Is my patient crazy? Negotiating Complications in patients

It has been a while since my last post. One of the reasons for this was that I was a victim of a Medical Error that became a Medical Complication.

I underwent an elective and routine oral surgery, wisdom teeth removal and 2 dental implants. Both procedures have a low risk of complication and most folks are back to their routine in a few days.  I expected to be one of them, I was not. 

As it turned out, I was one of the rare cases that developed an infection in my gums as a result of the bone graft necessary for the Oral Surgery. 

There were several distressing factors to my case:

• I was in pain and depended upon medication to manage it for 19 days and antibiotics for almost a month.
• I was angry at myself at choosing to have elective surgery knowing that there is always a chance of complications and not being properly prepared for this possibility.
• The amount of time and energy it took to resolve this problem was absurd. It took almost 1 month as I had to diagnose myself with the help of Google and advice from other healthcare professionals.  
• The most disturbing factor in my case was that my Oral Surgeon implied that I was crazy, instructed me to stop calling the office and suggested that I should go see an allergist.

I learned many things from this experience:

• I have a greater appreciation for what patients go through. I can now relate to feeling helpless when your body turns against you and you depend on medications just to get through the day.
• I also learned that pain meds mask the reason why you have pain and can make proper diagnosis difficult. When I went to my appointments I was on meds and didn’t feel that bad so my doctor did not get to witness me holding my jaw and wincing in pain praying that my meds took effect soon. Knowing what your medication does and discontinuing or change them can help to determine the cause of your problem. In my case my pain started 12 hours after I discontinued antibiotics. My pain decreased in half with antibiotics and anti-inflammatory meds. The pain was 85% resolved and I did not require pain meds when I was placed on the correct antibiotic.  The pain and need for antibiotic resolved completely after the abscess was drained and I finished my course of antibiotics. Therefore we deduced that I had an inflammatory problem that was caused by an infection.
• When speaking with an attorney who represents doctors in cases of malpractice, I was told that in his experience surgeons are reluctant to ever admit that something went wrong with their surgery.  Some may say that this is an ego thing and in some cases maybe it is. I think that if surgeons bring to their consciousness the amount of things that can and do wrong in a surgery, they may be unable to operate.
• In my career I have witnessed many patients who have been victims of complications and or medical errors and discarded by healthcare professionals. I believe there is frustration by doctor’s and others who are expected to know how to help these patients, and rather than admitting that they just don’t have an answer, they chose to dismiss the patient.

As a patient I would recommend the following:

• Do your research. Search the internet for “complications of ________” and/or search your symptoms. See what comes up, disregard that which does not make sense or does not apply.  Consider and share with your healthcare provider the possible reasons for your problem. If they rule out a possibility that seems plausible to you, ask them to explain why they are ruling it out and how they can be so certain. I would have had a quicker resolution to my problem had I done this. Unfortunately, I choose to accept my surgeon’s word that “there was no possible way that I had an infection “without question.
• Be honest with yourself.  Is there any way possible that your symptoms may be psychological in origin? I had to go through this process myself and list the reasons why my symptoms were not psychosomatic to justly discredit this possibility.
• WRITE YOUR CONCERNS/QUESTIONS DOWN ON PAPER AND MAKE SURE THEY GET ADDRESSED DURING YOUR VISIT.  I made this mistake as well. I had my list in my head and got distracted as I became upset by my doctor’s behavior.
• Find an ally. Get another opinion. I was referred by my surgeon to a dentist. Thankfully, this Dentist believed my story, and acted as a liaison between myself and the surgeon. Make sure that when you seek another professional ‘s opinion you are prepared for this visit by bringing all of your medical records and diagnostic tests. (PT’s and OT’s are often great allies).
• Communicate effectively to your health care provider by being concise and fact oriented. Give examples; in my case, I informed my surgeon that this was the sickest I have ever been in my life and the longest time I had been on antibiotics and pain meds. I added that when I gave birth to my daughter I did so without drugs and took a total of 3 Tylenol postpartum.  I don’t enjoy nor have the time in my life to be sick and that while he is the expert in dentistry, I am the expert of me and I believe that something is wrong.
• If you are having an elective or surgery do your research prior to your consultation, ask questions and make sure that you are prepared if circumstances do not turn out favorable.
• Understand that not having the answers and support from your healthcare professional in addition to feeling sick is DRAINING. Do only what you can and manage your energy.
• Get the word out to your doctors, friends and social media. It is an opportunity to get ideas from others as well as a venue to express yourself and share your story.

As a Professional I would recommend:

• Provide your patient with the before mentioned list of patient recommendations.
• Listen to the patient’s subjective history.  The answer or clues to why problem is occurring is usually there.
• If you are unable to help your patient for whatever reason, it is your obligation to tell them and refer them to someone who may help. This is scary territory.  As a highly trained professional you are sometimes expected to know everything. I have a former patient who praises me to this day for admitting that I was unable to help her and referring her to someone who knew how to perform a technique that at the time I was not trained to perform.
• Delicately discuss with your patient the possibility that their pain may be psychosomatic in nature and ask them to explain why they are sure it is not. If you are acting as a liaison with their doctor, you can share this information.  This is a very sensitive conversation, a suggested way to present it to your patient is the following; “you are experiencing some unusual symptoms and while they are real and legitimate, some people may feel that their origin is not physical, lets rule out not only the possible physical causes lets also rule out any possibility of an psychological cause”.  Ask them to list reasons way they are sure that their symptoms are physical in origin and ask them if they believe that there anything positive in going through what they are experiencing
• Ask advice from your colleagues. Use LinkedIn or other social media.  For those of you who have taken courses with the Institute of Physical Art, there is an IPA Google group where therapists share information and ask for ideas about challenging patients. You can request to join at ipa-functional-manual-therapy@googlegroups.com

The Mysterious Gait Deviation

Gait Deviations is one of the most perplexing ADL's to figure out. 

There are so many components that contribute to an efficient gait pattern, determining a patient's dysfunction can be extremely challenging when it come to treating walking problems.

Your patient will just not walk right. Or even better, they will walk perfectly out of your clinic after a session, and walk back in using their same old dysfunctional pattern.

I was dealing with this when I worked with my family member years ago. We were rehabbing at my home in spring time. After treatment, his home program would be to walk along the perimeter of the deck holding on the the railing with one hand and use the cane with the other.

He gait pattern was beautiful.

When he walked with the rolling walker on the sidewalk or 2 canes in the house, he reverted back to what I call his ugly gait:

• A small step length
• Narrow base of support
• Bent knee walking style.
• Slow deliberate cadence

What was going on?

He presented with what I call a Non Structural Dysfunction that was causing his Gait Deviation. What that means is that there wasn't a lack of range of motion due to an anatomical structure or tissue restriction that was physically blocking his range of motion that was causing the Ugly Gait.

It was something else.

Non-Structural Dysfunctions could be due to one of the following reasons:

• Inflammation
• Alignment
• Upper Motor Neuron or Lower Motor Neuron Disease or Injury
• Psychological Dysfunction including Fear
• Severe Atrophy

I noticed the same phenomenon in a toddlers gymnastics class the other day. A little one was walking the low  bean presenting with what I would consider to be a normal gait pattern. Yet when she went on the high beam, she presented with the Ugly Gait.

I realize now that my family members primary dysfunction was not a lack of range of motion, strength or even balance, it was a lack of confidence.

I was treating the wrong thing.

In addition to treating his physical symptoms, I should have also been doing things to boost his confidence and ease his fears. 

When the patient is a "train wreck" where do I start?

I was recently asked my advice on a complicated patient.

Although the patient was young in age and active, their past medical history read like Evil Knieval's (again I am dating myself). The therapist provided a through past medical history in about 3 pages of text.

Obviously both he and I understood that there were numerous areas with the potential for treatment, the question was where to start.

In spite of the therapist's complete description of the patient history, he forgot to include what I feel to be the most important component of the Subjective history. Questions that will be used to not only guide the evaluation, treatment, documentation and progress, but it will let the clinician know where to start, especially with complex patients.

It is: 

"What activities cause your pain and what activities do you have difficulty performing or can you not perform?" If my patient is being evaluated for balance and falling I then ask: "What were the circumstances of your falls or what activities cause you to feel off balance?"

This is usually is the first question that I ask when I meet my patient for multiple reasons:

1. I will now be able to provide functional goals for my documentation which are vital for insurance    reimbursement.

2. I can direct my evaluation to determine why a person is having pain or an inability to perform a task by; taking that activity,  breaking it down into its component parts, and evaluating each one. This will almost always show me the patient's dysfunction that is causing their functional problem or pain. As a result I now know where to start and what to treat. As a result, I can make significant gains in one visit.

3. While past medical history is important to avoid performing therapies that are contraindicated and understanding mechanism of injury, patients can spend their entire evaluation time telling you their life story. In today's healthcare setting we simply don't have the time and this information can be listed by the patient on their intake form.  I prefer to ask direct questions regarding these factors so I am in control of the conversation and can specifically ask the factors that are appropriate for their care right now.

4. While pain often inhibits ones ability to function, once the painful activity has been established, both the patient and I can determine their progress by the patient's ability to perform a certain activity rather than ask "how are you feeling?"

5. Their past medical history may not be a factor in their current functional deficit.

My greatest success using this process of evaluation was on a patient who had sustained multiple falls  resulting in fractured bones on 2 separate occasions. When I asked the circumstances of her falling, I had her safely repeat that motion. When she performed it, I observed that 1 of her feet was coming off of the ground prematurely.

Therefore, the reason that she was falling was that she was losing her base of support with only a slight weight shift.

I then determined why it was happening and treated her in one visit.

In the 3 years since that 1 evaluation and treatment she has not fallen.

It is interesting to note that this patient's fractures were on the opposite side of her dysfunctional foot and if I based my treatment on her past medical history, I would not have been treating the correct side of her body.

If you are not already asking these questions during your Initial Evaluation, give it a try, it is guaranteed to save you time and money while avoiding frustration and confusion.

Is Stretching Bad for you?

Is Stretching Bad for you?

If you are an athlete, Maybe.

Contrary to conventional belief and research in the 1980's and 90's, pre-exercise stretching neither improves performance nor decreases injuries.

Numerous studies have demonstrated that traditional static stretching actually decreases performance in activities that require strength, speed, and power. Studies of strength and power have demonstrated performance decreases of as much as 30% for up to 60 minutes after exercise.

A second major reason that many coaches and athletes still view static stretching as an important preactivity ritual is the belief that it reduces the likelihood of subsequent injury. Yet, A study of lower limb injuries among 1,538 male army recruits found that pre-exercise static stretching had no effect on injury rates after a 12-week stretching protocol.

So if you are stretching to prevent injury, while you are not doing harm, you are likely wasting your time.

Although the verdict is not out yet, other warm-up activities, including general muscle warming exercises
and dynamic active range-of-motion exercises, might be most beneficial in improving physical performance.

Prevent Ear Infections? Just Channel Carol Burnett

Prevent Ear Infections? Just Channel Carol Burnett

Once again I am dating myself here. 

For those of you who remember The Carol Burnett show, she would tug at her left earlobe at the end of each episode (In case you are interested, I have read that this was a way of communicating a hello to her Grandma).

Little did Carol know she may have been preventing ear infections, at least potential ones in her left ear as:

-There are a number of lymph vessels under the ear and tugging of it can help to stimulate lymph circulation secondary to movement and stretching of the skin.

 -A mechanism for ear infections is the blocking of the esutachian tubes. Pulling of the ear lobes facilitates the opening of them.

While there are other mechanisms for unblocking the esutachian tubes, none of the others can be as easily performed on young children as pulling of the ears and it is this population who are most susceptible to ear infections.

They are the primary reason for pediatrician visits, they can be associated with extremely high fevers resulting in visits to the ER, and multiple infections can result in the need for surgery.

It is interesting to note that the motion incorporated in the pulling of the ear lobe is similar to the action performed during breast feeding and it has been well documented in the literature that breastfeeding reduces the incidence of ear infections.

In order to perform this on your little ones, gently pinch your child’s earlobe with your thumb and index finger, tug gently up and down. You can even teach your older children to do this by themselves, particularly after bathing or swimming.

Traps like Mt. Everest?

Traps like Mt. Everest?

You know who I am talking about, the people who have their shoulders so elevated they appear to be trying to clean their ears with their Glenohumeral  joints. (see above)The ones that when you palpate their traps, accessory breathing muscles and especially their first rib, you feel like you need a hammer and chisel to break up the spasm.

They are often high strung; a little stressed out, and may have chronic pain, or even better RSD (chronic pain on steriods).

What is going on here?

Obviously, a lot of things but what these individuals will share is that they are breathing with their accessory muscles, not their diaphragm.  Most simply put these people are not breathing properly.

I calculated that person who takes the average 10 breaths per minute, breathes 16.560 times per day.

The diaphragm can handle this task; it is uniquely designed to do so, as it is both a smooth and skeletal muscle.  Smooth muscles do not fatigue. The traps and accessory muscles of the neck cannot, they are mere skeletal muscles, as a result of this unwanted demand placed upon them they become hypertonic and angry.  

The following is a link to watch the motions of the diaphragm.

https://www.youtube.com/watch?v=hp-gCvW8PRY

Aside from decreasing accessory muscle hypertonicity thus decrease neck and shoulder pain and pathology, other benefits of Diaphragmatic breathing include:

1.  Increased oxygenation
2. Stimulation of the parasympathetic nervous system to elicit relaxation
3.  Decreased emotional stress
4. Improved circulation and improved peristalsis due to the up and down action of the diaphragm on the abdominal viscera.
5. Decreased symptoms of chronic pain patient
6. Decreased symptoms of RSD and other autonomic disorders.
7. The patient has a lot of opportunity to practice (theoretically over 16,000 times per day)

The challenge is that it can be surprisingly difficult to teach. 

Traditional techniques included visualization, placing your hand or another item on your stomach and make it move. These work for some patients, but for the really tough ones I use the following;

3 easy ways to facilitate diaphragmatic breathing:

1.       Elevate your legs: This will put the weight of the abdominal viscera, and facilitate diaphragmatic breathing.

2.       Bend over so that your hips are at a 90 degree angle and make sure to rest your arms on a piece of furniture. Gravity is now acting on the abdominal viscera and facilitating the diaphragm to contract. In the picture below, note that the arms can be bent and supported closer to the trunk.

3.       Make an “OK” sign with your fingers, if you are old enough to remember Sasson jeans it is their logo.  It is called the Gyan Mudra and it is used in yoga and meditation practice to facilitate diaphragmatic breathing. 

If you don't know where to start with your treatment of a chronic pain patient begin the same as a human does as it enters the world, with a diaphragmatic breath. 

Forward head posture, its not in your head

We are a manifestation of our compensations.

Our bodies are experts at adapting to our environment.  They will even adapt to abnormalities within its own system. Unfortunately this adaptive ability may result in disease, injury, dysfunction and eventually disability.

Attempt the following

1.       Rotate your pelvis posteriorly (posterior pelvic tilt) to flatten your back. Make sure that you only move your pelvis.

2.       If you don’t move your thoracic spine or your neck forward,  you will feel like you are leaning backwards as if caught in a strong wind.  

Next:

1.       Keep your entire body stationary and bear 90 percent of your weight on your heels.


Again you will feel as if you are going to fall backwards and in order to maintain balance, you will need to compensate by moving;  either your head, trunk or both forward.

In these examples your center of gravity is being moved back and the body will feel off balance unless it compensates by moving the trunk, the head or both forward.  

The result being a forward head posture.

If the therapist treats the neck, shoulders or thoracic spine, there will be no carryover as the forward head posture is a compensation for their center of gravity being moved posteriorly. 

The therapist must treat the underlying cause of the problem, restoring center of gravity to it proper position in order to have success and carryover. 

In the previous examples a therapist will need to treat:

•  The Pelvis:  to increase anterior rotation
•  The ankle: Increasing dorsiflexion to increase weight bearing into the arch and toes.

    Only then would it be appropriate to treat the neck, thoracic spine and or shoulders.