Two hours before our scheduled 1st appointment I got a message to call this lady as she felt that she was in “too much pain” to attend for assessment. There was a time in my NHS service days of 20 min appointments and 25 cases/day that I would have been glad of such a reprieve but not now. My initial disgruntlement at the short notice cancellation was compounded by the knowledge that the appointment was only booked the previous day following a consultation (on the same day) with her Orofacial Pain Specialist. This raised a few alarm bells and I felt compelled to call her both to ascertain the extent of her flare-up, what her thought process was with regards to her expectation of Physiotherapy and to outline our 24 hour cancellation policy.
From there we began an interesting half hour telephone conversation. By way of background I should add that I work very closely with the Orofacial Pain Specialist who referred her and on that basis knew that there had been some degree of “priming”.
Our conversation went along these lines.
Good afternoon Mrs. Smith I believe you wanted to have a word with me regarding your scheduled appointment this afternoon?
Yes I won’t be able to make it, I am in too much pain
Oh you are calling to cancel the appointment? The message I had received was that you wanted to discuss whether it would be appropriate for you to proceed with assessment?
Oh no I am in too much pain. I couldn’t possibly make it. Can I reschedule next week?
What do you think would be different next week?
Oh it should settle down by then. I have been prescribed some new medication, which I am hoping will be effective.
Have you had a lot of medication in the past?
Yes I have tried them all. The last doctor didn’t tell me that I had to take the “nerve tablets” for weeks so they did nothing for me when I took them occasionally. I have had this problem since my husband died six years ago; I have seen three Rheumatologists and two Pain Specialists and none of them can do anything for me. Have you ever heard of Fibromyalgia? And none of them can do anything for me. Do you treat patients with this type of problem? Do you think you can help? What kind of treatment do you do?
Well undoubtedly you have a complex problem, which many skilled practitioners have failed to resolve. I wouldn’t do you the disservice of flippantly saying on the telephone that I could help you when so many others have obviously failed. Why do you think treatment hasn’t helped?
Well I have been a bit depressed since my husband died six years ago and I have tried every kind of treatment – Osteopathy, Chiropractic, Massage, Physiotherapy, Hot Stones. So I have tried everything I could and nothing seems to work. I also suffer from depression and that doesn’t help. But the doctor has given me new tablets so maybe that will improve things. Can I book an appointment to see you tomorrow?
Oh so you don’t want to see me?
No I didn’t say that. I said we couldn’t schedule an appointment for tomorrow. Do you feel the severe incapacitating pain that you have today will resolve sufficiently by tomorrow?
I don’t know.
How long do flare-ups usually last?
Oh can be a few days.
Well my suggestion is that you try at least one week with the new medication (Neurontin) that has been prescribed so you can judge the effect of that medication.
Well it’s just another tablet. I really don’t think it is going to help very much.
But a few minutes ago you suggested that you thought it was going to be a great help
Yeah I suppose so. Maybe it will. But I have tried so many I don’t have much confidence anymore. What do you think?
I think you need to try the medication for a week and see if it makes much difference to your symptoms.
Do you think it would help?
I am not going to predict if it’s going to help or not. I think you need to see whether it’s of any benefit and make a judgement.
But the doctor says it would take 6 weeks to work.
Yes indeed there can be a whole series of progressions on the drugs that you are on and it can take a 6 week period to work through. However, I think you will have a good indication in one week whether things are improving or not.
If you call me in one week then we can talk about whether you’re ready to commence Physiotherapy, what you’re expectations are and what you’re commitment to the rehabilitation process is? You tell me that you get great benefit from Chiropractic Manipulation so I would take it as a good indication that physical treatments have some role to play in your management. However it is clear that they are not the full solution and we need to address other issues, which may involve posture, muscle conditioning, ergonomics, pain management etc, etc.
Why do you not continue with chiropractic if it has been helpful?
Oh you seem to understand my problem so well. Can I not come and see you tomorrow?
I need to make this absolutely clear that no individual clinician is going to wave a magic wand and solve the symptoms that you have been experiencing. It is likely going to take multiple specialists in different areas to assist and also a significant change in your strategy of seeking a solution from what you have described so far. I would do you no favours by seeing you tomorrow, simply adding another opinion to the long list of opinions that you have sought and in all likelihood not living up to your expectations of miraculous improvements.
Oh, yes, I see. So do you not want to treat me? I can’t go on like this.
I don’t want you to feel that I am refusing to treat you. What I am trying to do is ensure that you are in a good place to respond to treatment. As we have discussed, you obviously have a complex problem and there is obviously no point in repeating speculative treatments, which have been tried in the past and failed.
I am very willing to try to help you but I think we need to clarify each of our respective roles in order to increase the likelihood of a positive outcome. So I will put the ball in your court and wait for a phone call from you next week to discuss the plan to move forward. Talk to you then.
This conversation struck a chord with me as I reflected on the thought processes of both parties and the strategies used in response to the conversation. I tried to adopt a style, which was challenging but not too confronting whilst at the same time recognising some fundamental belief system changes I felt were required.
The fact that I deferred arranging for a new appointment was partly to address the trial medication issues as discussed above (incidentally, my expectation is that there won’t be a significant change with the medications or the side effects will be to unacceptable) and secondly so that there can be no misconception that scheduling an appointment was purely for the purposes of me seeking financial gain (as I work in a Private Practice setting and hence my desire to be separated from the long list of other money grabbing failed clinicians). So I ask myself these questions:
Will she call in one week?
Is she likely to comply with a treatment regime?
How far can I go with challenging her distorted belief systems?
Is she likely to comply with a long-term management regime?
Is her depression likely to be an insurmountable compounding variable, which ultimately forms a roadblock?
How do you think I handled this situation?
What would you have done differently?
Let us know your thoughts.
Enjoy the clinical challenge.
DavidGHTime Code(s): nc nc
Breathing control is a topic close to the hearts of most physiotherapists. My recollection is that respiratory care in general was never a particularly popular speciality in my time as a rotational physiotherapist and I am not sure much has changed.
However, there was a temporary resurgence of interest in musculoskeletal applications of respiratory assessment over a decade ago with the evolution of core stability research. Don’t worry – we’re not going to get into another laborious discussion on the merits of core control here!
For those whose memories are short, part of the theoretical modelling of mechanisms of core control as proposed by Hodges and Jull was the synergic interaction of four muscle groups which formed an internal cylinder within the trunk. (see thoracolumbar fascia for review) These muscle groups consisted of:
The anterolateral abdominal wall.
The deep spinal musculature and associated thoracolumbar fascia.
The pelvic floor
The conceptual model was that the diaphragm generated a base line level of resting tone to provide mechanical resistance to stiffen the internal muscle cylinder comprised of the synergic muscles listed above and thereby facilitate spinal support. Superimposed upon this diaphragmatic postural function was the intermittent phasic contraction associated with the respiratory cycle. This fitted in nicely with the much described muscle activation model (Bergmark) of sustained tonic low level activation with superimposed bursts of phasic activity related to functional demand.
This became relevant to physiotherapists because of the common observation of breath holding when executing exercises aimed at core muscle activation. In fact many exercises, both rigorous, high load and fine dexterous tasks, are often associated with temporary breath holding simply associated with concentration on the task. However, from an instructional perspective, it was deemed important that physiotherapists recognise breath holding as a potential compensatory strategy to artificially achieve core stability, with the obvious disadvantage of not being sustainable for any longer than the period of breath holding.
Around this time also, in the field of occupational medicine, it became evident from EMG studies that prolonged sitting and typically in poor posture, compromised diaphragmatic excursion (simply as a consequence of the mechanical restraints of the thorax and ribcage) and thereby potentiated a compensatory strategy of inhibiting / relaxing the anterolateral abdominal wall as the path of least resistance relative to superior diagrammatic excursion into the restricted chest cavity.
Superimposed upon this sustained static loading scenario, was the frequent clinical observation of elevated / rounded shoulder girdles whether habitual, stress induced, ergonomic or breathing compensation induced, which all fed into a cycle of musculoskeletal compensation.
For some years, well known American physiotherapist Peter Edgelow, has been highlighting the merits of specific breathing control in treating thoracic outlet disorder’s (That well known clinical hot potato at which so many different therapies get thrown). Edgelow’s contention, also substantiated by the opinions of Travell & Simons’ in the myofascial world, contended that scalene hyperactivity associated with respiratory dysfunction had the potential to either change thoracic outlet dynamics by virtue of their rib attachments, or simply by increasing muscle tone and reducing the diameter of the thoracic outlet and hence the potential for neural irritation. Coupled with the adaptive changes in this area were potential tightness of the Pectoralis minor and a protracted shoulder girdle all increasing the likelihood of anterior compression.
I have always found teaching breathing control challenging in the clinical situation, partly because of the difficulty in achieving patient compliance and also because of the difficulty in proving direct association with the clinical features. With this in mind I was interested to see some recent developments in this area, which I intend to explore further.
The first is the work of a Canadian physiotherapist Laurie McLaughlin who presented at the 3rd international conference on movement dysfunction in Edinburgh a couple of years ago. She is using some interesting techniques to evaluate breathing function and her work is outlined in more detail if you follow the link.
The second factor, (which partly initiated this post) was a recent notification from Human Kinetics on a book publication entitled ‘Breath Strong, Perform better’. This looks an interesting one and is certainly on my ‘to read’ list.
For those who are interested in this subject the work of Simon Gandevia (who incidentally was a collaborator with Paul Hodges’ original work) has been a significant contribution in this field. There is a concept in the sports science literature known as ‘respiratory entrainment’, which studies the pattern of respiratory activity in association with limb and body position. This has been studied in cyclists and rowers in particular, with the view to attempting to understand mechanisms and also determine whether limb / body position and repetitive movement dictate the respiratory pattern or visa versa.
In the context of the recent Wimbledon Tennis tournament, the much talked about grunting and groaning of female tennis players has achieved it’s usual amount of attention but also appears to be associated with these breathing control / mechanical force output requirements.
So perhaps as musculoskeletal physiotherapists it is time to reconsider our attitude to breathing control and to evaluate the multitude of variables which impinge upon this function from a musculoskeletal perspective,
Let us know if you have any useful clinical strategies or experience in dealing with this type of caseload.
Enjoy the clinical challenge.
DavidGHTime Code(s): nc
The future of joint replacement?
As physiotherapists there is something intuitively attractive about biological joint replacement relative to traditional implant devices. The attraction of normal biomechanical charactaristics, physiological tissue loading behavior and less surgical destruction are obvious advantages. I was excited to see this excellent 6min video from the wonderful TED website discussing these issues and future directions of biologic joint replacement in relation to knee pathology. We have discussed knee replacement cases previously.
I have only seen 1 patient with a cartilage allograft to her patella. She was a 22 year old elite hockey player /athlete who had 6 arthroscopic debridements from the age of 16. Despite my enthusiasm and considerable effort with her rehabilitation she did not return to competitive sport. Nonetheless I think this is still a very exciting area and one I hope we will see more of. It will also be interesting to see how the mulit-national prosthetic manufacturers respond to this challenge? It looks like the future research in this area is focused in a different direction to the typical disciplines of materials science, mechanics and computer modelling.
Has anyone had experience with this type of caseload?
Let us know.
Enjoy the clinical challenge.
DavidGHTime Code(s): nc
Just for the record….
Pain does not provide a reliable measure of tissue state.
Pain is modulated by many factors from across somatic, psychological and social domains.
The relationship between pain and tissue state is less predictable as pain persists.
Pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger.
Returning to a theme we have discussed before (pain and the brain) the above are indisputable facts derived from scientific evidence produced in the emerging field of Multisensory Integration. This is a field of endeavour dedicated to understanding how the brain synthesises information from different senses to coordinate an appropriate coherent response. This is fertile ground for physiotherapists / clinicians treating pain disorders and dictates that we reconceptualise our model of pain and the framework for which we provide patient care. Hint: the psychosocial model is only part of this.
At the forefront of this research is physiotherapist Lorimer Moseley, Professor of Clinical Neurosciences and Chair in Physiotherapy at the University of South Australia, Adelaide. He has written 75 papers and published in all the prestigious Pain, Neuroscience and Physiotherapy journals and has a list of awards too long to mention here.
We recently caught up at a seminar he conducted entitled “Pain and the Performing Brain”. As the title suggests the focus of the day was to explore the multi-modal factors which influence pain perception and how these impact on performance. Many concepts were presented and we were fortunate to extract some key take home messages in an interview I recorded which is posted below. Click here if you can’t wait.
Lorimer’s team have proposed a theoretical construct termed the “Cortical Body Matrix” to integrate the broad spectrum of sensory and perceptual factors which have been shown to influence the pain experience. Readers may remember the neuromatrix concept proposed by Ronald Melzack some years ago in which the concept of an individual “neural signature” was proposed. I had the luxury of hearing the man himself explain how this concept evolved. In summary, developments in brain imaging demonstrated diffuse, variable and sometimes disparate cortical activity in response to painful stimuli – not explained by a “pain centre” which has now well and truly been put to bed (ie: it can’t be cut out or ablated by procedures!).
My admittedly limited understanding of the cortical body matrix concept is that it expands the envelope of sensory perception by incorporating elements of somatic, spatial and cortical processing into a paradigm which can be manipulated for clinical purposes.
Previous posts on Lorimer’s excellent www.BodyinMind.org site discuss aspects of sensory conflict which can be used to “break-up associations” in the neuronal tag which combine to output the pain experience. Some of the strategies involve:
Access Strategies to Cortical Body Matrix
Conflicting tactile /Proprioceptive /visual cues.
Visual distortion (magnification of effected part)
Image recognition (body part aspects and orientation)
As clinicians we are familiar with symptom reports of:
Swelling (when not visibly evident),
Heaviness (when identical size)
Localisation discrepancy (when obviously present)
Thermal sensory disturbance (with similar temperature)
Dysaesthesia (exploding, crushing, non-responsive, sluggish)
These can be coupled with…
Blood flow changes
Spatial processing deficits
Data was presented outlining the mechanisms behind these sensations with particular emphasis on the dynamic and contextual variations which occur across the spectrum of normal environmental conditions to ultimately modulate the pain experience.
This information forces us to move away from the modality specific – receptor pathway – sensory cortex model of nociception to integrate domains of patient perception, prior experience, context, perceived threat, cognitive and emotive processes as parts of a neuronal matrix which ultimately outputs pain sensation.
I would also add factors such patient satisfaction, confidence in the clinician, perceptions of empathy, clinician credibility, body language, communication skills, personality, commitment to help, therapeutic environment as other, parallel sensory input’s – at the risk of sounding a bit “new age-y”.
I don’t think we can continue to ignore (or at least not talk about) these factors even if they don’t lend themselves to such rigorous scrutiny as the neurosciences and cause some ( discomfort as we saw here ) when we do.
To paraphrase Charles Spence (The Handbook of Multisensory Processes).
From the existing body of research there can be no doubt that our senses are designed to function in concert and that our brains are organised to use the information derived from multi-sensory channels cooperatively to enhance rapid detection, identification and response. Even experiences that appear to be modality specific have most likely been influenced by other sensory input whether perceptible or sub-conscious.
This raises questions regarding the hierarchy of information processing and the underlying mechanisms of excitation / inhibition within the brain.
How does the brain weigh up the different input it receives from multi-sensory stimuli to produce a final perceptual output / experience?
What factors combine to determine the most dominant, pervasive sensory cue in a given context?
What factors influence the dynamic nature of this response?
These are questions which Lorimer’s team and other neuroscientists are striving to unravel.
I was fortunate to interview Lorimer after his workshop and I invite you to listen to the audio below.
Prof Lorimer Moseley Interview
Here are some of the issues we discussed
– the transition from disillusionment with physiotherapy to subsequent rejuvenation in the path subsequently taken.
– the use of visual illusions to illustrate discrepancies between sensation and perception.
– calls for classification of pain based on mechanisms rather than structure or symptoms.
– improvements in technology.
– proprioceptive deficiencies in low back pain patients and perceptual impairments of painful body parts.
– the clinical tools such as. “Explain pain” and the “Recognize” program
– evidence-based practice, the therapeutic relationship, outcome measures and perceptual components of human interaction – Where does this leave the double-blind clinical trial?
What a treat, got the intra-cellular juices flowing?
Enjoy the Clinical Challenge
DavidGHTime Code(s): nc nc nc nc nc nc
Hardly a day goes by where physiotherapists don’t see an article related to the importance of addressing psychosocial issues in the management of musculoskeletal pain disorders.
The model that has been fairly well established in pain clinics and tertiary care settings which typically involve multidisciplinary pain management input from a variety of clinical specialities. Too frequently, the practical reality is that by the time patients access these services they have become chronic and developed a spectrum of disability behaviours and are usually unemployed. These confounding variables increase the rehabilitation challenge and reduce the possibility of a successful outcome.
Epidemiological studies suggest that individuals out of work for more than six months have less than a 50% chance of ever returning to full time work. I must confess I find this statistic somewhat surprising and it doesn’t correlate with my clinical experience. Interestingly the structure of state benefit schemes does appear to influence the period of disability.
Here in Ireland individuals remain on full pay for six months following which time their case is either transferred to a case management company (in the case of private sector employees) or in the public sector the disability assessment board are involved in assessing fitness to work. From this point half normal pay rates are immediately instituted. I have been impressed with how frequently patient’s attitudes and beliefs about their level of disability change as the six month mark approaches. I do not think that they are specifically malingers or exaggerating their symptoms but simply that weighing up the balances (either consciously or sub-consciously) has allowed them to reach a decision to return to work with an acceptable level of discomfort. Interestingly other countries have shortened this period of disability support (eg Scandinavia) and statistical analysis has shown a similar pattern of absenteeism mirroring the period of full-pay social welfare support.
These are important factors to recognise as they are classed as ‘unmodifiable variables’ to which we clinicians have no direct control. As such it is important to recognise them as potential confounders to treatment progress, if for no other reason than to maintain physiotherapist’s sanity. It can be very taxing to work diligently on a systematic rehab programme and wonder why you are not seeing the effects of intervention, or the patient appears somewhat less enthusiastic about a rapid return of recovery (and return to work) despite your best efforts. This can easily lead to a breakdown in therapist/patient communication. That being said, in 22 years I have never had a patient specifically express that their intention is to stay out for the full period of allowable disability on full pay. Usually this information usually needs to be gleaned by “under the radar” techniques and an intelligent line of questioning.
As the title of today’s post implies, as clinicians we must always consider the reasons why we ask questions, but also to consider that if we ask certain questions are we prepared to engage in a meaningful way with the answers that we get? Given what we know of psychosocial factors and their influence in pain, then the onus is on the therapist to identify relevant risk factors, which would include some of the following:
Psychosocial Risk Factors
- Beliefs and attitudes about pain.
- Fear avoidance behaviour.
- Anxiety and phobia.
- Distorted beliefs.
- Conflicting information.
- Perception of disability.
- Fear of pain.
Over the years as this debate gathered momentum there has been a recurring discussion about professional boundaries and what are appropriate and inappropriate psychosocial factors to address. The clinical reality is that most of the common psychosocial issues contributing to musculoskeletal pain fall within the scope of practice of the treating clinician regardless of what their discipline.
Repeat: that most of the common psychosocial issues contributing to musculoskeletal pain fall within the scope of practice of the treating clinician regardless of what their discipline.
Only cases with overt mental health disease are outside the scope of practice of physiotherapy. This places demands upon the therapist in terms of how they frame their questions. How they interpret the answers they are given and how they analyse the information if it is not clear from the communication. Simply delivering a pain questionnaire and transferring care to a group management programme is an abdication of responsibility in my opinion. So with the immortal words of Jack Nicholson if you ask the pertinent questions ‘can you handle the truth?’ Are you equipped with the skills to challenge distorted belief systems, to address lifestyle and behavioural issues, to identify fear avoidance behaviour and replace these dysfunctions with an alternative better strategy?
It certainly won’t make for an easy life or even be met with rapturous enthusiasm but it still doesn’t mean we can ignore.
Enjoy the clinical challenge.
David.GHTime Code(s): nc nc nc nc nc nc nc nc