Making Sense of the Cranial Nerves: 3 SHORT FILMS

Cranial nerve testing should be within the skill set of ALL clinicians who treat neck, head and orofacial presentations.

Most clinicians are well versed and confident with neurological testing of the upper and lower limbs as well as upper motor neuron tests. However, when it comes to what is arguably the riskiest of anatomical regions, the head and neck ... there appears to be a strong suggestion that history and education have not prepared physiotherapists well for this.

The harsh reality is that many #Physios report that:

1. They were not taught CN’s at University

2. If they were, they are a little rusty with application and interpretation

3. It’s not something they do very often, and the tests are really hard to recall

Indeed a recent Twitter poll revealed that 53% of respondents suggested that they had not been taught these skills at University. Of those that had, over 50% suggested that they were not comfortable with applying them and interpreting the tests in clinical practice.

This is perhaps a little alarming for a profession which is championing the concepts of FCP and ACP roles within healthcare. There is a mismatch here, and a clear need to improve understanding, education and competencies. But it is not just FCP’s & ACP’s who need these skills. They are easily attainable for any clinician, and can easily be understood and applied from UG level. BUT DON'T FEEL BAD ... I think perhaps the educational system in some places (not all), has let us all down, and I agree entirely, the CN's are a bit complex and do at first provide a challenge to learn.

The missing links are often context, understanding, working knowledge and the application of clinical reasoning.

That is why I've put together 3 short films in the 'Fireside CPD Sessions' series, to help make sense of the cranial nerves, their functions + when and how we might test them.

FILM 1. Cranial Nerves: A Clinical Reasoning Guide

An opportunity to get to know the cranial nerves and their functions from a clinical reasoning perspective.

FILM 2. Cranial Nerves: Subjective questioning - A SHORT FILM

This short film is designed to introduce the cranial nerves and consider the subjective questions (that we often don't ask) that might lead us to test them in the clinical situation.

FILM 3. How to remember the Cranial Nerves: A Function Based Approach - A SHORT FILM This short, tongue in cheek, ‘Fireside CPD’ film, draws upon story telling, and offers an inventive and fun method of recalling the FUNCTIONS of the cranial nerves. Pull up a chair, open a bottle, or make a nice cuppa and enjoy a fun and inventive way to remember the cranial nerves based on FUNCTION.

These films should provide a solid base for all clinicians who wish to familiarise themselves with the cranial nerves, gain a basic understanding of their function, AND develop an easy method for recalling the tests.

ENJOY! For more on the Cranial Nerves, go to: http://alteredhaemodynamics.blogspot.... For a 'Cranial Nerves Country Song' ... go to: https://www.youtube.com/watch?v=WgjyE... Look out for 'Cervical Spine: Risk & Rehabilitation for Clinicians' ONLINE COURSE (2021)

The case of the ‘sprained ankle’: A reflection on the narrative of ‘harm’

Harm, harmed and harmful are words we hear daily in a range of contexts. In the world of MSK Physiotherapy, there has been a lively debate, relating to the ongoing use and abuse of those labels. Indeed, it has even been suggested that we should spend less time talking about the narrative of 'harm' and more time getting on with the task in hand. As uncomfortable and temporarily distracting as it may be, exploring in detail the psychosociology of the development of the 'harm' narrative, will allow us to do exactly that.  

It is clear, that everyone has their own frame of reference for their interpretation, context and use of the term 'harm', together with the narrative that goes with it. In any debate or discussion, it is helpful to form a view or even ask, exactly why or how someone formed their own views or perspective on a topic. Here's my own perspective on 'harm' ... a personal story, grounded in altered haemodynamics, musculoskeletal trauma, clinical reasoning and decision making. 

I’m going to tell you a very personal tale of actual, real measurable  material harm, as a direct result of inappropriately applied health care. It is a story which I wrote, but never thought I would publish. I have only ever revealed it to a handful of people, so as I take you (as a reader) into my confidence, do bear with me, as I eventually get to my point. It may go some way to explaining why for me, asking for harm data, is not some kind of game, but rather a serious and genuine question, with a potential end goal in mind.

I’d not been qualified that long as a Physiotherapist, when my Mother suffered an injury. It is a story in keeping with the title of this BLOG. My Mother’s name was Jessie … and my wife always described her as a Mrs Pepperpot like character. She was in her early 70’s, a short rotund, jocular lady who always seemed full of fun. She enjoyed painting, flower arranging, pottering about in her extensive garden and, as she called it ... “bending her tummy” (going to the Church hall exercise class). She phoned me on the day she twisted her ankle in the garden, I had a quick look, but she was in a lot of pain and the ankle was already very swollen. I decided to take her to the GP. He examined her and confidently explained from his physical tests that she had ‘sprained’ her ankle. He advised her to rest, ice, compress and elevate, the management recipe (at the time) for such injuries. I took her home and we dutifully followed the Doctor’s instructions, but I remember she was in a lot of pain and she could hardly weight bear. I was a little worried, but I tried to re-assure her, and left her with an ice pack and her leg propped on up on pillows, telling her that I would be back the next morning.

The next morning things were not good, she told me she had had a terribly painful night and could not stand the weight of the bed clothes on her ankle, I looked at the ankle and a bluey-red bruise was already apparent and the swelling could only be described as like a balloon. I called the Doctor; he listened patiently to my description, then re-assured us that this was a “normal soft tissue response to injury”. He advised some analgesia and a little gentle movement “as tolerated” and to continue with the RICE regime. I managed to locate a pair of crutches in the loft (every physio has crutches in the loft … don’t they?) and proceeded to teach her how to use them to get around. She seemed a little happier now that she could potter about a little and the analgesia was taking effect. Two weeks later, she was still unable to weight bear properly and remained in a lot of pain. Despite the RICE regime the ankle remained very swollen, very painful and very sensitive to touch.

Now a little worried, I’d been scanning the text books (back in the days before Google) and found the section on traumatic avulsion fractures of the ankle. I asked her if she had felt or heard anything when the ankle twisted? She paused briefly, and said, “just a popping sound like a chicken bone”. My eyes widened and I reached for the phone. I explained the situation and the Doctor agreed to see her at the end of his list. He had another look and this time tried to palpate the lateral malleolus … Jessie almost jumped through the ceiling … “It’s terribly tender Doctor, you can’t really touch it,” she explained, clearly embarrassed. “Mmmmm” he said, “I think we’d best send you for an X Ray, just to check” he reassured her with a smile. “Do you think it might be broken Doctor?” she asked, looking a little worried. “We can’t really tell till you’ve had an X ray,” he explained. “So I think we’d best be on the safe side”.

Sure enough, the X Ray at the local hospital revealed a small avulsion fracture of the lateral malleolus and it was decided to treat it with a back slab immobilisation because of the extensive swelling. She seemed much happier now that she had a diagnosis and the smile had returned to her face as she joked with the medical staff and toddled off (non-weight bearing) with her crutches.

6 weeks later she returned to the fracture clinic, the back slab was removed, an X Ray taken, and she was given the all clear to begin to weight bear “as tolerated”. I quietly listened to the instructions and exercises given by the physios and secretly suspected that my role would be to provide a little encouragement and guidance. As it happened, my role was minimal as she got on with the prescribed exercises and steadily began the process of weight bearing. Two weeks later she had progressed to a stick and things were going famously, but one thing troubled her, although the pain was now manageable, it still seemed very swollen. I reassured her that that was probably normal and that it would go down in time. It did go down… until 4 weeks later.

“I’m a bit worried,” she said, when I called round. “I’ve been pottering in the garden and I think I must have a rash or something, my ankle has gone all swollen again” and look at it” she said, pointing to the red, swollen ankle resting on the pillow. I’d never thought to measure the swelling (clinical tip), but it looked much more swollen to me and it was certainly redness extending up to the calf. “Can I touch it,” I asked, leaning forward to palpate the ankle “gently,” she said, “oh and my calf has started to hurt too,” she added. I pressed my thumb and fingers into the warm, swollen tissue, they left an indentation, there was obvious pitting oedema. Deep vein thrombosis came flooding back to my mind, I recalled the lectures, the text books, red, hot swollen, pitting oedema, history of trauma, immobilisation, Virchow's Triad etc. etc. 

We were soon sitting in the Doctors waiting room. “What seems to be the problem Jessie?” he said smiling. She took of her shoe and sock and without a word nodded at the swollen, red ankle. “Mmmm …” he said again, observing the temperature and pitting oedema, it looks like a case of phlebitis he said confidently. “Oh dear, that sounds bad” exclaimed Jessie, speaking up for the first time. “Oh … it’s nothing to worry about," said the Doctor reassuringly, noting her alarm at the undecipherable medical jargon (clinical tip). “We see it quite commonly after periods of immobilisation, we need to keep an eye on it, and if things don’t settle down, you may need some anti-inflammatories or maybe antibiotics for the inflammation. Oh … and I’ll ask the nurse to get you some compression stockings”. The Doctor seemed very confident and I was a newly qualified Physiotherapist barely making sense of all the information I’d acquired, but I couldn’t help myself … “How can you be sure that it’s not a DVT,” I stuttered unconvincingly, my mind racing. He shot me a glance, and putting two and two together accurately said, “Aaah … I remember now, Alan … you’re fresh out of Physiotherapy School aren’t you? Where are you working these days?” He paused, clearly thinking through his response, I didn’t answer. “Well we can never be entirely certain with these things, but I’ve seen lots of similar cases and I think it is phlebitis … BUT (he said with emphasis) we should keep an eye on it and if things don’t improve we’ll need to send Jessie back to the hospital for some tests.” 

4 or 5 days later (I don’t recall exactly) Jessie became feverish and breathless and was rushed into the local hospital. Everything was a blur, I vaguely remember some discussion and argument among the Doctors about her diagnosis. Eventually, she was sent for Duplex ultra-sound scans and was urgently medicated for the DVT that was revealed on the scans. She died in hospital 2 days later from the complications of a pulmonary embolus. The post mortem detailed both pathologies very clearly.

The family were naturally shocked, her granddaughters were too young to understand that they would miss out on hours of fun, painting, flower arranging and pottering in the garden with their grandmother. The pain of the event was immeasurable and had an impact across generations. There was talk among Jessie’s brothers and sisters, of misdiagnosis and medical malpractice; my head was in a spin. I arranged a meeting with the medical director of the hospital and the GP. We discussed the case and the events that led to Jessie’s death … they acknowledged that the management perhaps could have been different … that clinical decisions could have been expedited, the tests done quicker. I observed the pained look on their faces. They called it a “tragic case”. I asked them if they had learnt anything, the GP hung his head. Nothing came of it, no blame was apportioned and the family chose not to pursue a medico-legal case. I was relieved; it would have been too painful. I did make a request though, that they use the root cause analysis of the case as training for medical staff, Doctors, Nurses and Physiotherapists alike.

So … how do you reflect on a case like that, and what prompted me even to tell the story?

Well actually it was and still is, the current narrative in MSK physiotherapy that re-awakened the memory of this case and prompted me to want share the story.

I’ve watched with increasing discomfort and dismay, a range of prominent SoMe commentators from top researchers, bloggers, to every day Twitterati (including patients), confidently asserting that certain physiotherapy management methods are, in their words ... “harmful”. When I politely ask for data to support this contention, it becomes clear that (to date) there is no data. There is however, a quite reasonable associative argument, which though clear to see, remains unquantified. A debate has ensued and is still ongoing, about the use and definition of the word ‘harm’ and it became apparent that there are many. Similarly, everyone has their own particular frame of reference for their interpretation and context for the use of the term 'harm'.

If we go back to Jessie’s case in the cold light of day, the raw data = 1 premature death. 

Was there measurable harm? .... Yes.

Was there immeasurable harm? ... Very likely.

The unmeasured psychological trauma has not been captured … how could it be (effectively)? 

Was that down to the treatment/management in this case?

Maybe, … it certainly could be ascribed (in part) to delayed/misdiagnosis. Above all, it was down to errors in clinical decision making, and that is what clinical encounters will always be down to … doing the right thing, at the right time for the right patient, or as Greg Lehman would say, 'being a good clinician'.

A judgement on whether emotional distress is harmful or not, is entirely down to the ideas and beliefs of the individual. The very same thing applies to claims about treatments for MSK conditions. A period of ‘wrong’ management, may well have delayed the application of the ‘right’ management (an ever shifting phenomenon in most MSK domains). That (in most cases) won’t result in a measurable adverse event, but it could easily be an adverse or negative factor (physically, psychologically or socially) affecting ultimately, the recovery of the patient from whatever ails them.

Is that harmful? 

... and if it is (?), are we able to successfully identify when it transitions into harm ?

Clearly, all of THAT remains open to debate. All we can say is that IF a treatment is deemed ‘harmful’ … then it would be helpful to find a way to measure that harm. With that knowledge, in order to prevent further harm, action could be planned and taken. To do this we would have to take into account the evidence on efficacy of treatments, the health economics literature, the (captured) adverse events data; we have to listen to patient opinions about what they consider to be value or effective care, or harmful care, in a range of environments and from a range of experiences. It is clearly a very complex multi factorial topic, which has no easy answers and (currently) appears dominated more by emotion and volume than reason. 

The polarisation of the debate and the ongoing manipulation of language, creates fear and uncertainty, and gives impression that there is only one solution.

This BLOG post was NOT written or designed (because it contained a personal story) to be impermeable to critique, neither is it to suggest some kind of victim-hood, that would not have been Jessie's style nor is it mine. A single case study does not create or demolish a narrative. It may just however, explain the context of why I find the current physiotherapy narrative of harm uncomfortable, difficult, unnecessarily divisive. I wouldn't go as far as to say I'm personally harmed by it, but it is certainly one reason why I speak out against it. None of this makes me right either, and my own (or Jessie's) narrative does not negate anothers, everyone will have their own perspective and frame of reference for analysing the topic. 

If this story promotes a just a moment of critical thinking in 1 single person ... then it will have achieved its objective. That said, It would be really nice to see a positive outcome of this debate, a lot less conflict and even perhaps, an agreement  on a way forward. I know that Jessie would have been thrilled if she could have been, even a tiny part of that process. 

Thanks for listening and for getting this far ...

Please feel free to comment or critique in the usual way.

Footnote: Jessie of course, did not die of a sprained ankle (that would be UNSPEAK). Sprained ankles are not really harmful per se, and the doctors, nurses and therapists who deal with them, equally do not routinely deliver 'harmful' care. Jessie died from a pulmonary embolus due a complex series of human clinical decisions and events. Something I can only attempt to square up or put down to ‘the frailty of humans’. The root cause analysis of her case, made for an interesting, yet painful read.

I’m unsure whether it was irony or destiny that took my physiotherapy career and specific interest, down the route of vascular speciality and medico-legal work specialising in adverse vascular events and clinical reasoning errors. I try to see some ‘good’ in that. 

I've seen some very interesting and illuminating cases of real measurable, material harm and ongoing physical and psychological disability, linked directly to physiotherapy interventions over the years ... and still the cases still trickle in. 

 
HT to Blaise Doran, Carl Davies, Greg Lehman and a few others who in their own ways, have helped me to shape and tell this story. 

Author: Alan J Taylor is a writer and critic who tries to think about stuff . He works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness whilst maintaining a small clinical work load. The views contained in this blog are his own and are not linked to any organisation or institution.  He once rode the Tour of Britain and worked as a cycling soigneur. He still enjoys riding a bicyle through the leafy lanes of Nottinghamshire and Derbyshire. In a World full of conflict and division ... like Bukowski, he 'writes to stay sane'.

Death following a neck injury: What can we learn from the case of Katie May?

This commentary was originally written as a general interest article for publication on a Web news page. For one reason or another it was not published ... So here it is, in a modified Blog format.

Katie May, a 34 year old Playboy model and entrepreneur, died on February 4th 2016 following a stroke. Whilst the details are sketchy, media reports of a neck injury during a photo shoot raises questions as to how a fit healthy 34 year old, could go from an apparent neck strain to a fatal stroke in a matter of days. This report takes look at the mechanisms of early stroke and considers what we can learn from the case.

Neck pain is a common complaint that is thought to affect around 10-13% of the population. However, most patients do not have a life threatening condition. That said the cervical blood vessels can be susceptible to injury. This was illustrated graphically by the tragic death of Australian Cricketer Phillip Hughes. Hughes died from a sub arachnoid haemorrhage (bleed to the brain) following a blunt injury to a blood vessel in his neck from a cricket ball.

The blood flow to the brain is carried by two small vessels at the back of the neck called vertebral arteries, and two larger vessels at the front, called the carotid arteries. The carotids carry around of 80% of the blood flow to the brain. It is well known that any of these blood vessels can be injured by trauma or affected by disease. It is well known that the early presenting symptoms of arterial dissection may be neck pain or headache and that ischaemic symptoms may not develop until later.

A complex anatomical region ... https://www.flickr.com/photos/thomasfisherlibrary/12288500023

So, how could an apparently fit, healthy female, suffer a stroke leading to death at the age of 34?

The complete picture of exactly what happened in this case remains unknown, but we can learn from past experience. There are a number of potential scenarios.

One scenario is that like Phillip Hughes, Katie May had perfectly HEALTHY blood vessels that were injured internally (arterial dissection) by an ‘awkward’ fall during a photo shoot. What happened thereafter remains open to speculation. At that point ANY intervention whether it was advice (to keep moving), pain management/education or manual therapy/manipulation, may have ended with the same outcome.

It remains unexplained how some dissection pathologies resolve yet others go on to lead to stroke or death. It is thought that this may relate to variety of intrinsic conditions linked to connective tissue disorders and clotting factors. In addition, extrinsic factors may also play their part. A failure to recognise the signs and symptoms (assuming there were any) of a developing pathology in accident and emergency, at the GP practice, or under the care of a musculoskeletal therapist (Physiotherapist, Osteopath, Chiropractor) may be also be associated with fatal consequences. A common medico-legal scenario, is a delay to appropriate triage, in order to commence a trial of management or specific treatment.

 
 Thrombotic stroke - image en.wikipedia.org550 × 800Search by image 

A second scenario of many, is where a person develops musculoskeletal neck pain insidiously or via a minor trauma and seeks the attention of a manipulative therapist, such as a Chiropractor, Osteopath or Physiotherapist. Katie May Tweeted that she was going to see her Chiropractor, though no detail has been released. However, the wave of assumption and speculation implicating Chiropractors, could well be entirely unfounded as this single case study clearly illustrates. 

The status of the blood vessels at the time of ANY consultation, may be either healthy OR unhealthy. Unfortunately, without sophisticated equipment, there is no way of knowing whether vessels may be ‘weak’ or suffering from underlying disease such as fibromuscular dysplasia or atherosclerosis (rare in the younger patient). This is one of the reasons that manipulation in particular, has been called into question. At best the science remains equivocal. A recent systematic review found no association and suggested that, "the relative risk of ICA dissection after cervical spine manipulation compared with other health care interventions for neck pain, back pain, or headache is unknown". However, critics argue that spinal manipulation to the neck may injure vessels, leading to stroke.

Neck manipulation has many descriptions, but generally involves a high velocity manoeuvre, outside the control of the patient, which may produce a click or crack. There is evidence to suggest that for acute/subacute neck pain, cervical manipulation provides better pain relief and functional improvement than medications such as varied combinations of NSAIDs, analgesics and muscle relaxants. However, the caveat is that this benefit, may not be entirely risk free. Furthermore, it is suggested that the actual number of adverse events (injury, stroke, death) may be massively under reported. 

 

thebluediamondgallery.com1200 × 755Search by image

Could the risk be reduced?

The debate on the safety of manipulation has not been helped by the lack of agreement on the risk of blood vessel injury following treatment. Some reports suggest ratios between one in 50 ,000 to one in nearly 6 million manipulations, though as mentioned, many question the accuracy of this data, citing up to 100% under-reporting. A review of 134 case reports, published in 2012, said, “there was potential for a clinician to prevent 44.8% of adverse events (such as stroke or death) associated with manipulation”. The authors suggested, “10.4% of the events were unpreventable”. Interestingly, the patients who died had continued or excessive spinal manipulation, despite the fact that they were not responding to treatment, or their symptoms were worsening.

Despite RCT reports that in apparently healthy vessels, manipulation to the atlanto-

axial joint does NOT appear to increase mechanical stress on the vertebral artery, it remains unknown what the affect might be on diseased, weak or already dissecting vessels (vertebral or carotid).

As it stands, scientific knowledge can neither accurately quantify the risk associated with neck manipulation, nor establish an unequivocal link between manipulation and adverse events. A 2016 physiotherapy publication, a profession that has been prominent in the field of neck risk assessment, suggested that, at best, “early recognition of injury to blood vessels” may reduce the occurrences of inappropriate treatment. This raises the important question of what exactly is 'inappropriate treatment'? Whilst manipulation may have been demonised by some, it is important to understand that blindly defaulting to ANY favoured intervention in the absence of sound clinical examination and risk assessment ... may lead to adverse outcomes in the presence of arterial injury.

Could tragic events like this be prevented?

Disappointingly, the complexity of the human body and mind, dictates that the answer will vary from case to case and clinician to clinician. It remains essential for ALL CLINICIANS to retain an index of suspicion for arterial injury in cases of trauma, be cognisant of ‘red flags’ and apply appropriate clinical reasoning and examination procedures. A default to, a single school of thought or approach (whatever that may be), may lead to delays to triage, inappropriate management and potential medico-legal consequences. 

Atypical, worsening presentations, with OR without subtle ischaemic symptoms may alert the clinician to the presence of arterial injury. The diagnosis of arterial dissection rests on a careful clinical history, physical examination, and targeted ancillary investigations. Clinicials should be cognisant that delay may be fatal.

What do we all have to learn from cases like this?

1. Retain an index of suspicion for vascular injury in trauma cases. 

2. Know your anatomy and pathophysiology.

3. Hurt does = harm, in some cases. 

4. Examine and question the patient in detail.

5. Have, and retain vigilance for ‘Red Flags'.

6. A DELAY to appropriate management, is a common root cause in many medico-legal cases.

 ... There is NEVER absolute certainty

 

HT to Woody  Guthrie for being an inspiration -  "It's a folk singers critical thinkers job to comfort disturbed people and to disturb comfortable people"

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

You'll find him mostly on Twitter https://twitter.com/TaylorAlanJ

Forget models, mantras and gurus ... Listen to the patient

The current debate in Physiotherapy about the use and misuse of evidence based medicine (EBM) was well and truly polarised by Roger Kerry's recent Evidence-Based Physiotherapy: A Crisis in Movement.

In a brilliant no holds barred polemic, the author called made a plea for sanity in a World gone mad. It got me to thinking. I've long been an advocate of big picture thinking, and puzzled for many an hour and longer about why we think the way we do. Why for instance, physiotherapists got fixated with the vertebral artery, back in the day when spinal manipulation was all the rage. It slowly became apparent that there was more to cervical vascularity than just the vertebral arteries. Hence the development of a system based approach to the issue which focused on movement (not JUST manipulation), all of the vascular system (not JUST the vertebral artery) and all of the potential pathologies (not JUST dissection).

The result was a risk assessment framework which offers sound guidance and direction for those offering any movement based interventions (including assessment) for patients with head and neck pain. The IFOMPT document is not a guideline, rather a framework for THINKING, for clinical reasoning, and directs clinicians to make decisions based on the big picture. It exhorts clinicians to familiarise themselves with cranial nerve testing, surprisingly, (and perhaps alarmingly) not part of the skill set of many PT's, and to consider blood pressure as an additional risk assessment tool. None of this was rocket science BUT, it was perhaps an example of restricted thinking, dominated by the 'experts' of the time.

The new 'experts' of our time are the social media commentators, the 'institutes' the 'organisations' who shape our opinion with their interpretation of EBM. Many seem to shout loudly (and with significant bias) from the roof tops about what we should or shouldn't do. It is a fascinating dynamic, which I have observed from both within and afar. When internationally respected pain expert Mick Thacker wrote a guest editorial recently for Pain and Rehabilitation - the Journal of Physiotherapy Pain Association, he upset the apple cart. He challenged the use of 'mantras' and singular thinking with another brilliantly written piece entitled 'is pain in the brain?'  His commententary, that he was surprised that such views about pain were "…so widely accepted by physiotherapists considering our backgrounds", caused outrage in some quarters and he was was vilified on social media by disciples of the pain/biopsychosocial model. They argued their case with such tactical vigour, you would have to conclude they could not be wrong …. unless of course, you were thinking.

It is perhaps the absolute certainty of some, that I find most fascinating and perhaps a little dangerous.

It is time, as my colleague so rightly said, that we all begin to think for ourselves.

Image via

John Eisenschenk

https://www.flickr.com/photos/johne777/9388708662


There's no doubt that the biopsychosocial model has much to offer and only a fool would deny its role and value. But should you throw yourself at its alter? The biomedical model has many limitations, that are well recognised.




But when a patient presents with a worsening scenario, it is worth remembering that not everything is a 'flare up' and just as 'hurt does not always equal harm' ... SORRY but, sometimes it does!

Similarly, whilst modern science suggests most patients with LBP for instance don't require scans or X rays … some do.

It remains our job to be able to recognise those cases and manage the others with whatever skills we have left at our disposal. Otherwise, a sheep like adherence to one particular school of thought may prove to be our undoing. We need to know examination skills, we need to know pathologies … we need to know when scans or triage are appropriate, we need to know the limitations of our own thinking, all these things matter.

I decided to illustrate my point with a cute story ... which nicely illustrates the shortcomings of both 'models' and how we truly have to listen to our patients and put aside our preconceptions.

Mr Xrayspecs (a 52 year old builder and hobby cyclist) walked into my clinic recently, referred from another Physiotherapy colleague. He presented with a description of chronic lower back pain and non specific left leg pain.

I introduced myself and asked him why he'd come to see me.

"Well, I have this pain you see, and I think it's getting worse, so my physio sent me to see you … seems to think you might be able to help" he said, somewhat doubtfully.

"Tell more about it " I asked.

"Well it all started 34 years ago". "34 years", I mirrored and sat back in the chair ready for the long haul.

"They've tried everything" he went on. First, when my leg started aching (aged 18), they said I had a trapped nerve 'sciatica' they called it. They said I'd got an asymmetry. They gave me lots of treatment, you know manipulations and stuff but nothing worked. Then I went to the osteopath and he put all my joints back in … but that didn't work either."

It was a familiar story ... one I've heard (probably like you) many times before.

He went on "I just tried to ignore it and carry on riding my bike, but the pain came on every time and my leg felt weak."

Oh, so you felt it whilst you were cycling did you?" I interjected. "YES", he reiterated with some agitation. "Tell me more", I asked, ... "They said I must be trapping a nerve or something, probably because I was bending forward, on the bike". "Oh" I said, thoughtfully. "Then they sent me for a scan, but nothing showed up".

https://pixabay.com/en/bicycle-old-bike-cycle-retro-ride-497329/ 

He continued, "I was getting really fed up I can tell you, and about 3 years had gone by". "OK, I can understand that" I said compassionately. "Then what happened" I asked. "Well, thats when they said it might all be in my head" he said (his words). "They sent me to a pain clinic, gave me some injections and told me I should self manage it, but I knew something was wrong". "Oh" I said, brilliantly … pausing for dramatic effect.

"What did YOU think was wrong" I asked. "Well I didn't know what exactly ... but I knew my leg wasn't right, it felt weird, weak, strange, but when I started to say that, I think they thought I was a bit mad, so I backed off a bit". "Oh" I said again, somewhat repetitively, but he carried on regardless.

"I've been to every specialist you can name, orthopaedics, sport, pain, physios, osteopaths, chiropractors, masseurs, you name it, I've been there". "And" I said, probing hopefully. "Well its just getting worse and now I've got back ache too" he continued. "They sent me for more scans recently and I've got wear and tear and disc degeneration now ... and they said that must have been the problem all along".

"So now I'm labelled with chronic pain and I'm having CBT and all that psychological pain education stuff". "Oh", I said hopefully. "Yeah but that's a waste of time, just like the rest of it was … pacing whats that gonna do? Mindfulness? I'm a bloody builder … I'm getting worse, not better and NOBODY LISTENS", he said, pausing for effect.

"What do you mean" I said. "NOBODY LISTENS" he said again, somewhat menacingly.

Image via - http://strawberry-lollipops.deviantart.com/art/Listen-to-me-102802029

I leaned forward, listening intently with wide eyes. "Look when it all began, it always came on when I was exercising, and it still does, like when I ride my bike, or push a wheelbarrow on site or go up the steps to the roof … I might have back ache now but I didn't before and my leg still feels like it's got no blood flowing into it. To be fair I've been saying that for 34 years but everyone glazes over … Its like they only want to fit you into their bag, their particular pet theory".

At that point I laughed out loud. "It's not funny" he said. "No, no" I apologised, "I'm not laughing at YOU, I'm laughing at me ... US!" I stuttered.

"What do you mean" he demanded. 'Well" I began, " I think my colleague may have sent you to see me because he thinks I may have a pet theory too" … It went quiet … I took up the cudgels.

"When you said that your leg felt like it had no blood going to it, did anybody test for that." I asked. "No" he said, "they just kept talking about nerves or discs initially, then chronic pain and CBT and how 'pain is in the brain' and stuff, like I explained." he said.

I asked a few more probing questions about the nature of his pain and asked him to lay on the couch.

I took his lower limb pulses - Normal.
I took his brachial blood pressure - Normal.
I took his ankle blood pressures - Normal.

I asked if he was still riding his bicycle and if his pain still came on with cycling. "Yes" he said, "as regular as clockwork … as soon as I get to 145 bpm on the heart rate monitor." "Oh" I said. "Can we ask you to exercise to that level I asked'?

"You can bloody well ask me to do what you like if we can get to the bottom of this bugger" he said cracking a smile for the first time. I explained that we may find nothing at all, and asked him again if wished to continue with a simple exercise test. He was already climbing eagerly onto the exercise bike and adjusting his pulse monitor belt.

The exercise test quickly reproduced his leg pain as predicted, as soon as he reached around the 145 bpm mark. I pushed him a little further… 165 bpm "Yes", he said with some satisfaction. "Now my leg feels funny, weak, like theres no blood going to it".

He jumped off the bike and we lay him on the couch … we replaced the left and right BP monitors onto the ankles and inflated them, they ran simultaneously.

At minute 1 (post exercise) the systolic brachial BP was 185 mmhg

At minute 1 the right ankle systolic BP was 160 mmhg. The left recorded nothing (I waited … I'd seen this before) ... the BP can be lower than the machine can record.

At minute 2 the systolic brachial was 180

At minute 2 the RIGHT ankle BP = 155

At minute 2 the LEFT ankle BP = 70 mmhg 

Post exercise ankle brachial pressure index (ABPI) was calculated as 70/180 = 0.39

The published cut off point for post exercise ABPI is currently 0.6 (Peach et al, 2012)


I'd turned the BP monitors away from his gaze … He was anxious to know the result.

I explained that he would no longer need to continue with the mindfulness and CBT.

He was referred to the vascular surgeon with a full outline of the consultation and test results.

4 weeks later (after the tests had been repeated the vascular clinic) magnetic resonance imaging of the arteries revealed a significant flow reduction to the left lower limb in the region of the external iliac artery.

The patient underwent a 5 hour vascular surgery (longer than expected due to the complex intra-operative findings) involving endarterectomy and shortening of a 'significantly tortuous artery'.

He made a full recovery and 6 months post surgery reports NO LEG PAIN under any conditions, including exercise. He still gets intermittent low back pain, which he considers to be "normal".

His post exercise ABPI measures have returned to within normal limits (> 0.6)

He has returned to full function work/cycling/running/skiing with NO LEG SYMPTOMS.

For various reasons linked to clinical reasoning and therapist/physician beliefs ... it took 34 years to get to the bottom of this case.

For an analysis of quite how that could be ... try a stab at the 5 Whys of ROOT CAUSE ANALYSIS 

What do we all have to learn from this case.

1. Listen to the patient

2. There are limitations of BIOMEDICAL reasoning

3. There are limitations of BIOPSYCHOSOCIAL reasoning

4. NEVER have blind faith for 1 paradigm

5. Know your pathology

6. KEEP LISTENING TO THE PATIENT

7. N=1 (it REALLY does)

8. It's OK to be discombobulated ... Just say "Oh"

 ... and just for the record, there is NEVER absolute certainty.

Image via Steven Shorrock https://www.flickr.com/photos/highersights/6231641551

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist and University Assistant Professor ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

You'll find him mostly on Twitter https://twitter.com/TaylorAlanJ
... that is until, he finally deletes his account, or is 'evidence based blogged' to oblivion.