Part of my fellowship role is performing as a TA for NxtGen Institute of Physical Therapy’s Orthopaedic Residency program. Recently I presented to residents on material included in the Orthopaedic Section’s ISC 14.2.4 Basic Science of Bone and Cartilage. Among the information discussed was the effect of immobilization on articular cartilage; and I like to discuss immobilization in further detail within this post.
In the ISC 14.2.4 Fitzgerald did an excellent job in outlining detrimental changes to the articular cartilage after periods of immobilization. Some of these changes include thinning of articular cartilage, reduction in synthesis of proteoglycans, reduced amounts of articular cartilage matrix, and increases in water content with in the articular cartilage.1 Dr. Fitzgerald goes on to state “it’s reasonable for the therapist to assume that there have likely been some changes to the structural and mechanical properties of articular cartilage in the immobilized joints that make them temporarily less capable of bearing and distributing loads across the joint.”1 As physical therapists we would all agree with that statement based off our knowledge of anatomy and physiology.
We all know fear of movement (fear avoidance) can be a treatment barrier when interacting with a patient experiencing persistent low back pain (not sure if persistent or chronic is more appropriate, or less scary). It’s safe to say most clinicians are probably familiar with Waddell’s FABQ Questionnaire, which was developed to investigate fear-avoidance beliefs among LBP patients in the clinical setting.1 It also became more popular in clinical use when Tim Flynn et al. developed a clinical prediction rule which attempted to predict successful outcome of manipulation in patient’s with LBP, they found FABQ score was 1 of 5 variables that increased likelihood of success.2
I’m the first one to acknowledge the fear of movement may play a GIGANTIC role in the outcome of patient’s with persistent low back pain, and research shows that increased fear can actually lead to increased pain. It’s also been shown that utilizing therapeutic neuroscience education can reduce fear in patients and encourage movement, therefore decreasing pain. TNE has also been shown to affect another domain that is often less discussed in the clinical setting……self efficacy.
I wanted to share with everyone an email I received from a previous student of mine who just recently began his career as a physical therapist. I couldn’t be more proud of a CI than I am now knowing that he has the power/knowledge of how to handle these patients! Emails like this one make the extra work of being a CI worth it! Yes being a good clinical instructor should bring upon more work, not less.
“I evaluated this lady that was in her 40s that said that she has had chronic back pain for 10 years. Doctors kept getting her pills and home TENS and it had no effect and she was also stressed about losing her job because of the pain. I talked to her about pain and then I just had her do LTRs and simple back movements. Prone felt good and I just did light input manual to her low back and she said it felt really good. After we was done, she said that she has not felt that much relief in years and thanked me for listening to her and being understanding about her pain. I thought it was awesome that she was able to get some relief that fast. So thanks man for all you taught me during my clinical. You gave me some great foundations to build on and I appreciate it.”
There is extensive research in the literature regarding the effectiveness of various types of physical therapy interventions (manual therapy, exercise, modalities, dry needling, etc.). What isn’t researched as well, and perhaps may be more important, is the speech therapists use while interacting with the patient. In Bedell et al’s commentary “Words That Harm, Words That Heal” they describe language perfectly: “language is not merely a vehicle which carries ideas. It is itself, a shaper of ideas.” They go on to claim, “Medicine, like other professions, remains bogged down by technical jargon and metaphors that create fear and become what de Saint-Exupery calls the source of misunderstandings.” They nailed it with this last phrase.
This conference looks outstanding, some outstanding speakers will be present!
A few weeks ago I read an article on BBC News Health that really had me thinking. In summary, the article discussed the improvement in symptoms amputee Ture Johanson experienced after beginning “augmented reality treatment,” aka training with a virtual reality arm. What stuck out to me the most was how fast he experienced symptom resolution, after suffering with phantom pain for 48 YEARS! I’d like to delve into this a bit more and discuss possible mechanisms for the quick improvement as well as ways we can implement this into clinical practice. Continue reading