Critical Thinking

Stop Messing Around and Validate.Interact.

What would you say is the most important aspect of an initial patient interaction?  I would argue that it is validating the patients concerns and chief complaint.  I suspect this is true for any field of medicine but it is most definitely true in Physical Therapy.

One way we can validate the patients concerns is by demonstrating the ability to reproduce their chief complaint; as well as reduce it.  In my clinical expertise, this is the most important aspect during an initial examination (and during many subsequent sessions).  Maitland described this as the Comparable sign, which is defined as: “any combination of pain, stiffness and/or spasm, during a specific movement, which the examiner finds on examination and considers to be comparable with the patients symptoms” (Maitland).

Patients need to be reassured what they are experiencing is “real”.  In and of itself, that concept has phenomenological undertones, but in reality, their experience is their experience.  As therapists, we must simply attempt to understand their experience, demonstrate that we are attempting to understand it and attempt to help guide them in altering it.   I suspect many of us can become fixated on looking for so-many variables that “we become overwhelmed by the noise“.   This deductive process could easily be refined to a simple algorithm:  Rule out major pathology–> Discover the chief complaint –> Reproduce it –> Attempt to alter it –> Check if we altered it by attempting to reproduce again.

Sure we love special tests.  But in the process, do the results truly alter our clinical approach as described above (suspecting we truly perform clinical tests in the fashion in which they were validated—if they even went through this process)?  For example, if two people present to the clinic with a similar presentation of shoulder pain, but one has a positive Hawkins Kennedy and the other is negative, does the clinical approach change? Don’t get me wrong; special tests have a necessary role in practice and should be utilized to “Rule out major pathology—described above”.  I simply suspect an overabundance of unnecessary tests can mutter one’s thinking and stray us away from truly attempting to alter their experience.  What would happen if we stopped testing; and simply began interacting (test–>treat–>retest)?

What are your thoughts?

Maitland GD, Vertebral Manipulation, London, Butterworth-Heinemann, 5th Ed, 1986

 

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7 replies »

  1. The only thing I would argue with you is that you algorithm is for a mechanical pain, so first I would try to identify the main pain mechanism and if pain has a peripheral source (nerve or other tissue) I would try to reproduce it.

    • Sure. If we were to utilize the three mechanism classifications that are contributory to pain, as validated by Smart et al., nociceptive and peripheral neuropathic would be the two classes this algorithm truly would work for. The outlier, central sensitization, is a little more challenging. That stated, we could simply remove the “reproduce it” variable (secondary to having wide-spread regions that are unpredictable in provocation) and instead look for reduction mechanisms during our examination. I suspect reducing discomfort is likely as powerful as provocation and potentially the only necessary variable for this class.

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  2. Awesome post Joe, couldn’t agree more. I think special tests are more important in ruling out major medical pathology than their role as provocative tests. Special tests play a role in first order clinical decision making (rule out lumbar, rule out neurodynamics, rule in peripheral joint), but I don’t think many tests are needed to do this. Performing too many provocative tests can be detrimental because we’ve then shown the patient that their shoulder hurts in all different positions and motions; and we don’t want to provide that negative input of reproducing/provoking pain. What role does this have on their current state I’m not positive, but it could be suggested that this may lead to decreased motion and fear avoidance type behavior. Also too many provocative tests can definitely give “too much noise” leading to a biomechanical game of hide and go seek.

    I’m more of a fan of “relief tests,” finding things that reduce the symptoms can be just as important as finding tests that provoke it. Relief tests give the clinician some solid info, don’t provoke symptoms, and provide a good input to the neuromatrix. They also lead in HEP well, if something feels good in the clinic then that’s where I’m going for HEP. Introducing as much good input as possible. The most important thing we can do in the eval is validate their pain, keep provoking symptoms to minimal, treat and find something that improves symptoms and start there.

  3. Usually that works, and it is my preferred method. However, there are times when you can’t use a comparable sign. One example is a patient with neck pain due to rotator cuff weakness. You can “find” the neck pain, but actually strengthening the cuff and showing them that it will relieve their neck pain will take some time.
    The fewer tests used, though, probably the better. Using only tests with good LR ratios would cut Magee’s text by 75%.

    Remember also what Gayle Deyele calls “ticks and fleas.” Someone like has referred pain from a disc AND hamstring tendinitis or C5 referred pain AND cuff issues. In those cases, they may have 2 comparable signs.

    • How do you discern that neck pain is “from” RTC weakness and not vice versa? I would argue you can almost always find some sign, usually a direction of movement, that is main aggravating symptom. You can then treat and reassess that movement for increase ROM or decreased pain (for example) as your assessment for intercession change?

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