The Power of Silence

Image Credit: NASA

It is the space between the notes that make the music.  A wash of sound and pitch and tone does not stir emotion or evoke dance and tears.  It is the time taken, and placed, between to the vibrations that add meaning.

It is the silence and expanse of nature and wilderness that allows the existence of city life.  It must be there, a place to go to, or the mind cannot breathe.

When looking at the earth from space, we do not assume the only activity or important part is the part that is lit up.  The darkened areas are alive as well.  This is also the case with fMRI.  Yes one part is lit up, but this says nothing about the importance of the less active or “silent” areas.  They too are playing an important role.

And so it goes for any meaningful interaction, and in particular, care-based interaction.  Silence is the time when the ideas can settle, when concepts can take root, when importance is emphasized.

Mark Reid MD PTBT

We all know that a good history can yield some superb differential diagnosis choices. This can only happen in environmentally appropriate silence.  We already know what we know.  Therefore we can keep quiet about it.  We don’t know what the patient knows… so we must listen.

Alan Ristic PTBT

Silence has a time component.  Perhaps that’s why it’s so hard to come by…

Give silence a chance.

Matt D

How to use Special Tests

In studying for final comps/orals/boards we have come across many special tests that need knowing. We learn how to do them, where to place hands, what indicates a positive, tissues involved, etc.  If we have enough brain capacity after that, we try to remember gold standards in a pathology and how the special tests correlate.  And finally… we attempt to know whether a test is Sensitive or Specific for a certain pathology or impairment. Whew!

The last item is what I would like to focus on because it relates to clinical reasoning an differential diagnosis. Sensitivity and SpecificityContinue reading

Clinical Practice Algorithm: Motor Control Series

greyscale photography of car engine

Photo by Mikes Photos on Pexels.com

More of this Motor Control business.  See the previous Background and Learning post to get caught up.

“Science is built up of facts, as a house is built of stone; but an accumulation of facts is no more a science than a heap of stones is a house.”-Jules Henri Poincare

Practice is built upon theories, as a house is built of stone… Let’s put these theories into practice. Time to build a house….. Continue reading

Osteoarthritis and the Painful Knee: Part 2/2

men s black crew neck shirt

Photo by rawpixel.com on Pexels.com

Ok, so we discussed some of the contributing mechanisms of knee pain in Part 1/2 and we have yet to look at diagnosis, prognosis and treatment.  Let’s see what this prospective article, my main reference for this post series, suggests!

We have postulated that knee pain from osteoarthritis (OA) has three contributing factors: knee pathology, psychological distress, and neurophysiology.  So when diagnosing individuals with knee OA who have pain we must see if these criterion are met.  The authors in the article propose a phenotypical diagnostic thought process since the OA population is heterogeneous and broad.

The patient could present with varying levels of each of the three domains noted above along with a reported pain rating.  Example: a patient may have minimal radiographic changes, high psychological distress and moderate pain neurophysiology (central sensitization, etc) and report a 7/10 on the pain scale.  Another phenotype could present with high radiographic damage, and low distress and neurophysiology and report a 3/10.  This form of diagnosing a patient may help lead to the next two important steps; prognosis and treatment.

The authors do not state how to determine some of the levels in the different domains.  My question: how do you differentiate a person with high radiographic OA evidence with appropriate nociceptive input vs a person with high radiographic OA evidence with central sensitization as well?  I am sure there are diagnostic methods that are appropriate for PTs to administer in this arena.  (post to comments if you have some good guidelines!).  Ok, we continue… Continue reading

Osteoarthritis and the Painful knee: Part 1/2

Nocebo Confession: this image makes my knee hurt!

The recently published prospective (March 2014) Future directions in painful knee osteoarthritis: Harnessing complexity in a heterogeneous population really breaks-down some wonderful concepts about pathoanatomy and pain perception.

The article reports that 50% of individuals with osteoarthritis-like knee pain have positive radiographs for osteoarthritis (OA).  Interestingly enough, 50% of those with positive radiographs for OA have knee pain.  Citing the NIH they quote “it is important to separate conceptually the disease process of OA and the syndrome of musculoskeletal pain and disability.” They also refer to N. Hadler’s paper Knee Pain is the Malady, Not Osteoarthritis, which is a wonderful title indeed!

The authors propose a new conceptual model which is outstanding in breadth and scope.  They delineate the disease process into three contributing categories:  1) Knee pathology 2) Psychological distress 3) Pain neurophysiology.

Knee pathology involves the regular and commonly held positions about OA.  They include the radiographic (X-Ray) evidence, the chondral changes, osteophytes, the joint narrowing, the “bone-on-bone”, the “you have the knees of a 90 year old.” This part of the puzzle obviously contributes, but the relationship is NOT 1-to-1 for pain and dysfunction.  – Try explaining that to someone who has knee pain, has been told they have OA and been told they have the knees of a 90 yr old.  It will be a long discussion. Of course there are the biomechanical stresses on the knee including increased body mass and joint positioning that are implicated in the knee pathology puzzle piece.

The psychological distress part has to do with fear of movement (moving could cause pain!!) and catastrophizing (ruminating over the situation and winding it up into a hypersensitive syndrome) and other factors (don’t want to give it all away, read the article!) similar to other chronic pains.  It is shown that the better the coping mechanisms and the better the positive belief strategies that the patient can employ the better the outcomes.

The pain neurophysiology aspect is… well, please allow me to quote: Continue reading

Iliotibial Band? More like Lateral Knee Pain.

(Credits: This post is inspired by a recent Journal Club discussion)

 image credit from: http://saveyourself.ca/tutorials/iliotibial-band-syndrome.php

The Ilitotibial Band (ITB) pain that many people seek relief from and many of us will treat is a confusing phenomena. The ITB lies lateral to the thigh as a thickening in the compartmental fascia of the upper leg.  Proximally the tensor fascia lata and gluteus medius insert into the band and distally the fascia inserts onto the lateral femoral condyle and the proximal lateral tibia at Gerdy’s tubercle. The ITB also dives perpendicular to the fascial plane to meet and attach to the femur along the lateral linea aspera.  The muscle belly diectly under the ITB is primarily the vastus lateralis muscle and the cutaneous sensory innervation along the ITB is the lateral femoral cutaneous nerve. Continue reading