When ‘Evidence’ isn’t enough..

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by: Brett Windsor, PT, PhDc, MPA, OCS, FAAOMPT

This is the second post in a series on management of the orthopedic manual therapy patient. In the first post, we discussed the full scope of management, from education to activity modification all the way through to the role of the physical interventions such as manual therapy, exercise and modalities. Today, I want to apply the management process to a single case; one where education was indispensable and probably the defining factor in altering the course of this episode of care. The patient in question is a 24-year old female with knee pain. We’ll call her Jane. Jane was otherwise healthy in all respects, but has found herself in a tight spot because of her left knee.

Create a picture in your mind…athlete all through high-school and college…two left knee reconstructions, a torn meniscus, numerous sprains and strains…all topped off with a serious MVA where Jane’s knee was driven straight into the dashboard, encouraging the left patella to separate into numerous small pieces. Three years later, the wounds have largely healed. To look at the knee, you’d hardly guess that anything at all was wrong. It looks exactly like you would expect a knee to look in a 24-year. But, Jane is in pain..almost constant pain. Jane can’t stand the knee to be bent for more than a few minutes at a time. There are significant activity restrictions – Jane can’t run; can barely exercise in any way. Even sleep is difficult.

Jane has tried everything…doctors, physical therapists, chiropractors, medication, injections, manual therapy, dry-needling, acupuncture, Graston, Astym, massage, exercise, modalities. Nothing has helped. Imaging revealed almost nothing at all. At this point, Jane is frustrated and doesn’t know where to turn. Life participation is deteriorating Jane is desperate to find a workable solution. What are the impairments? Jane has full range of motion in the knee. It was tender to the touch, particularly with sustained compression over the patella, and there were strength deficits functionally. Jane had a poor squat; pain came on quickly with minimal descent. Single limb balance was impaired compared to the other side.

None of these were a surprise to Jane; the trick has been to find a way to begin working on these without aggravating the pain…so where do we begin? At face value, it looks like a difficult case, but these are the times when its good to trust your structure. With that in mind, I began with education. Jane needed answers – first and foremost about why she was actually having pain. I felt that some recent work by Dye on Tissue homeostasis offered a plausible perspective. Dye feels that a “variable mosaic of possible patho-physiologic processes, often caused by simple overload, best accounts for the etiology of patellofemoral pain in most patients.” He feels that pain is caused by a loss of homeostasis in the tissues.

Dye discusses pathophysiological processes – inflamed synovial lining and fat pad tissues, retinacular neuromas, increased intraosseous pressure, increased osseous metabolic activity of the patella – and makes the argument that all of these individual processes can together create the perception of anterior knee pain. In simple terms, repetitive and consistent loading has created abberant sensory input now reflected by increased pain signals. The smallest inputs are creating disproportional outputs. Therefore, any management plan must take these factors into account. It would seem that previous management plans haven’t. As a result, the symptoms have actually increased over time. The opposite of expected.

Do we know we’re ‘right’ here? No. Is this a logical and plausible theory about what may be happening? Yes. Does it provide a reasonable explanation for the symptoms and provide a basis for reasonable management? Yes. Are there any competing theories demanding our immediate attention? No. We discussed these views together – the concept of homeostasis and how its alteration can change the way signals are processed and create sensitivities to touch and activity that are vastly out of proportion to the normal responses. We related it to how and why previous treatments may have failed and how things would have to change in the future to a slow progression beginning with very low loads on the knee.

So far…no manual therapy, no exercise, no physical interventions of any kind. But, at the end of the first session together, we had a plausible mechanism for her symptoms. Jane understood it all and had the chance to ask questions. It made some sense. You could see some weight lifted, some optimism. The next step was to discuss a prognosis – a realistic time-frame and goal set specific to Jane. This is important in providing a sense of calm – it tends to minimize the ups and downs. Jane will understand exactly what factors are aggravating and relieving, what she can do and what PT can do to progress the condition and where she can realistically expect to progress over the next few months.

In the next post, we’ll discuss the prognosis and the development of a plan for physical interventions in light of the base we laid today.

Reference

Dye (2005). The pathophysiology of patello-femoral pain: A tissue based homeostasis perspective. Clinical Orthopedics and Related Research. 436; 100-110.

 

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