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Barrett's Forums This discussion is devoted to the latest advances in neuroscience and the clinical phenomena it explains.

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Old 31-12-2005, 07:10 PM   #1
Jason Silvernail
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Default The Perfect Pain Patient?

So I recently was a Clinical instructor for a DPT student rotating through my clinic. She was excellent, and made me realize how far we had come as a profession in the 8 years since I had graduated. It left me with no doubt that the APTA had made the right decision in moving toward a clinical doctorate.

Anyway, I was doing my best to help her and inculcate in her the principles of EBP, the use of Clinical Prediction rules, and classification of patients with the available tools to help their outcomes. Also, I was busy trying to dispel the many myths that PT schools still place in our students' heads, like: posture and pain being correlated, over-reliance on biomechanics and "dysfunction" to explain painful problems, lack of pain physiology education, and the unwillingess to provide a lot of manual care (especially manipulation - the use of which places me in the minority here, I realize).

I want to say "THANKS" to Barrett, Diane, and Nari, without whom many of these myths would still be in my head as well.

Anyway, a few weeks ago, we had what I would call the perfect pain patient.
She was in many ways prototypical: mid 40s female, a few traumas here and there (motor vehicle and slip/fall) many, many episodes of acute on chronic pain in neck and low back with radiation to some limbs at various points. Had been through multiple rounds of PT, Chiro, PM&R, Pain Managment, etc, etc for years and years.

After a history (during which I could feel my student become overwhelmed) the patient began to set some groundrules for us, her caregivers. I am paraphrasing here, so bear with me: she said that she didn't want to get any stretching exercises, because she had done a lot of those, and she was more flexible, but still had pain. She didn't want to do any walking on the treadmill, because it just made her sweaty AND painful. She didn't want any strength exercises, becuase she was stronger, but still had pain. She didn't want "the cracking, like the chiropractor" because it only gave her temporary relief, and became less and less effective as time went on. She didn't want the epidural steroid injections anymore, either because they hurt to get them, and didn't seem to change anything. She said she had had tons of MRIs, Xrays, CT Scans, and such things, and asked me if the "arthritis and disk problems" found on such studies could ever be "fixed" by anyone, or would she have to live with her pain forever?

She even said that she was tired of people (she mentioned the physiatrist specifically) telling her she was better because she could reach further down toward her toes (as in bending forward), do more repetitions of exercises, or walk longer on the treadmill. She said people were ignoring her PAIN, and that is what she wanted help with!

A few years ago, I would have groaned and felt I did not have much to offer this patient. However, I feel the recent advances in neurobiology and pain education research give us a lot of directions to go in to help a patient like this.
I silently wished for a videocamera and a blank consent form, as I feel what she had to say has a lot of value for those of us in Physical Therapy.

Before I tell anyone what approach I took, I wanted to get everyone's feedback on this so far.
And also, what would you do?

Yes, I fully expect my question to be answered with more questions...
J
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Old 31-12-2005, 08:13 PM   #2
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Jason,

Perfect pain post!!

Perfect example of where we go wrong sometimes with the idiosyncracies of managing pain. We do tend to ignore pain in the sense that we can "measure" it, treat offending 'causes', real or imaginary, and still discover with surprise that it's there, despite traditional approaches which "work" for some patients.

Approach? My first instinct is Simple Contact..she sounds ideal for it. Criteria? Quite likely an abnormal neurodynamic...

I might let Barrett answer that one...

But, in the days of pre-Simple Contact, I would have:

Looked at Yellow Flags, for the purpose of possibly understanding why she is in this situation....may not be relevant, but often is.

Tested for Slump, SLR, ULNT1,2,3,4. Likely to be positive.

Treat with the testing procedures...carefully...
AND, simultaneously:
Educate++ on the origin of this pain, its physiology and behaviour under various circumstances (eg, when lying down, trying to sleep)
Especially emphasise that this pain cannot HARM her, physically.

Do a Moseley test (I think that is around somewhere on the BB, if not, can post it) to test the level of understanding as the result of education. This is for her benefit, not mine.

Tell her to go and do whatever she wants to do - and that is anything at all -and help her get there. (However, if she aims to go climbing Mt Rainier, I would encourage a more realistic goal).

See her only once a week or fortnight, giving her food for thought and time to digest, without 'interference' from me.

I wouldn't touch vertebrae or muscle. Soft tissue work (especially the kind that Diane does) may help in my attempt to talk to her CNS.

Question: What sort of language does she use when describing her pain?

More later


Nari
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Old 31-12-2005, 08:43 PM   #3
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Does her pain change with movement and positioning?
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Old 31-12-2005, 09:33 PM   #4
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Thanks for posting this Jason, and you're welcome for earlier provision of any bits of virtual conversation that you may have read/felt that came to you from me.

Isn't it classic that all her practitioners declared her better by measuring some observable thing about her, but ignored her complaint? (Sound of me ripping out my hair.)

Kierkegaard said, "The majority of men are subjective towards themselves and objective towards all others - terribly objective sometimes - but the real task is in fact to be objective towards oneself and subjective toward all others." I think that's awfully good advice for therapists. Time to enter the woman's "movie" or narrative with her, and start to look for clues with some attentive resonance (see Cells and Stars for what that is).

Simple contact, like Nari said, would be a great tool, something she could work on herself.

Unlike Barrett, who finds it a nice way to hold a boundary between himself and his patients, I've found that on the contrary, it ends up opening up people and their stories quite rapidly, moreso and faster sometimes than I feel I have the capacity right now (winter) to handle. So I use it sparingly for people, saving it for ones who I could describe exactly the way you've described your gal.
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Old 31-12-2005, 11:04 PM   #5
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What color car is she driving? Okay, just kidding.

The physiologic signature of neural irritation is sympathetic dominance, so I'm wondering whether or not your patient is commonly cold. This might be related to her breathing pattern as well.

I'm also wondering about the resting posture of her legs when she lies supine. What you see in the photo linked below is what I look at. When the nervous tissue is pulled tautly (for lack of a better term), what you might find is relative internal rotation and/or adduction in the hips, usually the more symptomatic side is easily seen to be more adducted and the toes point toward the ceiling. This is derived from Breig's work published in "Spine" a few years ago. The second link demonstrates the position more commonly seen in right sided pain.

http://www.flickr.com/tools/uploader...e?ids=79939335,


http://www.flickr.com/tools/uploader...e?ids=79940389,
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Old 31-12-2005, 11:09 PM   #6
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(Barrett, any chance you could post the pictures again?.. all I get is a sign-up sheet for flickr.)
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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

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Old 31-12-2005, 11:21 PM   #7
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Try this:

http://www.flickr.com/photos/35469288@N00/79939335/

And then this:

http://www.flickr.com/photos/35469288@N00/79940389/

I don't know if these will work for you or not. As they say in the Army (and Jason will know about this), such things are beyond my pay grade.
Attached Images
File Type: jpg 79939335_2b71609da8.jpg (72.9 KB, 46 views)
File Type: jpg 79940389_e0d5a2fae7.jpg (73.8 KB, 33 views)

Last edited by bernard; 01-01-2006 at 11:00 AM. Reason: added pictures
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Old 01-01-2006, 12:02 AM   #8
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(Much better, thank you!)
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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 01-01-2006, 02:14 AM   #9
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Hi Jason,

Quote:
She said she had had tons of MRIs, Xrays, CT Scans, and such things, and asked me if the "arthritis and disk problems" found on such studies could ever be "fixed" by anyone, or would she have to live with her pain forever?
I always look out for comments like this because they offer a glimpse into the belief system of the patient regarding their pain that I think it is very important to address.

I had a very similar patient to this recently and I started where I gather you started, with education, specifically addressing her beliefs and mythconceptions (unfortunately she had even been told she would simply be managing her pain forever). After our very long talk I could see in her face and body a sense of relief and softening. She came three times and is doing fine now.

It's probably no surprise that I would use SC also, though I would want the same questions asked by Jon and Barrett answered before I started.

Like Diane I also find that it is a very rapid way of opening people up. It seems that as you provide a environment for authentic physical expression then authentic emotional/mental expression emerges also (never of the Barnes type though). However I am not so interested in the particular content, only that it allows them to become aware of things in their life they may desire to change (stressful commitments, habits, situations etc). Like Nari, I prefer if this happens without interference -I'm not trained to do much more than that anyway.

I can't wait to hear your approach.

Luke

Last edited by Luke Rickards; 01-01-2006 at 02:20 AM.
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Old 01-01-2006, 02:41 AM   #10
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Hi Luke

I wasn't referring to psychosocial history in particular re the use of the word "interfering" - but rather avoiding a verbal or tactile "interference" with her plans and goals to get herself better.

If therapists would occasionally butt out of the "I have to do something physical" line of thinking, and hand the ball over to the patient's court...it might be surprising what happens. Of course this can only happen with pain ed., passed on at the current level of understanding.

Something that haunts me post- Nanaimo is the notion of PTs 'doing nothing'...but what they do when they do nothing is extraordinary.

Jason...tell us your management plan soon...

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Old 01-01-2006, 02:44 AM   #11
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Nari,

I know you weren't. I am talking about the same thing.

Luke

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Old 01-01-2006, 02:49 AM   #12
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Ok... I misunderstood the sequence of your last paragraph.

Nari

PS - a disgusting day in Sydney and Canberra today?...why don't we live in the Northern Hemisphere???
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Old 01-01-2006, 02:52 AM   #13
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44'C!!! Ppphhew. I agree, though there is a slight sea breeze at Bondi.

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Old 01-01-2006, 05:39 PM   #14
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Well, I've only seen her once, so probably cannot post a case-study type of thing for anyone, but here goes:

Questions first:
-She was sympathetic dominant, one of the things I have trained my student to look for. The student picked it up as well. Definitely a shallow breather, but didn't ask about being cold frequently. (forgive me, I'm a beginner)
- She did have an IR'd LE on her painful side
-She did have neurodynamic issues on SLR B and in ULNT on her painful side

Approach:
- PAIN EDUCATION. I had my student work with her for about 45 min, while I handled the rest of the caseload that morning, b/c she had so much to learn from this patient
- Diaphragmatic breathing and an overview of how the autonomic state can impact the pain experience.
- Discussion of using her toes as a "dial" to dial down her pain by moving more into ER through breathing/relaxation
- Brief overview of ideomotor motion and how to go about starting it
- She worked on the beginning stages of the deep neck flexor activation exercise
-She said she had a really busy holiday, but would get back to me when it was all done. I hope to see her again.

Ideas? Feedback?


J
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Old 01-01-2006, 09:20 PM   #15
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Jason,

a few queries:

What is your reasoning for teaching deep neck flexor exercise?

Try neurodynamic movements (as per Shacklock et al), unilaterally and bilaterally? If the pain disappears, it enhances the education process; a perfect example of the nature of pain.

She certainly has criteria for an abnormal neurodynamic.

Good luck. (I don't know why that is such a common phrase - luck hasn't much to do with it!)

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Old 01-01-2006, 10:06 PM   #16
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Quote:
PAIN EDUCATION. I had my student work with her for about 45 min
Hi Jason,

What does "work with her" mean? I get the general educational things that were covered, I think, but tell us more about the ideomotion aspect of treatment.

Last edited by Jon Newman; 02-01-2006 at 04:36 AM.
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Old 02-01-2006, 10:34 PM   #17
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Nari-
I used the deep neck flexor exercises because she had a history of occipital headache and she had chronic neck pain. This exercise progression has shown to be of benefit for these subgroups of patients. I think the proposed mechanism of increased use of deep cervicals and decreased use of superficial cervicals along with mobilization of posterior neck structures (where she was TTP) is a fairly good reason to select that exercise. It at least gets her to move the painful part and I always teach it in conjunction with diaphragmatic breathing, so I think it might help to reduce her sympathetic dominance as well.

Jon-
I did not get too far in my work with her, as you might imagine, the history alone was extensive, so I didn't get into specific pain relieving motions. I think generally she made mention that static postures and prolonged activities worsened her pain (go figure) but no specific movements that she could remember.
On ideomotion: we discussed it briefly in terms of the automatic motions designed to relieve pain. I gave her the "hand on the stove" example of pain attempting to produce movement, and the example of children who shift to find comfort naturally. I discuss the diaphragmatic breathing and lowering autonomic state and to relax and allow the body to move whichever way it naturally wants to.

I think at this point, I am reaching the end of my expertise in terms of encouraging and eliciting ideomotor movement.
I have tried to do this manually, and I always end up sitting there feeling foolish, while the patient waits for me to do something. Even after a good intro into what it is we are trying to accomplish, I don't seem to have much luck getting those characteristics of correction that Barrett writes about and that I have asked the patient to look for.

However, I expect to see her again, and to quote King Arthur (played brilliantly in 1974 by Graham Chapman): "So anything you could do to help, would be.......well.... helpful."

J
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Old 02-01-2006, 11:00 PM   #18
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Jason, try the following:
1. Stand behind her (if she's tall and you aren't, have her sit), and place your hands very gently on both sides of her head. Hint: have warm soft sure hands and do not press them into her bones, or wiggle them around. Just lay them on top of the skin. Tell her you are only going to touch her skin with them, not "do" anything with them.
2. Ask her to let herself go inside for a moment, and "imagine" a way to "move in a way that will relieve pain," and then feel free to go ahead and let herself start to move that way, then let herself continue the movement.

Do 1. and 2. simultaneously.
Wait for three seconds. OK, wait as long as 5 seconds. Something will start to happen. The eyes will close and roll back, the head starts to bend slowly backwards into extension or off to one side or other. The movement will proceed from her own vertical axis. She will be in full control but will seem a bit hypnotized or something. She isn't, she's just moving from a nonconscious place although she will be completely aware of you and of herself. She might think you are moving her. You aren't - so tell her so. Tell her if she asks, that she is in full charge of this, that it's coming from inside her own motor areas of her brain. Try to stay in contact, on the lengthening side if you can. Only contact. Don't try to take over or help. She'll keep going as long as necessary, 5-10 minutes probably. New parts of the spine will add themselves to the movement. She may bend in all sorts of novel ways. Don't worry, let her go. To her it will feel effortless. Ask her if she feels warm anywhere. She will probably say yes, in general, or yes, in some body part. Let her continue until she stops on her own if possible, or, if you run out of time, you'll have to interrupt by saying something like, "..that's great.. we have to stop unfortunately because we're at the end of our time, but take a moment to complete this last little piece." Save a minute or two to check through the little list of 4 characteristics of correction, WESS. (Warming, effortlessness, softening, surprise.) and to reinforce that the patient produced this movement all by herself out of her own genious brain, and that she can do this whenever she wants, that she doesn't really need your hands to accomplish it although it's been a help to get her started.
If you don't sense any movement after contact for 5 seconds, move your hands to the shoulders. Elbows. Outside of the hips. Lateral contact points over bone where skin has the best reception. Good luck.
If you think you need to practice it first before trying it on an actual case pick your wife, or a child, or a co-worker, or a receptionist. Basically they need a body, a nervous system that is intact. They don't need to be in pain to notice they feel good doing this.
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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

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire
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Old 02-01-2006, 11:30 PM   #19
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Jason,

Diane has given a wonderful description above. Can I add, if you get nothing after 5-10 seconds with the hands on either side of the head, try one on the forehead and one on the occiput - very gentle. I find this contact the fastest way in. You really don't need to explain much to get movement. In fact, I leave the explanations until they have started to move or after the session. I think the surprise factor , which is greater when there has been no explanation, is a valuable part of this approach.

Try Diane's suggestion: come behind a seated friend or receptionist (someone who won't feel uncomfortable with unannounced touch), place your hands very gently/comfortingly around their forehead and occiput, then wait. Be ready to follow them at the first incling of movement.

Luke

Last edited by Luke Rickards; 02-01-2006 at 11:41 PM.
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Old 02-01-2006, 11:35 PM   #20
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Hi Jason

I can see the rationale behind the use of deep neck flexor activation, and would be interested in how she reacted to the movements. I have found, sometimes, it aggravates a sensitive CNS, but not always.

You mentioned she reported that static and prolonged activities increased pain; makes perfect sense when you think CNS and not muscles. The brain dislikes lack of movement and prolonged activity, depending on the activity, and will provoke a "OK, stop doing this..time's up for tolerance threshold" when sensitivity has contributed to a low adaptive potential. Jon can answer this one better, most likely.
Can't add to Diane's description of eliciting corrective movement..except to emphasise that the touch is light, non-invasive and, I think, accompanied by silence on your part after you have given the 'permission to move'. Have you tried it on youself, without or with discomfort/pain present?


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Old 03-01-2006, 12:07 AM   #21
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Jason,

Your description of that particular treatment session sounds very familiar to me as it describes my early practice. Diane and Luke's ideas are great.
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Old 03-01-2006, 02:42 AM   #22
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Wow...this is an interesting discussion! I have to admit that my knowledge of Simple Contact is rather poor, but I am still learning new things each day...especially from reading y'all's (forgive me I'm a Texan) posts.

Jason's patient in question seems very similiar to a patient I began treating on12/28/05 with a diagnosis of "left SI pain and bilateral knee OA". She told me she had a history of LBP and bilateral LE pain and occassional numbness. Per the patient, "I have that neuropathy in my legs and I take Oxycontin, etc...". For lack of a better explanation, she is a mess.

Three days later, I see that Jason posts this topic and a light bulb went off inside my wee cranium. I thought to myself, "The next time you see this patient, look at how she presents in supine, check extremity temperature, breathing patterns, etc.". Well, I did just that today and finally was able to see most of what Barrett has been referring to in regards to sympathetic dominance. I know...I'm a slow learner, but at least things are suddenly fitting into place and making sense. While in supine, her left LE was internally rotated and slightly adducted with her foot towards the ceiling, left foot was slightly cool to touch compared to the right, and was breathing with her chest as opposed to her diaphragm. After this, I took her into a private room and UNLOADED on her left SI joint...wham! Just joking...LOL! I tried my best at performing this effortless technique of Simple Contact, of which I have no experience except from what I've gathered on this site and formerly R.E.

I placed my hands on her left hip and knee, moved down to her knee and tibia, and finally her knee and lateral malleolus. I waited 3-5 seconds at each position until I began seeing her left LE externally rotate and slightly abduct. Prior to all of this, I made sure she understood what I was going to perform and provided her the best explanation I could of ideomotor movement and even used the same example Jason did of students sitting in class changing positions. She didn't report a dramatic decrease in pain, but did report some warmness and some decreased pain.

I forgot to mention I preceded this treatment with some nerve gliding, i.e. SLR with DF/INV/EV and that gave her some relief as well. All in all, I felt really good that something gave her relief from her pain. I have a great deal to learn, but this was surely a start for me. "Left SI pain and bilateral knee OA" seems like the least of her problems. An "abnormal neurodynamic" seems more appropriate for her.

Thanks for allowing me to ramble!
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Old 03-01-2006, 04:18 AM   #23
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Diane,

Do you normally treat with S.C. in the standing position or does it differ from patient to patient? Probably a silly question, but I thought I'd ask. How about the rest of you? Shouldn't the patient be in a position that is most comfortable for them during this type of approach?

Thanks!
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Old 03-01-2006, 04:22 AM   #24
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Chris,

Every position has its advantages. I don't seek comfort, I seek freedom.
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Old 03-01-2006, 04:29 AM   #25
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Barrett,

I figured as much in reference to positions. 'Comfort' versus 'freedom'...I need to be careful with my word selection around you, however, I do agree...freedom makes more sense.
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Old 03-01-2006, 04:32 AM   #26
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Chris

It doesn't matter.

Remember we are not looking at 'relaxation' and 'comfort' as the definitions that everyone is/was taught, ie to 'loosen' muscles etc.
Ideomotion is an example of what the brain has wanted to do perhaps for years and has been prevented from doing so by all sorts of constraints and commands from the external environment.

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Old 03-01-2006, 04:39 AM   #27
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Hi Chris,
I treat with people either sitting or standing. I let the patient choose. I usually stand on a little stool behind the patient because I'm shorter than most, if they stand. I'm more comfortable with them sitting, but I don't let my own preference interfere with their choice. (Your post is hilarious by the way!) It's easy to elicit corrective movement isn't it? Even if you are only treating "a leg".. you can practically feel the brain going back to normal.
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Old 03-01-2006, 04:53 PM   #28
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Thanks, Diane, that's a great introduction for me for next time with her.
I will post what happens when she comes in next.
Chris, glad to see you here....

J
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Old 03-01-2006, 07:42 PM   #29
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Glad to see you here as well Jason. It appears, per the little green box underneath the number of posts, that we are 'on a distinguished road'. I'm not sure what that means necessarily, but it sounds cool.
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Old 03-01-2006, 07:59 PM   #30
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You know, Chris, I did not notice the little green box until you mentioned it.
Are we all on a distinguished road? Must check....

I used to think quite often that I was on a road to nowhere. with physiotherapy. At least now there are some signs up on the road, and I can forget the map more and enjoy the territory...

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Old 06-01-2006, 02:10 AM   #31
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Update:
She leaves a message for me at our front desk.
She is concerned that she's not getting the TENS treatment her doctor "ordered".

This is particularly frustrating for me as a PT, because I went to great lengths to explain to her at first visit why the "TENS and aquatic therapy" requested (nobody orders me to do anything clinical) by her physiatrist was not likely to be helpful and that there were other things I wanted to try first. If those weren't helpful, then we would be happy to try the TENS. I did put her in our aquatic therapy program, for general conditioning (sure, that'll work...), because it was requested specifically. Now I feel that all the education I did with her and time spent "explaining pain" and explaining why I understood her pain experience and others did not was....well, wasted. It seems she just wants the magic "pills" recommended by someone with more cultural authority for her.
I really am not bothered by the "order" issue...I just ignore them. I also am not bothered that she sees her physiatrist as more important than me, lots of people feel that way, and hey, that's what the physiatrists love to hear anyway. What DOES bother me is that my investment in time and energy and compassion appears to have fallen on deaf and unappreciative ears.
Of course we've all been through that before, but because of her initial presentation, I really thought I could help her where others had failed. I was excited not for my possible accomplishment, but for her possible pain relief.

I guess I need to remember my buddhist roots, and remember that reality is not the problem, my expectations are the problem....

J
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Old 06-01-2006, 02:13 AM   #32
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Ah-h-h-h... Jason. Win some, lose a lot.
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Old 06-01-2006, 02:40 AM   #33
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Jason

This lady has turned out to be a bit manipulative - because originally she had told you she was 'tired' of her physiatrist. (what IS a physiatrist?) and now she bounces back wanting to know why you didn't do as he/she said.
We have all been caught at one time or the other by the ones who want a quick fix and nothing short of that will do, and they will happily play one health professional against the other.
Sure, she has pain, we cannot deny that, but she might be something of a professional patient...or has incredibly high expectations without effort from herself.
Was she impeccably dressed? Sometimes that is an indicator for someone who isn't being quite honest...

The dreaded 'orders' from doctors are often taken very literally by patients. I am glad to read that you don't take too much notice of them. Occasionally it puts us in a position where we have a cranky patient AND doctor..oh well, usually they get over it.


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Old 06-01-2006, 02:57 AM   #34
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Nari-
A physiatrist is a medical physician who graduated from a residency and passed board exam in Physical Medicine and Rehabilitation.

They are excellent for invasive stuff like epidural steroid injections, etc, but for other "physical medicine" things like the stuff we do...they are thoroughly useless. They usually know in general the patient's options, but can only actually DO a few things, where my "bag of tricks" is much larger.

I will keep everyone posted on how our conversation goes when I can reach the patient.

J
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Old 06-01-2006, 03:04 AM   #35
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Hi Jason,

Again, how familiar things sound. As Barrett has reassured so many people, in his characteristic way, "don't expect to be thanked".

Some food for thought. We have seen many studies that suggest behavioral changes can be quite difficult to make although I don't think any of us need a study to tell us that this is the case. Perhaps your education session was quite useful, just not in the time frame you collected data. Another thing to consider is if there might be some way of delivering information that is more easily digested than the mini-lecture.

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Old 06-01-2006, 03:37 AM   #36
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Crash course in learning theory

Here's the most recent entry from the Creating Passionate Users website. While some of it is not particularly applicable to the PT setting, much of it is.
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Old 06-01-2006, 04:21 AM   #37
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Well, I think I was upset more with her likely pain future (not much different than it is now) rather than her thanking me. Though that would be nice...

In the education vein, I had decided a while ago (this summer, actually after reading Explain Pain) that I really needed to develop a two part pain education class for use in our clinic. I mean, we have Sports Rehab, Lumbar Stabilization, Aquatic Therapy, and Back Education classes, but yet nothing really about pain?

After reading Explain Pain, I thought I had enough to start working on it, but life, tDPT, etc creeps up. I think she would be an ideal candidate for such a program. I envision it to be powerpoint lecture and Q&A, though I'm not sure that's enough different than the "mini-lecture" format I am currently using. I know enough about adult education to know that repetition is key, but after that....stumped.

I get the feeling that less talking overall would be a better approach, but jumping in toward "do nothing" as Barrett suggests is still a bit of a leap for me. Plus, talking is what I am comfortable doing-- ask anyone at my clinic, I have an opinion about everything. Though, I think in this group that puts me in the majority.
:teeth:
J
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Old 06-01-2006, 04:43 AM   #38
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Jason, talking is fine! Just allow plenty of short silences to permit brains to correlate info.

What about handouts on the nature of pain? Brief, point-style, not too much detail, etc etc.

Instead of power point presentations - how about a marker and whiteboard?
People tend to stay awake longer watching your hand moving to see what comes next. Lots of drawings (no, you don't have to be an artist - just diagrammatic stuff). Make it interactive - ask questions of them. Helps, again, to keep them vaguely interested.
I've had more success doing this with patients than I ever had with other PTs.
Patients usually are more receptive and thier slate is cleaner.

Just some 2c suggestions...

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Old 06-01-2006, 05:04 AM   #39
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Jason,

If you get a chance sometime in the future to attend an Explain Pain course with David, take it. He makes explaining pain so much fun, for both patient and therapist. He uses the whiteboard a lot, as Nari suggested.

I try to remember that the primary reason to do this is to dispell fear and improve self-efficacy, not to make the patient a neurophysiologist.

Luke

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Old 06-01-2006, 05:19 AM   #40
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Jamshed Bharucha has some thoughts on education as it pertains to the 2006 World Question.

Education as we know it does not accomplish what we believe it does
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Old 06-01-2006, 05:33 AM   #41
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Jason,

As much as I am able, I felt it when you described what this woman had done. I'm sure you know that there will always be people better at doing something like this they we could ever be at avoiding their games. At the risk of sounding a little paranoid I'd suggest you read The Sociopath Next Door By Stoudt. You might find that this book explains a great deal about the patients that drive us crazy-and I'm only partly kidding when I say that.

Perhaps this is her form of entertainment (according to Stoudt sociopaths do this). You're better off now, until the next one shows up. Maybe next time you'll figure this out before you present the case on an international forum (ha,ha).

Anyway, glad you came over. The level of discourse here seems a bit better these days than another site I used to write for regularly.
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Old 06-01-2006, 02:47 PM   #42
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Thanks, Barrett, I'll put it on my ever-growing list of good books to read.
I'm taking two DPT courses, starting in 2 weeks, so 8 credits plus work. That'll be fun.
I think when summer comes I'll reward myself with a few things:
1. The XBox 360
2. A few of the books on your list, as they sound really good. I think this one will be the first!

Incidentally, she just came in and I spoke with her briefly, this solidified my belief that my time is COMPLETELY wasted trying to work with her.
I happily signed her up for her TENS trial.

On a broader note, I think this personality thing is quite common among those identified in the "Chronic Pain" group (which includes some of our secondary gain type folks such as worker's comp, litigation involvement, etc). It is my personal opinion that part of what makes therapists everywhere roll their eyes at such a patient (mentally of course) is that we have seen far too many patients who behave this way, and are (justifiably I think) reluctant to work with them.

Between those experiences and the identified lack of pain physiology understanding from school, the picture of why "chronic pain" is so difficult to handle starts to become clearer to me. The multiple peddlers of placebo cures and it's booming business (the VAST majority of chronic pain patients are not responsible for paying for their care personally) also comes into better focus.

I wonder what we, as therapists, might be able to do to address this problem?
I don't suppose there's a CPR for determining sociopathic or game-playing behavior, is there?

J
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Old 06-01-2006, 02:57 PM   #43
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On the topic of playing games, consider this essay

Indirect Reciprocity
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Old 06-01-2006, 03:06 PM   #44
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Jason,

No, no CPR. This is a complex issue and requires careful thought and consideration while we remain mindful of the fact that, being human, we always maintain the ability to be exactly wrong in our conclusions. Careful reading of essays like the one Jon linked above may certainly help.

Of course, you might just immediately conclude that everyone who gives you a hard time or disagrees with you is a sociopath. Personally, I find that this approach saves me a lot of time.
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Old 06-01-2006, 04:22 PM   #45
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Jason,
"remember that reality is not the problem, my expectations are the problem...."
Thank you for this quote, this could be my new mantra. I feel your pain( pun intended), when it comes to trying to explain the reasons to some patients why their pain does what it does. I give everone the benefit of the doubt, but when you have to answer the same question for the 64th time, with the same answer, it gets a bit disheartening, of course at those times the rep who supplies TENs gets happy :teeth:

Scott
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Old 07-01-2006, 12:22 AM   #46
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Jon-
Really interesting reading. Thanks. Again.


Barrett-
I think I like your strategy better, it is at least simpler.

Scott-
Don't thank me, that's just a rework of Buddhist theory. If it appeals to you, pick up "Buddhism Plain and Simple" in your local bookstore. Not a religion, more like a philosophy. Gets you through those hard times when a patient you went out on a limb for cuts you off at the knees.
[raises glass] Here's to indirect reciprocity and karma...

J
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Old 07-01-2006, 01:18 AM   #47
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Hi Jason,

I wrote (on NOI) some time back about a person who'd seen most of the therapists at our hospital. She was new to me. I did many of the things common to a first visit including some of the education as well as ideomotion. She stops me and asks, "Do I really need to know any of this?" You've seen everyone in our department, apparently you do. Well that's what I thought anyway. As it turns out she preferred a different therapist (having sampled all of them) and went to him. In the month that followed they fixed her shoulder problem but she developed a knee problem which the same therapist also began to work on. She also developed a dizziness problem that a second therapist was working on.

I seem to remember that I wanted to cry.

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Old 07-01-2006, 01:37 AM   #48
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Jon, This woman didn't happen to relocate to WI from WA did she? just kidding but I remember having a lady say the exact same thing to me.

It helps me to realize that while some people think I'm crazy for working ideomotion with them and then go on to a PT that fits their expectaion, there are just as many who come from other therapists and thank me for introducing it to them... ok, it doesn't help much, I still get P.O'd.

Chris
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Old 07-01-2006, 01:45 AM   #49
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jon

I remember the NOI thread clearly; and I might ask in this bb:

What made you want to cry more about? The patient's expectations or the Cartesian-stacked therapists?? or both equally lacrimose-inducing?

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Old 07-01-2006, 02:02 AM   #50
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Hi Nari,

Much like Jason I lamented the failed opportunity itself but I also developed a deep appreciation for the symbolic significance of the failure. It was either cry or run scared. I didn't have anywhere to run to at the time.
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