After pain is the next issue strength, motor control, sensory, or structural?

September 8, 2020 Learning Session

 

Note – specific cases and names are not used.  A generalized review and key takeaways from the clinical perspective of the Smith Performance Physical Therapy Team are provided below.

Topic 1 – Patients and Home Plan Non-Compliance

When patients will not make adjustments in the short term to allow the injured tissue to heal

In many physical therapy cases, a key portion of the home plan and long term recovery is understanding the cause of the pain and the role of daily life in causing that pain. Occasionally, the cause of pain is identified however the patient cannot stop or will not stop the activity.

Our team discussed first the hallmarks of patients will not make adjustments in the short term to allow the injured tissue to heal:

The prognosis is clearly going to be in the worst case scenario

The message is understood by the patient

The patient cannot comply

The symptoms progress or stabilize

High level of patient and practitioner frustration

 

Possible Solutions:

Reiterate the known triggers and explain the limitations of manual therapy and therapeutic interventions if there is constant exacerbation

Objective data for activity (one example of this problem and a solution was close monitoring of step count with less than 10% increase in step count per week.  This allowed the injured tissue to heal.  Our team had more difficulty figuring out a solution for extremity and spine monitoring.  We are considering accelerometer tech for both.)

Replacement or strategies to augment the painful activity

Increase visit frequency to reduce the negative consequences of the triggers (This seems to be the most effective change in the plan of care)

Modify prognosis within the first few visits emphasizing that it may get better but will take more visits and more time

Continue to provide support

For cases with low severity of pain at the session and high irritability with sufficient delay, we may need a more thorough examination of triggers using a journal 

 

Topic 2 – Checklist for Prioritizing Treatment 

In pathologies that the pain has been resolved but can be easily irritated again, our team discussed what are the next steps to pursue in treatment.

Two checklists of progression were mentioned:

IAOM Management List

Pain Generator

Motion Segment

Neuromotor Control

Somatosensory Control

Fundamental Performance

Advanced Performance

Fundamental Advancement

This is listed and discussed at the beginning of most IAOM courses or lectures. 

 

Pathological Mechanisms Chapter in Gait Analysis  by Perry

Pain

Deformity/Anatomy

Muscle Weakness

Sensory Loss

Impaired Motor Control

Each of these issues are discussed by Perry because of their impact on walking gait. When changes to gait are noted, one or more of these issues are causing the problem.  While meant just for walking, the list is useful for any movement that is not normal.

Our team discussed the need to address pain first whenever possible as it impacts every other component of these lists.  For example, a patient with a painful anterior knee will show impaired strength, sensory control, motor control and performance.  If we tried to work on those impairments first without dampening or removing the pain, any progressions seem to be lost.

This discussion led to the discussion of differentiating muscle weakness and neuromotor control and the impact on prognosis.  

We discussed 3 levels using hip abduction strength that tests weak using standard muscle testing in sidelying:

 

Muscle Inhibition – Changes in performance occur immediately with activation.  The difficulty is getting this to stick.  After doing the activation, testing again finds a normal muscle test.  Prognosis is excellent as long as the patient can perform the activation technique repeatedly all the time.

 

Strength Deficit – Changes in performance are not moderate to minimal.  There does not appear to be muscle wasting.  After doing activation, testing finds mild improvement.  Prognosis is good but we expect a normal test within a month.  Most systematic home planning on progressing the physical therapy exercise targeting the gluteus medius.

 

Strength Atrophy – There is no improvement with muscle activation.  There is atrophy in the muscle. No improvement with activation or there is initial improvement that is small but not sustained.  Prognosis is guarded and expected improvement is more like 6 months with focused strength training on the muscle.  It is critical to understand and remove the cause of the muscle weakness.

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