When You SHOULD NOT Treat Your Patients Thoracic Pain

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When I was in physical therapy school, PTs in the States didn’t have direct access. 

I figured I needed to mainly focus on differential diagnosis of musculoskeletal issues and not worry about cancer or visceral referral pattern.  However, the States slowly has been adopting direct access for physical therapy and I also learned that regardless of having a referral, physicians don’t always spend enough time with patients to properly rule out other causes. 

The purpose of differential diagnosis is not to just identify a specific structure involved, but to also help determine prognosis, other psychosocial factors and to rule out serious pathology and identify conditions not appropriate for physical or massage therapy.

My patient was in her late 20’s and 6 weeks postpartum.  She had been having mid-thoracic pain and right scapular pain for almost 12 weeks.  Her physician sent her to therapy to receive manual therapy and strengthening. 

During the examination, I had difficulty reproducing her pain, but she stated her pain was worse at the end of the day after lifting, carrying and feeding her child all day.  She had weakness in her extensors and scapular retractors.  Even though I couldn’t reproduce her pain, I gave her some stretching and started some scapular stabilization exercises.  I figured her pain was from a sudden increase in lifting and carrying, sitting with her child and a change in her chest size.

Admittedly I treated her for 3 follow-up visits (with little change) before I realized what the problem was. 

On the third visit, her husband said: “I just don’t understand why the pain is always so bad late at night.”  He was more specific than she had been (end of the day).  The pain was late (10 pm) and often caused his wife violent vomiting.  That minute the lightbulb went on (and according to my patient I shouldn’t play poker because she knew!).  I asked her if she had ever had a White or light stool, she denied it, but her husband said: “don’t you remember the one when you were pregnant?”  She had a white bowel movement back when she was about 26 weeks pregnant!  She had denied pain anywhere else, but the minute I palpated her upper right abdominal quadrant she jumped off the table and reported radiation to her back/scapular area.

There it was….GALLBLADDER!  

She was admitted to the hospital an hour later and was in surgery 4 hours later.  The surgeon said she was days away from a rupture.

Quite honestly, I felt like an ass. 

I had seen her for 4 visits total before the husband had said the words that made gallbladder click in my head.  I realize she had seen both her Obstetrician and her Primary Care physicians prior to coming to see me, but that did little to make me feel much better at the time.  I had just started treating pregnancy and postpartum and couldn’t believe I almost missed something so important!  I went back and reviewed all my red flags and visceral referral patterns after this incident. 

I also share this story with every obstetrics in therapy class I teach.

Also, women and men often present differently with visceral referral patterns.  For gallbladder, women tend to have more vomiting than men.  Also, during pregnancy, the increase in estrogen leads to an increase in cholesterol in the bile and estrogen reduces gallbladder contractions.  The decrease in contractions leads to less bile leaving and an increased risk for gallbladder stones.  This can lead to severe pain and potential for infection.

Summary of Gallbladder symptoms:

  • Chills and/or low-grade fever
  • Dark colored urine
  • Jaundiced appearance
  • Light-colored stools
  • Nausea and vomiting (especially at night)
  • Stomach pain particularly after a high-fat meal
  • Right shoulder/scapular, mid back pain

We are never going to be perfect, but the goal is to learn from past patients and pick up on patterns faster the next time.  It also helps to share our experiences.  So keep these risk factors and symptoms in the back of your mind the next time your patient’s mid thoracic pain isn’t making sense! 

Articles Of The Week December 30, 2018

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New This Week

Our friend Ellie Somers talks training female runners. Do you have clients that don’t seem to be reaching her potential?  Here’s some info that may help her out:

3 Common Training Pitfalls Made by Female Runners

It’s the New Year and resolutions and diet crazes abound.  If we have a working liver do we really need to detox?  A Canadian professor of health law and science policy Timothy Caulfield put some of the most popular detoxes to the test:

The Delusion of Detoxing: There’s no Evidence to Support Holiday Cleanses, Experts Say  

 

The MTDC Year in Review

December: Myofascial Release: An Evolving and Simple Definition  

November: How Much Neuroscience Do We Really Need?  

October: Altered Skin Colour and Circulation, Result of Massage or Nervous System?

October: Predictive Coding: Why Expectation Matters for Movement and Pain

September: 4 Tissue Loading Progressions to Help with Knee Pain

July: Understanding Depression, Ways to Recognize and Help

May: Where Does the Social Fit in Biopsychosocial?  

April: Tissue Loading for Acute Injuries

April: Pathologizing: Our Words Matter

March: It’s Time to Start Building Your Tribe  

February: The Difficulty of Challenging Our Beliefs  

February: 6 Ways to Develop Leadership as a Massage Therapist  

January: Three Reasons It Matters Why a Treatment Works

Articles Of The Week December 9, 2018

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We know that pain isn’t always caused by tissue damage (although sometimes it is), but what about traumatic experiences? Is there a link between trauma and pain? It turns out that traumatic experiences can alter the way our mind and bodies function, which is outlined with several different conditions within this post.

“Trauma And Adult Pain – What’s The Connection?” – Joe Tatta

It’s the time of year where people start getting colds and are looking for something that will “boost” their immune system. But is this really possible? and what are these products really doing? It’s a long one, but lots of insight in this post.

“Boost Your Immune System?” – Mark Crislip MD

For any of you who have worked the sidelines in sport, this one is important to you. It’s more than just a fanny pack that gets worn on the bench, it’s a full on first aid kit with medications, tape, scissors, and a host of other things necessary to help athletes get through competition.

“More Than A Fanny Pack” – Jason White

We all know the importance of strength training, but some athletes worry how it will affect their performance, rather than realizing how much it helps. This post goes through some specific exercises runners can do, as well as how to properly progress them.

“How Can Strength Training Help Runners?” – Mike James

We have discussed several times on this blog the importance of tissue loading for healing injuries. A randomized control trial showed that unprotected weight-bearing post ankle surgery had better outcomes and returned to sport quicker than those who didn’t. LOAD THOSE TISSUES!

“Ankle Surgery Patients Should “Get Up And Walk” To A More Functional Life After Surgery” – Danielle. M. Torp

 

Myofascial Release: An Evolving And Simple Definition

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Urged on my peers on both sides of the argument, here is an initial version of what I hope becomes a more permanent way to describe the work I use and teach. Comments, suggestions, and criticisms are always welcome (post below). Edits will be made to this post as comments come forward, both here as well as from social media.

Myofascial release (MFR) is one style of manual therapy that uses slow, still, prolonged stretching through clothing or directly on the skin to facilitate change in the patient. Whether having its primary effects on fascia, as historically believed, or on skin, muscle, other tissues, or the nervous system in general, it is realistically a more complex direct and indirect interrelationship of overlapping systems. The goal of MFR is most often to reduce the feeling of tightness and to lessen pain, allowing for more freedom of movement and improvement in functional abilities. While other forms of MFR vary, The Walt Fritz, PT form of MFR relies on direct patient feedback to drive evaluation and treatment, assuring that interventions are patient-specific. (edit 5/13/18)

Myofascial release (MFR) is a style of manual therapy most typically associated with its historical roots, which relied on perceptions that one could label pain and various movement disorders a result of tightness/restriction within the fascia/connective tissue. Most therapists using MFR were taught that they were able to selectively and singularly impact these fascial restrictions to the exclusion of other tissues, with the goal of reducing pain and restoring more normal movement patterns, with any mention of the nervous system added as afterthoughts. While MFR has been a popular and effective form of manual therapy for decades, the claims made by its proponents have yet to be proven, though these issues exist for nearly all forms and brands of manual therapy and massage.

Most brands of MFR, manual therapy, and massage claim that pain/movement problems are due to one specific tissue and make claims to be able to specifically impact that particular problem, all while having remarkably similar styles of engagement as the next type of therapy.

While it may be possible to be able to target one tissue under the skin for intervention, more plausible explanations come from neuroscience-based explanations, as well as the potential impact of contextual factors. These models look at more central mechanisms to explain the local effects of manual therapy, including MFR. Using such principles as neurodynamic technique, where nerve tension is reduced, allowing more freedom of movement and less pain, as well as skin/superficially embedded receptors that can signal the effects of MFR at the local level, with changes in pain/movement problems being an outcome of brain output via the central nervous system. These ideas work from the knowledge that the nervous system is in ultimate control, though in partnership with, the remainder of the soft and bony structures in the body. Though neuroscience-based models also lack full proof, they may be “less wrong” than many of the various other models.

Briefly, MFR has a typical style of engagement that uses slow, still, prolonged stretching to facilitate change in the patient. Whether having its primary effects on skin, fascia, muscle, nerves, or other tissues, its goal is to reduce the feeling of tightness and to lessen pain, allowing for more freedom of movement. I call my work MFR in reference to a very recognizable style of hands-on engagement typically associated with myofascial release, rather than due to thoughts that it is fascia that I am selectively engaging.

With such uncertainty, where does that leave the therapist and consumer? Therapists still treat in the manner they were taught, with hands-on interventions typically very helpful. The best choice may be to keep explanations simple. While it may be the fascia, muscle, joints, knots, trigger points, or a host of other tissues and pathologies are responsible for our problems, we can only work through the skin. Everything else is a stretch (pun intended!).

Articles Of The Week December 2, 2018

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This is a great post, not just because it discusses low back pain, but rather because it discusses change. Change is important for us practitioners, in fact (as the article points out) it is required of us. When new research or data shows there is a better approach to what we are doing, we are required to change. The beauty part of this article is that the researcher is actually having to adapt and change their own research and adapt for better outcomes in patients.

“Explaining Pain For Acute Back Pain – Reflections On Traeger et al. Part 2” – Lorimer Moseley

It has been proven that the language we use with our patients can have a lasting impact. This makes it our responsibility to stay on top of current information so we can convey proper information to those patients. Here we learn about the role our intervertebral discs play and the reality around pain and the “slipped disc” we’ve heard so many patients worry about.

“Discs Don’t Slip DAMMIT!” – Jarod Hall

In response to an article published by an insurance company this past week (which essentially denounced massage therapy and compared it to a good nap), Richard compiled this list of systematic reviews proving the value of what we do.

“A List Of Systematic Reviews Of Massage Therapy” – Richard Lebert

This one isn’t an article, but rather a video. In it, Rob discusses the intimidation massage therapists seem to experience with assessments and a simple way to address it.

“Assessments And Pain Science” – Rob Haddow

There always seems to be debate around applying new research and what “we’ve seen work” when it comes to treating our patients. The reality is, both have a place in what we do, and both should be used. Here’s some advice on how to apply both along with a few extra tips in using science to get results.

“Four Ways To Use Science To Get The Best Results For Your Clients” – Alex McBrairty

When The Holidays Aren’t Happy; How Do We Help Our Patients?

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Last week I was working with a patient when she started getting emotional about the upcoming holiday season.  She was struggling enjoying her 8 month old’s first holidays and the sadness that she was also feeling.  “Why am I not just happy and enjoying this time?” she asked me.

I perked up for a variety of reasons.

One, I knew she struggled with postpartum depression immediately after her daughter’s birth.

Two, it is not unusual for people to have feelings of sadness and stress during the holidays, and then guilt for feeling that way!

So I listened; why was she feeling this way?  She was overwhelmed by demands from family to see the baby, juggling an infant’s sleep schedule while keeping them happy, and starting traditions of her own.  I told her this was completely normal, but also reminded her that she only needs to be responsible to herself, her daughter and her husband.

“How do I do that?!?” she responded a bit exasperated at the idea of telling the in-laws that no, they were not staying for 12 hours on Thanksgiving Day.

Every year I have similar conversations with patients. 

So what do we tell them?  While we all need to stay in our scope of practice, and our own comfort zone, the following will help us navigate the conversation.

There are many reasons why people experience a range of anxiety/depression/stress during the holidays.  Symptoms can be anywhere on the spectrum from “holiday blues” to a more serious depression.  The good news is, the vast majority of people will have a mild case of the blues.  In spite of long-held beliefs and even occasional media coverage, suicide rate and depression-related hospital admissions do not go up during the holiday season.  The U.S. Center for Health Statistics shows that November, December, and January actually have the lowest daily suicide rate.  However, that does not mean that the holiday blues are not a real concern.  

No systematic reviews exist regarding mental health around the holidays. 

However, the American Psychological Association has conducted surveys with some interesting information:

  • While the majority of people report feeling happy, loved and in high spirits during the holidays, they also report feeling fatigue, stress, and irritability.
  • 38% of the people said their stress level increased during the holidays.
  • 56% of people said their stress was the worst at work, while only 29% said the stress was experienced at home.
  • 53% of people said their stress had a financial component. 

So what do we tell our patients? The American Psychological Association recommend several coping strategies:

  • Most importantly, remember the holiday season does not banish reasons for feeling sad or lonely. There is room for all feelings and anything the person is feeling should be acknowledged and validated.
  • If they have experienced a recent loss or a loss around the holidays, grieving may be strong and surprising, even years later.  Reassure them all feelings are valid and sharing them is the best way to positively grieve.  Encourage them to share with trusted friends or a counselor and prepare to celebrate their loved one’s life in a positive manner.
  • Spend time with supportive and caring people.
  • Save time to take care of themselves. No guilt. Do whatever activity they wish.
  • Be aware of excessive drinking and excessive junk food.  There isn’t consistent evidence that one particular food staves off depression, but there is some research to suggest an overall healthy diet is helpful in treating depression.
  • Go to bed! Getting plenty of sleep will help manage anxiety and stress.
  • Get some light. Exposure to light, especially in the morning is important to anybody at risk for depression.
  • Exercise.  There is a lot of research that movement, any kind, can help with general mood.
  • Identify the source of the pressure and make priority lists. Don’t feel bad if something doesn’t make the list. 
  • Don’t be afraid to say “No” if occasions are not on your priority list.  Or say “Yes, but” as in “Yes I would love to see you but right now is not a good time and I really want to be fully engaged. How about we arrange that end of January?”
  • If feeling lonely, reach out or try other activities to make friends.
  • Finances are often the source of stress.  Set a budget, communicate intentions well ahead of time with loved ones and concentrate the larger reasons for the seasons.  Do a group outing or volunteer for a charity as a family instead of focusing on gifts.

It is important we know and recognize the signs for a more serious depression.  Past posts on The Massage Therapist Development Centre have done an excellent job of describing the signs and what we can do.  Find the link here.  For most of our patients, listening, validating, and giving them permission to be a priority will help them thrive, not just survive the holidays.  Reassuring them all feelings are normal and the stress is short-lived goes a long way to have the happiest of holidays.  And remember—that goes for us caregivers as well!  Remember to not just take care of your patients, but take care of yourselves and have the happiest of holidays!

References:

https://www.apa.org/helpcenter/holiday-stress.aspx

https://www.apa.org/pi/women/resources/news/holiday-blues.aspx

Day-Calder M  How to beat the post-holiday blues. Nurs Stand. 2016 Sep 14;31(3):37-38.

Hirthler MA  Change of shift. Holiday Blues.  Ann Emerg Med 2010 Dec, 56(6);690

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