A Pain in the Nut(s)

A quick note from Sarah: We’re pleased to present a blog post from a non-pelvic PT! We’ve had great chats with Steve at PT Pub Nights in the past, and were thrilled when he asked about sharing his experience. Of course, I’m personally always happy to see more support for my feelings that ALL physical therapists are pelvic health therapists is some small way. I’d also like to apologize to Steve, who wrote this blog quite sometime ago, and I have been slow to publish. Thank you for your post, and your patience!

A Pain in the Nut(s)

Steve Goostree, DPT, OCS, Cert. MDT, FAAOMPT
stevegoostree@gmail.com

I was inspired to write up and share a case I recently encountered after a conversation at PT Pub Night, sponsored by the lovely Sarah Haag and Sandy Hilton of Entropy Physiotherapy.

The patient was a healthy 24 y/o male that reported to PT with primary complaints of right testicular pain. He was referred by his PCP after a routine physical examination, which deemed his testicular pain as non-sinister. No imaging had been obtained, and the patient was not taking any medication. Past medical history was insignificant. He noted a recent gradual onset of right testicular pain after starting a new weightlifting regimen in the gym within the past month. The patient scored low on the Yellow Flag Questionnaire, indicating low psychosocial factors contributing to his pain. Special questions including bowel and bladder habits, swelling or change in structure were all negative. The patient did report a sedentary desk job, where he felt some lower back stiffness, which resulted in an increase in his testicular symptoms as th day progressed.

Being trained as an orthopedic manual PT, I was slightly uncomfortable performing a male pelvic exam, and was taught to always rule out the spine first as a primary source of referred pain. Before making this an uncomfortable experience for the patient and myself alike, I trusted my gut and screened the lumbar spine first. Having the patient actively cough was used as a symptom provoking baseline.

Lumbar AROM with overpressure was normal, except a positive right lumbar extension quadrant with overpressure, resulting in familiar right testicular complaints, rated 5/10 via NPRS. Sensation, myotome and DTR testing were all normal. Right unilateral passive accessory mobility pressures near L2-3 produced familiar symptoms radiating to the patient’s right testicle.

A repeated movement examination of the lumbar spine was performed next. After 30 repeated extensions in lying with clinician overpressure, the patient was asked to sit up and cough. He noted a decrease in symptoms. A right lumbar quadrant test with overpressure was reassessed, and the patient now noted a pain level of 2/10 via NPRS.

The patient was issued repeated extension in lying, using a belt for self overpressure 10 reps 5-6x/daily. The patient was seen for 3 visits, which included oscillatory mobilization targeting the right upper lumbar segments (Gr. III per Maitland) and a HEP following the lumbar extension principle with progression of forces as needed. Proper lifting technique in the gym was also reviewed as recovery of function. The patient stated he was ready for discharge after visit 3.

This brief case highlights the importance of a thorough spine screen for the orthopedic and pelvic health therapist, which is quick, easy and should be a day one priority for any neuromusculoskeletal complaint. The exact mechanism as to why this intervention was effective is unknown, but reviewing the photo may explain things anatomically. As always, further research is needed.

An open letter to my patient’s previous therapist(s):

I’m currently seeing a patient of yours – a young person who is having some pain in their pelvis.  I am quite aware that often times our patients hear something different than what we say, and sometimes what they recall being told isn’t entirely accurate.

During the initial evaluation, the patient shared some past experiences and noted that there was short-term relief, some variation of symptoms which was taken as a sign of progress.  This made me very happy, as it was felt therapy in the past had made a slight, but positive, difference.

Then we spoke of what goals they had for therapy.  Other than to stop hurting, this patient wanted to run, do CrossFit, go to college and ride a motorcycle.  To me, these goals sounded amazing and perfectly achievable.

It broke my heart when they looked at me with surprise and disbelief.  They had been told to not to go to college but to stay close to home.  To sell the motorcycle and use the money for something that ‘wouldn’t make them worse’.  To not do CrossFit as that was too intense and would certainly increase the pain.

I don’t often share my feelings, but this outrages me.  Our only job as Physical Therapists is to help people do what they want to do.  That’s it.  We go to work every day to help people do the impossible – walk after a spinal cord injury, return to work after a stroke, regain independence after catastrophic medical or traumatic events.  If you don’t believe in the resilience and strength people have, and you don’t think people can get better, why on Earth are you in this profession?

But before me sits a young person, with no identifiable medical condition.  They just hurt.  And a colleague in my profession told them to give up. To be careful. To stop doing anything that might increase pain.  Remarks like that are the opposite of our job.

I can understand the desire to help and to protect people from more pain. However, that’s not how pain works.  Pain is an experience a person has.  We know that doing things you love can make people feel better.  And you’ve stolen that away from this person – by making them scared of the very things that could make them feel better.  Or at least feel more like them.

I wanted to bring to your attention that the people who don’t come back aren’t always ok.  That sometimes they’ve gone elsewhere because they want to do more than ‘not hurt more’, they want to live.  I’m not sure I can help this person recover, but I can promise you I’m unscaring them as best as I can, so they can get back to doing the things they love.

Thanks in advance for trying to stop scaring people in the future,

Sarah

Pelvic Health PHODA - What is it and how can it help?

Finding the “right” areas to address when working with any patient is a challenging task for a health care provider. What is important to that patient? In what area can we work to make progress so that there is a meaningful change and impact for that individual? When the patient is open, shares, and can pick out a specific activity or experience in which they would love to engage in again or for the first time all I must do as the provider is listen. But what can I do when the patient cannot articulate their goals because there are too many things, or it has been so long that all they want is for the dysfunction or pain to end?

That is when I use the Pelvic Health PHODA (Photographs of Daily Activities). Sandy first gave me the idea to create a PHODA for pelvic health after we discussed the original version during a course by Cory Blickenstaff. She had been wanting to have one for several years but had not yet found the opportunity to create the cards. A little while later I found myself stranded on my way back to the clinic from my home in Northern Michigan just after Christmas. My car broke down and instead of going to work for the next few days I headed back home until I could find an alternate route to Chicago. When I told Sandy about being stranded she said, “Work on PHODA”.

To begin I did some research on what versions of the PHODA exist and how they are used. It has been validated for use on patients with high and low levels of Kinesiophobia (Trost et al, 2008) where the modified version was used. This version has 20 photographs compared to the 100 in the original version. There is also a version that was recently validated for use with the pediatric population (Verbunt et al, 2015). This version looked at activities specifically important to youth with musculoskeletal pain and how harmful they perceived certain activities.

During my search I found the modified version, the original was by Kugler et al, for download on-line. My impressions after un-zipping, installing, and using the file were not positive. The background is a horrid mustard-yellow, the pictures are small and outdated, and you have to use all 40 images in order to complete the test. The experience was off-putting with the nauseating color scheme and the repetition of similar images that all had to be placed on a scale.

What I envisioned was a tool that would allow patients to pick images out that resonated with them, how ever many they would like, and then lay them out in terms of easiest to hardest. This then serves as a tool for the clinician to focus treatment and for the patient to zero in on what they are looking for from physical therapy. So I set about finding pictures of a variety of daily activities that patients have reported loving, hating, or wishing they could do that thing.

When I use them with patients I say, “Here are some photographs of activities. Please pick out ones that appeal to you. Then place them from no difficulty to very challenging based on your reason for coming to physical therapy. I don’t care how many you chose but I would like at least one at each end of the spectrum. Then we will talk about why you chose each card.” I want them to feel free to pick 2 or 54 cards. Then I can use their own choices as a guide for treatment.

Eventually I would love to validate these cards and their specific use for the treatment of pelvic dysfunction. Bronwyn Thompson, PhD, MSc (Psych) 1st Class Hons, DipOT, Registered Occupational Therapist has a great article on validating PHODA for use in New Zealand.  For now I use them in conjunction with other outcome measures using the photos to gain insight and target my treatments to best serve each individual who comes through the door.

Hannah Mulder is a 3rd year DPT student from Rosalind Franklin University, doing an amazing job of applying research to her practice, as well as making excellent snacks for the courses at Entropy.  If you're interested in a set of your own PHODA for the Pelvis cards, you can buy a set now!!

References:

Trost Z, France C, Thomas J. Examination of the photograph series of daily activities (PHODA) scale in chronic low back pain patients with high and low kinesiophobia. Pain (03043959) [serial online]. February 2009;141(3):276-282. Available from: CINAHL Complete, Ipswich, MA. Accessed January 22, 2018.

Verbunt J, Nijhuis A, Goossens M, et al. The psychometric characteristics of an assessment instrument for perceived harmfulness in adolescents with musculoskeletal pain (PHODA-youth). European Journal Of Pain [serial online]. May 2015;19(5):695-705. Available from: PsycINFO, Ipswich, MA. Accessed January 22, 2018.

Kugler K, Wijn J, Geilen M, de Jong J, Vlaeyen JWS: The Photograph series of Daily Activities (PHODA). CD-rom version 1.0. Institute for Rehabilitation Research and School for Physiotherapy Heerlen, The Netherlands, 1999

HealthSkills Blog

It's prostatitis... or is it??

Hey Fellas!  This one if for you! Prostatitis is one of those diagnoses that may be given to a man who is experiencing discomfort 'down there'.  Men with this diagnosis have described their discomfort as pressure, burning throughout the saddle region, of 'like sitting on a golf ball'.  Functional complaints range from decreased stream when urinating, urinary frequency or urgency, 'never feeling empty', as well as various forms of sexual discomfort and dysfunction.

Usually the diagnosis of prostatitis  is made by a urologist.  A very common course of care is a combination of antibiotics and Flomax.  The antibiotics are to treat any infection that may be causing the inflammation.  The Flomax is to relax the smooth muscles in the urinary tract to improve urine flow.  When this works - it works!!  Unfortunately when it doesn't work men are left wondering what they can do...  or resign themselves to just dealing with their complaints on their own... or taking antibiotics again and again.  The worst thing is when you're doing the things you're supposed to be doing and it doesn't help.

If you'd like to read more about prostatitis, you can check out this blog post.

If you'd rather, you can check out this short video.

[embed width="320" height="240"]https://youtu.be/eA_GYqAbFOo[/embed]

To my cab driver– I meant it, that doctor did not tell you the truth:

Dear sir,  

I appreciated your kindness in making sure I had my seatbelt on.  And the humor about directions (you were right, it was the Northeast corner).  Your conversation about weight loss and getting shorter as we age was fun (keep moving and Pilates is a fine choice if you like it).  

But that thing just as you stopped at my place – we need to pull that apart, and I hope you do come to read this.  For the rest of you, it went like this:

Cabbie:  You’re a PT? Do you know anything about stiff muscles and trigger points?  Because I’ve been told that I have this thing wrong in my neck that is Myofascial trigger point something or other and that it will take a lot of treatment to get better.

Me: I know a bit about that, what else did the person say?

Cabbie:  Do you know ____________ ? She told me I need Saline solution injected into the trigger points and maybe cold laser.  But it’s expensive and she said it would take a long time to help and I’m not sure.

Me: No.  Don’t do that. There’s not good evidence for it, and there are better (more effective) ways to get you feeling normal – and most importantly, things you can do for your self so that you don’t need multiple visits for lots of money.

<I wrote the clinic information on the back of my receipt – I hope you do call!>

Cabbie:  Can it really get better without injections?  She said the trigger points are making it so the muscle is touching some nerves and that is bad.

Me:  Please call me!  I HOPE the muscle is touching those nerves, since they run through the muscles and are hardy things.  I can help you, without injections and teach you how to take care of yourself.

He drove off, and I am sitting watching the sun set thinking how wrong and indefensible it is for health care practitioners to be selling such unfounded stories to people who should instead be helped honestly and kindly.  Saline injections have no evidence to support their use.  There’s compelling evidence that we should all toss the term Trigger Point (Travell and Simons did NOT do proper study and there’s a recent chapter about pelvic trigger points where the author clearly states that Simmons and her “extrapolated” the pelvic trigger points… ) See this and this and this.

I promised him that I could help him learn to take care of himself and that if he didn’t see positive change in 6 visits or LESS, that we would not keep going. It’s Easter.  Let’s hope for a miracle and a shift in health care away from celebrating passive treatment and words designed to create passive (and fearful) patients – let’s aim for active change and self-empowerment.  I’m all for gentle, kind manual therapy to unstick the stuck spots – and for teaching people how to do that for themselves. For cabbies (and everyone else).

Sandy

What to Look for When You're Looking for Help with Pelvic Pain

Pelvic Pain can be hard to deal with.  The amazing amount of information (both good and bad, accurate and inaccurate) can be overwhelming.  How do you wade through everything and find the help that is right from you? Here are a few suggestions that you may find helpful.  Remember:  If you feel scared or hopeless, you’ve just not yet found the right person to help you.

Medically Induced Healthcare Issues

Healthcare can do better....

This weekend I had the good fortune to attend  a wonderful course, Comprehensive Management of Bowel Dysfunction.  As a pelvic health physio, patients with gastrointestinal, digestive, and bowel issues are always challenging.  And the fact of the matter is, if you ask your patients (even the ones coming to see you for their knees), they’d tell you about their bowels.

As much as I love talking about bowel issues, one of the most profound things that I experienced in this class was a completely comfortable, completely pain-free vaginal and rectal exam.  That’s right, even the rectal exam.

It got me thinking about what my patients go through on their quest for health.  The exams they experience, the things that they are told about their condition, and the testing they must endure are unfortunately unhelpful.   Many patients will come into the clinic ‘worse’ after visiting their physician for a recheck, or after undergoing ‘further testing’. Why are the examinations and tests people are put through making them worse?

In our clinic, we’ve started referring to these as ‘medically induced conditions’.

We unfortunately see this often.  Patients traumatized following their medical interventions or hospitalizations or physical therapy treatments.  Why does this continue to happen??  Is it necessary to ‘get worse before you get better’?  Is it necessary to endure further testing?  Here are some thoughts and questions for patients and clinicians to ponder.  I hope it makes clinicians (physios, physicians, anyone touching a patient ever) reflect and reconsider their actions/suggestions/prescriptions.  I hope it makes patients speak up if they’re being hurt.

1. If you poke anything hard enough, it’ll probably hurt.  This goes double for poking into any orifice.
2. Poking something hard enough to make it hurt won’t necessarily tell you what to do to help that person.  Especially if the person has already told you, ‘it hurts if this bit gets poked’.
3. Testing should be done to help rule out red flags, or to help direct the plan of care.
4. Patients should understand why they’re having a test, and understand how the results will impact their plan of care.
5. Clinicians should take the time to make the healthcare experience better.  Make the patient comfortable.  Take the time to explain what you’re doing.  Take the time to answer the questions.  Pay attention to verbal and non-verbal indications that what you’re doing to them is causing pain.
6. If a patient says ‘ouch, that hurts’, or they’re squirming on the table, stop hurting them.  Take a minute and reflect on what might be happening, and why in spite of your perfect technique this patient is not feeling better.
7. If a patient isn’t getting better, doing whatever you’re doing harder, deeper or more often isn’t likely the answer.

I have a hopeful heart, that even when patients have negative healthcare experiences, the healthcare practitioners are basically good people with good intentions.  There are a lot of us who also fancy ourselves to be wonderfully qualified:  specializations, advanced degrees, conference and course attendance trying to acquire  new knowledge, new skills, and new evidence to educate those patients.  Professional development (heck, learning in general) should be life-long.  However that knowledge should not replace common sense and good manners.