Lessons from a Student: The Brain

Oh It’s On

Believe it or not, I currently have someone interning with me for the next 12 weeks which is has led me to thinking about many things:

1)      People trust me with the youth of America?

2)      I have to justify what I am doing now?

3)      I hope I can teach her something.

I may have to drink the Hemlock by the end.
I may have to drink the hemlock by the end.

It has been a great and even nostalgic experience thus far. I remember just a couple years ago being in this young lady’s shoes having the same successes, failures, and questions she has now.

That does not mean that I actually wear women’s shoes…unless they are Prada.

I think working with me may have been quite a difference from the scholastic framework that she was accustomed to. This difference is because our common theme for the week was wait for it…………………………………….The Brain.

Most schools, especially in the orthopedic realm, teach about developing physical therapy diagnoses and treating various pathologies. However, we had a couple different cases in which we didn’t necessarily nail down a pathology yet got fantastic results.

Case 1

The first patient we saw was a lovely middle aged woman who was classic for the biopsychoscial treatment model I espouse. She comes into seeing us with chronic low back pain over the past 3 years, has had several TIAs, been diagnosed with an eating disorder, and generally lives a stressful life.  Our comparable sign for the day was flexion which was at 50% range and painful (or DP for you functional movement folks out there).

We discuss what we think is going on and the first words out of my intern’s mouth: Central Sensitization. Music to my ears, I think she will do just fine.

We then return to our patient, explain the pain experience, do some breathing exercises and voila, full flexion and no pain. An eye opening experience for all involved.

Case 2

Our next patient was a middle aged man coming to us for medial knee pain that began while playing volleyball. Upon observation, big findings were general hypermobility with a slight limitation in knee extension on the involved side. Our comparable sign for the day was stair negotiation.

This gentleman came in with the same frame of mind as the lady above, what is wrong with me, what structure is making me painful. His complaints were very vague and difficult to reproduce except for stairs. We perform a similar treatment to above–Explain pain, breathing exercises combined with some hip activation–and guess what happens? Knee extension mobility returns to full and decreased symptoms with stairs.

Once we finished with this patient, my intern asked me what I think was wrong. My answer: It could be a thalamus problem.

I think combo ultrasound clockwise is indicated for that.
I think combo ultrasound clockwise is indicated for that.

In both of these cases above, I could not pinpoint an exact “structure at fault” as we both were often taught in school, yet both patients improved.  I am inclined to believe that more and more that the structure at fault is and always will be the brain.

If you look at most of the research regarding anatomical correlates and pain, it is not so good. Depending on who you look at, 30-80% of asymptomatic individuals have abnormal MRI findings. Pain and structure do not always go hand in hand, and moreover, we are not very good at determining a structure. The most recent editorial in JOSPT by Paula Ludewig and a friend of mine Becky Lawrence discusses this problem, and it is definitely a step in the right direction.

Since we are not so good at finding and probably treating pathologies, I propose instead that we start treating people; people who are undergoing a pain experience that is compounded by multiple factors. That neck pain that fits a closing pattern may not have hurt if they did not undergo a stressful event a week prior. Even though we are always operating under some degree of uncertainty, the way we approach treatment ought to follow a similar step-by-step process:

  1. Rule out any potential red flags. Make sure they are someone you can help.
  2. Reduce threat perception.
  3. Determine the optimal sensory stimulus that your patient/client needs to change the pain experience, since all that we do is provide sensory input (Thank you On Intelligence).
  4. Re-establish optimal motor behaviors and movement to improve function.
  5. Empower the patient/client with the tools they need to take care of their trouble on their own.

More to come.