When the “Evidence” Isn’t Enough, Part Two

By Brett Windsor, PT

This post goes back somewhat, to continue a ‘series’ taking us through a patient case in light of a structured management model; a model built on a foundation of education, helping the patient to understand their diagnosis, prognosis, and their individualized management plan. Second, activity modification, which entails a deep understanding of patient postures, positions and movement patterns; modifying them to find positions that will ease the pain and biomechanical stress. These are the most difficult, yet most important, pieces of the management puzzle. Physical interventions (manual therapy, exercise, modalities) are largely useless unless education and activity modification have been addressed.

So we’re back to talking about Jane. In the last post on this topic, we spent a lot of time educating Jane about her knee and possible causes for her pathology. I shared a reference from 2005 detailing a little know but plausible explanation for Jane’s symptoms. At the end of that visit, Jane related that this was the first time someone actually sat down and explained what was wrong; as a result, it resonated – she now understood why her knee was painful. Even if the specific pathophysiological mechanism is completely wrong, the patient’s mindset has changed. There’s an acceptance and a willingness to actively participate in the solution. Jane was comfortable. She understood that a total absence of pain was probably an unrealistic goal, but control of the pain wasn’t. She saw a way to function.

We also spoke about why previous physical therapy probably hadn’t worked. This centered on an incomplete understanding of the specific tissues involved and how each of those tissues needed to be loaded in specific ways. Too little loading, and we make no difference to strength, ROM and function. Too much, and we aggravate already pain sensitive tissues. Treatment has to be aggressive enough to develop new neuromuscular patterns, but not so aggressive that more harm than good is done. To this point, Jane had been in physical therapy that didn’t push hard enough to make any difference. I think this happens a lot, and it may well be because of a lack of true understanding of the specificity of different tissue responses to loads. It’s the price of treatment guidelines and classification systems based on more general assessment and evaluation practices.

So herein lays the battle – why we need to be so specific with our activity modification. Jane spends an awful lot of time sitting down and works in a position where it’s extremely difficult to not sit. However, sustained flexion is the enemy – Jane simply cannot spend all day sitting if she wants this knee pain to get better. So we spoke first about the idea of perpetual motion in the knee. We talked about the idea that the knee needed to be moving very gently, but very consistently, and very continuously throughout the day. We talked about the fact that sustained positions were very likely to increase pressure in the patella system, in the periosteal system, and to put tension on synovial tissues and bursa tissues that were already irritated. The best way to provide a basis for the neuronal system to heal would be to consistently challenge it to move within the normal ranges of motion.

So this was the first piece, ensuring that she was not sitting for the entire day. We talked about simply breaking these periods of sitting up for periods of every 20 minutes, just get up for one or two minutes every 20 to 25 minutes. I asked her that when she needed to text, that she stand up and do it; when she was talking on the phone, to stand up and do it. We also talked about the idea of making sure she parked as far away from her office as possible, so that she could get some walking in, to take a walk at lunch time, to take a walk at the end of the day and to try and take a walk in the morning. All of these strategies would help to start get the knee moving and get it out of the sustained positions.

We also talked about shoes, no more high heels. Running, an activity that she did not enjoy, but was told to take up by her doctor for weight loss, was simply something that we could toss aside. Running is not necessary for weight-loss, running is not necessary for healthy knees, and in this case was actually aggravating and exacerbating the pain. In its place, the elliptical, a little bit of gentle cycling, but mostly, a reliance on the idea of walking and perpetual motion. That done, we began talking about an exercise program. At this visit I didn’t particularly feel that it was appropriate to move deeply into the exercise program yet, but we started to talk about some principles. I thought it was important to lay an endurance base first and to lay a very gentle range of motion base first. From there we could tend to move across towards the idea of strengthening the knee. The idea has to be based on progressive simplicity.

We started at this point simply by introducing some very gentle, static isometric exercises in a number of different positions. On top of all of this, we spoke about the idea to avoid pain. It was never going to be possible to eliminate the pain, but it was definitely possible to limit the pain. So we talked about the idea of backing off if the pain lasted for more than an hour or so after her exercise or walking sessions. We talked about the role of ice, we talked about the role of heat, but we talked about it in the context of managing her entire day. So we’re not yet at the point where we’re talking about the in clinic strengthening programs and intensive exercise programs. We’re simply looking at modifying her activities throughout the day to provide some sort of a base from which this knee can begin to be healthy again.

So at this point now we’ve laid a deep education base and we’ve laid a deep activity modification base. We have a stable base upon from which to work. At that point what I explained to her was that the next treatment session that we spent together would be spent evaluating other areas. I noticed in the initial evaluation that her functional range of motion in standing was restricted. This makes sense. A painful knee is going to stop moving to the point where we need to start looking at other areas. So I’m going to look at her superior tib/fib joint because I’m concerned about that area becoming a little unstable. I’m going to look at her ankle. I’m going to look at the muscle systems in her calf and her peroneals. I need to look at her hip and probably look at her pelvis to see if there are any compensations or adaptations developing there that could; A) Put more pressure on the knee; Or B) End up breaking down areas distant to the knee that will cause problems later on. So this would be the focus and then we can develop exercise and manual therapy interventions designed to alleviate these areas first.

So here we are two to three visits in to the process. We haven’t made any substantial difference yet, but we have a patient who at least now understands that there’s a lot more to this than just showing up at PT, getting a few tools, getting a few techniques, getting a few pokes and prods, and walking away with no pain. This is a 24-year old girl with significant history of long-term chronic injury. It may to take two or three years for this to resolve. But at least at this point we have a base from which to work. Here we are, a manual therapy organization, not advocating the immediate application of manual therapy techniques, because we don’t always have the answers as manual therapists. We have to remember that we’re physical therapists first. And we have to remember that the main role, the most important role of the physical therapist is as a teacher. The best teachers know their material well. They know how much to tell their patients, when to tell their patients, and most importantly, what the patients need to know to give them confidence in the sessions moving forward.

How would you ‘prove’ that this intervention is a worthwhile one? For this particular patient type…it would likely be a long and futile search. So, it would be best to stay calm and keep working.

Thanks for reading. I hope this is stimulating some thought and I hope it’s driving the idea that NAIOMT is about much more than just applying manual therapy techniques to patients. There’s more to what manual therapists do than manipulation and dry needling.



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