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

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2010. | Permalink | 2 comments | Add to del.icio.us
Post tags: Communication, Health, interpretation, Musculoskeletal Disorders, Patient compliance, patient disgruntlement, patient dissatisfaction, spinal degeneration, Spinal stenosis, Surgery, worsening pathology

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The typical research methodology examining cervical muscle function in neck pain involves strength and endurance testing using various forms of dynamometry devices.  Deficits in isometric strength and endurance have been consistently documented for the cervical flexors, the cranio-cervical flexors and the cervical extensor muscles.  Importantly, neck pain sufferers exhibit a poorer steadiness of contraction at low load (20% of MVC) compared to controls, which may reflect other muscle fatigue manifestations such as muscle tremor.

In accordance with the general theories of muscle imbalance the theoretical model suggests an impairment of deep cervical muscle function produces a secondary overload in synergic muscles – which appears what we frequently observe clinically.  This would appear to correlate with patient subjective reports of difficulty in sustained postures, classically keyboards, reading and driving.

More subtle forms of investigation into muscle function attempt to explore the efficiency of motor control.  This relates more specifically to the timing and intensity of synergic muscle function and the appropriateness of activation for a given functional task.  One of the fundamental principles of an efficient motor control is the efficiency of motor recruitment whereby there is:

1)      minimal extraneous muscle recruitment for the task in hand.

2)      optimal force generation specific to the task at hand

3)      sequencing of motor unit activation in accordance with the level of demand and

4)      deactivation / switching off of the activated groups following execution of the task.

In clinical practice the analyses of these variables is not always possible to explore in depth so we are left extrapolating information from the results of more primitive strength/endurance/alignment/length-tension relationships.

One of the biggest challenges that we face clinically is evaluating the contribution of the axioscapular musculature as a contributory mechanism to cervical pain.  This is compounded by the fact that frequently patients report exacerbating activities that involve the simultaneous challenge of the neck and use of the arm i.e. reading, keyboards and driving and therefore the challenge clinically is to determine which mechanism is the dominant driver.  The conventional wisdom is to view the most superficial muscles of the posterior neck as prime axio-scapular muscles i.e. trapezius and levator scapula and to evaluate their function in the context of efficiency of scapular/arm control on the basis of a separate intrinsic muscular control system for the neck.  This of course is a hypothetical construct (originally discussed in Bergmarks paper postulating local and global muscle function) but one, which seems to have some relevance clinically, at least to provide a guiding framework for intervention.

Because the timescale to improve muscle function both around the neck and the scapular area is likely to extend over weeks rather than days it becomes a management priority to determine the most legitimate target to treat.  I find kinesio tape to be of great assistance in this regard because it is straightforward to apply a supportive taping technique to either the cervical spine or scapular and assess the response on the next patient review.  This is what the renowned Australian Physiotherapist Bill Vicenzino calls a “treatment direction” test and is very worthwhile applying in the clinical setting.

It is also much easier to achieve patient compliance with specific (often subtle) corrective therapeutic exercise if it can be demonstrated that their symptoms are eased by changing the pattern of muscle activation artificially and therefore provide an incentive to comply with the rehabilitation regime to reinforce this.

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2010. | Permalink | 4 comments | Add to del.icio.us
Post tags: Kinesiotape, Muscle, muscle function, Musculoskeletal Disorders, Neck, neck exercises, neck muscle function, neck pain, neck pain causes, neck pain treatment, Scapula, Trapezius muscle

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