When patients defy all we’ve ever known….

By: Brett Windsor, PT

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This is a story that I often tell in my classes – sometimes you just cannot explain why what we do works or doesn’t work.

And it explains to me why all three of Sackett’s evidence pillars MUST be considered with our patients.

I was working with a student in California on a university site visit. Usually these visits are pretty mundane, but I’ll never forget this one…

The student told me about a 50-year old female she had seen with a shoulder problem – acute insidious onset of shoulder pain accompanied by worsening stiffness over time to the point where she had very limited abduction, internal and external rotation, and flexion. There was a history of diabetes, peripheral neuropathy, and depression. Finally, a confirmed diagnosis of capsulitis in the other shoulder two years ago. Treatment was not all that successful: this initial evaluation gave no reason to think that it would be all that successful in this case either.

We’ve all seen these patients…text-book stuff right?

Here’s where things got interesting. …

Three days later the patient came back. She professed no recollection of being in the clinic for a shoulder injury. She denied any problems with her shoulder – no stiffness, no pain, no functional deficits. Objectively, full range of motion, full strength, and no pain with any testing. In all respects this was an absolute completely healthy shoulder. This was a 180 degree turn from just three days prior.

What has happened here? True adhesive capsulitis just doesn’t disappear in three days. It’s not possible. Now, we can talk about whether or not this actually was adhesive capsulitis, or wasn’t, or maybe it was something else, or this was a student…, but the story was confirmed by two experienced clinicians. I had no reason not to take this story at face-value.

So what had happened here? How did this patient go from full-blown adhesive capsulitis to a ‘normal’ shoulder so quickly?

Well…The patient had been diagnosed with Multiple Personality Disorder. It just so happened that one of the personalities had adhesive capsulitis. The other personality did not have adhesive capsulitis. That was pretty jaw dropping for me. Our profession is so focused on mechanics, pathology, capsular patterns, tissues being scarred and restricted and tight, and then this happens? How do we possibly explain this? Well, there’s only one explanation for this and all the explanations point back to the same source, to a nervous system. Something about the different personalities, something about the context, and something about the environment has caused the central nervous system to completely disregard one set of information and regard another set of information as gospel.

Put simply, there’s a power in the brain that we’re only just beginning to understand.

So what does this mean for us?

We have some of the answers some of the time. We have none of the answers some of the time. We never have all of the answers. Each patient is an individual with multiple contexts and we never truly know how they will respond to manual therapy. We have to be open to trying different things and using our experience and the patient’s preferences to guide management.

Not every decision can be made by reading the latest research…which is usually very narrow in focus – often applied to patients we’ll never see.

Even if you think this whole post is bollocks…it’s thought-provoking.

Cheers

Brett

3 thoughts on “When patients defy all we’ve ever known….

  1. Hi Brett,
    Again, I truly enjoy reading your posts. It makes us realize that in physical therapy, after years of study to become what we are now, nothing is ever wrong, there is only a better way to do it. The human brain is powerful… the power of suggestion. If patient’s think their symptoms will go away with a treatment that we known as placebo, it will. Placebo is a powerful thing, I use it oftentimes to make patients progress. Whether we achieve their goals or not, in their eyes you become the best therapist in the world. It’s all about patient preference and values. The only thing we get out of it is the satisfaction of educating patients on what works best, based on the evidence. They can say it did not work for them, but they can never say that physical therapy did nothing at all.
    Andrei

    Like

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