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A novel case study

I was just speaking about this case to one of the PTs that works with me this week, and felt it a good learning opportunity to post to the inter webs.

78 year old male was referred to me from another PT. The patient underwent 6 weeks of PT with another therapist also certified in MDT.

I helped train that PT and she felt that the patient should be referred to me to see if there was anything missed during the appointments.

The patient had an extrusion at L3, affecting quad strength. He also had a loss of light touch sensation at the anterior thigh.

His only complaint was pain that would wake him up at 2 AM, which was very intense. He would take a Norco and walk for 30-45 minutes to reduce his pain. He could sleep until 6 or 7 AM, which is when the excruciating pain would return. Again, he would take a Norco and walk. The pain would go away and not return the rest of the day until 2AM. He was very active with Tai Chi and Kung Fu over 10 hrs per week.

His only complaint was pain in the middle of the night.

I couldn’t provoke his pain during the evaluation.

He had already been through 6 weeks of PT without change, so I was only trying to figure out his sleep issue.

I had a working hypothesis

1. Overnight, the disc imbibes fluid and increases in size.

2. It was possible that the change in fluid content was increasing his pain since the pain went away when he was up walking during the night

3. If I could prevent the disc from taking on fluid, his pain might shut off

That was my only thought pattern that made sense for his symptoms.

I had him sleep in a recliner and to call me in 2 days with the result.

He was painfree in the recliner and did not wake at all.

Because he already had 6 weeks with an MDT trained clinician, I didn’t feel that bringing him into the clinic was going to be productive, so I followed by phone.

After two weeks, which is how long it is expected to see results if given the right direction and load, he was able to return to bed without waking.

This patient returned to therapy for a different issue a year later and we had a conversation about his back (he was seeing a different therapist). His strength recovered and he didn’t require surgery.

Moral of the story:

1. Sometimes you have to think outside of the box

2. Don’t let the image dictate treatment

3. Only treat the patient if we can improve their lot in life

4. Always develop a relationship with the patient you are treating.

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Hip impingement? Is there a place for PT?

“surgical rates for correction of FAI have escalated, despite limited evidence to support a cause – and – affect relationship between FAI and hip pain.”

It is said that there is an 18X increase in procedures over the decade Studied.

The fact that this surgery has increased at such a dramatic rate may be a result of who the patient sees for the problem.

Physical Therapists do physical therapy.

Surgeons do surgery.

Pain management do management of pain through chemical means.

Chiropractors do chiropractic medicine.

Acupuncturists do acupuncture.

It’s a very easy equation to figure out. Who you see to manage your symptoms will dictate what is done for your symptoms.

“… The evidence from these studies is mostly level four (low level), the reported results are short term, and at least one studies suggest a notably lower level of sport activity at three years surgery. Currently, there are no high – quality randomized studies examining the effectiveness of surgery for FAI”

This makes it difficult to make a broad statement due to the lack of controlled research. For instance, a sham surgery (a surgery in which the patient is cut, but nothing else is done) compared to an actual surgery would start to give us information on the value of the surgery.

Looks like the study is in the process of being Completed.

I personally like case studies and case reports because sometimes a “classic study”, such as a randomized controlled study, may not capture the characteristics of the patient in front of the health care professional.

“75% of surgeons believe that FAI surgery prevent future osteoarthritis, although 62% of the surgeons were either unsure of or did not believe there was an optimal debridement of SAI lesions to prevent future osteoarthritis”

A belief plus 5 dollars will buy a coffee at Starbucks.

Not a fan of these types of studies because it demonstrates the bias of the profession. The shocking statistic is the reverse. The fact that 25% of surgeons don’t believe that surgery prevents future OA is cool. Unfortunately, we don’t know the education level, outside of the fact that the people polled were surgeons, of each person in the poll. For instance, if it’s the best of the bell curve that believe surgery has no effect on OA, then I may side with that opinion. We just have to think critically when reading these numbers.

“… The fact that 34% of both pediatric and adult patients diagnosed with FBI stated that they I knew they wanted FAI surgery (21% not willing to try conservative therapy for six months) suggest that orthopedic/sports patient has a propensity for overconfidence in surgery as the gold standard treatment.”

We are all salespeople for our profession.

Don’t believe me…just check out how many people are selling PTs education on Sales tactics and marketing.

It seems that surgeons are doing a great job of sales in that 1 in 3 believe that surgery is the answer.

As PTs, many of us are learning how our language affects the patient, both positive and negative.

It would be easy for me to convince a patient that they are weak and need us, but I don’t know if that is doing more of a service or disservice st that point.

“We think we could all benefit from learning from our past, when, despite similar increased endorsement of surgical intervention (746% increase in shoulder arthroscopy for impingement over a ten-year span), surgical patients fared no better than those treated conservatively.”

Yup.

Another way to say conservative = non surgical.

I’m going to leave this final quote from the article as the final statement. 👇

“Stop accepting morphology as pathology”

Link to the article