Category: Assessment & Treatment Planning

25 Feb 2017

Honouring Complexities when treating a patient

Complexities

I came upon another great blog this week:  http://www.billhartman.net/blog/from-my-notebook-complexity-and-constraints/

 

The premise of the blog was that humans are complex adaptive systems, and that the system is modified by behaviours.  At any time that we want to impact the system, we are at a different starting point each time.  Additionally, there is a non-linear relationship between cause and effect.  What does that mean when it comes to physical therapy and treatment of ‘living beings’?

 

Essentially, complex adaptive systems (i.e. humans, and I will also add animals) may require unique and previously untested methods (i.e. treatments) to solve problems, because there are an unknown number of unknowns!  As such, it may be important to experiment.  Not just any sort of random experimentation, but rather ‘safe-to-fail’ experiments (this means that if your experiment fails, no harm is done).  In fact, without doing so, we wouldn’t learn, progress, or be able to establish ‘best practices’ when treating a patient or certain condition.  Let’s be honest, many times we don’t really know why a treatment works, just that it does.  Become okay with that!  It’s reality!

 

There are often many theories on how to solve a complex problem, because complex problems may have multiple successful solutions.  Our experiences are what will therefore influence our understanding and decisions.

 

Take for example a PT friend of mine.  She had a patient with pin-point mid-back.  She mobilized the vertebra and mobilized the rib.  No changes.  She did a manipulation.  No change.  She used ultrasound.  No change. She gave him exercises to work that area.  No change.  She confessed to me that she was so frustrated that on one appointment she just rubbed the area, a bit of a friction technique.  And that worked!  She exclaimed, “I was so ticked off, he got better after I just rubbed it!  I just fricking rubbed the area!”  The point of the story is that she tried and failed, tried and failed, multiple times until she experimented with a different technique, and it worked!

 

A recent canine patient of mine has what we all suspect to be a cancer of one of the metatarsals of his foot.  He’s been slowly getting worse.  A couple of weeks ago he hit his foot on the stairs when coming up them.  His foot swelled up even more.  He became 3-legged lame.  But then 1.5 weeks and also 2.5 weeks later, he looked better than ever.  The foot swelling had gone down and he barely looks lame!  WTF???  (What the Frick!)  Maybe the ‘injury’ stimulated the healing process again?  Will I suggest trauma to other osteosarcomas?  Not likely!  But it does get me thinking about systems in the body and the various ways that healing happens.  Would I try ‘irritating’ a tendinopathy to stimulate healing?  Yes!  But that’s a low risk / safe-to-fail experiment, and an already tried and true treatment.  I can tell you that the experience of this event will go into my brain as “save that bit of information, you may need it one day!”

 

Back on topic here:  So when looking at ‘experimenting’ with treatments or approaches to a case, the blog suggested the following:

1. Describe the present

2. Identify what can be changed

3. Determine where you can monitor the impact of the intervention

4. Where will the intervention produce a beneficial result

5. If the result is not beneficial, how can I learn from it

6. Move between the complex and complicated domains

7. As the new state emerges, increase constraints to exploit and magnify the result

 

Be aware of the breadth of complexity of a living body.  Our therapies may be affecting (or may need to affect) Energy, ANS, Immune, Endocrine, Respiration, Circulation, Emotion, Experience, Understanding, Memories, etc.  Not just the neuromusculoskeletal system.  One of the quotes from the blog that stood out for me was: “If you think you’re somehow treating a pathology (structural) as a PT, you’re probably wrong or you’re thinking like an orthopedic surgeon.”

So, stop using the recipe books and train yourself to become a chef!  Try a little experimentation with your therapies.  This will help you learn, grow, and expand exponentially a practitioner.  

 

Have fun with it!  Cheers!  Laurie

 

 

 

 

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14 May 2017

NOVEL PAIN MANAGEMENT STRATEGIES

Temporomandibular Pain

So I hadn’t thought about using my own personal story as a blog post, but then I listened to a Physical Therapist’s podcast about a patient who had Temporomandibular Pain.  (http://www.themanualtherapist.com/2017/04/untold-physio-stories-s4e10-who-wants.html)  Facial pain, neck pain, headaches and difficulty eating were all found in the patient described.  She had physical dysfunctions with the jaw and neck and received manual therapy and exercises, which helped her neck pain, but didn’t help her facial pain.  She had however incidentally found that eating ice cream or yogurt made her face feel better.  So the therapist prescribed for her to eat these foods several times a day!  Maybe it would reset her nervous system.  She reported back that the yogurt wasn’t as effective as the ice cream (not cold enough)… but she was afraid to eat ice cream all day long as she was already starting to notice a weight gain.  So the physical therapist suggested for her to eat frozen blended bananas instead - a spoonful or two several times a day.  Well, golly!  That worked!  It took away her facial pain!  She was cured of the facial pain!

 

Now, as I’m scrolling through the listings of blogs I check out weekly / biweekly, I thought ‘WOW, someone else had this experience!’  So, my story, is that two summers ago, I cracked a tooth.  Not a visible crack mind you, but it quickly turned into an issue with cold and hot sensitivity.  Well, I toughed it out for about a month until I thought, ‘Something is really wrong’.  That’s when I went into my dentist.  He couldn’t see a crack, but painted the tooth with a sealant that should reduce sensitivity.  NO GO!  NO change!  So I went back in.  This time, he drilled out the existing filling, found the crack, buffed it out (who knew you could do that!), and refilled it.  He casually mentioned, “If this doesn’t work, you might end up like my wife.  She needed a root canal.”  

WHAT!??  I’m not getting a stupid root canal for this!!!

So, I’ve not been back to the dentist since, and unfortunately the pain remained the same.  I simply learned to eat food all on the left side of my mouth.  I avoid very cold foods.  I learned to tolerate hot food.  Totally normal, right?  

WRONG!

Turns out I’ve also started to develop more neck pain and some jaw achiness on my right side as well.  I tried some ‘happy thoughts therapy’  (I made that up).  And every time I’d eat something, I’d try to chew on BOTH sides of my mouth but focus on and think about the left/good side sensations and taste.  I tried thinking happy thoughts while chewing on the right side; “Isn’t it beautiful out right now?”  “I’m so happy I’m heading home”, “How luck am I to live in the country”, etc.  Well, that sort of helped.  Sort of.  It didn’t help AT ALL unless I was very conscious about it.

 

Then a few weeks ago, I was driving home and eating my celery and almond butter.  (Behind the scenes explanation:  I work 11 hour days on Tues & Thurs, and pack enough food to eat for my ride home as well.  Now, I know that dipping celery into almond butter MIGHT be considered distracted driving… but I’ve gotten so good at it, I don’t need to look down to do it!!)  Anyways… I dipped the celery in the almond butter and quickly popped the goopy end into my mouth, bit off a chunk, and a large bit of gooey almond butter coated the offending tooth on the right side of my mouth.  I was immediately panicked (usually, that would cause pain), but because it was so gooey, there was nothing I could do to remove the ‘offending’ goop fast enough.  So, my brain went into counter measures, and said, “Just enjoy the flavour instead”.  And I did just that!  To which I realized… I have forgotten to be tasting food with the right side of my mouth!  It’s like the taste buds were rusty!  And just like that, my tooth pain started to dissipate.  I continued to eat very flavourful food on the right side of my mouth and focus on savouring the taste.  In fact, now, I only have a bit of pressure sensitivity (like you do after getting a new filling… and since I didn’t use that tooth properly after the filling two years ago, it’s not been pressure desensitized or ‘reshaped’), but the cold sensitivity is almost gone!

 

It’s a long winded story with the moral being:  What are happy, pleasure causing things, that you can add into your therapy for canine patients?  Does licking peanut butter while doing a new exercise help the brain equate ‘happy’ with the exercise, or reduce pain signalling?  Maybe mixing up therapies so as to intermingle more uncomfortable therapies with relaxing / comforting ones could be beneficial.  Maybe use the TENS Machine or Alpha Stim as pain management strategies prior to exercise or in conjunction with manual therapies.  Maybe dogs get better faster than humans because their therapy sessions typically include treats!  Food for thought!  (Literally!  Ha ha!)

 

Until next time!

Cheers!   Laurie

 

PS  For more info, Members can check out Video Training 130 to see my “Back Pain Dance”.  

And for those, not wanting to see my dance, you can check out this cool video I found about Pain by one of my favourite physiotherapists, David Butler:

https://www.facebook.com/noigroup/videos/10154605323433527/?hc_ref=PAGES_TIMELINE

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21 May 2017

Literature Review - In house rehab after IVDH surgery

 Cart

Literature review:

 

Influence of in-house rehabilitation on the postoperative outcome of dogs with intervertebral disk herniation.

Hodgson MM, Bevan JM, Evans RB, and Johnson TI.

Veterinary Surgery. 2017;46:566-573.

 

Objective: To determine the influence of in-house rehabilitation on the postoperative outcome of dogs with intervertebral disk herniation (IVDH).

 

Methods:  The researchers conducted a retrospective cohort study, comprised of 248 dogs under 20 kg of weight, with single site, thoracolumbar, Hansen Type I IVDH.  They reviewed the medical records and classified the dogs into 2 groups depending on whether their postoperative management included an in-house rehabilitation program. (87 received in house rehab, and 161 were in the control group.) Preoperative and sequential postoperative modified Frankel scores (MFSs) were recorded. Time to ambulation, time to normal conscious proprioception, final MFS, and complications were compared between the groups.

 

Results: More dogs returned to full neurologic function (final MFS of Grade 5) when in-house rehabilitation was included in the postoperative management (33% compared to 9%). Normal conscious proprioception and ambulation returned earlier in the control group (42 days and 14 days, respectively) compared to the group with rehabilitation (49 days and 28 days, respectively). The complication rate was higher in the control group (29%) compared with the group with rehabilitation (16%).

 

Interjection of thought: It should be noted that the Rehab group contained more dogs that were lacking in deep pain perception – which could account for the ‘slower’ return of conscious proprioception and ambulation.  Mind you, the delay was only 1 – 2 weeks, and overall, the end results were better in the rehab group.

 

Conclusions and clinical relevance: In-house rehabilitation should be included in the postoperative management in dogs after surgical treatment of IVDH to improve neurologic function and reduce postoperative complications.

 

Inquiring Minds want to know… What did the rehab look like?

IVDH rehab

 

More thoughts:  It was noted in the paper that the rehab was not standardized, and that this would / should be a consideration in the future.  I strongly disagree, especially in neuro cases, where a trained therapist should work with the skills and function of the patient in front of them, as compared to a protocol, even a staged protocol.

 

So, there you go!  Spread this paper around like wildfire and get those post-op IVDH neuro dogs referred to you!

 

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11 Jun 2017

Do you use SOAP? Not me! No SOAP for me!

No SOAP

I hate SOAP. I don’t use SOAP.

I use my own charting categories, and I’ll suggest you might like to do the same!

Did I make you raise your eyebrows at the title?  Just a little?  Likely not!  Ah, disappointing…

 

Okay, so when we have interns come to our clinic, they are asked to provide an example of a SOAP note.  I always tell them, we don’t use traditional SOAP notes.  I don’t think they fit an outpatient practice.  Subjective and objective make sense.  Subjective is what the owner tells us happened, how things are going, what they’ve been doing, observing, etc.  Objective is what you find on your clinical evaluation of the dog (gait & movement analysis, what’s painful on palpation or ROM, or movement testing, what’s tight, atrophied, and your objective measures, etc.)  Sensible stuff!  But beyond that, I would like to make suggestions / alterations to the A & P parts of SOAP.

 

Classically, (and I dug out an old text book from 1990 to get this right… a whole text book on SOAP notes!!!), the A is for Assessment, where you would fill out a summarized list of the major issues from the S & O sections.  Okay, so this is likely dandy as part of your initial assessment, but it’s a pain in the butt to do with every charting input.  In our initial assessments, we use PT impression or PT Diagnosis.  That’s where I’d write out my thoughts 1) Suspect OA left shoulder and maybe put some bullets below:  Pain on end ROM flex / ext; Reduced end ROM flex; Off-loading LF leg.  And we’ll often have multiple findings i.e. 2) Rib and T/S dysfunctions, 3) abdominal motor control and timing deficit.  I could add in my goals etc. as well (in my initial assessment primarily).  But let me get back to a follow up treatment note.

 

In my follow up notes, I’ll use Subjective & Objective, and if there is something new that has come up or a change in my thinking of what’s going on (or a subtle nuance to what I think is going on), I’ll add in “I” for Impression.  Then I like to go with Rx (meaning treatment).  If you prefer you could use Tx for treatment.  Here I write what I did during the treatment THAT DAY.  I include therapy type, dosage, body part treated, etc.  Laser 2J/cm2 Superpulsed, Mobilizations T/S (dorsal glides and Transverse Pressures) – Grades 3 - 4.  (P.S.  I hate charting ‘amounts’ of manual therapy… it’s a ‘feel’ sort of a thing.  But that’s another topic.)  

 

If the dog had a fabulous response to my therapy (or in the case of a neuro dog) and I was to describe how the animal was after the treatment (or how he was during the session), then I’ll add a category for ‘Outcome’.  I think this is important.

 

Plan for me, means 1) What I plan to do next time, 2) What I’ve prescribed as homework, 3) When I want to see the patient again, 4) Anything else I PLAN to do (i.e. send note to referring doctor, email client exercise sheet, etc.)

 

All in all, I don’t use SOAP.  I use SOIRxOP!  And I feel ‘clean’ just the same!  If you’ve been struggling with SOAP, I hope this might work for you as well!

 

Cheers!  Laurie

 

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25 Jun 2017

Mobilizing the hypermobile joint

Joint Laxities

Laurie Edge-Hughes, BScPT, MAnimSt (Animal Physio), CAFCI, CCRT

 

This blog topic comes from a blog I found about whether or not it is appropriate to mobilize a painful lax ankle sprain.  http://www.themanualtherapist.com/2017/04/mmt-q-should-i-mobilize-painful-lax.html

 

And the answer I think is interesting, and should be thought about for both humans and our canine companions.  

 

So firstly, let’s think about where pathologic laxities might occur in our canine patients:  Full ACL tears; Medial Shoulder Instabilities; Carpal Hyperextension; Hip dysplasia; Lumbosacral Instabilities & Other Spinal Hypermobilities (non-surgical).  Secondly, it’s important to also note that mobilizations have effects not only on mobility (i.e.  stretching of tight ligamentous or fascial structures) but also on neural imputing and blood flow.

 

If in the case of a ‘lax’ joint, the patient (animal or human) is fearful of loading the joint (i.e. off-loading or making postural compensations), then return to function and appropriately strengthening isn’t possible.  Manual therapy gives us a window into the nervous system in order to reduce fears of loading a limb (i.e. as in a full CCL tear) or moving into certain postures (i.e. extension of the lumbosacral junction in dogs with lumbosacral disc disease), or to reduce pain signaling from a joint.

 

A bonus is that research studies have found that mobilizations have been able to increase strength in adjacent muscles and improve limb stability (i.e. single leg standing) as well.  So, mobilizing may actually affect proprioceptive awareness and balance in a limb.

 

Some of the real neurophysiological magic happens when joints are mobilized nearer to end range (i.e. grade 3 or 4 mobilizations).  So, the original blog post states, we shouldn’t fear mobilizing into these ranges so long as there is no pain or apprehension experienced by the patient.  (If there is, then stick with grades 1 - 2's.)

 

What would I do with each of the following scenarios?

 

Full ACL:  Cranial and caudal glides

Medial Shoulder Instabilities: Medial and lateral glides

Carpal Hyperextension:  Cranial glides of the carpal bones

Hip Dysplasia: Lateral glides

Lumbosacral Instabilities:  Flexion mobilizations, Side-bend glides in flexion, & Tail pulls

 

Mobilizing a joint might even be best before you do exercises.  Not hours of mobilizing, but perhaps 1 – 3 minutes’ worth.  (Note, I spend more time on spinal mobs than I do on extremity joint hypermobilities… the affected joint itself and a couple of adjacent segments.  This seems to setting things down nicely.)

And with that, Happy Mobilizing!

 

 

 

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