The Sensitive Nervous System Chapter VII: Assessment with a Place for the Nervous System

This is a summary of Chapter VII of “The Sensitive Nervous System” by David Butler.

Education

When it comes to patient education, there are four things that every patient wants to know:

1)      What is wrong with me?

2)      How long will it take to get better?

3)      What can I do for it?

4)      What can you (the clinician) do for it?

When we do educate, we must not forget that pain is a biopsychosocial phenomenon and multifactorial. The onion skin model below provides a good relationship analogy for this.

noinotes_img_1008
Courtesy of Explain Pain

The first goal addressed in education is making the patient understand pain.  Patients must realize that pain is the defender, not the offender. It is our body’s way to perceive a threat. Therefore, we must quell this fear before focusing on function. Here are some suggested ways to describe pain in non-threatening ways.

  • Back trouble.
  • Neck discomfort.
  • Twinges.
  • Feelings.

When obtaining pain information from our patients, this is something that we do not have to measure. Instead, it is important to look at variables associated with pain, namely.

1)      Geography & nature, aggravating/relieving factors, links.

2)      Mechanism of injury.

3)      Explore how patient’s classify their symptoms (e.g. my joints are worn out), and ask why they think the symptoms still persist.

4)      Consequences of the pain.

5)      Coping types.

6)      How the patient relates to pain (do they get angry or play the blame game).

When determining treatment course, instead of focusing on the structure at fault, look at sensitivity and function. We treat pain mechanisms, not sources. The way to classify sensitivity is by determining if the patient’s symptoms are nociceptive, peripheral neuropathic, or central-dominant. When looking at function, we look at general, specific, and mental qualities.

The Three Types of Function/Dysfunction

1)      General – What are physical activity levels and favorite activities? How do their goals relate to these components?

2)      Specific – Objective findings. These impairments have a heavier focus in acute pain than chronic.

3)      Mental – Fear, anxiety, coping, attitude.

Your patients may have problems in one or all of these areas to one degree or another, but the biggest question a clinician must ask is if these dysfunctions are adaptive or maladaptive to pain.

Poor Outcomes 101

There are several factors that contribute to poor outcomes, many of them involving mindsets towards pain.

  • Belief that back pain is harmful or potentially severely disabling.
  • Fear-avoidance behavior and decreased activity.
  • Low mood and social withdrawal.
  • Expecting passive treatments over active participation.

Why Perform a Physical Exam

There are three reasons why you should perform the ultimate manual therapy, a physical exam:

1)      Movement is how you engage the patient, and they expect it.

2)      Support/reject subjective findings.

3)      Allows for reassessment of patient’s problem. It helps show how you may be able to help them.

Give the patient what they want.

The Neurological Exam

1)      Nerve palpation.

2)      Nerve conduction – dermatome, myotome, reflexes. Use language like “That’s strong” to let the patient know the results.

3)      Neurodynamic testing.

Neurological Exam Precautions

In acute stages, proceed with caution during your exam. Any pinching or elongating movements could aggravate the symptoms. If a severe nerve injury seems plausible, continually retest findings.

In chronic stages, repeated movements probably are not necessary, as they could potentially aggravate central sensitization.

Realize that there are certain pathologies that can affect the nervous system and impact prognosis, namely diabetes, rheumatoid arthritis, and Guillan-Barre.

Lastly, the most important thing you can do is refer out patients inappropriate for your services. These would include any upper motor neuron signs or symptoms of a tethered cord.

If you see this, punt to the ER ASAP.