Biochemistry

Radiographic imaging

Elastography

Microdialysis techniques

Integration with our current understanding of pain mechanisms

Debate has now moved beyond whether Myofascial taut bands as entities actually exist into a more refined analysis of:

Identifying patient subgroups

Alternative etiological mechanisms

Identifying optimal management strategies.

The first point to recognise is that the cause of trigger points is still a matter of speculation. Travelle and Simons originally described both active and latent trigger points – latent to describe the concept of the clinical recognition of a palpable nodule, which was not reproducing symptoms.  The working assumption is that latent trigger points can exist without pain but then become activated for some reason.  As Robert Gerwin has alluded to trigger point tenderness does not occur except in regions of muscle hardness.  But regions of muscle hardness occur without local or referred pain.

It is currently “assumed” that the muscle hardness or taut band that occurs in the absence of pain is the first abnormality and that active trigger point is a more developed or second stage of the trigger point.  However this still remains hypotheses at this point.

Jay Shah amongst others has contributed largely to our knowledge on the biochemistry of the trigger points using microdialysis techniques.  This has indicated that there is a local mechanism of nerve sensitisation involving release of local neurotransmitters, hydrogen ions, potassium and cytokines, which are all classically associated with a peripheral inflammatory response (peripheral sensitisation).  The activation of these pathways also feeds into a central sensitivity state, which can become self-sustaining and independent of the peripheral components or essentially be a mirror of the state of peripheral sensitivity.

If the mechanical hypotheses of inducing trigger points is extrapolated there is a potential cascade of events involving neurotransmitters as alluded to above and also the release of acetylcholine at the motor end plate which amplifies motor end plate discharge and is thought to be associated with the development of localised muscle contractions – however this is only one of a number of theories.

Studies many years ago by Professor Patrick Wall indicated that taut bands can be produced in muscles simply by persistent depravation of sleep over a forty-eight hour period.  Clearly this mechanism is not associated with a mechanical event.  This raises the tantalising question of the chronic persistent myofascial pain syndrome in which:

Fatigue

Sleep disturbance

Muscle pain

are part of an integrated triad which is often challenging to resolve clinically.  What does appear evident from clinical observation is that mechanical muscle overload can occur at different ends of the spectrum from an acute severe overload that doesn’t induce fibre disruption but initiates sustained physical overload of  muscle fiber with the presumption of initiating the biochemical responses alluded to earlier.

At the other end of the spectrum is a low load, sustained activity associated with postural, ergonomic or occupational factors which by its nature is a less severe mechanical effect but cumulative over a longer period of time.

Other factors associated with the development of trigger points are:

Weakness

Hypoxia

Ischaemia

Central sensitisation

Referred pain

Gender

Hypermobility

The Diagnostic challenge

According to Jay Shah regarding this particular issue “validation of clinical diagnosis by palpation with these and other objective tests e.g. magnetic resonance & elastography would help establish the reliability of the clinical examination not as interrater reliability but in terms of the reliability of the physical examination to identify those patients whose myofascial trigger points is verifiable by other mean.

Current laboratory studies that show abnormalities would have to be validated themselves by showing that they independently identify trigger points that can be treated resulting in pain relief and improved function”.

Robert Gerwin adds “ there remains a need to develop a consensus on the clinical features required to diagnose myofascial trigger points.  There is also a need to develop objective laboratory criteria that can be used to standardise a diagnosis for the purposes of research.  They may have clinical value if they can be used to confirm an examination made by physical examination.  Elastography needs to be studied in a variety of trigger point pain syndromes”.

Treatment

The current treatment spectrum encompasses:

Stretch & spray

Local soft tissue mobilisation

Direct trigger point pressure

Dry needling

Injection therapy

Comparison of these modalities is still in its infancy other than anecdotal clinical evidence.

So in summary still much to do in this area of myofascial pain syndromes.

Enjoy the clinical challenge.

David

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Post tags: chronic myofascial pain, Myofascial pain, myofascial pain dysfunction, myofascial pain myofascial pain, myofascial pain symptoms

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Knowing what patients are thinking and saying about your Practice is an important aspect of patient management, which is rarely discussed amongst professionals.  On our first patient encounter we have no idea of their historical beliefs about Physiotherapy, their expectations, their fears, their level of compliance, their commitment to finding a definitive solution, their financial circumstances or their social environment.

On initial reflection our initial impression maybe that we cannot influence many of these variables because they are either outside our remit, outside our scope of practise or simply beyond our control.  Previous posts on this blog have referred  to psychosocial flags and extrapolated beyond the well known Red and Yellow flags to the more recently updated concept of Orange, Black and Blue flags.  If you are rusty on what those definitions refer too you can review them here and here.

It raises the very contentious issue of defining what variables are modifiable and which are not. This is contentious because Health Economists tell us repeatedly that education, socio-economic standing, geographical location and social structure are predictive factors of the utilisation of Health Services.  These factors are also strongly associated with poor outcomes, which then raises the obvious question – why bother?  In my own working environment, which is a Private Clinic, patients either self-fund or are reimbursed by a third party payer.  I naively thought many years ago that patients who were paying for treatment would be more motivated to achieve a rapid resolution of their situation and demonstrate enhanced compliance with recommended regimes.  Twenty-two years of experience, with twenty in the private sector, has convinced me that this is not the case.

However, I have concluded that patient expectations of a solution are certainly high in this environment – but that does not always translate into shifting the locus of control from the clinician to the patient in terms of compliance.  Perhaps it is a case of patients paying and therefore expecting the solution to be passively provided?  Whilst it is undoubtedly a pressure which clinicians in this environment will be aware of, it is frequently an untalked about subject and not particularly conducive to developing a good therapist/patient relationship when the initial discussion approaches ability to pay.

My dentist colleagues suggests that not discussing money at the outset of treatment is indicative of a lack of confidence of the therapist and a self-depreciating view of the value of the service provided.  Whilst this maybe one explanation I would contend that the Public’s perception of good dental hygiene – having the “Hollywood” smile is probably far more pervasive and well established than having optimal musculoskeletal health.  Dentists have shifted their paradigm from being “tooth extractors” to being preservers delivering prophylactic care and self enhancement services. I am still of the view that most patients consult physiotherapists when something has failed rather than to enquire about musculoskeletal health. We have a road to travel in this department.

On this basis the value that is attached by a patient to Physiotherapy relative to Dentistry I suspect is somewhat different unless they have had positive previous experiences.  Ultimately it comes down to individual choices and I have never come across a patient who has terminated their satellite TV subscription service, stopped smoking or reduced their frequency of pub visits in order to fund Physiotherapy.  Of course this may have happened without formal discussion but I suspect it would be a rare circumstance?

How frequently in clinical practice do you ask if patients are satisfied with the service  they are getting and whether it is meeting patient expectations?

Do patients get the message that you are satisfied with the rate of progress?

If patients have plateaued or are failing to respond are you comfortable approaching this subject in the knowledge that it is the pathology hindering resolution rather than therapist inadequacy?

Or is it a skill deficit?

This leads us then into a terrain which we have previously discussed regarding defining the patient’s prognosis and either confronting the issue of a poor outcome or making rational decisions for onward referral to other health professions who can be of practical assistance.  It is far to frequent an occurrence for Physiotherapists to send the patient back to the G.P. or for surgical consult when these strategies do not influence the practical management but simply abdicate the therapist from having a frank (and potentially unpleasant) conversation with the patient.  If we want to be respected as a profession we need to bear this responsibility as part of our duty of care.  We will return to this issue in subsequent posts no doubt.

Enjoy the clinical challenge

David

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Tissue repair
Fluid mechanics
Motor Control
Muscle Tone
Pain Mechanisms
Modes of therapeutic effect

The presentation servers as an excellent literature review as well as a thought provoking perspective on a common clinical issue.

Follow the link below to access

www.physiodigest.com/?attachment_id=5278

We also looked at core stability and gait mechanics in a previous post dealing with practical applications in a clinical setting.

Enjoy the clinical challenge.

David

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Like many aspects of diagnostic testing and most in musculoskeletal physiotherapy very few tests are definitive taken in isolation and the current trend is to use clinical prediction rules which group a number of tests in order to confirm or refute positivity. This allows the examiner to conclude with greater confidence when a group of tests are positive even in the presence of some non-positive tests.

Assessment of sacroiliac dysfunction – Foundations.

1. Active straight leg raise test.

2. Pain provocation test.

3. Kinetic tests.

4. Positional assessment.

5. Leg-length tests.

6. Passive movement assessment.

In previous posts I have discussed the role of positional assessment and Leg length testing in relation to mechanical assessment of the pelvic girdle. Today we will focus our discussion on the kinetic tests as they have been formally described. Several renowned authors have written on this topic over the years the most notable being Philip Greenman (an osteopath), Diane Lee (Canadian physiotherapist), Richard DonTingy (US physiotherapist) and Howard Turner (Australian Physiotherapist)  referred to above who has been conducting courses in the British Isles and internationally for the last 15 years on this topic.

Kinetic Tests

Forward Flexion in standing / sitting.

Hip Extension in standing.

Hip Flexion in standing (Stork / Fowler / Guillet Test).

Lateral Flexion in standin.

Rotation in standing / sitting.

When interpreting Kinetic tests it is important to recognize that the evidence of dysfunction does not infer a mechanism of pathology.

The pathology may lie in the articular system, the myofascial system.

The pathology may be local to the pelvic girdle and sacroiliac joint.

The pathology may be secondary to lumbar spine or general postural alignment characteristics

The interpretation of “positivity” is based on the extent of variance from expected norms and the number of positive tests.

The selection of legitimate targets for intervention is based on the degree of deviation on the kinetic tests rather than the side of dominant pain.

Those of you who treat the sacroiliac joint dysfunction frequently are well aware of the propensity of this joint to demonstrate alternating sides of symptoms which can sometimes leave a therapist “chasing pain” rather than identifying primary underlying mechanisms.

1. Forward Flexion in standing

Therapist : palpates inferior aspect of PSIS inferiorly

Patient : flexes forward to end of range.

Normal : PS IS move symmetrically bilaterally

Dysfunction: asymmetrical movement of PS I S. which may be early or late in the movement pattern or the PS I S. moves more Cephalad on flexion

2. Hip extension in standing

Therapist: palpates the idiom and sacrum on one sacroiliac joint.

Patient : extends the hip.

Normal: the PS I S raises cephalad relative to the sacrum

Dysfunction: PS I S. and sacrum move together

3. Hip Flexion in standing (Stork / Gillet / Fowler tests)

Therapist: palpates Ilium and sacrum of one SI joint

Patient: flexes they hit to 90° flexion.

Normal: PS I S. drops caudad relative to sacrum

Dysfunction: increased or decreased movement of Ilium relative to sacrum

4. Rotation in standing

Therapist: palpates Ilium and adjacent sacral segment.

Patient: rotates their torso.

Normal: sacrum lifts relative to PS I S.

Dysfunction: increased or decreased movement of sacrum relative to ilium

PS : the trunk  should rotate to the side of the tested S.i. joint.

5. Lateral flexion in standing

Therapist: palpates Ilium and sacrum of one SI joint.

Patient: performs lateral flexion.

Normal: PSIS drops and sacrum lifts on the side to which lateral flexion occurs

Dysfunction: increased or decreased movement of Ilium relative to sacrum

Clinical Thoughts?

1. Why does the Ilium move cephalad in standing flexion?
2. Why does the ilium move inferiorly relative to the sacrum in Gillet test?
3. How does the coupling of motion occur between Lumbar spine, Sacrum and Ilium in trunk rotation?
4. How do the pelvic biomechanics in lateral flexion occur ie how is the coupled motion achieved?

Enjoy the clinical challenge.

David

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Post tags: Anatomical terms of location, Conditions and Diseases, Diane Lee, Health, Howard Turner, Kinetic tests, Lumbar vertebrae, pelvic girdle dysfunction, pelvis, Philip Greenman, Physical therapy, Richard DonTingy, sacroiliac, Sacroiliac joint, Sacrum, SI Dysfunction

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Neurodynamic or adverse neural tension assessment as a concept of examination and treatment became popular in the 1980’s.  I had recently cause to reflect on how far things have come when I received a letter from my local Consultant Rheumatologist indicating that a patient he had assessed demonstrated a mild positive “Slump test”.  What was most satisfying from my perspective was that the slump test  (pioneered by a Physiotherapist) and utilised in routine musculoskeletal clinical practice has now transcended inter-disciplinary boundaries.

You may recall that Jeff Maitland was the first to describe the concept of a slump when he observed that patients reported an increase in their low back pain when flexing their head to get into a car seat.  This coincided with a body of anatomical work from a Swedish Orthopaedic Surgeon Alf  Nachemson, who performed much of the basic science research looking at neural tissue movement, its relationship to the interface and the mechanisms of pathophysiology.

Other pioneer’s in the field of peripheral neuropathic physiology were Sir Sidney Sunderland and Goran Lunborg.  Both of these researchers contributed vastly to the understanding of peripheral nerve physiology and most importantly the nerve pressure gradient, which is the mechanism for understanding normal homeostasis across a peripheral nerve.  In the early 1980’s two Australian Physiotherapists Bob Elvey and David Butler simultaneously described nerve sensitivity tests for the upper limb, which became known as the Brachial Plexus Tension Tests and have more recently been defined as the Upper Limb Neurodynamic Tests.  These have become so widespread in Undergraduate Physiotherapy Curriculum’s that testing for neural sensitivity either in the axial skeleton or the peripheries is now considered a mandatory component of any physical examination performed by competent Manual Therapist’s.

My colleagues in Occupational Medicine tell me that it is becoming more prevalent to see Occupational Physicians describing normal or positive upper limb tension test responses in patients they examine.  Over the years I have spent some considerable time training, studying and teaching with some of the above-mentioned experts and trying to impart some of this knowledge on the G.P. training schemes for which I have input.  I must sadly acknowledge that I have never received a letter from a G.P. describing altered neurodynamics and do wonder whether these concepts have reached the broader aspects of application in musculoskeletal primary care.

Do any of you have evidence of neurodynamic evaluation by your referring physicians?

Perhaps this is a secret which should be kept amongst Physiotherapists and used as a silver bullet to resolve challenging pain problems where altered neurodynamics form part of the symptom pathology?

Let us know your thoughts.

PS The positive Slump test reported was actually localised dorsal sacroiliac ligament pain with pseudo sciatica from Piriformis syndrome but that’s a discussion for another day!!

Enjoy the clinical challenge.

David

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Post tags: adverse neural tension, david butler, goran lundborg, jeff maitland, neurodynamics, sidney sunderland

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Paul has sent me the details below. Feel free to contact me directly or Paul by any of the means below. If this does not apply to you perhaps you know of someone who would appreciate this opportunity?

Details below:

• Head of Physiotherapy – Bachelor degree plus post grad qualification preferred. Good to have working experience with spine patients at a rehabilitation/physiotherapy clinic or hospital. This person will run the general operation of the Physiotherapy Department in coordination with the Medical Director. Will lead a team of approximately 3 other Physiotherapists.
• Physiotherapists – To work under the guidance of the Head of Physiotherapy. Must have experience working with spine patients in a rehab or physio clinic/hospital.

The place is called Wooridul Spinal Centre Northern Emirates (WSCNE). It is a joint venture between  www.wooridul.com and www.mubadala.ae

Mubadala is a government (UAE) sovereign wealth fund basically. They have vast amount of money and are tasked to use it wisely. This venture will start in Dubai and eventually have a dedicated hospital in Abu Dhabi. The clinic is Dubai will stay though. Operations initially will be done in another hospital in Dubai until their place is set yup in Abu Dhabi.

All inclusive package in UK pounds of between 4-6000 per month (the accommodation portion of this is around 2000 per month), dependant upon experience etc. In addition to this also are business class flights for self and family once per annum to point of hire, schooling allowance for up to 3 kids.

A single person would obviously be ideal but, as you can see, there is the opportunity here for a family also.

PS First round of interviews on May 31^st (telephonic option available).

Kind regards

Paul Johnson

Director

Outsourcing Consultants

Mobile: +971 50 4988 073

Tel:  +971 4 359 7282                           Fax: +971 4 359 7272

P.O. Box 71814                                     Dubai, United Arab Emirates

Email: paul@outconsult.com Website: www.outconsult.com

Connect with me through linkedin

Follow me on Twitter

Visit my blog: Outconsult

Skype Address: paul.johnson681

Outsourcing Consultants on Facebook

Enjoy the clinical challenge
David

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Current treatment options

May involve modalities such as;

Ultrasound

Interferrential

Laser

Deep transverse frictions

Acupuncture

Manipulation

Strengthening exercises

Epicondylar clasps

Corticosteroid

Surgery

Not surprisingly most of the modalities do not come out particularly favorably when subjected to rigorous critical review with the exception of indication’s that laser may be beneficial.

There was definitive and important research regarding the role of corticosteroids in chronic lateral epicondylalgia.  Suffice it to say in summary that the initial acute symptomatic relief frequently obtained with corticosteroid infiltration is associated with a relapse rate of up to 70% at six month review.

In essence, Professor Vicenzino highlighted the role of specific manual therapy interventions to continuously assess function on a test / re-test basis using a grip strength measure following the application of manual therapy techniques.  We have discussed in previous posts the relevance of using grip strength measure and there was particular emphasis on the use of pain free grip strength as opposed to maximal grip strength as a measure of treatment effectiveness.

The preferred manual therapy interventions involve the use of mobilisation with movement (MWM) as originally pioneered by Brian Mulligan.  Bill has developed a manual therapy intervention protocol based on a sequence of specific MWM techniques with the assessment of pre and post treatment pain free grip strength as the measure of effectiveness.

If you get a chance I strongly recommend attending one of these workshops to learn the specific handling techniques and the sequence for application, which he has developed.  Some of these techniques were described in a master class paper published in Manual Therapy in 2003.  We also covered soft tissue taping techniques to unload painful tissues for cases in which the condition was so irritable that manual therapy did not offer significant relief of symptoms.

Much of the conventional wisdom regarding the etiology and pathology of this notoriously resistant condition was challenged in discussion and certainly provided an ample volume of data from which to review our clinical practice.

Some interesting concepts regarding muscle imbalance between wrist extensors and long finger extensors was also presented with a tantalising observation that chronic lateral epicondylalgia sufferers display reduced wrist extension bilaterally on grip assessment.  I wonder if this will become part of a pre-employment/pre-participation screening profile?

We also covered specific exercise prescription as part of a corrective regime and reviewed the convincing data indicating that six to eight weeks of weekly, structured, supervised, progressive exercise is an essential component for effective outcomes.

The day concluded with a lively Q&A session and Bill fielding questions with great efficiency and refreshing Australian directness.  Some of this discussion veered into topics we have discussed before on this blog, regarding therapist creditability and the delivery of effective care.

Suffice to say it is essential that our interventions demonstrate measurable effect and are associated with a positive response (even if we don’t fully understand the response mechanism). The implication is that we therapists must wisely choose the selection of techniques on the basis of their most likely efficacy. In the real world we do not have the luxury of repeatedly trying different techniques in the hope of improving a patient’s well being.  They simply won’t hang around to allow us to run this type of experiment.

All in all a very worthwhile day, some excellent practical clinical information obtained.  Again I recommend you keep an eye out for Bill’s work and also for his forthcoming coming publication on mobilisation with movement, which is due out in the end of 2010, published by Elsevier.

Enjoy the clinical challenge.

David

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Post tags: Acupuncture, chronic lateral epicondylalgia, corticosteriod injection, Deep transverse frictions, Epicondylar clasps, Interferrential, laser, manipulation, manual therapy, mobilisation with movement, pain free grip, Physical therapy, physiotherapy, Strengthening exercises, Surgery, ultrasound

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This analogy applies to both sides of the patient/therapist equation.  This is something we have discussed previously on this blog - ( managing poor prognosis).

Can we safely assume that the normal measures of worsening pathology from a patient’s perspective are:

Signs of worsening Pathology

Increase in severity of p

Slowness to resolve

Resistance to previously successful treatments

Progressive functional impairment.

Expanding area of pain.

This cluster of markers should be used to alert the therapist and need to be incorporated into the report of clinical findings.  Incidentally the Chiropractic profession place huge emphasis on the “Report of findings” component of clinical examination – so much so that it is often the main element of follow-up consultation’s preceding initial assessment and examination.  One may argue that the motivation here is to get patient “buy in“ to a protracted course of treatment leading to a wellness regime, which is profit driven rather than patient centred – but that’s a discussion for another day.

Suffice is to say that it is considered an essential component in order to establish collaboration with a patient to comply a recommended management regime.  As Physiotherapists we are often faced with the clinical challenge of determining the pain generators and the mechanism of symptoms. Frequently this thought process is not relayed to the patient.  One can argue that patients only want to know the conclusive findings at the end of your examination but in more recent years they have tried to integrate a discussion on differential diagnosis and indicators for ancillary /elective investigations when necessary or appropriate.  I note an increasing trend of blanket testing without rational selection based on clinical findings. This is a symptom of defensive practise, lazy clinical reasoning and wasteful f resources.

Whilst not all patients may need this reassurance it does have the effect of demonstrating that the examination has considered all potential options and drawn a conclusion based on the clinical examination and history.  I think many patients find this a reassuring strategy.  This does not mean trying to blow the patient away with self-indulgent technical jargon but is a question of balance in delivery using language relevant to the patient (and yes this is a judgement call!).  As I have a tendency to over analyse I plead guilty to this on occasion, certainly more so in my formative clinical years but I think I’m cured now?

Another important factor in achieving effective communication of what may essentially be “bad new” is to correlate the functional impairments between previous and current episodes and to define that in terms of known pathologies.  This maybe alerting a patient to increasing morning stiffness associated with progressive degenerative change or reduced tolerance for sustained loading i.e. sitting, gardening indicative of changes in tissue biomechanics / intolerance.

For more clearly defined pathology the fall back position of supplemental radiology (largely to confirm a clinical diagnosis) can be helpful but only in the cohort of patients where surgical intervention is being considered as an alternative management strategy.  Of course many of the patients we see are at some point along the pathological continuum and may end up as surgical candidates but electing not to do so unless forced.

From a therapist’s perspective identifying and recognising stepwise deterioration in established pathology is important for credibility because promising a cure and failing to deliver has obvious implications for perceived competency.  If we add to the cocktail the fact that predicting response to treatment is not an exact science we are frequently left in the situation where we define components of a condition which we think are most amenable to treatment and then set ourselves a target of perhaps three to four treatments to observe useful worthwhile change as a result of intervention.  Observing the response over this time gives an indication not only of the potential for recovery but the rate at which it may occur.  It does not of course give information as to what the full functional capacity may transpire to be.  These are the dilemmas and challenges which we clinicians wrestle with daily and what make this job so exciting.  Feel free to share your thoughts as always.

Enjoy the clinical challenge.

David

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Post tags: Conditions and Diseases, defining prognosis, Few Good Men, Health, Jack Nicholson, pathology, signs of worsening pathology, Tom Cruise

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I recently had cause to reflect on a clinical situation where a patient was dissatisfied with the treatment he had received from me on the basis that his condition was not responding in a way that it usually had done. Notwithstanding the somewhat “tense situation” which arose naturally I was at pains to explain that the current situation did not reflect his previous experiences because the clinical indicators suggested that the pathology was somewhat different. Although ultimately I was unable to convince the patient of this situation it got me thinking of similar experiences (of which there have been many over the years) and how we can manage the situation most effectively.

Just so we can be clear about the type of patient I’m talking about this and was a 62-year-old patient with a history of recurrent intermittent low back pain and transient radicular pain without gross neurological deficit. He had undertaken frequent short courses of manual therapy under our supervision usually as a “self-directed intervention” rather than following a full rehabilitation protocol but nonetheless appeared happy with this strategy. He re-presented having had some cardiac procedures which required immobilization over a two-month period and had reported that his back symptoms progressively deteriorated following return to more normal activity. He complained of increasing intermittent radicular pain again without neurological deficit and on examination he showed all the features of degenerative lumbar spine disease – most likely from lateral recess encroachment and probably some modest degree of spinal stenosis.

In my experience it is usually a case of managing symptoms with conservative measures until a surgical option is the only reasonable way to alleviate symptoms.  Being no fan of unnecessary surgery I don’t recommend this course of action lightly but usually on the basis of a failure to respond to appropriate manual therapy or drug management.

Reflecting on the dynamics of our communication the obvious question to ask are whether this was a failure in my own communication or a failure in the interpretation of information by the patient. Perhaps as clinicians we tend to “blame the patient “in these situations although some personal introspection is warranted regardless of how uncomfortable it may be. Systematically analyzing how we can relay that a flare-up of an underlying pathology represents a deteriorating situation I think there are a number of markers which we should be aware of to ensure that we relay information to patients effectively.

Key communication objectives

1. Defining the contributing sources to symptoms i.e. joint, nerve muscle etc.

2. Defining the likely mechanisms by which these structures are become sensitized ie degenerative, traumatic, inflammatory, mechanical, overuse.

3. Identifying the functional limitations and comparing them with previous functional restrictions.

4. Matching the functional restrictions to symptom characteristics and the liking known pathology.

5. Identifying alternative treatment strategies (if they are available).

6 Identifying possible variations in manual therapy procedures or muscle strengthening techniques which may be at variance from previously used treatments with clear indications / clarification as to the choice of selection of technique.

7.  Clear indications for abandoning treatment techniques which may have previously been successful but are either inappropriate or contraindicated due to the current circumstances.

The more I thought about this scenario I recalled the frequent patient reports of initial episodes of back pain being resolved by miraculous manipulation or specific procedures  carried out at the time of an acute flare-up. I can’t help wondering if such marvelous procedures were so effective why have these folks come to see me? Have all of these “gurus” passed over to the great clinic in the sky?

Feeling somewhat inadequate and under pressure to perform, one would obviously like to match these miracle cures allegedly administered in times past – although I must humbly knowledge that I rarely have such experiences on a day-to-day basis. Maybe because the majority of my caseload is chronic / recurrent mechanical low back pain I should not have such expectations?

Today’s discussion is familiar scenario  in that the clinical challenge is identifying which flare-ups are leading to incremental deterioration in a condition and which are just part of a degenerative pattern which can be maintained at the current state with optimize  function within expected parameters. Therein lies the challenge of defining parameters – but that’s for another day.

I do try to make patients aware that it is not an exact  science  and that there are a number of variables which need to be a integrated when making a decision as to whether one is looking at a progressive stepwise deterioration in a degenerative problem or whether we are out of “physiotherapy options” to restore function.

Obviously these objectives did not materialize in this case – just goes to show that you can’t please everybody all the time.  Of course it would be easy not to treat patients with degenerative problems (and avoid potentially challenging interactions) on the basis that they have established pathology and the condition is not worth treating – a far too common assertion in my view! I must confess if I took that perspective I would probably run out of patients to treat and I’m convinced that there are there would be people with an inferior quality of life having been denied the option of improving their function within parameters of established pathology. This, of course, is not what researchers, health authorities or insurance companies want to hear but is the clinical reality which many of us operate.

Enjoy the clinical challenge

David

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Post tags: Communication, Health, interpretation, Musculoskeletal Disorders, Patient compliance, patient disgruntlement, patient dissatisfaction, spinal degeneration, Spinal stenosis, Surgery, worsening pathology

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Commercialisation of information exchange – let the buyer beware.  Whilst recently reviewing my CPD manual I was reminded of weekend courses from times past and memorable conferences in not so exotic places.  Some were remembered more fondly than others and careful reflection revealed why.  When listening to any presentation it is easy for the listener to judge the willingness of the speaker to exchange useful information or whether they are guarded/ reserved about sharing.  This was highlighted recently at a Movement Dysfunction conference where several of the keynote speakers gave overview presentations which were essentially commercial pitches for attending workshops, buying products or purchasing books.

Whilst this has no doubt been the case since time began the overt commercialisation was striking, as was the superficial skimming of the topic under discussion.  It is easy to see the potential conflict which can arise. Academics who produce published research have effectively already received their payment as part of the their academic salary and therefore have no purpose in “re-purposing” information which is available from published resources.

Conversely when there is substantial “back-end” financial gain from accessory products then one can clearly see the conflict between exchanging information and withholding with a view to secondary profit.  Perhaps ultimately the speaker selection process and scope of content need to be more rigorously defined in advance to prevent these “pitch fests” becoming the norm.

Reflecting on my 25 years in Physiotherapy I tried to trace the chronological sequence of this commercialisation and drew the following conclusions:

The simplest strategy is mis-naming a course as of intermediate or advanced content when in fact it is not.  Whether that is a reflection of the lecturer’s perception or the natural variance of course attendees is debateable.

The next development was the multiple module model, where compulsory attendance of initial (introductory) weekends were required prior to completing parts one, two and three etc. even if the material has been covered via alternative methods.  From a lecturer’s perspective one could argue that having a cohort of students covering similar material at each stage is a desirable objective and ensures a smooth flowing of information exchange.  However, in practice there is frequently significant padding and review of the previous modules in order to fulfil the allotted time.

Another strategy is to use an attractive course title to lure subscribers and then present material on a different topic.  I had a memorable three days some years ago when an International Lecturer came to visit these shores to talk about the “Oblique Sling System” and its mechanism in pelvic stability.  After two days practising core stability assessment and reviewing theory it became clear that any systematic teaching of the sling support mechanisms was not going to occur and if we wished to pursue this topic further then the videos would be available for purchase subsequently.  Needless to say there was general dissatisfaction on that weekend!!.

Another more recent trend I have noticed is of course outlines being general without specific timetabling of content or pre-course reading.  This has the advantage of allowing the Lecturer meander across a broad number of topics whilst not making it particularly obvious that they are deviating from an outlined schedule.  As a participant trying to decide whether the course is worthy of committment, is very hard to make judgements other than to “take a flyer”

I raise these issues here because undoubtedly increasing commercialisation is not going to go away anytime soon. We need to be able to make an informed decision when we pay for a course or conference that the information we are going to be exposed to is complete or is it  merely an overview which will require further measures in order to ascertain useful, practical information to apply clinically.

How many of you felt “short-changed” by conferences or seminars you have attended?

Am I being unrealistic to expect open information exchange in a forum of professional colleagues?

Please share your thoughts.

Enjoy the clinical challenge.

David.

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2010. | Permalink | No comment | Add to del.icio.us
Post tags: Academia, Academic publishing, Communication, Information, Social sciences

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