9/10/2018

MANUAL & EFFECTIVE PATIENT COMMUNICATION

Erik Gregersen, PT, DPT, OCS, CSCS, Fellow in Training

INTRODUCTION ••Who are we? •• Instructor •• Erik Gregersen,Gregersen , DPT, OCS, Fellow in Training •• Teaching Assistant •• Matt Paluchniak,Paluchniak , DPT, OCS, ATC

••Who are you?

1 9/10/2018

TIMELINE

•• 2:00 to 2:15 Intro, Objects, and Rules •• 2:15 to 2:45 Presentation Mechanisms of •• 2:45 to 3:30 Lab Manual Therapy Basics •• 3:30 to 3:45 Break •• 3:45 to 4:15 Presentation Placebo and the Importance of What We Say •• 4:15 to 5:00 Lab Manual Therapy Continued and Manipulation

OBJECTIVES

•• Understand the evidence behind the mechanisms of manual therapy •• Understand the concepts of placebo, nocebo and patient expectations •• Gain an appreciation for soft therapeutic hands and the nuances of manual therapy and actually “feeling” •• Begin to demonstrate the motor skill for performing manipulation •• HAVE FUN!

2 9/10/2018

RULES FOR THE DAY

•• Engage •• Have fun •• Learn •• Expect to provide and receive feedback •• Be open to constructive critique •• Discussion •• This is a safe place •• It is your individual responsibility to protect yourself •• Stop if you do not feel comfortable

WHAT IS MANUAL THERAPY?

http://www.woodbinephysiotherapy.com/images/manualbw.jpg

3 9/10/2018

MANUAL THERAPY

•• “Manual therapy techniques are skilled hand movements and skilled passive movements of joints and soft tissue and are intended to improve tissue extensibility; increase range of motion; induce relaxation; mobilize or manipulate soft tissue and joints; modulate pain; and reduce soft tissue swelling, inflammation, or retraction . Technique may include manual lymphatic drainage, manual traction, , mobilization/manipulation, and passive range of motion .”.”

•• Guide to Practice 3.0, American Physical Therapy Association

MANUAL THERAPY

•• “Physical therapists select, prescribe, and implement manual therapy techniques when the examination findings, diagnosis, and prognosis indicate use of these techniques to decrease edema, pain, spasm, or swelling; enhance health, wellness, and fitness; enhance or maintain physical performance; increase the ability to move; or prevent or remediate impairment in body functions and structures, activity limitations, or participation restrictions to improve physical function.”

•• Guide to Physical Therapy Practice 3.0, American Physical Therapy Association

4 9/10/2018

HOW DOES MT WORK?

WHAT WERE/ARE YOU TAUGHT? •• BioBio--mechanicalmechanical •• ArthokinematicsArthokinematics;; applying manual therapy based off convex/concave on concave/convex rules •• Stretching tight or stiff tissues •• Leg length discrepancy •• Muscle Technique, Osteopathic Lesion •• Subluxation Theory, •• illegal for PTs to use in the state of WI •• PathoPatho--anatomicalanatomical •• Disc herniation in the spine •• Shoulder impingement syndrome •• Patellar Femoral Pain Syndrome (a.k.a. Anterior Knee Pain) •• Lateral Epicondylitis (a.k.a. Lateral EpicondylalgiaEpicondylalgia))

5 9/10/2018

BIALOSKI ET AL., JOSPT, 2018

Bialoski et al., JOSPT, 2018

6 9/10/2018

MECHANISMS OF MANUAL THERAPY MCDEVITT ET AL., JMMT, 2015

•• “…outcomes may further be influenced by interaction between these (biomechanical, neurophysiological, etc.) effects combined with other nonnon--specificspecific factors including patient specific psychosocial factors and patient expectation.” •• Patient expectation •• Placebo, nocebo •• Physical Therapist Equipoise •• Patient Education

CORONADO ET AL., JMMT, 2017

7 9/10/2018

• “The successful use of manual therapy depends on a comprehensive understanding of the complex interplay between multiple inputs, including the patient, the provider, and the environment. Relying simply on biomechanical mechanisms is a recipe for failure.” • “We feel strongly that manual therapy is a useful intervention to facilitate pain-free functional movement. But it is just one treatment option for us to consider, in what should be an ever-evolving skillset.” • Paul E. Mintken, Jason Rodeghero & Joshua A. Cleland (2018) Manual therapists – Have you lost that loving feeling?!, Journal of Manual & Manipulative Therapy, 26:2, 53-54, DOI: 10.1080/10669817.2018.1447185

• “We propose that manual examination skills should be considered in the light of contemporary pain science, and manual therapy as a potential component of a multidimensional intervention.” • “…conducting a physical examination may in part contribute to the perceived credibility of the clinician and help establish trust and a positive therapeutic alliance.” • “Thus, we argue that in most clinical cases a physical examination incorporating manual examination is appropriate.” • “We suggest that where manual therapy is used it should be applied alongside an honest explanation of its short-term hypoalgesic effects whilst challenging any associated biomedical beliefs. Matched home exercises should be employed to consciously move the locus of control to the person experiencing pain.”

8 9/10/2018

• “…we believe manual examination skills and manual therapy interventions need to be aligned with contemporary pain science. A reconceptualization is needed from a model dependent solely on a mechanical interpretation of examination findings and basis for manual therapy, to a contemporary multidimensional, neurophysiologically- based manual examination and intervention which may include appropriately-timed manual therapy. “ • “To eliminate manual examination from the clinical evaluation would mean the loss of important data that can be usefully interpreted in terms of modern pain science, be used to facilitate a person's understanding of their presentation, and guide clinical management as part of a multidimensional approach.” • “Any rationale for manual therapy given to the patient must also be framed accordingly, and language or practice encouraging dependence on a predominantly passive approach should be avoided.” • “However, if these age-old and intensively- acquired skills are used in a manner consistent with contemporary practice, their selective and judicious use still has an important place.” • Rabey M, Hall T, Hebron C, Palsson TS, Christensen SW, Moloney N. Reconceptualising manual therapy skills in contemporary practice. Musculoskeletal Science and Practice . 2017;29:28-32. doi:10.1016/j.msksp.2017.02.010.

• Louw A, Farrell K, Landers M, et al. The effect of manual therapy and neuroplasticity education on chronic : a randomized clinical trial. Journal of Manual & Manipulative Therapy . 2016;25(5):227-234. doi:10.1080/10669817.2016.1231860.

9 9/10/2018

ADDITIONAL THOUGHTS

•• “There are no techniques. Technique is the brainchild of ingenuity for the given circumstance.” •• Geoffrey Maitland

•• “There are no great manual therapists, only great PTs that use manual therapy.” •• Dr. Niall Langridge

PARADIGM SHIFT?

http://blogs.kent.ac.uk/jonw/files/215/04/mech.jp g

10 9/10/2018

USING MT PRACTICALLYPRACTICALLY……

•• What technique do you apply when? •• Many apply techniques based off biomechanical models •• Most lack efficacy •• Most hypothetical •• Seems to have a large neuroneuro--physiologicalphysiological component •• Still, we are not exactly sure how to use mechanisms to prescribe treatment

USING MT PRACTICALLYPRACTICALLY……

•• We would proposepropose…… •• You may initially apply based off your treatment paradigm •• Do not box yourself in •• Utilize extreme caution against detailed explanations for you patients related to biomechanical or or pathopatho--anatomicalanatomical causes of pain and/or mechanisms behibehindnd treatreatmenttment •• Let TestTest--ReRe--TestTest related to a meaningful, patientpatient--specificspecific comparable ssignign guide you •• Apply based off current understanding of pain neuroscience principles and mechanisms of manual therapy

11 9/10/2018

USING MT PRACTICALLYPRACTICALLY……

•• “Manual therapy is a means to an end” •• May create a “Window of opportunity” •• Fisher BE, Piraino A, Lee YY--Y,Y, et al. The Effect of Velocity of Joint MobilizMobilizationation on Corticospinal Excitability in Individuals With a History of AnAnklekle Sprain. Journal of Orthopedic & Sports Physical Therapy. 2016;46(7):5622016;46(7):562--570.570. •• Mitigate pain to help facilitate active intervention •• Calm stuff down to allow us to build stuff up •• Greg Lehman: http://www.greglehman.ca

WHEN IS MT APPROPRIATE? •• “A risk : benefit model can provide a simple framework for decisiondecision-- making through consideration of risk factors, predicted benefit of OMT intervention, and analysis of possible action.” •• Rushton et al., 2013

https://www.tga.gov.au/sites/default/files/product-regulation-according-to- risk -1.gif

12 9/10/2018

MAKING THE BEST DECISION

•• Risk to Benefit Ratio •• Identify the likely benefit •• Acute LBP CPR for manipulation •• Flynn et al., 2002, Childs et al., 2007, Cleland et al., 2009 •• Neck pain CPR for cervical manipulation •• Putendura et al., JOSPT, 20122012 •• Identify the likely risk •• Contraindications and precautions

MAKING THE BEST DECISION

•• “The clinician must accept that the clinical decision is made in the absence of certainty and that the aim of the assessment is to make a decision based on a balance of probabilities.” • Rushton et al., 2013 •• “It is the responsibility of the clinician to make the best decision regarding treatment in these situations using their clinical reasoning skills and consideration of patient preferences.” • Rushton et al., 2013

13 9/10/2018

CONTRAINDICATIONS AND PRECAUTIONS

•• Articular derangements •• Circulatory disturbances •• ArthritidesArthritides:: acute inflammation, RA, •• Aneurysm ankylosing spondylitis •• Anticoagulant therapy •• Clotting disorders •• Hypermobility: dislocation/subluxation, •• Atherosclerosis Down syndrome, CP, etc. •• VBI/CAI •• Ligamentous rupture, spondylolisthesis •• Progressive neuralgic deficit •• Bone weakening •• Disc herniation •• Fracture •• Infections disease •• Malignancy •• •• Osteoporosis/Osteoporosis/peniapenia Pregnancy •• Osteomyelitis •• Active growth plates •• TBTB •• Spasticity PETERSEN, C. and FOLEY, R. (2002). Active and passive movement testing . New York: McGraw- Hill.

HANDS ON LAB CONSIDERATIONS

•• Soft hands/relaxed body •• Focus on quality set up •• Work on creating a standard operating procedure •• Table Position •• Patient Position •• Therapists Position •• Hand Position •• Final minor adjustments •• Provide quality feedback •• Change up partners; different body shapes and sizes

14 9/10/2018

LUMBAR ACCESSORY ASSESSMENT AND TREATMENT

BASICS/PEARLS

•• Patient Comfort •• Standardization •• •• Observation Passes •• Predictable speed and depth •• Introduce your hands •• Communication •• Hand and body/arm position •• Nuances of angles •• Vector •• What do you want to feel? •• Use your body •• Quality, quantity and end feel •• Severity and irritability

15 9/10/2018

16 9/10/2018

LUMBAR UPA’S

17 9/10/2018

18 9/10/2018

19 9/10/2018

PATIENT COMMUNICATION

Erik Gregersen, PT, DPT, OCS, CSCS, Fellow in Training

OVERVIEW

•• Definitions: Placebo, nocebo, therapeutic alliance, •• Enhancing placebo •• Limiting nocebo

20 9/10/2018

DEFINITIONS

•• Placebo: the phenomenon in which patients may improve while receiving a harmless treatment that is without therapeutic benefit. The effects of the treatment are unintentional.

•• Examples?

DEFINITIONS

•• NoceboNocebo:: The negative counterpart of placebo. A patient’s sx’ssx’s worsen after receiving a harmless treatment without therapeutic benefit. The effects of this treatment, are again, unintentional.

•• Examples?

21 9/10/2018

DEFINITIONS

•• Therapeutic alliance: refers to the sense of collaboration, warmth, and support between patient and practitioner. (Ferreira, 2013)

WHY DO WE CARE ABOUT PLACEBO AND NOCEBONOCEBO?? •• Studies have shown objective brain changes in response to placebo •• Top down control of sensory input plays a fundamental role in shaping the global perceptual experience ((BendettiBendetti,, 2007) •• Intensity and severity of sx’ssx’s can be shaped by the psypsychologicalchological state of the patient. ((BendettiBendetti,, 2007)

22 9/10/2018

ENHANCING PLACEBO

Be Optimistic!

ENHANCING PLACEBO

Positive Framing: Explain things in a positive light. The glass is ½ full!

•• Example: While there are side effects, a great majority of patients with your issue respond well to this medication. Versus Five percent of patient’s with your issue will have bloating, cramping, diarrhea, vomiting, nausea, and chills when taking this medication.

23 9/10/2018

ENHANCING PLACEBO

•• Shape patient expectations •• Many patients have no idea what to expect when receiving PT

•• Don’t be afraid to: •• Ask the patient what they expect •• Let them know what is going to happen that day and throughout the progression of their treatment plan

ENHANCING PLACEBO

•• Shape patient expectations •• What if the patient has a negative expectation •• Need to address as soon as possible

•• Expectations of a negative outcome may induce the worsening of a sxsx(s) ((s) ( BBendettiendetti, 2007), 2007) •• When a patient has a high expectation there is evidence for better short term outcomes (Bishop, 2013)

24 9/10/2018

ENHANCING PLACEBO

•• Shape patient expectations

•• When shaping a patient expectations we need to understand that each patients’ expectations are unique •• Patient expectations are shaped by past personal, family, and friend experiences (Bishop, 2013)

ENHANCING PLACEBO

•• Acknowledge patient preferences •• If efficacious and safe, perform •• Increases overall patient participation •• Positively influences their beliefs and emotions •• Increases patient satisfaction

25 9/10/2018

ENHANCING PLACEBO

•• Speak with logic and clarity

•• Do not use medical jargon or complicated terminology •• The unknown is scary

ENHANCING PLACEBO

•• Monitor adherence •• Evidence for adherence: self paying for sessions, paying coco--pay,pay, not missing sessions, attending sessions on time, performing HEP, asks questions within session

•• Adherence is enhanced through a positive relationship with patient

•• What if you do not see evidence for adherence?

26 9/10/2018

LIMITING THE EFFECTS OF NOCEBO

•• We need to limit the effects of nocebo by being aware of the words we are using

•• Being ill inherently corrodes the sense of self, making patient’s vulnerable to the words of their physicians. ((BedellBedell,, 2004)

LIMITING THE EFFECTS OF NOCEBO

•• The goal of our words are to evaluate, educate, and rere--assure.assure. Not to produce fear, anxiety, despair, hopelessness. ((BedellBedell,, 2004) •• Words should convey optimism and help patients take ownership in their own healthcare. ((BedellBedell,, 2004)

27 9/10/2018

LIMITING THE EFFECTS OF NOCEBO

•• Limit the use of medical jargon •• The unkown is frightening •• Example: Degenerative disc disease, Lumbar disc herniatherniationion , fatty lipomalipoma,, Osgood Schlatter’s disease, other examples?

LIMITING THE EFFECTS OF NOCEBO

•• avoid frightening metaphors •• Examples: your heart is a ticking time bomb, widow maker blockage, examples?

•• Bad metaphors can also shape how a patient chooses their healthcare. ((BedellBedell,, 2004)

28 9/10/2018

LIMITING THE EFFECTS OF NOCEBO

•• What happens when we use bad language that induce painful thoughts? •• Studies show that there are increased subjective complaints of pain with complementary objective brain changes through the below described mechanism. •• When we anticipate pain or negative outcome: •• increased anxiety •• increased CCKergic pathway

•• Turns up the volume on pain transmission and decreases endogenous opioidopioid production. ((BendettiBendetti,, 2007)

LIMITING THE EFFECTS OF NOCEBO

•• Why would we use words that harm? •• We are unsure of the patient’s outcome or unsure of the situation •• We are rushed •• We intentionally are trying to create fear to motivate. Example: Trying to get someone to quit smoking •• Unaware, assume everyone knows what you are talking about ((BendettiBendetti,, 2007)

29 9/10/2018

HEALING LANGUAGE

•• How do we ensure the use of healing language? •• Define the problem •• Elaborate on specific interventions •• Ask clarifying questions •• Further rere--assureassure

•• Healing language should bolster the patient’s strengths, validate their perspective, and give the patient the locus of control. ((BendettiBendetti,, 2007)

WHO IS MOST SUSCEPTIBLE?

•• Patients with: •• chronic pain •• back pain •• arthritis •• headaches •• depression •• anxiety

30 9/10/2018

The goal of purposefully using placebo is to enhance the effects of evidence based , not to replace it.it.

ACCESSORY MOBILITY TESTING

•• Compare to opposite side

•• Looking for pain vs. resistanceresistance--thisthis will guide your grade of mobilization if needed

•• Assessment and treatment are the same

•• Does everyone know the difference between physiological and accessory motion?

31 9/10/2018

SHOULDER ACCESSORYACCESSORY--POSTERIOR,POSTERIOR, ALTERNATE

•• Patient supine, arm off edge of table •• Therapists uses distal hand to support the patient’s arm at the humeroushumerous/elbow,/elbow, holding the forearm against their body with their elbow •• Therapists uses both hands to grasp the shoulder applying a posterior force (and slightly lateral) to the patient’s proximal humeral head with the length of both thumbs •• The patients shoulder can be moved into various positions based off symptoms and response

32 9/10/2018

PASSIVE SHOULDER FLEXION WITH GLENOHUMERAL ISOLATION •• Patient supine, arm at edge of table •• Therapists uses one hand to block lateral boarder of the patient’s scapula (before elevating the arm) and grasps at the arm at the distal humorous •• Therapist takes shoulder into endend--rangerange flexion blocking the scapula for upward rotation looking to isolate glenogleno--humeralhumeral flexion •• Alternate “hooked” handhand-- hold can be used to stabilize the scapula (shown)

TREATMENT --LONGLONG AXIS DISTRACTION

•• Patient supine pelvis/body stabilized (alternatives) •• Therapist grasps lower leg above malleoli •• Lifts leg into slight flexion, abdabd,, and IR or ER (alternative hand holds) •• Provide distraction force by leaning backwards •• Graded mobilizations and thrust can be applied for treatment

33 9/10/2018

TREATMENTTREATMENT-- TALOTALO--CRUALCRUAL DISTRACTION MANIPULATION •• Patient lies supine with foot off edge of table •• Clinician grasps mid foot, hooking talus with lateral portion of both hands taking up the slack in lower extremity and joint •• Distraction thrust is performed by pulling caudal and slightly posterior direction

WRAP UP

•• We covered: •• Manual therapy ––howhow does it really work? •• Importance how WHAT you say to patients •• Hand skills •• Soapbox •• Career vs job •• WPTA and opportunites •• Have a plan

34 9/10/2018

THANK YOU!

Contact Information: erik@[email protected] (314) 283283--44594459

35