Issue link: https://www.massageandbodyworkdigital.com/i/1402696
movement assessments before beginning to treat the patient with a combination of electrotherapy and massage. He did neither, but he did question her closely on the quality, pattern, and behavior of the pain. On palpation, he located some tender points that elicited a twitch response in the patient's levator scapulae, supraspinatus, and rhomboids, and gentle massage gradually eased the patient's discomfort. A one-hour session using electrotherapy modalities combined with massage seemed to resolve the acute phase of the hand/forearm complaint. The patient refused acupuncture, and said she was unlikely to maintain an exercise regimen. Can this therapist be said to have followed an evidence- based medicine approach, based on this description? What would you have done differently? BIOPSYCHOSOCIAL DETAILS This was a highly educated patient, aware of the basics of physical health, comfortable with scientific terminology. She had struggled with cervical pain for many years, and more recently, lower back pain due to work-related strain, and the therapist had unsuccessfully encouraged her before to attempt to adopt a gentle exercise regimen, but she had not done so. The patient had no outside assistance for manual work around the home, was strongly independent, and saw the idea of seeking help as weakness. This episode had made her fearful, as prior to seeing the physiotherapist she had seen a series of specialists, fearing an autoimmune condition. Though her lab work had come back clear, she had endured several months of limited functionality and constant low-grade, occasionally acute pain, and was concerned that this might lead to sensitization. The patient's sleep pattern was inconsistent and poor, and she worked long hours at her desk. She had previously experienced a series of family bereavements, ongoing caregiving responsibilities, a partner with chronic pain and mobility issues, and a relocation involving a lot of heavy carrying. Though these events had occurred over a year prior to the presentation of these symptoms, they may have resulted in stresses, tensions, and strains reflecting both physical and psychological trauma. The therapist questioned the patient regarding daily activities, the pain onset and pattern, and her openness to following an exercise regimen. He also sought her preferences regarding treatment options. Discussion revealed she often carried heavy shopping bags and lifted heavy objects, and her office chair was the likely cause of coccygeal pain and cervical tension. The therapist emphasized the weakness of her back muscles, the compensation occurring due to this, and reminded her of previous visits due to cervical pain flares. On inquiry, the patient was already aware of the anatomical interactions making this muscle weakness an important target for intervention. The therapist restated the reasons and benefits for making certain lifestyle changes, acknowledging the patient's resistance to doing so, but did not provide a solution to overcome that resistance beyond demonstrating a couple of easy exercises to perform at home. After this session, the patient bought a cart to carry heavy loads and shopping bags from her driveway to her door, and began getting outside paid help for the heavier yard work. The following winter, she wore gloves indoors to guard against the Raynaud's symptoms, which had previously triggered digital joint pain. She bought a new office chair, paid more attention to her sitting posture, and guarded the painful arm, favoring the other whenever possible. Within a few months she had put on several pounds (going up two dress sizes), continued to avoid exercise, and her sleep continued to be patchy. A year after this episode (there had been no recurrences), she still favored her "good" arm and continued to avoid the heavier tasks she had done in the past. She did not seek further help. Exercise Note your answers to the following questions before reading further. • Have the therapist's attempts at helping this patient make lifestyle corrections been successful? • Where did they succeed, where did they fall short, and why? • What would you have done differently, based on the information above? • What information is still missing? L i s te n to T h e A B M P Po d c a s t a t a b m p.co m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 41 Can this therapist be said to have followed an evidence-based medicine approach, based on this description? What would you have done differently?