18-09-2016, 04:24 PM   #4
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People definitely ARE more than muscles and bones. They have 72 kilometres of nerves, some of which may be mechanically stressed, deformed, and cranky. I just saw Michael Shacklock's new video earlier this morning, demonstrating his new under-the-radar approach for neurodynamic treatment for nerves.
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Old 18-09-2016, 07:22 PM   #5
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The nerves are not something not often considered despite their ubiquity and presence. If there's another organ can signal, I don't know of it. The muscles are more visible though we know that their quality (aside from their size) is unknown without challenge. I have some indication of this and wrote what Jeb couldn't see some time ago. What he concluded was reasonable, but might have been closer to what was known with a little investigation.

The patient "doesn't mean" to move when he gains some relief. I can think of a way of using that.

Chronic pain is not like a bad habit and I'll consider that a terrible analogy until someone explains it to me.
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Old 18-09-2016, 08:34 PM   #6
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I chose the analogy of bad habit with this patient to indicate that at some point he was going to need to use non automatic responses to move beyond the pain.

His initial protective responses post -MVA make sense from a protective point of view. The pain caused him to seek medical assistance, which cleared red flags. Doctors and lawyers and therapists added layers of protection and guarding to the pain experience.

At this point he seems trapped, and afraid.

And it seems to me that he is going to need to make a habit of changing his response to pain in his arm from
"Now what did I do to hurt myself (because hurt in his mind stll equals harm) to what response can I(the patient ) use right now to find my way out of this pain experience and back into moving.

I am not totally comfortable with calling it a pain habit, but I don't think most habits (especially unhealthy ones )happen by choice , but most good habits happen by choosing to make better choices on a regular perhaps habitual basis.

After years of frustration with the problem of pain, I continue to search for words that make sense to the patient I am with, and value your questions, suggestions and knowledge

Geralyn

Last edited by gollygosh; 19-09-2016 at 01:25 AM. Reason: spelling
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Old 02-01-2017, 07:42 AM   #7
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Geralyn, I think what has contributed significantly to this poor fellow's persisting pain to begin with was the insistence that he cease activities which involved pain - cooking,playing piano.

The doc/s told him this, and it may have convinced him there is something really wrong.
The problem is convincing him he cannot damage himself if he does play the piano; even if the pain increases after a while. How long does it take to settle back to "normal" levels?

When he plays the piano, set a time limit, and have him stop. Then reset the alarm for a little longer, and so on. He hopefully will feel: I can play for 3 minutes longer now! In that way he "obeys" the ticking clock and not what his brain is grumbling about.

It sounds like you have achieved a whole lot already with him.
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Old 03-01-2017, 12:31 AM   #8
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Quote:
Originally Posted by Barrett Dorko View Post
t.

Chronic pain is not like a bad habit and I'll consider that a terrible analogy until someone explains it to me.
But some of the habits that develop due to chronic pain can be unhelpful...
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Old 03-01-2017, 01:31 AM   #9
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Quote:
Originally Posted by gollygosh View Post
After years of frustration with the problem of pain, I continue to search for words that make sense to the patient I am with, and value your questions, suggestions and knowledge
Since this man loves music, maybe you could use music as metaphor,

maybe a conductor of an orchestra who does well year after year until
something disturbes him (you fill in something like an analogy to a MVA)
and after this he starts to make errors conducting say letting the brass
section play too loud and occasionaly on wrong moments, after a while
things sort out to normal but if things are disturbed again (& again)
So to fix this both conductor and orchestra need to maybe ease down
and start rehearsing more gently, getting confident again ,....etc.

(just tried to come up with hints)
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Old 03-01-2017, 05:31 AM   #10
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Default update

At this point, he continues to progress. I taught him somd qi gong movements which he uses to soothe his pain. His old piano teacher has been helping to coach through appropriate drills and progressions. About 6 weeks ago one of his doctors ordered nerve conduction velocity test to rule out a pinched nerve. I advocated against it-- felt it could do more harm than good -especially since his complaints were getting less and his activity level increasing. Fortunately the test did not exacerbate pain. The test came out normal.
After over a year of not using the arm he is de conditioned. One of his current goals is to get stronger. His tolerance to activity is low but improving,. His attitude is less protective, and I see him problem solving, seeing things in the gym that he would like to try. He cooks for his family almost everyday. He is periodically surprised by pain because he isn't constantly protecting the arm. When he comes against a painful activity, for example, pulling up his covers, we practice it, trouble shoot, and reassure.
In short, it seems like he won't need me much longer.

Thanks for the suggestions, it is kind of the track I've been on. I definitely feel like I have been interacting, and not operating.

Geralyn
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Old 26-03-2017, 06:47 PM   #11
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Default Abstract accepted

I decided to submit an abstract to the Missouri Physical Therapy Association for a poster presentation. My motivation is from Soma Simple. If we don't share this information, people won't learn it. It was intimidating to submit because while I feel motivated, and have experienced some success, I don't feel incredibly qualified. Anyway, here is the abstract. I will also be posting the text that with the help of my graphic design daughter will become a poster presentation.

I appreciate your input (with fear and trembling)

Geralyn
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Old 26-03-2017, 06:52 PM   #12
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Default poster presentation

here is the text of my poster presentation. My daughter will help me with turning this into a poster presentation.

Geralyn
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Old 26-03-2017, 07:40 PM   #13
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Quote:
If we don't share this information, people won't learn it.
Too true.

Quote:
It was intimidating to submit because while I feel motivated, and have experienced some success, I don't feel incredibly qualified.
I went through similar crippling self doubt when I started getting asked to teach. If you just do it, it gets easier to do.

All the best!!
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Old 26-03-2017, 07:43 PM   #14
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Your layout is very thorough.
Your approach is very congruent with Peter O'Sullivan's cognitive functional therapy.
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

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Old 27-03-2017, 02:40 PM   #15
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I second Diane's comments - very nicely done: comprehensive and very much in line with up-to-date knowledge!
Thanks for sharing it!
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Old 27-03-2017, 02:43 PM   #16
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A little edit note: "The subject was a 45-year-old male that " should be who.
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Old 01-04-2017, 12:51 AM   #17
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Default Almost finished

Last night my daughter--graphic designer and explained that I had way too much text. I pulled the specific treatments on to a handout for the interested to take with them, and with assistance added some visual appeal--you don't want to see my first attempt.

Makes me glad we paid for her education.

Also made me remember all those times I sat next to her and helped her edit papers for school. Paybacks.

Do you know if I should include "work cited" on poster, or on handout? Does it sound like I have been out of school forever?

Geralyn
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